Impairment of the normal corticosteroid response during critical illness can be multifactorial. The frequency of adrenal insufficiency (AI) in patients with septic shock is variable and the incidence varies depending on the underlying clinical condition. Recent data suggests that the majority of patients with septic shock should be worked up for AI. We conducted this retrospective study to assess how frequently physicians suspected AI amongst this cohort and to identify the circumstances that lead them to do so, if any.
The records of patients admitted to the MICU requiring vasopressors were reviewed and those meeting criteria for septic shock were analyzed. AI was confirmed with a random serum cortisol level < 15 mcg/dl or with a random cortisol level between 15-34 mcg/dl and an increase in response to cosyntropin-stimulation test (250 mcg) < 9 mcg/dl.
Ninety two patients were included in the study. Mean (± SD) age was 59 ± 18 years. APACHE II, SOFA, and SAPS II scores were 27.6 ± 8.5, 11.6 ± 3.8, and 60.2 ± 21.5, respectively. Overall mortality was 51%. AI was suspected in 44 patients (48%) and confirmed in 25 (57%). Maximal doses of vasopressors were comparable between groups but more patients in whom AI was suspected were on phenylephrine and/or vasopressin and more were treated with activated protein C (aPC) (P < 0.05). Patients in whom AI was suspected were in shock for 3.1 ± 7.4 days before work up was initiated.
In spite of evidence of increased incidence of AI in septic shock, this condition was suspected only in about half of our patients. No reliable indicators leading to AI work up could be identified other than increased number of vasopressors needed and the use of aPC.
AI occurs frequently in patients with septic shock but clinicians under diagnose this condition. Adoption of clinical algorithms incorporating cortisol testing early on the course of septic shock can avoid delays in diagnosis and improve outcomes. Adrenal insufficiencyAPACHE IISOFAMICU LOS (d)Na+ (mmol/L)K+ (mmolL)Survival (%)Suspected26.3 ± 7.911.3 ± 3.511.2 ± 12.4138.0 ± 5.14.5 ± 1.350Not Suspected28.8 ± 8.911.8 ± 4.18.4 ± 8.2137.7 ± 6.14.5 ± 0.944
N.M. Elsouri, None.