EVALUATION AND MANAGEMENT OF ADRENAL INSUFFICIENCY IN CRITICALLY ILL PATIENTS: DISEASE STATE REVIEW

AACE Adrenal Scientific Committee

Research output: Contribution to journalReview article

7 Citations (Scopus)

Abstract

OBJECTIVE: The definition of normal adrenal function in critically ill patients remains controversial, despite a large body of literature. We review the clinical presentation, diagnosis, and treatment of adrenal insufficiency in critically ill patients and discuss the authors' personal approach to patient management.

METHODS: Extensive literature review, guidelines from professional societies, and personal experience.

RESULTS: A decrease in cortisol breakdown rather than an increase in cortisol production has been suggested as the main contributor to elevated cortisol levels in critically ill patients. The concept of relative adrenal insufficiency has multiple pathophysiologic flaws and is not supported by current evidence. Patients with septic shock who are pressor dependent or refractory to fluid resuscitation may receive a short course of hydrocortisone regardless of their serum cortisol levels or their response to a cosyntropin stimulation test (CST). Patients without septic shock who are suspected to have adrenal insufficiency should have their random cortisol levels measured. In patients with low and near-normal cortisol-binding proteins, a serum cortisol of <10 or 15 μg/dL, respectively, may trigger need for glucocorticoid treatment. Assays of free cortisol levels offer an advantage over total cortisol levels in patients with low binding proteins. Most critically ill patients have a normal random free cortisol level of >1.8 μg/dL, although further studies are needed to define a normal range in critically ill patients based on both severity and duration of illness. A CST may be used to further evaluate adrenal function in patients without septic shock who have borderline random serum or free cortisol levels.

CONCLUSION: Evaluation of adrenal function in critically ill patients is complex. Recent findings of decreased cortisol breakdown in critically ill patients as the main contributor to elevated cortisol levels calls for better-designed studies to explore the optimal evaluation and treatment of adrenal insufficiency in critically ill patients.

ABBREVIATIONS: ACTH = adrenocorticotropic hormone; AI = adrenal insufficiency; CBG = corticosteroid-binding globulin; CORTICUS = Corticosteroid Therapy of Septic Shock; CRH = corticotropin-releasing hormone; CST = cosyntropin stimulation test; GC = glucocorticoid; GR = glucocorticoid receptor; HPA = hypothalamic-pituitary-adrenal; IL = interleukin; RAI = relative adrenal insufficiency.

Original languageEnglish (US)
Pages (from-to)716-725
Number of pages10
JournalEndocrine practice : official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists
Volume23
Issue number6
DOIs
StatePublished - Jun 1 2017

Fingerprint

Adrenal Insufficiency
Critical Illness
Hydrocortisone
Cosyntropin
Septic Shock
Adrenocorticotropic Hormone
Serum
Transcortin
Calcium Gluconate
Interleukins
Corticotropin-Releasing Hormone
Glucocorticoid Receptors
Resuscitation
Glucocorticoids
Carrier Proteins
Adrenal Cortex Hormones
Reference Values
Therapeutics

ASJC Scopus subject areas

  • Endocrinology, Diabetes and Metabolism
  • Endocrinology

Cite this

@article{fcde28cef6ca463daea173344ef70c92,
title = "EVALUATION AND MANAGEMENT OF ADRENAL INSUFFICIENCY IN CRITICALLY ILL PATIENTS: DISEASE STATE REVIEW",
abstract = "OBJECTIVE: The definition of normal adrenal function in critically ill patients remains controversial, despite a large body of literature. We review the clinical presentation, diagnosis, and treatment of adrenal insufficiency in critically ill patients and discuss the authors' personal approach to patient management.METHODS: Extensive literature review, guidelines from professional societies, and personal experience.RESULTS: A decrease in cortisol breakdown rather than an increase in cortisol production has been suggested as the main contributor to elevated cortisol levels in critically ill patients. The concept of relative adrenal insufficiency has multiple pathophysiologic flaws and is not supported by current evidence. Patients with septic shock who are pressor dependent or refractory to fluid resuscitation may receive a short course of hydrocortisone regardless of their serum cortisol levels or their response to a cosyntropin stimulation test (CST). Patients without septic shock who are suspected to have adrenal insufficiency should have their random cortisol levels measured. In patients with low and near-normal cortisol-binding proteins, a serum cortisol of <10 or 15 μg/dL, respectively, may trigger need for glucocorticoid treatment. Assays of free cortisol levels offer an advantage over total cortisol levels in patients with low binding proteins. Most critically ill patients have a normal random free cortisol level of >1.8 μg/dL, although further studies are needed to define a normal range in critically ill patients based on both severity and duration of illness. A CST may be used to further evaluate adrenal function in patients without septic shock who have borderline random serum or free cortisol levels.CONCLUSION: Evaluation of adrenal function in critically ill patients is complex. Recent findings of decreased cortisol breakdown in critically ill patients as the main contributor to elevated cortisol levels calls for better-designed studies to explore the optimal evaluation and treatment of adrenal insufficiency in critically ill patients.ABBREVIATIONS: ACTH = adrenocorticotropic hormone; AI = adrenal insufficiency; CBG = corticosteroid-binding globulin; CORTICUS = Corticosteroid Therapy of Septic Shock; CRH = corticotropin-releasing hormone; CST = cosyntropin stimulation test; GC = glucocorticoid; GR = glucocorticoid receptor; HPA = hypothalamic-pituitary-adrenal; IL = interleukin; RAI = relative adrenal insufficiency.",
author = "{AACE Adrenal Scientific Committee} and Hamrahian, {Amir H.} and Maria Fleseriu",
year = "2017",
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doi = "10.4158/EP161720.RA",
language = "English (US)",
volume = "23",
pages = "716--725",
journal = "Endocrine Practice",
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publisher = "American Association of Clinical Endocrinology",
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AU - AACE Adrenal Scientific Committee

AU - Hamrahian, Amir H.

AU - Fleseriu, Maria

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N2 - OBJECTIVE: The definition of normal adrenal function in critically ill patients remains controversial, despite a large body of literature. We review the clinical presentation, diagnosis, and treatment of adrenal insufficiency in critically ill patients and discuss the authors' personal approach to patient management.METHODS: Extensive literature review, guidelines from professional societies, and personal experience.RESULTS: A decrease in cortisol breakdown rather than an increase in cortisol production has been suggested as the main contributor to elevated cortisol levels in critically ill patients. The concept of relative adrenal insufficiency has multiple pathophysiologic flaws and is not supported by current evidence. Patients with septic shock who are pressor dependent or refractory to fluid resuscitation may receive a short course of hydrocortisone regardless of their serum cortisol levels or their response to a cosyntropin stimulation test (CST). Patients without septic shock who are suspected to have adrenal insufficiency should have their random cortisol levels measured. In patients with low and near-normal cortisol-binding proteins, a serum cortisol of <10 or 15 μg/dL, respectively, may trigger need for glucocorticoid treatment. Assays of free cortisol levels offer an advantage over total cortisol levels in patients with low binding proteins. Most critically ill patients have a normal random free cortisol level of >1.8 μg/dL, although further studies are needed to define a normal range in critically ill patients based on both severity and duration of illness. A CST may be used to further evaluate adrenal function in patients without septic shock who have borderline random serum or free cortisol levels.CONCLUSION: Evaluation of adrenal function in critically ill patients is complex. Recent findings of decreased cortisol breakdown in critically ill patients as the main contributor to elevated cortisol levels calls for better-designed studies to explore the optimal evaluation and treatment of adrenal insufficiency in critically ill patients.ABBREVIATIONS: ACTH = adrenocorticotropic hormone; AI = adrenal insufficiency; CBG = corticosteroid-binding globulin; CORTICUS = Corticosteroid Therapy of Septic Shock; CRH = corticotropin-releasing hormone; CST = cosyntropin stimulation test; GC = glucocorticoid; GR = glucocorticoid receptor; HPA = hypothalamic-pituitary-adrenal; IL = interleukin; RAI = relative adrenal insufficiency.

AB - OBJECTIVE: The definition of normal adrenal function in critically ill patients remains controversial, despite a large body of literature. We review the clinical presentation, diagnosis, and treatment of adrenal insufficiency in critically ill patients and discuss the authors' personal approach to patient management.METHODS: Extensive literature review, guidelines from professional societies, and personal experience.RESULTS: A decrease in cortisol breakdown rather than an increase in cortisol production has been suggested as the main contributor to elevated cortisol levels in critically ill patients. The concept of relative adrenal insufficiency has multiple pathophysiologic flaws and is not supported by current evidence. Patients with septic shock who are pressor dependent or refractory to fluid resuscitation may receive a short course of hydrocortisone regardless of their serum cortisol levels or their response to a cosyntropin stimulation test (CST). Patients without septic shock who are suspected to have adrenal insufficiency should have their random cortisol levels measured. In patients with low and near-normal cortisol-binding proteins, a serum cortisol of <10 or 15 μg/dL, respectively, may trigger need for glucocorticoid treatment. Assays of free cortisol levels offer an advantage over total cortisol levels in patients with low binding proteins. Most critically ill patients have a normal random free cortisol level of >1.8 μg/dL, although further studies are needed to define a normal range in critically ill patients based on both severity and duration of illness. A CST may be used to further evaluate adrenal function in patients without septic shock who have borderline random serum or free cortisol levels.CONCLUSION: Evaluation of adrenal function in critically ill patients is complex. Recent findings of decreased cortisol breakdown in critically ill patients as the main contributor to elevated cortisol levels calls for better-designed studies to explore the optimal evaluation and treatment of adrenal insufficiency in critically ill patients.ABBREVIATIONS: ACTH = adrenocorticotropic hormone; AI = adrenal insufficiency; CBG = corticosteroid-binding globulin; CORTICUS = Corticosteroid Therapy of Septic Shock; CRH = corticotropin-releasing hormone; CST = cosyntropin stimulation test; GC = glucocorticoid; GR = glucocorticoid receptor; HPA = hypothalamic-pituitary-adrenal; IL = interleukin; RAI = relative adrenal insufficiency.

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