Critical illness-related corticosteroid insufficiency laboratory findings: Difference between revisions
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Several [[blood test]] abnormalities can suggest corticosteroid insufficiency, such as [[hypoglycaemia]], [[hyponatremia]], [[hyperkalemia]], [[hypercalcemia]], [[neutropenia]], [[eosinophilia]], [[hyperprolactinemia]] and [[hypothyroidism]].<ref>http://www.ncbi.nlm.nih.gov/pubmed?term=18695699</ref> | Several [[blood test]] abnormalities can suggest corticosteroid insufficiency, such as [[hypoglycaemia]], [[hyponatremia]], [[hyperkalemia]], [[hypercalcemia]], [[neutropenia]], [[eosinophilia]], [[hyperprolactinemia]] and [[hypothyroidism]].<ref>http://www.ncbi.nlm.nih.gov/pubmed?term=18695699</ref> | ||
Both random total cortisol levels, total cortisol levels or increment after ACTH stimulation tests, free cortisol levels, or a combination of these have been proposed as diagnostic tests. Other stimulation tests for adrenal insufficiency which are used in non-critical patients, such as the test using [[metyrapone]] or a test which employs [[insulin]] to induce [[hypoglycemia]], are not preferred for CIRCI.<ref name="pmid18695699"/> Both a metyrapone-induced decrease in cortisol and hypoglycemia are potentially harmful to intensive care patients. The exact dose of ACTH remains a matter of debate.<ref name="pmid15886236">{{cite journal |author=Widmer IE, Puder JJ, König C, ''et al'' |title=Cortisol response in relation to the severity of stress and illness |journal=J. Clin. Endocrinol. Metab. |volume=90 |issue=8 |pages=4579–86 |year=2005 |month=August |pmid=15886236 |doi=10.1210/jc.2005-0354 |url=http://jcem.endojournals.org/cgi/pmidlookup?view=long&pmid=15886236}}</ref> In the CORTICUS study, ACTH stimulation testing predicted mortality whereas baseline cortisol levels did not.<ref name="pmid17334243">{{cite journal |author=Lipiner-Friedman D, Sprung CL, Laterre PF, ''et al'' |title=Adrenal function in sepsis: the retrospective Corticus cohort study |journal=Crit. Care Med. |volume=35 |issue=4 |pages=1012–8 |year=2007 |month=April |pmid=17334243 |doi=10.1097/01.CCM.0000259465.92018.6E |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?doi=10.1097/01.CCM.0000259465.92018.6E}}</ref> However, possible benefits of corticosteroid therapy do not seem to be completely predicted by ACTH stimulation testing.<ref name="pmid18184957">{{cite journal |author=Sprung CL, Annane D, Keh D, ''et al'' |title=Hydrocortisone therapy for patients with septic shock |journal=N. Engl. J. Med. |volume=358 |issue=2 |pages=111–24 |year=2008 |month=January |pmid=18184957 |doi=10.1056/NEJMoa071366 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=18184957&promo=ONFLNS19}}</ref><ref name="pmid12186604">{{cite journal |author=Annane D, Sébille V, Charpentier C, ''et al'' |title=Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock |journal=JAMA |volume=288 |issue=7 |pages=862–71 |year=2002 |month=August |pmid=12186604 |doi= |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=12186604}}</ref> For these reasons, guidelines currently do not recommend that ACTH stimulation testing should guide the decision whether or not to administer corticosteroids.<ref> name=http://www.ncbi.nlm.nih.gov/pubmed?term=18158437</ref><ref name="pmid18158437"/> Cortisol [[immunoassays]] on the other hand have been shown to be prone to both over- and underestimation.<ref> name=http://www.ncbi.nlm.nih.gov/pubmed?term=18158437<ref | Both random total cortisol levels, total cortisol levels or increment after ACTH stimulation tests, free cortisol levels, or a combination of these have been proposed as diagnostic tests. Other stimulation tests for adrenal insufficiency which are used in non-critical patients, such as the test using [[metyrapone]] or a test which employs [[insulin]] to induce [[hypoglycemia]], are not preferred for CIRCI.<ref name="pmid18695699"/> Both a metyrapone-induced decrease in cortisol and hypoglycemia are potentially harmful to intensive care patients. The exact dose of ACTH remains a matter of debate.<ref name="pmid15886236">{{cite journal |author=Widmer IE, Puder JJ, König C, ''et al'' |title=Cortisol response in relation to the severity of stress and illness |journal=J. Clin. Endocrinol. Metab. |volume=90 |issue=8 |pages=4579–86 |year=2005 |month=August |pmid=15886236 |doi=10.1210/jc.2005-0354 |url=http://jcem.endojournals.org/cgi/pmidlookup?view=long&pmid=15886236}}</ref> In the CORTICUS study, ACTH stimulation testing predicted mortality whereas baseline cortisol levels did not.<ref name="pmid17334243">{{cite journal |author=Lipiner-Friedman D, Sprung CL, Laterre PF, ''et al'' |title=Adrenal function in sepsis: the retrospective Corticus cohort study |journal=Crit. Care Med. |volume=35 |issue=4 |pages=1012–8 |year=2007 |month=April |pmid=17334243 |doi=10.1097/01.CCM.0000259465.92018.6E |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?doi=10.1097/01.CCM.0000259465.92018.6E}}</ref> However, possible benefits of corticosteroid therapy do not seem to be completely predicted by ACTH stimulation testing.<ref name="pmid18184957">{{cite journal |author=Sprung CL, Annane D, Keh D, ''et al'' |title=Hydrocortisone therapy for patients with septic shock |journal=N. Engl. J. Med. |volume=358 |issue=2 |pages=111–24 |year=2008 |month=January |pmid=18184957 |doi=10.1056/NEJMoa071366 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=18184957&promo=ONFLNS19}}</ref><ref name="pmid12186604">{{cite journal |author=Annane D, Sébille V, Charpentier C, ''et al'' |title=Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock |journal=JAMA |volume=288 |issue=7 |pages=862–71 |year=2002 |month=August |pmid=12186604 |doi= |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=12186604}}</ref> For these reasons, guidelines currently do not recommend that ACTH stimulation testing should guide the decision whether or not to administer corticosteroids.<ref> name=http://www.ncbi.nlm.nih.gov/pubmed?term=18158437</ref><ref name="pmid18158437"/> Cortisol [[immunoassays]] on the other hand have been shown to be prone to both over- and underestimation.<ref> name=http://www.ncbi.nlm.nih.gov/pubmed?term=18158437</ref> | ||
==References== | ==References== |
Revision as of 15:48, 20 September 2012
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
The exact diagnostic tests and cut-off values to diagnose critical illness-related corticosteroid insufficiency are not agreed upon.[1] This also applies to the distinction between absolute and relative adrenal insufficiency, a reason why the term critical illness–related corticosteroid insufficiency is preferred to relative adrenal insufficiency.[2] The variation in cortisol levels according to disease type and severity, as well as variation within the same patient, hampers the establishment of a clear threshold below which CIRCI occurs.[2] Moreover, in patients who's adrenals are already maximally stimulated, a stimulation test would not be informative.[3] Furthermore, a short test might not adequately assess response to the chronic stress of critical illness.[2]
Laboratory Findings
Several blood test abnormalities can suggest corticosteroid insufficiency, such as hypoglycaemia, hyponatremia, hyperkalemia, hypercalcemia, neutropenia, eosinophilia, hyperprolactinemia and hypothyroidism.[4]
Both random total cortisol levels, total cortisol levels or increment after ACTH stimulation tests, free cortisol levels, or a combination of these have been proposed as diagnostic tests. Other stimulation tests for adrenal insufficiency which are used in non-critical patients, such as the test using metyrapone or a test which employs insulin to induce hypoglycemia, are not preferred for CIRCI.[2] Both a metyrapone-induced decrease in cortisol and hypoglycemia are potentially harmful to intensive care patients. The exact dose of ACTH remains a matter of debate.[5] In the CORTICUS study, ACTH stimulation testing predicted mortality whereas baseline cortisol levels did not.[6] However, possible benefits of corticosteroid therapy do not seem to be completely predicted by ACTH stimulation testing.[7][8] For these reasons, guidelines currently do not recommend that ACTH stimulation testing should guide the decision whether or not to administer corticosteroids.[9][10] Cortisol immunoassays on the other hand have been shown to be prone to both over- and underestimation.[11]
References
- ↑ http://www.ncbi.nlm.nih.gov/pubmed?term=18496365"
- ↑ 2.0 2.1 2.2 2.3
- ↑ name="pmid18695699"
- ↑ http://www.ncbi.nlm.nih.gov/pubmed?term=18695699
- ↑ Widmer IE, Puder JJ, König C; et al. (2005). "Cortisol response in relation to the severity of stress and illness". J. Clin. Endocrinol. Metab. 90 (8): 4579–86. doi:10.1210/jc.2005-0354. PMID 15886236. Unknown parameter
|month=
ignored (help) - ↑ Lipiner-Friedman D, Sprung CL, Laterre PF; et al. (2007). "Adrenal function in sepsis: the retrospective Corticus cohort study". Crit. Care Med. 35 (4): 1012–8. doi:10.1097/01.CCM.0000259465.92018.6E. PMID 17334243. Unknown parameter
|month=
ignored (help) - ↑ Sprung CL, Annane D, Keh D; et al. (2008). "Hydrocortisone therapy for patients with septic shock". N. Engl. J. Med. 358 (2): 111–24. doi:10.1056/NEJMoa071366. PMID 18184957. Unknown parameter
|month=
ignored (help) - ↑ Annane D, Sébille V, Charpentier C; et al. (2002). "Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock". JAMA. 288 (7): 862–71. PMID 12186604. Unknown parameter
|month=
ignored (help) - ↑ name=http://www.ncbi.nlm.nih.gov/pubmed?term=18158437
- ↑
- ↑ name=http://www.ncbi.nlm.nih.gov/pubmed?term=18158437