Critical illness-related corticosteroid insufficiency laboratory findings: Difference between revisions
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==Overview== | ==Overview== | ||
The exact diagnostic tests and cut-off values to diagnose critical illness-related corticosteroid insufficiency are not agreed upon.<ref>http://www.ncbi.nlm.nih.gov/pubmed?term=18496365"</ref> 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 | The exact diagnostic tests and cut-off values to diagnose critical illness-related corticosteroid insufficiency are not agreed upon.<ref>http://www.ncbi.nlm.nih.gov/pubmed?term=18496365"</ref> 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<ref> name=http://www.ncbi.nlm.nih.gov/pubmed?term=18695699</ref>. 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.<ref> name=http://www.ncbi.nlm.nih.gov/pubmed?term=18695699</ref> Moreover, in patients who's adrenals are already maximally stimulated, a stimulation test would not be informative.<ref> name=http://www.ncbi.nlm.nih.gov/pubmed?term=18695699</ref> Furthermore, a short test might not adequately assess response to the chronic stress of critical illness.<ref> name=http://www.ncbi.nlm.nih.gov/pubmed?term=18695699</ref> | ||
==Laboratory Findings== | ==Laboratory Findings== |
Revision as of 15:52, 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.[3] Moreover, in patients who's adrenals are already maximally stimulated, a stimulation test would not be informative.[4] Furthermore, a short test might not adequately assess response to the chronic stress of critical illness.[5]
Laboratory Findings
Several blood test abnormalities can suggest corticosteroid insufficiency, such as hypoglycaemia, hyponatremia, hyperkalemia, hypercalcemia, neutropenia, eosinophilia, hyperprolactinemia and hypothyroidism.[6]
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.[7] 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.[8] In the CORTICUS study, ACTH stimulation testing predicted mortality whereas baseline cortisol levels did not.[9] However, possible benefits of corticosteroid therapy do not seem to be completely predicted by ACTH stimulation testing.[10][11] For these reasons, guidelines currently do not recommend that ACTH stimulation testing should guide the decision whether or not to administer corticosteroids.[12][13] Cortisol immunoassays on the other hand have been shown to be prone to both over- and underestimation.[14]
References
- ↑ http://www.ncbi.nlm.nih.gov/pubmed?term=18496365"
- ↑ name=http://www.ncbi.nlm.nih.gov/pubmed?term=18695699
- ↑ name=http://www.ncbi.nlm.nih.gov/pubmed?term=18695699
- ↑ name=http://www.ncbi.nlm.nih.gov/pubmed?term=18695699
- ↑ name=http://www.ncbi.nlm.nih.gov/pubmed?term=18695699
- ↑ 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
- ↑ name=http://www.ncbi.nlm.nih.gov/pubmed?term=18158437