Occult Adrenal Dysfunction in Hypotensive ED Patients
ABSTRACT & COMMENTARY
Source: Rivers EP, et al. Adrenal dysfunction in hemodynamically unstable patients in the emergency department. Acad Emerg Med 1999;6:626-630.
Adult patients who presented to the ed in shock (requiring vasopressor support after adequate fluid resuscitation) were included in this prospective study. Shock was defined as a mean arterial pressure less than or equal to 60 mmHg; adequate fluid resuscitation was defined as either a central venous pressure of 12-15 mmHg or administration of at least 40 cc/kg of volume resuscitation. Patients with trauma, hemorrhage, AIDS, or reported steroid use within the last six months were excluded. All patients received an a corticotropin ACTH stimulation test, with serum cortisol levels obtained at 0, 30, and 60 minutes. The referenced criterion standard for classification of adrenal insufficiency in the face of shock that was employed was a random serum cortisol of less than 20 mcg/dL. Patients were classified as having functional hypoadrenalism by the following referenced criterion standards: a combination of a random serum cortisol greater than or equal to 20 mcg/dL plus a 60-minute serum cortisol of less than 30 mcg/dL or a delta cortisol (60-minute level minus baseline level) of less than or equal to 9 mcg/dL.
Of the 57 enrolled patients meeting eligibility criteria, eight (14%) were found to have adrenal insufficiency. Of the remaining 49 patients, another three (5%) met criteria for functional hypoadrenalism. Overall mortality was high for all study patients (51%); there was no significant difference in mortality between patients with adrenal insufficiency and those with preserved adrenal function (P = 0.052). Interestingly, seven of eight (86%) patients with adrenal insufficiency survived, whereas only 21 of 46 (46%) with intact adrenal function survived; the authors noted that cortisol levels were made available to treating physicians to guide patient management, but do not report who did and did not receive glucocorticoid supplementation. Rivers et al concluded that 19% of ED patients meeting their criteria for shock have adrenal dysfunction. They deferred comment on therapeutic glucocorticoid replacement, since that was not specifically investigated.
Comment by Richard A. Harrigan, MD, FAAEM, FACEP
The diagnosis of adrenal insufficiency is difficult, because all the signs and symptoms of the entity are nonspecific, and the confirmatory laboratory tests are not available emergently.1 Why are 19% of these patients meeting criteria for adrenal dysfunction? Rivers et al explored this, reporting that plasma ACTH levels were at the low end of normal in a subgroup with adrenal insufficiency (4 of the 8 had ACTH levels), which may reflect hypothalamic-pituitary axis suppression. Only one of three patients with functional hypoadrenalism had an ACTH level obtained, and it was very high, perhaps reflecting true adrenal gland failure. The authors hypothesized that shock may actually cause the adrenal failure due to decreased perfusion, creating a "chicken-and-egg" dilemma: does the adrenal dysfunction cause the shock, or does the shock cause the adrenal dysfunction? They also reminded us that inflammatory mediators have been shown to decrease corticotropin-releasing hormone, which would lead to hypothalamic-pituitary axis suppression. Secondary adrenal failure due to exogenous steroid therapy may still have played a role in these patients, despite the exclusion criteria. Although patients reporting steroid therapy within the previous six months were excluded, these would be the toughest patients from whom to reliably obtain that history due to their critical illness. Some have suggested that anyone on long-term steroid therapy within the last 12 months can develop adrenal insufficiency when stressed.2
References
1. Krasner AS. Glucocorticoid-induced adrenal insufficiency. JAMA 1999;282:671-676.
2. Leshin M. Acute adrenal insufficiency: Recognition, management, and prevention. Urol Clin North Am 1982;9:229-235.
In the study by Rivers et al on adrenal dysfunction in ED patients:
a. most patients had adrenal failure due inadequate steroid tapers within the last six months.
b. most patients had adrenal failure due to inadequate steroid tapers within the last 12 months.
c. most patients with adrenal failure responded well to dexamethasone administered in the ED.
d. a random cortisol level of less than 20 mcg/dL served as the definition of adrenal insufficiency for patients in shock.
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