1
|
Mehra M, Sachdeva M, Dayal S, Gupta A, Deswal M. Addisonian pigmentation associated with acute lymphoblastic leukemia: A rare paraneoplastic phenomenon. Pediatr Dermatol 2023; 40:1112-1114. [PMID: 37160270 DOI: 10.1111/pde.15341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 04/18/2023] [Indexed: 05/11/2023]
Abstract
Addisonian pigmentation usually presents with nonspecific symptoms and signs, which are often ignored or misdiagnosed as a sign of other more common diseases. We present a case of 12-year-old child in whom diffuse Addisonian hyperpigmentation of skin was associated with underlying acute lymphoblastic leukemia (B-type), a rare paraneoplastic phenomenon in hematological malignancies.
Collapse
Affiliation(s)
- Mani Mehra
- Department of Dermatology, Pandit Bhagwat Dayal Sharma Postgraduate Institute of Medical Sciences, Rohtak, India
| | - Meenakshi Sachdeva
- Department of Dermatology, Pandit Bhagwat Dayal Sharma Postgraduate Institute of Medical Sciences, Rohtak, India
| | - Surabhi Dayal
- Department of Dermatology, Pandit Bhagwat Dayal Sharma Postgraduate Institute of Medical Sciences, Rohtak, India
| | - Aanchal Gupta
- Department of Pathology, Pandit Bhagwat Dayal Sharma Postgraduate Institute of Medical Sciences, Rohtak, India
| | - Monica Deswal
- Department of Pediatrics, Pandit Bhagwat Dayal Sharma Postgraduate Institute of Medical Sciences, Rohtak, India
| |
Collapse
|
2
|
Tao Q, Liu S, Zhang J, Jiang J, Jin Z, Huang Y, Liu X, Lin S, Zeng X, Li X, Tao G, Chen H. Clinical applications of smart wearable sensors. iScience 2023; 26:107485. [PMID: 37636055 PMCID: PMC10448028 DOI: 10.1016/j.isci.2023.107485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023] Open
Abstract
Smart wearable sensors are electronic devices worn on the body that collect, process, and transmit various physiological data. Compared to traditional devices, their advantages in terms of portability and comfort have made them increasingly important in the medical field. This review takes a unique clinical physician's standpoint, diverging from conventional sensor-type-based classifications, and provides a comprehensive overview of the diverse clinical applications of wearable sensors in recent years. In this review, we categorize these applications according to different diseases, encompassing skin diseases and injuries, cardiovascular diseases, abnormal human motion, as well as endocrine and metabolic disorders. Additionally, we discuss the challenges and perspectives hindering the development of sensors for clinical use, emphasizing the critical need for interdisciplinary collaboration between medical and engineering professionals. Overall, this review would serve as an important reference for the future direction of sensor devices in clinical use.
Collapse
Affiliation(s)
- Qingxiao Tao
- Department of Dermatology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Suwen Liu
- Department of Dermatology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Jingyu Zhang
- Department of Dermatology, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen 518052, China
- Shenzhen University Medical School, Shenzhen 518060, China
| | - Jian Jiang
- Department of Dermatology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Zilin Jin
- Department of Dermatology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Yuqiong Huang
- Department of Dermatology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Xin Liu
- Department of Dermatology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Shiying Lin
- Department of Dermatology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Xin Zeng
- Department of Dermatology, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen 518052, China
| | - Xuemei Li
- Department of Dermatology, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen 518052, China
| | - Guangming Tao
- Wuhan National Laboratory for Optoelectronics, Huazhong University of Science and Technology, Wuhan 430074, China
- State Key Laboratory of Material Processing and Die & Mould Technology, School of Materials Science and Engineering, Huazhong University of Science and Technology, Wuhan 430074, China
| | - Hongxiang Chen
- Department of Dermatology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Department of Dermatology, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen 518052, China
| |
Collapse
|
3
|
Chen Cardenas SM, Santhanam P, Morris-Wiseman L, Salvatori R, Hamrahian AH. Perioperative Evaluation and Management of Patients on Glucocorticoids. J Endocr Soc 2022; 7:bvac185. [PMID: 36545644 PMCID: PMC9760550 DOI: 10.1210/jendso/bvac185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Indexed: 12/04/2022] Open
Abstract
Myriad questions regarding perioperative management of patients on glucocorticoids (GCs) continue to be debated including which patients are at risk for adrenal insufficiency (AI), what is the correct dose and duration of supplemental GCs, or are they necessary for everyone? These questions remain partly unanswered due to the heterogeneity and low quality of data, studies with small sample sizes, and the limited number of randomized trials. To date, we know that although all routes of GC administration can result in hypothalamic-pituitary-adrenal (HPA) axis suppression, perioperative adrenal crisis is rare. Correlation between biochemical testing for AI and clinical events is lacking. Some of the current perioperative management recommendations based on daily GC dose and duration of therapy may be difficult to follow in clinical practice. The prospective and retrospective studies consistently report that continuing the daily dose of GCs perioperatively is not associated with a higher risk for adrenal crises in patients with GC-induced AI. Considering that oral GC intake may be unreliable in the early postoperative period, providing the daily GC plus a short course of IV hydrocortisone 25 to 100 mg per day based on the degree of surgical stress seems reasonable. In patients who have stopped GC therapy before surgery, careful assessment of the HPA axis is necessary to avoid an adrenal crisis. In conclusion, our literature review indicates that lower doses and shorter duration of supplemental GCs perioperatively are sufficient to maintain homeostasis. We emphasize the need for well-designed randomized studies on this frequently encountered clinical scenario.
Collapse
Affiliation(s)
- Stanley M Chen Cardenas
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Prasanna Santhanam
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Lilah Morris-Wiseman
- Division of Endocrine Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Roberto Salvatori
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Amir H Hamrahian
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| |
Collapse
|
4
|
Jett L, Mooshian S, Anderson E. Acquired Systolic Dysfunction and Subsequent Congestive Heart Failure Following Treatment of Hypoadrenocorticism in Two Dogs. J Am Anim Hosp Assoc 2022; 58:297-302. [PMID: 36315864 DOI: 10.5326/jaaha-ms-7223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2021] [Indexed: 06/16/2023]
Abstract
Acquired cardiomyopathies have been described in human patients with hypoadrenocorticism. Several mechanisms have been described to explain the cardiac effects of primary adrenal insufficiency, but, clinically, these manifestations may be underappreciated in dogs. In humans, there is an infrequently described, reversible dilated cardiomyopathy in patients with hypoadrenocorticism. Two dogs were presented to a single referral center for evaluation of weakness or collapse and were subsequently diagnosed with hypoadrenocorticism after a full diagnostic workup. Following the diagnosis of hypoadrenocorticism and administration of glucocorticoids and desoxycorticosterone pivalate, both dogs developed left-sided congestive heart failure and had systolic dysfunction diagnosed by echocardiogram. Both dogs were euthanized; one because of recurrent congestive heart failure and another because of a concern for poor long-term prognosis and decreased quality of life. The purpose of this case report is to document multiple cases of hypoadrenocorticism-associated systolic dysfunction and subsequent cardiogenic pulmonary edema in dogs.
Collapse
Affiliation(s)
- Lindsey Jett
- From Pittsburgh Veterinary Specialty and Emergency Center, Pittsburgh, Pennsylvania (L.J., S.M.)
| | - Shaina Mooshian
- From Pittsburgh Veterinary Specialty and Emergency Center, Pittsburgh, Pennsylvania (L.J., S.M.)
| | - Erin Anderson
- Pittsburgh Veterinary Cardiology, Pittsburgh, Pennsylvania (E.A.)
| |
Collapse
|
5
|
Seo KH. Perioperative glucocorticoid management based on current evidence. Anesth Pain Med (Seoul) 2021; 16:8-15. [PMID: 33445232 DOI: 10.17085/apm.20089] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 11/30/2020] [Indexed: 01/04/2023] Open
Abstract
Glucocorticoid preparations, adreno-cortical steroids, with strong anti-inflammatory and immunosuppressive effects, are widely used for treating various diseases. The number of patients exposed to steroid therapy prior to surgery is increasing. When these patients present for surgery, the anesthesiologist must decide whether to administer perioperative steroid supplementation. Stress-dose glucocorticoid administration is required during the perioperative period because of the possibility of failure of cortisol secretion to cope with the increased cortisol requirement due to surgical stress, adrenal insufficiency, hemodynamic instability, and the possibility of adrenal crisis. Therefore, glucocorticoids should be supplemented at the same level as that of normal physiological response to surgical stress by evaluating the invasiveness of surgery and inhibition of the hypothalamus-pituitary-adrenal axis. Various textbooks and research articles recommend the stress-dose of glucocorticoids during perioperative periods. It has been commonly suggested that glucocorticoids should be administered in an amount equivalent to about 100 mg of cortisol for major surgery because it induces approximately 5 times the normal secretion. However, more studies, with appropriate power, regarding the administration of stress-dose glucocorticoids are still required, and evaluation of patients with possible adrenal insufficiency and appropriate glucocorticoid administration based on surgical stress will help improve the prognosis.
Collapse
Affiliation(s)
- Kwon Hui Seo
- Department of Anesthesiology and Pain Medicine, Hallym University Sacred Heart Hospital, Hallym University School of Medicine, Anyang, Korea
| |
Collapse
|
6
|
Prognostic Value of Relative Adrenal Insufficiency During Cardiogenic Shock: A Prospective Cohort Study With Long-Term Follow-Up. Shock 2018; 47:86-92. [PMID: 27984534 DOI: 10.1097/shk.0000000000000710] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Relative adrenal insufficiency (RAI) is common in intensive care unit patients, particularly during septic shock (SS). Cardiogenic shock (CS) may share some pathophysiological features with SS. The aim of this study was to evaluate the prevalence and long-term prognosis of RAI during CS. PATIENTS AND METHODS Prospective observational study conducted in the intensive care and cardiology units in one university hospital in France. Patients meeting the criteria for CS without prior corticosteroid therapy were included. Total blood cortisol levels were assessed immediately before (T0) a short corticotropin stimulation test (0.25 mg i.v. of tetracosactrin) and 30 and 60 min afterward. Δmax was defined as the difference between the maximal value after the test and T0. RESULTS Of the 92 patients enrolled, 42 (46%) (95% confidence interval [CI] [36%-56%]) died in hospital and 7 more died during a median follow-up of 616 [57-2,498] days, for an overall mortality rate of 53% (95% CI [43%-63%]). Three groups were identified based on the corticotropin test: group 1 (T0 ≤798 nmol/L and Δmax >473 nmol/L), group 2 ([T0 >798 nmol/L and Δmax >473 nmol/L] or [T0 ≤798 nmol/L and Δmax ≤473 nmol/L]), and group 3 (T0 >798 nmol/L and Δmax ≤473 nmol/L) with an overall survival of 76%, 43%, and 15%, respectively (log rank P = 0.003). In the multivariable analysis, adrenal nonresponse (group 3) was an independent predictor of mortality (P = 0.04), along with left ventricular ejection fraction, Simplified Acute Physiology Score II, and cardiac arrest. CONCLUSIONS These data suggest that a short corticotropin test has a good prognostic value in CS and allows identifying patients at higher risk of death.
Collapse
|
7
|
Aissa I, Meziane M, El Koundi A, Bensghir M, Siah S, Alaoui SJ. Refractory collapse and severe burn: Think about acute adrenal insufficiency. Am J Emerg Med 2018; 36:733.e1-733.e2. [PMID: 29306651 DOI: 10.1016/j.ajem.2017.12.066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 12/28/2017] [Accepted: 12/28/2017] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Adrenal insufficiency (AI) is a rare endocrine disorder, which can in its acute form be life-threatening in case of late diagnosis or treatment. The stress during a thermal burn can easily decompensate the AI. We report the case of an acute adrenal insufficiency (AAI) discovered following a refractory collapse occurred after a severe thermal burn. CASE PRESENTATION A 60-year-old woman was accidentally burned to the lower limbs by hot water. Total burn surface area was 36 %. The patient had local care and dressings, vascular filling, and analgesics. Four hours later, she became dyspneic, and presented tachycardia associated with collapse at 60/40mmHg. Suspecting a hypovolemic origin, we performed a solid fluid replacement with colloids. However, hemodynamic stability was not achieved and motivated a continuous injection of norepinephrine. Despite high doses, immediate evolution was marked by a persistent precarious hemodynamic state. AAI was suspected, and a substitutive hormonotherapy was started. The clinical condition progressively improved and catecholamines were quickly stopped. CONCLUSION AAI is a vital emergency. The large burn is a possible cause of the AI decompensation. This diagnosis must be kept in mind when the hemodynamic status remains unstable despite an adequate vascular treatment.
Collapse
Affiliation(s)
- Ismail Aissa
- Department of Anesthesiology and Intensive Care, Military Hospital Med V, Faculty of Medicine and Pharmacy of Rabat, University Souissi-Med V, Rabat, Morocco.
| | - Mohammed Meziane
- Department of Anesthesiology and Intensive Care, Military Hospital Med V, Faculty of Medicine and Pharmacy of Rabat, University Souissi-Med V, Rabat, Morocco
| | - Abdelghafour El Koundi
- Department of Anesthesiology and Intensive Care, Military Hospital Med V, Faculty of Medicine and Pharmacy of Rabat, University Souissi-Med V, Rabat, Morocco
| | - Mustapha Bensghir
- Department of Anesthesiology and Intensive Care, Military Hospital Med V, Faculty of Medicine and Pharmacy of Rabat, University Souissi-Med V, Rabat, Morocco
| | - Samir Siah
- Department of Anesthesiology and Intensive Care, Military Hospital Med V, Faculty of Medicine and Pharmacy of Rabat, University Souissi-Med V, Rabat, Morocco
| | - Salim Jaafar Alaoui
- Department of Anesthesiology and Intensive Care, Military Hospital Med V, Faculty of Medicine and Pharmacy of Rabat, University Souissi-Med V, Rabat, Morocco
| |
Collapse
|
8
|
Cortet C, Barat P, Zenaty D, Guignat L, Chanson P. Group 5: Acute adrenal insufficiency in adults and pediatric patients. ANNALES D'ENDOCRINOLOGIE 2017; 78:535-543. [DOI: 10.1016/j.ando.2017.10.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
9
|
Dimarakis I, Shaw S, Venkateswaran R. Durable left ventricular assist device as a bridge to recovery for addisonian crisis related cardiomyopathy. J Card Surg 2017; 32:665-666. [PMID: 28895194 DOI: 10.1111/jocs.13209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
A 19-year-old female with addisonian crisis-related cardiomyopathy underwent temporary mechanical circulatory support followed by insertion of a durable left ventricular assist device. Successful device explanation was possible 2.5 years following implantation.
Collapse
Affiliation(s)
- Ioannis Dimarakis
- Department of Cardiothoracic Surgery, Wythenshawe Hospital, Manchester, United Kingdom
| | - Steven Shaw
- Department of Cardiothoracic Surgery, Wythenshawe Hospital, Manchester, United Kingdom
| | | |
Collapse
|
10
|
Fujii K, Miyashita K, Kurihara I, Hiratsuka K, Sato S, Yokota K, Kobayashi S, Shibata H, Itoh H. Adrenal Insufficiency under Standard Dosage of Glucocorticoid Replacement after Unilateral Adrenalectomy for Cushing's Syndrome. Case Rep Endocrinol 2016; 2016:2347528. [PMID: 27375907 PMCID: PMC4914725 DOI: 10.1155/2016/2347528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 05/08/2016] [Indexed: 11/17/2022] Open
Abstract
Glucocorticoid replacement is needed for patients after adrenal surgery for Cushing's syndrome; however, the adequate dosage is not easily determined. The patient was a 62-year-old woman who has had hypertension for 5 years and presented with heart failure due to hypertrophic cardiomyopathy. She consulted with us because of general fatigue, facial edema, and muscle weakness and was diagnosed with Cushing's syndrome. A laparoscopic left adrenalectomy was performed, standard dosage of postoperative replacement was administered, and she was discharged with 30 mg/day of hydrocortisone (cortisol). However, she suffered from loss of appetite and was transferred to an emergency unit with the symptoms of adrenal insufficiency on postoperative day 15. After initial hydrocortisone replacement with 200 mg/day, the dosage was gradually decreased during hospitalization; however, reduction of hydrocortisone dosage lower than 60 mg/day was difficult because of nausea and fatigue. Her circadian cortisol profile after hydrocortisone administration showed delayed and lowered peaks, which suggested that hydrocortisone absorption in the intestine was impaired. Therefore, complicated heart failure may have led to the adrenal insufficiency in the patient. In such cases, we should consider postoperative administration of more than the standard dosage of hydrocortisone to avoid adrenal insufficiency after surgery for Cushing's syndrome.
Collapse
Affiliation(s)
- Kentaro Fujii
- Department of Internal Medicine, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Kazutoshi Miyashita
- Department of Internal Medicine, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Isao Kurihara
- Department of Internal Medicine, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Ken Hiratsuka
- Department of Internal Medicine, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Seiji Sato
- Department of Internal Medicine, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Kenichi Yokota
- Department of Internal Medicine, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Sakiko Kobayashi
- Department of Internal Medicine, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Hirotaka Shibata
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology, Faculty of Medicine, Oita University, 700 Dannoharu, Oita 870-1192, Japan
| | - Hiroshi Itoh
- Department of Internal Medicine, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| |
Collapse
|
11
|
Hyland KA, Altman DS, Perkins JM. Reversible Heart Failure as a Result of Newly Diagnosed Primary Adrenal Insufficiency. AACE Clin Case Rep 2016. [DOI: 10.4158/ep15835.cr] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
12
|
Abstract
Pituitary apoplexy, a rare clinical syndrome secondary to abrupt hemorrhage or infarction, complicates 2%-12% of pituitary adenomas, especially nonfunctioning tumors. Headache of sudden and severe onset is the main symptom, sometimes associated with visual disturbances or ocular palsy. Signs of meningeal irritation or altered consciousness may complicate the diagnosis. Precipitating factors (increase in intracranial pressure, arterial hypertension, major surgery, anticoagulant therapy or dynamic testing, etc) may be identified. Corticotropic deficiency with adrenal insufficiency may be life threatening if left untreated. Computed tomography or magnetic resonance imaging confirms the diagnosis by revealing a pituitary tumor with hemorrhagic and/or necrotic components. Formerly considered a neurosurgical emergency, pituitary apoplexy always used to be treated surgically. Nowadays, conservative management is increasingly used in selected patients (those without important visual acuity or field defects and with normal consciousness), because successive publications give converging evidence that a wait-and-see approach may also provide excellent outcomes in terms of oculomotor palsy, pituitary function and subsequent tumor growth. However, it must be kept in mind that studies comparing surgical approach and conservative management were retrospective and not controlled.
Collapse
Affiliation(s)
- Claire Briet
- Service d'Endocrinologie et des Maladies de la Reproduction and Centre de Référence des Maladies Endocriniennes Rares de la Croissance (C.B., S.S., P.C.), Hôpital de Bicêtre, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre F94275, France; Service d'Endocrinologie (C.B.), Centre Hospitalier Universitaire d'Angers, Angers 49000, France; Service d'Endocrinologie (J.-F.B.), Centre Hospitalier Universitaire de Liège, Liège B4000, Belgium; Unité Mixte de Recherche S1185 (P.C.), Université Paris-Saclay, Université Paris-Sud; and Institut National de la Santé et de la Recherche Médicale Unité 1185, Faculté de Médecine Paris-Sud, Le Kremlin-Bicêtre F94276, France; and Neurosurgery, Harvard Medical School, Brigham and Women's Hospital (E.R.L.), Boston, Massachusetts 02115
| | - Sylvie Salenave
- Service d'Endocrinologie et des Maladies de la Reproduction and Centre de Référence des Maladies Endocriniennes Rares de la Croissance (C.B., S.S., P.C.), Hôpital de Bicêtre, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre F94275, France; Service d'Endocrinologie (C.B.), Centre Hospitalier Universitaire d'Angers, Angers 49000, France; Service d'Endocrinologie (J.-F.B.), Centre Hospitalier Universitaire de Liège, Liège B4000, Belgium; Unité Mixte de Recherche S1185 (P.C.), Université Paris-Saclay, Université Paris-Sud; and Institut National de la Santé et de la Recherche Médicale Unité 1185, Faculté de Médecine Paris-Sud, Le Kremlin-Bicêtre F94276, France; and Neurosurgery, Harvard Medical School, Brigham and Women's Hospital (E.R.L.), Boston, Massachusetts 02115
| | - Jean-François Bonneville
- Service d'Endocrinologie et des Maladies de la Reproduction and Centre de Référence des Maladies Endocriniennes Rares de la Croissance (C.B., S.S., P.C.), Hôpital de Bicêtre, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre F94275, France; Service d'Endocrinologie (C.B.), Centre Hospitalier Universitaire d'Angers, Angers 49000, France; Service d'Endocrinologie (J.-F.B.), Centre Hospitalier Universitaire de Liège, Liège B4000, Belgium; Unité Mixte de Recherche S1185 (P.C.), Université Paris-Saclay, Université Paris-Sud; and Institut National de la Santé et de la Recherche Médicale Unité 1185, Faculté de Médecine Paris-Sud, Le Kremlin-Bicêtre F94276, France; and Neurosurgery, Harvard Medical School, Brigham and Women's Hospital (E.R.L.), Boston, Massachusetts 02115
| | - Edward R Laws
- Service d'Endocrinologie et des Maladies de la Reproduction and Centre de Référence des Maladies Endocriniennes Rares de la Croissance (C.B., S.S., P.C.), Hôpital de Bicêtre, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre F94275, France; Service d'Endocrinologie (C.B.), Centre Hospitalier Universitaire d'Angers, Angers 49000, France; Service d'Endocrinologie (J.-F.B.), Centre Hospitalier Universitaire de Liège, Liège B4000, Belgium; Unité Mixte de Recherche S1185 (P.C.), Université Paris-Saclay, Université Paris-Sud; and Institut National de la Santé et de la Recherche Médicale Unité 1185, Faculté de Médecine Paris-Sud, Le Kremlin-Bicêtre F94276, France; and Neurosurgery, Harvard Medical School, Brigham and Women's Hospital (E.R.L.), Boston, Massachusetts 02115
| | - Philippe Chanson
- Service d'Endocrinologie et des Maladies de la Reproduction and Centre de Référence des Maladies Endocriniennes Rares de la Croissance (C.B., S.S., P.C.), Hôpital de Bicêtre, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre F94275, France; Service d'Endocrinologie (C.B.), Centre Hospitalier Universitaire d'Angers, Angers 49000, France; Service d'Endocrinologie (J.-F.B.), Centre Hospitalier Universitaire de Liège, Liège B4000, Belgium; Unité Mixte de Recherche S1185 (P.C.), Université Paris-Saclay, Université Paris-Sud; and Institut National de la Santé et de la Recherche Médicale Unité 1185, Faculté de Médecine Paris-Sud, Le Kremlin-Bicêtre F94276, France; and Neurosurgery, Harvard Medical School, Brigham and Women's Hospital (E.R.L.), Boston, Massachusetts 02115
| |
Collapse
|
13
|
Steroids: The Evidence. The Rationale for Perioperative Glucocorticoid Supplementation for Patients Under Chronic Steroid Treatment. CURRENT ANESTHESIOLOGY REPORTS 2015. [DOI: 10.1007/s40140-014-0093-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
14
|
Critical illness-related corticosteroid insufficiency in cirrhotic patients with acute gastroesophageal variceal bleeding: risk factors and association with outcome*. Crit Care Med 2015; 42:2546-55. [PMID: 25083978 DOI: 10.1097/ccm.0000000000000544] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Critical illness-related corticosteroid insufficiency can adversely influence the prognosis of critically ill patients. However, its impact on the outcomes of patients with cirrhosis and acute gastroesophageal variceal bleeding remains unknown. We evaluated adrenal function using short corticotropin stimulation test in patients with cirrhosis and gastroesophageal variceal bleeding. The main outcomes analyzed were 5-day treatment failure and 6-week mortality. DESIGN Prospective observational study. SETTING Ten-bed gastroenterology-specific medical ICU at a 3,613-bed university teaching hospital in Taiwan. PATIENTS Patients with liver cirrhosis and acute gastroesophageal variceal bleeding. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We evaluated adrenal function using short corticotropin stimulation test in 157 episodes of gastroesophageal variceal bleeding in 143 patients with cirrhosis. Critical illness-related corticosteroid insufficiency occurred in 29.9% of patients. The patients with critical illness-related corticosteroid insufficiency had higher rates of treatment failure and 6-week mortality (63.8% vs 10.9%, 42.6% vs 6.4%, respectively; p < 0.001). The cumulative rates of survival at 6 weeks were 57.4% and 93.6% for the critical illness-related corticosteroid insufficiency group and normal adrenal function group, respectively (p < 0.001). The cortisol response to corticotropin was inversely correlated with Model for End-Stage Liver Disease and Child-Pugh scores and positively correlated with the levels of high-density lipoprotein and total cholesterol. Hypovolemic shock, high-density lipoprotein, platelet count, and bacterial infection at inclusion are independent factors predicting critical illness-related corticosteroid insufficiency, whereas critical illness-related corticosteroid insufficiency, Model for End-Stage Liver Disease score, hypovolemic shock, hepatocellular carcinoma, and active bleeding at endoscopy are independent factors to predict treatment failure. Multivariate analysis also identified Model for End-Stage Liver Disease score, hypovolemic shock, and bacterial infection at inclusion as independent factors associated with 6-week mortality. CONCLUSIONS Critical illness-related corticosteroid insufficiency is common in cirrhotic patients with acute gastroesophageal variceal bleeding and is an independent factor to predict 5-day treatment failure.
Collapse
|
15
|
Abstract
Hemodynamic instability as a clinical state represents either a perfusion failure with clinical manifestations of circulatory shock or heart failure or 1 or more out-of-threshold hemodynamic monitoring values, which may not necessarily be pathologic. Different types of causes of circulatory shock require different types of treatment modalities, making these distinctions important. Diagnostic approaches or therapies based on data derived from hemodynamic monitoring assume that specific patterns of derangements reflect specific disease processes, which respond to appropriate interventions. Hemodynamic monitoring at the bedside improves patient outcomes when used to make treatment decisions at the right time for patients experiencing hemodynamic instability.
Collapse
Affiliation(s)
- Eliezer L Bose
- Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, 336 Victoria Hall, 3500 Victoria Street, Pittsburgh, PA 15261, USA
| | - Marilyn Hravnak
- Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, 3500 Victoria Street, 336 Victoria Building, Pittsburgh, PA 15261, USA.
| | - Michael R Pinsky
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, 606 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15261, USA
| |
Collapse
|
16
|
Li W, Okwuwa I, Toledo-Frazzini K, Alhomosh A. Adrenal crisis in a patient with acute myeloid leukaemia. BMJ Case Rep 2013; 2013:bcr-2013-010426. [PMID: 23843412 DOI: 10.1136/bcr-2013-010426] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Adrenal crisis is a group of clinical manifestation predominantly with hypotensive shock, electrolyte imbalance in a patient with adrenal insufficiency or in a patient who was abruptly withdrawn from glucocorticoid treatment acute myeloid leukaemia (AML) is one of the most common acute leukaemia in adults. Though the above diseases are commonly seen in individual patients, the coexistence of both conditions in the same patient is rare. We reported a 64-year-old African-American man with a history of bilateral deep vein thrombosis, who presented initially with fatigue, neutropenia and macrocytic anaemia. The patient developed a small bowel obstruction during his first hospital course, which resolved spontaneously with conservative management after an exploratory laparotomy. While waiting for his bone marrow biopsy, the patient developed hypotension, hyponatraemia and hyperkalaemia for which adrenal crisis was suspected. Later on, laboratory studies confirmed the diagnosis of primary adrenal insufficiency and the bone marrow was conclusive for AML.
Collapse
Affiliation(s)
- Wang Li
- Department of Family and Community Medicine, Texas Tech University Health Sciences Center, Odessa, Texas, USA.
| | | | | | | |
Collapse
|
17
|
Park JH, Kwon DH, Starling RC, Marwick TH. Role of imaging in the detection of reversible cardiomyopathy. J Cardiovasc Ultrasound 2013; 21:45-55. [PMID: 23837113 PMCID: PMC3701778 DOI: 10.4250/jcu.2013.21.2.45] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Revised: 03/14/2013] [Accepted: 05/22/2013] [Indexed: 12/19/2022] Open
Abstract
Heart failure is a major clinical problem in developed countries with about half of heart failure patients exhibiting decreased left ventricular systolic function. The correct identification and prompt treatment of some specific etiologies can reverse heart failure, and recognition of myocardial recovery may avoid long-term therapy. However, the echocardiographic patterns of patients with a variety of etiologies of heart failure are similar, so the selective use of other imaging techniques is necessary for identification of specific etiologies. The role of repeat imaging in monitoring the therapeutic response is controversial, as is the cessation of medical therapy in patients demonstrating recovery.
Collapse
Affiliation(s)
- Jae-Hyeong Park
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Oh, USA. ; Cardiology Division of Internal Medicine, Chungnam National University College of Medicine, Chungnam National University Hospital, Daejeon, Korea
| | | | | | | |
Collapse
|
18
|
Trifan A, Chiriac S, Stanciu C. Update on adrenal insufficiency in patients with liver cirrhosis. World J Gastroenterol 2013; 19:445-56. [PMID: 23382623 PMCID: PMC3558568 DOI: 10.3748/wjg.v19.i4.445] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Revised: 12/03/2012] [Accepted: 12/20/2012] [Indexed: 02/06/2023] Open
Abstract
Liver cirrhosis is a major cause of mortality worldwide, often with severe sepsis as the terminal event. Over the last two decades, several studies have reported that in septic patients the adrenal glands respond inappropriately to stimulation, and that the treatment with corticosteroids decreases mortality in such patients. Both cirrhosis and septic shock share many hemodynamic abnormalities such as hyperdynamic circulatory failure, decreased peripheral vascular resistance, increased cardiac output, hypo-responsiveness to vasopressors, increased levels of proinflammatory cytokines [interleukine(IL)-1, IL-6, tumor necrosis factor-alpha] and it has, consequently, been reported that adrenal insufficiency (AI) is common in critically ill cirrhotic patients. AI may also be present in patients with stable cirrhosis without sepsis and in those undergoing liver transplantation. The term hepato-adrenal syndrome defines AI in patients with advanced liver disease with sepsis and/or other complications, and it suggests that it could be a feature of liver disease per se, with a different pathogenesis from that of septic shock. Relative AI is the term given to inadequate cortisol response to stress. More recently, another term is used, namely "critical illness related corticosteroid insufficiency" to define "an inadequate cellular corticosteroid activity for the severity of the patient's illness". The mechanisms of AI in liver cirrhosis are not completely understood, although decreased levels of high-density lipoprotein cholesterol and high levels of proinflammatory cytokines and circulatory endotoxin have been suggested. The prevalence of AI in cirrhotic patients varies widely according to the stage of the liver disease (compensated or decompensated, with or without sepsis), the diagnostic criteria defining AI and the methodology used. The effects of corticosteroid therapy on cirrhotic patients with septic shock and AI are controversial. This review aims to summarize the existing published information regarding AI in patients with liver cirrhosis.
Collapse
|
19
|
Acute adrenal insufficiency in cervical spinal cord injury. World Neurosurg 2011; 77:561-3. [PMID: 22120347 DOI: 10.1016/j.wneu.2011.06.041] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2011] [Revised: 05/15/2011] [Accepted: 06/24/2011] [Indexed: 11/20/2022]
Abstract
BACKGROUND Adequate adrenal response is fundamental for the maintenance of physiological homeostasis in the setting of trauma and severe illness. Patients with neurogenic shock are at risk of severe consequences if adrenal insufficiency (AI) is not rapidly identified and treated. OBJECTIVE To analyze the incidence of AI in patients with acute cervical spinal cord injury and its effect on in-hospital complications. METHODS The medical records of patients older than 18 years who were admitted to the adult neurosurgery service at the University District Hospital as the result of neurogenic shock after acute cervical spinal cord injury from January 2004 to December 2009 were reviewed retrospectively. RESULTS One hundred ninety-nine patients were admitted with acute cervical spinal cord injury. A total of 37 patients met the pre-established criteria for neurogenic shock. The incidence of AI in patients with neurogenic shock was 22%. The average random cortisol was 9.3 μg/dL in patients with AI versus 29.2 μg/dL in non-AI. The presence of AI was positively correlated with complications and an increase in the risk of intubation (P = 0.01 and P = 0.002). The 30-day mortality rate in patients with AI was 13% compared with the 3% in the non-AI group (P = 0.39). CONCLUSIONS Adrenal insufficiency is a poorly recognized complication in patients with acute cervical spinal cord injury and its aggressive treatment is of utmost importance to avoid further neurological injury.
Collapse
|
20
|
Autoimmune adrenal insufficiency mimicking bilateral adrenal metastases from adenocarcinoma of the lung on PET/CT. Clin Nucl Med 2011; 36:409-10. [PMID: 21467871 DOI: 10.1097/rlu.0b013e31820adf35] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
21
|
Cohn SL, Harte B. Postoperative Hypertension/Hypotension. Perioper Med (Lond) 2011. [DOI: 10.1007/978-0-85729-498-2_34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
|
22
|
Arabi YM, Aljumah A, Dabbagh O, Tamim HM, Rishu AH, Al-Abdulkareem A, Knawy BA, Hajeer AH, Tamimi W, Cherfan A. Low-dose hydrocortisone in patients with cirrhosis and septic shock: a randomized controlled trial. CMAJ 2010; 182:1971-7. [PMID: 21059778 DOI: 10.1503/cmaj.090707] [Citation(s) in RCA: 146] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Recent studies have reported a high prevalence of relative adrenal insufficiency in patients with liver cirrhosis. However, the effect of corticosteroid replacement on mortality in this high-risk group remains unclear. We examined the effect of low-dose hydrocortisone in patients with cirrhosis who presented with septic shock. METHODS We enrolled patients with cirrhosis and septic shock aged 18 years or older in a randomized double-blind placebo-controlled trial. Relative adrenal insufficiency was defined as a serum cortisol increase of less than 250 nmol/L or 9 μg/dL from baseline after stimulation with 250 μg of intravenous corticotropin. Patients were assigned to receive 50 mg of intravenous hydrocortisone or placebo every six hours until hemodynamic stability was achieved, followed by steroid tapering over eight days. The primary outcome was 28-day all-cause mortality. RESULTS The trial was stopped for futility at interim analysis after 75 patients were enrolled. Relative adrenal insufficiency was diagnosed in 76% of patients. Compared with the placebo group (n = 36), patients in the hydrocortisone group (n = 39) had a significant reduction in vasopressor doses and higher rates of shock reversal (relative risk [RR] 1.58, 95% confidence interval [CI] 0.98-2.55, p = 0.05). Hydrocortisone use was not associated with a reduction in 28-day mortality (RR 1.17, 95% CI 0.92-1.49, p = 0.19) but was associated with an increase in shock relapse (RR 2.58, 95% CI 1.04-6.45, p = 0.03) and gastrointestinal bleeding (RR 3.00, 95% CI 1.08-8.36, p = 0.02). INTERPRETATION Relative adrenal insufficiency was very common in patients with cirrhosis presenting with septic shock. Despite initial favourable effects on hemodynamic parameters, hydrocortisone therapy did not reduce mortality and was associated with an increase in adverse effects. (Current Controlled Trials registry no. ISRCTN99675218.).
Collapse
Affiliation(s)
- Yaseen M Arabi
- Department of Intensive Care Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
23
|
|
24
|
Menon K, Ward RE, Lawson ML, Gaboury I, Hutchison JS, Hébert PC. A prospective multicenter study of adrenal function in critically ill children. Am J Respir Crit Care Med 2010; 182:246-51. [PMID: 20299532 DOI: 10.1164/rccm.200911-1738oc] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Adrenal insufficiency is a clinical condition associated with fluid- and catecholamine-resistant hypotension. OBJECTIVES The objectives of this study were to determine the prevalence of adrenal insufficiency, risk factors and potential mechanisms for its development, and its association with clinically important outcomes in critically ill children. METHODS A prospective, cohort study was conducted from 2005 to 2008 in seven tertiary-care, pediatric intensive care units in Canada on patients up to 17 years of age with existing vascular access. Adrenocorticotropic hormone stimulation tests (1 microg) were performed and adrenocorticotropic hormone levels measured in all participants. MEASUREMENTS AND MAIN RESULTS A total of 381 patients had adrenal testing on admission. The prevalence of adrenal insufficiency was 30.2% (95% confidence interval, 25.9-35.1). Patients with adrenal insufficiency had higher baseline cortisol levels (28.6 microg/dl vs. 16.7 microg/dl, P < 0.001) and were significantly older (11.5 yr vs. 2.3 yr, P < 0.001) than those without adrenal insufficiency. Adrenal insufficiency was associated with an increased need for catecholamines (P < 0.001) and more fluid boluses (P = 0.026). The sensitivity and specificity of the low-dose adrenocorticotropic hormone stimulation test were 100% and 84%, respectively. CONCLUSIONS Adrenal insufficiency occurs in many disease conditions in critically ill children and is associated with an increased use of catecholamines and fluid boluses. It is likely multifactorial in etiology and is associated with high baseline cortisol levels. Further research is necessary to determine which of these critically ill children are truly cortisol deficient before any treatment recommendations can be made.
Collapse
Affiliation(s)
- Kusum Menon
- Pediatric Intensive Care Unit, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1S 3H2 Canada.
| | | | | | | | | | | | | |
Collapse
|
25
|
Hittle K, Hsieh S, Sheeran P. Acute adrenal crisis masquerading as septic shock in a healthy young woman. J Pediatr Health Care 2010; 24:48-52. [PMID: 20122478 DOI: 10.1016/j.pedhc.2009.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2009] [Accepted: 09/28/2009] [Indexed: 10/20/2022]
Affiliation(s)
- Kristin Hittle
- Children's Medical Center Dallas, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | | |
Collapse
|
26
|
Wu JY, Hsu SC, Ku SC, Ho CC, Yu CJ, Yang PC. Adrenal insufficiency in prolonged critical illness. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 12:R65. [PMID: 18466605 PMCID: PMC2481448 DOI: 10.1186/cc6895] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2008] [Revised: 04/30/2008] [Accepted: 05/08/2008] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Adrenal insufficiency is common in critically ill patients and affects their prognosis, but little is known about how adrenal function changes during prolonged critical illness. This study was conducted to investigate dynamic changes in cortisol levels in patients with critical illness who do not improve after treatment. METHODS This observational cohort study was performed in the intensive care units of a university hospital. We studied acutely ill patients with initial cortisol level above 34 microg/dl, but who did not improve after treatment and in whom follow-up cortisol levels were determined during critical illness. All clinical information and outcomes were recorded. RESULTS Fifty-seven patients were included. Ten patients had follow-up cortisol levels above 34 microg/dl, 32 patients had levels between 34 and 15 microg/dl, and 15 patients had levels under 15 microg/dl. Outcomes did not differ significantly among the three groups with different follow-up cortisol levels. In Cox regression analysis, those patients who survived to hospital discharge with second cortisol levels under 15 microg/dl had a longer hospital length of stay (odds ratio = 14.8, 95% confidence interval = 2.4 to 90.0; P = 0.004). CONCLUSION The majority of acutely ill patients who remained in a critical condition had decreased serum cortisol levels. Depressed cortisol levels at follow up may lead to worse clinical outcomes. We propose that repeated adrenal function testing be conducted in patients with prolonged critical illness.
Collapse
Affiliation(s)
- Jenn-Yu Wu
- Department of Internal Medicine, National Taiwan University Hospital, Chung-Shan South Road, Taipei, Taiwan 100, Republic of China
| | | | | | | | | | | |
Collapse
|
27
|
Taylor RW. Adrenal Insufficiency in the Critically Ill Patient. Crit Care Med 2008. [DOI: 10.1016/b978-032304841-5.50062-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
28
|
Spijkstra JJ, Thijs LG. Adrenal dysfunction in critical illness: a clinical entity that requires treatment? Curr Opin Anaesthesiol 2007; 13:99-103. [PMID: 17016286 DOI: 10.1097/00001503-200004000-00003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Corticosteroids are of key importance in controlling the immune system and in the maintenance of cardiovascular function. Thus, an adequate function of the adrenal cortex is essential for survival in critical illness. There is growing evidence that adrenocortical function can become impaired during critical illness, because of deleterious effects of cytokines, leading to a state of relative adrenal dysfunction. Under these circumstances, administration of corticosteroids is necessary for recovery of the patient. How such a state of adrenal dysfunction should be detected is still not clear, however, making it difficult to decide when to administer corticosteroids and to which patients.
Collapse
Affiliation(s)
- J J Spijkstra
- Surgical Intensive Care and bMedical Intensive Care, University Hospital Vrije Universiteit, Amsterdam, The Netherlands.
| | | |
Collapse
|
29
|
Lipiner-Friedman D, Sprung CL, Laterre PF, Weiss Y, Goodman SV, Vogeser M, Briegel J, Keh D, Singer M, Moreno R, Bellissant E, Annane D. Adrenal function in sepsis: the retrospective Corticus cohort study. Crit Care Med 2007; 35:1012-8. [PMID: 17334243 DOI: 10.1097/01.ccm.0000259465.92018.6e] [Citation(s) in RCA: 188] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To refine the value of baseline and adrenocorticotropin hormone (ACTH)-stimulated cortisol levels in relation to mortality from severe sepsis or septic shock. DESIGN Retrospective multicenter cohort study. SETTING Twenty European intensive care units. PATIENTS Patients included 477 patients with severe sepsis and septic shock who had undergone an ACTH stimulation test on the day of the onset of severe sepsis. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Compared with survivors, nonsurvivors had higher baseline cortisol levels (29.5 +/- 33.5 vs. 24.3 +/- 16.5 microg/dL, p = .03) but similar peak cortisol values (37.6 +/- 40.2 vs. 35.2 +/- 22.9 microg/dL, p = .42). Thus, nonsurvivors had lower Deltamax (i.e., peak cortisol minus baseline cortisol) (6.4 +/- 22.6 vs. 10.9 +/- 12.9 microg/dL, p = .006). Patients with either baseline cortisol levels <15 microg/dL or a Deltamax <or=9 microg/dL had a likelihood ratio of dying of 1.26 (95% confidence interval, 1.11-1.44), a longer duration of shock, and a shorter survival time. Patients with a Deltamax <or=9 microg/dL but any baseline cortisol value had a likelihood ratio of dying of 1.38 (95% confidence interval, 1.18-1.61). CONCLUSIONS Although delta cortisol and not basal cortisol level was associated with clinical outcome, further studies are still needed to optimize the diagnosis of adrenal insufficiency in critical illness. Etomidate influenced ACTH test results and was associated with a worse outcome.
Collapse
Affiliation(s)
- Diane Lipiner-Friedman
- Service de Réanimation, Hôpital Raymond Poincaré (APHP), Faculté de Médecine Paris Ile de France Ouest (UVSQ), Garches, France
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
30
|
Annane D, Maxime V, Ibrahim F, Alvarez JC, Abe E, Boudou P. Diagnosis of Adrenal Insufficiency in Severe Sepsis and Septic Shock. Am J Respir Crit Care Med 2006; 174:1319-26. [PMID: 16973979 DOI: 10.1164/rccm.200509-1369oc] [Citation(s) in RCA: 247] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Diagnosis of adrenal insufficiency in critically ill patients has relied on random or cosyntropin-stimulated cortisol levels, and has not been corroborated by a more accurate diagnostic standard. OBJECTIVE We used the overnight metyrapone stimulation test to investigate the diagnostic value of the standard cosyntropin stimulation test, and the prevalence of sepsis-associated adrenal insufficiency. METHODS This was an inception cohort study. MEASUREMENTS AND RESULTS In two consecutive septic cohorts (n = 61 and n = 40), in 44 patients without sepsis and in 32 healthy volunteers, we measured (1) serum cortisol before and after cosyntropin stimulation, albumin, and corticosteroid-binding globulin levels, and (2) serum corticotropin, cortisol, and 11beta-deoxycortisol levels before and after an overnight metyrapone stimulation. Adrenal insufficiency was defined by postmetyrapone serum 11beta-deoxycortisol levels below 7 microg/dl. More patients with sepsis (31/61 [59% of original cohort with sepsis] and 24/40 [60% of validation cohort with sepsis]) met criteria for adrenal insufficiency than patients without sepsis (3/44; 7%) (p < 0.001 for both comparisons). Baseline cortisol (< 10 microg/dl), Delta cortisol (< 9 microg/dl), and free cortisol (< 2 microg/dl) had a positive likelihood ratio equal to infinity, 8.46 (95% confidence interval, 1.19-60.25), and 9.50 (95% confidence interval, 1.05-9.54), respectively. The best predictor of adrenal insufficiency (as defined by metyrapone testing) was baseline cortisol of 10 microg/dl or less or Delta cortisol of less than 9 microg/dl. The best predictors of normal adrenal response were cosyntropin-stimulated cortisol of 44 microg/dl or greater and Delta cortisol of 16.8 microg/dl or greater. CONCLUSIONS In sepsis, adrenal insufficiency is likely when baseline cortisol levels are less than 10 microg/dl or delta cortisol is less than 9 microg/dl, and unlikely when cosyntropin-stimulated cortisol level is 44 microg/dl or greater or Delta cortisol is 16.8 microg/dl or greater.
Collapse
Affiliation(s)
- Djillali Annane
- Service de Réanimation, Hôpital Raymond Poincaré (AP-HP), Faculté de Médecine Paris Ile de France Ouest (UVSQ), 104 Boulevard Raymond Poincaré, 92380 Garches, France.
| | | | | | | | | | | |
Collapse
|
31
|
Wolff B, Machill K, Schulzki I, Schumacher D, Werner D. Acute reversible cardiomyopathy with cardiogenic shock in a patient with Addisonian crisis: a case report. Int J Cardiol 2006; 116:e71-3. [PMID: 17079038 DOI: 10.1016/j.ijcard.2006.07.207] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2006] [Accepted: 07/29/2006] [Indexed: 11/16/2022]
Abstract
A 42 year-old female, admitted to the ICU, with Addisonian crisis developed acute cardiopulmonary failure after hydrocortisone therapy was initiated. An echocardiogram showed severe reduction in the left-ventricular ejection fraction. Additionally, profound ECG abnormalities with diffuse ST-elevation and decreased QRS-amplitudes occurred, whereas Troponin-I was only moderately increased. Chest X-ray displayed bilateral pulmonary edema. The patient's condition culminated in respiratory failure and cardiogenic shock requiring catecholamines and ventilatory support. After a week, she had recovered uneventfully.
Collapse
|
32
|
Gopichandran V, Sathya A, Srinivasan B, Parasuraman G, Ravikumar L, Mahadevan S, Sriram U. Assessment of knowledge, attitudes and practices about adrenal insufficiency in the critically ill among endocrinologists and intensivists practicing in Chennai. Indian J Crit Care Med 2006. [DOI: 10.4103/0972-5229.27859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
33
|
Tsai MH, Peng YS, Chen YC, Liu NJ, Ho YP, Fang JT, Lien JM, Yang C, Chen PC, Wu CS. Adrenal insufficiency in patients with cirrhosis, severe sepsis and septic shock. Hepatology 2006; 43:673-81. [PMID: 16557538 DOI: 10.1002/hep.21101] [Citation(s) in RCA: 174] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Patients with cirrhosis are susceptible to bacterial infection, which can result in circulatory dysfunction, renal failure, hepatic encephalopathy, and a decreased survival rate. Severe sepsis is frequently associated with adrenal insufficiency, which may lead to hemodynamic instability and a poor prognosis. We evaluated adrenal function using short corticotropin stimulation test (SST) in 101 critically ill patients with cirrhosis and severe sepsis. Adrenal insufficiency occurred in 51.48% of patients. The patients with adrenal insufficiency had a higher hospital mortality rate when compared with those with normal adrenal function (80.76% vs. 36.7%, P < .001). The cumulative rates of survival at 90 days were 15.3% and 63.2% for the adrenal insufficiency and normal adrenal function groups, respectively (P < .0001). The hospital survivors had a higher cortisol response to corticotropin (16.2 +/- 8.0 vs. 8.5 +/- 5.9 microg/dL, P < .001). The cortisol response to corticotropin was inversely correlated with various disease severity, Model for End-Stage Liver Disease, and Child-Pugh scores. Acute physiology, age, chronic health evaluation III score, and cortisol increment were independent factors to predict hospital mortality. Mean arterial pressure on the day of SST was lower in patients with adrenal insufficiency (60 +/- 14 vs. 74.5 +/- 13 mm Hg, P < .001), and a higher proportion of these patients required vasopressors (73% vs. 24.48%, P < .001). Mean arterial pressure, serum bilirubin, vasopressor dependency, and bacteremia were independent factors that predicted adrenal insufficiency. In conclusion, adrenal insufficiency is common in critically ill patients with cirrhosis and severe sepsis. It is related to functional liver reserve and disease severity and is associated with hemodynamic instability, renal dysfunction, and increased mortality.
Collapse
Affiliation(s)
- Ming-Hung Tsai
- Division of Gastroenterology, Chang Gung Memorial Hospital, Chia-Yi, Taipei, Taiwan
| | | | | | | | | | | | | | | | | | | |
Collapse
|
34
|
Gonzalez H, Nardi O, Annane D. Relative Adrenal Failure in the ICU: An Identifiable Problem Requiring Treatment. Crit Care Clin 2006; 22:105-18, vii. [PMID: 16399022 DOI: 10.1016/j.ccc.2005.09.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Critically ill patients at some stage may develop adrenal insufficiency (AI). This article reviews the mechanisms, diagnosis criteria, consequences, and treatment of AI in various ICU conditions. Glucocorticoid insufficiency may be related to a decrease in glucocorticoid synthesis (ie, adrenal insufficiency) or to a reduced delivery of glucocorticoid to target tissues and cells. Diagnosis relies on clinical suspicion and ACTH test results. The length of cortisol replacement therapy should be at least 7 days and the adjunction of fludrocortisone is recommended.
Collapse
Affiliation(s)
- Hélène Gonzalez
- Service de Réanimation Médicale, Hôpital Raymond Poincaré, 104 Boulevard Raymond Poincaré, 92380 Garches, France
| | | | | |
Collapse
|
35
|
Cohan P, Wang C, McArthur DL, Cook SW, Dusick JR, Armin B, Swerdloff R, Vespa P, Muizelaar JP, Cryer HG, Christenson PD, Kelly DF. Acute secondary adrenal insufficiency after traumatic brain injury: a prospective study. Crit Care Med 2005; 33:2358-66. [PMID: 16215393 DOI: 10.1097/01.ccm.0000181735.51183.a7] [Citation(s) in RCA: 207] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To determine the prevalence, time course, clinical characteristics, and effect of adrenal insufficiency (AI) after traumatic brain injury (TBI). DESIGN Prospective intensive care unit-based cohort study. SETTING Three level 1 trauma centers. PATIENTS A total of 80 patients with moderate or severe TBI (Glasgow Coma Scale score, 3-13) and 41 trauma patients without TBI (Injury Severity Score, >15) enrolled between June 2002 and November 2003. MEASUREMENTS Serum cortisol and adrenocorticotropic hormone levels were drawn twice daily for up to 9 days postinjury; AI was defined as two consecutive cortisols of < or =15 microg/dL (25th percentile for extracranial trauma patients) or one cortisol of < 5 microg/dL. Principal outcome measures included: injury characteristics, hemodynamic data, usage of vasopressors, metabolic suppressive agents (high-dose pentobarbital and propofol), etomidate, and AI status. MAIN RESULTS AI occurred in 42 TBI patients (53%). Adrenocorticotropic hormone levels were lower at the time of AI (median, 18.9 vs. 36.1 pg/mL; p = .0001). Compared with patients without AI, those with AI were younger (p = .01), had higher injury severity (p = .02), had a higher frequency of early ischemic insults (hypotension, hypoxia, severe anemia) (p = .02), and were more likely to have received etomidate (p = .049). Over the acute postinjury period, patients with AI had lower trough mean arterial pressure (p = .001) and greater vasopressor use (p = .047). Mean arterial pressure was lower in the 8 hrs preceding a low (< or =15 microg/dL) cortisol level (p = .003). There was an inverse relationship between cortisol levels and vasopressor use (p = .0005) and between cortisol levels within 24 hrs of injury and etomidate use (p = .002). Use of high-dose propofol and pentobarbital was strongly associated with lower cortisol levels (p < .0001). CONCLUSIONS Approximately 50% of patients with moderate or severe TBI have at least transient AI. Younger age, greater injury severity, early ischemic insults, and the use of etomidate and metabolic suppressive agents are associated with AI. Because lower cortisol levels were associated with lower blood pressure and higher vasopressor use, consideration should be given to monitoring cortisol levels in intubated TBI patients, particularly those receiving high-dose pentobarbital or propofol. A randomized trial of stress-dose hydrocortisone in TBI patients with AI is underway.
Collapse
Affiliation(s)
- Pejman Cohan
- Division of Neurosurgery, UCLA School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
36
|
Goodman S, Sprung CL, Ziegler D, Weiss YG. Cortisol changes among patients with septic shock and the relationship to ICU and hospital stay. Intensive Care Med 2005; 31:1362-9. [PMID: 16151722 DOI: 10.1007/s00134-005-2770-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2004] [Accepted: 07/25/2005] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To evaluate adrenal function in patients with severe sepsis or septic shock. DESIGN A prospective study of unstimulated and high-dose ACTH stimulated cortisol levels on days 1 and 2 following ICU admission and day 28 or last day of hospitalization (herein day 28). SETTING General intensive care unit. PATIENTS 34 septic patients. INTERVENTIONS On days 1, 2, and 28 of sepsis unstimulated and ACTH stimulated cortisol levels were evaluated. End-points were length of ICU and hospital stay and 28 day all cause mortality. MEASUREMENTS AND RESULTS Eight patients on days 1 and 2 had criteria of adrenal insufficiency defined as unstimulated cortisol levels less than 15 microg/dl. Patients with unstimulated cortisol levels less than 15 microg/dl on day 1 or change of 9 microg/dl or less had longer ICU stays. Patients with unstimulated cortisol levels less than 15 microg/dl on day 1 also demonstrated longer hospital stay. On day 1 regression analysis revealed that unstimulated cortisol levels had a significant inverse correlation with length of ICU and hospital stay. The proportional change between unstimulated cortisol and post-ACTH cortisol (Delta%) is a new modality; the higher this Delta% value, the longer is the patient's ICU and hospital stay. A significant positive correlation was found in survivors when comparing unstimulated cortisol vs. day 28 changes. CONCLUSIONS The present study highlights the wide range of cortisol levels among patients with sepsis. We observed a difference in cortisol response pattern between survivors and nonsurvivors on day 28. The proportional change between unstimulated cortisol and post-ACTH cortisol was used as a method to evaluate the relative change in cortisol levels between patients.
Collapse
Affiliation(s)
- Sergei Goodman
- Department of Anesthesiology and Critical Care Medicine, Hadassah University Hospital, Hadassah Medical School, Hebrew University, P.O.B. 12000, 91120 Jerusalem, Israel
| | | | | | | |
Collapse
|
37
|
Milde AS, Böttiger BW, Morcos M. [Adrenal cortex and steroids. Supplementary therapy in the perioperative phase]. Anaesthesist 2005; 54:639-54. [PMID: 15947898 DOI: 10.1007/s00101-005-0867-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Since the publication of two case reports that are considered to represent the first clinical demonstration of iatrogenic adrenal insufficiency, it has been the generally accepted practice to cover steroid-treated patients undergoing surgery with glucocorticoids in the perioperative period. Both the inclusion criteria for the patients and the extent of the substitution pattern have been selected on an empirical rather than on a rational basis. Scientific advances over the past 50 years in the knowledge of the hypothalamic-pituitary-adrenal system's physiology and the molecular mechanism of action of its biologically active components are, for the most part, not reflected in current clinical practice and instead seem to be ignored. Clinical and experimental evidence suggests, however, that even glucocorticoid-treated patients undergoing surgery do not require maximum stress doses of hydrocortisone, which should be reserved for the treatment of sepsis. With regard to the broad spectrum of efficacy of glucocorticoids and their side effects, revision and modification of the historical regimen appear prudent.
Collapse
Affiliation(s)
- A S Milde
- Klinik für Anaesthesiologie, Universitätsklinikum, Heidelberg
| | | | | |
Collapse
|
38
|
Pimentel-Filho FR, Silva MER, Nogueira KC, Berger K, Cukiert A, Liberman B. Pituitary-adrenal dynamics after ACTH-secreting pituitary tumor resection in patients receiving no steroids post-operatively. J Endocrinol Invest 2005; 28:502-8. [PMID: 16117190 DOI: 10.1007/bf03347237] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
It has recently been suggested that the classical routine of glucocorticoid administration before and after transsphenoidal surgery (TSS) in Cushing's disease (CD) patients may not be necessary, since it is likely that peritumoral normal corticotrophs are not completely suppressed during this period. We compared the dynamics of ACTH and cortisol from a group of CD patients (cured and not cured), receiving no steroids post-operatively, with a control group of acromegalic patients who presented normal hypothalamic-pituitary-adrenal (HPA) axis. Blood samples for ACTH and cortisol determination were obtained immediately before, at the end of surgery and at 4, 8, 12, 16, 24, 48 and 72 h after surgery, in 8 cured CD patients (Group I), 9 not cured CD patients (Group II) and in 7 subjects with acromegaly (Group III) who presented normal HPA axis (control group). The mean ACTH level in Group I was significantly lower than in Group III from 4 to 12 h and lower than in Group II from 8 to 12 h post-operatively. The mean cortisol level in Group I was lower than in Groups II and III from 8 to 72 h after surgery. No difference in mean cortisol level was observed among Groups II and III during the evaluated period. The lowest cortisol value in Group II was 193 nmol/l (at 24 h after surgery) and in Group I patients, after 20 h post-operatively, the highest cortisol level was 165 nmol/l. Although all cured CD patients (Group I) presented serum cortisol level lower than 55 nmol/l until 72 h after surgery, none had significant complications related to adrenal insufficiency. Ours findings are in agreement with recent observations that there is probably no need for glucocorticoid administration until clinical and/or laboratorial data are suggestive of adrenal insufficiency. However, we have also shown that a subphysiological HPA axis response could be observed in cured CD patients after TSS, and a definitive conclusion about glucocorticoid management during and after this procedure could not be made on the ground of the few cases studied in the literature.
Collapse
|
39
|
Poon D, Cheung YB, Tay MH, Lim WT, Lim ST, Wong NS, Koo WH. Adrenal insufficiency in intestinal obstruction from carcinomatosis peritonei--a factor of potential importance in symptom palliation. J Pain Symptom Manage 2005; 29:411-8. [PMID: 15857745 DOI: 10.1016/j.jpainsymman.2004.07.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/19/2004] [Indexed: 11/23/2022]
Abstract
Corticosteroids are used in the management of intestinal obstruction (IO) in carcinomatosis peritonei. There is considerable overlap in the symptoms experienced in IO and functional adrenal insufficiency (AI). The success of symptom palliation in IO may be related to the presence of AI. The aim of this preliminary study was to evaluate the incidence of functional adrenal insufficiency in patients with IO and its relation to clinical outcome and symptom control. Twenty-nine consecutive patients with IO and carcinomatosis peritonei from gastrointestinal cancers admitted to our inpatient service between January and October 2002 were analyzed. They were screened for AI using the short corticotropin stimulation test. Thirteen patients (45%) had functional AI. Differences in characteristics of patients with normal adrenal function (Group 1) and adrenal insufficiency (Group 2) were not statistically significant. Time taken to control symptoms in Group 2 was longer. Mean duration of hospitalization per month of survival was two times longer in Group 2 relative to Group 1 (7.9 versus 4.0 days, P=0.011). Functional AI may be caused by cytokines produced in advanced cancer mediating direct adrenal suppression. Prompt corticosteroid therapy in the presence of AI may facilitate IO symptom palliation.
Collapse
Affiliation(s)
- Donald Poon
- Department of Medical Oncology, National Cancer Center Singapore, Singapore
| | | | | | | | | | | | | |
Collapse
|
40
|
Guichelaar MMJ, Leenen LPH, Braams R. Transient Adrenocortical Insufficiency following Traumatic Bilateral Adrenal Hemorrhage. ACTA ACUST UNITED AC 2004; 56:1135-7. [PMID: 15179259 DOI: 10.1097/01.ta.0000044626.18085.0c] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Maureen M J Guichelaar
- Surgical Intensive Care Unit, Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
| | | | | |
Collapse
|
41
|
Dunser MW, Wenzel V, Mayr AJ, Hasibeder WR. Management of vasodilatory shock: defining the role of arginine vasopressin. Drugs 2003; 63:237-56. [PMID: 12534330 DOI: 10.2165/00003495-200363030-00001] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
The rationale for an arginine vasopressin (argipressin) infusion was put forward after it was discovered that patients in shock states might have an endogenous arginine vasopressin deficiency. Subsequently, several investigations impressively demonstrated that arginine vasopressin can successfully stabilise haemodynamics even in advanced vasodilatory shock. We report on physiological and pharmacological aspects of arginine vasopressin, and summarise current clinical knowledge on employing a continuous arginine vasopressin infusion in critically ill patients with catecholamine-resistant vasodilatory shock of different aetiologies. In view of presented experimental evidence and current clinical experience, a continuous arginine vasopressin infusion of approximately 2 to approximately 6 IU/h can be considered as a supplemental strategy to vasopressor catecholamines in order to preserve cardiocirculatory homeostasis in patients with advanced vasodilatory shock. Because data on adverse effects are still limited, arginine vasopressin should be reserved for patients in whom adequate haemodynamic stabilisation cannot be achieved with conventional vasopressor therapy or who have obvious adverse effects of catecholamines that result in further significant haemodynamic deterioration. For the same reasons, arginine vasopressin should not be used as a single, alternative vasopressor agent instead of catecholamine vasopressors. Future prospective studies will be necessary to define the exact role of arginine vasopressin in the therapy of vasodilatory shock.
Collapse
Affiliation(s)
- Martin W Dunser
- Division of General and Surgical Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Leopold-Franzens-University, Innsbruck, Austria
| | | | | | | |
Collapse
|
42
|
Abstract
OBJECTIVES To describe hypothalamic-pituitary-adrenal (HPA) activation and the role of glucocorticoids in immune modulation during critical illness, and to review clinical trials of pharmacologic and "replacement"' doses of glucocorticoids in early and late acute respiratory distress syndrome (ARDS) and sepsis. DATA EXTRACTION AND SYNTHESIS Selected review of published literature (1963 to present), clinical trials, and meta-analyses. DATA SUMMARY HPA axis activation is an important component of the compensatory anti-inflammatory response to critical illness. Cortisol supports vascular tone and endothelial integrity, modulates a large number of proinflammatory cytokines, and suppresses phospholipase A(2), cyclo-oxygenase, and nitric oxide synthase. Cortisol has putative antifibrotic activities, including inhibition of fibroblast growth and collagen deposition and stimulation of T-cell and monocyte apoptosis. During critical illness, neurohumoral factors, cytokines, endothelin, and atrial natriuretic peptide all may participate in HPA axis activation, resulting in elevated plasma cortisol production and plasma concentrations. In general, cortisol concentrations correlate with severity of illness, and higher plasma concentrations are associated with a poorer outcome. Failure of adrenocorticotropic hormone to augment plasma cortisol appears to be a poor prognostic finding in vasopressor-dependent sepsis and may indicate "relative adrenal insufficiency." Replacement glucocorticoid/mineralocorticoid therapy over 7 days appears to be beneficial in such individuals. However, a meta-analysis of high-dose, short-course glucocorticoid treatment involving 1,297 patients with sepsis enrolled in nine trials showed a trend toward harm, and four trials in patients with, or at risk for, ARDS showed no benefit or a greater likelihood of progression to ARDS. In contrast, observational studies and one small randomized controlled trial suggest that lower pharmacologic doses of glucocorticoids given late (>1 wk) in the course of ARDS may be beneficial. The National Heart, Lung, and Blood Institute's ARDS Network currently is testing the use of methylprednisolone in late ARDS. This study was reviewed by an independent data safety monitoring board for safety and efficacy after enrolling 60 and 120 patients and is currently ongoing. CONCLUSION Current evidence indicates that short-duration, high-dose glucocorticoid therapy is not effective for early ARDS or severe sepsis. One small randomized, controlled trial suggests that moderate doses of glucocorticoids may be beneficial for patients with late ARDS; a much larger randomized controlled trial is ongoing. Some patients with pressor-dependent severe sepsis appear to have relative adrenal insufficiency and benefit from replacement glucocorticoid/mineralocorticoid therapy. The accuracy of the diagnostic criteria for, and the prevalence of, relative adrenal insufficiency in patients with acute lung injury/ARDS is unknown. It is also unclear whether such a response, if present, predisposes patients to ongoing lung inflammation and the development of late fibroproliferative ARDS, or if it is predictive of a beneficial response to steroids. Studies of HPA axis activation and the role of relative adrenal insufficiency on the outcome of patients with acute lung injury are needed.
Collapse
Affiliation(s)
- B Taylor Thompson
- Pulmonary and Critical Care Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| |
Collapse
|
43
|
Affiliation(s)
- Mark S Cooper
- Division of Medical Sciences, University of Birmingham, Queen Elizabeth Hospital, Edgbaston, Birmingham, United Kingdom
| | | |
Collapse
|
44
|
Dünser MW, Mayr AJ, Gasser R, Rieger M, Friesenecker B, Hasibeder WR. Cardiac failure and multiple organ dysfunction syndrome in a patient with endocrine adenomatosis. Acta Anaesthesiol Scand 2002; 46:1161-4. [PMID: 12366515 DOI: 10.1034/j.1399-6576.2002.460918.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
In this case report, we present the successful therapy of severe cardiac failure in pituitary adrenal insufficiency. A previously healthy 56-year-old-man in pituitary coma due to an atypical variant of multiple endocrine adenomatosis (pituitary adenoma and pheochromocytoma) suffered from cardiac failure resistant to catecholamine and standard hydrocortisone therapy. After two bolus injections of dexamethasone (2 x 24 mg) mean arterial pressure and cardiac function dramatically improved, probably due to restoration of permissive effects on catecholamine action and reversal of pathophysiological mechanisms of cardiac failure. We conclude that in patients with severe cardiovascular failure in pituitary coma the administration of potent glucocorticoids may be more effective in reversing cardiovascular failure than standard dosages of hydrocortisone.
Collapse
Affiliation(s)
- M W Dünser
- Division of General and Surgical Intensive Care Medicine, Department of Anesthesia and Critical Care Medicine, the Leopold Franzens University of Innsbruck, Innsbruck, Austria.
| | | | | | | | | | | |
Collapse
|
45
|
Abstract
Acute liver failure and septic shock share many clinical features, including hyperdynamic cardiovascular collapse. Adrenal insufficiency may result in a similar cardiovascular syndrome. In septic shock, adrenal insufficiency, defined using the short synacthen test (SST), is associated with hemodynamic instability and poor outcome. We examined the SST, a dynamic test of adrenal function, in 45 patients with acute hepatic dysfunction (AHD) and determined the association of these results with hemodynamic profile, severity of illness, and outcomes. Abnormal SSTs were common, occurring in 62% of patients. Those who required noradrenaline (NA) for blood pressure support had a significantly lower increment (median, 161 vs. 540 nmol/L; P <.001) following synacthen compared with patients who did not. Increment and peak were lower in patients who required ventilation for the management of encephalopathy (increment, 254 vs. 616 nmol/L, P <.01; peak, 533 vs. 1,002 nmol/L, P <.01). Increment was significantly lower in those who fulfilled liver transplant criteria compared with those who did not (121 vs. 356 nmol/L; P <.01). Patients who died or underwent liver transplantation had a lower increment (148 vs. 419 nmol/L) and peak (438 vs. 764 nmol/L) than those who survived (P <.01). There was an inverse correlation between increment and severity of illness (Sequential Organ Failure Assessment, r = -0.63; P <.01). In conclusion, adrenal dysfunction assessed by the SST is common in AHD and may contribute to hemodynamic instability and mortality. It is more frequent in those with severe liver disease and correlates with severity of illness.
Collapse
Affiliation(s)
- Rachael Harry
- Institute of Liver Studies, Kings College Hospital, London, England
| | | | | |
Collapse
|
46
|
|
47
|
Burchard K. A review of the adrenal cortex and severe inflammation: quest of the "eucorticoid" state. THE JOURNAL OF TRAUMA 2001; 51:800-14. [PMID: 11586182 DOI: 10.1097/00005373-200110000-00033] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- K Burchard
- Department of Surgery, Section of General Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire 03756-0001, USA.
| |
Collapse
|
48
|
Van den Berghe G. Bad news about growth hormone treatment in the intensive care unit: need for some clarification. Curr Opin Anaesthesiol 2001; 14:127-9. [PMID: 17016391 DOI: 10.1097/00001503-200104000-00001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
49
|
Abstract
The endocrine adaptations to critical illness are varied. In the diabetic patient, counterregulatory hormones predispose to insulin resistance and hyperglycemia, a derangement accentuated by the use of glucocorticoids and enteral or parenteral nutrition. Thyroid abnormalities include the euthyroid sick syndrome, which may manifest as a low T3, low T4, low TSH, or all three. Illness in patients with pre-existing hypothyroidism or hyperthyroidism may precipitate myxedema coma or thyroid storm, respectively. The most important issue related to calcium is that of acute hypercalcemia, which, in the intensive care unit, usually is caused by malignancy and dehydration. Hyponatremia, a frequently encountered electrolyte disturbance, is evaluated best and treated according to volume status.
Collapse
Affiliation(s)
- F R Vasa
- Center for Endocrinology, Metabolism and Molecular Medicine, Northwestern University Medical School, Chicago, Illinosis
| | | |
Collapse
|
50
|
Briegel J. Hydrocortisone and the reduction of vasopressors in septic shock: therapy or only chart cosmetics? Intensive Care Med 2000; 26:1723-6. [PMID: 11271077 DOI: 10.1007/s001340000736] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|