1
|
Abdelrehim AB, Mohsen FM, Haredi MA, Abdel Hameed Z, Ibrahim WH. PROGNOSTIC VALUE OF LOW-DOSE ADRENOCORTICOTROPIC HORMONE TEST IN CRITICALLY ILL PATIENTS. Shock 2023; 59:871-876. [PMID: 37011042 DOI: 10.1097/shk.0000000000002124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
Abstract
ABSTRACT Background: Previous trials evaluated the incidence of critical illness-related corticosteroid insufficiency (CIRCI) using 250 μg adrenocorticotropic hormone (ACTH). However, this supraphysiological dose could result in false-positive levels. We aimed to determine the incidence of CIRCI in septic patients using a 1 μg ACTH stress test. Methods: We conducted a prospective cohort study on 39 patients with septic shock. Critical illness-related corticosteroid insufficiency was defined as a Δ max cortisol <9 μg/dL after 1 μg ACTH stress test. The primary outcome of the study was death. Secondary outcomes included days of vasopressors, days of mechanical ventilation (MV), amount of fluid per day, the incidence of acute kidney injury (AKI), and days of intensive care unit (ICU) stay. Results: The incidence of CIRCI in our cohort was 43.6% using 1 μg ACTH. There were no significant differences between groups in terms of ICU scores, laboratory investigations, vasopressors, MV days, amount of fluid per day, and the ICU stay ( P = > 0.05). The CIRCI group had lower median survival and survival probability rates (5 days and 48.4%, respectively) compared with the non-CIRCI group (7 days and 49.5%, respectively). In addition, the CIRCI group had a shorter time to develop AKI and a higher probability of developing AKI (4 days and 44.6%, respectively) in comparison with the non-CIRCI group (6 days and 45.57%, respectively). Conclusion: We concluded that the CIRCI group had a lower mean survival rate and a higher incidence of AKI. We recommend the use of 1 μg ACTH test in septic shock patients to identify this subgroup of patients.
Collapse
Affiliation(s)
| | - Fatma M Mohsen
- Department of Internal Medicine, Critical Care Unit, Assiut University Hospital, Egypt
| | - Mostafa A Haredi
- Department of Internal Medicine, Endocrinology Unit, Assiut University Hospital, Egypt
| | | | - Walaa Hosny Ibrahim
- Department of Internal Medicine, Nephrology Unit, Assiut University Hospital, Egypt
| |
Collapse
|
2
|
Fan HP, Zhou Y, Zhou Y, Jin J, Hu TY. Association between short-term systemic use of glucocorticoids and prognosis of cardiogenic shock: a retrospective analysis. BMC Anesthesiol 2023; 23:169. [PMID: 37202727 PMCID: PMC10193317 DOI: 10.1186/s12871-023-02131-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 05/09/2023] [Indexed: 05/20/2023] Open
Abstract
OBJECTIVE To investigate the prescription rate of short-term systemic use of glucocorticoids during hospitalization in patients with cardiogenic shock (CS), and outcomes related with glucocorticoid use. METHODS We extracted patients' information from the Medical Information Mart for Intensive Care IV version 2.0 (MIMIC-IV v2.0) database. The primary endpoint was 90-day all-cause mortality. Secondary safety endpoints were infection identified by bacterial culture and at least one episode of hyperglycemia after ICU admission. Propensity score matching (PSM) was used to balance baseline characteristics. The difference in cumulative mortality rate between these treated with and without glucocorticoids was assessed by Kaplan-Meier curve with log-rank test. Independent risk factors for endpoints were identified by Cox or Logistic regression analysis. RESULTS A total of 1528 patients were enrolled, and one-sixth of these patients received short-term systemic therapy of glucocorticoids during hospitalization. These conditions, including rapid heart rate, the presence of rheumatic disease, chronic pulmonary disease and septic shock, high lactate level, the requirements of mechanical ventilation and continuous renal replacement therapy, were associated with an increase in glucocorticoid administration (all P ≤ 0.024). During a follow-up of 90 days, the cumulative mortality rate in patients treated with glucocorticoids was significantly higher than that in these untreated with glucocorticoids (log-rank test, P < 0.001). Multivariable Cox regression analysis showed that glucocorticoid use (hazard ratio 1.48, 95% confidence interval [CI] 1.22-1.81; P < 0.001) was independently associated with an increased risk for 90-day all-cause mortality. This result was consistent irrespective of age, gender, the presence of myocardial infarction, acute decompensated heart failure and septic shock, and inotrope therapy, but was more evident in low-risk patients as assessed by ICU scoring systems. Additionally, multivariable Logistic regression analysis showed that glucocorticoid exposure was an independent predictor of hyperglycemia (odds ratio 2.14, 95% CI 1.48-3.10; P < 0.001), but not infection (odds ratio 1.23, 95% CI 0.88-1.73; P = 0.221). After PSM, glucocorticoid therapy was also significantly related with increased risks of 90-day mortality and hyperglycemia. CONCLUSIONS Real-world data showed that short-term systemic use of glucocorticoids was common in CS patients. Importantly, these prescriptions were associated with increased risks of adverse events.
Collapse
Affiliation(s)
- Hua-Ping Fan
- Department of Cardiology, 63650 Military Hospital, Urumqi, Xinjiang, 841700, China
| | - Yan Zhou
- Department of Ophthalmology, The First People's Hospital of Ziyang, Sichuan, 641300, China
| | - Yu Zhou
- Department of Cardiology, 63650 Military Hospital, Urumqi, Xinjiang, 841700, China
| | - Jun Jin
- Institute of Cardiovascular Diseases, Xinqiao Hospital, Army Medical University, Chongqing, 400038, China
| | - Tian-Yang Hu
- Precision Medicine Center, The Second Affiliated Hospital of Chongqing Medical University, 74 Linjiang Road, Yuzhong District, Chongqing, 400010, China.
| |
Collapse
|
3
|
Krychtiuk KA, Vrints C, Wojta J, Huber K, Speidl WS. Basic mechanisms in cardiogenic shock: part 2 - biomarkers and treatment options. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:366-374. [PMID: 35218355 DOI: 10.1093/ehjacc/zuac022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 02/02/2022] [Accepted: 02/11/2022] [Indexed: 06/14/2023]
Abstract
Cardiogenic shock mortality rates remain high despite significant advances in cardiovascular medicine and the widespread uptake of mechanical circulatory support systems. Except for early invasive angiography and percutaneous coronary intervention of the infarct-related artery, all other widely used therapeutic measures are based on low-quality evidence. The grim prognosis and lack of high-quality data warrant further action. Within Part 2 of this two-part educational review on basic mechanisms in cardiogenic shock, we aimed to highlight the current status of translating our understanding of the pathophysiology of cardiogenic shock into clinical practice. We summarize the current status of biomarker research in risk stratification and therapy guidance. In addition, we summarized the current status of translating the findings from bench-, bedside, and biomarker studies into treatment options. Several large randomized controlled trials (RCTs) are underway, providing a huge opportunity to study contemporary cardiogenic shock patients. Finally, we call for translational, homogenous, biomarker-based, international RCTs testing novel treatment approaches to improve the outcome of our patients.
Collapse
Affiliation(s)
- Konstantin A Krychtiuk
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
- Duke Clinical Research Institute, 300 W Morgan Street, 27701 Durham, NC, USA
| | - Christiaan Vrints
- Research Group Cardiovascular Diseases, Department GENCOR, University of Antwerp, Prinsstraat 13, 2000 Antwerp, Belgium
- Department of Cardiology, Antwerp University Hospital (UZA), Drie Eikenstraat 655, 2650 Edegem, Belgium
| | - Johann Wojta
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
- Ludwig Boltzmann Institute for Cardiovascular Research, Waehringer Guertel 18-20, 1090 Vienna, Austria
- Core Facilities, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Kurt Huber
- Ludwig Boltzmann Institute for Cardiovascular Research, Waehringer Guertel 18-20, 1090 Vienna, Austria
- 3rd Department of Internal Medicine, Cardiology and Intensive Care Unit, Wilhelminenhospital, Montleartstraße 37, 1160 Vienna, Austria
- Medical School, Sigmund Freud University, Freudplatz 1, 1020 Vienna, Austria
| | - Walter S Speidl
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
- Ludwig Boltzmann Institute for Cardiovascular Research, Waehringer Guertel 18-20, 1090 Vienna, Austria
| |
Collapse
|
4
|
Low-dose corticosteroid therapy for cardiogenic shock in adults (COCCA): study protocol for a randomized controlled trial. Trials 2022; 23:4. [PMID: 34980224 PMCID: PMC8722083 DOI: 10.1186/s13063-021-05947-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 12/17/2021] [Indexed: 01/04/2023] Open
Abstract
Background Cardiogenic shock (CS) is a life-threatening condition characterized by circulatory insufficiency caused by an acute dysfunction of the heart pump. The pathophysiological approach to CS has recently been enriched by the tissue consequences of low flow, including inflammation, endothelial dysfunction, and alteration of the hypothalamic-pituitary-adrenal axis. The aim of the present trial is to evaluate the impact of early low-dose corticosteroid therapy on shock reversal in adults with CS. Method/design This is a multicentered randomized, double-blind, placebo-controlled trial with two parallel arms in adult patients with CS recruited from medical, cardiac, and polyvalent intensive care units (ICU) in France. Patients will be randomly allocated into the treatment or control group (1:1 ratio), and we will recruit 380 patients (190 per group). For the treatment group, hydrocortisone (50 mg intravenous bolus every 6 h) and fludrocortisone (50 μg once a day enterally) will be administered for 7 days or until discharge from the ICU. The primary endpoint is catecholamine-free days at day 7. Secondary endpoints include morbidity and all-cause mortality at 28 and 90 days post-randomization. Pre-defined subgroups analyses are planned, including: postcardiotomy, myocardial infarction, etomidate use, vasopressor use, and adrenal profiles according the short corticotropin stimulation test. Each patient will be followed for 90 days. All analyses will be conducted on an intention-to-treat basis. Discussion This trial will provide valuable evidence about the effectiveness of low dose of corticosteroid therapy for CS. If effective, this therapy might improve outcome and become a therapeutic adjunct for patients with CS. Trial registration ClinicalTrials.gov, NCT03773822. Registered on 12 December 2018
Collapse
|
5
|
Nso N, Nassar M, Baraka B, Mbome Y, Alfishawy M. Adrenal Insufficiency in patients with cardiogenic shock: A meta-analysis. Diabetes Metab Syndr 2021; 15:102274. [PMID: 34628137 DOI: 10.1016/j.dsx.2021.102274] [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: 04/18/2021] [Revised: 08/30/2021] [Accepted: 09/01/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Adrenal Insufficiency (AI) is rarely observed in patients with cardiogenic shock (CS). We aimed to identify the prevalence of AI in patients with CS and its effect on their clinical outcomes. AIMS Our study aimed to determine the prevalence of AI in CS patients who underwent treatments for CS. METHODS The articles concerning AI in CS were extracted for review from PubMed/Medline, Science Direct, World Wide Science.org, and Pro-Quest. The research articles included patients with CS, post-cardiac-arrest shock, out-of-hospital cardiac arrest, and CS after acute myocardial infarction. RStudio (version 1.0.136) was used for analyzing AI in CS patients. RESULTS The search revealed 1463 unique publications, including 256 studies identified after screening the titles and the abstracts. Five observational cohort studies met the eligibility criteria for meta-analysis after the preliminary screening. The included studies reported a corticotropin stimulation test for AI diagnosis. The studies reportedly exhibited a low-to-fair quality. The random-effects pooled estimates indicated a 32% AI prevalence in the setting of CS [95% CI; 21%-45%; I2 = 81%]. The outcomes from the included studies were statistically significant for high heterogeneity (P = 0.001). The pooled results confirmed an 11%-51% AI prevalence in CS patients. CONCLUSIONS This meta-analysis revealed a moderate level prevalence of AI in CS patients.
Collapse
Affiliation(s)
- Nso Nso
- Internal Medicine Department, Icahn School of Medicine at Mount Sinai / NYC Health+Hospitals / Queens, New York, NY, USA.
| | - Mahmoud Nassar
- Internal Medicine Department, Icahn School of Medicine at Mount Sinai / NYC Health+Hospitals / Queens, New York, NY, USA.
| | - Bahaaeldin Baraka
- Clinical Oncology Department, Nottingham University Hospital, Nottingham, UK.
| | - Yolanda Mbome
- Internal Medicine Department, Richmond University Medical Center, New York, USA.
| | - Mostafa Alfishawy
- Infectious Diseases, Infectious Diseases Consultants and Academic Researchers of Egypt (IDCARE), Cairo, Egypt.
| |
Collapse
|
6
|
Bagate F, Bedet A, Tomberli F, Boissier F, Razazi K, de Prost N, Carteaux G, Mekontso Dessap A. Critical illness-related corticosteroid insufficiency during difficult weaning from mechanical ventilation. Ann Intensive Care 2021; 11:65. [PMID: 33900478 PMCID: PMC8072727 DOI: 10.1186/s13613-021-00852-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 04/10/2021] [Indexed: 12/19/2022] Open
Abstract
Background Critical illness-related corticosteroid insufficiency (CIRCI) is common during critical illness and is usually associated with poor outcomes, as prolonged duration of mechanical ventilation (MV) and higher mortality. CIRCI may alter cardiac and vascular functions. Weaning-induced pulmonary oedema (WiPO) is a major mechanism of weaning failure. The aim of this study was to evaluate the role of CIRCI in patients with difficult ventilator weaning and its possible relation with WiPO. Methods This is a prospective study conducted in the intensive care of a university hospital in France. Patients under MV for more than 24 h, meeting weaning criteria and having failed the first spontaneous breathing trial (SBT) underwent a corticotropin stimulation test, with assessment of total blood cortisol levels immediately before (T0) 0.25 mg iv of tetracosactrin and 30 and 60 min afterward. Δmax was defined as the difference between the maximal value after the test and T0. CIRCI was defined as T0 < 10 μg/dL (276 nmol/L) and/or Δmax < 9 μg/dL (248 nmol/L) and inadequate adrenal reserve as Δmax < 9 μg/dL. Biomarkers (natriuretic peptide and protidemia) sampling and echocardiograms were performed during the second SBT and were used to diagnose WiPO, which was defined according to two definitions (one liberal and one conservative) derived from recent publications on the topic. Successful extubation was defined as patient alive without reintubation 7 days after extubation. A competing risk analysis was used to assess extubation failure and mortality. Results Seventy-six consecutive patients (63 ± 14 years; 49 men) with difficult weaning were enrolled. CIRCI and inadequate adrenal reserve occurred in 25 (33%) and 17 (22%) patients, respectively. The probability of successful extubation was significantly decreased in patients with CIRCI or inadequate adrenal reserve, as compared to their counterparts, and this association persisted after adjustment on severity (SOFA score at first SBT). WiPO occurred in 44 (58%) and 8 (11%) patients, according to the liberal and conservative definition, respectively. WiPO was not associated with CIRCI nor with inadequate adrenal reserve. Conclusion CIRCI was common during difficult weaning and was associated with its prolongation. We did not find a significant association between CIRCI and WiPO. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-021-00852-2.
Collapse
Affiliation(s)
- François Bagate
- AP-HP, DHU A-TVB, Service de Médecine Intensive Réanimation, Centre Hospitalo-Universitaire Henri Mondor, 51, avenue du Mal de Lattre de Tassigny, 94010, Créteil Cedex, France. .,Groupe de Recherche Clinique CARMAS, Faculté de Médecine, Université Paris Est Créteil, 94010, Créteil, France.
| | - Alexandre Bedet
- AP-HP, DHU A-TVB, Service de Médecine Intensive Réanimation, Centre Hospitalo-Universitaire Henri Mondor, 51, avenue du Mal de Lattre de Tassigny, 94010, Créteil Cedex, France.,Groupe de Recherche Clinique CARMAS, Faculté de Médecine, Université Paris Est Créteil, 94010, Créteil, France
| | - Françoise Tomberli
- AP-HP, DHU A-TVB, Service de Médecine Intensive Réanimation, Centre Hospitalo-Universitaire Henri Mondor, 51, avenue du Mal de Lattre de Tassigny, 94010, Créteil Cedex, France.,Groupe de Recherche Clinique CARMAS, Faculté de Médecine, Université Paris Est Créteil, 94010, Créteil, France
| | - Florence Boissier
- AP-HP, DHU A-TVB, Service de Médecine Intensive Réanimation, Centre Hospitalo-Universitaire Henri Mondor, 51, avenue du Mal de Lattre de Tassigny, 94010, Créteil Cedex, France.,Service de Réanimation Médicale, CHU de Poitiers, Poitiers, France.,INSERM CIC 1402 (ALIVE Group), Université de Poitiers, Poitiers, France
| | - Keyvan Razazi
- AP-HP, DHU A-TVB, Service de Médecine Intensive Réanimation, Centre Hospitalo-Universitaire Henri Mondor, 51, avenue du Mal de Lattre de Tassigny, 94010, Créteil Cedex, France.,Groupe de Recherche Clinique CARMAS, Faculté de Médecine, Université Paris Est Créteil, 94010, Créteil, France
| | - Nicolas de Prost
- AP-HP, DHU A-TVB, Service de Médecine Intensive Réanimation, Centre Hospitalo-Universitaire Henri Mondor, 51, avenue du Mal de Lattre de Tassigny, 94010, Créteil Cedex, France.,Groupe de Recherche Clinique CARMAS, Faculté de Médecine, Université Paris Est Créteil, 94010, Créteil, France.,INSERM U955, Institut Mondor de Recherche Biomédicale, 94010, Créteil, France
| | - Guillaume Carteaux
- AP-HP, DHU A-TVB, Service de Médecine Intensive Réanimation, Centre Hospitalo-Universitaire Henri Mondor, 51, avenue du Mal de Lattre de Tassigny, 94010, Créteil Cedex, France.,Groupe de Recherche Clinique CARMAS, Faculté de Médecine, Université Paris Est Créteil, 94010, Créteil, France.,INSERM U955, Institut Mondor de Recherche Biomédicale, 94010, Créteil, France
| | - Armand Mekontso Dessap
- AP-HP, DHU A-TVB, Service de Médecine Intensive Réanimation, Centre Hospitalo-Universitaire Henri Mondor, 51, avenue du Mal de Lattre de Tassigny, 94010, Créteil Cedex, France.,Groupe de Recherche Clinique CARMAS, Faculté de Médecine, Université Paris Est Créteil, 94010, Créteil, France.,INSERM U955, Institut Mondor de Recherche Biomédicale, 94010, Créteil, France
| |
Collapse
|
7
|
Critical Illness-Related Corticosteroid Insufficiency in Cardiogenic Shock Patients: Prevalence and Prognostic Role. Shock 2019; 50:408-413. [PMID: 29280926 DOI: 10.1097/shk.0000000000001090] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Cardiogenic shock shares with septic shock common hemodynamic features, inflammatory patterns, and most likely similar complications such as critical illness-related corticosteroid insufficiency. The aim of this study was to evaluate the prevalence of critical illness-related corticosteroid insufficiency in cardiogenic shock patients and to secondarily assess its prognostic value on 90-day mortality. METHODS A single-center prospective observational study conducted over a 3-year period and including all patients with cardiogenic shock. Main exclusion criteria were patients with prior cardiac arrest, sepsis, ongoing corticosteroid therapy, and etomidate administration. A short corticotropin test was performed in the first 24 h following admission. Serum cortisol levels were measured before (T0) and 60 min (T60) after administration of 250 μg of cosyntropin. Critical illness-related corticosteroid insufficiency was defined according to the 2017 consensus definition (basal total cortisol<10 μg·dL or a delta cortisol T60-T0<9 μg·dL) as well as the thresholds published in 2016 in cardiogenic shock patients associated with worst prognosis (basal total cortisol>29 μg·dL and delta cortisol T60-T0<17 μg·dL). RESULTS Seventy-nine consecutive patients hospitalized in intensive care for cardiogenic shock met the inclusion criteria. Overall mortality was 43% at day 90. Forty-two percent had critical illness-related corticosteroid insufficiency using the 2017 consensus definition and 32% using the 2016 cardiogenic shock thresholds. Presence of critical illness-related corticosteroid insufficiency was not an independent factor associated with 90-day mortality irrespective of the thresholds used. CONCLUSION Critical illness-related corticosteroid insufficiency is a frequent occurrence in medical cardiogenic shock. However, in this study, such insufficiency was not associated with prognosis.
Collapse
|
8
|
Lopez-Sobrino T, Yusef H, Gershlick T. Predicting outcomes in cardiogenic shock: are we at risk of having too many scores but too little information? Eur Heart J 2019; 40:2695-2699. [DOI: 10.1093/eurheartj/ehz488] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Affiliation(s)
- Teresa Lopez-Sobrino
- Cardiovascular Institute, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Hakeem Yusef
- University Hospitals of Leicester, Leicester, UK
| | - Tony Gershlick
- University of Leicester, University Hospitals of Leicester, Leicester Biomedical Research Centre, Leicester, UK
| |
Collapse
|
9
|
Is Inappropriate Response to Cosyntropin Stimulation Test an Indication of Corticosteroid Resistance in Septic Shock? Shock 2019; 49:543-550. [PMID: 28991048 DOI: 10.1097/shk.0000000000001014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
We recently published a comparison of two hydrocortisone dosage regimens in patients with septic shock. We compare the results conferred by the two regimens as a function of the response to cosyntropin stimulation test (CST). Patients with septic shock were treated by one of two hydrocortisone regimens: either a 50-mg intravenous bolus every 6 h during 7 days (200 mg group; n = 49), or a 100-mg initial bolus followed by a continuous infusion of 300 mg daily for 5 days (300 mg group; n = 50). Nonresponders was defined as a CST response of 9 μg/dL or less. Nonresponders had more severe septic shock, greater fluid resuscitation needs, and greater vasopressor dependence than responders. When analyzed only as a function of CST results, there was no difference in survival between responders and nonresponders. However, analyses crossing CST results and the treatment regimens showed that patients who were responders and in the 300 mg group had significantly less intensive care unit mortality compared with responders in the 200 mg group (respective mortality of 24% vs. 55% [relative risk 0.43, 95% confidence interval, 0.20 to 0.94, P = 0.018]). Multivariate analysis identified baseline blood cortisol as an independent prognostic factor for 28-day mortality in all groups (hazard ratio 1.002, 95% confidence interval, 1.001 to 1.002, P ≤ 0.0001). The results suggest that in patients who respond to CST, hydrocortisone can provide a dose-dependent benefit. In contrast, nonresponse may indicate corticosteroid resistance. This heterogeneity of response to hydrocortisone may explain the difficulties encountered when trying to demonstrate its benefit in septic shock.
Collapse
|
10
|
Song JH, Kim JH, Lee SM, Lee J. Prognostic Implication of Adrenocortical Response during the Course of Critical Illness. Acute Crit Care 2019; 34:38-45. [PMID: 31723903 PMCID: PMC6849045 DOI: 10.4266/acc.2018.00339] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 12/29/2010] [Accepted: 01/10/2019] [Indexed: 12/14/2022] Open
Abstract
Background Critical illness-related corticosteroid insufficiency (CIRCI) and adrenocorticotropic hormone (ACTH)-cortisol dissociation are hormonal conditions frequently observed in patients in the intensive care unit (ICU). The aim of this study was to evaluate the association between ACTH-cortisol dissociation and clinical outcomes of critically ill patients. Methods We retrospectively reviewed the medical records of 94 ICU patients who underwent two rapid cosyntropin tests during hospital admission and compared the clinical aspects of patients with and without ACTH-cortisol dissociation. ACTH-cortisol dissociation was defined as plasma ACTH and serum cortisol concentrations of <22 pmol/L and >600 nmol/L, respectively. Results Dissociation was present in 30 of the 94 patients (31.9%). Patients with ACTH-cortisol dissociation in the initial test had significantly higher hospital mortality rate than those in the control group (55% vs. 25.7%, P=0.013) There was no difference in hospital mortality between patients classified as having CIRCI and those who were not. In multivariate adjusted Cox regression analysis, the mortality risk was higher in the group with ACTH-cortisol dissociation (hazard ratio, 2.98; 95% confidence interval, 1.34 to 6.63; P=0.007). Patients with dissociation in two consecutive stimulation tests showed the highest hospital mortality rate among groups classified according to stimulation test results (100% vs. 31.3%). Conclusions The hospital mortality was higher in ICU patients diagnosed with ACTH-cortisol dissociation. It is clinically feasible to evaluate the presence of ACTH-cortisol dissociation by analyzing rapid ACTH stimulation test results in critically ill patients.
Collapse
Affiliation(s)
- Jin Hwa Song
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jung Hee Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sang-Min Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jinwoo Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| |
Collapse
|
11
|
What's New in SHOCK October 2017? Shock 2018; 48:387-389. [PMID: 28915213 DOI: 10.1097/shk.0000000000000942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
12
|
Mongardon N, Savary G, Geri G, El Bejjani MR, Silvera S, Dumas F, Charpentier J, Pène F, Mira JP, Cariou A. Prognostic value of adrenal gland volume after cardiac arrest: Association of CT-scan evaluation with shock and mortality. Resuscitation 2018; 129:135-140. [PMID: 29852197 DOI: 10.1016/j.resuscitation.2018.05.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 05/18/2018] [Accepted: 05/26/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Adrenal gland volume is associated with survival in septic shock. As sepsis and post-cardiac arrest syndrome share many pathophysiological features, we assessed the association between adrenal gland volume measured by computerized tomography (CT)-scan and post-cardiac arrest shock and intensive care unit (ICU) mortality, in a large cohort of out-of-hospital cardiac arrest (OHCA) patients. We also investigated the association between adrenal hormonal function and both adrenal gland volume and outcomes. PATIENTS AND METHODS Prospective analysis of CT-scan performed at hospital admission in patients admitted after OHCA (2007-2012). A pair of blinded radiologist calculated manually adrenal gland volume. In a subgroup of patients, plasma cortisol was measured at admission and 60 min after a cosyntropin test. Factors associated with post-cardiac arrest shock and ICU mortality were identified using multivariate logistic regression. RESULTS Among 775 patients admitted during this period after OHCA, 138 patients were included: 72 patients (52.2%) developed a post-cardiac arrest shock, and 98 patients (71.1%) died. In univariate analysis, adrenal gland volume was not different between patients with and without post-cardiac arrest shock: 10.6 and 11.3 cm3, respectively (p = 0.9) and between patients discharged alive or dead: 10.2 and 11.8 cm3, respectively (p = 0.4). Multivariate analysis confirmed that total adrenal gland volume was associated neither with post-cardiac arrest shock nor mortality. Neither baseline cortisol level nor delta between baseline and after cosyntropin test cortisol levels were associated with adrenal volume, post-cardiac arrest shock onset or mortality. CONCLUSION After OHCA, adrenal gland volume is not associated with post-cardiac arrest shock onset or ICU mortality. Adrenal gland volume does not predict adrenal gland hormonal response.
Collapse
Affiliation(s)
- Nicolas Mongardon
- Medical Intensive Care Unit, Cochin Hospital, Hôpitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, 15 rue de l'Ecole de Médecine, 75006 Paris, France
| | - Guillaume Savary
- Medical Intensive Care Unit, Cochin Hospital, Hôpitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, 15 rue de l'Ecole de Médecine, 75006 Paris, France
| | - Guillaume Geri
- Medical Intensive Care Unit, Cochin Hospital, Hôpitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, 15 rue de l'Ecole de Médecine, 75006 Paris, France; INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 56 rue Leblanc, 75015 Paris, France
| | - Marie-Rose El Bejjani
- Radiology Department, Cochin Hospital, Hôpitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - Stéphane Silvera
- Radiology Department, Cochin Hospital, Hôpitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - Florence Dumas
- Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, 15 rue de l'Ecole de Médecine, 75006 Paris, France; INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 56 rue Leblanc, 75015 Paris, France; Emergency Department, Cochin Hospital, Hôpitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - Julien Charpentier
- Medical Intensive Care Unit, Cochin Hospital, Hôpitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, 15 rue de l'Ecole de Médecine, 75006 Paris, France
| | - Frédéric Pène
- Medical Intensive Care Unit, Cochin Hospital, Hôpitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, 15 rue de l'Ecole de Médecine, 75006 Paris, France
| | - Jean-Paul Mira
- Medical Intensive Care Unit, Cochin Hospital, Hôpitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, 15 rue de l'Ecole de Médecine, 75006 Paris, France
| | - Alain Cariou
- Medical Intensive Care Unit, Cochin Hospital, Hôpitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, 15 rue de l'Ecole de Médecine, 75006 Paris, France; INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 56 rue Leblanc, 75015 Paris, France.
| |
Collapse
|
13
|
Age Shock Index is Superior to Shock Index and Modified Shock Index for Predicting Long-Term Prognosis in Acute Myocardial Infarction. Shock 2017; 48:545-550. [DOI: 10.1097/shk.0000000000000892] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
14
|
|
15
|
Association between relative adrenal insufficiency and septic cardiomyopathy: a preliminary report. Intensive Care Med 2017; 43:1924-1926. [PMID: 28779223 DOI: 10.1007/s00134-017-4901-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2017] [Indexed: 10/19/2022]
|
16
|
What's New in Shock, January 2017? Shock 2016; 47:1-4. [PMID: 27984532 DOI: 10.1097/shk.0000000000000774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|