Diagnosis of adrenal insufficiency in severe sepsis and septic shock. Export

@article{citeulike:2671066, 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.}, address = {Service de R\'{e}animation, H\^{o}pital Raymond Poincar\'{e} (AP-HP), Facult\'{e} de M\'{e}decine Paris Ile de France Ouest (UVSQ), 104 Boulevard Raymond Poincar\'{e}, 92380 Garches, France. djillali.annane@rpc.aphp.fr}, author = {Annane, D. and Maxime, V. and Ibrahim, F. and Alvarez, J. C. and Abe, E. and Boudou, P.}, citeulike-article-id = {2671066}, citeulike-linkout-0 = {http://dx.doi.org/10.1164/rccm.200509-1369OC}, citeulike-linkout-1 = {http://view.ncbi.nlm.nih.gov/pubmed/16973979}, citeulike-linkout-2 = {http://www.hubmed.org/display.cgi?uids=16973979}, day = {15}, doi = {10.1164/rccm.200509-1369OC}, issn = {1073-449X}, journal = {American journal of respiratory and critical care medicine}, keywords = {adrenal\_insufficiency}, month = {December}, number = {12}, pages = {1319--1326}, posted-at = {2008-04-15 03:05:45}, priority = {2}, title = {Diagnosis of adrenal insufficiency in severe sepsis and septic shock.}, url = {http://dx.doi.org/10.1164/rccm.200509-1369OC}, volume = {174}, year = {2006} }

TY - JOUR ID - citeulike:2671066 L3 - citeulike-article-id:2671066 N2 - 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. IS - 12 JF - American journal of respiratory and critical care medicine SN - 1073-449X AD - Service de Réanimation, Hôpital Raymond Poincaré (AP-HP), Faculté de Médecine Paris Ile de France Ouest (UVSQ), 104 Boulevard Raymond Poincaré, 92380 Garches, France. djillali.annane@rpc.aphp.fr EP - 1326 TI - Diagnosis of adrenal insufficiency in severe sepsis and septic shock. VL - 174 SP - 1319 KW - adrenal_insufficiency AU - Annane, D AU - Maxime, V AU - Ibrahim, F AU - Alvarez, JC AU - Abe, E AU - Boudou, P PY - 2006/12/15/ UR - http://dx.doi.org/10.1164/rccm.200509-1369OC ER -