Adrenocortical function during prolonged critical illness and beyond: a prospective observational study

Purpose For patients suffering from prolonged critical illness, it is unknown whether and when the hypothalamus–pituitary–adrenal axis alterations recover, and to what extent adrenocortical function parameters relate to sepsis/septic shock, to clinical need for glucocorticoid treatment, and to survi...

Full description

Saved in:
Bibliographic Details
Published in:Intensive care medicine 2018-10, Vol.44 (10), p.1720-1729
Main Authors: Peeters, Bram, Meersseman, Philippe, Vander Perre, Sarah, Wouters, Pieter J., Vanmarcke, Dimitri, Debaveye, Yves, Billen, Jaak, Vermeersch, Pieter, Langouche, Lies, Van den Berghe, Greet
Format: Article
Language:English
Subjects:
ACTH
Adrenal glands
Adrenal Insufficiency - diagnosis
Adrenocorticotropic hormone
Aged
Anesthesiology
Binding
Binding proteins
Breakdown
Care and treatment
Corticosteroids
Critical Care Medicine
Critical Illness
Discharge
Emergency Medicine
Female
Glucocorticoids
Glucocorticoids - therapeutic use
Hormones
Hospital patients
Humans
Hydrocortisone - blood
Hypothalamo-Hypophyseal System - physiopathology
Hypothalamus
Illnesses
Intensive
Intensive care
Intensive Care Units
Male
Medicine
Medicine & Public Health
Middle Aged
Observational studies
Original
Pain Medicine
Patients
Pediatrics
Pituitary
Pituitary-Adrenal System - physiopathology
Plasma
Pneumology/Respiratory System
Prospective Studies
Protein binding
Proteins
Sepsis
Septic shock
Shock
Shock, Septic
Survival
Urine
Citations: Items that this one cites
Items that cite this one
Online Access:Get full text
Tags: Add Tag
No Tags, Be the first to tag this record!
Description
Summary:Purpose For patients suffering from prolonged critical illness, it is unknown whether and when the hypothalamus–pituitary–adrenal axis alterations recover, and to what extent adrenocortical function parameters relate to sepsis/septic shock, to clinical need for glucocorticoid treatment, and to survival. Methods Patients still in ICU on day 7 ( N  = 392) and 20 matched healthy subjects were included. Morning blood and 24-h urine were collected daily and cosyntropin tests (250 µg) performed weekly, repeated 1 week after ICU discharge on the regular ward. Results In all patients free of glucocorticoid treatment up until ICU day 28 ( N  = 347), plasma ACTH always remained low/normal, whereas free cortisol remained high ( P  ≤ 0.002) explained by reduced binding proteins ( P  ≤ 0.02) and suppressed cortisol breakdown ( P  ≤ 0.001). Beyond ICU day 28 ( N  = 64 long-stayers), plasma (free)cortisol was no longer elevated. One week after ICU discharge, plasma ACTH and (free)cortisol always rose to supra-normal levels ( P  ≤ 0.006), most pronounced in long-stayers. Long-stayers always showed low incremental total ( P  ≤ 0.001), but normal incremental free cortisol responses to weekly cosyntropin tests, explained by low cortisol plasma binding proteins. Sepsis/septic shock patients were not different from others, patients subsequently receiving glucocorticoids ( N  = 45) were not different from those who did not, and non-survivors were distinguishable from survivors only by higher (free)cortisol. Conclusions Irrespective of sepsis/septic shock, need for glucocorticoids and survival, low cortisol plasma binding proteins and suppressed cortisol breakdown determine systemic (free)cortisol availability in prolonged critical illness, the latter no longer elevated beyond ICU day 28. The uniform rise in ACTH and cortisol to supra-normal levels 1 week after ICU discharge indicates recovery of a central adrenocortical suppression while in ICU. Low cortisol plasma binding invalidates the cosyntropin test.
ISSN:0342-4642
1432-1238
DOI:10.1007/s00134-018-5366-7