Intensive Care Medicine

, Volume 31, Issue 3, pp 388–392 | Cite as

Risk factors of relative adrenocortical deficiency in intensive care patients needing mechanical ventilation

  • Gabriel Malerba
  • Florence Romano-Girard
  • Aurélie Cravoisy
  • Brigitte Dousset
  • Lionel Nace
  • Bruno Lévy
  • Pierre-Edouard BollaertEmail author



To study the factors associated with relative adrenocortical deficiency in mechanically ventilated, critically ill patients

Design and setting

Prospective observational study in a multidisciplinary ICU of a university-affiliated teaching hospital


Sixty-two consecutive, acutely ill patients needing mechanical ventilation for more than 24 h.

Measurements and results

A high-dose short corticotropin test 24 h after endotracheal intubation. Relative adrenocortical deficiency (“nonresponder” group of patients) was defined by a rise in cortisol less than 90 µg/l after stimulation. Twenty-seven patients were classified as nonresponders and 35 as responders. On univariate analysis nonresponders were more often men, had lower mean arterial pressure, required vasoactive agents more often, had lower creatinine clearance, higher SAPS II, higher organ dysfunction scores, and received etomidate as a single bolus for endotracheal intubation more often than responders. On multivariate analysis, only etomidate administration was related to relative adrenocortical deficiency (OR 12.21; 95% CI 2.99–49.74) while female gender was protective (OR 0.13; 95% CI 0.03–0.57).


A single bolus infusion of etomidate could be a major risk factor for the development of relative adrenocortical deficiency in ICU patients for at least 24 h after administration. Female gender is an independent protective factor.


Adrenal Corticotropin Etomidate Shock Endotracheal intubation Critical care 


  1. 1.
    Sibbald W, Short A, Cohen MP, Wilson RF (1977) Variations in adrenocortical responsiveness during severe bacterial infections. Ann Surg 186:29–33Google Scholar
  2. 2.
    Rothwell PM, Udwadia ZF, Lawler PG (1991) Cortisol response to corticotropin and survival in septic shock. Lancet 337:582–583CrossRefGoogle Scholar
  3. 3.
    Moran JL, Chapman MJ, O’Fatharaigh MS, Peisach AR, Pannall PR, Leppard P (1994) Hypocortisolaemia and adrenocortical responsiveness at onset of septic shock. Intensive Care Med 20:489–495Google Scholar
  4. 4.
    Tayek JA, Atienza VJ (1995) Pituitary-adrenal function in systemic inflammatory response syndrome. Endocrine 3:315–318Google Scholar
  5. 5.
    Annane D, Sebille V, Troche G, Raphaël JC, Gajdos P, Bellissant E (2000) A 3-level prognostic classification in septic shock based on cortisol levels and cortisol response to corticotropin. JAMA 283:1038–1045CrossRefGoogle Scholar
  6. 6.
    Bollaert PE, Fieux F, Charpentier C, Levy B (2003) Baseline cortisol levels, cortisol response to corticotropin and prognosis in late septic shock. Shock 19:13–15CrossRefGoogle Scholar
  7. 7.
    Annane D, Sebille V, Charpentier C, Bollaert PE, François B, Korach JM, Capellier G, Cohen Y, Azoulay Y, Troche G, Chaumet-Riffaut P, Bellissant E (2002) Effects of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA 288:862–871PubMedGoogle Scholar
  8. 8.
    Cooper MS, Stewart PM (2003) Corticosteroid insufficiency in acutely ill patients. N Engl J Med 348:727–734CrossRefGoogle Scholar
  9. 9.
    Van de Voort PH, Gerritsen RT, Bakker AJ, Boerma EC, Kuiper MA, de Heide L (2003) HDL-cholesterol level and cortisol response to synacthen in critically ill patients. Intensive Care Med 29:2199–2203CrossRefGoogle Scholar
  10. 10.
    Bergen JM, Smith DC (1997) A review of etomidate for rapid sequence intubation in the emergency department. J Emerg Med 15:221–230CrossRefGoogle Scholar
  11. 11.
    McCabe WR, Jackson GG (1962) Gram negative bacteremia. I. Etiology and ecology. Arch Intern Med 110:847–855Google Scholar
  12. 12.
    Knaus WA, Zimmermann JE, Wagner DP, Draper EA, Lawrence DE (1981) APACHE-acute physiology and chronic health evaluation: a physiologically based classification system. Crit Care Med 9:591–597PubMedGoogle Scholar
  13. 13.
    Le Gall JR, Lemeshow S, Saulnier F (1993) A new Simplified Acute Physiology Score (SAPSII) based on a European/North American multicenter study. JAMA 276:802–810Google Scholar
  14. 14.
    Fagon JY, Chastre J, Novara A, Medioni P, Gibert C (1993) Characterization of intensive care unit patients using a model based on the presence or absence of organ dysfunctions and/or infection: the ODIN model. Intensive Care Med 19:137–144PubMedGoogle Scholar
  15. 15.
    Beishuizen A, Thijs LG (2001) Relative adrenal failure in intensive care: an identifiable problem requiring treatment? Baillieres Best Pract Res Clin Endocrinol Metab 15:513–531CrossRefGoogle Scholar
  16. 16.
    Marik PE (2004) Unraveling the mystery of adrenal failure in the critically ill. Crit Care Med 32:596–597CrossRefGoogle Scholar
  17. 17.
    Hamrahian AH, Oseni TS, Arafah BM (2004) Measurements of serum free cortisol in critically ill patients. N Engl J Med 350:1629–1638CrossRefGoogle Scholar
  18. 18.
    Wagner RL, White PF, Kan PB, Rosenthal MH, Feldman D (1984) Inhibition of adrenal steroidogenesis by the anesthetic etomidate. N Engl J Med 310:1415–1421Google Scholar
  19. 19.
    De Jong FH, Mallios C, Jansen C, Scheck PAE, Lamberts SWJ (1984) Etomidate suppresses adrenocortical function by inhibition of 11β-hydroxylation. J Clin Endocrinol Metab 59:1143–1147Google Scholar
  20. 20.
    Watt I, Ledingham ImcA (1984) Mortality amongst multiple trauma patients admitted to an intensive therapy unit. Anaesthesia 39:973–981Google Scholar
  21. 21.
    Fragen RJ, Shanks CA, Molteni A (1983) Effect on plasma cortisol concentrations of a single induction dose of etomidate or thiopentone. Lancet II:625Google Scholar
  22. 22.
    Duthie DJR, Fraser R, Nimmo WS (1985) Effect of induction of anaesthesia with etomidate on corticosteroid synthesis in man. Br J Anaesth 57:156–159Google Scholar
  23. 23.
    Absalom A, Pledger D, Kong A (1999) Adrenocortical function in critically ill patients 24 h after a single dose of etomidate. Anaesthesia 54:861–867CrossRefGoogle Scholar
  24. 24.
    Schenarts CL, Burton JH, Riker RR (2001) Adrenocortical dysfunction following etomidate induction in emergency department patients. Acad Emerg Med 8:1–7Google Scholar
  25. 25.
    Wichmann MW, Inthorn D, Andress HJ, Schildberg FW (2000) Incidence and mortality of severe sepsis in surgical intensive care patients: the influence of patient gender on disease process and outcome. Intensive Care Med 26:167–172CrossRefGoogle Scholar
  26. 26.
    Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky MR (2001) Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med 29:1303–1310CrossRefPubMedGoogle Scholar
  27. 27.
    EPISEPSIS Study Group (2004) EPISEPSIS: a reappraisal of the epidemiology and outcome of severe sepsis in French intensive care units. Intensive Care Med 30:580–588CrossRefGoogle Scholar
  28. 28.
    Samy TSA, Rue III LW, Chaudry IH (2003) Critical role of hormones in traumatic injury and outcome. In: Vincent JL (ed) Yearbook of intensive care and emergency medicine, Springer, Berlin Heidelberg New York, pp 861–872Google Scholar
  29. 29.
    Remmers DE, Wang P, Cioffi WG, Bland KI, Chaudry IH (1997) Testosterone receptor blockade after trauma-hemorrhage improves cardiac and hepatic functions in males. Am J Physiol Heart Circ Physiol 273:H2919–H2925Google Scholar
  30. 30.
    Ba ZF, Wang P, Koo DJ, Zhou M, Cioffi WG, Bland KI, Chaudry IH (2000) Testosterone receptor blockade after trauma and hemorrhage attenuates depressed adrenal function. Am J Physiol Regul Integr Comp Physiol 279:R1841–R184Google Scholar

Copyright information

© Springer-Verlag 2005

Authors and Affiliations

  • Gabriel Malerba
    • 1
  • Florence Romano-Girard
    • 3
  • Aurélie Cravoisy
    • 2
  • Brigitte Dousset
    • 4
  • Lionel Nace
    • 1
  • Bruno Lévy
    • 2
  • Pierre-Edouard Bollaert
    • 2
    Email author
  1. 1.Service d’aide médicale urgenteCentre Hospitalier UniversitaireNancy CedexFrance
  2. 2.Service de Réanimation MédicaleCentre Hospitalier UniversitaireNancy CedexFrance
  3. 3.Service d’Epidémiologie et Evaluation CliniqueCentre Hospitalier UniversitaireNancy CedexFrance
  4. 4.Laboratoire de BiochimieCentre Hospitalier UniversitaireNancy CedexFrance

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