Skip to main content
SpringerLink
Log in

Adrenal axis function does not appear to be associated with hemodynamic improvement in septic shock patients systematically receiving glucocorticoid therapy

  • Original
  • Published:
Intensive Care Medicine Aims and scope Submit manuscript

Abstract

Objective

There is mounting evidence showing the value of low-dose corticosteroids in patients with septic shock requiring vasopressor therapy. It remains unclear whether adrenal function tests should be carried out systematically to guide the decision on glucocorticoid therapy.

Methods

The retrospective study was conducted in 52 patients in three university hospital ICUs. We included consecutive patients with catecholamine-dependent septic shock who had not received ketoconazole, glucocorticoids, or etomidate in the 24 h before the ACTH test, and who had survived to day 3 after the shock onset. All patients had a 250-μg ACTH test before systematic glucocorticoid therapy was started. Various definitions of relative adrenal insufficiency were used (based on cortisol basal level and/or change in cortisol level after ACTH stimulation). We defined hemodynamic improvement as a 50% reduction in the vasoactive agent dose in the 3 days following the initiation of glucocorticoid treatment. The relationship between the hemodynamic improvement and the results of the adrenal function tests was analyzed.

Results

Hemodynamic improvement occurred in 29 patients (55.8%). Baseline characteristics, sites of infection, types of micro-organisms and antibiotic management did not differ between patients with and those without hemodynamic improvement. Relative adrenal insufficiency whatever the definition was not associated with hemodynamic improvement.

Conclusion

In catecholamine-dependent septic shock patients managed with systematic glucocorticoid therapy the results of ACTH stimulation do not predict hemodynamic improvement.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Prigent H, Maxime V, Annane D (2004) Clinical review: corticotherapy in sepsis. Crit Care 8:122–129

    Article  PubMed  Google Scholar 

  2. Annane D, Sebille V, Troché G, Raphael JC, Gajdos P, Bellissant E (2000) A3-level prognostic classification in septic shock based on cortisol levels and cortisol response to corticotropin JAMA 283:1038–1045

  3. Annane D, Sebille V, Charpentier C, Bollaert PE, Francois B, Korach JM, Capellier G, Cohen Y, Azoulay E, Troche G, Chaumet-Riffaut P, Bellissant E (2002) Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA 288:862–871

    Article  PubMed  CAS  Google Scholar 

  4. Annane D, Bellissant E, Bollaert PE, Briegel J, Keh D, Kupfer Y (2004) Corticosteroids for treating severe sepsis and septic shock (Cochrane Review). In: The Cochrane Library, issue 2. Wiley, Chichester

  5. Minneci PC, Deans KJ, Banks SM, Eichacker PQ, Natanson C (2004) Meta-analysis: the effect of steroids on survival and shock during sepsis depends on the dose. Ann Intern Med 141:47–56

    PubMed  CAS  Google Scholar 

  6. Keh D, Sprung CL (2004) Use of corticosteroid therapy in patients with sepsis and septic shock: an evidence base review. Crit Care Med 32 [Suppl] 527–533

    Google Scholar 

  7. Dellinger RP, Carlet JM, Masur H, Gerlach H, Calandra T, Cohen J, Gea-Banaloche J, Keh D, Marshall JC, Parker MM, Ramsay G, Zimmerman JL, Vincent JL, Levy MM (2004) Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Intensive Care Med 30:536–555

    Article  PubMed  Google Scholar 

  8. Vincent JL, Abraham E, Annane D, Bernard G, Rivers E, Van den Berghe G (2002) reducing mortality in sepsis: new directions. Crit Care 6 [Suppl 3]:1–18

    Google Scholar 

  9. American College of Chest Physicians/ Society of Critical Care Medicine Consensus Conference (1992) Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit Care Med 20:864–874

    Article  Google Scholar 

  10. Raphael JC, Antony I, Bellissant E, Bonmarchand J, Cotting J, Fierobe L, Gouyon JB, Hasselmann G, Leleu G, Misset B, Thevenin D (1996) Utilisation des catecholamines au cours du choc septique (adultes-enfants) XVeme conference de consensus en réanimation et médecine d' urgence. Reanimation Soins Intensifs Med Urgence 5:441–450

    Google Scholar 

  11. McCabe WR, Jackson GG (1962) Gram-negative bacteraemia etiology and ecology. Arch Intern Med 110:847–852

    Google Scholar 

  12. Le Gall JR, Lemeshow S, Saulnier F (1993) A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. JAMA 270:2957–2963

    Article  PubMed  Google Scholar 

  13. Vincent JL, Moreno R, Takala J, Wilatts S, De Mendonça A, Bruining H, Reinhart CK, Suter PM, Thijs LG (1996) The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. Intensive Care Med 22:707–710

    Article  PubMed  CAS  Google Scholar 

  14. Marik PE, Zaloga GP (2003) Adrenal insufficiency during septic shock. Crit Care Med 31:141–145

    Article  PubMed  CAS  Google Scholar 

  15. Bollaert PE, Charpentier C, Levy B, Debouverie M, Audibert G, Larcan A (1998) Reversal of late septic shock with supraphysiologic doses of hydrocortisone. Crit Care Med 26:645–650

    Article  PubMed  CAS  Google Scholar 

  16. Oppert M, Reinicke A, Graf KJ, Barckow D, Frei U, Eckardt KU (2000) Plasma cortisol levels before and during ‘low-dose’ hydrocortisone therapy and their relationship to haemodynamic improvement in patients with septic shock. Intensive Care Med 26:1747–1755

    Article  PubMed  CAS  Google Scholar 

  17. Luce JM (2004) Physicians should administer low-dose corticosteroids selectively to septic patients until an ongoing trial is completed. Ann Intern Med 141:70–72

    PubMed  CAS  Google Scholar 

  18. Annane D (2002) Cortisol replacement for severe sepsis and septic shock: what should I do? Crit Care 6:190–191

    Article  PubMed  Google Scholar 

  19. Annane D, Bellissant E, Sebille V, Lesieur O, Mathieu B, Raphael JC, Gajdos P (1998) impaired pressor sensitivity to noradrenaline in septic shock patients with and without impaired adrenal function reserve. Br J Clin Pharmacol 46:589–597

    Article  PubMed  CAS  Google Scholar 

  20. Annane D, Bellissant E (2000) Effect of hydrocortisone on phenylephrine-mean arterial pressure dose response relationship in septic shock. Clin Pharmacol Ther 68:293–303

    Article  PubMed  Google Scholar 

  21. Schenarts CL, Burton JH, Riker RR (2001) Adrenocortical dysfunction following etomidate induction in emergency department patients. Acad Emerg Med 8:1–7

    Article  PubMed  CAS  Google Scholar 

  22. Absalom A, Pledger D, Kong A (1999) Adrenocortical function in critically ill patients 24 h after a single dose of etomidate. Anaesthesia 54:861–867

    Article  PubMed  CAS  Google Scholar 

  23. Malerba G, Romano-Girard F, Cravoisy A, Dousset B, Nace L, Levy B, Bollaert PE (2005) Risk factors of relative adrenocortical deficiency in intensive care patients needing mechanical ventilation. Intensive Care Med 31:388–392

    Article  PubMed  Google Scholar 

  24. Annane D (2005) ICU physicians should abandon the use of etomidate! Intensive Care Med 31:325–326

    Google Scholar 

  25. Cooper MS, Stewart PM (2003) Corticosteroid insufficiency in acutely ill patients. N Engl J Med 348:727–734

    Article  PubMed  CAS  Google Scholar 

  26. Abraham E, Evans T (2002) Corticosteroids and septic shock. JAMA 288:886–887

    Article  PubMed  Google Scholar 

  27. Hamrahian AH, Oseni TS, Arafah BM (2004) Measurements of serum free cortisol in critically ill patients. N Engl J Med 350:1629–1638

    Article  PubMed  CAS  Google Scholar 

  28. Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson E, Tomlanovich M (2000) Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 345:1368–1377

    Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Polyvalent Intensive Care Unit, Hospital Bellevue, 42055, Saint Etienne Cedex 2, France

    Jerome Morel, Christophe Venet, David Charier, Stephane Guyomarc'h, Eric Diconne, Jean Claude Bertrand & Fabrice Zeni

  2. Medical Intensive Care Unit, Hôpitaux sud, Marseille, France

    Yannis Donati & Laurent Papazian

  3. Medical Intensive Care Unit, Hôpital Mont-pieds, Clermont-Ferrand, France

    Jerome Liotier & Bertrand Souweine

  4. Laboratory of nuclear medicine Hospital Bellevue, Saint Etienne, France

    Delphine Frere-Meunier

Authors
  1. Jerome Morel
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Christophe Venet
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Yannis Donati
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. David Charier
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Jerome Liotier
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Delphine Frere-Meunier
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Stephane Guyomarc'h
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Eric Diconne
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Jean Claude Bertrand
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Bertrand Souweine
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Laurent Papazian
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Fabrice Zeni
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Fabrice Zeni.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Morel, J., Venet, C., Donati, Y. et al. Adrenal axis function does not appear to be associated with hemodynamic improvement in septic shock patients systematically receiving glucocorticoid therapy. Intensive Care Med 32, 1184–1190 (2006). https://doi.org/10.1007/s00134-006-0233-3

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00134-006-0233-3

Keywords

Search

Navigation