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ADRENAL INSUFFICIENCY AND CRITICAL ILLNESS

BACKGROUND

  • An acquired, reversible adrenal insufficiency can occur in any critically ill patient, but occurs most commonly in the context of sepsis and septic shock. Common etiologies of adrenal insufficiency in critical illness are listed in Table 60-1.

  • Many of the patients who are admitted to the ICU have been/are on chronic steroid therapy and may lack an intact hypothalamic–pituitary axis (HPA), leading to refractory hypotension.

  • The incidence of adrenal insufficiency ranges widely (17%–52%) in children with septic shock. This variability is partly due to the lack of consensus in terms of diagnostic strategies.14

TABLE 60-1

Common Etiologies of Adrenal Insufficiency

DIAGNOSIS

  • A diagnosis of adrenal insufficiency may be made by checking a cortisol level (morning or random), but may need to be verified with an adrenocorticotropic hormone (ACTH) stimulation test.

  • There is variability in corticotropin stimulation testing dosing, using basal cortisol values vs. threshold values after corticotropin stimulation, and controversy over whether to use total vs. free cortisol levels. Table 60-2 reveals the variability in diagnostic criteria.

TABLE 60-2

Diagnostic Criteria, Dose of ACTH Used for Adrenal Stimulation, and Incidence of Adrenal Insufficiency in Children with Septic Shock

TREATMENT

  • In cases of adrenal insufficiency, hydrocortisone is generally started at 50 mg/m2/day divided every 6 hours.

    • Dosing should be verified to ensure that the patient is actually on “stress dose” steroids in relation to their previous dose of steroid.

  • In sepsis, hydrocortisone is given as a daily stress dose of 50 mg/m2 or divided over 24 hours as currently recommended ...

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