Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content +++ 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.1–4 ++ ++Table Graphic Jump LocationTABLE 60-1Common Etiologies of Adrenal Insufficiency View Table||Download (.pdf) TABLE 60-1 Common Etiologies of Adrenal Insufficiency Location Etiology Pathophysiology Central Hypothalamic or pituitary disease Brain injury/brain death Recent or chronic steroid use Peripheral Preexisting adrenal failure Addison's disease, congenital adrenal hyperplasia (CAH) Acute adrenal destruction Adrenal hemorrhage, autoimmune adrenalitis P450 enzyme dysfunction Etomidate, antifungals (azoles), sepsis, prematurity Increased clearance Occurs with phenytoin, phenobarbital, rifampin End-organ/tissue/cellular unresponsiveness Cytokines and inflammatory mediators can alter glucocorticoid receptor sensitivity Other Sepsis/inflammation HPA axis suppression secondary to CIRCI HPA, hypothalamic pituitary axis; CIRCI, critical illness related corticosteroid 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 Graphic Jump LocationTABLE 60-2Diagnostic Criteria, Dose of ACTH Used for Adrenal Stimulation, and Incidence of Adrenal Insufficiency in Children with Septic Shock View Table||Download (.pdf) TABLE 60-2 Diagnostic Criteria, Dose of ACTH Used for Adrenal Stimulation, and Incidence of Adrenal Insufficiency in Children with Septic Shock Authors Diagnostic Criteria ACTH Dose Used Incidence of AI Hatherill et al. Peak cortisol increase <7 μg/dL 145 μg/m2 52% Bone et al. A.M. basal cortisol <5 μg/dL; 0.5 μg/m2 17% Peak cortisol <18 μg/dL Pizarro et al. Peak control increase <9 μg/dL 250 μg 44% Menon et al. Basal cortisol <7 μg/dL 125 μg (<10 kg) 31% Peak cortisol <18 μg/dL 250 μg (>10 kg) ACTH, adrenocorticotropin hormone. AI, adrenal insufficiency. Peak cortisol is cortisol level after administration of ACTH. +++ 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 ... Your Access profile is currently affiliated with [InstitutionA] and is in the process of switching affiliations to [InstitutionB]. Please select how you would like to proceed. Keep the current affiliation with [InstitutionA] and continue with the Access profile sign in process Switch affiliation to [InstitutionB] and continue with the Access profile sign in process Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Error: Incorrect UserName or Password Username Error: Please enter User Name Password Error: Please enter Password Sign in Forgot Password? Forgot Username? Download the Access App: iOS | Android Sign in via OpenAthens Sign in via Shibboleth You already have access! Please proceed to your institution's subscription. Create a free profile for additional features.