M Zervou

Adrenal hyporesponsiveness to the low-dose stimulation test (LDST) is associated with a higher mortality in early sepsis and/or septic shock

The aim of the study was to determine the status of the hypothalamic–pituitary–adrenal axis in critically ill patients with early sepsis and/or septic shock and to investigate whether adrenal responses are related to mortality. Forty-two patients (32 male; median age 62 years; range 17–82 years) had cortisol, corticotropin (ACTH) and dehydroepiandrosterone sulphate (DHEAS) levels measured at onset of sepsis and/or septic shock. Adrenal responsiveness was assessed by the LDST. A peak cortisol < 18 μg/dl on the LDST was considered as representing an inadequate response. For the entire patient population, hormone concentrations were as follows (median or mean ± SD values): baseline cortisol 17.8 μg/dl, stimulated cortisol 24.8 ± 9.4 μg/dl, increment in cortisol 5.9 ± 4.4 μg/dl, ACTH 21.2 pg/ml and DHEAS 1553 ± 1157 ng/ml. Eight (19%) of the 42 patients had inadequate cortisol responses following the LDST. Overall, 21 patients died and 21 patients survived. There were no differences between survivors and nonsurvivors with regard to baseline cortisol (17.2 vs 18.9 μg/dl, P = 0.20), stimulated cortisol (23.5 vs 25.1 μg/dl, P = 0.94), ACTH (20.1 vs 26.1 pg/ml, P = 0.48) or DHEAS (1754 ± 1333 vs 1352 ± 939 ng/ml, P = 0.26) levels. In contrast, nonsurvivors had a lower increment in cortisol following the LDST compared with survivors (4.2 ± 3.5 vs 7.5 ± 4.7 μg/dl, P < 0.05). In conclusion, a substantial (19%) proportion of patients has evidence of adrenal hyporesponsiveness at onset of sepsis and/or septic shock. Attenuated adrenal responses are associated with a higher mortality rate in such patients.