Wilma E. Monteban-Kooistra

Multicentric, Randomized, Controlled Trial to Evaluate Blood Glucose Control by the Model Predictive Control Algorithm Versus Routine Glucose Management Protocols in Intensive Care Unit Patients: Response to Plank et al.

In the February issue of Diabetes Care , Plank et al. (1) reported the results of their computer-assisted model predictive control (MPC) algorithm versus routine glucose management in 60 postoperative thoracosurgical patients in three different hospitals. We agree that better glycemic control is worth …

The ACTH test should not be used in the decision to start low dose steroids in catecholamine-dependent septic shock

In the August issue of Intensive Care Medicine Dr. Morel and collegues [1] report that the results of the ACTH stimulation test did not predict hemodynamic improvement in catecholamine-dependent septic shock patients managed with lowdose steroid therapy. The ACTH stimulation test was introduced as a test for adrenocortical insufficiency by George Thorn [2] in 1948. However, plasma concentrations of cortisol, one of the products of the adrenal cortex, are usually increased and even high in critically ill patients [3]. Therefore, why should we actually test the function of an organ that appears to be functioning well? We agree, that several studies have shown a beneficial effect of low dose steroids on hemodynamic improvement [4, 5, 6]. This suggests alternative methods of action: so-called low-dose steroid therapy results in plasma cortisol levels of 3350 nmol/l, which is threeto fivefold higher than the already increased concentrations found in critically ill patients [7]. We agree with the conclusion of Dr. Morel et al. and would like to emphasize that there is no evidence to support a treatment strategy based on a random or stimulated cortisol level. For cost containment, patient comfort, and prevention of time loss we should skip the ACTH stimulation test. Rapid hemodynamic improvement of catecholamine-dependent patients after substitution with low-dose steroids still is the best available clue to diagnosis [8]. Fixation on adrenal insufficiency hampers unbiased research of the working mechanisms of low-dose steroids in shock. Unraveling this problem might lead to new therapies with fewer side effects.