3 Incidence of adrenal insufficiency in trauma patients.
Article Type: Perspectiva general de la enfermedad/trastorno
Subject: Enfermedad de Addison (Cuidado y tratamiento)
Enfermedad de Addison (Investigacion cientifica)
Enfermedad de Addison (Analisis de casos)
Pub Date: 06/01/2009
Publication: Name: Puerto Rico Health Sciences Journal Publisher: Universidad de Puerto Rico, Recinto de Ciencias Medicas Language: Spanish Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2009 Universidad de Puerto Rico, Recinto de Ciencias Medicas ISSN: 0738-0658
Issue: Date: June, 2009 Source Volume: 28 Source Issue: 2
Geographic: Geographic Name: Puerto Rico
Accession Number: 201212352
Full Text: 3 Incidence of Adrenal Insufficiency in Trauma Patients. Ricardo Guerrero MD, Suhein Galloza MD, Pablo Rodriguez MD, Gloria Rodriguez-Vega MD; Department of Surgery, Puerto Rico Trauma Center, University of Puerto Rico, Medical Sciences Campus.

Introduction: Acute adrenal insufficiency (AI) is a condition frequently observed in critically ill trauma patients. This is a major health concern, resulting in severe morbidity and mortality if not diagnosed on time. The reported incidence of AI varies widely (0-77%) depending on the population of patients studied and the diagnostic criteria. Our study evaluated the incidence of acute AI in trauma patients and the clinical predictions of AI. Methods: Sixty-two adult patients admitted to our trauma center were followed with cortisol levels for 6 consecutive days. The incidence of biochemical and clinical AI was evaluated. Biochemical AI was defined as a random plasma cortisol level < 25mcg/dl plus a consyntropin test with a cortisol rise of less than 9mcg/dl. Clinical AI was defined as hemodynamic instability despite adequate administration of intravenous fluids. Blood samples were obtained at arrival and every 24hrs subsequently for 6 days. Exclusion criteria for this study were: previous use of corticosteroids or treatment with corticosteroids upon arrival. The Institutional Review Board of the University of Puerto Rico approved this study. Results: In this study 57(92%) of 62 patients had biochemical AI; one patient had clinical AI (1.6%) and 6.4% did not have biochemical or clinical AI. Thirty-nine patients with biochemical AI were 18 to 25 years old. Most patients had a positive ACTH test done 30 and 60 minutes after cosyntropin administration due to plasma cortisol less than 25mcg/dl (27% & 17%, respectively). At arrival, 38% of the patients had normal cortisol levels between 25-35 mcg/dl; at 24 hrs 37% of the patients had cortisol levels between 5-15mcg/dl. In this study 41 % of patients had non-severe trauma index severity score (TISS); 26% had severe TISS; and 33% had very severe TISS. All patients with TISS had positive biochemical AI, but only one patient with very severe TISS showed clinical AI. Upon arrival, 69% had normal cortisol levels independent of the TISS. Sixty-three (63%) of the patients had undergone some surgical procedure; 68% of the patients operated upon at arrival had normal cortisol. All patients (100%) operated developed biochemical AI at some time during hospitalization; 83% of patients without surgery developed biochemical AI. Concerning expected blood loss (EBL), we observed low plasma cortisol levels in 40% of the patients with less than 500m] EBL; in 28% of patients with 500-750m1 EBL, and in 28% patients with 750-1500m1 EBL. Twenty-nine percent of the patients received less than 2 packed red blood cell (PRBC) transfusions; 50% received more than 2 PRBC transfusions; and 21% had none. Approximately 35% of patients with <2 PRBC transfusions and 37% with > 2 PRBC had low cortisol levels, and 33% of patients with no transfusions also had decreased cortisol levels. From 86% of patients with biochemical AI, 63% stayed at the hospital less than 1 week; 13% left the hospital after 2-3 weeks; and 25% had a length-of-stay of 3-4 weeks. Conclusions: The incidence of biochemical and clinical AI was 92% and 1.6%, respectively. The age group with the highest incidence of biochemical AI was 18-25 years old (40%). The more sensitive parameter for a positive ACTH test was plasma cortisol of less than 25mcg/ml after cosyntropin administration. A large number of patients had a normal cortisol level upon arrival, but we observed a tendency to a progressive daily decrease throughout the hospital stay. This trend may be due to adrenal exhaustion. Patients with very severe TISS show lower cortisol levels. We observed a positive correlation between surgery and development of biochemical AI, but the incidence of biochemical or clinical AI is not related to the necessity of surgery. We did not observe any correlation between the amount of EBL and plasma cortisol levels or the incidence of biochemical AI, but blood loss is directly related to the incidence of biochemical AI. We did not observe an absolute correlation between PRBC transfusions and plasma cortisol. We concluded that development of biochemical AI was a factor independent of PRBC transfusions (p< 0.02). The length of stay at this trauma facility was not related to the incidence of biochemical AI.
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