Document Detail

Diagnosis of corticosteroid insufficiency in Thai patients with septic shock.
MedLine Citation:
PMID:  20364574     Owner:  NLM     Status:  MEDLINE    
BACKGROUND: The reported incidence of critical illness-related corticosteroid insufficiency (CIRCI) varies widely, depending on the patient population studied and the diagnostic criteria used. Surviving Sepsis Campaign guidelines suggest that corticosteroid therapy should be considered for adult septic shock when hypotension responds poorly to adequate fluid resuscitation and vasopressors, regardless of any results of diagnostic tests. However, steroid treatment may be associated with an increase risk of infection. This study aims to identify the best diagnostic tool for predicting responsiveness to corticosteroid therapy in Thai septic shock patients with poorly responsive to fluid resuscitation and vasopressors. MATERIAL AND METHOD: Twenty-nine septic shock patients who were poorly responsive to fluid therapy and vasopressors were studied. A baseline serum total cortisol was measured in all patients and then 250 mcg corticotropin was injected to patients. Cortisol level was obtained 30 and 60 minutes after injection. All patients were given hydrocortisone (100 mg i.v., then 200 mg i.v. in 24 hrs for at least 5 days). Patients were considered steroid responsive if vasopressor agent could be discontinued within 48 hrs after the first dose of hydrocortisone. RESULTS: Hospital mortality was 62% in which 45% of the patients were steroid responsive. Baseline serum cortisol was 27.6 +/- 11.4 microg/dl in the steroid-responsive patients compared with 40 +/- 16.9 microg/dl in the steroid-nonresponsive patients (p = 0.03). The area under the ROC curves for predicting steroid responsiveness was 0.72 for baseline cortisol level. Serum cortisol level of 35 microg/dl or less was the most accurate diagnostic threshold to determine hemodynamic response to hydrocortisone treatment (p = 0.04). Using baseline cortisol level of < or = 35 microg/dl to diagnose adrenal insufficiency, the sensitivity was 85%, the specificity was 62% and the accuracy was 72%. A use of (delta cortisol) showed sensitivity of 50%, specificity of 30% and accuracy of 41%. CONCLUSION: Baseline cortisol level < or = 35 microg/dl is a useful diagnostic threshold for diagnosis of steroid responsiveness in Thai patients with septic shock and ACTH stimulation test should not be used.
Ranistha Ratanarat; Panuwat Promsin; Apiradee Srivijitkamol; Chantanij Leemingsawat; Chairat Permpikul
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Publication Detail:
Type:  Journal Article    
Journal Detail:
Title:  Journal of the Medical Association of Thailand = Chotmaihet thangphaet     Volume:  93 Suppl 1     ISSN:  0125-2208     ISO Abbreviation:  J Med Assoc Thai     Publication Date:  2010 Jan 
Date Detail:
Created Date:  2010-04-06     Completed Date:  2010-05-04     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  7507216     Medline TA:  J Med Assoc Thai     Country:  Thailand    
Other Details:
Languages:  eng     Pagination:  S187-95     Citation Subset:  IM    
Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Siriraj hospital, Mahidol University, Bangkok, Thailand.
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MeSH Terms
Adrenal Cortex Function Tests / methods
Adrenal Insufficiency / diagnosis*,  epidemiology,  etiology
Adrenocorticotropic Hormone / diagnostic use
Fluid Therapy
Follow-Up Studies
Hospital Mortality
Hydrocortisone / blood,  therapeutic use*
Hypothalamo-Hypophyseal System / physiopathology
Middle Aged
Pituitary-Adrenal System / physiopathology
Prospective Studies
Sensitivity and Specificity
Shock, Septic / blood,  drug therapy*,  epidemiology
Vasoconstrictor Agents / therapeutic use
Reg. No./Substance:
0/Vasoconstrictor Agents; 50-23-7/Hydrocortisone; 9002-60-2/Adrenocorticotropic Hormone

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