Adrenal insufficiency in cardiothoracic patients: An evaluation of the corticotrophin stimulation test and other diagnostic methods

• Published in: Journal of critical care Vol. 27; no. 5; pp. 528.e1 - 528.e6
• Main Authors: Eriksson, Evert A., MD, Willekes, Charles L., MD, FACS, McAllen, Karen J., PharmD, Romeo, Oreste M., MD, Hooker, Robert L., MD, FACS, Hoogeboom, James E., DO, FCCM, FACOS, Barletta, Jeffrey F., PharmD, FCCM
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.10.2012; Elsevier Limited
• Subjects: Adrenal glands; Adrenal insufficiency; Adrenal Insufficiency - diagnosis; Adrenal Insufficiency - drug therapy; Adrenocorticotropic Hormone - administration & dosage; Aged; Cardiac Surgical Procedures - statistics & numerical data; Cardiothoracic surgery; Corticotropin; Critical Care; Diabetes; Dose-Response Relationship, Drug; Female; Heart failure; Heart surgery; Humans; Hypertension; Hypotheses; Incidence; Liver diseases; Male; Methods; Middle Aged; Morbidity; Mortality; Patients; Pituitary gland; Population; Prospective Studies; Response rates; Stress; Vasoconstrictor Agents - administration & dosage; Cardiothoracic surgery; Corticotropin; Adrenal insufficiency
• ISSN: 0883-9441; 1557-8615
• DOI: 10.1016/j.jcrc.2011.12.014

Abstract Purpose The purposes of the study were to determine the incidence of adrenal insufficiency (AI) using several published techniques, compare the response rates using a low-dose (LD) corticotropin (ACTH) stimulation test vs a standard dose (SD), and identify the technique that is most closely related to vasopressor use. Materials and Methods Consecutive adult patients who were undergoing open heart surgery for CAD or valvular disease were prospectively enrolled. Exclusion criteria included history of steroid use, operative steroid, or etomidate administration. Postoperatively, each patient underwent ACTH stimulation with 1 μ g (LD) and 249 μ g (SD), 60 minutes apart. Agreement among the tests was evaluated, and vasopressor use was compared between groups. Results There were 40 patients evaluated. The incidence of AI based on operative change, postoperative values, and LD-ACTH and SD-ACTH tests was 53%, 38%, 60%, and 38%, respectively. Agreement between the LD- and SD-ACTH tests was 73% ( κ = 0.476, P = .001). There was a significant difference in the need for (93% vs 52%, P = .013) and duration (18.9 [0-180.6] vs 0.6 [0-73.2] hours, P = .003) of vasopressor therapy in patients with and without AI but only using the SD-ACTH definition. Conclusion The incidence of AI will vary greatly based on technique used for diagnosis. The SD-ACTH stimulation test should be used to determine AI in open heart patients postoperatively because of the close association with vasopressor usage.