Assessment of adrenocortical function in the critically ill

Area of Science:

• Critical Care Medicine
• Endocrinology
• Internal Medicine

Background:

• Adrenal insufficiency's role in critically ill patients is under renewed investigation.
• The debate on steroid use in sepsis and the prevalence of adrenal insufficiency in critical illness continues.
• Adrenocortical function is vital for survival during critical illness, but its definition in this context is unclear.

Purpose of the Study:

• To review current concepts in diagnosing adrenocortical disease in critically ill patients.
• To examine the controversy surrounding steroid use in sepsis and adrenal insufficiency diagnosis.
• To clarify the diagnostic challenges of adrenal insufficiency in the intensive care setting.

Main Methods:

• A comprehensive review of existing literature on adrenocortical insufficiency in acutely ill patients.
• Analysis of studies addressing the diagnosis and management of adrenal dysfunction in critical care.
• Synthesis of current evidence regarding cortisol levels and ACTH stimulation tests.

Main Results:

• Absolute adrenal insufficiency is uncommon in intensive care units; relative adrenal insufficiency diagnosis is debated.
• Elevated basal cortisol with a blunted response to ACTH stimulation characterizes relative adrenal insufficiency.
• Current diagnostic criteria for adrenal insufficiency in critically ill patients lack consensus.

Conclusions:

• No definitive gold standard exists for diagnosing adrenal insufficiency in critical illness.
• Interpreting single cortisol values requires caution; repeat measurements and awareness of assay variations are crucial.
• Plasma free cortisol and low-dose ACTH testing may offer more relevant insights than total cortisol and high-dose testing, warranting further research.