Adrenal insufficiency in the critically III trauma population

Area of Science:

• Critical Care Medicine
• Endocrinology
• Trauma Surgery

Background:

• Acute adrenal insufficiency is a known complication in patients with shock.
• The prevalence and impact of occult adrenal insufficiency in critically ill trauma patients require further investigation.
• Hypoproteinemia (low albumin) may affect the reliability of random cortisol levels in diagnosing adrenal insufficiency.

Purpose of the Study:

• To evaluate the rate of occult adrenal insufficiency in critically ill trauma patients.
• To determine the influence of hypoproteinemia on using random cortisol levels as a marker for adrenal insufficiency.
• To assess the outcomes of untreated occult adrenal insufficiency in this population.

Main Methods:

• Prospective enrollment of 41 critically ill trauma patients in the trauma intensive care unit.
• Collection of random total serum cortisol and albumin levels on hospital Days 1, 4, 8, and 14.
• Definition of occult adrenal insufficiency as cortisol < 25 mcg/dL with albumin > 2.5 g/dL.

Main Results:

• Prevalence of low cortisol (< 25 mcg/dL) ranged from 51-81% and peaked on Days 4 and 8.
• Prevalence of low albumin (≤ 2.5 g/dL) ranged from 37-60% and also peaked on Days 4 and 8.
• Patients with low albumin showed a high prevalence of low cortisol (67-100%); adrenal insufficiency (low cortisol, normal albumin) prevalence was 41-82%.
• None of the patients with occult adrenal insufficiency received steroids; survival was 100%.

Conclusions:

• Occult adrenal insufficiency is a common and dynamic condition in critically ill trauma patients, potentially resolving during illness.
• A random cortisol level of 25 mcg/dL may not be an adequate marker; low albumin predicts low cortisol.
• Hemodynamically stable occult adrenal insufficiency in trauma patients does not require steroid replacement, with excellent survival rates observed.