Relative adrenal insufficiency in post-cardiac arrest shock is under-recognized

Suppression of the adrenal axis may occur frequently in post-cardiac arrest patients. Physiological doses of corticosteroids have been shown to reverse hypotension and decrease mortality in other forms of shock. We sought to investigate current clinical practice pertaining to the evaluation for relative adrenal insufficiency in post-cardiac arrest shock.

We performed a retrospective analysis of post-cardiac arrest patients in an urban emergency department. Inclusion criteria included pre-hospital cardiac arrest patients over the age of 18 with a sustained return of spontaneous circulation that required vasopressor support. Exclusion criteria were traumatic arrest and cardiac arrest in the presence of healthcare personnel. The primary endpoint was the percent of patients in refractory shock that either had their adrenal axis tested or were treated for presumed relative adrenal insufficiency. Data analysis was descriptive in nature.

A total of 79 post-cardiac arrest patients were analyzed. Of the 79 patients, 69 were vasopressor-dependent. Of this group, 13% (9/69) had a cortisol level checked (with or without cosyntropin stimulation). Of those who had a cosyntropin stimulation test performed, 86% met biochemical criteria for relative adrenal insufficiency. Seventeen percent of vasopressor-dependent patients received corticosteroids explicitly for their shock state. Overall, only 32% of patients in refractory shock had testing for relative adrenal insufficiency or received corticosteroids for shock.

Though vasopressor-dependent shock is common in post-cardiac arrest patients, adrenal insufficiency was not considered in the majority of cases.