May 2008
Dr Wong Wai Tat
Resident specialist, Caritas Medical Centre
Background: Recent review concluded that corticosteroid replacement had a beneficial effect on mortality in patients with septic shock and relative adrenal insufficiency (RAI). Previous study had demonstrated improved adrenocortical response to ACTH in septic shock patients after entering the recovery phase. The duration of corticosteroid treatment was recommended as 5 to 11 days. However, the duration of relative adrenal insufficiency and optimal duration of corticosteroid treatment remains unclear.
Objectives: To evaluate the change of the adrenocortical function in patients with severe sepsis or septic shock in the acute phase and the recovery phase by serial ACTH stimulation tests, to look for factors associated with delayed recovery of the adrenocortical function in septic patients, to assess the duration of the adrenal insufficiency in sepsis and to discuss the optimal duration of stress dose corticosteroid treatment.
Study design: This is a prospective observational study performed in the intensive care unit in a general district hospital. Totally 51 patients were enrolled in the initial acute phase of severe sepsis. 20 survived patients had serial short synacthen tests performed. Serial short synacthen tests were repeated on day 14, day 28 and day 90.
Results: 60.9 percent of patient with severe sepsis and septic shock was diagnosed to have relative adrenal insufficiency. 28 day mortality of patients with relative adrenal insufficiency was 32.2%. They were found to be associated with requirement of higher dose of vasopressor, higher bilirubin and ALT level on admission. Basal and peak cortisol level significantly decline in both groups of patients in the recovery phase. Delta cortisol level significantly drop in RAI group of patients, but not in non-RAI group of patients. 95% of patient had their adrenal function fully recovered as judged by the peak cortisol level.
Conclusion: Non RAI and RAI patients had different behavior in the adrenal function from the acute phase to the recover phase. Relative adrenal insufficiency is a genuine phenomenon in patients with severe sepsis and septic shock. Most of the patients had their adrenal function recovered within two weeks, replacement corticosteroid for vasopressor dependent septic shock should not be longer than two weeks.
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