Adrenal Insufficiency in Critically Ill Patients: Drugs, Mechanisms, and Impact, Slides of Medicine

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ADRENAL INSUFFICIENCY

IN THE CRITICALLY ILL

PATIENT

Physiology,Diagnosis,Management.

DRUG MECHANISM IMPACT EXAMPLE

Estrogen Increased CBG

Higher total cortisol; Normal free cortisol

Estrogen, oral contraceptives; pregnancy; hepatitis

Ketoconazole

Decreased synthesis of cortisol

Lower serum cortisol; low free cortisol Patients receiving the drug

Spironolactone

Interference in the assay depending on antibody specificity

Generally higher levels; variable influence depending on the assay specificity

Patients on the drug

Aminoglutathemide Inhibit cortisol synthesis^

Lower serum total and free cortisol

Patients on the drug e.g., medical adrenalectomy for metastatic breast cancer.

Etomidate

Decreased synthesis due to 11-Beta hydroxylase inhibition

Lower serum cortisol levels; decreased responsiveness to Cosyntropin

Use of the drug

LPS injection → ↑

• ACTH

• Catecholamines

• GH

• Cortisol (11.5 → 29

μ g/dl within 2 hrs)

• Anti-inflammatory

cytokine IL-11 (protective

role during sepsis)

Immunobiology (1993) 187:403 – 416 Infect Immun. 1997 June; 65(6): 2378 – 2381

 Helpful approach in understanding the body’s

response to acute inflammation

 Not considered a good model for sepsis or

septic shock

Experimental Endotoxemia

 Data obtained in patients during experimental

endotoxemia cannot be extrapolated/applied to others

with sepsis or septic shock