Objective: To refine the value of baseline and adrenocorticotropin hormone (ACTH)-stimulated cortisol levels in relation to mortality from severe sepsis or septic shock.
Design: Retrospective multicenter cohort study.
Setting: Twenty European intensive care units.
Patients: Patients included 477 patients with severe sepsis and septic shock who had undergone an ACTH stimulation test on the day of the onset of severe sepsis.
Measurements and Main Results: Compared with survivors, nonsurvivors had higher baseline cortisol levels (29.5 ± 33.5 vs. 24.3 ± 16.5 μg/dL, p = .03) but similar peak cortisol values (37.6 ± 40.2 vs. 35.2 ± 22.9 μg/dL, p = .42). Thus, nonsurvivors had lower Δmax (i.e., peak cortisol minus baseline cortisol) (6.4 ± 22.6 vs. 10.9 ± 12.9 μg/dL, p = .006). Patients with either baseline cortisol levels <15 μg/dL or a Δmax ≤9 μg/dL had a likelihood ratio of dying of 1.26 (95% confidence interval, 1.11–1.44), a longer duration of shock, and a shorter survival time. Patients with a Δmax ≤9 μg/dL but any baseline cortisol value had a likelihood ratio of dying of 1.38 (95% confidence interval, 1.18–1.61).
Conclusions: Although delta cortisol and not basal cortisol level was associated with clinical outcome, further studies are still needed to optimize the diagnosis of adrenal insufficiency in critical illness. Etomidate influenced ACTH test results and was associated with a worse outcome.
From Service de Réanimation, Hôpital Raymond Poincaré (APHP), Faculté de Médecine Paris Ile de France Ouest (UVSQ), Garches, France (DL-F, DA); Department of Anesthesiology and Critical Care Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel (CLS, YW, SVG); Department of Critical Care Medicine, St Luc University Hospital, UCL, Brussels, Belgium (PFL); Institute of Clinical Chemistry (MV) and Department of Anesthesiology (JB), Hospital of the University of Munich, Munich, Germany; Department of Anesthesiology and Intensive Care Medicine, Charité–Berlin University Medicine, Campus Virchow-Clinic, Berlin, Germany (DK); Department of Medicine and Wolfson Institute of Biomedical Research, University College London, London, UK (MS); Unidade de Cuidados Intensivos Polivalente, Hospital de St. António dos Capuchos, Centro Hospitalar de Lisboa (Zona Central), Al. de St. António dos Capuchos, Lisboa, Portugal (RM); and Centre d'Investigation Clinique INSERM 0203, Hôpital de Pontchaillou, Faculté de Médecine, Université de Rennes 1, Rennes, France (EB).
This study has been carried out with financial support from the Commission of the European Communities, specific RTD program “Quality of Life and Management of Living Resources,” QLRT-1999–30589 Corticus. It does not necessarily reflect its views and in no way anticipates the Commission's future policy in this area. The authors also received financial support from the European Society of Intensive Care Medicine and the International Sepsis Forum.
The authors have not disclosed any potential conflicts of interest.
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