POSTOPERATIVE ACUTE ADRENAL FAILURE CAUSED BY TRANSIENT CORTICOTROPINDEFICIENCY

Background. Acute adrenal insufficiency after a surgical procedure or trauma is rarefy reported. In recent years, however, we have treated s even patients with acute primawry adrenal insufficiency and three pati ents with secondary adrenal insufficiency who presented with shock aft er a surgical procedure or trauma. The standard cosyntropin test was m isleading for the diagnosis of corticotropin deficiency. Methods. In t his study we measured serum cortisol in patients older than 65 years w ho had unexplained hypotension after an abdominal surgical procedure. If the serum cortisol was less than 15 mu g/dl, we performed 1 mu g an d standard (250 mu g) cosyntropin tests and measured thyroxine, thyrot ropin, leutinizing hormone in all patients, and free testosterone in m en. Results. We identified five (5%) of 105 patients after an operatio n who displayed evidence of corticotropin deficiency (i.e., serum cort isol <15 mu g/dl during hypotension, prompt hemodynamic improvement wi th glucocorticoid therapy, and normal response to standard dose cosynt ropin). In these patients 1 mu g cosyntropin produced abnormal peak co rtisol levels. These patients also had thyrotropin or leutinizing horm one deficiency. After recovery the low hormone levels improved or beca me normal. Conclusions. Postoperative adrenal insufficiency, particula rly that caused by transient corticotropin deficiency, is more common in patients than currently recognized. The 1 mu g cosyntropin test may be more sensitive than the standard test for identifying secondary ad renal insufficiency.