Adrenal dysfunction in hemodynamically unstable patients in the emergency department

Objective: Adrenal failure, a treatable condition, can have catastrophic co nsequences if unrecognized in critically ill ED patients. The authors' obje ctive was; to prospectively study adrenal function in a case,series of hemo dynamically unstable (highrisk) patients from a large, urban ED over a 12-m onth period. Methods: In a prospective manner, critically ill adult patient s presenting to the ED were enrolled when presenting with a: mean arterial blood pressure less than or equal to 60 mm Hg requiring vasopressor therapy for more than one: hour after receiving fluid resuscitation (central venou s pressure of 12-15 mm Hg or a minimum of 40 mL/kg of crystalloid). Patient s were excluded if presenting with hemorrhage, trauma, or AIDS, or if stero ids were used, within the previous six months. An adrenocorticotropic hormo ne (ACTH) stimulation test was performed and serum cortisol was measured. T reatment for adrenal insufficiency was not instituted. Results: A total of 57 consecutive patients were studied. Of these, eight (14%) had baseline se rum cortisol concentrations of <20 mu g/dL (<552 nmol/L), which was conside red adrenal insufficiency (AI). Three additional patients (5%) had subnorma l 60-minute post-ACTH-stimulation cortisol responses (<30. mu g/dL) and a d elta cortisol less than or equal to 9 mu g/dL, which is the difference betw een the baseline and 60-minute levels. This is functional hypoadrenalism (F H). There were no laboratory abnormalities that distinguished patients with AI or FH from those with presented adrenal function (PAF). Rates of surviv al to discharge did not differ between the Al group (7 of 8) and PAF patien ts (21 of 46; p = 0.052). Conclusions: Adrenal dysfunction is common in hig h-risk ED patients. Overall, it has a frequency of 19% among a homogeneous population of hemodynamically unstable vasopressor-dependent patients. The effect of physiologic glucocorticoid replacement in this setting remains to be determined.