A 3-level prognostic classification in septic shock based on cortisol levels and cortisol response to corticotropin

Context The hypothalamic-pituitary-adrenal axis is a major determinant of t he host response to stress. The relationship between its activation and pat ient outcome is not known. Objective To evaluate the prognostic Value of cortisol levels and a short c orticotropin stimulation test in patients with septic shock. Design and Setting Prospective inception cohort study conducted between Oct ober 1991 and September 1995 in 2 teaching hospital adult intensive care un its in France. Participants A total of 189 consecutive patients who met clinical criteria for septic shock. Intervention A short corticotropin stimulation test was p erformed in all patients by intravenously injecting 0.25 mg of tetracosactr in; blood samples were taken immediately before the test (T0) and 30 (T30) and 60 (T60) minutes afterward, Main Outcome Measures Twenty-eight-day mortality as a function of variables collected at the onset of septic shock, including cortisol levels before t he corticotropin test and the cortisol response to corticotropin (Delta max , defined as the difference between T0 and the highest value between T30 an d T60). Results The 28-day mortality was 58% (95% confidence interval [CI], 51%-65% )and median time to death was 17 days (95% CI, 14-27 days). In multivariate analysis, independent predictors of death (P less than or equal to.001 for all) were McCabe score greater than 0, organ system failure score greater than 2, arterial lactate level greater than 2.8 mmol/L, ratio of PaO2 to fr action of inspired oxygen no more than 160 mm Hg, cortisol level at T0 grea ter than 34 mu g/dL and Delta max no more than 9 mu g/dL. Three groups of p atient prognoses were identified: good (cortisol level at T0 less than or e qual to 34 mu g/dL and Delta max >9 mu g/dL; 28-day mortality rate, 26%), i ntermediate (cortisol level at T0 34 mu g/dL and Delta max less than or equ al to 9 mu g/dL or cortisol level at T0 >34 mu g/dL and Delta max >9 Delta g/dL; 28-day mortality rate, 67%), and poor (cortisol level at T0 >34 mu g/ dL and Delta max less than or equal to 9 mu g/dL; 28-day mortality rate, 82 %). Conclusion Our data suggest that a short corticotropin test has a good prog nostic value and could be helpful in identifying patients with septic shock at high risk for death.