title: Adrenal dysfunction in hemodynamically unstable patients in the emergency department.
abstract: OBJECTIVE
  Adrenal failure, a treatable condition, can have catastrophic consequences if unrecognized in critically ill ED patients. The authors' objective was to prospectively study adrenal function in a case series of hemodynamically unstable (high-risk) patients from a large, urban ED over a 12-month period.
  
  
  METHODS
  In a prospective manner, critically ill adult patients presenting to the ED were enrolled when presenting with a mean arterial blood pressure < or =60 mm Hg requiring vasopressor therapy for more than one hour after receiving fluid resuscitation (central venous pressure of 12-15 mm Hg or a minimum of 40 mL/kg of crystalloid). Patients were excluded if presenting with hemorrhage, trauma, or AIDS, or if steroids were used within the previous six months. An adrenocorticotropic hormone (ACTH) stimulation test was performed and serum cortisol was measured. Treatment for adrenal insufficiency was not instituted.
  
  
  RESULTS
  A total of 57 consecutive patients were studied. Of these, eight (14%) had baseline serum cortisol concentrations of <20 microg/dL (<552 nmol/L), which was considered adrenal insufficiency (AI). Three additional patients (5%) had subnormal 60-minute post-ACTH-stimulation cortisol responses (<30 microg/dL) and a delta cortisol < or =9 microg/dL, which is the difference between the baseline and 60-minute levels. This is functional hypoadrenalism (FH). There were no laboratory abnormalities that distinguished patients with AI or FH from those with preserved adrenal function (PAF). Rates of survival to discharge did not differ between the AI group (7 of 8) and PAF patients (21 of 46; p = 0.052).
  
  
  CONCLUSIONS
  Adrenal dysfunction is common in high-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.
authors.affiliation: Department of Emergency Medicine, Case Western Reserve University, Henry Ford Hospital, Detroit, MI 48202, USA. erivers1@hfhs.org
authors.forename: E P
authors.initials: EP
authors.lastname: Rivers
authors.forename: H C
authors.initials: HC
authors.lastname: Blake
authors.forename: B
authors.initials: B
authors.lastname: Dereczyk
authors.forename: J A
authors.initials: JA
authors.lastname: Ressler
authors.forename: E L
authors.initials: EL
authors.lastname: Talos
authors.forename: R
authors.initials: R
authors.lastname: Patel
authors.forename: H A
authors.initials: HA
authors.lastname: Smithline
authors.forename: M Y
authors.initials: MY
authors.lastname: Rady
authors.forename: J
authors.initials: J
authors.lastname: Wortsman
mesh_terms: D000309:Adrenal Insufficiency / Q000150:complications / Q000175:diagnosis / Q000188:drug therapy / Q000453:epidemiology*; D000324:Adrenocorticotropic Hormone / Q000097:blood / Q000627:therapeutic use; D000368:Aged; D000704:Analysis of Variance; D016638:Critical Illness; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D006854:Hydrocortisone / Q000097:blood*; D007022:Hypotension / Q000150:complications*; D015994:Incidence; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D016896:Treatment Outcome; D014505:Urban Population
chemical_list: D000324:Adrenocorticotropic Hormone; D006854:Hydrocortisone