title: Relative adrenal insufficiency among trauma patients in a community hospital.
abstract: BACKGROUND
  The integrity of the hypothalamic-pituitary-adrenal (HPA) axis is a major determinant of the host response to stress. Recent studies have proven that low doses of hydrocortisone and fludrocortisone can significantly reduce mortality in patients with relative adrenal insufficiency (RAI) without increasing adverse events.
  
  
  METHODS
  This study was a retrospective chart review of patients in a community hospital who carried the diagnosis of both adrenal insufficiency and trauma.
  
  
  RESULTS
  Over a 16-month period, the incidence of RAI among severely injured patients (injury severity score >/= 13) was 3%. Only 1 patient had the classic electrolyte findings of adrenal insufficiency, but all had vasopressor-dependent hypotension. Our patients had an average intensive care unit day stay of 37 days and were not tested for RAI on average until day 20 of their intensive care unit stay. Random cortisol levels did not correlate with injury severity. Six patients (75%) had a positive hemodynamic response to steroids.
  
  
  CONCLUSIONS
  Relative adrenal insufficiency after trauma is rare. In RAI, clear signs and symptoms are usually absent. The clinical diagnostic clue may be the unexplained hypotension and the resistance to inappropriately high doses of inotropes and vasoactive agents. The hemodynamic profile often shows a hyperdynamic state of high cardiac output and a low systemic vascular resistance. Baseline serum cortisol levels did not correlate with injury severity scores in this group of patients, which suggests a defect in the HPA axis. An intensive care unit day stay of greater than or equal to 20 days, ventilator dependence/acute respiratory distress syndrome, and a hyperdynamic state mandates consideration of endocrine testing to exclude RAI. Physiologic doses of hydrocortisone can reverse this potentially life-threatening syndrome.
authors.affiliation: Department of Surgery, Synergy Medical Education Alliance, 1000 Houghton Avenue, Saginaw, MI 48603, USA. bman62707@yahoo.com
authors.forename: Brian R
authors.initials: BR
authors.lastname: Beeman
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Veverka
authors.forename: Phillip
authors.initials: P
authors.lastname: Lambert
authors.forename: Dennis M
authors.initials: DM
authors.lastname: Boysen
mesh_terms: D000309:Adrenal Insufficiency / Q000097:blood* / Q000150:complications* / Q000188:drug therapy; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000893:Anti-Inflammatory Agents / Q000627:therapeutic use; D005260:Female; D006764:Hospitals, Community; D006801:Humans; D006854:Hydrocortisone / Q000627:therapeutic use; D015601:Injury Severity Score; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D014947:Wounds and Injuries / Q000097:blood* / Q000150:complications*
chemical_list: D000893:Anti-Inflammatory Agents; D006854:Hydrocortisone