title: Hydrocortisone supplementation enhances hemodynamic stability in brain-dead patients.
abstract: BACKGROUND
  Hemodynamic instability is frequent in brain-dead patients and may result, in part, from absolute or relative adrenal insufficiency. Corticosteroid supplementation is widely used to restore hemodynamic stability in septic shock and to reduce the time of shock resolution. The authors verified that supplementation with hydrocortisone may enhance hemodynamic stability in brain-dead patients.
  
  
  METHODS
  All consecutive brain-dead patients with hypotension requiring vasopressor agents were included in this single-center noninterventional clinical observation study. Assessment of baseline and adrenocorticotropic hormone (ACTH)-stimulated plasma cortisol concentrations was performed. Immediately after, patients were systematically treated with a single intravenous injection of hydrocortisone (50 mg), and norepinephrine administration was adjusted every 15 min to maintain mean arterial pressure between 65 and 90 mmHg. Adrenal insufficiency was defined as baseline plasma cortisol concentration less than 15 microg/dl and/or delta plasma cortisol concentration less than 9 microg/dl. Patients were considered as ACTH responders when delta cortisol concentration was more than 9 microg/dl 30 min after ACTH injection.
  
  
  RESULTS
  Among the 31 patients included, the incidence of adrenal insufficiency was 87% [95% CI, 70-96%]. A significant (> or =30%) decrease in norepinephrine dose was obtained 180 min after hydrocortisone injection in 18 (59%) patients, from 0.31 [0.16-0.44] microg . kg(-1) . min(-1) to 0.18 [0.10-0.24] microg . kg(-1) . min(-1) (P < 0.01). The incidence of hemodynamic response was greater in ACTH nonresponders than in ACTH responders: 86% versus 50%, respectively, P < 0.05.
  
  
  CONCLUSIONS
  Adrenal insufficiency with hemodynamic instability is frequent in brain-dead patients. After ACTH stimulation testing and hydrocortisone infusion, hemodynamic stability is enhanced especially in patients with true adrenal nonfunction.
authors.affiliation: Department of Anesthesiology and Critical Care, Groupe Hospitalier Pitié-Salpêtrière, Paris, France. armelle.nicolas-robin@psl.aphp.fr
authors.forename: Armelle
authors.initials: A
authors.lastname: Nicolas-Robin
authors.forename: Jérome D
authors.initials: JD
authors.lastname: Barouk
authors.forename: Julien
authors.initials: J
authors.lastname: Amour
authors.forename: Pierre
authors.initials: P
authors.lastname: Coriat
authors.forename: Bruno
authors.initials: B
authors.lastname: Riou
authors.forename: Olivier
authors.initials: O
authors.lastname: Langeron
mesh_terms: D000309:Adrenal Insufficiency / Q000188:drug therapy / Q000503:physiopathology; D000328:Adult; D001926:Brain Death / Q000503:physiopathology*; D005260:Female; D006439:Hemodynamics / Q000187:drug effects* / Q000502:physiology*; D006801:Humans; D006854:Hydrocortisone / Q000008:administration & dosage*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies
chemical_list: D006854:Hydrocortisone