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Prognostic value of relative adrenal insufficiency after out-of-hospital cardiac arrest

Intensive Care Medicine Aims and scope Submit manuscript

Abstract

Objective

To assess the prevalence of relative adrenal insufficiency in patients successfully resuscitated after cardiac arrest, and its prognostic role in post-resuscitation disease.

Design and setting

A prospective observational single-center study in a medical intensive care unit.

Patients

64 patients hospitalised in the intensive care unit after successful resuscitation for out-of-hospital cardiac arrest.

Measurements and results

A corticotropin-stimulation test was performed between 12 and 24 h following admission: serum cortisol level was measured before and 60 min after administration of tetracosactide 250 µg. Patients with an incremental response less than 9 µg/dl were considered to have relative adrenal insufficiency (non-responders). Variables were expressed as medians and interquartile ranges. 33 patients (52%) had relative adrenal insufficiency. Baseline cortisol level was higher in non-responders than in responders (41 [27.2–55.5] vs. 22.8 [15.7–35.1] µg/dl respectively, P=0.001). A long interval before initiation of cardiopulmonary resuscitation was associated with relative adrenal insufficiency (5 [3–10] vs. 3 [3–5] min, P=0.03). Of the 38 patients with post-resuscitation shock, 13 died of irreversible multiorgan failure. The presence of relative adrenal insufficiency was identified as a poor prognostic factor of shock-related mortality (log-rank P=0.02). A trend towards higher mortality in non-responders was identified in a multivariate logistic regression analysis (odds ratio 6.77, CI 95% 0.94–48.99, P=0.058).

Conclusions

Relative adrenal insufficiency occurs frequently after successful resuscitation of out-of-hospital cardiac arrest, and appears to be associated with a poor prognosis in cases of post-resuscitation shock. The role of corticosteroid supplementation should be evaluated in this setting

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References

  1. Cooper MS, Stewart PM (2003) Corticosteroid insufficiency in acutely ill patients. N Engl J Med 348:727–734

    Google Scholar 

  2. Rothwell PM, Udwadia ZF, Lawler PG (1991) Cortisol response to corticotropin and survival in septic shock. Lancet 337:582–583

    Google Scholar 

  3. Annane D, Bellissant E (2000) Prognostic value of cortisol response in septic shock. JAMA 284:308–309

    Google Scholar 

  4. Hoen S, Asehnoune K, Brailly-Tabard S, Mazoit JX, Benhamou D, Moine P, Edouard AR (2002) Cortisol response to corticotropin stimulation in trauma patients: influence of hemorrhagic shock. Anesthesiology 97:807–813

    Google Scholar 

  5. Marik PE, Kiminyo K, Zaloga GP (2002) Adrenal insufficiency in critically ill patients with human immunodeficiency virus. Crit Care Med 30:1267–1273

    Google Scholar 

  6. Dimopoulou I, Tsagarakis S, Kouyialis AT, Roussou P, Assithianakis G, Christoforaki M, Ilias I, Sakas DE, Thalassinos N, Roussos C (2004) Hypothalamic-pituitary-adrenal axis dysfunction in critically ill patients with traumatic brain injury: incidence, pathophysiology, and relationship to vasopressor dependence and peripheral interleukin-6 levels. Crit Care Med 32:404–408

    Google Scholar 

  7. Dimopoulou I, Tsagarakis S, Anthi A, Milou E, Ilias I, Stavrakaki K, Charalambidis C, Tzanela M, Orfanos S, Mandragos K, Thalassinos N, Roussos C (2003) High prevalence of decreased cortisol reserve in brain-dead potential organ donors. Crit Care Med 31:1113–1117

    Google Scholar 

  8. Annane D, Sebille V, Charpentier C, Bollaert PE, Francois B, Korach JM, Capellier G, Cohen Y, Azoulay E, Troche G, Chaumet-Riffaut P, Bellissant E (2002) Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA 288:862–871

    Google Scholar 

  9. Eisenberg MS, Mengert TJ (2001) Cardiac resuscitation. N Engl J Med 344:1304–1313

    Google Scholar 

  10. Negovsky VA (1988) Postresuscitation disease. Crit Care Med 16:942–946

    Google Scholar 

  11. Laurent I, Monchi M, Chiche JD, Joly LM, Spaulding C, Bourgeois B, Cariou A, Rozenberg A, Carli P, Weber S, Dhainaut JF (2002) Reversible myocardial dysfunction in survivors of out-of-hospital cardiac arrest. J Am Coll Cardiol 40:2110–2116

    Google Scholar 

  12. Adrie C, Adib-Conquy M, Laurent I, Monchi M, Vinsonneau C, Fitting C, Fraisse F, Dinh-Xuan AT, Carli P, Spaulding C, Dhainaut JF, Cavaillon JM (2002) Successful cardiopulmonary resuscitation after cardiac arrest as a “sepsis-like” syndrome. Circulation 106:562–568

    Google Scholar 

  13. Spaulding CM, Joly LM, Rosenberg A, Monchi M, Weber SN, Dhainaut JF, Carli P (1997) Immediate coronary angiography in survivors of out-of-hospital cardiac arrest. N Engl J Med 336:1629–1633

    Google Scholar 

  14. 14 Anonymous (2002) Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med 346:549–556

    Google Scholar 

  15. Bernard SA, Gray TW, Buist MD, Jones BM, Silvester W, Gutteridge G, Smith K (2002) Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med 346:557–563

    Google Scholar 

  16. Le Gall JR, Lemeshow S, Saulnier F (1993) A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. JAMA 270:2957–2963

    Google Scholar 

  17. Le Gall JR, Klar J, Lemeshow S, Saulnier F, Alberti C, Artigas A, Teres D (1996) The Logistic Organ Dysfunction system. A new way to assess organ dysfunction in the intensive care unit. ICU Scoring Group. JAMA 276:802–810

    Google Scholar 

  18. Safar P (1988) Resuscitation from clinical death: pathophysiologic limits and therapeutic potentials. Crit Care Med 16:923–941

    Google Scholar 

  19. Adrie C, Laurent I, Monchi M, Cariou A, Dhainaou JF, Spaulding C (2004) Postresuscitation disease after cardiac arrest: a sepsis-like syndrome? Curr Opin Crit Care 10:208–212

    Google Scholar 

  20. Schultz CH, Rivers EP, Feldkamp CS, Goad EG, Smithline HA, Martin GB, Fath JJ, Wortsman J, Nowak RM (1993) A characterization of hypothalamic-pituitary-adrenal axis function during and after human cardiac arrest. Crit Care Med 21:1339–1347

    Google Scholar 

  21. Lindner KH, Strohmenger HU, Ensinger H, Hetzel WD, Ahnefeld FW, Georgieff M (1992) Stress hormone response during and after cardiopulmonary resuscitation. Anesthesiology 77:662–668

    Google Scholar 

  22. Krismer AC, Wenzel V, Voelckel WG, Stadlbauer KH, Wagner-Berger H, Schaefer A, Lindner KH (2003) Effects of vasopressin on adrenal gland regional perfusion during experimental cardiopulmonary resuscitation. Resuscitation 56:223–228

    Google Scholar 

  23. Kornberger E, Prengel AW, Krismer A, Schwarz B, Wenzel V, Lindner KH, Mair P (2000) Vasopressin-mediated adrenocorticotropin release increases plasma cortisol concentrations during cardiopulmonary resuscitation. Crit Care Med 28:3517–3521

    Google Scholar 

  24. Wenzel V, Krismer AC, Arntz HR, Sitter H, Stadlbauer KH, Lindner KH (2004) A comparison of vasopressin and epinephrine for out-of-hospital cardiopulmonary resuscitation. N Engl J Med 350:105–113

    Google Scholar 

  25. Marik PE, Zaloga GP (2002) Adrenal insufficiency in the critically ill: a new look at an old problem. Chest 122:1784–1796

    Google Scholar 

  26. Hamrahian AH, Oseni TS, Arafah BM (2004) Measurements of serum free cortisol in critically ill patients. N Engl J Med 350:1629–1638

    Google Scholar 

  27. Absalom A, Pledger D, Kong A (1999) Adrenocortical function in critically ill patients 24 h after a single dose of etomidate. Anaesthesia 54:861–867

    Google Scholar 

  28. Chi OZ, Choi YK, Lee DI, Kim YS, Lee I (2001) Intraoperative mild hypothermia does not increase the plasma concentration of stress hormones during neurosurgery. Can J Anaesth 48:815–818

    Google Scholar 

  29. Beilin B, Shavit Y, Razumovsky J, Wolloch Y, Zeidel A, Bessler H (1998) Effects of mild perioperative hypothermia on cellular immune responses. Anesthesiology 89:1133–1140

    Google Scholar 

  30. Bollaert PE, Charpentier C, Levy B, Debouverie M, Audibert G, Larcan A (1998) Reversal of late septic shock with supraphysiologic doses of hydrocortisone. Crit Care Med 26:645–650

    Google Scholar 

  31. Giugliano GR, Giugliano RP, Gibson CM, Kuntz RE (2003) Meta-analysis of corticosteroid treatment in acute myocardial infarction. Am J Cardiol 91:1055–1059

    Google Scholar 

  32. Hafezi-Moghadam A, Simoncini T, Yang E, Limbourg FP, Plumier JC, Rebsamen MC, Hsieh CM, Chui DS, Thomas KL, Prorock AJ, Laubach VE, Moskowitz MA, French BA, Ley K, Liao JK (2002) Acute cardiovascular protective effects of corticosteroids are mediated by non-transcriptional activation of endothelial nitric oxide synthase. Nat Med 8:473–479

    Google Scholar 

  33. Schurr A (2001) Glucose and the ischemic brain: a sour grape or a sweet treat? Curr Opin Clin Nutr Metab Care 4:287–292

    Google Scholar 

  34. Capes SE, Hunt D, Malmberg K, Pathak P, Gerstein HC (2001) Stress hyperglycemia and prognosis of stroke in nondiabetic and diabetic patients: a systematic overview. Stroke 32:2426–2432

    Google Scholar 

  35. Norhammar AM, Ryden L, Malmberg K (1999) Admission plasma glucose. Independent risk factor for long-term prognosis after myocardial infarction even in nondiabetic patients. Diabetes Care 22:1827–1831

    Google Scholar 

  36. Wahab NN, Cowden EA, Pearce NJ, Gardner MJ, Merry H, Cox JL (2002) Is blood glucose an independent predictor of mortality in acute myocardial infarction in the thrombolytic era? J Am Coll Cardiol 40:1748–1754

    Google Scholar 

  37. Malmberg K (1997) Prospective randomised study of intensive insulin treatment on long term survival after acute myocardial infarction in patients with diabetes mellitus. DIGAMI (Diabetes Mellitus, Insulin Glucose Infusion in Acute Myocardial Infarction) Study Group. BMJ 314:1512–1515

    Google Scholar 

  38. Van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, Vlasselaers D, Ferdinande P, Lauwers P, Bouillon R (2001) Intensive insulin therapy in the critically ill patients. N Engl J Med 345:1359–1367

    Google Scholar 

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Correspondence to Frédéric Pene.

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Pene, F., Hyvernat, H., Mallet, V. et al. Prognostic value of relative adrenal insufficiency after out-of-hospital cardiac arrest. Intensive Care Med 31, 627–633 (2005). https://doi.org/10.1007/s00134-005-2603-7

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  • DOI: https://doi.org/10.1007/s00134-005-2603-7

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