抗合成酶抗体综合征误诊1例

1　病例报告女 ,5 1岁。 2 0 0 1- 0 7因双手背、腰腹部皮肤色素沉着 0 .5 a就诊于本市某三级医院内分泌科。查血游离皮质醇 8.5 μg/ dl(8时 15～ 2 5μg/ dl) ,2 .6μg/ dl(16时 :3～ 12μg/ dl) ,2 4 h尿游离皮质醇 2 . 9μg(2 0～ 10 0 μg)。血清促肾上腺皮质激素(ACTH)正常 ;双侧肾上腺 B超未见异常 ;诊断 Addison病。予醋酸考的松口服早 2 5 mg、晚 12 .5 mg治疗。 1个月后出现渐进性胸闷、气促伴双上肢水肿 ,入另一家医院内分泌科。多次复查血游离皮质醇、ACTH均正常 ,仍予激素治疗。入院后 1周余出现发热 ,胸片提示双下肺炎症…     

小剂量促肾上腺皮质激素刺激实验在危重病患儿肾上腺功能评估中的作用

目的 探讨小剂量(1 μg/1.73 m2)促肾上腺皮质激素(ACTH)刺激实验在儿童危重症相关性肾上腺皮质功能障碍(CIRCI)评估中的意义.方法 对收入上海交通大学附属儿童医院儿童重症监护病房(PICU)患儿24 h内测定血液基础皮质醇(T0)后,静脉注射ACTH(1μg/1.73 m2),30 min后测定刺激后血液皮质醇(T1)水平,根据T0和皮质醇增值(Δmax=T1-T0)判断肾上腺功能,以T0＜ 10 μg/dL或Δmax≤9 μg/dL为判断肾上腺功能障碍标准.结果 95例患儿中,严重感染35例,非感染重症患儿30例,大手术患儿30例,总病死率为12.6％ (12/95).CIRCI发生率55.8％ (53/95),其中重症感染组、非感染重症组、大手术组患儿CIRCI发生率分别是60％、53.3％和53.3％,差异无统计学意义(P＞0.05).重症感染组、非感染重症组、大手术组、T0和71分别为(37.17±47.35) μ.g/dL、(31.52±52.78) μg/dL、(28.61±17.45) μg/dL和(50.26±48.21) μg/dL、(58.56±73.21) μg/dL、(42.41±13.56)μg/dL,3组差异无统计学意义(P＞0.05).CIRCI组和正常皮质醇反应组患儿病死率分别是7.5％和19.0％ (P＞0.05).T0和T1水平与儿童危重病例评分(PCIS)有关(P＜0.05).结论 危重症患儿存在肾上腺功能障碍,CIRCI发生率较高,小剂量ACTH刺激实验可以作为肾上腺功能功能判断的依据.本研究未发现危重病患儿CIRCI与病死率的显著相关性.     

超声诊断肾上腺皮质腺瘤1例

患者，女，38岁。以肥胖、毛发增多，间断头晕、心慌半年为主诉而入院就诊。体检：血压200／100mmHg，向心性肥胖，颜面皮肤多脂、油腻，毛孔粗大，四肢毛发增多?实验室检查：皮质醇(8am)33．62μg/dl，(4pm)26．22μg／dl，(0am)22.21μg/dl，(次日8am)20．52μg／dl均高于正常；性激素全套：睾酮112．32μg／dl，明显升高，余各项指标正常。     

顺铂注射治疗肝癌三例

1989年10月到1990年4月,我们采用细针顺铂注射治疗(PCI)3例肝癌,收到一定疗效.例1男,42岁.B 超、CT 示肝内肿块,直径18.4×14.7cm,细针穿刺活检,病理诊断:肝细胞型肝癌。采用 PCI 一次后,B 超复查,肿块大小无变化,胎甲球值(AFP)从795.89ng/ml 降至400ng/ml,肝胆酸值(CG)从1523.64μg/dl 降至986.98μg/dl.患者要求改用其它方法治疗,出院后,随访4个月死亡.例2,男,51岁.B 超,CT 示肝内肿块,直径5.9×4.0cm,细针穿刺活检,病理诊断:肝细胞型肝癌.PCI4次后,AFP 由535ng/ml 降至245.9ng/ml,肝癌特异性蛋白质(SHC SP)由阳性转为阴性,CG 从1584.8μg/dl 降至947.4μg/dl,唾液酸(F-8836)治疗前后均在正常值范围,B 超复查肿块缩小为3.8×2.2cm,细针穿刺活检,病理示癌细胞变性坏死.随访,已存活10个月。例3,女,56岁,结肠癌术后一年,B 超示肝内肿块直径14.2×10.2cm,穿刺活检,病理诊断:肝转移腺癌。PCI5次后,AFP 治疗前后均在正常值范围,SHCsP 转为阴性.CG 从117.5μg/dl降至76.6μg/dl,F-8836从0.230A 降至0.195A,     

口腔扁平苔癣患者焦虑和唾液皮质醇水平相关性研究

目的 探讨口腔扁平苔癣(OLP)患者焦虑和唾液皮质醇之间的关系.方法 使用化学发光法检测OLP患者和对照组唾液皮质醇水平,使用Spielberger焦虑量表评定两组人群的焦虑状态和焦虑特性.结果 56例OLP患者唾液皮质醇平均浓度为1.32 μg/dl,60例对照组为0.97 μg/dl(P<0.001);OLP组平均焦虑状态评分和平均焦虑特性评分分别为46.78和49.89,对照组分别为39.98和39.21(均P=0.001).唾液皮质醇水平、焦虑状态和特性评分显著高于对照组.唾液皮质醇水平、焦虑状态和特性水平与OLP显著相关(P值分别为0.02,0.04,0.03).结论 OLP发病与精神紧张密切相关,OLP患者存在明显心理异常,因此,对OLP患者进行传统治疗的同时要进行心理治疗.     

小剂量促肾上腺皮质激素刺激实验在儿童危重症相关性肾上腺皮质功能障碍评估中的意义

目的研究小剂量促肾上腺皮质激素(ACTH)刺激实验在儿童危重症相关性肾上腺皮质功能障碍(CIRCI)评估中的意义。方法选择2012年2月至2014年2月儿童ICU病房接受治疗的102例患儿作为研究对象。对所有患儿进行ACTH刺激试验,54例CIRCI患儿设为CIRCI组;其余设为正常组。对比观察两组实验室检查指标和基础性皮质醇的浓度(T0)、刺激后的皮质醇浓度(T1),不同研究方向下的肾上腺功能情况,以及不同危重评分及年龄段患者的肾上腺功能情况。结果两组患儿实验室检查指标及T0无显著差异(P0.05)。CIRCI组的T1水平均显著低于正常组,差异有统计学意义(P0.05)。患儿在感染情况、PRISMⅢ评分及器官障碍数目等研究方向上分别进行组间对比,T0、T1及CIRCI发生率的差异均无统计学意义(均P0.05)。危重评分值为70~90分的患儿T0及T1水平显著低于≤70分者的水平,差异有统计学意义(P0.05)。但对比CIRCI发生率的差异无统计学意义(P0.05)。在年龄阶段方面,随着儿童年龄的增长,T0及T1的水平均下降,各组间差异有统计学意义(P0.05)。但对比各组间CIRCI发生率,差异均无统计学意义(均P0.05)。结论小剂量的ACTH刺激试验对CIRCI患儿进行评估,对其疾病危重形式有一定的预测价值,但提倡与其他种类的测定方式联合应用,从而更加可靠地预测疾病进展。     

青少年男性假两性畸形1例的心理护理

我科2010-07-27收治1例青少年男性假两性畸形的患者.患此疾病的患者及家属心理压力大、心理问题突出,通过对其实施心理护理干预,使患者能够正确看待人生,回顾社会.分析如下.1病历摘要社会性别女性,15岁,因外生殖器发育异常15 a,第二性征缺乏2 a余收住入院.15 a前行双侧睾丸切除术.妇检:外生殖器呈女性化,双侧大阴唇似退化的阴囊,两侧小阴唇发育不完全,阴蒂肥大(可疑小阴茎),阴道呈盲端.性激素测定:促卵泡刺激素(FSH) 142.2 mIU/ml,黄体生成激素(LH) 27.48mIU/ml,睾酮(TES)0.32 ng/dl,雌二醇(E2)11.0 pg/ml,生长激素(HGH)3.363 ng/ml,8:00促肾上腺皮质激素(ACTH)15.57 pg/ml,血皮质醇激素(F):18.45μg/dl.盆腔MRI示:所见盆腔未见子宫、前列腺、精囊腺信号影.诊断:男性假两性畸形、睾丸切除术后.入院后完善相关检查,结合其病史特点,给予雌激素终生替代治疗[1]以促进和维持女性第二性征.     

系统性红斑狼疮伴极度胰岛素抵抗综合征一例

患者女,46岁,主因乏力、水肿伴双手霄诺现象6个月,加重10 d以系统性红斑狼疮(SLE)收住入院.人院前曾在多家省级三甲医院门诊就诊,查甲状腺功能示亚临床甲状腺功能减低,服用左旋甲状腺素片每日25μg治疗,症状无缓解.先后查头颅CT未见异常,除生长激素(GH,14.7μg/L)增高外,余垂体激素及皮质醇均在正常范围内,未能明确诊断.     

镰状细胞贫血病人铁的分布——尸体解剖研究

本文研究2例镰状细胞贫血(SCA)病人的尸体解剖。所取的器官组织用40％甲醛固定后石腊切片,苏木精伊红(HE)及普鲁士蓝法铁染色,并做对照检查。病例1:男,37岁,于8岁时诊断为SCA。曾多次发生危象,10年前患糖尿病。最近一次,因中度贫血,血清铁蛋白4500μg/ml(正常25—350μg/ml),血清铁300μg/dl(正常42—135μg/dl)而住院。病     

原子荧光光谱法测定饮用水中微量元素硒

采用原子荧光光谱测定饮用水中的微量元素硒,用5%(v/v)的盐酸和1 g/dl的硫脲-1 g/dl额定抗坏血酸混合试剂处理样品,并以1.5 g/dl硼氢化钠-0.2 g/dl氢氧化钠为还原剂,3%(v/v)的盐酸介质中测定硒。该方法具有操作简单、快速,干扰少、灵敏度高等优点,方法检出限为0.15μg/L,线性范围0~350μg/L。     

相对性肾上腺皮质功能不全与呼吸机撤离的关系及对预后的影响

目的对机械通气的重症患者进行肾上腺皮质功能状态分析,探讨相对性肾上腺皮质不全(RAI)与呼吸机撤离的关系,评价肾上腺皮质功能测定对呼吸机撤离及预后的意义。方法选择上海仁济医院急诊科及急诊ICU机械通气超过24 h的患者,使用250μg促肾上腺皮质激素(ACTH)静脉注射,测定刺激前及刺激后60 min血浆总皮质醇水平,即T60与T0,二者的差值ΔT≤9μg/dl定义为RAI。分析RAI与呼吸机撤离的相关性,使用Kaplan-Meier评价RAI与机械通气患者30 d存活率的相关性。结果共60例机械通气患者纳入研究,其中有创通气38例,无创通气22例;撤机成功24例,撤机失败36例。卡方检验显示,成功撤机组RAI患者比例明显著低于非RAI患者(P=0.000 11),并在有创通气组中更为明显。同时机械通气患者30 d存活率观察发现,合并RAI的患者死亡率明显高于非RAI通气患者(P=0.000 3)。结论 RAI明显影响有创通气的撤机成功率,并与机械通气的死亡率显著相关。     

Adrenal insufficiency in critically ill patients with human immunodeficiency virus

OBJECTIVE: The adrenal gland is the endocrine organ most commonly involved in patients infected with human immunodeficiency virus (HIV). It is important to recognize patients with adrenal insufficiency, because this disorder may be fatal if untreated. The incidence of adrenal insufficiency in critically ill HIV-infected patients is unclear, partly because different criteria are used to diagnose adrenal insufficiency. To help clarify the incidence of adrenal insufficiency in HIV-infected critically ill patients, we compared the incidence based on the stress cortisol concentration, low-dose corticotropin stimulation test, and high-dose corticotropin stimulation test. SETTING: Medical intensive care unit. PATIENTS: Twenty-eight critically ill patients with HIV, mean age 43 +/- 9 years; 20 were male; 54% died. INTERVENTIONS: We performed a 1-microg (low-dose adrenocorticotropic hormone; LD-ACTH) and 249 microg (high-dose; HD-ACTH) corticotropin stimulation test in HIV-infected critically ill patients not receiving corticosteroids. According to results of the stress serum cortisol concentration and LD-ACTH and HD-ACTH tests, patients were classified as having adrenal insufficiency or as normal. The results of newly revised diagnostic criteria for adrenal insufficiency (i.e., stress cortisol concentration and cortisol response to LD-ACTH <25 microg/dL) were compared with the traditional criteria (i.e., stress cortisol level and response to HD-ACTH <18 microg/dL). In addition, the associations between adrenal insufficiency and the CD4 count, human cytomegalovirus antigenemia, and other risk factors for adrenal insufficiency were determined. MEASUREMENTS AND MAIN RESULTS: When we used a stress cortisol concentration <18 microg/dL as the sole diagnostic threshold for diagnosis of adrenal insufficiency, 50% (14 of 28) of patients had adrenal insufficiency. The incidence was 75% (21 of 28) when we used a diagnostic threshold of <25 microg/dL for the stress cortisol concentration. When we used both the stress cortisol concentration and LD-ACTH test with a diagnostic cortisol threshold concentration <18 microg/dL, 21% (six of 28) had adrenal insufficiency. The incidence was 46% (13 of 28) when we used a cortisol diagnostic threshold concentration of <25 microg/dL. When we used both the stress cortisol concentration and the HD-ACTH stimulation test with a diagnostic cortisol threshold of <18 microg/dL, 7% (two of 28) had adrenal insufficiency. The incidence of adrenal insufficiency was 21% (six of 28) with a cortisol diagnostic threshold value of <25 microg/dL. Human cytomegalovirus antigenemia was the only variable assessed that was associated with adrenal insufficiency. CONCLUSION: There is a high incidence of adrenal insufficiency in critically ill HIV-infected patients that varies with the criteria used to diagnose adrenal insufficiency. The LD-ACTH stimulation test is more sensitive than the high-dose test for diagnosing adrenal insufficiency in this population. Because of the high incidence of inadequate adrenal function, all critically ill HIV-infected patients should undergo an evaluation for adrenal insufficiency with the stress cortisol concentration and LD-ACTH stimulation tests.     

Glucose absorption and gastric emptying in critical illness

Introduction

Gallstones are the most common cause of acute pancreatitis worldwide. Patients with severe acute biliary pancreatitis (SABP) constitute a subgroup of severe acute pancreatitis (SAP) patients in whom systemic inflammation may be triggered and perpetuated by different mechanisms. The aim of this prospective investigation was to examine the adrenal response to corticotropin and the relationship between adrenal function and outcome in patients with SABP.

Methods

Thirty-two patients with SABP were enrolled in this study. A short corticotropin (250 μg) stimulation test (SST) was performed within the first 24 hours of admission to the ICU. Critical illness related corticosteroid insufficiency (CIRCI) was defined as follows: baseline value less than 10 μg/dL, or cortisol response less than 9 μg/dL.

Results

CIRCI occurred in 34.4% of patients. The patients with CIRCI were more severely ill as evidenced by higher APACHE II and SOFA scores and numbers of organ system dysfunction on the day of SST. The in-hospital mortality for the entire group was 21.9%. The CIRCI group had a higher hospital mortality rate compared to those with normal adrenal function (45.5% vs. 9.5%, P = 0.032). The hospital survivors had a higher cortisol response to corticotropin (17.4 (8.3–27.1) vs. 7.2 (1.7–12) μg/dL, P = 0.019). The cortisol response to corticotropin inversely correlated with SOFA score and the number of organ dysfunction on the day of SST. The rates of pancreatic necrosis and bacteremia were significantly higher in the CIRCI group (100% vs 42.9%, P = 0.002; 81.8% vs 23.8%, P = 0.003, respectively).

Conclusions

CIRCI is common in patients with SABP. It is associated with bacteremia, multiple organ dysfunction and increased mortality.     

Steroidogenesis in the adrenal dysfunction of critical illness: impact of etomidate

ABSTRACT: INTRODUCTION: This study was aimed at characterizing basal and adrenocorticotropic hormone (ACTH)-induced steroidogenesis in sepsis and nonsepsis patients with a suspicion of critical illness-related corticosteroid insufficiency (CIRCI), taking the use of etomidate-inhibiting 11β-hydroxylase into account. METHOD: This was a prospective study in a mixed surgical/medical intensive care unit (ICU) of a university hospital. The patients were 62 critically ill patients with a clinical suspicion of CIRCI. The patients underwent a 250-μg ACTH test (n = 67). ACTH, adrenal steroids, substrates, and precursors (modified tandem mass spectrometry) also were measured. Clinical characteristics including use of etomidate to facilitate intubation (n = 14 within 72 hours of ACTH testing) were recorded. RESULTS: At the time of ACTH testing, patients had septic (n = 43) or nonseptic critical illness (n = 24). Baseline cortisol directly related to sepsis and endogenous ACTH, independent of etomidate use. Etomidate was associated with a lower baseline cortisol and cortisol/11β-deoxycortisol ratio as well as higher 11β-deoxycortisol, reflecting greater 11β-hydroxylase inhibition in nonsepsis than in sepsis. Cortisol increases < 250 mM in exogenous ACTH were associated with relatively low baseline (HDL-) cholesterol, and high endogenous ACTH with low cortisol/ACTH ratio, independent of etomidate. Although cortisol increases with exogenous ACTH, levels were lower in sepsis than in nonsepsis patients, and etomidate was associated with diminished increases in cortisol with exogenous ACTH, so that its use increased, albeit nonsignificantly, low cortisol increases to exogenous ACTH from 38% to 57%, in both conditions. CONCLUSIONS: A single dose of etomidate may attenuate stimulated more than basal cortisol synthesis. However, it may only partly contribute, particularly in the stressed sepsis patient, to the adrenal dysfunction of CIRCI, in addition to substrate deficiency.     

Adrenal function in non-septic long-stay critically ill patients: evaluation with the low-dose (1 micro g) corticotropin stimulation test

OBJECTIVE: To investigate the adrenal function in non-septic, long-stay critically ill patients. DESIGN: Prospective, consecutive study. SETTING: General intensive care unit in a university hospital. PATIENTS: Forty-three non-septic patients with protracted critical illness. INTERVENTIONS: A morning blood sample was first obtained to measure baseline plasma cortisol. Subsequently, 1 micro g of corticotropin (ACTH, Synacthene) was injected intravenously and 30 min later a second blood sample was drawn to determine stimulated plasma cortisol. Patients having a stimulated cortisol level of at least 18 micro g/dl were defined as responders. In 36 patients, morning interleukin-6 (IL-6) was also measured. MEASUREMENTS AND RESULTS: Baseline and stimulated plasma cortisol were 16.8+/-4.1 micro g/dl and 21.2+/-5.1 micro g/dl, respectively. Interleukin-6 was high (median 39.3 pg/ml, interquartile range 24.9-86.6 pg/ml) and correlated negatively with stimulated plasma cortisol (r=-0.40, p<0.05). Of the 43 patients studied, 31 patients (72%) were responders and 12 patients (28%) were non-responders to the ACTH stimulation test. Overall, 18 patients died and 25 patients survived to hospital discharge. Non-responders had significantly higher IL-6 levels compared to responders (106+/-73 versus 48+/-42 pg/ml, p<0.05), whereas mortality rate was comparable in the two groups (50% versus 38%, p=0.74). CONCLUSIONS: Circulating plasma IL-6 levels are high during protracted critical illness, and are partially responsible for the relative adrenal insufficiency found in a subset of severely ill patients.     

Duration of adrenal inhibition following a single dose of etomidate in critically ill patients

Objective To determine the incidence and duration of adrenal inhibition induced by a single dose of etomidate in critically ill patients. Design Prospective, observational cohort study. Setting Three intensive care units in a university hospital. Patients Forty critically ill patients without sepsis who received a single dose of etomidate for facilitating endotracheal intubation. Measurements and main results Serial serum cortisol and 11β-deoxycortisol samples were taken at baseline and 60 min after corticotropin stimulation test (250 μg 1–24 ACTH) at 12, 24, 48, and 72 h after etomidate administration. Etomidate-related adrenal inhibition was defined by the combination of a rise in cortisol less than 250 nmol/l (9 μg/dl) after ACTH stimulation and an excessive accumulation of serum 11β-deoxycortisol concentrations at baseline. At 12 h after etomidate administration, 32/40 (80%) patients fulfilled the diagnosis criteria for etomidate-related adrenal insufficiency. This incidence was significantly lower at 48 h (9%) and 72 h (7%). The cortisol to 11β-deoxycortisol ratio (F/S ratio), reflecting the intensity of the 11β-hydroxylase enzyme blockade, improved significantly over time. Conclusions A single bolus infusion of etomidate resulted in wide adrenal inhibition in critically ill patients. However, this alteration was reversible by 48 h following the drug administration. The empirical use of steroid supplementation for 48 h following a single dose of etomidate in ICU patients without septic shock should thus be considered. Concomitant serum cortisol and 11β-deoxycortisol dosages are needed to provide evidence for adrenal insufficiency induced by etomidate in critically ill patients. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users. Financial support: All of the authors have disclosed that they have no financial relationship with or interest in any commercial companies.     

Impact of fluconazole prophylaxis on cortisol levels in critically ill surgical patients

Fluconazole is widely used in the intensive care unit for prevention and treatment of fungal infections. Case reports have described an association between fluconazole and adrenal dysfunction, an important cause of morbidity and mortality in critically ill patients. We sought to determine whether 400 mg of fluconazole per day administered to critically ill surgical patients was associated with a reduction in cortisol levels. Cortisol levels were measured in stored plasma specimens drawn from 154 critically ill surgical patients randomized in 1998-1999 to receive fluconazole or placebo for the prevention of candidiasis. The primary outcome measure was the median plasma cortisol level > or =1 day after study drug initiation (MPCL). Secondary outcomes were adrenal dysfunction, defined as an MPCL of <15 microg/dl, changes in cortisol levels over time, and mortality. The median MPCL was 15.75 microg/dl (interquartile range [IQR], 11.65 to 21.33 microg/dl) in 79 patients randomized to fluconazole and 16.71 microg/dl (IQR, 11.67 to 23.00 microg/dl) in 75 patients randomized to placebo (P = 0.52). Patients randomized to fluconazole did not have significantly increased odds of adrenal dysfunction compared to patients randomized to placebo (odds ratio, 0.98; 95% confidence interval, 0.48 to 2.01). Randomization to fluconazole was not associated with a significant difference in cortisol level changes over time. Mortality was not different between patients with and without adrenal dysfunction, nor was it different between patients with adrenal dysfunction who were randomized to fluconazole and those randomized to placebo. Fluconazole prophylaxis in this population of critically ill surgical patients did not result in significant adrenal dysfunction.     

Serum free cortisol index,free cortisol,and total cortisol in critically ill children

Background  In critical illness, serum total cortisol (TC) may not adequately reflect adrenal function because of reduced cortisol-binding globulin (CBG). Aim  To evaluate adrenal function of critically ill children, using free cortisol index (FCI), calculated free cortisol (cFC), and TC levels. Methods  Thirty-two critically ill and 36 healthy children were included. All children underwent the 1 μg cosyntropin test. TC and CBG levels were measured. Basal and peak TC, FCI, and cFC were determined. Results  Basal and peak TC, FCI, and cFC of critically ill children were significantly higher than those of the controls. Compared with TC, both basal and peak FCI and cFC of the patients were higher than those of controls to a greater degree. Use of FCI or cFC to diagnose adrenal insufficiency (AI) reduced the frequency of diagnosis of AI by 50%. Conclusion  FCI and cFC better reflect the dynamic changes of adrenal function of critically ill children.     

Cortisol levels in patients with severe community-acquired pneumonia

Objectives To evaluate cortisol levels and prevalence of adrenal insufficiency in patients with severe community-acquired pneumonia (CAP). Design and setting Retrospective cohort study in a 24-bed medical-surgical intensive care unit (ICU). Patients Forty patients with severe CAP admitted to the ICU from March 2003 and May 2005. Measurements and results Random cortisol levels were measured up to 72 h after ICU admission. A threshold of 20 μg/dl was considered for the diagnosis of adrenal insufficiency. Median cortisol levels were 15.5 μg/dl (IQR 10.8–25.1), and 26 patients (65%) met the criteria for adrenal insufficiency. Other cutoff levels of cortisol were evaluated, and 30 patients (75%) had cortisol levels below 25 μg/dl and 19 (47.5%) had cortisol levels below 15 μg/dl. When only patients with septic shock (n = 19) were evaluated, 12 (63%) had adrenal insufficiency. Conclusions Relative adrenal insufficiency occurs in a high proportion of patients with severe CAP. This finding highlights the importance of measuring cortisol levels and may help explain the potential benefits of hydrocortisone infusion in these patients.     

The diagnosis of adrenal insufficiency in the critically ill patient: does it really matter?

The definition of what constitutes a 'normal' adrenal response to critical illness is unclear. Consequently, published studies have used a variety of biochemical criteria to define 'adrenal insufficiency'. These criteria have been based on the baseline cortisol level or the increment in cortisol following corticotropin administration. However, in critically ill patients there are a number of confounding factors that make interpretation of these tests difficult. Furthermore, in those patients who are most likely to benefit from treatment with low-dose glucocorticoids, there is no evidence that treatment should be based on adrenal function testing. In those patients in whom the diagnosis of adrenal insufficiency may be important, this diagnosis may best be made based on the free cortisol level or the total cortisol level stratified by serum albumin.