DOI: 10.1097/CCM.0b013e3181932cfa

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PMID: 19318823

Issn Print: 0090-3493

Publication Date: 2009/01/01


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Is the cortrosyn test necessary in high basal corticoid patients with septic shock?

Paul E. Marik; R Phillip Dellinger

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We thank Dr. Moraes et al for their thoughtful comments. It would seem intuitively logical that a high random cortisol level would exclude adrenal insufficiency. Indeed, one of us has previously suggested that a random cortisol above 25 μg/dL makes the diagnosis of adrenal insufficiency unlikely (1). The Critical Illness Related Corticosteroid Insufficiency guidelines represented the consensus of 16 experts in the field (2). A recommendation was suggested with essentially the same wording as proposed by Dr. Rafael et al; however, the majority did not agree. The lack of consensus was based largely on the study by Annane et al (3) who used the overnight metapyrone test to diagnose adrenal insufficiency in patients with severe sepsis and septic shock. In this study, the area under the receiver operating characteristic curve for total cortisol was only 0.54 with the positive likelihood ratio of a random cortisol >25 μg/dL being 0.95 (95% confidence interval: 0.43–2.10) (see online supplementary material from Ref. 3). In addition, a post hoc analysis of the French and Corticosteroid Therapy of Septic Shock studies (4, 5) failed to demonstrate a random cortisol level that could reliably distinguish those patients who are most likely to respond to corticosteroid therapy (D. Annane, C. Sprung, personal communication, 2008). Similarly, Meduri et al (6) found that a random cortisol level did not predict response to corticosteroids in patients with severe acute respiratory distress syndrome.
Interpretation of the serum cortisol level is complex as it represents the total rather than the free biologically active hormone (7). Furthermore, the timing of cortisol measurements may be important as large hourly variations in cortisol have been reported (8). To complicate the issue further, the specificity, sensitivity, and performance of the commercially available assays are not uniform (9). It is speculated that the variation in assay characteristics might be even more significant in critically ill patients, especially those with septic shock. Because of the difficulty in accurately diagnosing adrenal insufficiency and the coexistent problem of corticosteroid resistance, the Critical Illness Related Corticosteroid Insufficiency guidelines and the Surviving Sepsis guidelines recommend that the decision to treat patients with corticosteroids should be based on clinical criteria (blood pressure poorly responsive to vasopressors following adequate fluid resuscitation) rather than on tests of the hypothalamic-pituitary-adrenal axis alone (2, 10).
The authors have not disclosed any potential conflicts of interest.

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