Adrenal insufficiency and critical illness

(NEJM 2003;348:727; JAMA 2009;301:2362)

• Low cortisol binding proteins; ∴ dx of adrenal insufficiency problematic (NEJM 2013;368:1477)
• Adrenal insufficiency rare in most cases of shock unless adrenal infarction or bleed, Waterhouse-Friderichson, CNS or pituitary bleed
• Reasonable to collect cortisol level in HoTN Pt w/ suspicion for adrenal insufficiency
• Can consider above dx criteria, but decision for Rx should also be based on clinical assessment due to risk of false ⊖ and ⊕ results in context of altered physiology
• If concerned, initiate corticosteroids early: use hydrocortisone 100 mg IV followed by 50 mg IV q6h
• Controversial data for empiric steroids in all critically ill Pts sepsis and shock