Scientific paper
The adrenal response after severe trauma

Presented at the 54th Annual Meeting of the Southwestern Surgical Congress, Coronado, California, April 7–10, 2002.
https://doi.org/10.1016/S0002-9610(02)01101-7Get rights and content

Abstract

Background

The integrity of the hypothalamic-pituitary-adrenal axis is a major determinant of the host response to stress. Relative adrenal insufficiency has been implicated in poor outcome from systemic inflammatory states; however, whether low endogenous glucocorticoid levels are adaptive or pathologic remains controversial. The purpose of this study was to prospectively evaluate the cortisol response and determine the incidence of occult adrenal insufficiency after severe trauma.

Methods

Over an 18-month period, 22 severely injured patients admitted to the surgical intensive care unit of our level 1 trauma center were prospectively identified and followed. Demographic and outcome data were tabulated. In addition, random serum cortisol levels were obtained on days 0, 5, and 10 after injury. Relative adrenal insufficiency was defined as a random serum cortisol level less than 18 μg/dL.

Results:

Mean baseline cortisol levels were elevated (35 ± 3 μg/dL) and significantly declined over the next 10 days (day 5: 24 ± 2 μg/dL; and day 10: 22 ± 2 μg/dL; P <0.01). Thirteen of 22 (60%) patients had random serum cortisol levels less than 18 μg/dL. Only 1 of the 2 patients who died had a serum cortisol level less than 18 μg/dL. The mean cortisol levels at baseline were higher in the 2 patients who died compared with those who survived but this was not statistically significant (43.4 ± 8.8 μg/dL versus 35.0 ± 3.6 μg/dL, P = 0.5).

Conclusions

Serum cortisol levels increased immediately and gradually returned towards normal after severe trauma. Occult adrenal insufficiency was common (60%) in this small group of severely injured patients. This did not, however, affect mortality in these patients. Further study is needed to delineate the role of occult adrenal insufficiency after severe injury.

Section snippets

Methods

Between June 1, 1999, and February 28, 2000, a convenience sample of severely injured adult patients admitted to the surgical intensive care unit at Denver Health Medical Center, a regional level 1 trauma center, was prospectively identified and studied. Patients were followed until death or discharge. Demographic and outcome data were tabulated. Selection of patients to be studied was determined by the trauma attending and was based on assessement of injury severity using anatomic and

Results

Over the 18-month study period, 22 severely injured patients were identified and followed. The mean age was 35 ± 4 years and 14 (62%) were male. Blunt mechanism of injury was present in 15 patients (68%). Despite the severe nature of the injuries (mean ISS: 33 ± 3), overall mortality was only 9% (2 of 22). Mean admission cortisol levels were elevated (35 ± 3 μg/dL) and declined significantly over the following 10 days (Fig. 1). Admission cortisol levels did not correlate with injury severity (

Comments

Critical illness results in a stress response that is characterized by activation of the hypothalamic-pituitary-adrenal axis and the sympathetic nervous system [11]. This coordinated reaction generally initiates metabolic and cardiovascular responses designed to maintain homeostasis. Cortisol is the major stress response hormone mediating many of these effects. In response to critical illness, enhanced corticotropin-releasing factor release from the hypothalamus stimulates an increase in ACTH

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