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Department of Intensive Care; Päijät-Häme Central Hospital; Lahti, Finland; pekka.loisa{at}phks.fi (Loisa) Department of Intensive Care; Kuopio University Hospital; Kuopio, Finland (Uusaro, Ruokonen)
In Response:
Drs. Dimopoulou et al. (1) questioned why we used only cortisol responses to measure adrenal function in our study (2). Their question is justified because the diagnosis of adrenal insufficiency is still controversial. So far, there are neither uniformly accepted diagnostic criteria nor consensus concerning the reference values for the ACTH stimulation test in critical illness. However, the Surviving Sepsis Guidelines recommend the use of an increment in cortisol <9 µg/dL (248 nmol/L) as a threshold for the diagnosis of relative adrenal insufficiency in septic shock patients (3). This criterion is probably the most widely used for detecting adrenal dysfunction; evidence from prospective studies supports the concept that this threshold increment can be used for both prognostic and therapeutic purposes (4,5). We admit that using cortisol increment has potential weaknesses in clinical practice, which we discussed in our article.
Drs. Dimopoulou et al. reported that they observed good correlation between two consecutive ACTH tests in septic shock patients. They used a small-dose (1 µg) ACTH test, considered to be more sensitive than a large-dose ACTH test to detect adrenal failure in patients with preexisting hypothalamic-pituitary-adrenal disease. This test has not been validated in critically ill patients, and the experience for using it in the critical care setting is very limited (6). The Surviving Sepsis Guidelines support the use of traditional testing in septic shock patients (3). Drs. Dimopoulou et al. also suggested that our results might be due to a too-small study population. It is true that the results of the two ACTH tests were nearly identical in many septic shock patients. However, we showed (Fig. 2c) that in 11 septic shock patients, the ACTH test results differed on Days 1 and 2. Additionally, in seven septic shock patients, the correlation in cortisol responses was absolutely diminished. We suggest that if Dimopoulou et al. had recruited more patients in their study, they too would be able to identify those septic shock patients whose adrenal function differed in two consecutive ACTH tests.
Our study's major goals were to evaluate: 1) how well current diagnostic recommendations work in septic shock patients and 2) possible limitations of the ACTH test in these patients. Our results are clear. However, we fully agree with Dimopoulou et al. that a larger study with proper analysis of individual cortisol profiles is needed to clarify this important issue.
REFERENCES
This article has been cited by other articles:
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  P. K. Sinha and T. Koshy Defective Double Lumen Tubes: Mallinckrodt the Culprit! Anesth. Analg., June 1, 2007; 104(6): 1603 - 1604. [Full Text] [PDF]
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