Análisis de los niveles de cortisol sérico en pacientes críticos con inestabilidad hemodinámica / Analysis of serum cortisol levels in critical patients with hemodynamic inestability

RESUMO

There is currently no consensus as to expected levels of serum cortisol (SC) in critical patients. Some authors, based on the ACTH test, consider 18 ug/dL and up as normal while others start >25-30 ug/dL. There are no reports of critical patients with Systemic Inflammatory Response Syndrome (SIRS). In this study we determine the SC in a group of critical patients with SIRS and correlate this value with the hemodynamic response and vasoactive drug requirements. SC was measured under conditions of stree defined by important hemodynamic instability within the SIRS context. We studied patients with no known history of steroid therapy nor use of other drugs that could alter the adrenal axis, and with no suspicion of adrenal failure. Enzimuntests Roche ES 300(CV 6 percent) was used. Based on our experience and on different studies, patients were classified into theree groups according to the SCvalue under stress. Group 1 SC <18 ug/dL, Group 2 SC 18,1 to 28 ug/dL, and Group 3 CS > 28 ug/dL. We studied 20 patients, 15 men and 5 women, all presenting SIRS, 17 with septic schock, 1 with severe head injuries, 1 hypovolemic shock, 1 postsurgery. The initial PA median was 80/50 mmHg. CS values varied between 10,3 and > 46 ug/dL. Group 1 8/20 patients (40 percent) with a variation between 10,3 and 17,3 ug/dL; Group 2 7/20 patients (35 percent) between 19,9 and 27,8 ug/dL, and Group 3 5/20 (25 percent) between 30,8 and > 46 ug/dL. The most significant difference among groups was found in Group 1 patients who required maximun dosage of DVA and presented hemodynamic stabilization with 150 to 300 mg of hydrocortisone perc day. There were no differences between groups 2 and 3 in DVA dosage, which was lower than for Group 1, and these did not evidence hemodynamic stabilization with hydrocortisone. In conclusion: A SC level > 18 ug/dL can be expected in critical patients undergoing SIRS during periods of hemodynamic instability. 2.- SC values lower than 18 ug/dL contribute to the hemodynamic instability determined by the initial sickness, and these cases require the administration of hydrocortisone in stress dosage. 3.- Patients with cortisol levels over 18 ug/dL receive no benefits from hydrocortisone. 4.- More studies in this field are requires to establish different patterns of steroidad response in critical patients