This paper is only available as a PDF. To read, Please Download here.
Background. Acute adrenal insufficiency after a surgical procedure or trauma is rarely reported. In recent years, however, we have treated seven patients with acute primary adrenal insufficiency and three patients with secondary adrenal insufficiency who presented with shock after a surgical procedure or trauma. The standard cosyntropin test was misleading for the diagnosis of corticotropin deficiency.
Methods. In this study we measured serum cortisol in patients older than 65 years who had unexplained hypotension after an abdominal surgical procedure. If the serum cortisol was less than 15 μg/dl, we performed 1 μg and standard (250 μg) cosyntropin tests and measured thyroxine, thyrotropin, leutinizing hormone in all patients, and free testosterone in men.
Results. We identified five (5%) of 105 patients after an operation who displayed evidence of corticotropin deficiency (i.e., serum cortisol <15 μg/dl during hypotension, prompt hemodynamic improvement with glucocorticoid therapy, and normal response to standard dose cosyntropin). In these patients 1 jug cosyntropin produced abnormal peak cortisol levels. These patients also had thyrotropin or leutinizing hormone deficiency. After recovery the low hormone levels improved or became normal.
Conclusions. Postoperative adrenal insufficiency, particularly that caused by transient corticotropin deficiency, is more common in patients than currently recognized. The 1 μg cosyntropin test may be more sensitive than the standard test for identifying secondary adrenal insufficiency.
To read this article in full you will need to make a payment
Purchase one-time access:Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
One-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:Subscribe to Surgery
Already a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
- Acute adrenal insufficiency presenting as shock after trauma and surgery: three cases and review of the literature.J Trauma. 1992; 32: 94-100
- Transient corticotropin deficiency in critical illness.in: 2nd ed. Mayo Clin Proc. 68. 1993: 435-441
- Normal cortisol response to corticotropin in patients with secondary adrenal failure.Arch Intern Med. 1983; 143: 2276-2279
- Adrenocorticotropin stimulation test: effects of basal cortisol level, time of day, and suggested new sensitive low dose test.J Clin Endocrinol Metab. 1991; 72: 773-778
- Rapid adrenocorticotropic hormone test in practice: retrospective review.Am J Med. 1985; 79: 679-684
- The hypothalamic-pituitary-adrenal axis in critical illness: response to dexamethasone and corticotropin-releasing hormone.J Clin Endocrinol Metab. 1993; 77: 151-156
- Biphasic changes in hypothalamo-pituitary-adrenal function during the early recovery period after major abdominal surgery.J Clin Endocrinol Metab. 1991; 73: 111-117
- Pulsatile activation of the hypothalamic-pituitary-adrenal axis during major surgery.Metabolism. 1992; 41: 839-845
- Adrenal crisis.Crit Care Clin. 1991; 7: 23-42
- Occult hypoadrenalism in critically ill patients.Arch Surg. 1993; 128: 673-676
- Plasma cortisol levels in patients with septic shock.Crit Care Med. 1990; 18: 259-263
- Endocrinology in critical care.in: Hoyt J.W. Tonnesen A.S. Allen S.J. Critical care practice. Saunders, Philadelphia1991: 331
- Critical care endocrinology.in: 2nd ed. Textbook of critical care. Saunders, Philadelphia1989: 742
- Diagnosis and therapy surveillance in Addison's disease: rapid adrenocorticotropin (ACTH) test and measurement of plasma ACTH, renin activity, and aldosterone.J Clin Endocrinol Metab. 1992; 75: 259-264
- The adrenal response to trauma, operation, and cosyntropin stimulation.Surg Gynecol Obstet. 1990; 170: 513-516
- Diminished adrenocorticotropin response to insulin-induced hypoglycemia in nondepressed, actively drinking male alcoholics.J Clin Endocrinol Metab. 1990; 71: 712-717
- Adrenocortical suppression in multiply injured patients: a complication of etomidate treatment.BMJ. 1983; 287: 1835-1837
- Effect of induction of anesthesia with etomidate on corticosteroid synthesis in man.Br J Anaesth. 1985; 57: 156-164
- Inhibition of adrenal steroidogenesis by the anesthetic etomidate.N Engl J Med. 1984; 310: 1415-1421
- A longitudinal evaluation of thyroid function in critically ill surgical patients.Ann Surg. 1985; 201: 456-464
- Tumor necrosis factor: a putative mediator of the sick euthyroid syndrome in man.J Clin Endocrinol Metab. 1990; 71: 1567-1572
- Tumor necrosis factor a inhibits the hormonal response of the pituitary gland to hypothalamic releasing factors.Endocrinology. 1990; 127: 101-106
- Cachectin: more than a tumor necrosis factor.N Engl J Med. 1987; 316: 379-385
☆Supported by a grant from the Gundersen Medical Foundation
☆☆Presented at the Fifteenth Annual Meeting of the American Association of Endocrine Surgeons, Dearborn, Mich., April 17–19, 1994.
© 1994 Published by Elsevier Inc.