Cortisol deficiency in critically ill patients after major trauma

Introduction

Severe injury with activation of the systemic inflammatory response syndrome stimulates the release of cortisol from the adrenal cortex. Relative cortisol insufficiency is well described in critically ill patients, especially in severe sepsis, and is associated with increased mortality. There is conflicting data regarding the effect of major trauma and haemorrhagic shock on endogenous cortisol levels and the effects of early relative cortisol deficiency.

Materials and methods

We measured random cortisol levels in 20 patients with severe trauma and haemorrhagic shock who were admitted to the ICU after initial resuscitation and emergency surgery. Injury severity scores (ISS), fluid and blood product requirements, inotrope requirements after fluid resuscitation, and mortality at 28 days were also measured. Relative cortisol deficiency was defined as a random cortisol level < 400 nmol/l.

Results

Six out of 20 (30%) patients had a cortisol level > 400 nmol/l. This group of patients had a mean (± SD) ISS of 18 (± 7) and a mean cortisol level of 606 nmol/l (± 155). None required inotropic support, and mortality was 0/6 (0%). Fourteen out of 20 (70%) patients had a cortisol level < 400 nmol/l. This group of patients had a mean ISS of 28 (± 7.5) and a mean cortisol level of 253 (± 89). Six out of 14 (43%) required inotropic support, and the mortality was 3/14 (21.5%). These patients also had significantly higher fluid and blood product requirements.

Conclusion

Cortisol deficiency is common in patients after major trauma and is associated with a higher ISS, increased fluid and blood product requirements, increased inotrope requirements, and increased mortality. These patients may benefit from early steroid replacement therapy.