Is there any place to corticotropin test in sepsis?

During the past years, the use of corticosteroid therapy (CT) in patients with sepsis and septic shock became usual.

Aim

To know whether the corticotropin (ACTH) test is really useful before starting corticoids.

Patients and methods

During 2 years (September 2001–August 2003) were enrolled all patients with septic shock requiring high doses of vasoactive agents. The ACTH test is performed each time before we start corticosteroids (300 mg hydrocortisone daily). The normal value of basal cortisol level (BCL) is 200 g/l in patients with septic shock [1].

Results

Ninety-four patients were enrolled, mean age 47 years, SAPS II score 3919. CT is begun at the 10th hour on average. The result of the ACTH test allowed us to distinguish four groups of patients (Table 1). Forty-three patients have a relative adrenal insufficiency: normal or high serum cortisol level (CL) but with a weak increase after ACTH (< 90 g/l). Twenty-five patients have a low BCL and a weak response to ACTH. In these cases hydrocortisone is maintained for 5 days. If we consider the BCL, only 30 patients should have corticosteroids instead of 68.

Table 1

We analysed the same data using the Cooper algorithm [2] (Table 2). Nineteen patients have a low CL. Thirty-one patients have a relative adrenal insufficiency. If we consider only the value of BCL, 19 patients will be treated by corticosteroids instead of 68.

Table 2

Discussion

According to the Cooper algorithm, the BCL helps us to identify three groups of patients, those with low CL where CT is very likely; the group with a high BCL where CT is unlikely to be useful, and a group with an intermediate value of CL in which CT is necessary only if there is no increase after the ACTH test. So if we do not practice the ACTH test, there is a group of patients that will receive corticosteroid abusively. Can we consider a cutoff value of the BCL as 340 g/l?

Conclusion

The BCL may be useful alone to identify patients that need CT, but we should continue to practice the ACTH test until we have enough data to confirm this.