Endocrine Abstracts

The role of the hypothalamic–pituitary adrenal axis in host response to an infection is crucial. The initial inflammatory response to sepsis activates the endogenous release of cortisol which in turn will modulate the synthesis and release of both pro- and anti-inflammatory mediators to restrict inflammation to the infected tissues. However, a number of factors including vascular or ischemic damage, inflammation and apoptosis within the hypothalamic–pituitary adrenal axis, and drugs induced altered cortisol metabolism, may cause adrenal insufficiency. One major problem ICU physicians are faced with is the diagnosis at the bedside of sepsis induced adrenal insufficiency. A recent international task force recommended that sepsis induced adrenal insufficiency is best recognized by basal cortisol is of <10 μg/dl or delta cortisol of <9 μg/dl. The diagnostic value of salivary free cortisol in this setting remains to be investigated. While sepsis adrenal insufficiency is undoubtedly associated with a poor prognosis, the indication and practical modalities of corticosteroids therapy remained controversial. Based on the two largest randomised, placebo-controlled trials, this author suggested that septic shock patients with hypotension poorly responsive to fluid replacement and vasopressors should receive a seven day treatment with the combination of hydrocortisone at a dose of 200 mg/day and fludrocortisone at the dose of 50 μg/day.