Clarifying Cortisol Metabolism in Critically Ill Patients: Complicated and Somewhat Less Confusing

The response of the hypothalamic-pituitary-adrenal axis in critically ill patients is poorly understood. Such patients might be at risk for relative adrenal insufficiency, and early studies suggested a mortality benefit from stress doses of steroids in patients with septic shock who had low responses to adrenocorticotropin hormone (ACTH) stimulation testing (indicating relative adrenal insufficiency). In contrast, the largest randomized trial showed no benefit from moderate-dose corticosteroids (regardless of adrenal response to corticotropin), although steroids did shorten the duration of shock (JW General Medicine Jan 9 2008).

In a series of clinical studies, investigators sought to better understand cortisol metabolism by comparing plasma…