Critical illness-related corticosteroid insufficiency after multiple traumas: a multicenter, prospective cohort study

Abstract

Background: Given that the observed prevalence and time course of critical illness-related corticosteroid insufficiency (CIRCI) remain inconsistent in trauma patients, the present study was designed to investigate the prevalence, time course, and effect of CIRCI on the outcome of critically ill patients with multiple injuries.

Methods: In this multicenter, prospective cohort study, patients with multiple injuries in seven intensive care units in China were enrolled. Adrenocorticotropic hormone (ACTH) stimulation tests were performed by administering intravenously 250 μg of synthetic ACTH on Days 1, 2, 3, 5, and 7 after traumatic injury. CIRCI was defined as baseline cortisol level of less than 10 μg/dL or a Δcortisol (difference baseline and highest cortisol level at 30 or 60 minutes after ACTH stimulation) less than 9 μg/dL. The incidence and time course of CIRCI and 28-day mortality were recorded.

Results: CIRCI occurred in 54.3% (38 of 70) of the patients with multiple injuries, including 10 patients with total cortisol level of less than 10 μg/dL and 28 patients with Δcortisol of less than 9 μg/dL. Most (94.7%) diagnosis of CIRCI was made in the first 48 hours after traumatic injury. The CIRCI patients had significantly more severe illness on the day of admission. At each time point, the baseline cortisol level was comparable between the CIRCI and non-CIRCI patients, while Δcortisol in the CIRCI group was significantly lower compared with the non-CIRCI group. The CIRCI patients with a Δcortisol of less than 9 μg/dL had a significantly higher 28-day mortality (39.3%) compared with those with a baseline cortisol level of less than 10 μg/dL (10.0%) and non-CIRCI patients (6.3%). Only Δcortisol of less than 9 μg/dL but not baseline cortisol level of less than 10 μg/dL seemed to be an independent risk factor for death (odds ratio, 1.19; p = 0.023).

Conclusion: CIRCI is common in critically ill trauma population and usually occurs in the early stages. Only the results of the ACTH stimulation test but not baseline cortisol level was associated with poor prognosis.

Level of evidence: Prognostic study, level II.