Adrenal axis testing and corticosteroid replacement therapy in septic shock patients - local and national perspectives

Recently, there has been renewed interest in corticosteroid therapy for patients with septic shock. The cortisol response to a tetracosactide stimulation test, otherwise known as a short synacthen test, may identify which patients are most likely to benefit from corticosteroid replacement. Controversy over interpretation of the cortisol response and the correct tetracosactide dose remains. We retrospectively analysed all septic shock patients who had full cortisol results following a 1-mug short synacthen test. All cortisol results were re-evaluated by three common ways of interpreting the cortisol response to a short synacthen test. The thresholds were a cortisol rise greater than or equal to 250 nmol.l(-1) , a peak cortisol greater than or equal to 550 nmol.l(-1) and a peak cortisol greater than or equal to 700 nmol.l(-1) . We found a significant relationship between the peak cortisol results and haemodynamic improvement in patients given corticosteroids. There was no association between a cortisol rise greater than or equal to 250 nmol.l(-1) and haemodynamic improvement after corticosteroids. A postal questionnaire was sent to adult intensive care units in the United Kingdom to assess national practice. Sixty per cent of intensive care units use corticosteroids in septic shock patients, but only 22% use a short synacthen test to guide therapy.