Podcast
Questions and Answers
Which factor least contributes to the increase of circulating cortisol levels during the activation of the hypothalamic-pituitary-adrenal (HPA) axis in critically ill patients?
Which factor least contributes to the increase of circulating cortisol levels during the activation of the hypothalamic-pituitary-adrenal (HPA) axis in critically ill patients?
- Increased levels of circulating cortisol.
- Reduced binding of cortisol to albumin and cortisol binding globulin. (correct)
- Peripheral conversion of precursors to cortisol.
- Reduced cortisol breakdown.
In the context of sepsis, what is a primary challenge in diagnosing critical illness-related corticosteroid insufficiency (CIRCI)?
In the context of sepsis, what is a primary challenge in diagnosing critical illness-related corticosteroid insufficiency (CIRCI)?
- The established consensus on 'normal' cortisol levels during septic shock.
- The widespread agreement on diagnostic criteria and reliable assays.
- The unclear definition and lack of reliable assays in critically ill patients. (correct)
- The consistent response to adrenocorticotropic hormone stimulation testing.
A patient with a history of recent head trauma and prolonged etomidate use is admitted to the ICU with septic shock. Which mechanism is most likely contributing to adrenal insufficiency?
A patient with a history of recent head trauma and prolonged etomidate use is admitted to the ICU with septic shock. Which mechanism is most likely contributing to adrenal insufficiency?
- Peripheral conversion of cortisol precursors.
- Increased glucocorticoid receptor affinity.
- Impairment of the HPA axis. (correct)
- Activation of the hypothalamic-pituitary-adrenal (HPA) axis.
How does the beta-isoform of the glucocorticoid receptor potentially contribute to the pathophysiology of sepsis?
How does the beta-isoform of the glucocorticoid receptor potentially contribute to the pathophysiology of sepsis?
Which statement best describes the incidence of absolute adrenal insufficiency among critically ill patients?
Which statement best describes the incidence of absolute adrenal insufficiency among critically ill patients?
A patient with septic shock exhibits elevated cortisol levels. Which mechanism could explain why the patient is not responding appropriately to the elevated cortisol?
A patient with septic shock exhibits elevated cortisol levels. Which mechanism could explain why the patient is not responding appropriately to the elevated cortisol?
In the context of sepsis, what is the primary effect of activating the hypothalamic-pituitary-adrenal (HPA) axis?
In the context of sepsis, what is the primary effect of activating the hypothalamic-pituitary-adrenal (HPA) axis?
Which of the following conditions is least likely to impair the hypothalamic-pituitary-adrenal (HPA) axis in critically ill patients?
Which of the following conditions is least likely to impair the hypothalamic-pituitary-adrenal (HPA) axis in critically ill patients?
What factor complicates the interpretation of cortisol levels in critically ill patients with sepsis?
What factor complicates the interpretation of cortisol levels in critically ill patients with sepsis?
A researcher is investigating the role of glucocorticoid receptors in sepsis. What aspect of these receptors would most strongly suggest glucocorticoid resistance?
A researcher is investigating the role of glucocorticoid receptors in sepsis. What aspect of these receptors would most strongly suggest glucocorticoid resistance?
Flashcards
Relative Adrenal Insufficiency (CIRCI)
Relative Adrenal Insufficiency (CIRCI)
Adrenal cortisol production insufficient to meet the body's demands during critical illness.
Absolute Adrenal Insufficiency
Absolute Adrenal Insufficiency
Rare condition where the adrenal glands do not produce enough cortisol, incidence estimated to be ≤3 percent
Mechanisms of Adrenal Insufficiency in Sepsis
Mechanisms of Adrenal Insufficiency in Sepsis
Activation of the hypothalamic-pituitary-adrenal axis, HPA impairment, and glucocorticoid resistance.
Cortisol Levels in Critical Illness
Cortisol Levels in Critical Illness
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Altered Cortisol Metabolism in Sepsis
Altered Cortisol Metabolism in Sepsis
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Factors Impairing the HPA Axis
Factors Impairing the HPA Axis
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Glucocorticoid Resistance in Sepsis
Glucocorticoid Resistance in Sepsis
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Hypothalamic-Pituitary-Adrenal (HPA) Axis
Hypothalamic-Pituitary-Adrenal (HPA) Axis
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ACTH Stimulation Testing
ACTH Stimulation Testing
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Cortisol Metabolism
Cortisol Metabolism
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Study Notes
- Absolute adrenal insufficiency occurs rarely among critically ill patients, with an estimated incidence of ≤3 percent.
- Relative adrenal insufficiency or critical illness-related corticosteroid insufficiency (CIRCI) may be common among critically ill patients, where the adrenal cortisol production is insufficient.
- There is no agreement about diagnostic criteria of CIRCI.
- There is disagreement over what qualifies as a "normal" cortisol level in septic shock.
- Disagreement exists over what dose of adrenocorticotropic hormone should be used for stimulation testing.
- No consensus exists on what constitutes an adequate response in stimulation testing.
- The lack of a clear definition and reliable assays makes the existence of CIRCI as a true diagnostic entity speculative.
Mechanisms of Adrenal Insufficiency in Sepsis
- Critical illness affects cortisol level and function.
- Mechanisms include hypothalamic-pituitary-adrenal (HPA) axis activation.
- Mechanisms include HPA impairment, resulting in adrenocortical hyporesponsiveness.
- Mechanisms include glucocorticoid resistance.
Activation of the HPA Axis
- In critically ill patients, serum cortisol rises, reaching levels as high as 40 to 50 mcg/dL.
- Cortisol metabolism and function may be altered in sepsis.
- Sepsis results in reduced cortisol breakdown.
- Sepsis results in reduced binding of cortisol to albumin and cortisol binding globulin.
- Sepsis leads to increased glucocorticoid receptor affinity for cortisol.
- Sepsis causes peripheral conversion of precursors to cortisol.
Impairment of the HPA Axis
- Several factors impair the HPA axis among critically ill patients.
- Factors include head injury and central nervous system depressants.
- Factors include pituitary infarction and adrenal hemorrhage.
- Factors include infections and malignancy.
- Factors include previous glucocorticoid therapy and several drugs (eg, ketoconazole, phenytoin, and etomidate).
Glucocorticoid Resistance
- Glucocorticoid resistance may play a role in adrenal insufficiency.
- One study reported higher expression levels of the beta-isoform of the glucocorticoid receptor in patients with sepsis.
- The beta-isoform of the glucocorticoid receptor is associated with glucocorticoid resistance.
- However, functional differences were not observed in the study.
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Description
Adrenal insufficiency occurs rarely among critically ill patients. Relative adrenal insufficiency or critical illness-related corticosteroid insufficiency (CIRCI) may be common among critically ill patients, where the adrenal cortisol production is insufficient. Critical illness affects cortisol level and function.
