The idea that many critically ill patients have inadequate adrenal reserve has gained currency in recent years. In this study from Taiwan, researchers explored a possible effect of adrenal insufficiency on weaning from mechanical ventilation among 93 clinically stable ICU patients who had been mechanically ventilated for more than 72 hours and were ready for weaning. Pneumonia and sepsis were the most common diagnoses.
Seventy patients had inadequate responses on 1-hour cosyntropin stimulation testing (<9 µg/dL increase in serum cortisol) and thus were considered to have adrenal insufficiency. These patients were randomized to receive either hydrocortisone (50 mg intravenously every 6 hours during weaning) or placebo. The proportion of successfully weaned patients (i.e., no requirement for reintubation or noninvasive positive-pressure ventilation after extubation) was significantly higher in the steroid group than in the placebo group (91% vs. 69%, P=0.04). The steroid group also had shorter duration of weaning (mean, 3.4 vs. 6.5 days; P=0.04) and shorter ICU stays (mean, 12.6 vs. 17.3 days; P=0.09).
A large proportion of these patients had inadequate adrenal reserve, according to cosyntropin stimulation testing, and the effect of supplemental steroids was impressive. Nevertheless, because steroid therapy in critically ill patients is not necessarily benign, these results should be duplicated — preferably in a larger multicenter study — before this practice is adopted widely.
Reference:
Huang C-J and Lin H-C. Association between adrenal insufficiency and ventilator weaning. Am J Respir Crit Care Med 2006 Feb 1; 173:276-80.