Discordant response to ACTH stimulation in patients with septic shock

Excerpt

Sir: Recent evidence suggests that the administration of parenteral hydrocortisone has haemodynamic and prognostic benefits in some patients with septic shock [1, 2, 3]. Following the study by Annane and colleagues [3] ACTH stimulation has been widely employed to identify patients that might benefit from corticosteroid replacement therapy. However, the mechanism underlying adrenocortical dysfunction in sepsis, and therefore the question of how best to define it remains to be fully elucidated. More recently the demonstration that ‘total cortisol’ measurements, on which present indices are based, are only poorly correlated with physiologically active ‘free cortisol’ concentrations in hypoalbuminaemic, critically ill patients [4] has added to the uncertainty. …