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Relative adrenal insufficiency in the intensive care population; background and critical appraisal of the evidence

Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia

Summary

Dysfunction of the hypothalamo-pituitary adrenal axis has become a central feature in descriptions of the pathophysiology of sepsis. However, despite hundreds of published articles including literature reviews and consensus statements, controversy still exists regarding the fundamental nature of the disorder and its relevance to clinical management. Often referred to as 'relative adrenal insufficiency', a recent consensus conference has proposed the alternate term 'critical illness related corticosteroid insufficiency' and suggested diagnostic criteria of a delta serum cortisol of less than 9 µg/l after adrenocorticotrophic hormone administration or a random total cortisol of under 10 µg/l.
This review attempts to establish a critical reappraisal of the evidence for the existence of relative adrenal insufficiency/critical illness related corticosteroid insufficiency in patients with sepsis andl examines the background, controversies and possibilities for future research into the condition.

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