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Short synacthen test identifies septic patients at high risk of death.

 

Overall 28-day mortality 58%.   ACTH result divides patients into 3 groups.
Low risk 28%, intermediate risk 67%, high risk 80%.

Level 2+ evidence

 

Citation/s:  A 3-level prognostic classificiation in septic shock based on cortisol levels and cortisol response to corticotrophin. JAMA 2000;283:1038-1045.
 

Lead author's name and fax:    Djillali Annane, Hopital R Poincare, 92380 Garches, France. djillali.annane@rpc.ap-hop-paris.fr

 

Three-part Clinical Question: In patients with septic shock does cortisol response to ACTH identify patients at increased risk of death?
 

Search Terms: 1. exp sepsis/ or severe sep$.tw or sept$.tw or sepsis syn$.tw 2. exp critical care/ 3. 1 and 2 4. prognosis filter 5. 3 and 4

 

The Study:    There was a well-defined sample at a uniform (early) stage of illness. Follow-up was long enough; follow-up was complete. There were blind, objective outcome criteria. Adjustment was not made for other prognostic factors. There was no validation in an independent test-set of patients.
 

The Study Patients: Consecutive patients fulfilling study septic shock criteria admitted to ICUs in 2 French Hospitals. Criteria: 1) ACCP/SCCM criteria for SIRS, 2) evidence of nidus of infection, 3) < 24 h of SBP < 90 mmHg despite fluids and dopamine or inotropes, and 2 signs of organ hypoperfusion - lactic acidosis, oliguria, alteration in mental status.
 

Prognostic Factor: Short synacthen test and baseline cortisol.
 

The Outcome: 28-day mortality

The Evidence:

Prognostic Factor

Outcome

Mortality

95% CI

Baseline cortisol £ 940 nmol.l-1 and D cortisol > 250 nmol.l-1.

28-day mortality

26%

15% to 38%

Baseline cortisol £ 940 nmol.l-1 and D cortisol £ 250 nmol.l-1 or baseline cortisol. > 940 nmol.l-1 and D cortisol > 250 nmol.l-1

28-day mortality

67%

58% to 77%

Baseline cortisol > 940 nmol.l-1 and D cortisol £ 250 nmol.l-1

28-day mortality

80%

65% to 93%

 

Comments:

1. Needs confirmation in second, independent (test-set) of patients.

2. Identifies patients needing steroid supplementation in septic shock.

Appraised by: Malcolm Daniel, Department of Anaesthesia, Glasgow Royal Infirmary; Saturday, September 07, 2002      Email: md23s@udcf.gla.ac.uk

 

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