The postresuscitation phase after out-of-hospital circulatory arrest shares similarities with
severe sepsis.
Corticosteroid replacement is beneficial in patients with
septic shock and adrenal dysfunction. The goal of this study was to assess baseline
cortisol and adrenal reserve of out-of-hospital circulatory arrest patients after recovery of spontaneous circulation. Thirty-three consecutive patients successfully resuscitated after
cardiac arrest were prospectively included between March 2002 and June 2003. A serum
cortisol assay and a
corticotropin test (250 microg i.v.) were done 6 to 36 h after circulatory arrest. A
cortisol increase smaller than 9 microg/dL after
corticotropin (nonresponders) defined adrenal reserve insufficiency. Response status was compared in the three outcome groups: survival with full neurologic recovery (n = 4), early death from refractory
shock (n = 10), or later death from
neurologic dysfunction (n = 19). Patients who died of early refractory
shock had lower baseline
cortisol levels than patients who died of
neurologic dysfunction (27 microg/dL [15-47] vs. 52 microg/dL [28-73], respectively; P < 0.01), suggesting an inadequate adrenal response to severe systemic
inflammation.
Corticotropin response status was not associated with standard severity markers and seemed uninfluenced by
therapeutic hypothermia. In conclusion, patients who die of early refractory
shock after
cardiopulmonary resuscitation may have an inadequate adrenal response to the stress associated with this condition. Thresholds for
cortisol levels at baseline and after
corticotropin need to be determined in this clinical setting.