-icu- - pindi

[ArchivalUser]

A 45-year-old female is admitted to the intensive care unit with several days of dysuria and recent confusion. She has no other medical problems and takes no medications regularly. Physical examination on admission shows a temperature of 40°C (104°F), a pulse of 140 beats/min, a respiratory rate of 30, and blood pressure of 70/30 mmHg.

The patient is confused, but aside from tachypnea and tachycardia, cardiac and pulmonary examinations are normal. Abdominal examination is unremarkable.

Catheterization-obtained urinalysis shows numerous white blood cells and many bacteria. White blood cell count is 25,000/mm3. Blood pressure is unchanged after adequate fluid administration. After the initiation of vasopressors, which of the following tests is indicated to evaluate the low blood pressure?

A. Cosyntropin stimulation test
B. Metyrapone test
C. Salivary cortisol measurement
D. Serum ACTH measurement
E. None of the above

[ArchivalUser]

eeee

[ArchivalUser]

Ee

[ArchivalUser]

A....

[ArchivalUser]

correct answer is ...A...

The patient presents with urosepsis and fails to increase blood pressure after the administration of intravenous fluid.

Vasopressors are indicated at this point. In addition, recent data have suggested that there is an increased prevalence of relative adrenal insufficiency in the critically ill patient population.

Furthermore, treatment of this relative adrenal insufficiency with hydrocortisone and fludrocortisone is associated with a mortality benefit.

Current recommendations are to assess adrenal function in critically ill patients with 250 g cosyntropin and replete with hydrocortisone and fludrocortisone in patients whose serum cortisol levels rise 9 g/dL or less.

Serum ACTH, salivary cortisol, and metyrapone testing have not
been used for this purpose.

[ArchivalUser]

but in unstable pt we do direct serum cortisol??????????