Elsevier

Critical Care Clinics

Volume 23, Issue 3, July 2007, Pages 467-490
Critical Care Clinics

Endocrine Assessments During Critical Illness

https://doi.org/10.1016/j.ccc.2007.05.007Get rights and content

The evaluation of hormonal status in critically ill patients is challenging and has many pitfalls. This article reviews proper assessment of glycemic status AND adrenal and thyroid function during critical care.

Section snippets

Assessment of glycemic status

Stress-induced hyperglycemia, defined as a transient increase in blood glucose concentrations during acute physiological illness, is common among critical care patients, frequently even those without a prior history of diabetes [1]. Critical illness is associated with the number of alterations in carbohydrate metabolism, including: dramatic increases in glucose counter-regulatory hormones and various cytokines; an accelerated catabolic state (increased lipolysis, increased proteolysis,

Assessment of adrenal status

Critical illness is associated with activation of the hypothalamic-pituitary-adrenal (HPA) axis [38]. The stress stimulus leads the hypothalamus to release corticotropin-releasing hormone (CRH), which acts on the pituitary to increase adrenocorticotropic hormone (ACTH) production, which, in turn, stimulates the adrenal cortex to dramatically increase secretion of glucocorticoids. In general, the degree of activation of the HPA axis is proportionate to the severity of illness. This rise in

Assessment of thyroid function

Acute illness also often is associated with significant abnormalities in thyroid function tests (TFTs), often termed the euthyroid sick syndrome (ESS) or nonthyroidal illness (NTI) syndrome [66], [67], [68]. To correctly interpret TFT results in the patient in intensive care, the clinician should be familiar with the changes that occur in the regulation of the hypothalamic-pituitary-thyroid (HPT) axis and in thyroid hormone metabolism, and the effects of commonly used medications on thyroid

References (109)

  • P.M. Rothwell et al.

    Cortisol response to corticotropin and survival in septic shock

    Lancet

    (1991)
  • I.J. Chopra

    Nonthyroidal illness syndrome or euthyroid sick syndrome?

    Endocr Pract

    (1996)
  • A.R. Harris et al.

    Effect of starvation, nutriment replacement, and hypothyroidism on in vitro hepatic T4 to T3 conversion in the rat

    Metabolism

    (1978)
  • B. Afandi et al.

    Selective consumption of thyroxine-binding globulin during cardiac bypass surgery

    Metabolism

    (2000)
  • B. Afandi et al.

    Concordant decreases of thyroxine and thyroxine-binding protein concentrations during sepsis

    Metabolism

    (2000)
  • R. Ekins

    Analytic measurements of free thyroxine

    Clin Lab Med

    (1993)
  • Inzucchi SE GP, Dziura JD, Siegel M, et al. Risk factors for poor glycemic control in a medical intensive care unit...
  • L. Lind et al.

    Impaired glucose and lipid metabolism seen in intensive care patients is related to severity of illness and survival

    Clin Intensive Care

    (1994)
  • J.J. Ligtenberg et al.

    Mean glucose level is not an independent risk factor for mortality in mixed ICU patients

    Intensive Care Med

    (2006)
  • K. Malmberg

    Prospective randomised study of intensive insulin treatment on long-term survival after acute myocardial infarction in patients with diabetes mellitus. DIGAMI (Diabetes Mellitus, Insulin Glucose Infusion in Acute Myocardial Infarction) study group

    BMJ

    (1997)
  • G. van den Berghe et al.

    Intensive insulin therapy in the critically ill patients

    N Engl J Med

    (2001)
  • G. Van den Berghe et al.

    Intensive insulin therapy in the medical ICU

    N Engl J Med

    (2006)

  • American College of Endocrinology and American Diabetes Association consensus statement on inpatient diabetes and glycemic control

    Endocr Pract

    (2006)
  • S. Meijering et al.

    Towards a feasible algorithm for tight glycaemic control in critically ill patients: a systematic review of the literature

    Crit Care

    (2006)
  • M. Wilson et al.

    Intensive insulin therapy in critical care: a review of 12 protocols

    Diabetes Care

    (2007)
  • P.A. Goldberg et al.

    Implementation of a safe and effective insulin infusion protocol in a medical intensive care unit

    Diabetes Care

    (2004)
  • A. Malhotra

    Intensive insulin in intensive care

    N Engl J Med

    (2006)
  • D.B. Sacks et al.

    Guidelines and recommendations for laboratory analysis in the diagnosis and management of diabetes mellitus

    Clin Chem

    (2002)

  • Bedside blood glucose monitoring in hospitals

    Diabetes Care

    (2004)
  • D.E. Goldstein et al.

    Tests of glycemia in diabetes

    Diabetes Care

    (2004)
  • R.F. Louie et al.

    Point-of-care glucose testing: effects of critical care variables, influence of reference instruments, and a modular glucose meter design

    Arch Pathol Lab Med

    (2000)
  • F.M. Brunkhorst et al.

    Blood glucose measurements in the critically ill: more than just a blood draw

    Crit Care

    (2006)
  • D.R. Blake et al.

    Point-of-care testing for diabetes

    Crit Care Nurs Q

    (2004)
  • P. D'Orazio et al.

    Approved IFCC recommendation on reporting results for blood glucose: International Federation of Clinical Chemistry and Laboratory Medicine Scientific Division, Working Group on Selective Electrodes and Point-of-Care Testing (IFCC-SD-WG-SEPOCT)

    Clin Chem Lab Med

    (2006)
  • K. Dungan et al.

    Glucose measurement: confounding issues in setting targets for inpatient management

    Diabetes Care

    (2007)
  • J.G. Ray et al.

    Pilot study of the accuracy of bedside glucometry in the intensive care unit

    Crit Care Med

    (2001)
  • R.E. Maser et al.

    Use of arterial blood with bedside glucose reflectance meters in an intensive care unit: are they accurate?

    Crit Care Med

    (1994)
  • A. Kulkarni et al.

    Analysis of blood glucose measurements using capillary and arterial blood samples in intensive care patients

    Intensive Care Med

    (2005)
  • A.M. Corstjens et al.

    Accuracy and feasibility of point-of-care and continuous blood glucose analysis in critically ill ICU patients

    Crit Care

    (2006)
  • S.H. Atkin et al.

    Fingerstick glucose determination in shock

    Ann Intern Med

    (1991)
  • H.F. Sylvain et al.

    Accuracy of fingerstick glucose values in shock patients

    Am J Crit Care

    (1995)
  • Z. Tang et al.

    Effects of different hematocrit levels on glucose measurements with handheld meters for point-of-care testing

    Arch Pathol Lab Med

    (2000)
  • P.A. Goldberg et al.

    Experience with the continuous glucose monitoring system in a medical intensive care unit

    Diabetes Technol Ther

    (2004)
  • W.L. Clarke et al.

    Evaluating the clinical accuracy of two continuous glucose sensors using continuous glucose error grid analysis

    Diabetes Care

    (2005)
  • B.M. Arafah

    Hypothalamic pituitary adrenal function during critical illness: limitations of current assessment methods

    J Clin Endocrinol Metab

    (2006)
  • M.S. Cooper et al.

    Corticosteroid insufficiency in acutely ill patients

    N Engl J Med

    (2003)
  • W. Oelkers

    Adrenal insufficiency

    N Engl J Med

    (1996)
  • K. Burchard

    A review of the adrenal cortex and severe inflammation: quest of the eucorticoid state

    J Trauma

    (2001)
  • D. Annane et al.

    Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock

    JAMA

    (2002)
  • J.M. Luce

    Physicians should administer low-dose corticosteroids selectively to septic patients until an ongoing trial is completed

    Ann Intern Med

    (2004)

    • Cited by (15)

    • Hyperglycemia associated with parenteral nutrition in noncritical patients

      2020, Human Nutrition and Metabolism
      Citation Excerpt :

      Regarding lipid metabolism, Messoten and colleagues [26] demonstrated that insulin is able to control hypertriglyceridemia, reduce levels of free fatty acids, and increase HDL-c values. At the level of protein metabolism, insulin attenuates hypercatabolism, promotes protein synthesis in the skeletal muscle, and helps reverse endothelial dysfunction [27]. Therefore, in case of hyperglycemia, we should consider insulin management, which can be performed in two ways: a) in the PN solution with amounts of 0.05 up to 0.2 U of fast-acting insulin for each gram of dextrose administered, and/or b) in accordance with the requirements of the patient, administered in bolus or by continuous infusion [28].

    • Association of the -1031T > C polymorphism and soluble TNF-α levels with Acute Coronary Syndrome

      2016, Cytokine

    • Endocrine and metabolic changes during sepsis: An update

      2012, Medical Clinics of North America
      Citation Excerpt :

      The initial and most commonly observed abnormality is a decrease in total triiodothyronine (total T3) concentration secondary to a block in the action of type 1 deiodinase (5′-monodeiodinase) that catalyzes conversion of thyroxin (T4) in the periphery to T3 (type 1 deiodinase is located in the kidney, liver, and muscle). Several factors have been proposed as possible candidates involved in reducing 5′-deiodinase activity (hypocaloric state, endogenous or exogenous glucocorticoids, high-dose propranolol, free fatty acids, iodinated contrasts, amiodarone, and cytokines such as TNF, IL-6, interferon-α, and nuclear factor κB).52,53 While total T3 levels are reduced, thyroxin conversion to reverse T3 (rT3) still occurs.

    • Critical Illness-Related Corticosteroid Insufficiency in Small Animals

      2011, Veterinary Clinics of North America - Small Animal Practice
      Citation Excerpt :

      There was no significant difference in either delta cortisol or delta aldosterone concentration when survivors were compared with nonsurvivors. Clinical signs of CIRCI can be vague and nonspecific, such as depression, weakness, fever, vomiting, diarrhea, and abdominal pain.3,11,55,56 In addition, clinical signs that are secondary to the underlying disease process responsible for CIRCI (ie, septic shock, hepatic disease, trauma, etc) can mask the clinical features of CIRCI.11

    • Stress hyperglycemia and its control with insulin in critically ill patients. Current evidence

      2010, Medicina Intensiva

    • Adrenal Insufficiency and Other Adrenal Oncologic Emergencies

      2009, Emergency Medicine Clinics of North America
      Citation Excerpt :

      In the ITT, insulin is used to induce hypoglycemia, following which cortisol levels are then measured, as hypoglycemia is a potent stimulus of the HPA axis. A cortisol level greater than 18 to 25 μg/dL is generally considered to represent an adequate response.4–6 Blood sugar levels are usually reduced to less than 40 mg/dL, which makes the ITT impractical in the very ill, the elderly, and patients with a history of cardiac disease, seizures, or cerebrovascular disease.6

    View all citing articles on Scopus
    View full text
    Copyright © 2007 Elsevier Inc. All rights reserved.