Patient selection:
(1) critically ill
(2) significant liver disease (fulminant acute, chronic, recent or remote liver transplantation)
Laboratory criteria for adrenal insufficiency:
(1) In the presence of severe physiologic stress (respiratory failure with hypoxemia, hypotension), random serum cortisol < 20 µg/dL
(2) In the absence of severe physiologic stress, one of the following:
(2a) random serum cortisol < 15 µg/dL
(2b) serum cortisol < 20 µg/dL after a 1 microgram dose of cosynotropin
The only finding predictive of adrenal insufficiency was a low serum HDL (mean 8.2 mg/dL, +/- 7.6).
Significance of adrenal status in the vasopressor-dependent patient with liver disease:
(1) A patient with normal adrenal function and vasopressor dependence has a poor prognosis (mortality rate 75%).
(2) A patient with adrenal insufficiency and vasopressor dependence will require a significant reduction in vasopressor dosage if treated with hydrocortisone (mortality rate 26% if treated with glucocorticoids and 46% if not).
