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Adrenal response after trauma is affected by time after trauma and sedative/analgesic drugs
Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
Umeå University, Faculty of Science and Technology, Department of Mathematics and Mathematical Statistics.
Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
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2014 (English)In: Injury, ISSN 0020-1383, E-ISSN 1879-0267, Vol. 45, no 8, 1149-1155 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: The adrenal response in critically ill patients, including trauma victims, has been debated over the last decade. The aim of this study was to assess the early adrenal response after trauma. METHODS: Prospective, observational study of 50 trauma patients admitted to a level-1-trauma centre. Serum and saliva cortisol were followed from the accident site up to five days after trauma. Corticosteroid binding globulin (CBG), dehydroepiandrosterone (DHEA) and sulphated dehydroepiandrosterone (DHEAS) were obtained twice during the first five days after trauma. The effect of time and associations between cortisol levels and; severity of trauma, infusion of sedative/analgesic drugs, cardiovascular dysfunction and other adrenocorticotropic hormone (ACTH) dependent hormones (DHEA/DHEAS) were studied. RESULTS: There was a significant decrease over time in serum cortisol both during the initial 24 h, and from the 2nd to the 5th morning after trauma. A significant decrease over time was also observed in calculated free cortisol, DHEA, and DHEAS. No significant association was found between an injury severity score >/= 16 (severe injury) and a low (< 200 nmol/L) serum cortisol at any time during the study period. The odds for a serum cortisol < 200 nmol/L was eight times higher in patients with continuous infusion of sedative/analgesic drugs compared to patients with no continuous infusion of sedative/analgesic drugs. CONCLUSION: Total serum cortisol, calculated free cortisol, DHEA and DHEAS decreased significantly over time after trauma. Continuous infusion of sedative/analgesic drugs was independently associated with serum cortisol < 200 nmol/L.

Place, publisher, year, edition, pages
Elsevier, 2014. Vol. 45, no 8, 1149-1155 p.
Keyword [en]
Multiple trauma, Adrenal insufficiency, Sedatives
National Category
Anesthesiology and Intensive Care
Identifiers
URN: urn:nbn:se:umu:diva-91640DOI: 10.1016/j.injury.2014.02.001PubMedID: 24975481ISBN: 1879-0267 (Electronic) 0020-1383 (Linking) (print)OAI: oai:DiVA.org:umu-91640DiVA: diva2:737515
Available from: 2014-08-13 Created: 2014-08-13 Last updated: 2017-12-05Bibliographically approved
In thesis
1. Trauma - logistics and stress response
Open this publication in new window or tab >>Trauma - logistics and stress response
2014 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Trauma is a major cause of death and disability. Adverse events, such as prolonged prehospital time, hypoxia, hypotension and/or hyperventilation have been reported to correlate to poor outcome.

Adequate cortisol levels are essential for survival after major trauma. In hypotensive critically ill patients, lack of sufficient amount of cortisol can be suspected, and a concept of critical illness related corticosteroid insufficiency has been proposed. Corticosteroid therapy has many adverse effects in critically ill patients and should only be given if life-saving. Correct measurement of serum cortisol levels is important but difficult in critically ill patients with capillary leakage. Estimation of the free and biologically active cortisol is preferable. In serum less than 10% of cortisol is free and biologically active and not possible to measure with routine laboratory methods. Salivary cortisol can be used as a surrogate for free cortisol, but salivary production is reduced in critically ill patients. Liver resection could reduce cortisol levels due to substrate deficiency.

Aims: 1. Evaluate the occurrence of early adverse events in patients with traumatic brain injury and relate them to outcome. 2. Assess cortisol levels over time after trauma and correlate to severity of trauma, sedative/analgesic drugs and cardiovascular function. 3. Evaluate if saliva stimulation could be performed without interfering with salivary cortisol levels. 4. Assess cortisol levels over time after liver resection in comparison to other major surgery.

Results: There was no significant correlation between prehospital time ³60 minutes, hypoxia (saturation <95%), hypotension (systolic blood pressure <90 mmHg), or hyperventilation (ETCO2 <4.5 kPa) and a poor outcome (Glasgow Outcome Scale 1-3) in patients with traumatic brain injury. Cortisol levels decreased significantly over time after trauma, but there was no correlation between low (<200 nmol/L) serum cortisol levels and severity of trauma.

Infusion of sedative/analgesic drugs was the strongest predictor for a low (<200 nmol/L) serum cortisol. The odds ratio for low serum cortisol levels (<200 nmol/L) was 8.0 for patients receiving continuous infusion of sedative/analgesic drugs. There was no significant difference between unstimulated and stimulated salivary cortisol levels (p=0.06) in healthy volunteers. Liver resection was not associated with significantly lower cortisol levels compared to other major surgery.

Conclusion: There was no significant correlation between early adverse events and outcome in patients with traumatic brain injury. Cortisol levels decreased significantly over time in trauma patients. Low cortisol levels (<200 nmol/L) were significantly correlated to continuous infusion of sedative/analgesic drugs. Saliva stimulation could be performed without interfering with salivary cortisol levels. Liver resection was not associated with low cortisol levels compared to other major surgery.

Place, publisher, year, edition, pages
Umeå Universitet, 2014. 65 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1654
Keyword
traumatic brain injury, multiple trauma, hydrocortisone, adrenal insufficiency, hypnotics and sedatives, citric acid, glycerol, saliva, liver, colorectal surgery
National Category
Anesthesiology and Intensive Care
Identifiers
urn:nbn:se:umu:diva-93324 (URN)978-91-7601-072-3 (ISBN)
Public defence
2014-10-10, E04 byggnad 6E NUS, Norrlands Universitetssjukhus, Umeå, 09:00 (Swedish)
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Available from: 2014-09-19 Created: 2014-09-17 Last updated: 2014-09-18Bibliographically approved

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