Correspondence

Case 9-2004: An 18-Year-Old Man with Respiratory Symptoms and Shock

N Engl J Med 2004; 351:105-106July 1, 2004

Article

To the Editor:

In the case of influenza presented by Todres and discussed by Gerberding et al. (March 18 issue),1 there are two points that need further examination. First, the obese patient had received at least 20 liters of fluid in 32 hours before he died from unremitting shock, yet no mention is made of measurement of the intraabdominal pressure. There is a growing body of evidence that suggests that the body-mass index and massive fluid resuscitation are the main independent causes of intraabdominal hypertension.2,3

Second, the patient received hydrocortisone after he was found to have a baseline cortisol level of 27.1 μg per deciliter (748 nmol per liter) that increased to 41.5 μg per deciliter (1145 nmol per liter) after the administration of cosyntropin. According to a study by Annane et al.,4 this patient would be classified in the lowest risk group — patients who are considered to have “adequate” activation of the hypothalamic–pituitary–adrenal axis and who would probably not benefit from the administration of corticosteroids.

Petros Kopterides, M.D.
Attikon University Hospital, 12462 Athens, Greece
petkop@ath.forthnet.gr

4 References

1. 1

   Case Records of the Massachusetts General Hospital (Case 9-2004). N Engl J Med 2004;350:1236-1247
   Full Text | Web of Science | Medline

2. 2

   Malbrain ML. Abdominal pressure in the critically ill: measurement and clinical relevance. Intensive Care Med 1999;25:1453-1458
   CrossRef | Web of Science | Medline

3. 3

   Malbrain ML. Is it wise not to think about intraabdominal hypertension in the ICU? Curr Opin Crit Care 2004;10:132-145
   CrossRef | Medline

4. 4

   Annane D, Sebille V, Troche G, Raphael JC, Gajdos P, Bellissant E. A 3-level prognostic classification in septic shock based on cortisol levels and cortisol response to corticotropin. JAMA 2000;283:1038-1045
   CrossRef | Web of Science | Medline

Author/Editor Response

Measurement of the intraabdominal pressure was not performed in this patient. However, it is unlikely that a clinically significant increase in abdominal pressure was present because mechanical ventilation was effectively carried out with relatively low peak inspiratory pressures and positive end-expiratory pressures. With regard to the administration of hydrocortisone, testing for the cortisol response was performed before the administration of the drug, which was then continued until the test showed a positive result, thus no longer indicating that the drug was needed in this patient.

I. David Todres, M.D.
MassGeneral Hospital for Children, Boston, MA 02114