To the Editor: In the case of influenza presented by Todresand discussed by Gerberding et al. (March 18 issue),1 thereare two points that need further examination. First, the obesepatient had received at least 20 liters of fluid in 32 hoursbefore he died from unremitting shock, yet no mention is madeof measurement of the intraabdominal pressure. There is a growingbody of evidence that suggests that the body-mass index andmassive fluid resuscitation are the main independent causesof intraabdominal hypertension.2,3
Second, the patient received hydrocortisone after he was foundto 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 beclassified in the lowest risk group — patients who areconsidered to have "adequate" activation of the hypothalamic–pituitary–adrenalaxis and who would probably not benefit from the administrationof corticosteroids.
Petros Kopterides, M.D. Attikon University Hospital 12462 Athens, Greece petkop{at}ath.forthnet.gr
References
Case Records of the Massachusetts General Hospital (Case 9-2004). N Engl J Med 2004;350:1236-1247. [Free Full Text]
Malbrain ML. Abdominal pressure in the critically ill: measurement and clinical relevance. Intensive Care Med 1999;25:1453-1458. [CrossRef][Web of Science][Medline]
Malbrain ML. Is it wise not to think about intraabdominal hypertension in the ICU? Curr Opin Crit Care 2004;10:132-145. [Medline]
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. [Free Full Text]
The discussant replies: Measurement of the intraabdominal pressurewas not performed in this patient. However, it is unlikely thata clinically significant increase in abdominal pressure waspresent because mechanical ventilation was effectively carriedout with relatively low peak inspiratory pressures and positiveend-expiratory pressures. With regard to the administrationof hydrocortisone, testing for the cortisol response was performedbefore the administration of the drug, which was then continueduntil the test showed a positive result, thus no longer indicatingthat the drug was needed in this patient.
I. David Todres, M.D. MassGeneral Hospital for Children Boston,MA 02114
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