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Tue May 15 05:28:01 BST 2007

Doctor George,

Of the top of my head, I believe that progressive hemorrhage and shock is associated very directly with progressive glandular (apocrine and endocrine) paresis. Glandular protein synthesis and secretion require liberal blood flow, and low flow states compromise this ability. If sustained, ischemia and necrosis of glandular tissue is the predictable eventuality. Studies show that both hypoadrenalism, as well as hypothyroidism occur in sustained hemorrhagic shock. That being said, however, we also know that the initial or acute response to injury includes glandular hypersecretion secondary to physiologic (sympathetic) stimulation. Stress hormones (corticosterone, epinephrine, norepinephrine, ad nauseum) rise acutely in acute hemorrhage, as do insulin and renin. Note that the medullary hormones (epinephrine and norepinephring) have short half lives in the blood; thus, the renin-angiotensin system may well be more important in the compensatory maintainance of blood pressure in acute hem
orrhage. But I digress...

Although supplemental cortisone is probably not beneficial preoperatively (unless the clinician has reason to suspect adrenal insufficiency - patient is taking steroids), since blood levels are high anyway. If shock is sustained to the postoperative period however, steroids may be of benefit.

Anybody know of any evidence for or against?

DB

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adrenal insufficiency