Introduction: There is considerable variation in practice when assessing adrenal function in adrenal insufficiency; duration of glucocorticoid defined to confer risk, early morning cortisol assay (EMC), Synacthen test (ST) - both low dose (LDST) (1microgram) or standard dose (SDST) (36microgram/kg [maximum 250micrograms]) and symptomatology. At our tertiary children’s hospital, even between departments, there is variation in those identified as being at risk of adrenal insufficiency and in their assessment.
Aims: To perform a cross-sectional review, establishing how and when our two Synacthen test protocols (LDST and SDST) and EMC are being used. Overall, aiming to standardise practice, improve patient care and service delivery.
Methods: Patients identified through inpatient and day case lists over a six-month period, June to December 2021. Data was collected from electronic records.
Results: 54 patients were identified as being at risk of impaired adrenal function. Of the 54, 66.6% (n=36/54) had their ST during the review period. The assessments were carried out by 11 different subspecialties. 80.5% had an EMC (n=29/36). Mean EMC was 244nmol/l (lower quartile [LQ]113.5nmol/l and upper quartile [UQ] 359.5nmol/l). Two patients had an EMC >450nmol/l and proceeded to have a ST which they passed. 41.6% (n=15/26) had an EMC <150nmol/l and proceeded to have ST, peak cortisol >450nmol/l in 40% (n=6/15), of those most had a baseline <150nmol/l (n=4/6). 77.8% had a LDST (n=28/36). Those who underwent LDST compared with SDST had a mean lighter weight and younger age (14.5 kg lighter and 4.6 years younger). There was minimal observed difference in peak cortisol for LDST (569nmol/l LQ 384nmol/l, UQ 722nmol/l) vs SDST (578nmol/l LQ 559nmol/l, UQ 700nmol/l).
Conclusion: The review highlights the need for a pathway, to identify and assess patients at risk of adrenal insufficiency, in order to standardise and improve patient care; prior to proceeding to ST protocol. Although the numbers are small, decision for LDST included younger and lighter patients. There was minimal observed difference LDST and SDST peak cortisol. Whilst further studies are needed, in this cohort, it suggests SDST did not result in false positives. EMC can be used to triage patients. Locally, those with an EMC >450nmol/l can be assumed as being adrenally sufficient and the majority of those with EMC <150nmol/l can be assumed as being adrenally insufficient, without the need for further assessment with ST. A pathway utilising EMC as first line, would enable us to rationalise resources locally and standardise our care.
15 Sep 2022 - 17 Sep 2022