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Are we correctly diagnosing adrenal insufficiency or are we just spitting into the wind?

Adrenal insufficiency continues to be a common and poorly understood associated feature of pediatric critical illness.(1,2) Incidence rates range widely from 30 to 88%. Part of the reason for this disparity is likely due to the variety of diagnostic strategies. Not only is there variability in the use of low- or high-dose corticotropin stimulation testing versus simple measurement of a baseline cortisol level, but the literature also points to the variance in results based on the use of total or free cortisol levels.(3,4) Normally 90% of cortisol is bound to cortisol binding globulin (CBG) or to albumin; however, the free form of cortisol is the active form. During critical illness there is a significant decrease in CBG and albumin leading to a drop in total cortisol, but not necessarily in free cortisol. The reduced total cortisol level may then inappropriately suggest adrenal insufficiency.(5)