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July 19, 2000

Prognostic Value of Cortisol Response in Septic Shock—Reply

Author Affiliations

Stephen J.LurieMD, PhD, Contributing EditorIndividualAuthor

JAMA. 2000;284(3):308-309. doi:10.1001/jama.284.3.303

In Reply: Drs Marik and Zaloga raise 2 points, the first concerning the interpretation of serum cortisol levels in stress situations, and the second concerning the validity of the 250-µg corticotropin stimulation test. It has been known for more than 40 years that, in sepsis, plasma cortisol levels are likely to be higher in patients who will not survive.1 Our work goes further by defining the cutoff value for baseline cortisol levels that best discriminates between survivors and nonsurvivors. This value is 34 µg/dL, not 20 µg/dL or 45 µg/dL, as empirically proposed by Marik and Zaloga. Moreover, we think that changes in cortisol levels following a corticotropin stimulation test must be interpreted in the context of baseline cortisol levels. Indeed, our study clearly demonstrates the usefulness in predicting mortality with the combination of baseline plasma cortisol levels and cortisol response to corticotropin instead of using only baseline cortisol levels.

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