In recent years, the short Synacthen test (SS) has become the most widely used test to assess adrenal reserve. Despite its frequent use, there are still several areas related to the short Synacthen test (SST), which have no consensus including the optimum sampling times, that is, whether a 60 min post-Synacthen administration cortisol is necessary or not.MethodologyWe performed a retrospective data analysis of 492 SSTs performed on adult patients in a tertiary referral teaching hospital in Ireland. The SSTs were performed in the inpatient and outpatient setting and included patients across all medical disciplines and not exclusively to the endocrinology department.Results313 patients had 0, 30 and 60 min samples available for analysis. A total of 270/313 (82%) were deemed to pass the test, that is, cortisol ≥500 nmol/L at both 30 and 60 min. Of the 313 patients, 19 (6%) patients had an indeterminate response, cortisol <500 nmol/L at 30 min, but rising to ≥500 nmol/L on the 60 min sample. Of these 19 patients, only 9/19 patients had a serum cortisol level at 30 min <450 nmol/L, requiring clinical treatment with glucocorticoid replacement. All 24/313 (8%) patients who had insufficient responses at 60 min were also insufficient at 30 min sampling. No individuals passed (≥500 nmol/L) at 30 min and then failed (<500 nmol/L) at 60 min.ConclusionUsing the 30 min cortisol sample post-Synacthen administration alone identifies clinically relevant adrenal insufficiency in the majority of cases. A small subset of patients have a suboptimal response at 30 min but have a 60 min cortisol concentration above the threshold for a pass. Data regarding the long-term outcomes and management of such patients are lacking and require further study.

No abstract

No abstract

Pulmonary hypertension is a complex chronic cardiopulmonary disease. The condition is an independent riskfactor for peri-operative morbidity and mortality in patients undergoing non-cardiac surgery, with mortality rates of up to 18%. Due to this, patients with pulmonary hypertension are frequently counselled against undergoing all but essential surgery. In this report, we describe the use of ultra-low-dose spinal anaesthetic delivered via intrathecal catheter to allow a patient with severe pulmonary hypertension to safely undergo an elective primary hip arthroplasty for osteoarthritis which was causing intolerable pain. The use of an intrathecal catheter avoided general anaesthesia in a patient who may not have tolerated positive pressure ventilation. The technique also allowed the use of ultra-low doses of spinal anaesthesia, with the option of titrating to effect and duration of surgery. Invasive monitoring allowed proactive management of the haemodynamic effects of neuraxial anaesthesia, specifically the fall in systemic vascular resistance that may be associated with higher doses of spinal anaesthesia. While this report describes a patient with severe pulmonary hypertension, the technique may also be considered for patients with other obstructive cardiac lesions including severe aortic or mitral stenosis.

No abstract