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Jurnal Anestesiologi Indonesia
Published by Universitas Diponegoro
Jurnal Anestesiologi Indonesia (JAI) diterbitkan oleh Perhimpunan Dokter Spesialis Anestesiologi dan Terapi Intensif (PERDATIN) dan dikelola oleh Program Studi Anestesiologi dan Terapi Intensif Fakultas Kedokteran Universitas Diponegoro (UNDIP) bekerjasama dengan Perhimpunan Dokter Spesialis Anestesiologi dan Terapi Intensif (PERDATIN) cabang Jawa Tengah.
Articles by issue : Vol 3, No 2 (2011): Jurnal Anestesiologi Indonesia
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Articles
Etomidat Menurunkan Kadar Gula Darah Pasca Induksi Anestesi

Riffayadi, Oddi, Jatmiko, Heru Dwi, Sasongko, Himawan

Jurnal Anestesiologi Indonesia Vol 3, No 2 (2011): Jurnal Anestesiologi Indonesia
Publisher : Perhimpunan Dokter Spesialis Anestesiologi dan terapi Intensif

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Abstract

Backgrounds: The apperehensiveness of etomidate that causing hypoglicemia becomed problem. A rapid onset of action, a low cardiovascular risk profile, and less likely to cause a significant drop in blood pressure provide etomidate choose an anesthetic induction drug.Objectives: To proved the usage effects of etomidate that causing decrement of blood glucose level.Method: Pretest posttest controlled group design on 40 patients who are undergoing surgery with general anesthesia, divided into two groups (n =20), group E2 and E4, which received etomidate 0,2 mg/kgbw and 0,4 mg/kgbw respectively. Each groups was examined its blood glucose 3 times, before 2 hours and 6 hours after unduction. All data in E2 an E4 were analyzed by paired T-test and wilcoxon rank sum test.Results: Blood glucose of E2 were significantly different P=0,05 between before. And 2 hours after intervention 106, 95 ± 15, 453 mg/dl -96, 40 ± 14, 966mg/dl ; between 2 hours and 6 hour after intervention P= 0, 016; 96,40 ± mg/dl-99,35 ± 15,938 mg/dl; between before 6 hours after intervention P= 0.041 ; 102,60 ± 12,696 mg/dl – 98,25 ± 19,878 mg/dl. However, there were no significant differences between E2 and E4 in decreasing blood glucose on 2 hours P = 0,550; 96, 40 ±14, 966 mg/dl – 99, 35 ± 15, 938 mg/dl and 6 hours after intervention P = 0, 104; 108, 85 ± 27, 238 mg/dl – 98, 25 ± 19, 878 mg/dl. Statistically, etomidate could cause decrement on blood glucose, both in group E2 and E4 but stil in normal border or clinically insignificant.Conclusions: etomidate 0,2 mg/kgbw (E2) and 0,4 mg/ kg bw (E4) were statistically significant in decreasing blood glucose on 2 hours and 6 hours after induction.Keywords : Etomidate, adrenal suppresion, blood glucose.ABSTRAKLatar belakang: Kekhawatiran etomidat menyebabkan hipoglikemi menjadi masalah. Onset aksi cepat, profil kardiovaskuler rendah dan kurang signifikan menyebabkan penurunan tekanan darah membuat etomidat menjadi pilihan obat anestesi induksi yang cukup baik.Tujuan: membuktikan pengaruh pemberian etomidat dalam menyebabkan penurunan kadar gula darah.Metode: merupakan penelitian pretest postest controlled design pada 40 pasien yang menjalani operasi dengan anestesi umum, dibagi menjadi dua kelompok (n=20), kelompok1,etomidat 0,2 mg/kg ( E2) dan kelompok 2, 0, 4 mg/ kg ( E4). Masing- masing kelompok diperiksa kadar gula darah sebelum 2 jam dan 6 jam sesudah induksi. Uji statistik pair T-test dan Wilcoxon rank sum test terhadap E2 dan E4.Hasil: pada E2 terdapat perbedaan bermakna P= 0,05 antara sebelum dan 2 jam sesudah perlakuan 106, 95 ± 15, 453 mg/dl – 96, 40 ± 14, 966 mg/ dl ; 2 jam dan 6 jam sesudah perlakuan P= 0, 016 ; 96, 40 ±14, 966 mg/dl – 108, 85 ± 27, 238 mg/dl. Sedangkan pada E4 terdapat perbedaan bermakna P= 0, 041 baik sebelum dan 2 jam sesudah 102,60n± `12, 696 mg/dl – 99, 35 ± 15, 938 mg/dl ; sebelum dan 6 jam sesudah perlakuan P= 0, 041; 99, 35 ± 15, 938 mg/dl – 98, 25 ±± 19, 878 mg/dl. Tetapi tidak terdapat perbedaan bermakna antara E2 dan E4 dalam menyebabkan penurunan kadar gula darah baik 2 jam P= 0, 550 ; 96, 40 ± 14, 966 mg/ dl- 99, 35 ± 15, 938 mg/ dl, maupun sesudah 6 jam pemberian P= 0, 104 ; 108, 85 ± 27, 238 mg/ dl – 98, 25 ± 19, 878 mg/dl. Secara statistik etomidat menurunkan kadar gula darah baik pada E2 maupun pada E4 tetapi masih dalam batas normal atau secara klinik tidak bermakna.Kesimpulan: etomidat 0, 2 mg/dl (E2) dan 0, 2 mg/ dl (E4) secara statistik bermakna menurunkan kadar gula darah pada 2 jam dan 6 jam sesudah induksi

Pengaruh Induksi dengan Propofol dan Etomidat Terhadap Kadar Gula Darah

Bernardus, Johan Eduard, ., Witjaksono, ., Soenarjo

Jurnal Anestesiologi Indonesia Vol 3, No 2 (2011): Jurnal Anestesiologi Indonesia
Publisher : Perhimpunan Dokter Spesialis Anestesiologi dan terapi Intensif

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Abstract

Backgrounds: Etomidate is primarily known for an ideal anesthetic agent due to its hemodynamic stability, minimally respiratory effect and neuroprotection properties, but in years have become not popular as it suppress cortisol synthesis and lowers glucose level although its clinical effect remain controversy. Objectives: To analyze the different effect of propofol and etomidate on glucose level of patients underwent elective surgery in general anesthesia. Methods: This was a double blind, Randomized controlled Trial with 38 subjects in which divided into two groups (n=19), control group and treatment group and treatment group which received either intravenous propofol 2,5 mg/kgBW or etomidate 0,2 mg/kgBW pre-operation respectively. Each group was then examined for glucose level at baseline, 2 hours post induction, and 8 hours post induction. Wilcoxon Signed Rank Test was performed to compare glucose level in each group. Statistically, Man Whitney Test was used to compare between control and treatment group. Results: There were significant different of glucose level between pre-anesthesia and 2 post induction in etomidate group (122,42+4,98 vs 78,73+4,56). It showed that decreament of etomidate dosage into 0,2 mg/kgBW still decrease glucose level production significantly from 2 to 8 hours. Conversely, in propofol group glucose level. It was proven that propofol did not decrease glucose level. Compared with propofol, etomidate significantly supress glucose level at 2 hours post induction. Conclusions: Etomidate 02 mg/kgBW decrease glucose level at 2 hours post induction, but return to its normal level at 9 hours post induction. Propofol 2,5 mg/kgBW did not decrease capillary glucose level.Keywords : Etomidate, propofol, general anesthesia, blood glucoseABSTRAKLatar belakang: Etomidat memiliki keunggulan karakteristik berupa keamanan dari segi hemodinamik, respirasi, maupun neuroproteksi, akan tetapi efeknya terhadap fungsi adrenal, kortisol dan menurunkan kadar gula darah menjadikan penggunanya terbatas. Tujuan: Membuktikan adanya perbedaan pengaruh pemberian propofol 2,5 mg/kgBB intravena dan etomidat 0,2 mg/kgBB intravena terhadap penurunan kadar gula darah. Metode: Penelitian ini menggunakan desain Randomized Clinical Control Trial pada 38 pasien yang menjalani anastesi umum, dibagi menjadi 2 kelompok perlakuan (n=19), etomidat dan propofol. Masing-masing kelompok diperiksa kadar gula darah sebelum induksi,2 dan 8 jam setelah induksi. Uji statistik Wilcoxon Signed Rank Test digunakan untuk membandingkan kadar gula darah pada masing-masing kelompok sedangkan uji statistik Mann Whitney U Test digunakan untuk membandingkan antar kelompok perlakuan. Hasil: Terdapat perbedaan bermakna kadar gula darah sebelum dan 2 jam pasca induksi pada kelompok etomidat (122,42+4,98 vs 78,73+4,56), tetapi tidak pada 8 jam pasca induksi. Hasil penelitian ini menunjukkan bahwa pengurangan dosis etomidat sampai 0,2 mg/kgBB masih menurunkan kadar gula secara signifikan sampai < 8 jam pasca induksi. Pada kelompok propofol terdapat peningkatan bermakna kadar gula darah 2 jam pasca induksi (P=0,000). Hasil penelitian ini menunjukkan bahwa propofol tidak memiliki efek menurunkan kadar gula darah. Kesimpulan: Pemberian etomidat 0,2 mg/kgBB menurunkan sintesis gula darah pada 2 jam pasca induksi namun kembali normal 8 jam pasca induksi. Pemberian propofol 2,5 mg/kgBB tidak menyebabkan penurunan kadar gula darah.

Midazolam Intravena Dosis Rendah Tidak Mempengaruhi Nitric Oxide Intraperitoneal Mencit Balb/C Yang Terpapar Lipopolisakarida

Ridconi, Akhmad, Satoto, Hariyo, Budiono, Uripno

Jurnal Anestesiologi Indonesia Vol 3, No 2 (2011): Jurnal Anestesiologi Indonesia
Publisher : Perhimpunan Dokter Spesialis Anestesiologi dan terapi Intensif

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Abstract

Background: Apoptosis as a pathologic mechanism of multiple organs dysfunction syndrome in sepsis can be induced by lipoplysaccharide via the transcriptional factor NF-kB activation. Nitric oxide (NO), a proinflammatory factor cytokine, has a potential rule in pathogenesis of systemic hypotension in sepsis which is caused by the activation of NF-kB. Antioxidant can reduce the effect of lipopolysacharide and inhibit NF-kB production. Midazolam, as an sedative anesthetic agent, is commonly used in intensive care unit for septic patients. This agent is recognized has antioxidant and anti-inflammatory effects via blockade of ubiquitin system of NF-kB, so the NO production can be inhibited. Objectives: to study the effect of midazolam 0,07-0,2 mg/kg on intraperitoneal NO level on Balb/c mice with injection of lipopolysaccharide intraperitoneally. Methods: a randomized post test only controlled group laboratoric experimental study on animal, used 20 male Balb/c mice divided into 4 groups, P1 as the control group. All mice were injected by lipopolysaccharide 20mg/kg intraperitoneally and 6 hours later were injected by midazolam 0,07;0,1; and 0,2mg/kg intravenously in group P2, P3, and P4 respectively. NO was taken from peritoneal macrophage culture and observed by Grease method. The results will be analyzed by Kruskal-Walis and Mann-Whitney statistical assay, with reliability p < 0,05. Results: Mann-Whitney nonparametric assay for intraperitoneal macrophage NO level showed no significant differences between group P2 and P1 (1,77 ± 0,23 vs. 1,76 ± 0,26, p=0,841) and between group P3 and P1 (1,50 ±0,22 vs. 1,76 ± 0,26, p=0,310). NO level of group P4(3,11 ± 0,44) was higher than control groupsignificantly (p=0,032). Conclusion: Midazolam is not effective for decreasing nitric oxide level in sepssi mechanisms. Midazolam 0,1 mg/kg can not decrease intraperitoneal nitric oxide level significantly. Midazolam 0,2 mg/kg will increase intraperitoneal nitric oxide level significantly.Keywords : midazolam, lipopolysaccharide, nitric oxide.ABSTRAKLatar belakang: Lipopolisakarida dapat mengaktivasi NF-kB (Nuclear Factor kappa B) untuk terjadinya apoptosis dan kegagalan organ. NO (nitric oxide), suatu sitokin pro inflamasi, memiliki peranan penting dalam patogenesis terjadinya hipoten si sistemik pada syok septik akibat aktivasi faktor transkripsional NF-kB. Antioksidan dapat melemahkan efek paparan dari lipopolisakarida dan memblok produksi NF-kB. Midazolam, obat sedasi yang seringkali digunakan di ruang rawat intensif (ICU) untuk penderita sepsis, diduga memiliki efek antioksidan dan anti inflamasi melalui penghambatan sistem ubiquitin NF-kB, sehingga pembentukan NO dapat dihambat. Tujuan: mengetahui pengaruh pemberian Midazolam dalam dosis 0,07-0,2 mg/kg terhadap kadar NO mencit yang diberi endotoksin lipopolisakarida intraperitoneal. Metode: merupakan penelitian eksperimental laboratorik dengan desain randomized post test only controlled group pada 20 ekor mencit Balb/c yang disuntik lipoplisakarida intraperitoneal dan midazolam dosis 0,07 ; 0,1 ; dan 0;2 mg/kg intravena. Mencit dibagi menjadi 4 kelompok secara random, yaitu kelompok P1 sebagai kontrol, kelompok P2 yang mendapat midazolam 0,07 mg/kg, kelompok P3 yang mendapat midazolam 0,1 mg/kg, dan kelompok P4 yang mendapat midazolam dosis 0,2 mg/kg. Pemeriksaan NO diambil dari kultur makrofag intraperitoneal setelah 6 jam pemberian midazolam. Hasil dinilai dengan uji statistik nonparametrik Kruskal Walis dan Mann-Whitney dengan derajat kemaknaan p<0,05. Hasil: Tidak terdapat perbedaan kadar NO yang signifikan pada kelompok P2 dibanding P1 (1,77 ± 0,23 vs. 1,76 ± 0,26, p=0,841) dan P3 dibanding P1 (1,50 ±0,22 vs. 1,76 ± 0,26, p=0,310). Kadar NO pada kelompok P4 (3,11 ± 0,44) lebih tinggi dibanding P1 Secara signifikan (p=0,032). Simpulan: Pada mencit Balb/c sepsis, pemberian midazolam 0,1 mg/kg tidak dapat menurunkan kadar NO intraperitoneal secara signifikan. Pemberian midazolam 0,2 mg/kg meningkatkan kadar NO intraperitoenal mencit endotoksemia secara signifikan.

Ketamin dan Meperidin Untuk Pencegahan Menggigil Pasca Anestesi Umum

Sarim, Budi Yulianto, Budiono, Uripno, Sutiyono, Doso

Jurnal Anestesiologi Indonesia Vol 3, No 2 (2011): Jurnal Anestesiologi Indonesia
Publisher : Perhimpunan Dokter Spesialis Anestesiologi dan terapi Intensif

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Abstract

Background: Post anesthesia shivering is common complication after anesthesia. It can causes uncomfortable situation and so many risk. Post anesthesia shivering must be prevented or treated. Most commonly drug that used is meperidine. Objective: The aim of this study is to proved that giving intra venous ketamine 0,25mg/kgBW as soon before the end of the surgery is more effective than intravenous meperidine 0.5mg /kgBW as soon before the end of the surgery to prevent shivering after general anesthesia. Methods: This experimental study was designed as randomized post test only controlled group of 72 patients underwent elective surgery with general anesthesia. Vital sign (diastolic and systolic blood pressure, mean arterial pressure, heart rate and SaO 2) were measured five minutes before induction. Induction procedure of standardized general anesthesia were done. Esophageal temperature was measured as soon as intubation done. Duration of operation was limited 2 - 3 hours. At the end of surgery, inhalation drugs were stopped. After adequate spontaneous breathing and laryngeal reflex shown, randomization was done. Patients divided into three groups, and received intravenously ketamine 0,25 mg/kgBW for group 1, meperidine 0.5 mg/kgBW for group 2 and NaCl 0,9 % for group 3. E xtubation was done 5 minutes after the drug was given. Vital sign were measured as soon as after extubation and every 5 minutes for 30 minutes long. Body temperature were measured as soon as and 15 minutes after extubation. After extubation patients were receiving oxygen 6L/minute face mask. Statistical analysis were performed by One-way Anova and chi-square, which were p-value < 0,05 was considered significant. Results : Basic data, clinical characteristic data before induction, were not significantly different (p>0.05). Vital sign after extubation between group 1 and group 3 were significantly different (p<0.05). Incidence of shivering on group 1 is 4 people (16.6%) consisted of 3 people suffer 1 st degree and 1 people suffer 2 nd degree, while at group 2 is 5 people (20.8%) consisted of 4 people suffer 1 st degree and 1 people suffer 2 nd degree, this matter statistically were not significantly different (p=0.500). Differences of body temperature between group 1 and group 2 were not significantly different (p>0.05). Side effects that developed on group 1 were 2 subjects had nausea, which group 2 were 7 subjects had nausea and 2 subjects had difficulty for breathing, this matter statistically were significantly different (p=0.012). Conclusions : Ketamine 0,25 mg/kgBW and meperidine 0.5 mg/kgBW have similar effectivity on the prevention of shivering after general anesthesia, but ketamine have lower side effect nausea than meperidine.Keywords : post anesthesia shivering, ketamine, meperidine.ABSTRAKLatar Belakang: Menggigil pasca anestesi merupakan komplikasi yang cukup sering terjadi. Menggigil menimbulkan keadaan yang tidak nyaman dan berbagai resiko. Karena itu menggigil harus segera dicegah atau diatasi. Sampai saat ini obat paling sering digunakan adalah meperidin. Tujuan: Membuktikan bahwa pemberian ketamin 0,25 mg/kgBB intra vena menjelang akhir operasi lebih efektif dari pada meperidin 0,5mg/kgBB intra vena menjelang akhir operasi untuk mencegah kejadian menggigil pasca anestesi umum. Metode: Merupakan penelitian eksperimental dengan desain “randomized post test only controlled group” pada 72 pasien dengan usia 16 – 60 tahun yang menjalani operasi dengan anestesia umum. Tanda vital ( Tekanan darah diastolik dan sistolik, tekanan arteri rerata, laju jantung dan SaO2 ) diukur 5 menit sebelum induksi. Prosedur induksi anestesi umum dilakukan sesuai standar. Temperatur esofagus diukur segera setelah induksi. Lama operasi dibatasi antara 2 -3 jam. Pada akhir operasi, obat inhalasi dihentikan. Setelah nafas spontan adekuat, reflek laringeal positif dilakukan randomisasi. Pasien dibagi menjadi tiga kelompok, dan mendapatkan secara intravena ketamin 0,25 mg/kgBB untuk kelompok 1, meperidin 0,5 mg/kgBB untuk kelompok 2 dan NaCI 0,9% untuk kelompok 3. Ekstubasi dilakukan 5 menit setelah perlakuan. Tanda vital di ukur dicatat segera setelah ekstubasi dan tiap lima menit selama 30 menit. Suhu tubuh diukur segera dan 15 menit setelah ekstubasi. Pasca ekstubasi pasien diberi oksigen 6L/menit. Uji statistik dilakukan dengan menggunakan One-way ANOVA dan Chi- kuadrat, dengan derajat kemaknaan yaitu p<0,005 Hasil : Data dasar dan data karakteristik klinis sebelum induksi, berbeda tidak bermakna (p>0,05). Terdapat perbedaan bermakna tanda vital antara kelompok 1 dengan kelompok 3 saat setelah ekstubasi. Kejadian menggigil pada grup 1 yaitu 4 orang (16,6%) terdiri dari 3 orang menderita derajat 1 dan 1 orang menderita derajat 2, sedangkan pada kelompok 2 terjadi pada 5 orang (20,8%) terdiri dari 4 orang derajat 1 dan 1 orang derajat 2, hal ini secara statistik berbeda tidak bermakna (p=0,500). Perbedaan suhu tubuh grup 1 dan grup 2 berbeda tidak bermakna (p>0,05). Efek samping obat yang timbul pada kelompok 1 sebanyak 1 penderita mengalami mual, sedangkan kelompok 2 sebanyak 7 penderita mengalami mual dan 2 penderita depresi nafas, berbeda bermakna (p=0,012). Kesimpulan: Ketamin 0,25 mg/kgBB dan meperidin 0,5 mg/kgBB mempunyai efektifitas yang sama dalam mencegah menggigil pasca anestesi umum, tetapi ketamin mempunyai efek samping mual yang lebih rendah dibandingkan meperidin.

Fisiologi Lateral Dekubitus dan Monitoring Durante Operasi Bedah Thoraks

Bayu, Derajad, Satoto, Hari Hendriarto, Soesilowati, Danu

Jurnal Anestesiologi Indonesia Vol 3, No 2 (2011): Jurnal Anestesiologi Indonesia
Publisher : Perhimpunan Dokter Spesialis Anestesiologi dan terapi Intensif

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Abstract

Today the area of thoracic surgery in the more advanced, in line with the development of the science of anesthesiology. Some actions are performed on patients in the latera l decubitus position. Lateral decubitus position caused a variety of physiological changes to the patient. As with other operations, operations on the thoracic surgery requires monitoring and handling of various things that happen.Keywords : -ABSTRAKDewasa ini pembedahan di daerah thoraks semakin maju, sejalan dengan perkembangan ilmu anestesiologi. Beberapa tindakan tersebut dilakukan terhadap pasien dalam posisi lateral dekubitus. Posisi lateral dekubitus menimbulkan berbagai perubahan fisiologis terhadap pasien. Sebagaimana halnya operasi yang lain, operasi pada bedah thoraks memerlukan monitoring dan penanganan terhadap berbagai hal yang terjadi.

Fisiologi dan Patofisiologi Aksis Hipotalamus-Hipofisis-Adrenal

Nugroho, Taufik Eko, Pujo, Jati Listiyanto, Nurcahyo, Widya Istanto

Jurnal Anestesiologi Indonesia Vol 3, No 2 (2011): Jurnal Anestesiologi Indonesia
Publisher : Perhimpunan Dokter Spesialis Anestesiologi dan terapi Intensif

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Abstract

The endocrine system consists of glands that secrete hormones that help maintain and regulate vital functions such as (1) in response to stress and injury, (2) the growth and development, (3) reproduction, (4) ion homeostasis, (5) energy metabolism, and (6) the immune response. Secretion of cortisol by the adrenal cortex is regulated by negative feedback system involving the arc length of the hypothalamus and anterior pituitary. In the system of the hypothalamic-pituitary-adrenal axis, corticotropin releasing hormone (CRH) causes the release of pituitary ACTH. ACTH then stimulates the adrenal cortex to secrete cortisol. Cortisol returned to give further feedback on the hypothalamic-pituitary axis, and inhibits the production of CRH-ACTH. Fluctuating system, will vary according to the physiological needs of cortisol. If the system produces too much ACTH, so that too much cortisol, the cortisol affects the back and inhibit the production of CRH by the hypothalamus and decreased sensitivity of ACTH-producing cells to CRH by working directly on the anterior pituitary. Through this dual approach, cortisol negative feedback control to stabilize itself in the plasma concentration. When cortisol levels begin to drop, the inhibitory effects of cortisol on the hypothalamus and anterior pituitary is reduced so that the factors that stimulate increased secretion of cortisol (CRH-ACTH) will increase. The system is sensitive for the production of cortisol or cortisol administration or other synthetic glucocorticoid excess can rapidly inhibit the hypothalamic-pituitary and stop the production of ACTH.Keywords : -ABSTRAKSistem endokrin terdiri dari kelenjar-kelenjar yang mensekresi hormon yang membantu memelihara dan mengatur fungsi-fungsi vital seperti (1) respons terhadap stres dan cedera, (2) pertumbuhan dan perkembangan, (3) reproduksi, (4) homeostasis ion, (5) metabolisme energi, dan (6) respons kekebalan tubuh. Sekresi kortisol oleh korteks adrenal diatur oleh sistem umpan balik negatif lengkung panjang yang melibatkan hipotalamus dan hipofisis anterior. Pada sistem hipotalamus-hipofisis-adrenal, corticotropin releasing hormone (CRH) menyebabkan hipofisis melepaskan ACTH. Kemudian ACTH merangsang korteks adrenal untuk mensekresi kortisol. Selanjutnya kortisol kembali memberikan umpan balik terhadap aksis hipotalamus-hipofisis, dan menghambat produksi CRH-ACTH. Sistem mengalami fluktuasi, bervariasi menurut kebutuhan fisiologis akan kortisol. Jika sistem menghasilkan terlalu banyak ACTH, sehingga terlalu banyak kortisol, maka kortisol akan mempengaruhi kembali dan menghambat produksi CRH oleh hipotalamus serta menurunkan kepekaan sel-sel penghasil ACTH terhadap CRH dengan bekerja secara langsung pada hipofisis anterior. Melalui pendekatan ganda ini, kortisol melakukan kontrol umpan balik negatif untuk menstabilkan konsentrasinya sendiri dalam plasma. Apabila kadar kortisol mulai turun, efek inhibisi kortisol pada hipotalamus dan hipofisis anterior berkurang sehingga faktor-faktor yang merangsang peningkatan sekresi kortisol (CRH-ACTH) akan meningkat. Sistem ini peka karena produksi kortisol atau pemberian kortisol atau glukokortikoid sintetik lain secara berlebihan dapat dengan cepat menghambat aksis hipotalamus-hipofisis dan menghentikan produksi ACTH.