Annane D, Sébille V, Troché G, Raphaël J C, Gajdos P, Bellissant E
Department of Intensive Care Unit, Hospital Raymond Poincaré, School of Medicine of Paris-Ouest, Garches, France.
JAMA. 2000 Feb 23;283(8):1038-45. doi: 10.1001/jama.283.8.1038.
The hypothalamic-pituitary-adrenal axis is a major determinant of the host response to stress. The relationship between its activation and patient outcome is not known.
To evaluate the prognostic value of cortisol levels and a short corticotropin stimulation test in patients with septic shock.
Prospective inception cohort study conducted between October 1991 and September 1995 in 2 teaching hospital adult intensive care units in France.
A total of 189 consecutive patients who met clinical criteria for septic shock.
A short corticotropin stimulation test was performed in all patients by intravenously injecting 0.25 mg of tetracosactrin; blood samples were taken immediately before the test (T0) and 30 (T30) and 60 (T60) minutes afterward.
Twenty-eight-day mortality as a function of variables collected at the onset of septic shock, including cortisol levels before the corticotropin test and the cortisol response to corticotropin (delta max, defined as the difference between T0 and the highest value between T30 and T60).
The 28-day mortality was 58% (95% confidence interval [CI], 51%-65%) and median time to death was 17 days (95% CI, 14-27 days). In multivariate analysis, independent predictors of death (P < or = .001 for all) were McCabe score greater than 0, organ system failure score greater than 2, arterial lactate level greater than 2.8 mmol/L, ratio of PaO2 to fraction of inspired oxygen no more than 160 mm Hg, cortisol level at T0 greater than 34 microg/dL and delta max no more than 9 microg/dL. Three groups of patient prognoses were identified: good (cortisol level at T0 < or = 34 microg/dL and delta max > 9 microg/dL; 28-day mortality rate, 26%), intermediate (cortisol level at T0 34 microg/dL and delta max < or = 9 microg/dL or cortisol level at T0 > 34 microg/dL and delta max > 9 microg/dL; 28-day mortality rate, 67%), and poor (cortisol level at T0 > 34 microg/dL and delta max < or = 9 microg/dL; 28-day mortality rate, 82%).
Our data suggest that a short corticotropin test has a good prognostic value and could be helpful in identifying patients with septic shock at high risk for death.
下丘脑 - 垂体 - 肾上腺轴是宿主对应激反应的主要决定因素。其激活与患者预后之间的关系尚不清楚。
评估皮质醇水平和短程促肾上腺皮质激素刺激试验对感染性休克患者的预后价值。
1991年10月至1995年9月在法国2家教学医院的成人重症监护病房进行的前瞻性起始队列研究。
共189例符合感染性休克临床标准的连续患者。
所有患者均通过静脉注射0.25mg二十四肽促皮质素进行短程促肾上腺皮质激素刺激试验；在试验前即刻（T0）、试验后30分钟（T30）和60分钟（T60）采集血样。
以感染性休克发作时收集的变量为函数的28天死亡率，包括促肾上腺皮质激素试验前的皮质醇水平和皮质醇对促肾上腺皮质激素的反应（最大变化值，定义为T0与T30和T60之间的最高值之差）。
28天死亡率为58%（95%置信区间[CI]，51% - 65%），中位死亡时间为17天（95%CI, 14 - 27天）。在多变量分析中，死亡的独立预测因素（所有P≤0.001）为麦凯布评分大于0、器官系统衰竭评分大于2、动脉乳酸水平大于2.8mmol/L、动脉血氧分压与吸入氧分数之比不超过160mmHg、T0时皮质醇水平大于34μg/dL且最大变化值不超过9μg/dL。确定了三组患者预后：良好（T0时皮质醇水平≤34μg/dL且最大变化值>9μg/dL；28天死亡率，26%）、中等（T0时皮质醇水平>34μg/dL且最大变化值≤9μg/dL或T0时皮质醇水平>34μg/dL且最大变化值>9μg/dL；28天死亡率，67%）和较差（T0时皮质醇水平>34μg/dL且最大变化值≤9μg/dL；28天死亡率，82%）。
我们的数据表明，短程促肾上腺皮质激素试验具有良好的预后价值，有助于识别感染性休克死亡高风险患者。
