Offner Patrick J, Moore Ernest E, Ciesla David
Trauma Service, St. Anthony Central Hospital, 1641 West 16th Ave., Denver, CO 80204, USA.
Am J Surg. 2002 Dec;184(6):649-53; discussion 653-4. doi: 10.1016/s0002-9610(02)01101-7.
The integrity of the hypothalamic-pituitary-adrenal axis is a major determinant of the host response to stress. Relative adrenal insufficiency has been implicated in poor outcome from systemic inflammatory states; however, whether low endogenous glucocorticoid levels are adaptive or pathologic remains controversial. The purpose of this study was to prospectively evaluate the cortisol response and determine the incidence of occult adrenal insufficiency after severe trauma.
Over an 18-month period, 22 severely injured patients admitted to the surgical intensive care unit of our level 1 trauma center were prospectively identified and followed. Demographic and outcome data were tabulated. In addition, random serum cortisol levels were obtained on days 0, 5, and 10 after injury. Relative adrenal insufficiency was defined as a random serum cortisol level less than 18 microg/dL.
Mean baseline cortisol levels were elevated (35 +/- 3 microg/dL) and significantly declined over the next 10 days (day 5: 24 +/- 2 microg/dL; and day 10: 22 +/- 2 microg/dL; P <0.01). Thirteen of 22 (60%) patients had random serum cortisol levels less than 18 microg/dL. Only 1 of the 2 patients who died had a serum cortisol level less than 18 microg/dL. The mean cortisol levels at baseline were higher in the 2 patients who died compared with those who survived but this was not statistically significant (43.4 +/- 8.8 microg/dL versus 35.0 +/- 3.6 microg/dL, P = 0.5).
Serum cortisol levels increased immediately and gradually returned towards normal after severe trauma. Occult adrenal insufficiency was common (60%) in this small group of severely injured patients. This did not, however, affect mortality in these patients. Further study is needed to delineate the role of occult adrenal insufficiency after severe injury.
下丘脑 - 垂体 - 肾上腺轴的完整性是宿主对应激反应的主要决定因素。相对肾上腺功能不全与全身炎症状态下的不良预后有关；然而，内源性糖皮质激素水平低是适应性的还是病理性的仍存在争议。本研究的目的是前瞻性评估皮质醇反应，并确定严重创伤后隐匿性肾上腺功能不全的发生率。
在18个月的时间里，前瞻性地确定并跟踪了22名入住我们一级创伤中心外科重症监护病房的重伤患者。将人口统计学和结局数据制成表格。此外，在受伤后第0、5和10天获取随机血清皮质醇水平。相对肾上腺功能不全定义为随机血清皮质醇水平低于18μg/dL。
平均基线皮质醇水平升高（35±3μg/dL），并在接下来的10天内显著下降（第5天：24±2μg/dL；第10天：22±2μg/dL；P<0.01）。22名患者中有13名（60%）随机血清皮质醇水平低于18μg/dL。死亡的2名患者中只有1名血清皮质醇水平低于18μg/dL。与存活患者相比，死亡的2名患者基线时的平均皮质醇水平更高，但无统计学意义（43.4±8.8μg/dL对35.0±3.6μg/dL，P = 0.5）。
严重创伤后血清皮质醇水平立即升高，随后逐渐恢复正常。在这一小群重伤患者中，隐匿性肾上腺功能不全很常见（60%）。然而，这并未影响这些患者的死亡率。需要进一步研究来阐明严重损伤后隐匿性肾上腺功能不全的作用。
