Sessler Curtis N
Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University Health System, Medical College of Virginia Hospitals, Richmond 23298, USA.
Chest. 2003 May;123(5 Suppl):482S-9S. doi: 10.1378/chest.123.5_suppl.482s.
The role of corticosteroid therapy in the management of septic shock has been debated for half a century. Results from large, well-designed, randomized clinical trials demonstrate no benefit, and perhaps harm, associated with short duration, high-dose methylprednisolone or dexamethasone administered at the onset of septic shock. Based on evidence of "relative adrenal insufficiency" and steroid-responsive adrenergic receptor desensitization in sepsis, administration of modest doses (200 to 300 mg/d) of hydrocortisone for 1 to 3 weeks has been investigated. A multicenter, placebo-controlled clinical trial demonstrated improved survival rates and faster cessation of vasopressors among patients with septic shock who have a poor response to corticotropin injection, consistent with relative adrenal insufficiency. However, concerns regarding a trend for higher mortality among corticotropin responders and the possibility that patients with true adrenal insufficiency may have been enrolled in this placebo-controlled trial, potentially skewing results, should be considered.
半个世纪以来，皮质类固醇疗法在感染性休克治疗中的作用一直存在争议。大型、设计良好的随机临床试验结果表明，在感染性休克发作时给予短疗程、大剂量甲泼尼龙或地塞米松并无益处，甚至可能有害。基于脓毒症中“相对肾上腺功能不全”及类固醇反应性肾上腺素能受体脱敏的证据，人们研究了给予中等剂量（200至300毫克/天）氢化可的松1至3周的情况。一项多中心、安慰剂对照临床试验表明，对于促肾上腺皮质激素注射反应不佳的感染性休克患者，生存率有所提高，血管升压药停用更快，这与相对肾上腺功能不全相符。然而，应考虑到促肾上腺皮质激素反应者中死亡率有升高趋势的担忧，以及真正肾上腺功能不全的患者可能被纳入该安慰剂对照试验从而潜在地扭曲结果的可能性。
