Manglik Savita, Flores Eugene, Lubarsky Laura, Fernandez Fernando, Chhibber Vijay L, Tayek John A
Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA, USA.
Crit Care Med. 2003 Jun;31(6):1668-75. doi: 10.1097/01.CCM.0000063447.37342.A9.
To identify the incidence of secondary adrenal insufficiency in severe sepsis.
Prospective clinical trial testing 100 patients with a 250-microg adrenocorticotropic hormone (ACTH) stimulation test.
County-university teaching hospital.
One hundred patients with sepsis and septic shock. Forty patients had bacteremia and 17% shock.
ACTH, cortisol, aldosterone, and electrolyte concentrations were measured at baseline. Cortisol and aldosterone were measured 30 and 60 mins after ACTH (250 microg).
Nine of the 100 patients (9%) failed the ACTH stimulation test (all serum cortisol <20 microg/dL). The 91 patients with sepsis began with a serum cortisol at 29.3 +/- 2.5, and it increased to 40.1 +/- 2.6 and 46.9 +/- 2.7 microg/dL at times 30 and 60 mins, respectively. Serum cortisol in nine septic patients who failed the ACTH stimulation test had an initial concentration of 11.3 +/- 1.8 microg/dL, and it increased at time 30 mins to 14.0 +/- 1.9 microg/dL and at 60 mins to 15.7 +/- 1.8 microg/dL. Four of the nine patients had secondary adrenal insufficiency as determined by a normal aldosterone response to ACTH. The remaining five patients had an absent aldosterone response to ACTH and baseline ACTH concentrations that were not elevated, suggesting adrenal dysfunction. Serum sodium (128 +/- 4 vs. 138 +/- 1 mmol/L, p <.05) and glucose concentrations (121 +/- 20 vs. 163 +/- 11 mg/dL, p <.05) were reduced in the nine patients. Of the four patients with secondary adrenal insufficiency, two had a history of amenorrhea after birth of their children many years earlier.
These data demonstrate that 9% of adults with sepsis fail the ACTH stimulation test due to a mixture of etiologies. A reduced sodium or glucose concentration may be helpful in identifying glucocorticoid (adrenal) insufficiency in patients with sepsis.
确定严重脓毒症患者继发性肾上腺皮质功能减退的发生率。
对100例患者进行250微克促肾上腺皮质激素（ACTH）刺激试验的前瞻性临床试验。
县立大学教学医院。
100例脓毒症和脓毒性休克患者。40例有菌血症，17%有休克。
在基线时测量促肾上腺皮质激素、皮质醇、醛固酮和电解质浓度。在注射促肾上腺皮质激素（250微克）后30分钟和60分钟测量皮质醇和醛固酮。
100例患者中有9例（9%）促肾上腺皮质激素刺激试验未通过（所有血清皮质醇<20微克/分升）。91例脓毒症患者血清皮质醇起始值为29.3±2.5，在30分钟和60分钟时分别升至40.1±2.6和46.9±2.7微克/分升。9例促肾上腺皮质激素刺激试验未通过的脓毒症患者血清皮质醇初始浓度为11.3±1.8微克/分升，在30分钟时升至14.0±1.9微克/分升，60分钟时升至15.7±1.8微克/分升。9例患者中有4例根据醛固酮对促肾上腺皮质激素的正常反应确定为继发性肾上腺皮质功能减退。其余5例患者醛固酮对促肾上腺皮质激素无反应且基线促肾上腺皮质激素浓度未升高，提示肾上腺功能障碍。9例患者血清钠（128±4 vs. 138±1毫摩尔/升，p<.05）和血糖浓度（121±20 vs. 163±11毫克/分升，p<.05）降低。4例继发性肾上腺皮质功能减退患者中有2例在多年前生育子女后有闭经史。
这些数据表明，9%的脓毒症成年患者因多种病因促肾上腺皮质激素刺激试验未通过。钠或血糖浓度降低可能有助于识别脓毒症患者的糖皮质激素（肾上腺）功能不全。
