Annane D, Bellissant E, Bollaert P E, Briegel J, Keh D, Kupfer Y
Critical Care Department, Hôpital Raymond Poincaré, Assistance Publique - Hôpitaux de Paris, 104. Boulevard Raymond Poincaré, Garches, Ile de France, France.
Cochrane Database Syst Rev. 2004(1):CD002243. doi: 10.1002/14651858.CD002243.pub2.
BACKGROUND: Sepsis may be complicated by impaired corticosteroid production. Giving corticosteroids could potentially benefit patients. OBJECTIVES: To examine the effects of corticosteroids on death at one month in patients with severe sepsis and septic shock. SEARCH STRATEGY: We searched the Cochrane Infectious Diseases Group's trial register (August 2003), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3, 2003), MEDLINE (August 2003), EMBASE (August 2003), LILACS (August 2003), reference lists of articles, and also contacted trial authors. SELECTION CRITERIA: Randomized and quasi-randomized controlled trials of corticosteroids versus placebo or supportive treatment in severe sepsis and septic shock. DATA COLLECTION AND ANALYSIS: Two pairs of reviewers agreed the eligibility of trials. One reviewer extracted data, which was checked by the other reviewers and the primary author of the paper whenever possible. We obtained some missing data from the trial authors. We assessed trial methodological quality. MAIN RESULTS: We identified 15 trials (n =2023). Corticosteroids did not change 28-day all-cause mortality (15 trials, n = 2022, relative risk (RR) 0.92, 95% confidence interval (CI) 0.75 to 1.14; random effects model) and hospital mortality (13 trials, n = 1418, RR 0.89, 95% CI 0.71 to 1.11; random effects model); however, there was statistically significant heterogeneity, with some evidence that this was related to the dosing strategy. Corticosteroids reduced intensive care unit mortality (4 trials, n = 425, RR 0.83, 95% CI 0.70 to 0.97), increased the proportion of shock reversal by day 7 (6 trials, n = 728, RR 1.22, 95% CI 1.06 to 1.40) and by day 28 (4 trials, n = 425, RR 1.26, 95% CI 1.04 to 1.52), without increasing the rate of gastroduodenal bleeding (10 trials, n = 1321, RR 1.16, 95% CI 0.82 to 1.65), superinfection (12 trials, n = 1705, RR 0.93, 95% CI 0.73 to 1.18), and of hyperglycaemia (6 trials, n = 608, RR 1.22, 0.84 to 1.78). REVIEWER'S CONCLUSIONS: Overall, corticosteroids did not change 28-day mortality and hospital mortality in severe sepsis and septic shock. Long course of low dose corticosteroids reduced 28-day all-cause mortality, and intensive care unit and hospital mortality.
背景：脓毒症可能并发皮质类固醇生成受损。给予皮质类固醇可能对患者有益。 目的：研究皮质类固醇对严重脓毒症和脓毒性休克患者1个月时死亡率的影响。 检索策略：我们检索了Cochrane传染病组试验注册库（2003年8月）、Cochrane对照试验中央注册库（CENTRAL）（《Cochrane图书馆》2003年第3期）、MEDLINE（2003年8月）、EMBASE（2003年8月）、LILACS（2003年8月）、文章参考文献列表，还联系了试验作者。 选择标准：关于皮质类固醇与安慰剂或支持治疗在严重脓毒症和脓毒性休克中对比的随机和半随机对照试验。 数据收集与分析：两对评审员确定试验的合格性。一名评审员提取数据，其他评审员和论文第一作者尽可能进行核对。我们从试验作者处获取了一些缺失数据。我们评估了试验方法学质量。 主要结果：我们确定了15项试验（n = 2023）。皮质类固醇未改变28天全因死亡率（15项试验，n = 2022，相对危险度（RR）0.92，95%置信区间（CI）0.75至1.14；随机效应模型）和医院死亡率（13项试验，n = 1418，RR 0.89，95% CI 0.71至1.11；随机效应模型）；然而，存在统计学上的显著异质性，有证据表明这与给药策略有关。皮质类固醇降低了重症监护病房死亡率（4项试验，n = 425，RR 0.83，95% CI 0.70至0.97），增加了第7天（6项试验，n = 728，RR 1.22，95% CI 1.06至1.40）和第28天（4项试验，n = 425，RR 1.26，95% CI 1.04至1.52）休克逆转的比例，且未增加胃十二指肠出血率（10项试验，n = 1321，RR 1.16，95% CI 0.82至1.65）、二重感染率（12项试验，n = 1705，RR 0.93，95% CI 0.73至1.18）以及高血糖发生率（6项试验，n = 608，RR 1.22，0.84至1.78）。 评审员结论：总体而言，皮质类固醇未改变严重脓毒症和脓毒性休克患者的28天死亡率和医院死亡率。长疗程低剂量皮质类固醇降低了28天全因死亡率、重症监护病房死亡率和医院死亡率。
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