Pene Frédéric, Hyvernat Hervé, Mallet Vincent, Cariou Alain, Carli Pierre, Spaulding Christian, Dugue Marie-Annick, Mira Jean-Paul
Medical Intensive Care Unit, Cochin University Hospital, Assistance Publique-Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75679 Paris Cedex 14, France.
Intensive Care Med. 2005 May;31(5):627-33. doi: 10.1007/s00134-005-2603-7. Epub 2005 Apr 19.
To assess the prevalence of relative adrenal insufficiency in patients successfully resuscitated after cardiac arrest, and its prognostic role in post-resuscitation disease.
A prospective observational single-center study in a medical intensive care unit.
64 patients hospitalised in the intensive care unit after successful resuscitation for out-of-hospital cardiac arrest.
A corticotropin-stimulation test was performed between 12 and 24 h following admission: serum cortisol level was measured before and 60 min after administration of tetracosactide 250 microg. Patients with an incremental response less than 9 microg/dl were considered to have relative adrenal insufficiency (non-responders). Variables were expressed as medians and interquartile ranges. 33 patients (52%) had relative adrenal insufficiency. Baseline cortisol level was higher in non-responders than in responders (41 [27.2-55.5] vs. 22.8 [15.7-35.1] microg/dl respectively, P=0.001). A long interval before initiation of cardiopulmonary resuscitation was associated with relative adrenal insufficiency (5 [3-10] vs. 3 [3-5] min, P=0.03). Of the 38 patients with post-resuscitation shock, 13 died of irreversible multiorgan failure. The presence of relative adrenal insufficiency was identified as a poor prognostic factor of shock-related mortality (log-rank P=0.02). A trend towards higher mortality in non-responders was identified in a multivariate logistic regression analysis (odds ratio 6.77, CI 95% 0.94-48.99, P=0.058).
Relative adrenal insufficiency occurs frequently after successful resuscitation of out-of-hospital cardiac arrest, and appears to be associated with a poor prognosis in cases of post-resuscitation shock. The role of corticosteroid supplementation should be evaluated in this setting.
评估心脏骤停后成功复苏患者相对肾上腺皮质功能不全的患病率及其在复苏后疾病中的预后作用。
在一家医疗重症监护病房进行的前瞻性观察性单中心研究。
64例因院外心脏骤停成功复苏后入住重症监护病房的患者。
入院后12至24小时内进行促肾上腺皮质激素刺激试验：在静脉注射250微克替可克肽前及注射后60分钟测量血清皮质醇水平。增量反应小于9微克/分升的患者被认为存在相对肾上腺皮质功能不全（无反应者）。变量以中位数和四分位数间距表示。33例患者（52%）存在相对肾上腺皮质功能不全。无反应者的基线皮质醇水平高于有反应者（分别为41[27.2 - 55.5]与22.8[15.7 - 35.1]微克/分升，P = 0.001）。开始心肺复苏前的时间间隔较长与相对肾上腺皮质功能不全相关（5[3 - 10]与3[3 - 5]分钟，P = 0.03）。在38例复苏后休克患者中，13例死于不可逆的多器官功能衰竭。相对肾上腺皮质功能不全的存在被确定为休克相关死亡率的不良预后因素（对数秩检验P = 0.02）。在多因素逻辑回归分析中发现无反应者有更高死亡率的趋势（比值比6.77，95%可信区间0.94 - 48.99，P = 0.058）。
院外心脏骤停成功复苏后相对肾上腺皮质功能不全频繁发生，且在复苏后休克病例中似乎与不良预后相关。在此情况下应评估补充皮质类固醇的作用。
