Morel Jerome, Venet Christophe, Donati Yannis, Charier David, Liotier Jerome, Frere-Meunier Delphine, Guyomarc'h Stephane, Diconne Eric, Bertrand Jean Claude, Souweine Bertrand, Papazian Laurent, Zeni Fabrice
Polyvalent Intensive Care Unit, Hospital Bellevue, 42055 Saint Etienne Cedex 2, France.
Intensive Care Med. 2006 Aug;32(8):1184-90. doi: 10.1007/s00134-006-0233-3. Epub 2006 Jun 20.
There is mounting evidence showing the value of low-dose corticosteroids in patients with septic shock requiring vasopressor therapy. It remains unclear whether adrenal function tests should be carried out systematically to guide the decision on glucocorticoid therapy.
The retrospective study was conducted in 52 patients in three university hospital ICUs. We included consecutive patients with catecholamine-dependent septic shock who had not received ketoconazole, glucocorticoids, or etomidate in the 24 h before the ACTH test, and who had survived to day 3 after the shock onset. All patients had a 250-microg ACTH test before systematic glucocorticoid therapy was started. Various definitions of relative adrenal insufficiency were used (based on cortisol basal level and/or change in cortisol level after ACTH stimulation). We defined hemodynamic improvement as a 50% reduction in the vasoactive agent dose in the 3 days following the initiation of glucocorticoid treatment. The relationship between the hemodynamic improvement and the results of the adrenal function tests was analyzed.
Hemodynamic improvement occurred in 29 patients (55.8%). Baseline characteristics, sites of infection, types of micro-organisms and antibiotic management did not differ between patients with and those without hemodynamic improvement. Relative adrenal insufficiency whatever the definition was not associated with hemodynamic improvement.
In catecholamine-dependent septic shock patients managed with systematic glucocorticoid therapy the results of ACTH stimulation do not predict hemodynamic improvement.
越来越多的证据表明低剂量皮质类固醇对需要血管升压药治疗的感染性休克患者具有价值。肾上腺功能测试是否应系统地进行以指导糖皮质激素治疗的决策仍不明确。
这项回顾性研究在三家大学医院重症监护病房的52例患者中进行。我们纳入了在促肾上腺皮质激素（ACTH）测试前24小时内未接受酮康唑、糖皮质激素或依托咪酯治疗且休克发作后存活至第3天的连续性儿茶酚胺依赖性感染性休克患者。在开始系统的糖皮质激素治疗前，所有患者均接受了250微克的ACTH测试。采用了相对肾上腺皮质功能不全的各种定义（基于皮质醇基础水平和/或ACTH刺激后皮质醇水平的变化）。我们将血流动力学改善定义为糖皮质激素治疗开始后3天内血管活性药物剂量降低50%。分析了血流动力学改善与肾上腺功能测试结果之间的关系。
29例患者（55.8%）出现了血流动力学改善。有血流动力学改善和无血流动力学改善的患者在基线特征、感染部位、微生物类型和抗生素管理方面无差异。无论采用何种定义，相对肾上腺皮质功能不全均与血流动力学改善无关。
在接受系统糖皮质激素治疗的儿茶酚胺依赖性感染性休克患者中，ACTH刺激的结果不能预测血流动力学改善。
