Annane Djillali, Maxime Virginie, Ibrahim Fidaa, Alvarez Jean Claude, Abe Emuri, Boudou Philippe
Service de Réanimation, Hôpital Raymond Poincaré (AP-HP), Faculté de Médecine Paris Ile de France Ouest (UVSQ), 104 Boulevard Raymond Poincaré, 92380 Garches, France.
Am J Respir Crit Care Med. 2006 Dec 15;174(12):1319-26. doi: 10.1164/rccm.200509-1369OC. Epub 2006 Sep 14.
Diagnosis of adrenal insufficiency in critically ill patients has relied on random or cosyntropin-stimulated cortisol levels, and has not been corroborated by a more accurate diagnostic standard.
We used the overnight metyrapone stimulation test to investigate the diagnostic value of the standard cosyntropin stimulation test, and the prevalence of sepsis-associated adrenal insufficiency.
This was an inception cohort study.
In two consecutive septic cohorts (n = 61 and n = 40), in 44 patients without sepsis and in 32 healthy volunteers, we measured (1) serum cortisol before and after cosyntropin stimulation, albumin, and corticosteroid-binding globulin levels, and (2) serum corticotropin, cortisol, and 11beta-deoxycortisol levels before and after an overnight metyrapone stimulation. Adrenal insufficiency was defined by postmetyrapone serum 11beta-deoxycortisol levels below 7 microg/dl. More patients with sepsis (31/61 [59% of original cohort with sepsis] and 24/40 [60% of validation cohort with sepsis]) met criteria for adrenal insufficiency than patients without sepsis (3/44; 7%) (p < 0.001 for both comparisons). Baseline cortisol (< 10 microg/dl), Delta cortisol (< 9 microg/dl), and free cortisol (< 2 microg/dl) had a positive likelihood ratio equal to infinity, 8.46 (95% confidence interval, 1.19-60.25), and 9.50 (95% confidence interval, 1.05-9.54), respectively. The best predictor of adrenal insufficiency (as defined by metyrapone testing) was baseline cortisol of 10 microg/dl or less or Delta cortisol of less than 9 microg/dl. The best predictors of normal adrenal response were cosyntropin-stimulated cortisol of 44 microg/dl or greater and Delta cortisol of 16.8 microg/dl or greater.
In sepsis, adrenal insufficiency is likely when baseline cortisol levels are less than 10 microg/dl or delta cortisol is less than 9 microg/dl, and unlikely when cosyntropin-stimulated cortisol level is 44 microg/dl or greater or Delta cortisol is 16.8 microg/dl or greater.
重症患者肾上腺功能不全的诊断依赖于随机或促肾上腺皮质激素刺激后的皮质醇水平，且尚未得到更准确诊断标准的证实。
我们采用过夜甲吡酮刺激试验来研究标准促肾上腺皮质激素刺激试验的诊断价值以及脓毒症相关肾上腺功能不全的患病率。
这是一项队列起始研究。
在两个连续的脓毒症队列（n = 61和n = 40）、44例非脓毒症患者以及32名健康志愿者中，我们测量了：（1）促肾上腺皮质激素刺激前后的血清皮质醇、白蛋白和皮质类固醇结合球蛋白水平；（2）过夜甲吡酮刺激前后的血清促肾上腺皮质激素、皮质醇和11β - 脱氧皮质醇水平。肾上腺功能不全的定义为甲吡酮刺激后血清11β - 脱氧皮质醇水平低于7μg/dl。脓毒症患者中符合肾上腺功能不全标准的人数（31/61 [原脓毒症队列的59%]和24/40 [验证脓毒症队列的60%]）多于非脓毒症患者（3/44；7%）（两项比较p均< 0.001）。基线皮质醇（< 10μg/dl）、皮质醇变化量（< 9μg/dl）和游离皮质醇（< 2μg/dl）的阳性似然比分别等于无穷大、8.46（95%置信区间，1.19 - 60.25）和9.50（95%置信区间，1.05 - 9.54）。肾上腺功能不全（由甲吡酮试验定义）的最佳预测指标是基线皮质醇为10μg/dl或更低或皮质醇变化量小于9μg/dl。肾上腺正常反应的最佳预测指标是促肾上腺皮质激素刺激后的皮质醇为44μg/dl或更高以及皮质醇变化量为16.8μg/dl或更高。
在脓毒症中，当基线皮质醇水平低于10μg/dl或皮质醇变化量小于9μg/dl时，肾上腺功能不全很可能存在；而当促肾上腺皮质激素刺激后的皮质醇水平为44μg/dl或更高或皮质醇变化量为16.8μg/dl或更高时，肾上腺功能不全则不太可能存在。
