Fernández Javier, Escorsell Angels, Zabalza Michel, Felipe Vanessa, Navasa Miguel, Mas Antoni, Lacy Antonio M, Ginès Pere, Arroyo Vicente
Liver Unit, Department of Surgery and Centro de Investigaciones Biomédicas Esther Koplowitz, IMDiM, IDIBAPS, Hospital Clínic, University of Barcelona, Spain.
Hepatology. 2006 Nov;44(5):1288-95. doi: 10.1002/hep.21352.
Relative adrenal insufficiency is frequent in patients with severe sepsis and is associated with hemodynamic instability, renal failure, and increased mortality. This study prospectively evaluated the effects of steroids on shock resolution and hospital survival in a series of 25 consecutive patients with cirrhosis and septic shock (group 1). Adrenal function was evaluated by the short corticotropin test within the first 24 hours of admission. Patients with adrenal insufficiency were treated with stress doses of intravenous hydrocortisone (50 mg/6 h). Data were compared to those obtained from the last 50 consecutive patients with cirrhosis and septic shock admitted to the same intensive care unit in whom adrenal function was not investigated and who did not receive treatment with steroids (group 2). Incidence of adrenal insufficiency in group 1 was 68% (17 patients). Adrenal dysfunction was frequent in patients with advanced cirrhosis (Child C: 76% vs. Child B: 25%, P = .08). Resolution of septic shock (96% vs. 58%, P = .001), survival in the intensive care unit (68% vs. 38%, P = .03), and hospital survival (64% vs. 32%, P = .003) were significantly higher in group 1. The main causes of death in group 1 were hepatorenal syndrome or liver failure (7 of 9 patients). In contrast, refractory shock caused most of the deaths in group 2 (20 of 34 patients). In conclusion, relative adrenal insufficiency is very frequent in patients with advanced cirrhosis and septic shock. Hydrocortisone administration in these patients is associated with a high frequency of shock resolution and high survival rate.
相对肾上腺功能不全在严重脓毒症患者中很常见，且与血流动力学不稳定、肾衰竭及死亡率增加相关。本研究前瞻性评估了类固醇对一系列连续25例肝硬化合并感染性休克患者（1组）休克缓解及住院生存率的影响。在入院后的头24小时内通过短促肾上腺皮质激素试验评估肾上腺功能。肾上腺功能不全的患者接受应激剂量的静脉氢化可的松治疗（50mg/6小时）。将数据与来自同一重症监护病房收治的最后50例连续肝硬化合并感染性休克患者的数据进行比较，这些患者未进行肾上腺功能检查且未接受类固醇治疗（2组）。1组中肾上腺功能不全的发生率为68%（17例患者）。晚期肝硬化患者中肾上腺功能障碍很常见（Child C级：76% 对Child B级：25%，P = 0.08）。1组中感染性休克的缓解率（96% 对58%，P = 0.001）、重症监护病房生存率（68% 对38%）及住院生存率（64% 对32%，P = 0.003）显著更高。1组的主要死亡原因是肝肾综合征或肝衰竭（9例患者中的7例）。相比之下，难治性休克导致了2组中的大多数死亡（34例患者中的20例）。总之，相对肾上腺功能不全在晚期肝硬化合并感染性休克患者中非常常见。在这些患者中给予氢化可的松与休克缓解的高频率及高生存率相关。
