Llompart-Pou J A, Pérez-Bárcena J, Raurich J M, Burguera B, Ayestarán J I, Abadal J M, Homar J, Ibáñez J
Intensive Care Medicine Service, Son Dureta University Hospital, Palma de Mallorca, Spain.
J Endocrinol Invest. 2007 May;30(5):393-8. doi: 10.1007/BF03346316.
Barbiturate coma is the second tier measure recommended by guidelines to treat post-traumatic refractory intracranial pressure. Systemic hypotension is its most important side effect. Recent evidence suggests that low-dose corticosteroid therapy may be used in a subset of patients with traumatic brain injury (TBI) to avoid hypotension. We evaluated adrenal function in TBI patients undergoing barbiturate coma, as treatment of their refractory intracranial hypertension.
We prospectively studied 40 patients with moderate to severe TBI. Group A (17 patients) were treated with barbiturate coma. Group B (23 patients) presented intracranial hypertension controlled with first tier measures, and acted as a control. Adrenal function was evaluated by using the high-dose corticotropin stimulation test within 24 h after brain injury and after barbiturate coma induction.
Within 24 h after TBI, adrenal function was similar in both groups. Once barbiturate coma was induced, patients in group A treated with barbiturate coma presented a higher incidence of adrenal insufficiency compared with the control group B (53% vs 22%, p=0.03). Patients treated with barbiturates, who developed adrenal impairment, required higher doses of norepinephrine to maintain cerebral perfusion pressure than patients treated with barbiturates without adrenal impairment (1.07+/-1.04 microg/kg/min vs 0.31+/-0.32 mug/kg/min, p=0.03).
Patients with TBI treated with barbiturate coma are at higher risk of developing adrenal insufficiency. This subset of patients presented higher requirements of vasoactive support to avoid hypotension. In these patients corticosteroid therapy may have potential therapeutic implications to treat hemodynamic instability.
巴比妥类药物昏迷疗法是指南推荐的治疗创伤后难治性颅内压的二线措施。系统性低血压是其最重要的副作用。最近的证据表明，低剂量皮质类固醇疗法可用于一部分创伤性脑损伤（TBI）患者以避免低血压。我们评估了接受巴比妥类药物昏迷疗法治疗难治性颅内高压的TBI患者的肾上腺功能。
我们前瞻性地研究了40例中重度TBI患者。A组（17例患者）接受巴比妥类药物昏迷疗法治疗。B组（23例患者）颅内高压通过一线措施得到控制，并作为对照组。在脑损伤后24小时内以及诱导巴比妥类药物昏迷后，通过高剂量促肾上腺皮质激素刺激试验评估肾上腺功能。
TBI后24小时内，两组的肾上腺功能相似。一旦诱导巴比妥类药物昏迷，与对照组B相比，接受巴比妥类药物昏迷疗法治疗的A组患者肾上腺功能不全的发生率更高（53%对22%，p=0.03）。发生肾上腺功能损害的巴比妥类药物治疗患者比未发生肾上腺功能损害的巴比妥类药物治疗患者需要更高剂量的去甲肾上腺素来维持脑灌注压（1.07±1.04微克/千克/分钟对0.31±0.32微克/千克/分钟，p=0.03）。
接受巴比妥类药物昏迷疗法治疗的TBI患者发生肾上腺功能不全的风险更高。这部分患者对血管活性支持的需求更高以避免低血压。在这些患者中，皮质类固醇疗法可能对治疗血流动力学不稳定具有潜在的治疗意义。
