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一项关于急性危重病中肾上腺皮质反应及预后预测的前瞻性研究:来自203例混合重症监护病房患者的大型队列研究结果

A prospective study on adrenal cortex responses and outcome prediction in acute critical illness: results from a large cohort of 203 mixed ICU patients.

作者信息

Dimopoulou Ioanna, Stamoulis Konstantinos, Ilias Ioannis, Tzanela Marinella, Lyberopoulos Panagiotis, Orfanos Stylianos, Armaganidis Apostolos, Theodorakopoulou Maria, Tsagarakis Stylianos

机构信息

Attikon Hospital, Medical School, Second Department of Critical Care Medicine, University of Athens, 2 Pesmazoglou Street, 14561 Athens, Greece.

出版信息

Intensive Care Med. 2007 Dec;33(12):2116-21. doi: 10.1007/s00134-007-0790-0. Epub 2007 Aug 8.

Abstract

OBJECTIVE

To assess whether adrenal cortex hormones predict ICU mortality in acute, mixed, critically ill patients.

DESIGN AND SETTING

Prospective study in consecutive intensive care patients in the general ICU of a teaching hospital.

PATIENTS

203 severely ill patients with multiple trauma (n = 93), medical (n = 57), or surgical (n = 53) critical states.

MEASUREMENTS AND RESULTS

Within 24 h of admission in the ICU a morning blood sample was obtained to measure baseline cortisol, corticotropin (ACTH), and dehydropiandrosterone sulfate (DHEAS). Subsequently a low-dose (1 microg) ACTH test was performed to determine stimulated cortisol. The incremental rise in cortisol was defined as stimulated minus baseline cortisol. Overall, 149 patients survived and 54 died. Nonsurvivors were older and in a more severe critical state, as reflected by higher SOFA and APACHE II scores. Nonsurvivors had a lower incremental rise in cortisol (5.0 vs. 8.3 microg/dl and lower DHEAS (1065 vs. 1642 ng/ml) than survivors. The two groups had similar baseline and stimulated cortisol. Multivariate logistic regression analysis revealed that age (odds ratio 1.02), SOFA score (1.36), and the incremental rise in cortisol (0.88) were independent predictors for poor outcome.

CONCLUSIONS

In general ICU patients a blunted cortisol response to ACTH within 24 h of admission is an independent predictor for poor outcome. In contrast, baseline cortisol or adrenal androgens are not of prognostic significance.

摘要

目的

评估肾上腺皮质激素是否可预测急性、混合型危重症患者在重症监护病房(ICU)的死亡率。

设计与背景

在一家教学医院的综合ICU对连续入住的重症监护患者进行前瞻性研究。

患者

203例患有多重创伤(n = 93)、内科疾病(n = 57)或外科疾病(n = 53)的危重症患者。

测量与结果

在入住ICU的24小时内采集一份清晨血样,以测量基础皮质醇、促肾上腺皮质激素(ACTH)和硫酸脱氢表雄酮(DHEAS)。随后进行低剂量(1微克)ACTH试验以测定刺激后的皮质醇。皮质醇的增量定义为刺激后皮质醇减去基础皮质醇。总体而言,149例患者存活,54例死亡。非存活者年龄更大,病情更严重,序贯器官衰竭评估(SOFA)和急性生理与慢性健康状况评分系统(APACHE II)评分更高。与存活者相比,非存活者皮质醇的增量更低(5.0对8.3微克/分升),DHEAS也更低(1065对1642纳克/毫升)。两组的基础皮质醇和刺激后皮质醇相似。多因素逻辑回归分析显示,年龄(比值比1.02)、SOFA评分(1.36)和皮质醇的增量(0.88)是预后不良的独立预测因素。

结论

在综合ICU患者中,入院24小时内对ACTH的皮质醇反应迟钝是预后不良的独立预测因素。相比之下,基础皮质醇或肾上腺雄激素无预后意义。

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