Cotton Bryan A, Guillamondegui Oscar D, Fleming Sloan B, Carpenter Robert O, Patel Shivani H, Morris John A, Arbogast Patrick G
Division of Trauma and Surgical Critical Care, Department of Surgery, Vanderbilt University Medical Center, 1211 21st Ave S, 404 Medical Arts Bldg, Nashville, TN 37212, USA.
Arch Surg. 2008 Jan;143(1):62-7; discussion 67. doi: 10.1001/archsurg.143.1.62.
Timely diagnosis and treatment of adrenal insufficiency (AI) dramatically reduces mortality in trauma patients. We sought to identify risk factors and populations with a high risk of developing AI.
Retrospective registry study.
Academic level I trauma center.
All trauma patients in the intensive care unit who underwent cosyntropin stimulation testing (CST) for presumed AI from January 1, 2002, through December 31, 2004.
Cosyntropin stimulation testing, in which response was defined as an increase of 9 mug/dL (248 nmol/L) or more in cortisol level.
Risk factors for developing AI in critically ill trauma patients.
In 137 patients, CST was performed; 83 (60.6%) were nonresponders and 54 (39.4%) were responders. Age, sex, race, trauma mechanism, Injury Severity Score, and Revised Trauma Score were not statistically different between the groups. Rates of sepsis/septic shock, mechanical ventilation, and mortality were also similar between the 2 groups. However, rates of hemorrhagic shock on admission (45 [54%] vs 16 [30%]), requirement of vasopressor support (65 [78%] vs 28 [52%]), and etomidate exposure (59 [71%] vs 28 [52%]) were all significantly higher in the nonresponder group (P < .01). The increased risk of AI remained after controlling for potential confounding covariates (age, mechanism, Injury Severity Score, and Revised Trauma Score).
Exposure to etomidate is a modifiable risk factor for the development of AI in this sample of critically injured patients. The use of etomidate for procedural sedation and rapid-sequence intubation in this patient population should be reevaluated.
及时诊断和治疗肾上腺功能不全（AI）可显著降低创伤患者的死亡率。我们试图确定发生AI的风险因素及高危人群。
回顾性登记研究。
一级学术创伤中心。
2002年1月1日至2004年12月31日期间在重症监护病房因疑似AI接受促肾上腺皮质激素刺激试验（CST）的所有创伤患者。
促肾上腺皮质激素刺激试验，反应定义为皮质醇水平升高9μg/dL（248nmol/L）或更多。
重症创伤患者发生AI的风险因素。
137例患者接受了CST；83例（60.6%）无反应者，54例（39.4%）有反应者。两组患者的年龄、性别、种族、创伤机制、损伤严重程度评分和修订创伤评分无统计学差异。两组患者的脓毒症/感染性休克、机械通气和死亡率也相似。然而，无反应组入院时出血性休克发生率（45[54%]对16[30%]）、血管升压药支持需求率（65[78%]对28[52%]）和依托咪酯暴露率（59[71%]对28[52%]）均显著更高（P<.01）。在控制潜在混杂协变量（年龄、机制、损伤严重程度评分和修订创伤评分）后，AI风险增加仍然存在。
在这个重伤患者样本中，依托咪酯暴露是发生AI的一个可改变的风险因素。该患者群体中使用依托咪酯进行程序性镇静和快速顺序插管应重新评估。
