Mesotten Dieter, Vanhorebeek Ilse, Van den Berghe Greet
Department of Intensive Care Medicine, University Hospital Gasthuisberg, Herestraat 49, B-3000 Leuven, Belgium.
Nat Clin Pract Endocrinol Metab. 2008 Sep;4(9):496-505. doi: 10.1038/ncpendmet0921.
Critical illness is generally hallmarked by activation of the hypothalamic-pituitary-adrenal axis. The development of very high levels of cortisol has been associated with severe illness and a raised risk of death. Likewise, a response that is inadequate relative to the degree of stress, termed relative adrenal insufficiency (also known as critical-illness-related corticosteroid insufficiency) has been associated with increased mortality. Much controversy exists with regard to the definition and biochemical testing of an adequate adrenal response to critical illness, which hampers diagnosis. High doses of glucocorticoids have been shown to have no effect in this setting and might be harmful. Moderate doses have been advocated, however, for critically ill patients with inflammatory conditions, such as acute respiratory distress syndrome and septic shock syndrome. Initial results from proof-of-concept studies were promising but thus far have not been reproduced in large, multicenter trials, although the latter were underpowered to yield definite conclusions. The role of glucocorticoid therapy in intensive care, therefore, remains uncertain. Until the debate has been settled, we recommend that use of glucocorticoid therapy in critically ill patients should continue to be based on the clinician's judgment and that routine adjuvant use should be avoided.
危重病通常以下丘脑 - 垂体 - 肾上腺轴的激活为特征。皮质醇水平极高与严重疾病及死亡风险增加有关。同样，相对于应激程度而言反应不足，即所谓的相对肾上腺皮质功能不全（也称为危重病相关皮质类固醇功能不全），也与死亡率增加相关。关于对危重病肾上腺反应充分性的定义和生化检测存在诸多争议，这妨碍了诊断。高剂量糖皮质激素在这种情况下已被证明无效且可能有害。然而，对于患有炎症性疾病的危重病患者，如急性呼吸窘迫综合征和脓毒性休克综合征，有人主张使用中等剂量。概念验证研究的初步结果很有前景，但迄今为止尚未在大型多中心试验中得到重复验证，尽管后者的样本量不足以得出明确结论。因此，糖皮质激素治疗在重症监护中的作用仍不确定。在这场争论解决之前，我们建议危重病患者糖皮质激素治疗的使用应继续基于临床医生的判断，并且应避免常规辅助使用。
