Salluh Jorge I F, Bozza Fernando A, Soares Márcio, Verdeal Juan Carlos R, Castro-Faria-Neto Hugo C, Lapa E Silva José Roberto, Bozza Patrícia T
Intensive Care Unit, Instituto Nacional de Câncer, Fiocruz.
Instituto de Pesquisa Clínica Evandro Chagas, Fiocruz; Laboratory of Immunopharmacology, Instituto Oswaldo Cruz, Fiocruz.
Chest. 2008 Nov;134(5):947-954. doi: 10.1378/chest.08-1382. Epub 2008 Aug 27.
High cortisol levels are frequent in patients with severe infections. However, the predictive value of total cortisol and of the presence of critical illness-related corticosteroid insufficiency (CIRCI) in severe community-acquired pneumonia (CAP) remains to be thoroughly evaluated. The aim of this study was to investigate the predictive value of adrenal response in patients with severe CAP admitted to the ICU.
Baseline and postcorticotropin cortisol levels C-reactive protein (CRP), d-dimer, clinical variables, sequential organ failure assessment (SOFA), APACHE (acute physiology and chronic health evaluation) II, and CURB-65 (confusion, urea nitrogen, respiratory rate, BP, age > or = 65 years) scores were measured in the first 24 h. Results are shown as median (interquartile range [IQR]). The major outcome measure was hospital mortality.
Seventy-two patients with severe CAP admitted to the ICU were evaluated. Baseline cortisol levels were 18.1 microg/dL (IQR, 14.4 to 26.7 microg/dL), and the difference between baseline and postcorticotropin cortisol after 250 microg of corticotropin was 19 microg/dL (IQR, 12.8 to 27 microg/dL). Baseline cortisol levels presented positive correlations with scores of disease severity, including CURB-65, APACHE II, and SOFA (p < 0.05). Cortisol levels in nonsurvivors were higher than in survivors. CIRCI was diagnosed in 29 patients (40.8%). In univariate analysis, baseline cortisol, CURB-65, and APACHE II were predictors of death. The discriminative ability of baseline cortisol (area under receiver operating characteristic curve, 0.77; 95% confidence interval, 0.65 to 0.90; best cutoff for cortisol, 25.7 microg/dL) for in-hospital mortality was better than APACHE II, CURB-65, SOFA, d-dimer, or CRP.
Baseline cortisol levels are better predictors of severity and outcome in severe CAP than postcorticotropin cortisol or routinely measured laboratory parameters or scores as APACHE II, SOFA, and CURB-65.
严重感染患者中皮质醇水平升高很常见。然而，在严重社区获得性肺炎（CAP）中，总皮质醇及危重病相关皮质类固醇功能不全（CIRCI）的预测价值仍有待全面评估。本研究旨在调查入住重症监护病房（ICU）的严重CAP患者肾上腺反应的预测价值。
在前24小时内测量基础及促肾上腺皮质激素刺激后皮质醇水平、C反应蛋白（CRP）、D-二聚体、临床变量、序贯器官衰竭评估（SOFA）、急性生理与慢性健康状况评分系统（APACHE）II以及CURB-65（意识模糊、尿素氮、呼吸频率、血压、年龄≥65岁）评分。结果以中位数（四分位间距[IQR]）表示。主要结局指标为住院死亡率。
对72例入住ICU的严重CAP患者进行了评估。基础皮质醇水平为18.1μg/dL（IQR，14.4至26.7μg/dL），250μg促肾上腺皮质激素刺激后基础与刺激后皮质醇水平的差值为19μg/dL（IQR，12.8至27μg/dL）。基础皮质醇水平与疾病严重程度评分呈正相关，包括CURB-65、APACHE II和SOFA（p<0.05）。非幸存者的皮质醇水平高于幸存者。29例患者（40.8%）被诊断为CIRCI。在单因素分析中，基础皮质醇、CURB-65和APACHE II是死亡的预测因素。基础皮质醇对住院死亡率的判别能力（受试者工作特征曲线下面积，0.77；95%置信区间，0.65至0.90；皮质醇最佳截断值，25.7μg/dL）优于APACHE II、CURB-65、SOFA、D-二聚体或CRP。
在严重CAP中，基础皮质醇水平比促肾上腺皮质激素刺激后皮质醇水平或常规测量的实验室参数以及如APACHE II、SOFA和CURB-65等评分更能预测疾病严重程度和结局。
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