Zhang Yu-cai, Zhang Sai-ji, Teng Guo-liang, Tian Guo-li, Xu Liang, Cao Rui-fen, Zhang Yu-ming
Critical Illness Institute, Intensive Care Center, Children's Hospital Affiliated to Shanghai Jiaotong University, Shanghai 200040, China.
Zhonghua Er Ke Za Zhi. 2008 May;46(5):328-32.
Sepsis and septic shock remain a common problem that results in significant mortality and morbidity in pediatric intensive care units (PICU). According to literature, the use of more physiologic steroid replacement therapy is associated with hemodynamic and survival benefits in adult patients with relative adrenal insufficiency (RAI) and catecholamine-resistant septic shock. But little information is available in children. The aim of the current prospective study was to determine the prevalence of adrenal insufficiency in children with sepsis and septic shock using a low-dose adrenocorticotropic hormone (ACTH) stimulation test (1 microg/1.73 m2) in children.
The authors performed cortisol estimation at baseline and after low-dose (1 microg/1.73 m2) ACTH stimulation at 30 mins in children during the first 24 hours in patients with sepsis or septic shock admitted to our PICU. Adrenal insufficiency was defined as a response < or = 90 microg/L. Absolute adrenal insufficiency (AAI) was further defined as baseline cortisol (T0) < 200 microg/L and RAI insufficiency by T0 > or = 200 microg/L.
Sixty-two consecutive cases with sepsis and septic shock admitted to PICU of Shanghai Jiaotong University Affiliated Children's Hospital from April, 2006 to March, 2007. The median age was 37.6 months (range, 2 - 168 months), and their gender distribution was 42 (67.7%) males and 20 (32.3%) females, 53 cases had sepsis (85.5%) and 9 had septic shock (14.5%). The mean pediatric critical illness score (PCIS) was 79.3 +/- 9.2 and median pediatric risk of mortality score (PRMSIII) 11.3 (5 - 19), respectively. Overall mortality of sepsis and septic shock was 27.42%. The evaluation of adrenal insufficiency was conducted as follows. (1) The mean cortisol levels at baseline (T0) and 30 mins after ACTH stimulation (T1) were (318.6 +/- 230.4) microg/L, (452.3 +/- 230.7) microg/L and (454.7 +/- 212.7) microg/L, (579.3 +/- 231.9) microg/L in patients with severe sepsis and septic shock group, respectively. There were no significant difference between the two groups (P > 0.05). (2) The proportion of patients with adrenal insufficiency in the study population was 40.3% as defined by a response < or = 90 microg/L post test. The proportion of patients with adrenal insufficiency in sepsis and septic shock were 39.6% and 44.4%, respectively (chi2) = 0.073, P > 0.05). (3) The serum T0 and T1 levels were (320.5 +/- 223.9) microg/L, (462.3 +/- 212.0) microg/L and (384.3 +/- 258.3) microg/L, (500.7 +/- 470.6) microg/L, respectively, and the proportion of patients with adrenal insufficiency were 37.8% and 47.1% in the survivors and the dead (P > 0.05). The levels of T0 and T1 were related to the PCIS (P < 0.05). The morbidity of adrenal insufficiency was not related to the PCIS, PRISMIII, and number of organ that developed functional insufficiency (P > 0.05).
Adrenal insufficiency may occur in patients with sepsis and septic shock in children. ACTH stimulation test may be helpful to determine whether corticosteroid therapy has a survival benefit in patients with relative adrenal insufficiency. A low-dose ACTH stimulation test can be used to evaluate the adrenal function status of severe sepsis and septic shock in children.
脓毒症和脓毒性休克仍是一个常见问题，在儿科重症监护病房（PICU）中导致显著的死亡率和发病率。根据文献，在患有相对肾上腺功能不全（RAI）和儿茶酚胺抵抗性脓毒性休克的成年患者中，使用更符合生理的类固醇替代疗法与血流动力学和生存获益相关。但儿童相关信息较少。本前瞻性研究的目的是通过对儿童进行低剂量促肾上腺皮质激素（ACTH）刺激试验（1微克/1.73平方米）来确定脓毒症和脓毒性休克患儿肾上腺功能不全的患病率。
作者对入住我们PICU的脓毒症或脓毒性休克患儿在最初24小时内于基线及低剂量（1微克/1.73平方米）ACTH刺激30分钟后进行皮质醇测定。肾上腺功能不全定义为反应≤90微克/升。绝对肾上腺功能不全（AAI）进一步定义为基线皮质醇（T0）<200微克/升，而T0≥200微克/升时为RAI功能不全。
2006年4月至2007年3月，上海交通大学附属儿童医院PICU连续收治62例脓毒症和脓毒性休克患儿。中位年龄为37.6个月（范围2 - 168个月），性别分布为男性42例（67.7%），女性20例（32.3%），53例患有脓毒症（85.5%），9例患有脓毒性休克（14.5%）。小儿危重疾病评分（PCIS）均值为79.3±9.2，小儿死亡风险评分（PRMSIII）中位数为11.3（5 - 19）。脓毒症和脓毒性休克的总体死亡率为27.42%。肾上腺功能不全的评估如下。（1）严重脓毒症和脓毒性休克组患者基线（T0）及ACTH刺激后30分钟（T1）的平均皮质醇水平分别为（318.6±230.4）微克/升、（452.3±230.7）微克/升以及（454.7±212.7）微克/升、（579.3±231.9）微克/升。两组间无显著差异（P>0.05）。（2）根据试验后反应≤90微克/升定义，研究人群中肾上腺功能不全患者比例为40.3%。脓毒症和脓毒性休克患者中肾上腺功能不全的比例分别为39.6%和44.4%（χ2 = 0.073，P>0.05）。（3）存活者和死亡者的血清T0和T1水平分别为（320.5±223.9）微克/升、（462.3±212.0）微克/升以及（384.3±258.3）微克/升、（500.7±470.6）微克/升，肾上腺功能不全患者比例分别为37.8%和47.1%（P>0.05）。T0和T1水平与PCIS相关（P<0.05）。肾上腺功能不全的发病率与PCIS、PRISMIII以及发生功能不全的器官数量无关（P>0.05）。
儿童脓毒症和脓毒性休克患者可能发生肾上腺功能不全。ACTH刺激试验可能有助于确定皮质类固醇疗法对相对肾上腺功能不全患者是否具有生存获益。低剂量ACTH刺激试验可用于评估儿童严重脓毒症和脓毒性休克的肾上腺功能状态。
