Guillamondegui Oscar D, Gunter Oliver L, Patel Shivani, Fleming Sloan, Cotton Bryan A, Morris John A
Department of Surgery, Division of Trauma, Vanderbilt University Medical Center, Nashville, Tennessee 37212, USA.
Am Surg. 2009 Apr;75(4):287-90.
Acute adrenal insufficiency in the trauma patient is underrecognized and the impact poorly understood. Our hypothesis was that the identification and treatment of acute adrenal insufficiency reduces mortality in trauma patients. Institutional Review Board approval for the retrospective review of a prospective database from a Level 1 trauma center for 2002 to 2004 was obtained. The study population included patients receiving a cosyntropin stimulation test (250 microg) and/or random cortisol level based on our practice management guideline and an intensive care unit stay longer than 24 hours. Demographic, acuity, and outcome data were collected. The nonresponders had baseline cortisol levels less than 20 microg/dL or poststimulation rise less than 9 microg/dL. Independent t tests and chi2 statistics were used. One hundred thirty-seven patients had cosyntropin stimulation tests performed. Eighty-two (60%) patients were nonresponders of which 66 were treated with hydrocortisone and 16 went untreated as a result of the discretion of the attending physician. The 55 (40%) responders showed no statistical differences in outcome variables whether or not they received hydrocortisone. The untreated adrenal-insufficient patients had significantly higher mortality, longer hospital length of stay, intensive care unit days, and ventilator-free days. Conclusions were: (1) treatment of acute adrenal insufficiency reduces mortality by almost 50 per cent in the trauma patient; and (2) acute adrenal insufficiency recognized by low random cortisol levels or nonresponse to a stimulation tests should be considered for treatment.
创伤患者的急性肾上腺功能不全未得到充分认识，其影响也知之甚少。我们的假设是，识别并治疗急性肾上腺功能不全可降低创伤患者的死亡率。我们获得了机构审查委员会的批准，对一家一级创伤中心2002年至2004年的前瞻性数据库进行回顾性研究。研究人群包括根据我们的实践管理指南接受促肾上腺皮质激素刺激试验（250微克）和/或随机皮质醇水平检测且重症监护病房住院时间超过24小时的患者。收集了人口统计学、病情严重程度和预后数据。无反应者的基线皮质醇水平低于20微克/分升或刺激后升高幅度低于9微克/分升。使用独立t检验和卡方统计。137例患者接受了促肾上腺皮质激素刺激试验。82例（60%）患者无反应，其中66例接受了氢化可的松治疗，16例因主治医师的判断未接受治疗。55例（40%）有反应者无论是否接受氢化可的松治疗，其预后变量均无统计学差异。未接受治疗的肾上腺功能不全患者死亡率显著更高，住院时间、重症监护病房住院天数和无呼吸机天数更长。结论为：（1）治疗急性肾上腺功能不全可使创伤患者死亡率降低近50%；（2）对于因随机皮质醇水平低或刺激试验无反应而识别出的急性肾上腺功能不全应考虑进行治疗。
