Brander Lukas, Haltmeier Tobias, Suter Anna, Studer Peter, Inderbitzin Daniel, Candinas Daniel, Vogt Andreas, Henzen Christoph, Takala Jukka, Jakob Stephan M
Department of Intensive Care Medicine, Inselspital, Bern University Hospital, Bern, Switzerland.
Surgery. 2009 Jul;146(1):88-99. doi: 10.1016/j.surg.2009.01.018. Epub 2009 Apr 21.
To test the hypothesis that reduced responsiveness to adrenocorticotropin (ACTH) stimulation before elective major abdominal surgery is associated with an increased incidence of postoperative complications.
A low-dose (1 microg) ACTH test was performed the day before surgery, during the operation, on the first postoperative day, and before discharge from the hospital in 77 patients undergoing major abdominal surgery (age 62 [47;69] yrs [median, quartiles]; 30 female). Thirty-one patients undergoing minor, non-abdominal surgery (mostly inguinal hernia repair) (age 57 [40;66] yrs; 14 female) served as controls with minor surgical stress. A stimulated plasma cortisol concentration >or=500 nmol/l or an increment of >or=200 nmol/l in response to 1 microg ACTH was defined as normal. Scores for surgical stress and comprehensive risk, postoperative complications, and length of hospital stay (LOS) were assessed.
On the day before major abdominal surgery, basal and stimulated plasma cortisol were 242 (165;299) nmol/l and 497 (404;568) nmol/l, respectively. Eighteen (23%) patients had an abnormal ACTH test, and 7 of these (39%) had complications versus 25 (42%) of the 59 patients with normal ACTH tests (P = .992). Surgical stress, comprehensive risk, and intra- and postoperative basal cortisol levels were higher and the response to ACTH stimulation smaller in patients with major abdominal compared to minor surgery. The peri-operative course of ACTH responses was not associated with complications or LOS in abdominal surgery patients.
In patients scheduled for abdominal surgery, pre-operatively reduced adrenal response to stimulation with 1 microg ACTH is common but not associated with postoperative complications.
为验证择期腹部大手术前促肾上腺皮质激素（ACTH）刺激反应降低与术后并发症发生率增加相关这一假说。
对77例接受腹部大手术的患者（年龄62 [47;69]岁[中位数，四分位数]；30例女性）在手术前一天、手术期间、术后第一天及出院前进行低剂量（1微克）ACTH试验。31例接受小型非腹部手术（主要为腹股沟疝修补术）的患者（年龄57 [40;66]岁；14例女性）作为手术应激较小的对照组。将刺激后血浆皮质醇浓度≥500 nmol/l或对1微克ACTH反应增加≥200 nmol/l定义为正常。评估手术应激和综合风险评分、术后并发症及住院时间（LOS）。
腹部大手术前一天，基础及刺激后血浆皮质醇分别为242（165;299）nmol/l和497（404;568）nmol/l。18例（23%）患者ACTH试验异常，其中7例（39%）发生并发症，而59例ACTH试验正常的患者中有25例（42%）发生并发症（P = 0.992）。与小型手术患者相比，腹部大手术患者的手术应激、综合风险以及术中和术后基础皮质醇水平更高，对ACTH刺激的反应更小。腹部手术患者围手术期ACTH反应过程与并发症或住院时间无关。
在计划接受腹部手术的患者中，术前对1微克ACTH刺激的肾上腺反应降低很常见，但与术后并发症无关。
