Burns Trauma and Critical Care Research Centre, University of Queensland, Brisbane, QLD.
Crit Care Resusc. 2009 Dec;11(4):287-9.
The concept of relative adrenal insufficiency in patients with severe sepsis continues to be controversial. This arises in part from the lack of an accepted "gold standard" for the diagnosis of adrenal insufficiency in the critically ill. Historically, assessment of adrenal function in this population has relied on measurement of plasma total cortisol level, in a blood sample taken either at random or as part of a corticotropin stimulation test. However, an alternative is to focus on the site of glucocorticoid activity within the tissues as a potentially more useful index of functional adrenal status. We review the mechanisms known to affect tissue glucocorticoid activity and examine how they may be modified by critical illness. These include both free and interstitial cortisol concentrations, intracellular cortisol generation, and glucocorticoid-receptor activity and density. Changes in these factors are not reflected in plasma total cortisol concentrations, and more sophisticated techniques, including genetic transcriptional surveys, may be required to reveal the role of glucocorticoid insufficiency in critical illness.
在严重脓毒症患者中，相对肾上腺功能不全的概念仍然存在争议。这部分是由于缺乏公认的“金标准”来诊断危重病患者的肾上腺功能不全。从历史上看，对该人群的肾上腺功能的评估依赖于测量取自随机或促皮质素刺激试验的血液样本中的血浆总皮质醇水平。然而，另一种方法是关注组织内糖皮质激素活性的部位，作为功能性肾上腺状态的一个潜在更有用的指标。我们回顾了已知影响组织糖皮质激素活性的机制，并研究了它们如何被危重病所改变。这些包括游离和间质皮质醇浓度、细胞内皮质醇生成以及糖皮质激素受体活性和密度。这些因素的变化并没有反映在血浆总皮质醇浓度中，可能需要更复杂的技术，包括基因转录调查，来揭示糖皮质激素不足在危重病中的作用。
