General Intensive Care Unit, Raymond Poincaré Hospital (AP-HP), University of Versailles SQY, 104 boulevard Raymond Poincaré, 92380 Garches, France.
Ann Intensive Care. 2011 Apr 13;1(1):7. doi: 10.1186/2110-5820-1-7.
Septic shock is characterized by uncontrolled systemic inflammation that contributes to the progression of organ failures and eventually death. There is now ample evidence that the inability of the host to mount an appropriate hypothalamic-pituitary and adrenal axis response plays a major in overwhelming systemic inflammation during infections. Proinflammatory mediators released in the inflamed sites oppose to the anti-inflammatory response, an effect that may be reversed by exogenous corticosteroids. With sepsis, via nongenomic and genomic effects, corticosteroids restore cardiovascular homeostasis, terminate systemic and tissue inflammation, restore organ function, and prevent death. These effects of corticosteroids have been consistently found in animal studies and in most recent frequentist and Bayesian meta-analyses. Corticosteroids should be initiated only in patients with sepsis who require 0.5 μg/kg per minute or more of norepinephrine and should be continued for 5 to 7 days except in patients with poor hemodynamic response after 2 days of corticosteroids and with a cortisol increment of more than 250 nmol/L after a standard adrenocorticotropin hormone (ACTH) test. Hydrocortisone should be given at a daily dose of 200 mg and preferably combined to enteral fludrocortisone at a dose of 50 μg. Blood glucose levels should be kept below 150 mg/dL.
感染性休克的特征是失控的全身炎症，这会导致器官衰竭的进展，最终导致死亡。现在有充分的证据表明，宿主不能产生适当的下丘脑-垂体-肾上腺轴反应，在感染期间会导致全身性炎症反应失控。在炎症部位释放的促炎介质与抗炎反应相对抗，这种效应可以被外源性皮质类固醇逆转。在脓毒症中，皮质类固醇通过非基因组和基因组作用恢复心血管稳态，终止全身和组织炎症，恢复器官功能，并预防死亡。这些皮质类固醇的作用在动物研究和最近的频率和贝叶斯荟萃分析中得到了一致的发现。皮质类固醇应仅在需要每分钟 0.5μg/kg 或更多去甲肾上腺素的脓毒症患者中启动，并且应继续使用 5 至 7 天，除非在皮质类固醇治疗 2 天后血流动力学反应不佳且标准促肾上腺皮质激素 (ACTH) 试验后皮质醇增加超过 250nmol/L。应给予氢化可的松每日 200mg，并最好与 50μg 剂量的口服氟氢可的松联合使用。应将血糖水平保持在 150mg/dL 以下。
