早期启动小剂量皮质类固醇治疗脓毒性休克的回顾性观察研究。
Early initiation of low-dose corticosteroid therapy in the management of septic shock: a retrospective observational study.
机构信息
Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 135-710, Republic of Korea.
出版信息
Crit Care. 2012 Jan 7;16(1):R3. doi: 10.1186/cc10601.
INTRODUCTION
The use of low-dose steroid therapy in the management of septic shock has been extensively studied. However, the association between the timing of low-dose steroid therapy and the outcome has not been evaluated. Therefore, we evaluated whether early initiation of low-dose steroid therapy is associated with mortality in patients with septic shock.
METHODS
We retrospectively analyzed the clinical data of 178 patients who received low-dose corticosteroid therapy for septic shock between January 2008 and December 2009. Time-dependent Cox regression models were used to adjust for potential confounding factors in the association between the time to initiation of low-dose corticosteroid therapy and in-hospital mortality.
RESULTS
The study population consisted of 107 men and 71 women with a median age of 66 (interquartile range, 54 to 71) years. The 28-day mortality was 44% and low-dose corticosteroid therapy was initiated within a median of 8.5 (3.8 to 19.1) hours after onset of septic shock-related hypotension. Median time to initiation of low-dose corticosteroid therapy was significantly shorter in survivors than in non-survivors (6.5 hours versus 10.4 hours; P=0.0135). The mortality rates increased significantly with increasing quintiles of time to initiation of low-dose corticosteroid therapy (P=0.0107 for trend). Other factors associated with 28-day mortality were higher Simplified Acute Physiology Score (SAPS) 3 (P<0.0001) and Sequential Organ Failure Assessment (SOFA) scores (P=0.0007), dose of vasopressor at the time of initiation of low-dose corticosteroid therapy (P<0.0001), need for mechanical ventilation (P=0.0001) and renal replacement therapy (P<0.0001), while the impaired adrenal reserve did not affect 28-day mortality (81% versus 82%; P=0.8679). After adjusting for potential confounding factors, the time to initiation of low-dose corticosteroid therapy was still significantly associated with 28-day mortality (adjusted odds ratio (OR) 1.025, 95% confidence interval (CI) 1.007 to 1.044, P=0.0075). The early therapy group (administered within 6 hours after the onset of septic shock, n=66) had a 37% lower mortality rate than the late therapy group (administered more than 6 hours after the onset of septic shock, n=112) (32% versus 51%, P=0.0132).
CONCLUSIONS
Early initiation of low-dose corticosteroid therapy was significantly associated with decreased mortality.
简介
在脓毒性休克的治疗中，低剂量类固醇治疗的应用已得到广泛研究。然而，低剂量类固醇治疗的起始时间与结局之间的关系尚未得到评估。因此，我们评估了脓毒性休克患者中低剂量类固醇治疗的起始时间是否与死亡率相关。
方法
我们回顾性分析了 2008 年 1 月至 2009 年 12 月期间接受低剂量皮质类固醇治疗的 178 例脓毒性休克患者的临床数据。使用时间依赖性 Cox 回归模型调整低剂量皮质类固醇治疗起始时间与院内死亡率之间关联的潜在混杂因素。
结果
研究人群包括 107 名男性和 71 名女性，中位年龄为 66（四分位距，54 至 71）岁。28 天死亡率为 44%，低剂量皮质类固醇治疗在脓毒性休克相关低血压发作后中位时间 8.5（3.8 至 19.1）小时开始。存活者的低剂量皮质类固醇治疗起始时间中位数明显短于非存活者（6.5 小时与 10.4 小时；P=0.0135）。随着低剂量皮质类固醇治疗起始时间的五分位数增加，死亡率显著增加（趋势 P=0.0107）。其他与 28 天死亡率相关的因素包括更高的简化急性生理学评分（SAPS）3（P<0.0001）和序贯器官衰竭评估（SOFA）评分（P=0.0007）、低剂量皮质类固醇治疗起始时的血管加压药剂量（P<0.0001）、需要机械通气（P=0.0001）和肾脏替代治疗（P<0.0001），而肾上腺储备受损并不影响 28 天死亡率（81%与 82%；P=0.8679）。在调整潜在混杂因素后，低剂量皮质类固醇治疗的起始时间仍与 28 天死亡率显著相关（校正优势比（OR）1.025，95%置信区间（CI）1.007 至 1.044，P=0.0075）。早期治疗组（发病后 6 小时内开始治疗，n=66）的死亡率比晚期治疗组（发病后 6 小时以上开始治疗，n=112）低 37%（32%与 51%，P=0.0132）。
结论
早期开始低剂量皮质类固醇治疗与死亡率降低显著相关。
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