Division of Neurocritical Care, Department of Neurology, Washington University School of Medicine, Saint Louis, MO 63110, USA.
J Crit Care. 2013 Feb;28(1):111.e1-7. doi: 10.1016/j.jcrc.2012.04.015. Epub 2012 Jul 2.
Corticosteroids are used to promote hemodynamic stability and reduce inflammatory organ injury after brain death. High-dose (HD) methylprednisolone has become the standard regimen based on comparisons to untreated/historical controls. However, this protocol may exacerbate hyperglycemia. Our objective was to compare a lower-dose (LD) steroid protocol (adequate for hemodynamic stabilization in adrenal insufficiency and sepsis) to the traditional HD regimen in the management of brain-dead organ donors.
We evaluated 132 consecutive brain-dead donors managed before and after changing the steroid protocol from 15 mg/kg methylprednisolone (HD) to 300 mg hydrocortisone (LD). Primary outcome measures were glycemic control, oxygenation, hemodynamic stability, and organs transplanted.
Groups were balanced except for nonsignificantly higher baseline Pao(2) in the LD cohort. Final Pao(2) remained higher (394 mm Hg LD vs 333 mm Hg HD, P=.03); but improvement in oxygenation was comparable (+37 mm Hg LD vs +28 mm Hg HD, P=.43), as was the proportion able to come off vasopressor support (39% LD vs 47% HD, P=.38). Similar proportions of lungs (44% vs 33%) and hearts (31% vs 27%) were transplanted in both groups. After excluding diabetics, median glucose values at 4 hours (170 mmol/L vs 188 mmol/L, P=.06) and final insulin requirements (2.9 U/h vs 8.4 U/h, P=.01) were lower with LD steroids; and more patients were off insulin infusions (74% LD vs 53% HD, P=.02).
A lower-dose corticosteroid protocol did not result in worsened donor pulmonary or cardiac function, with comparable organs transplanted compared with the traditional HD regimen. Insulin requirements and glycemic control were improved. High-dose methylprednisolone may not be required to support brain-dead donors.
皮质类固醇用于促进脑死亡后血流动力学稳定和减轻炎症性器官损伤。高剂量（HD）甲基强的松龙已成为基于与未治疗/历史对照比较的标准方案。然而，该方案可能会加剧高血糖。我们的目的是比较低剂量（LD）类固醇方案（在肾上腺功能不全和败血症中足以稳定血流动力学）与脑死亡供体管理中的传统 HD 方案。
我们评估了在改变类固醇方案后连续 132 例脑死亡供体，方案从 15mg/kg 甲基强的松龙（HD）改为 300mg 氢化可的松（LD）。主要观察指标为血糖控制、氧合、血流动力学稳定和移植器官。
两组平衡，除 LD 队列的基线 Pao（2）略高外无显著差异。最终 Pao（2）仍较高（LD 为 394mmHg，HD 为 333mmHg，P=0.03）；但氧合改善相似（LD 为+37mmHg，HD 为+28mmHg，P=0.43），能够停用血管加压支持的比例也相似（LD 为 39%，HD 为 47%，P=0.38）。两组肺（44%比 33%）和心脏（31%比 27%）的移植比例相似。排除糖尿病患者后，LD 类固醇组 4 小时（170mmol/L 比 188mmol/L，P=0.06）和最终胰岛素需求（2.9U/h 比 8.4U/h，P=0.01）的中位数葡萄糖值较低；且更多患者停用胰岛素输注（LD 为 74%，HD 为 53%，P=0.02）。
与传统的 HD 方案相比，低剂量皮质类固醇方案不会导致脑死亡供体的肺或心脏功能恶化，移植的器官相似。胰岛素需求和血糖控制得到改善。支持脑死亡供体可能不需要高剂量甲基强的松龙。
