Department of Pharmacy, Mount Sinai Hospital, Toronto, Ontario, Canada.
Shock. 2013 Feb;39(2):144-8. doi: 10.1097/SHK.0b013e31827daf0b.
Our objectives were to determine the incidence of critical illness-related corticosteroid insufficiency (CIRCI) in patients with septic shock using a 1 μg corticotropin (ACTH) test and to describe their clinical outcomes. We retrospectively identified 219 consecutive patients with septic shock assessed for CIRCI with a 1 μg ACTH test. Standardized testing involved plasma cortisol measurements at baseline (T0) and at 30 min (T30) and 60 min (T60) after ACTH administration. The maximal increase in cortisol (Δ max) was calculated as the difference between T0 and the highest cortisol value at T30 or T60. Critical illness-related corticosteroid insufficiency was defined as Δ max less than 9 μg/dL after ACTH administration. The mean age of the cohort was 63.0 ± 15.8 years, mean Acute Physiology and Chronic Health Evaluation II score was 26.3 ± 8.1, 85.6% were mechanically ventilated, and the mean number of organ failures was 3.0 ± 1.2. Critical illness-related corticosteroid insufficiency was diagnosed in 70.8% of patients. Twenty-eight-day mortality was highest in patients with baseline cortisol greater than 65 μg/dL (62.5%) and in those with baseline cortisol 34 μg/dL or greater and Δ max less than 9 μg/dL (50.0%). There was no difference in mortality in patients with and without CIRCI (53.9% vs. 36.4%, P = 0.08). Corticosteroids were administered to 69.4% of patients for 5.3 ± 3.6 days. For patients with CIRCI, intensive care unit mortality was similar for those who received corticosteroids compared with those who did not (46.0% vs. 25.0%, P = 0.166). The incidence of CIRCI based on 1 μg ACTH was high in this septic shock cohort. The highest mortality rates were observed in patients with high baseline cortisol and in those who failed to respond appropriately to ACTH. The administration of corticosteroids was not associated with a reduction in mortality.
我们的目的是使用 1μg 促皮质素（ACTH）试验确定脓毒性休克患者发生危重病相关皮质激素不足（CIRCI）的发生率，并描述其临床结局。我们回顾性地确定了 219 例接受 1μg ACTH 试验评估 CIRCI 的连续脓毒性休克患者。标准化检测包括 ACTH 给药前（T0）、给药后 30 分钟（T30）和 60 分钟（T60）时的血浆皮质醇测量。皮质醇的最大增加（Δ max）定义为 T0 与 T30 或 T60 时最高皮质醇值之间的差值。ACTH 给药后 Δ max 小于 9μg/dL 定义为 CIRCI。队列的平均年龄为 63.0±15.8 岁，急性生理学和慢性健康评估 II 评分平均为 26.3±8.1，85.6%接受机械通气，器官衰竭的平均数量为 3.0±1.2。70.8%的患者诊断为 CIRCI。基线皮质醇大于 65μg/dL（62.5%）和基线皮质醇 34μg/dL 或更高且 Δ max 小于 9μg/dL（50.0%）的患者 28 天死亡率最高。有和没有 CIRCI 的患者死亡率没有差异（53.9%比 36.4%，P=0.08）。皮质类固醇被给予 69.4%的患者，持续 5.3±3.6 天。对于 CIRCI 患者，接受皮质类固醇治疗的患者与未接受皮质类固醇治疗的患者的 ICU 死亡率相似（46.0%比 25.0%，P=0.166）。在该脓毒性休克队列中，基于 1μg ACTH 的 CIRCI 发生率很高。基线皮质醇较高的患者和对 ACTH 反应不佳的患者死亡率最高。皮质类固醇的使用与死亡率降低无关。
