Department of Endocrinology, Diabetes, and Metabolism (D.A.V., M.T., S.T.), Evangelismos Hospital, 106 76 Athens, Greece; Second Department of Critical Care Medicine (I.D., S.E.O.), National and Kapodistrian University of Athens, School of Medicine, Attikon University Hospital, 124 62 Athens, Greece; and First Department of Critical Care Medicine (E.D., O.L., A.K.), National and Kapodistrian University of Athens, School of Medicine, Evangelismos Hospital, 106 76 Athens, Greece.
J Clin Endocrinol Metab. 2014 Dec;99(12):4471-80. doi: 10.1210/jc.2014-2619.
Adrenal dysfunction remains a controversial issue in critical care. The long-stay intensive care unit (ICU) population may be at increased risk of adrenal insufficiency.
We aimed to determine whether adrenal dysfunction develops during the course of sepsis.
This is a prospective observational longitudinal study.
The study was conducted in the ICU of a secondary/tertiary care hospital.
We studied 51 consecutive mechanically ventilated patients with sepsis.
We measured cortisol, ACTH, cortisol-binding globulin, cytokines, and cortisol 30 minutes after 1 μg ACTH(1-24), upon sepsis diagnosis and every 3 to 4 days, until Day 30 or until recovery or death.
We looked for changes in baseline and stimulated cortisol levels and its relationship to ACTH levels, sepsis severity or survival.
Baseline and stimulated cortisol levels did not vary significantly. Septic patients with shock had higher baseline (20 ± 6 vs 17 ± 5 μg/dL, P = .03) and stimulated cortisol levels (26 ± 5 vs 23 ± 6 μg/dL, P = .04), compared with those without shock. On Day 1, ACTH levels could not predict cortisol levels (R(2) = 0.06, P = .08). ACTH levels increased significantly after Day 10 and, at this time point, they related to cortisol levels (R(2) = 0.35, P < .001). Development of septic shock, or resolution from it, was not associated with changes in baseline, stimulated cortisol levels, or the cortisol increment. There was much inpatient variability in the diagnosis of adrenal dysfunction at different time points.
Total cortisol levels relate both to the severity and outcome of sepsis and remain fairly unchanged during the course of illness. Initially, cortisol levels are largely ACTH independent, whereas ACTH increases and correlates with cortisol levels later on. Adrenal dysfunction does not seem to be a major problem during the prolonged phase of sepsis. Although not significant, the variation in cortisol levels may be such that classification of patients varies, questioning the utility of arbitrary cut-offs to define adrenal dysfunction in septic patients.
在重症监护中，肾上腺功能障碍仍然是一个有争议的问题。长期入住重症监护病房（ICU）的患者可能有发生肾上腺功能不全的风险增加。
我们旨在确定脓毒症过程中是否会发生肾上腺功能障碍。
这是一项前瞻性观察性纵向研究。
该研究在一家二级/三级护理医院的 ICU 进行。
我们研究了 51 例连续机械通气的脓毒症患者。
我们在脓毒症诊断时、之后每 3 至 4 天测量一次皮质醇、ACTH、皮质醇结合球蛋白、细胞因子以及 ACTH(1-24) 刺激后 30 分钟的皮质醇水平，直至第 30 天或直至患者康复或死亡。
我们观察了基础和刺激皮质醇水平的变化，以及其与 ACTH 水平、脓毒症严重程度或生存的关系。
基础和刺激皮质醇水平没有显著差异。有休克的脓毒症患者的基础（20 ± 6 比 17 ± 5 μg/dL，P =.03）和刺激（26 ± 5 比 23 ± 6 μg/dL，P =.04）皮质醇水平更高。在第 1 天，ACTH 水平不能预测皮质醇水平（R(2) = 0.06，P =.08）。ACTH 水平在第 10 天后显著增加，此时与皮质醇水平相关（R(2) = 0.35，P <.001）。脓毒性休克的发生或缓解与基础、刺激皮质醇水平或皮质醇增加的变化无关。在不同时间点，对肾上腺功能障碍的诊断存在很大的住院内变异性。
总的皮质醇水平与脓毒症的严重程度和预后相关，在疾病过程中基本保持不变。最初，皮质醇水平在很大程度上与 ACTH 无关，而 ACTH 增加并与皮质醇水平相关。在脓毒症的长期阶段，似乎没有出现肾上腺功能障碍的主要问题。虽然没有统计学意义，但皮质醇水平的变化可能会导致患者分类的变化，质疑使用任意的截止值来定义脓毒症患者的肾上腺功能障碍的实用性。
