Song Jin Hwa, Kim Jung Hee, Lee Sang-Min, Lee Jinwoo
Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.
Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.
Acute Crit Care. 2019 Feb;34(1):38-45. doi: 10.4266/acc.2018.00339. Epub 2019 Jan 30.
Critical illness-related corticosteroid insufficiency (CIRCI) and adrenocorticotropic hormone (ACTH)-cortisol dissociation are hormonal conditions frequently observed in patients in the intensive care unit (ICU). The aim of this study was to evaluate the association between ACTH-cortisol dissociation and clinical outcomes of critically ill patients.
We retrospectively reviewed the medical records of 94 ICU patients who underwent two rapid cosyntropin tests during hospital admission and compared the clinical aspects of patients with and without ACTH-cortisol dissociation. ACTH-cortisol dissociation was defined as plasma ACTH and serum cortisol concentrations of <22 pmol/L and >600 nmol/L, respectively.
Dissociation was present in 30 of the 94 patients (31.9%). Patients with ACTH-cortisol dissociation in the initial test had significantly higher hospital mortality rate than those in the control group (55% vs. 25.7%, P=0.013) There was no difference in hospital mortality between patients classified as having CIRCI and those who were not. In multivariate adjusted Cox regression analysis, the mortality risk was higher in the group with ACTH-cortisol dissociation (hazard ratio, 2.98; 95% confidence interval, 1.34 to 6.63; P=0.007). Patients with dissociation in two consecutive stimulation tests showed the highest hospital mortality rate among groups classified according to stimulation test results (100% vs. 31.3%).
The hospital mortality was higher in ICU patients diagnosed with ACTH-cortisol dissociation. It is clinically feasible to evaluate the presence of ACTH-cortisol dissociation by analyzing rapid ACTH stimulation test results in critically ill patients.
危重症相关皮质类固醇功能不全（CIRCI）和促肾上腺皮质激素（ACTH）-皮质醇解离是重症监护病房（ICU）患者中经常观察到的激素状况。本研究的目的是评估ACTH-皮质醇解离与危重症患者临床结局之间的关联。
我们回顾性分析了94例在住院期间接受两次快速促肾上腺皮质激素试验的ICU患者的病历，并比较了有和没有ACTH-皮质醇解离患者的临床情况。ACTH-皮质醇解离定义为血浆ACTH浓度<22 pmol/L且血清皮质醇浓度>600 nmol/L。
94例患者中有30例（31.9%）存在解离。初始试验中出现ACTH-皮质醇解离的患者的医院死亡率显著高于对照组（55%对25.7%，P=0.013）。被归类为患有CIRCI的患者与未患CIRCI的患者之间的医院死亡率没有差异。在多变量调整的Cox回归分析中，ACTH-皮质醇解离组的死亡风险更高（风险比，2.98；95%置信区间，1.34至6.63；P=0.007）。在根据刺激试验结果分类的各组中，连续两次刺激试验出现解离的患者的医院死亡率最高（100%对31.3%）。
诊断为ACTH-皮质醇解离的ICU患者的医院死亡率更高。通过分析危重症患者的快速ACTH刺激试验结果来评估ACTH-皮质醇解离的存在在临床上是可行的。
