NIHR-Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
Royal Centre for Defence Medicine, Queen Elizabeth Hospital Birmingham, UK.
J Clin Endocrinol Metab. 2020 Mar 1;105(3):925-37. doi: 10.1210/clinem/dgz302.
Survival rates after severe injury are improving, but complication rates and outcomes are variable.
This cohort study addressed the lack of longitudinal data on the steroid response to major trauma and during recovery.
We undertook a prospective, observational cohort study from time of injury to 6 months postinjury at a major UK trauma centre and a military rehabilitation unit, studying patients within 24 hours of major trauma (estimated New Injury Severity Score (NISS) > 15).
We measured adrenal and gonadal steroids in serum and 24-hour urine by mass spectrometry, assessed muscle loss by ultrasound and nitrogen excretion, and recorded clinical outcomes (ventilator days, length of hospital stay, opioid use, incidence of organ dysfunction, and sepsis); results were analyzed by generalized mixed-effect linear models.
We screened 996 multiple injured adults, approached 106, and recruited 95 eligible patients; 87 survived. We analyzed all male survivors <50 years not treated with steroids (N = 60; median age 27 [interquartile range 24-31] years; median NISS 34 [29-44]). Urinary nitrogen excretion and muscle loss peaked after 1 and 6 weeks, respectively. Serum testosterone, dehydroepiandrosterone, and dehydroepiandrosterone sulfate decreased immediately after trauma and took 2, 4, and more than 6 months, respectively, to recover; opioid treatment delayed dehydroepiandrosterone recovery in a dose-dependent fashion. Androgens and precursors correlated with SOFA score and probability of sepsis.
The catabolic response to severe injury was accompanied by acute and sustained androgen suppression. Whether androgen supplementation improves health outcomes after major trauma requires further investigation.
严重创伤后的存活率正在提高，但并发症发生率和结果仍存在差异。
本队列研究旨在解决严重创伤和康复期间对主要类固醇反应缺乏纵向数据的问题。
我们在英国一家主要创伤中心和一家军事康复单位进行了一项前瞻性、观察性队列研究，在创伤后 24 小时内研究了严重创伤患者（估计新损伤严重程度评分（NISS）> 15）。
我们通过质谱法测量血清和 24 小时尿液中的肾上腺和性腺类固醇，通过超声和氮排泄评估肌肉损失，并记录临床结果（呼吸机天数、住院时间、阿片类药物使用、器官功能障碍和脓毒症的发生率）；通过广义混合效应线性模型分析结果。
我们筛选了 996 名多发性创伤成年人，接近 106 名，并招募了 95 名符合条件的患者；87 人幸存。我们分析了所有年龄<50 岁且未接受类固醇治疗的男性幸存者（N=60；中位年龄 27[四分位距 24-31]岁；中位 NISS 34[29-44]）。尿氮排泄和肌肉损失分别在 1 周和 6 周后达到峰值。血清睾酮、脱氢表雄酮和硫酸脱氢表雄酮在创伤后立即下降，分别需要 2、4 和超过 6 个月才能恢复；阿片类药物治疗以剂量依赖性方式延迟脱氢表雄酮的恢复。雄激素和前体与 SOFA 评分和脓毒症的发生概率相关。
严重创伤后的分解代谢反应伴随着急性和持续的雄激素抑制。雄激素补充是否能改善严重创伤后的健康结果需要进一步研究。
