Lu Xin, Han Wei, Gao Yan-Xia, Guo Shi-Gong, Yu Shi-Yuan, Yu Xue-Zhong, Zhu Hua-Dong, Li Yi
Emergency Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China.
Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences Chinese Academy of Medical Sciences/ School of Basic Medicine Peking Union Medical College, Beijing 100005, China.
World J Emerg Med. 2021;12(2):124-130. doi: 10.5847/wjem.j.1920-8642.2021.02.007.
The use of corticosteroids in septic shock has been studied for many decades but yielded conflicting results. We conducted a systematic review to evaluate the efficacy and the safety of corticosteroids in immunocompetent patients with septic shock.
Medline via PubMed, Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, and EMBASE were searched from inception to March 2020. Two reviewers independently identified randomized controlled trials (RCTs) comparing corticosteroids with a control group for immunocompetent patients with septic shock. Data were abstracted and reported following the and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The efficacy outcome included mortality and shock reversal. The safety outcomes were infection, gastrointestinal bleeding, and hyperglycemia.
Nine RCTs with a total of 1,298 patients were included. Compared with the control group, corticosteroid group did not lower the short-term (28 or 30 days) mortality (risk ratio [] 0.95, 95% confidence interval () 0.85 to 1.06, inconsistency [ ]=0%, trial sequential analysis [TSA]-adjusted 0.83 to 1.09, moderate-certainty evidence). Corticosteroids significantly shortened the time to shock reversal compared with the control group (mean difference [] -21.56 hours; 95% -32.95 to -10.16, =0%; TSA-adjusted -33.33 to -9.78, moderate-certainty evidence). The corticosteroid treatment was associated with an increased risk of hyperglycemia but not the infection or gastrointestinal bleeding.
The corticosteroid treatment is not associated with lower short- or long- term mortality compared with placebo in immunocompetent patients with septic shock. However, corticosteroids significantly shorten the time to shock reversal without increasing the risk of infection. The patient's immune status should also be considered during clinical treatment and clinical trials in future.
数十年来一直在研究皮质类固醇在感染性休克中的应用，但结果相互矛盾。我们进行了一项系统评价，以评估皮质类固醇在免疫功能正常的感染性休克患者中的疗效和安全性。
检索了从创刊至2020年3月的PubMed中的Medline、Cochrane图书馆中的Cochrane对照试验中央注册库（CENTRAL）和EMBASE。两名研究者独立识别比较皮质类固醇与免疫功能正常的感染性休克患者对照组的随机对照试验（RCT）。按照系统评价和Meta分析的首选报告项目（PRISMA）声明提取并报告数据。疗效结局包括死亡率和休克逆转。安全性结局为感染、胃肠道出血和高血糖。
纳入了9项RCT，共1298例患者。与对照组相比，皮质类固醇组未降低短期（28或30天）死亡率（风险比[RR]0.95，95%置信区间[CI]0.85至1.06，异质性[I²]=0%，试验序贯分析[TSA]调整后RR 0.83至1.09，中等确定性证据）。与对照组相比，皮质类固醇显著缩短了休克逆转时间（平均差[MD]-21.56小时；95%CI -32.95至-10.16；I²=0%；TSA调整后MD -33.33至-9.78，中等确定性证据）。皮质类固醇治疗与高血糖风险增加相关，但与感染或胃肠道出血无关。
在免疫功能正常的感染性休克患者中，与安慰剂相比，皮质类固醇治疗与短期或长期死亡率降低无关。然而，皮质类固醇显著缩短了休克逆转时间，且不增加感染风险。未来在临床治疗和临床试验中也应考虑患者的免疫状态。
