Bagate François, Bedet Alexandre, Tomberli Françoise, Boissier Florence, Razazi Keyvan, de Prost Nicolas, Carteaux Guillaume, Mekontso Dessap Armand
AP-HP, DHU A-TVB, Service de Médecine Intensive Réanimation, Centre Hospitalo-Universitaire Henri Mondor, 51, avenue du Mal de Lattre de Tassigny, 94010, Créteil Cedex, France.
Groupe de Recherche Clinique CARMAS, Faculté de Médecine, Université Paris Est Créteil, 94010, Créteil, France.
Ann Intensive Care. 2021 Apr 26;11(1):65. doi: 10.1186/s13613-021-00852-2.
Critical illness-related corticosteroid insufficiency (CIRCI) is common during critical illness and is usually associated with poor outcomes, as prolonged duration of mechanical ventilation (MV) and higher mortality. CIRCI may alter cardiac and vascular functions. Weaning-induced pulmonary oedema (WiPO) is a major mechanism of weaning failure. The aim of this study was to evaluate the role of CIRCI in patients with difficult ventilator weaning and its possible relation with WiPO.
This is a prospective study conducted in the intensive care of a university hospital in France. Patients under MV for more than 24 h, meeting weaning criteria and having failed the first spontaneous breathing trial (SBT) underwent a corticotropin stimulation test, with assessment of total blood cortisol levels immediately before (T) 0.25 mg iv of tetracosactrin and 30 and 60 min afterward. Δ was defined as the difference between the maximal value after the test and T. CIRCI was defined as T < 10 μg/dL (276 nmol/L) and/or Δ < 9 μg/dL (248 nmol/L) and inadequate adrenal reserve as Δ < 9 μg/dL. Biomarkers (natriuretic peptide and protidemia) sampling and echocardiograms were performed during the second SBT and were used to diagnose WiPO, which was defined according to two definitions (one liberal and one conservative) derived from recent publications on the topic. Successful extubation was defined as patient alive without reintubation 7 days after extubation. A competing risk analysis was used to assess extubation failure and mortality.
Seventy-six consecutive patients (63 ± 14 years; 49 men) with difficult weaning were enrolled. CIRCI and inadequate adrenal reserve occurred in 25 (33%) and 17 (22%) patients, respectively. The probability of successful extubation was significantly decreased in patients with CIRCI or inadequate adrenal reserve, as compared to their counterparts, and this association persisted after adjustment on severity (SOFA score at first SBT). WiPO occurred in 44 (58%) and 8 (11%) patients, according to the liberal and conservative definition, respectively. WiPO was not associated with CIRCI nor with inadequate adrenal reserve.
CIRCI was common during difficult weaning and was associated with its prolongation. We did not find a significant association between CIRCI and WiPO.
危重症相关皮质类固醇功能不全（CIRCI）在危重症期间很常见，通常与不良预后相关，如机械通气（MV）时间延长和死亡率升高。CIRCI可能会改变心脏和血管功能。撤机诱发的肺水肿（WiPO）是撤机失败的主要机制。本研究的目的是评估CIRCI在困难撤机患者中的作用及其与WiPO的可能关系。
这是一项在法国一家大学医院重症监护室进行的前瞻性研究。接受MV超过24小时、符合撤机标准且首次自主呼吸试验（SBT）失败的患者接受促肾上腺皮质激素刺激试验，在静脉注射0.25mg替可克肽前（T）、注射后30分钟和60分钟评估总血皮质醇水平。Δ定义为试验后最大值与T之间的差值。CIRCI定义为T＜10μg/dL（276nmol/L）和/或Δ＜9μg/dL（248nmol/L），肾上腺储备不足定义为Δ＜9μg/dL。在第二次SBT期间进行生物标志物（利钠肽和蛋白血症）采样和超声心动图检查，用于诊断WiPO，WiPO根据该主题最近发表的两篇文献定义（一个宽松定义和一个保守定义）。成功拔管定义为拔管后7天患者存活且未再次插管。采用竞争风险分析评估拔管失败和死亡率。
连续纳入76例撤机困难的患者（63±14岁；49例男性）。分别有25例（33%）和17例（22%）患者发生CIRCI和肾上腺储备不足。与无CIRCI或肾上腺储备充足的患者相比，CIRCI或肾上腺储备不足患者的成功拔管概率显著降低，并且在根据严重程度（首次SBT时的序贯器官衰竭评估[SOFA]评分）进行调整后，这种关联仍然存在。根据宽松定义和保守定义，分别有44例（58%）和8例（11%）患者发生WiPO。WiPO与CIRCI和肾上腺储备不足均无关。
CIRCI在困难撤机期间很常见，并与其延长有关。我们未发现CIRCI与WiPO之间存在显著关联。
