地塞米松治疗的危重症 COVID-19 患者中未解决的急性呼吸窘迫综合征使用大剂量类固醇：一项多中心队列研究。

High-Dose Steroids for Nonresolving Acute Respiratory Distress Syndrome in Critically Ill COVID-19 Patients Treated With Dexamethasone: A Multicenter Cohort Study.

机构信息

Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France.

Groupe de Recherche Clinique CARMAS, Université Paris Est Créteil, Créteil, France.

出版信息

Crit Care Med. 2023 Oct 1;51(10):1306-1317. doi: 10.1097/CCM.0000000000005930. Epub 2023 May 18.

DOI:10.1097/CCM.0000000000005930

PMID:37199534

Abstract

OBJECTIVES

To determine the impact of high doses of corticosteroids (HDCT) in critically ill COVID-19 patients with nonresolving acute respiratory distress syndrome (ARDS) who had been previously treated with dexamethasone as a standard of care.

DESIGN

Prospective observational cohort study. Eligible patients presented nonresolving ARDS related to severe acute respiratory syndrome coronavirus 2 infection and had received initial treatment with dexamethasone. We compared patients who had received or not HDCT during ICU stay, consisting of greater than or equal to 1 mg/kg of methylprednisolone or equivalent for treatment of nonresolving ARDS. The primary outcome was 90-day mortality. We assessed the impact of HDCT on 90-day mortality using univariable and multivariable Cox regression analysis. Further adjustment for confounding variables was performed using overlap weighting propensity score. The association between HDCT and the risk of ventilator-associated pneumonia was estimated using multivariable cause-specific Cox proportional hazard model adjusting for pre-specified confounders.

SETTING

We included consecutive patients admitted in 11 ICUs of Great Paris area from September 2020 to February 2021.

PATIENTS

Three hundred eighty-three patients were included (59 in the HDCT group, 324 in the no HDCT group).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

At day 90, 30 of 59 patients (51%) in the HDCT group and 116 of 324 patients (35.8%) in the no HDCT group had died. HDCT was significantly associated with 90-day mortality in unadjusted (hazard ratio [HR], 1.60; 95% CI, 1.04-2.47; p = 0.033) and adjusted analysis with overlap weighting (adjusted HR, 1.65; 95% CI, 1.03-2.63; p = 0.036). HDCT was not associated with an increased risk of ventilator-associated pneumonia (adjusted cause-specific HR, 0.42; 95% CI, 0.15-1.16; p = 0.09).

CONCLUSIONS

In critically ill COVID-19 patients with nonresolving ARDS, HDCT result in a higher 90-day mortality.

摘要

目的

确定在先前接受地塞米松标准治疗后仍未缓解的 COVID-19 伴有急性呼吸窘迫综合征（ARDS）的危重症患者中，大剂量皮质类固醇（HDCT）的影响。

设计

前瞻性观察队列研究。符合条件的患者表现为与严重急性呼吸综合征冠状病毒 2 感染相关的未缓解的 ARDS，并且已接受地塞米松初始治疗。我们比较了在 ICU 住院期间接受或未接受 HDCT 的患者，HDCT 治疗方案为大于或等于 1mg/kg 甲泼尼龙或等效药物治疗未缓解的 ARDS。主要结局为 90 天死亡率。我们使用单变量和多变量 Cox 回归分析评估 HDCT 对 90 天死亡率的影响。使用重叠加权倾向评分进一步调整混杂变量。使用多变量特定原因 Cox 比例风险模型调整预先指定的混杂因素来估计 HDCT 与呼吸机相关性肺炎风险之间的关联。

设置

我们纳入了 2020 年 9 月至 2021 年 2 月期间来自大巴黎地区 11 个 ICU 的连续患者。

患者

共纳入 383 名患者（HDCT 组 59 名，无 HDCT 组 324 名）。

干预措施

无。

测量和主要结果

第 90 天，HDCT 组 59 名患者中有 30 名（51%），无 HDCT 组 324 名患者中有 116 名（35.8%）死亡。HDCT 在未调整（风险比 [HR]，1.60；95%CI，1.04-2.47；p=0.033）和使用重叠加权调整分析（调整 HR，1.65；95%CI，1.03-2.63；p=0.036）中与 90 天死亡率显著相关。HDCT 与呼吸机相关性肺炎的风险增加无关（调整后的特定原因 HR，0.42；95%CI，0.15-1.16；p=0.09）。