Bouachour G, Tirot P, Gouello J P, Mathieu E, Vincent J F, Alquier P
Service de Réanimation Médicale, Centre Hospitalier Universitaire, Angers, France.
Intensive Care Med. 1995 Jan;21(1):57-62. doi: 10.1007/BF02425155.
To investigate, in patients with severe septic shock, the adrenocortical function assessed by daily plasma cortisol determinations during the first 72 h and by the short synthetic ACTH stimulation test performed within 24 h of the onset of shock.
Prospective clinical investigation.
Medical intensive care unit in a university teaching hospital.
40 consecutive patients with documented septic shock requiring at least hemodynamic resuscitation and respiratory support.
There were no interventions.
Basal cortisol concentrations were increased with a mean value of 36.8 micrograms/dl (range 7.9-113). Of the overall cortisol determinations 92% were above 15 micrograms/dl. No statistically significant differences in basal cortisol concentrations were found when survival, type of infection, and positive blood cultures were considered. Patients with hepatic disease had significantly higher cortisol (50.1 (+/- 6.2) micrograms/dl versus 35.9(+/- 3.3) micrograms/dl, p = 0.035) levels compared to other patients. No correlations were found between basal plasma cortisol concentrations and factors such as SAPS, OSF, hemodynamic measurements, duration of shock, and amount of vasopressor and/or inotropic agents. Cortisol concentrations had significant but weak correlation with ACTH levels in survivors (r = 0.4; p = 0.03; n = 28) but not in non-survivors (r = 0.03; p = 0.85; n = 52). Cortisol levels in non-survivors increased significantly from enrollment time to the 72nd hour of the survey (day 1: 38.9(+/- 3.8) micrograms/dl versus day 3: 66.7(+/- 17.1) micrograms/dl; p = 0.046) and were significantly higher than those recorded in survivors. Responses to the short ACTH stimulation test were not significantly different between survivors and non-survivors. According to the different criteria used to interpret the response to the ACTH stimulation test, incidence of adrenocortical insufficiency was highly variable ranging from 6.25-75% in patients with septic shock. Only one patient had absolute adrenocortical insufficiency (basal cortisol level below 10 micrograms/dl; response to the ACTH stimulation test below 18 micrograms/dl).
Our data suggest that in a selected population of patients with severe septic shock single plasma cortisol determination has no predictive value. The short ACTH stimulation test performed within the first 24 h of onset shock can neither predict outcome nor estimate impairment in adrenocortical function in patients with high basal cortisol level. Adrenal insufficiency is rare in septic shock and should be suspected when cortisol level is below 15 micrograms/dl and then confirmed by a peak cortisol level lower than 18 micrograms/dl during the short ACTH stimulation test.
在严重脓毒性休克患者中，通过在最初72小时内每日测定血浆皮质醇以及在休克发作后24小时内进行短程合成促肾上腺皮质激素（ACTH）刺激试验来评估肾上腺皮质功能。
前瞻性临床研究。
一所大学教学医院的医学重症监护病房。
40例连续的有记录的脓毒性休克患者，至少需要血流动力学复苏和呼吸支持。
无干预措施。
基础皮质醇浓度升高，平均值为36.8微克/分升（范围7.9 - 113）。在所有皮质醇测定中，92%高于15微克/分升。在考虑生存情况、感染类型和血培养阳性时，基础皮质醇浓度未发现统计学显著差异。与其他患者相比，肝病患者的皮质醇水平显著更高（50.1（±6.2）微克/分升对35.9（±3.3）微克/分升，p = 0.035）。基础血浆皮质醇浓度与急性生理与慢性健康状况评分系统（SAPS）、器官功能衰竭评分（OSF）、血流动力学测量、休克持续时间以及血管升压药和/或正性肌力药物用量等因素之间未发现相关性。在幸存者中，皮质醇浓度与促肾上腺皮质激素水平有显著但较弱的相关性（r = 0.4；p = 0.03；n = 28），而在非幸存者中无相关性（r = 0.03；p = 0.85；n = 52）。非幸存者的皮质醇水平从入组时到调查的第72小时显著升高（第1天：38.9（±3.8）微克/分升对第3天：66.7（±17.1）微克/分升；p = 0.046），且显著高于幸存者记录的水平。幸存者和非幸存者对短程ACTH刺激试验的反应无显著差异。根据用于解释ACTH刺激试验反应的不同标准，脓毒性休克患者肾上腺皮质功能不全的发生率差异很大，范围为6.25% - 75%。只有1例患者存在绝对肾上腺皮质功能不全（基础皮质醇水平低于10微克/分升；对ACTH刺激试验的反应低于18微克/分升）。
我们的数据表明，在选定的严重脓毒性休克患者群体中，单次血浆皮质醇测定无预测价值。在休克发作后的最初24小时内进行的短程ACTH刺激试验既不能预测结局，也不能评估基础皮质醇水平高的患者的肾上腺皮质功能损害。肾上腺功能不全在脓毒性休克中罕见，当皮质醇水平低于15微克/分升时应怀疑，并通过短程ACTH刺激试验期间皮质醇峰值低于18微克/分升来确诊。
