Schultz C H, Rivers E P, Feldkamp C S, Goad E G, Smithline H A, Martin G B, Fath J J, Wortsman J, Nowak R M
Gerard B. Martin Resucitation Unit, Department of Emergency Medicine, Henry Ford Health Systems, Detroit, MI.
Crit Care Med. 1993 Sep;21(9):1339-47. doi: 10.1097/00003246-199309000-00018.
This study characterizes hypothalamic-pituitary-adrenal axis function during cardiopulmonary arrest and after return of spontaneous circulation.
Prospective case series.
A large urban emergency department and intensive care unit over an 8-month period.
Two hundred five adult patients presenting in cardiopulmonary arrest to an urban emergency department. Three patients known to be taking corticosteroids were excluded from the study.
Cortisol concentrations were measured before and after advanced cardiac life support and for five consecutive hours after return of spontaneous circulation. Adrenocorticotropic hormone (ACTH) concentrations were measured before advanced cardiac life support and when the cosyntropin stimulation tests were performed 6 and 24 hrs after the return of spontaneous circulation. The mean initial serum cortisol concentration was 32.0 +/- 33.1 micrograms/dL (882.9 +/- 913.2 nmol/L). Fifty-three percent of patients had cortisol concentrations of < 20 micrograms/dL (< 552 nmol/L) at the end of cardiac arrest. Among 44 patients who achieved return of spontaneous circulation, 98% had initial cortisol concentrations of > 10 micrograms/dL (> 276 nmol/L) and 73% of patients had initial cortisol concentrations of > 20 micrograms/dL (> 552 nmol/L). Mean serum cortisol concentrations increased significantly (p = .0001) from 1 to 6 hrs after return of spontaneous circulation and decreased significantly (p = .03) from 6 to 24 hrs. A serum cortisol concentration of < 30 micrograms/dL (< 828 nmol/L) was associated with a 96% and 100% mortality rate at 6 and 24 hrs, respectively. Mean ACTH concentrations were increased without a significant difference between the initial and 6-hr concentrations. Mean ACTH concentrations decreased between 6 and 24 hrs (p = .06). There were no significant responses to the cosyntropin stimulation at 6 and 24 hrs.
Cortisol concentrations after out-of-hospital cardiac arrest are lower than those concentrations reported in other stress states. There is an association between cortisol concentrations and short-term survival after cardiac arrest. Survivors have a significantly greater increase in serum cortisol concentrations than nonsurvivors during the first 24 hrs. Lower than expected cortisol concentrations for the extreme stress of cardiac arrest may have pathologic significance in the hemodynamic instability seen after return of spontaneous circulation. The etiology of the low cortisol concentrations may be primary adrenal dysfunction.
本研究旨在描述心肺骤停期间及自主循环恢复后下丘脑 - 垂体 - 肾上腺轴的功能。
前瞻性病例系列研究。
一家大型城市急诊科和重症监护病房，为期8个月。
205名成年患者在城市急诊科出现心肺骤停。已知正在服用皮质类固醇的3名患者被排除在研究之外。
在高级心脏生命支持前后以及自主循环恢复后连续5小时测量皮质醇浓度。在高级心脏生命支持前以及自主循环恢复后6小时和24小时进行促肾上腺皮质激素（ACTH）刺激试验时测量ACTH浓度。初始血清皮质醇平均浓度为32.0±33.1微克/分升（882.9±913.2纳摩尔/升）。53%的患者在心脏骤停结束时皮质醇浓度<20微克/分升（<552纳摩尔/升）。在44名实现自主循环恢复的患者中，98%的患者初始皮质醇浓度>10微克/分升（>276纳摩尔/升），73%的患者初始皮质醇浓度>20微克/分升（>552纳摩尔/升）。自主循环恢复后1至6小时血清皮质醇平均浓度显著升高（p = 0.0001），6至24小时显著降低（p = 0.03）。血清皮质醇浓度<30微克/分升（<828纳摩尔/升）分别与6小时和24小时的死亡率96%和100%相关。平均ACTH浓度升高，初始浓度与6小时浓度之间无显著差异。6至24小时之间平均ACTH浓度降低（p = 0.06）。在6小时和24小时对促肾上腺皮质激素刺激试验无显著反应。
院外心脏骤停后的皮质醇浓度低于其他应激状态下报告的浓度。心脏骤停后皮质醇浓度与短期生存之间存在关联。在最初24小时内，幸存者血清皮质醇浓度的升高明显大于非幸存者。对于心脏骤停这种极端应激而言，低于预期的皮质醇浓度可能对自主循环恢复后出现的血流动力学不稳定具有病理意义。皮质醇浓度低的病因可能是原发性肾上腺功能障碍。
