Della Corte F, Mancini A, Valle D, Gallizzi F, Carducci P, Mignani V, De Marinis L
Institute of Anesthesiology and Intensive Care, Catholic University of the Sacred Heart, Policlinico A. Gemelli, Rome, Italy.
Crit Care Med. 1998 Aug;26(8):1419-26. doi: 10.1097/00003246-199808000-00030.
To evaluate the effect of severe head injury on both the secretion of basal pituitary hormones and the response to exogenous synthetic hypothalamic releasing factors administration.
Prospective, clinical study.
General intensive care unit in a university teaching hospital, Italy.
Comatose, head-injured patients (n = 22), all intubated and mechanically ventilated, invasively monitored without previous endocrinologic problems and substitutive therapies.
Routine neuroemergency procedures; administration of exogenous, synthetic hypothalamic releasing hormones.
Determinations of basal concentrations of growth hormone (GH), prolactin (PRL), thyroid-stimulating hormone (TSH), triiodothyronine, and thyroxine were performed daily in the first week and on days 15 and 16 after the trauma. Plasma insulin-like growth factor-I and cortisol were also determined on days 2, 7, and 15. We carried out a thyrotropin-releasing hormone (TRH) test for the evaluation of the PRL, TSH, and GH responses on days 1 and 16 after the trauma and a growth hormone-releasing hormone (GHRH) test for the evaluation of GH and PRL responses on days 2, 7, and 15 after the trauma. Outcome was evaluated at 6 mos with the GOS. Triiodothyronine showed low values, even if in the normal range; thyroxine remained in the normal range. Significant increases in insulin-like growth factor-I concentrations were observed on both days 7 and 15 compared with day 2 (p = .024 and p = .034, respectively). The GH response to GHRH was significantly greater on days 7 and 15 than in the very acute phase (p< .01 comparing days 7 and 15 vs. day 2). We found a higher GH response to GHRH on day 7 in group 1 vs. group 2 (as both peak and area under the curve, p = .018 and p = .015, respectively). No difference in GH response was detected on days 2 and 15. A "paradoxical" response of GH to TRH was observed on the day after the head trauma (basal vs. peak, p = .002) but not on day 16. The GH peak response to TRH was greater on day 1 in those patients with an unfavorable course (group 1 vs. group 2, p < .05). The TSH response to TRH was not significantly correlated to the severity of trauma, but it was significantly (p < .04) higher in group 1 than in group 2. Finally, a "paradoxical" PRL response to GHRH administration was present on day 2 (basal vs. peak, p=.0003), day 7 (basal vs. peak, p = .01), and on day 15 after the trauma (basal vs. peak, p = .04).
Some of the responses to provocative tests have been identified as "paradoxical" and seem to have a great importance in the definition of prognosis in severe head-injured patients, specifically the GH response to TRH and the PRL response to GHRH that are significantly correlated with outcome.
评估重型颅脑损伤对垂体基础激素分泌以及对外源性合成下丘脑释放因子给药反应的影响。
前瞻性临床研究。
意大利一家大学教学医院的综合重症监护病房。
昏迷的颅脑损伤患者（n = 22），均已插管并进行机械通气，在无既往内分泌问题和替代治疗的情况下进行有创监测。
常规神经急救程序；给予外源性合成下丘脑释放激素。
在创伤后的第一周以及第15天和第16天每天测定生长激素（GH）、催乳素（PRL）、促甲状腺激素（TSH）、三碘甲状腺原氨酸和甲状腺素的基础浓度。在第2天、第7天和第15天还测定了血浆胰岛素样生长因子-I和皮质醇。我们在创伤后第1天和第16天进行促甲状腺激素释放激素（TRH）试验以评估PRL、TSH和GH反应，在创伤后第2天、第7天和第15天进行生长激素释放激素（GHRH）试验以评估GH和PRL反应。在6个月时用格拉斯哥预后评分（GOS）评估结果。三碘甲状腺原氨酸值较低，即使在正常范围内；甲状腺素仍在正常范围内。与第2天相比，在第7天和第15天观察到胰岛素样生长因子-I浓度显著升高（分别为p = 0.024和p = 0.034）。在第7天和第15天，GH对GHRH的反应显著大于极急性期（比较第7天和第15天与第2天，p < 0.01）。我们发现第1组在第7天对GHRH的GH反应高于第2组（无论是峰值还是曲线下面积，分别为p = 0.018和p = 0.015）。在第2天和第15天未检测到GH反应的差异。在颅脑创伤后第1天观察到GH对TRH的“反常”反应（基础值与峰值，p = 0.002），但在第16天未观察到。在病程不佳的患者中，第1天GH对TRH的峰值反应更大（第1组与第2组，p < 0.05）。TSH对TRH的反应与创伤严重程度无显著相关性，但第1组显著高于第2组（p < 0.04）。最后，在创伤后第2天（基础值与峰值，p = 0.0003）、第7天（基础值与峰值，p = 0.01）和第15天存在PRL对GHRH给药的“反常”反应（基础值与峰值，p = 0.04）。
已确定一些激发试验的反应为“反常”反应，并且似乎在重型颅脑损伤患者预后的定义中具有重要意义，特别是GH对TRH的反应以及PRL对GHRH的反应与预后显著相关。
