Annane D, Bellissant E, Sebille V, Lesieur O, Mathieu B, Raphael J C, Gajdos P
Service de Réanimation Médicale, Hôpital R. Poincaré, Garches, Université Paris V, France.
Br J Clin Pharmacol. 1998 Dec;46(6):589-97. doi: 10.1046/j.1365-2125.1998.00833.x.
To investigate the relationship between adrenal gland function and pressor response to noradrenaline in septic shock.
Basal cortisol level, noradrenaline--mean arterial pressure dose-response curve and cortisol response to intravenous corticotrophin bolus were obtained in nine patients fulfilling usual criteria for septic shock and in six normal volunteers. In patients with septic shock, dose-response curve to noradrenaline was determined a second time 60 min after a 50 mg intravenous hydrocortisone bolus.
As compared with controls, patients with septic shock had increased basal cortisol levels (mean+/-s.d.: 1564+/-818 vs 378+/-104 nmol l(-1) , P=0.002, 95% confidence interval for difference in means: [452, 1920]) and a blunted cortisol response to corticotrophin (403+/-461 vs 1132+/-195 nmol l(-1), P=0.008, [-1163, -2951). Five patients had impaired adrenal function reserve. As compared with controls, septic patients displayed a moderate and non significant decrease in pressor sensitivity to noradrenaline (P=0.112). As compared with patients with adequate adrenal response, patients with impaired adrenal function reserve showed a significant decrease in pressor sensitivity to noradrenaline (P=0.038). In septic patients, hydrocortisone improved pressor response to noradrenaline (P=0.032). This effect was more marked in patients with impaired adrenal function reserve so that, as compared with patients with adequate response, the difference was no longer significant (P=0.123).
In septic shock, impaired adrenal function reserve may partly be accounted for by the depressed pressor sensitivity to noradrenaline. The latter may be substantially improved by physiological doses of hydrocortisone.
研究脓毒性休克时肾上腺功能与去甲肾上腺素升压反应之间的关系。
对9例符合脓毒性休克常规标准的患者和6名正常志愿者测定基础皮质醇水平、去甲肾上腺素-平均动脉压剂量反应曲线以及静脉注射促肾上腺皮质激素后皮质醇的反应。对于脓毒性休克患者，在静脉注射50mg氢化可的松推注60分钟后，再次测定去甲肾上腺素的剂量反应曲线。
与对照组相比，脓毒性休克患者基础皮质醇水平升高（均值±标准差：1564±818 vs 378±104 nmol/L，P = 0.002，均值差异的95%置信区间：[452, 1920]），对促肾上腺皮质激素的皮质醇反应减弱（403±461 vs 1132±195 nmol/L，P = 0.008，[-1163, -2951]）。5例患者肾上腺功能储备受损。与对照组相比，脓毒症患者对去甲肾上腺素的升压敏感性有中度但不显著的降低（P = 0.112）。与肾上腺反应正常的患者相比，肾上腺功能储备受损的患者对去甲肾上腺素的升压敏感性显著降低（P = 0.038）。在脓毒症患者中，氢化可的松改善了对去甲肾上腺素的升压反应（P = 0.032）。这种效应在肾上腺功能储备受损的患者中更为明显，因此与反应正常的患者相比，差异不再显著（P = 0.123）。
在脓毒性休克中，肾上腺功能储备受损可能部分归因于对去甲肾上腺素的升压敏感性降低。生理剂量的氢化可的松可显著改善后者。
