Corticosteroid Treatment and Intensive Insulin Therapy for Septic Shock in Adults A Randomized Controlled Trial
Corticosteroid Treatment and Intensive Insulin Therapy for Septic Shock in Adults A Randomized Controlled Trial
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DOI：
10.1001/jama.2010.2
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发表时间：
2010-01-27
影响因子：
120.7
通讯作者：
Chevret, Sylvie
中科院分区：
文献类型：
--
作者：
Annane, Djillali;Cariou, Alain;Chevret, Sylvie
背景：皮质类固醇治疗可诱导感染性休克患者出现潜在的有害高血糖。此外，在这种情况下添加氟化可的松的益处尚不清楚。目的评价氢化可的松治疗脓毒性休克患者强化胰岛素治疗的疗效，并评价氟化可的松的疗效。设计、环境和患者：2006年1月至2009年1月，在法国的11个重症监护室进行了一项多中心、2 × 2因子的随机试验，纳入509名出现多器官功能障碍的脓毒性休克成人患者，这些患者的顺序器官衰竭评估评分为8分或以上，并接受了氢化可的松治疗。患者被随机分为4组：连续静脉注射胰岛素单用氢化可的松组、连续静脉注射胰岛素单用氢化可的松组、常规胰岛素单用氢化可的松组、常规胰岛素单用氢化可的松组、常规胰岛素单用氢化可的松组和常规胰岛素单用氢化可的松组。氢化可的松每6小时给药50 mg，氟化可的松50 μ g片口服，每天1次，连用7天。主要结局指标：住院死亡率。结果255例强化胰岛素治疗患者中有117例（45.9%）死亡，254例常规胰岛素治疗患者中有109例（42.9%）死亡（相对危险度[RR]为1.07；95%可信区间[CI]为0.88-1.30;P = 0.50）。强化胰岛素治疗的患者发生严重低血糖的次数明显增加(
Context Corticosteroid therapy induces potentially detrimental hyperglycemia in septic shock. In addition, the benefit of adding fludrocortisone in this setting is unclear.Objectives To test the efficacy of intensive insulin therapy in patients whose septic shock was treated with hydrocortisone and to assess, as a secondary objective, the benefit of fludrocortisone.Design, Setting, and Patients A multicenter, 2 x 2 factorial, randomized trial, involving 509 adults with septic shock who presented with multiple organ dysfunction, as defined by a Sequential Organ Failure Assessment score of 8 or more, and who had received hydrocortisone treatment was conducted from January 2006 to January 2009 in 11 intensive care units in France.Interventions Patients were randomly assigned to 1 of 4 groups: continuous intravenous insulin infusion with hydrocortisone alone, continuous intravenous insulin infusion with hydrocortisone plus fludrocortisone, conventional insulin therapy with hydrocortisone alone, or conventional insulin therapy with intravenous hydrocortisone plus fludrocortisone. Hydrocortisone was administered in a 50-mg bolus every 6 hours, and fludrocortisone was administered orally in 50-mu g tablets once a day, each for 7 days.Main Outcome Measure In-hospital mortality.Results Of the 255 patients treated with intensive insulin, 117 (45.9%), and 109 of 254 (42.9%) treated with conventional insulin therapy died (relative risk [RR], 1.07; 95% confidence interval [CI], 0.88-1.30; P = .50). Patients treated with intensive insulin experienced significantly more episodes of severe hypoglycemia (