Association of Corticosteroid Treatment With Outcomes in Adult Patients With Sepsis A Systematic Review and Meta-analysis
Association of Corticosteroid Treatment With Outcomes in Adult Patients With Sepsis A Systematic Review and Meta-analysis
复制标题
皮质类固醇治疗与成人脓毒症患者预后的关系系统评价和荟萃分析
DOI：
10.1001/jamainternmed.2018.5849
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发表时间：
2019-02-01
影响因子：
39
通讯作者：
You, Chao
中科院分区：
文献类型：
--
作者：
Fang, Fang;Zhang, Yu;You, Chao
重要性虽然糖皮质激素被广泛用于成人脓毒症患者，但其总体获益和潜在风险仍不清楚。目的对糖皮质激素在脓毒症患者中的疗效和安全性进行系统评价和荟萃分析。数据来源和研究选择MEDLINE、Embase和科克伦对照试验中心注册中心从开始到2018年3月20日进行检索，并于2018年8月10日更新。单独或组合检索了术语皮质类固醇、脓毒症、脓毒性休克、氢化可的松、对照试验和随机对照试验。随机临床试验（RCTs）被纳入，比较管理的皮质类固醇与安慰剂或标准的支持性治疗在成人sepsis.DATA提取和合成Meta分析进行使用随机效应模型计算风险比（RR）和平均差异（MD）与相应的95%CI。两名独立的评审员完成了引文筛选、数据提取和风险评估。主要结果和指标28天死亡率。结果这项荟萃分析包括37项随机对照试验（N = 9564例患者）。11项试验被评定为低偏倚风险。皮质类固醇的使用与28天死亡率降低相关（RR，0.90; 95% CI，0.82-0.98; I-2 = 27%）和重症监护室（ICU）死亡率（RR，0.85; 95% CI，0.77-0.94; I-2 = 0%）和住院死亡率（RR，0.88; 95% CI，0.79-0.99; I-2 = 38%）。皮质类固醇与第7天增加的休克逆转显著相关（MD，1.95; 95% CI，0.80-3.11）和无血管加压药天数（MD，1.95; 95% CI，0.80-3.11）和ICU住院时间（MD，-1.16; 95% CI，-2.12至-0.20），第7天的序贯器官衰竭评估评分（MD，-1.38; 95% CI，-1.87至-0.89）和至休克消退的时间（MD，-1.35; 95% CI，-1.78至-0.91）。然而，皮质类固醇的使用与高血糖（RR，1.19; 95%CI，1.08-1.30）和高钠血症（RR，1.57; 95%CI，1.24-1.99）的风险增加有关。结论和相关性研究结果表明，与安慰剂或标准支持治疗相比，皮质类固醇的使用与28天死亡率降低有关。需要更多的研究将个性化药物与皮质类固醇治疗联系起来，以选择更有可能显示获益的合适患者。
IMPORTANCE Although corticosteroids are widely used for adults with sepsis, both the overall benefit and potential risks remain unclear.OBJECTIVE To conduct a systematic review and meta-analysis of the efficacy and safety of corticosteroids in patients with sepsis.DATA SOURCES AND STUDY SELECTION MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched from inception until March 20, 2018, and updated on August 10, 2018. The terms corticosteroids, sepsis, septic shock, hydrocortisone, controlled trials, and randomized controlled trial were searched alone or in combination. Randomized clinical trials (RCTs) were included that compared administration of corticosteroids with placebo or standard supportive care in adults with sepsis.DATA EXTRACTION AND SYNTHESIS Meta-analyses were conducted using a random-effects model to calculate risk ratios (RRs) and mean differences (MDs) with corresponding 95% CIs. Two independent reviewers completed citation screening, data abstraction, and risk assessment.MAIN OUTCOMES AND MEASURES Twenty-eight-day mortality.RESULTS This meta-analysis included 37 RCTs (N = 9564 patients). Eleven trials were rated as low risk of bias. Corticosteroid use was associated with reduced 28-day mortality (RR, 0.90; 95% CI, 0.82-0.98; I-2 = 27%) and intensive care unit (ICU) mortality (RR, 0.85; 95% CI, 0.77-0.94; I-2 = 0%) and in-hospital mortality (RR, 0.88; 95% CI, 0.79-0.99; I-2 = 38%). Corticosteroids were significantly associated with increased shock reversal at day 7 (MD, 1.95; 95% CI, 0.80-3.11) and vasopressor-free days (MD, 1.95; 95% CI, 0.80-3.11) and with ICU length of stay (MD, -1.16; 95% CI, -2.12 to -0.20), the sequential organ failure assessment score at day 7 (MD, -1.38; 95% CI, -1.87 to -0.89), and time to resolution of shock (MD, -1.35; 95% CI, -1.78 to -0.91). However, corticosteroid use was associated with increased risk of hyperglycemia (RR, 1.19; 95% CI, 1.08-1.30) and hypernatremia (RR, 1.57; 95% CI, 1.24-1.99).CONCLUSIONS AND RELEVANCE The findings suggest that administration of corticosteroids is associated with reduced 28-day mortality compared with placebo use or standard supportive care. More research is needed to associate personalized medicine with the corticosteroid treatment to select suitable patients who are more likely to show a benefit.