Diagnosis of adrenal insufficiency in severe sepsis and septic shock
Diagnosis of adrenal insufficiency in severe sepsis and septic shock
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DOI：
10.1164/rccm.200509-1369oc
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发表时间：
2006-12-15
影响因子：
24.7
通讯作者：
Boudou, Philippe
中科院分区：
文献类型：
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作者：
Annane, Djillali;Maxime, Virginie;Boudou, Philippe
基本原理：危重患者肾上腺皮质功能不全的诊断依赖于随机或促肾上腺皮质激素刺激的皮质醇水平，并且还没有得到更准确的诊断标准的证实。目的：我们使用过夜甲吡酮刺激试验来研究标准促肾上腺皮质激素刺激试验的诊断价值，以及脓毒症相关肾上腺皮质功能不全的患病率。方法：这是一项初始队列研究。测量和结果：在两个连续的脓毒症队列（n = 61和n = 40）中，在44名无脓毒症患者和32名健康志愿者中，我们测量了（1）促肾上腺皮质激素刺激前后的血清皮质醇、白蛋白和皮质类固醇结合球蛋白水平，以及（2）隔夜甲吡酮刺激前后的血清促肾上腺皮质激素、皮质醇和11 β-脱氧皮质醇水平。肾上腺功能不全定义为甲吡酮给药后血清11 β-脱氧皮质醇水平低于7 μ g/dl。脓毒症患者（31/61 [脓毒症原始队列的59%]和24/40 [脓毒症验证队列的60%]）比无脓毒症患者（3/44; 7%）更多符合肾上腺功能不全标准（两项比较p < 0.001）。基线皮质醇（< 10 μ g/dl）、δ皮质醇（< 9 μ g/dl）和游离皮质醇（< 2 μ g/dl）的阳性似然比分别等于无穷大，8.46（95%置信区间，1.19-60.25）和9.50（95%置信区间，1.05-9.54）。肾上腺功能不全的最佳预测因子（由甲吡酮试验定义）是基线皮质醇10 μ g/dl或更低或δ皮质醇小于9 μ g/dl。正常肾上腺反应的最佳预测因子是促肾上腺皮质激素刺激的皮质醇为44 μ g/dl或更高，δ皮质醇为16.8 μ g/dl或更高。在脓毒症中，当基线皮质醇水平低于10 μ g/dl或δ皮质醇低于9 μ g/dl时，可能出现肾上腺功能不全，当促肾上腺皮质激素刺激的皮质醇水平为44 μ g/dl或更高或δ皮质醇为16.8 μ g/dl或更高时，则不太可能。
Rationale: Diagnosis of adrenal insufficiency in critically ill patients has relied on random or cosyntropin-stimulated cortisol levels, and has not been corroborated by a more accurate diagnostic standard.Objective: We used the overnight metyrapone stimulation test to investigate the diagnostic value of the standard cosyntropin stimulation test, and the prevalence of sepsis-associated adrenal insufficiency.Methods: This was an inception cohort study.Measurements and Results: In two consecutive septic cohorts (n = 61 and n = 40), in 44 patients without sepsis and in 32 healthy volunteers, we measured (1) serum cortisol before and after cosyntropin stimulation, albumin, and corticosteroid-binding globulin levels, and (2) serum corticotropin, cortisol, and 11 beta-deoxycortisol levels before and after an overnight metyrapone stimulation. Adrenal insufficiency was defined by postmetyrapone serum 11 beta-deoxycortisol levels below 7 mu g/dl. More patients with sepsis (31/61 [59% of original cohort with sepsis] and 24/40 [60% of validation cohort with sepsis]) met criteria for adrenal insufficiency than patients without sepsis (3/44; 7%) (p < 0.001 for both comparisons). Baseline cortisol (< 10 mu g/dl), Delta cortisol (< 9 mu g/dl), and free cortisol (< 2 mu g/dl) had a positive likelihood ratio equal to infinity, 8.46 (95% confidence interval, 1.19-60.25), and 9.50 (95% confidence interval, 1.05-9.54), respectively. The best predictor of adrenal insufficiency (as defined by metyrapone testing) was baseline cortisol of 10 mu g/dl or less or Delta cortisol of less than 9 mu g/dl. The best predictors of normal adrenal response were cosyntropin-stimulated cortisol of 44 mu g/dl or greater and Delta cortisol of 16.8 mu g/dl or greater.Conclusions: In sepsis, adrenal insufficiency is likely when baseline cortisol levels are less than 10 mu g/dl or delta cortisol is less than 9 mu g/dl, and unlikely when cosyntropin-stimulated cortisol level is 44 mu g/dl or greater or Delta cortisol is 16.8 mu g/dl or greater.