A 3-level prognostic classification in septic shock based on cortisol levels and cortisol response to corticotropin
A 3-level prognostic classification in septic shock based on cortisol levels and cortisol response to corticotropin
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DOI：
10.1001/jama.283.8.1038
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发表时间：
2000-02-23
影响因子：
120.7
通讯作者：
Bellissant, E
中科院分区：
文献类型：
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作者：
Annane, D;Sébille, V;Bellissant, E
背景下丘脑-垂体-肾上腺轴是宿主对应激反应的主要决定因素。目的评估感染性休克患者皮质醇水平和短促肾上腺皮质激素刺激试验的预后价值。设计和设置1991年10月至1995年9月在法国2所教学医院成人重症监护病房进行的前瞻性队列研究。干预：对所有患者进行短期促肾上腺皮质激素刺激试验，静脉注射四环素0.25 mg；分别在试验前(T0)、试验后30分钟(T30)和60分钟(T60)采集血样。主要结果：28天的死亡率与感染性休克时收集的变量有关，包括试验前的皮质醇水平和皮质醇对促肾上腺皮质激素的反应(Delta max，定义为T0与T30和T60之间的最高值的差值)。结果28天的死亡率为58%(95%可信区间，51%-65%)，中位死亡时间为17天(95%可信区间，14-27天)。在多因素分析中，死亡的独立预测因素(P均小于或等于.001)为McCabe评分>0，脏器功能衰竭评分>2，动脉血乳酸水平>2.8 mmol/L，PaO2与吸入氧分压之比不超过160 mm Hg，T0时皮质醇水平>34µg/dL，Delta max不超过9µg/dL。确定了三组患者的预后：良好(T0皮质醇水平小于或等于34mug/dL和Delta max>；28天死亡率，26%)；中等(皮质醇水平T034mgg/dL和Delta max小于或等于9mug/dL；T0和gt；34mug/dL和Delta max>；9 Delta g/dL；28天死亡率，67%)和差(T0和GT皮质醇水平；34mug/dL和Delta max>；28天死亡率，67%)；34µg/dL和Delta max小于或等于9µg/dL；28天病死率82%)。结论短促肾上腺皮质激素试验具有良好的预后价值，有助于确定感染性休克患者死亡的高危因素。
Context The hypothalamic-pituitary-adrenal axis is a major determinant of the host response to stress. The relationship between its activation and patient outcome is not known.Objective To evaluate the prognostic Value of cortisol levels and a short corticotropin stimulation test in patients with septic shock.Design and Setting Prospective inception cohort study conducted between October 1991 and September 1995 in 2 teaching hospital adult intensive care units in France.Participants A total of 189 consecutive patients who met clinical criteria for septic shock. Intervention A short corticotropin stimulation test was performed in all patients by intravenously injecting 0.25 mg of tetracosactrin; blood samples were taken immediately before the test (T0) and 30 (T30) and 60 (T60) minutes afterward,Main Outcome Measures Twenty-eight-day mortality as a function of variables collected at the onset of septic shock, including cortisol levels before the corticotropin test and the cortisol response to corticotropin (Delta max, defined as the difference between T0 and the highest value between T30 and T60).Results The 28-day mortality was 58% (95% confidence interval [CI], 51%-65%)and median time to death was 17 days (95% CI, 14-27 days). In multivariate analysis, independent predictors of death (P less than or equal to.001 for all) were McCabe score greater than 0, organ system failure score greater than 2, arterial lactate level greater than 2.8 mmol/L, ratio of PaO2 to fraction of inspired oxygen no more than 160 mm Hg, cortisol level at T0 greater than 34 mu g/dL and Delta max no more than 9 mu g/dL. Three groups of patient prognoses were identified: good (cortisol level at T0 less than or equal to 34 mu g/dL and Delta max >9 mu g/dL; 28-day mortality rate, 26%), intermediate (cortisol level at T0 34 mu g/dL and Delta max less than or equal to 9 mu g/dL or cortisol level at T0 >34 mu g/dL and Delta max >9 Delta g/dL; 28-day mortality rate, 67%), and poor (cortisol level at T0 >34 mu g/dL and Delta max less than or equal to 9 mu g/dL; 28-day mortality rate, 82%).Conclusion Our data suggest that a short corticotropin test has a good prognostic value and could be helpful in identifying patients with septic shock at high risk for death.