危重病人肾上腺皮质功能不全PPT.ppt

260 pats in ICU Mean serum cortisol level Survivors: 27ug/dl Nonsurvivors: 47ug/dl Cortisol 25ug/dl: 对应激缺乏反应 基础皮质醇 25ug/dl预后凶险的独立危险因素 Rothwell PM, et al. Crit Care Med, 1995, 23: 78-83 危重病人 Stress level of cortisol 25ug/ml AI in high-risk surgical ICU pats River EP,et al. Chest, 2001,119: 889-896. 基础皮质醇25ug/dl作为AI诊断标准 River EP,et al. Chest, 2001,119: 889-896. Cortisol 浓度25ug/dl是类固醇治疗有效性休克 基础cortisol浓度对感染性休克患者预后的判断 Threshold values (%) Plasma level(ug/ml) Survivors (n=77) Nonsurvivir (n=112) x2 P 25 17 53(69) 88(79) 2.3 .13 50 26 32(42) 62(55) 3.5 .06 Mean 34 16(21) 47(42) 9.2 .002 75 45 12(16) 36(36) 6.6 .01 Annane D. JAMA, 2000,283: 1038-1045. T0皮质醇水平越高---预后越差 T0皮质醇(ug/dl) Total Survivors (Annane,n=77) (中大医院，n=28) Nonsurvivors (Annane,n=112) (中大医院，n=24) p Annane 34?28 28?18 39?33 0.002 中大医院 27.9?12.8 21.4 ?10.1 35.5 ?11.5 0.000 Annane D. JAMA, 2000,283: 1038-1045. 基础皮质醇危重病人平均水平 作为AI诊断标准 二、ACTH应激试验 ACTH应激试验 ＝ 肾上腺皮质的储备功能 如何用ACTH试验来判断肾上腺皮质功能低下？？ River EP,et al. Chest, 2001,119: 889-896. AI患者：GS逆转休克/降低病死率更为突出 AI：ACTH test ---?cortisol 9ug/dl ACTH test--?Max对感染性休克患者预后的判断 Threshold values (%) Plasma level(ug/ml) Survivors(n=77) Nonsurvivir (n=112) x2 P 25 2 65(84) 75(67) 7.2 .007 50 8 51(66) 43(38) 14.1 .001 Ref value 9 50(65) 36(32) 19.8 .001 Mean 11 42(55) 36(32) 9.4 .002 75 16 31(40) 16(14) 16.5 .001 Annane D. JAMA, 2000,283: 1038-1045. AI：ACTH后?cortisol 9ug/dl Objective: evaluated low dose GS to survival in septic shock patients and AI Design: placebo-controlled, randomized,double-blind, parallel-group trial Setting: 19 ICU in France(95.10~99.2) Two groups Hydrocortisone(n=151)(50mg,iv,bolus every 6h and fludrocortisone 50ug tablet once daily for 7days) Placebo(n=149) Annane D,et al. JAMA, 2002,288: 862-871 AI: ACTH test－?cortisol 9ug/dl的治疗反应 Nonresponders Placebo N=115 Steroids N=114 P 28d mortality 63%(73) 53%(60) 0.04 ICU mortality 70%(81) 58%(66) 0.02 Hosp mortality 72%(83) 61%(70) 0.04 1Y mortality 77%(88) 68%(77) 0.07 Responders Plac