(1)sepsis-研究生课-(精选·公开·课件).ppt

* The utilization of stress dose (“low-dose”) steroids is recommended for the treatment of patients with severe sepsis who continue to require significant amounts of vasopressors despite adequate fluid replacement. It should be noted that this recommendation includes a range of daily steroid dosing as well as alternative dosing methods to include intermittent dosing or continuous infusion. The rationale behind the construction of this recommendation is that it is a hybrid of regimens from the Ananne study, the Bollard study and the Briegel study. * 7 In a study by Witek-Janusek and colleagues, utilizing a rodent preparation of septic shock, a comparison was made among effect of intact adrenal gland, ablation of adrenal cortex function (ADRNX) and ablation of adrenal medullary function (MEDX) on survival. The ablation of the glucocorticoid producing cortex produced a significant increase in mortality, whereas ablation of the medulla (mineralocorticoids production) had no significant effect on survival, and was similar to the intact adrenal (see above). This type of animal evidence supports the importance of glucocorticoids and not mineralocorticoids in ameliorating sequelae of septic shock. * The apriori analysis group in the 2002 Annane study were patients who were non-responders to ACTH stimulation, i.e., relative adrenal insufficiency (see previous slide). This patient population was defined based on a previous Annane study showing that septic shock patients who were unable to raise their cortisol by 10 or more at either 30 or 60 minutes following 250 ?g ACTH stimulation, were at high risk for death. There was no evidence of benefit in non-responders (as shown above). * If the ACTH stimulation test is to be performed dexamethasone can be initiated pending performance of the ACTH stim test, as unlike hydrocortisone or methylprednisolone, it does not have cortisol-like metabolites, which interfere with the cortisol assay. * Another option during steroid t