重症病人内分泌功能紊乱.pptVIP

非甲状腺疾病综合征 (NTIS) 也被称为甲状腺功能正常病态综合征(Euthyroid sick syndrome)或低T3综合征(Low-T3 syndrome) 甲状腺外因素导致的患者血浆T3或者T4水平下降以及rT3 水平升高 见于全身性感染、创伤、发热、饥饿、手术等患者 重症病人中NITS的发病率 急诊手术的老年病人中NTIS的发病率达51.5% Girvent M, et al. Surgery, 1998,123:560-7 心脏转流术后病人中NTIS的发病率可高达100% Cerillo AG, et al. Clin Chem Lab Med, 2005, 43:289-293 Plikat K, et al. Metabolism Clinical and Experimental, 2007, 56: 239– 244 44.1% NTIS的临床预后 ICU mortality :(light gray boxes) MV patients: (dark gray boxes)  Plikat K, et al. Metabolism Clinical and Experimental, 2007, 56: 239– 244 4 内分泌系统在重症疾病中的变化概况 1 2 3 5 HPA 轴在重症疾病中的变化 HPT轴在重症疾病中的变化 应激性高血糖与重症疾病 HG分泌在重症疾病中的变化 6 HPG轴在重症疾病中的变化 应激性高血糖 既往无已知的糖尿病的患者在重症疾病时出现暂时性的血糖升高 诊断标准：空腹血糖6.9mmol/L，或随机血糖11mmol/L 发生率随疾病和人群的不同有很大差异 全身感染早期高血糖发生接近50% 儿科急诊室的高血糖发生率3-5% 休克病人中高血糖发生率10-40% Nylen ES, Muller B. J ICM, 2004, 19:67-82 应激性高血糖的可能导致因素 潜在易感因素 胰岛素抵抗 胰腺炎 治疗因素 外源性GC 血管活性药物 输入葡萄糖 营养支持治疗 疾病本身 儿茶酚胺产生增多 HPA 轴活化 炎症因子 氧化应激 高血糖 Leonidia Leonidou, et al. J Infection, 2007,55: 340-346 Percentage (%) numbers of survivors and non-survivors in the three patients’ groups Cytokines in the three patients’ groups Alaedeen DI, et al. Journal of Pediatric Surgery (2006) 41, 239–244 P = .006 P = .03 P = .006 下丘脑：TRH（促甲状腺激素释放激素）；GnRH（促性腺激素释放激素）；GHIH * acute phase of illness (first hours to a few days after onset)：the secretory activity of the anterior pituitary is essentially maintained or amplified, anabolic target organ hormones are inactivated, Cortisol levels are elevated in concert with ACTH. chronic phase of protracted critical illness (intensive care dependent for weeks), the secretory activity of the anterior pituitary suppressed, stimulating target endocrine organs circulating levels of target organ hormones reduce. levels of cortisol remain elevated through a peripheral drive, The onset of recovery is characterized by restored sensitivity of the anterior pituitary to reduced feedback control. * Figure 1 . The receiver operating curves for outcome prediction of t