糖皮質激素在膿毒癥中的應用課件

1、糖皮質激素在膿毒癥中的應用浙江省中醫(yī)院ICU 雷澍體內(nèi)的作用對應激誘發(fā)的反應的反饋系統(tǒng)的活化，保證人體在防御機制方面不反應過度 應用的現(xiàn)狀 2003年6月，SSC制定了新的膿毒癥治療指南： 推薦對膿毒性休克靜脈使用小劑量氫化可的松 50mg，q6h，連續(xù)7天(C級)；可以同時每日給 予氟氫可的松 50ug ，鼻飼(E級)；避免氫化可 的松300mg/d(A級).相對腎上腺皮質功能不全周圍抵抗膿毒癥GC相對不足炎癥反應過度循環(huán)衰竭病情加重外源性GC 相對腎上腺皮質功能不全的發(fā)生機制-及促皮質素抑素抑制腎上腺功能并降低皮質醇水平機體水平偏低活化的淋巴細胞產(chǎn)生片段干擾經(jīng)典的功能 腎上腺皮質血液灌注不

2、足 周圍抵抗的發(fā)生機制皮質醇向炎癥部位轉運障礙糖皮質激素受體 ()數(shù)目減少和親和力下降炎癥部位皮質醇濃度調節(jié)異常 如何確定存在相對腎上腺功能不全以興奮試驗后皮質醇的升幅被削峰為特征臨床癥狀和體征是決定診斷的關鍵因素快速刺激實驗時，皮質醇增加幅度9/若任意時間血皮質醇水平低于 552nmol/L（19.3ug/dl)相對腎上腺功能不全試驗后血皮質醇低于 690nmol/L （24.2ug/dl) 相對腎上腺功能不全和周圍抵抗的發(fā)生率相對腎上腺功能不全:基于的不同定義 ,膿毒癥及感染性休克時 ,其發(fā)生率為 6.25% 75%周圍抵抗: ? 相對腎上腺功能不全一項 由Annane 等完成的189例膿

3、毒性休克患者的隊列研究證實,相對腎上腺皮質功能不全的最佳定義為 :快速刺激實驗時 ,皮質醇增加幅度 9/。應用此概念 ,嚴重膿毒癥時相對腎上腺皮質功能不全發(fā)生率約 50% ,28的死亡率約75% 。 區(qū)分相對腎上腺功能不全和腎上腺功能不全ACTH testpost-corticotropin plasma cortisol levels 18 g/dL2.an increase in plasma cortisol level 18 g/dL (excluding adrenal insufficiency) hydrocortisone (100 mg i.v. three times da

4、ily for 5 days) , a significant improvement in hemodynamics and a beneficial effect on survival. These beneficial effects do not appear related to adrenocortical insufficiency Crit Care Med. 1999, Briegel J, Prospective, randomized, double-blind, single-center study, Forty patients with septic shock

5、, Hydrocortisone was started with a loading dose of 100 mg given within 30 mins and followed by a continuous infusion of 0.18 mg/ kg/hr. When septic shock had been reversed, the dose of hydrocortisone was reduced to 0.08 mg/kg/hr. This dose was kept constant for 6 days, reduced the time to cessation

6、 of vasopressor therapy in human septic shock. This was associated with a trend to earlier resolution of sepsis-induced organ dysfunctions. Overall shock reversal and mortality were not significantly different between the groupsJAMA.2002, Djillali Annane, Placebo-controlled, randomized, double-blind

7、, parallel-group trial performed in 19 intensive care units in France. Three hundred adult patients with septic shock, (50-mg intravenous bolus every 6 hours) and fludrocortisone (50-g tablet once daily) for 7 days, significantly reduced the risk of death in patients with septic shock and relative adrenal insufficiency, There was no significant difference between groups in responders 所有的膿毒性休克患者需要激素嗎patients who responded normally t