糖皮質(zhì)激素在膿毒癥中的應(yīng)用課件

1、糖皮質(zhì)激素在膿毒癥中的應(yīng)用浙江省中醫(yī)院ICU 雷澍體內(nèi)的作用對(duì)應(yīng)激誘發(fā)的反應(yīng)的反饋系統(tǒng)的活化，保證人體在防御機(jī)制方面不反應(yīng)過(guò)度 應(yīng)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(duì)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(jí))；可以同時(shí)每日給 予氟氫可的松 50ug ，鼻飼(E級(jí))；避免氫化可 的松300mg/d(A級(jí)).相對(duì)腎上腺皮質(zhì)功能不全周圍抵抗膿毒癥GC相對(duì)不足炎癥反應(yīng)過(guò)度循環(huán)衰竭病情加重外源性GC 相對(duì)腎上腺皮質(zhì)功能不全的發(fā)生機(jī)制-及促皮質(zhì)素抑素抑制腎上腺功能并降低皮質(zhì)醇水平機(jī)體水平偏低活化的淋巴細(xì)胞產(chǎn)生片段干擾經(jīng)典的功能 腎上腺皮質(zhì)血液灌注不

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

3、毒性休克患者的隊(duì)列研究證實(shí),相對(duì)腎上腺皮質(zhì)功能不全的最佳定義為 :快速刺激實(shí)驗(yàn)時(shí) ,皮質(zhì)醇增加幅度 9/。應(yīng)用此概念 ,嚴(yán)重膿毒癥時(shí)相對(duì)腎上腺皮質(zhì)功能不全發(fā)生率約 50% ,28的死亡率約75% 。 區(qū)分相對(duì)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