促肾上腺皮质激素刺激对脓毒症及脓毒性休克患儿肾上腺功能评估的意义

目的 探讨小剂量(1μg/1.73 m2)促肾上腺皮质激素(ACTH)刺激实验评估儿童脓毒症和脓毒性休克肾上腺功能状态的价值.方法 患儿入院24h内完成基础皮质醇(T0)测定,静脉注射1μg/1.73m2 ACTH,30 min后测定血液皮质醇(T1),根据T0和皮质醇增值(△max=T1-T0)判断肾上腺功能,以△max≤90μg/L为肾上腺功能障碍(AI)指标.结果 62例中,脓毒症53例,脓毒性休克9例,病死率为27.4%(17/62).肾上腺功能障碍(adrenal insufficiency,AI)发生率40.3%(25/62),其中脓毒症和脓毒性休克患儿AI发生率分别是39.6%和44.4%,差异无显著统计学意义(P>0.05).两组脓毒症和脓毒性休克平均T0和T1分别是(318.6±230.4)μg/L、(452.3±230.7)μg/L和(454.7±212.7)μg/L、(579.3±231.9)μg/L,差异无统计学意义(P>0.05).存活组和死亡组患儿T0、T1分别是(320.5±223.9)μg/L、(462.3±212.0)μg/L和(384.3±258.3)μg/L、(500.7±470.6)μg/L,两组AI发生率分别是37.8%和47.1%,差异无统计学意义(P>0.05).T0和T1水平与儿童危重病例评分(PCIS)有关(P<0.05),AI发生率与PCIS、PRISMⅢ和器官功能障碍数目无关(P>0.05).结论 儿童脓毒症和脓毒性休克患儿AI发生率较高.小剂量ACTH刺激实验可以判断严重感染患者肾上腺功能,可为激素治疗提供依据.

Adrenal function evaluation using ACTH stimulation test in children with sepsis and septic shock

Objective Sepsis and septic shock remain a common problem that results in significant mortality and morbidity in pediatric intensive care units(PICU).According to literature,the use of more physiologic steroid replacement therapy is associated with hemodynamic and survival benefits in adult patients with relative adrenal insufficiency (RAI) and catecholamine-resistant septic shock.But little information is available in children.The aim of the current prospective study was to determine the prevalence of adrenal insufficiency in children with sepsis and septic shock using a low-dose adrenocorticotropic hormone(ACTH)stimulation test (1μg/1.73 m2) in children.Methods The authors performed cortisol estimation at baseline and after low-dose (1μg/1.73m2) ACTH stimulation at 30 mins in children during the first 24 hours in patients with sepsis or septic shock admitted to our PICU.Adrenal insufficiency was defined as a response≤90 μg/L Absolute adrenal insufficiency (AAI) was further defined as baseline cortisol(TO)<200μg/L and RAI insufficiency by TO≥200μg/L Results Sixty-two consecutive cases with sepsis and septic shock admitted to PICU of Shanghai Jiaotong University Affiliated Children's Hospital from April,2006 to March,2007.The median age was 37.6 months(range,2-168 months),and their genderdistribution was 42(67.7%)males and 20(32.3%)females,53 cases had sepsis(85.5%) and 9 had septic shock(14.5%).The mean pediatric critical illness score(PCIS) was 79.3±9.2 and median pediatric risk of mortality score (PRMSⅢ) 11.3(5-19),respectively.Overall mortality of sepsis and septic shock was 27.42%.The evaluation of adrenal insufficiency was conducted as follows.①The mean cortisol levels at baseline(T0) and 30 mins after ACTH stimulation (T1) were(318.6±230.4)μg/L,(452.3±230.7)μg/L and(454.7±212.7)μg/L,(579.3±231.9)μg/L in patients with severe sepsis and septic shock group,respectively.There were no significant difference between the two groups(P>0.05).②The proportion of patients with adrenal insufficiency in the study population was 40.3% as defined by a response ≤90μg/L post test. The proportion of patients with adrenal insufficiency in sepsis and septic shock were 39.6% and 44.4%,respectively (x2=0.073,P>0.05).③The serum T0 and T1 levels were(320.5±223.9)μg/L,(462.3±212.0)μg/L and(384.3±258.3)μg/L,(500.7±470.6)μg/L,respectively,and the proportion of patients with adrenal insufficiency were 37.8% and 47.1% in the survivors and the dead(P>0.05).The levels of T0 and T1 were related to the PCIS(P<0.05).The morbidity of adrenal insufficiency was not related to the PCIS,PRISM Ⅲ,and number of organ that developed functional insufficiency (P>0.05).Conclusions Adrenal insufficiency may occur in patients with sepsis and septic shock in children. ACTH stimulation test may be helpful to determine whether corticostemid therapy has a survival benefit in patients with relative adrenal insufficiency.A low-dose ACTH stimulation test can be used to evaluate the adrenal function status of severe sepsis and septic shock in children.