糖皮质激素在脓毒症中的应用课件

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,精选文本,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,二级,三级,四级,五级,精选文本,*,糖皮质激素在脓毒症中的应用,浙江省中医院ICU 雷澍,1,精选文本,糖皮质激素在脓毒症中的应用1精选文本,体内的作用,对应激诱发的反应的反馈系统的活化，保证人体在防御机制方面不反应过度,2,精选文本,体内的作用2精选文本,应用的现状,2003年6月，SSC制定了新的脓毒症治疗指南：,推荐对脓毒性休克静脉使用小剂量氢化可的松,50mg，q6h，连续7天(C级)；可以同时每日给,予氟氢可的松 50ug ，鼻饲(E级)；避免氢化可,的松300mg/d(A级).,3,精选文本,应用的新理论依据,伴发相对肾上腺皮质功能不全,周围抵抗,GC相对不足,4,精选文本,应用的新理论依据伴发相对肾,相对肾上腺,皮质功能不全,周围抵抗,脓毒症,GC相,对不足,炎症反应过度,循环衰竭,病情,加重,外源性GC,5,精选文本,相对肾上腺周围抵抗脓毒症GC相炎症反应过度循环衰竭病情外,相对肾上腺皮质功能不全的发生机制,-及促皮质素抑素抑制肾上腺功能并降低皮质醇水平,机体水平偏低,活化的淋巴细胞产生片段干扰经典的功能,肾上腺皮质血液灌注不足,6,精选文本,相对肾上腺皮质功能不全的发生机制-及促皮质素抑素抑,周围抵抗,的发生机制,皮质醇向炎症部位转运障碍,糖皮质激素受体 ()数目减少和亲和力下降,炎症部位皮质醇浓度调节异常,7,精选文本,周围抵抗的发生机制皮质醇向炎症部位转运障碍糖,如何确定存在相对,肾上腺功能不全,以兴奋试验后皮质醇的升幅被削峰为特征,临床症状和体征是决定诊断的关键因素,快速刺激实验时，皮质醇增加幅度9/,若任意时间血皮质醇水平低于 552nmol/L（19.3ug/dl),相对,肾上,腺功能不全,试验后血皮质醇低于 690nmol/L （24.2ug/dl),8,精选文本,如何确定存在相对肾上腺功能不全以兴奋试验后,Features suggesting corticosteroid insufficiency,Symptoms,Weakness and fatigue,Anorexia, nausea, vomiting,Abdominal pain,Myalgia or arthralgia,Postural dizziness,Craving for salt,Headaches,Memory impairment,Depression,Findings on physical examination,Increased pigmentation,Hypotension (postural),Tachycardia,Fever,Decreased body hair,Vitiligo,Features of hypopituitarism,Amenorrhea,Intolerance of cold,Clinical problems,Hemodynamic instability,Hyperdynamic (common),Hypodynamic (rare),Ongoing inflammation with no obvious source,Mutiple-organ dysfunction,Hypoglycemia,Laboratory findings,Hyponatremia,Hyperkalemia,Hypoglycemia,Eosinophilia,Elevated thyrotropin levels,9,精选文本,Features suggesting corticoste,相对,肾上腺功能不全和周围抵抗的发生率,相对肾上腺功能不全:基于的不同定义 ,脓毒症及感染性休克时 ,其发生率为 6.25% 75%,周围抵抗: ?,10,精选文本,相对肾上腺功能不全和周围抵抗的发生率10精选文本,相对,肾上腺功能不全,Lancet. 1991,Rothwell PM,septic shock,13/32（41%）,rise less than 250 nmol/l(9ug/dl) to corticotropin,Intensive Care Med. 1994, Moran JL, septic shock ,22/33(67%),rise less than 200 nmol/l to corticotropin,Intensive Care Med. 1995, Bouachour G,septic shock,1/40(2.5%),basal cortisol level below 10 micrograms/dl; response to the ACTH stimulation test below 18 micrograms/dl,Exp Clin Endocrinol Diabetes. 1997, Aygen B,sepsis, 16.3%,rise less than 250 nmol/l(9ug/dl) to corticotropin,JAMA,.,2002, Djillali,Annane,septic shock , 229/299(77%),rise less than 250 nmol/l(9ug/dl) to corticotropin,11,精选文本,相对肾上腺功能不全Lancet.,相对,肾上腺功能不全,一项 由Annane 等完成的189例脓毒性休克患者的队列研究证实,相对肾上腺皮质功能不全的最佳定义为 :快速刺激实验时 ,皮质醇增加幅度 9/。应用此概念 ,严重脓毒症时相对肾上腺皮质功能不全发生率约 50% ,28的死亡率约75% 。,12,精选文本,相对肾上腺功能不全12精选文本,相对,肾上腺功能不全,较高的皮质醇水平,较低的ACTH反应,高死亡率,13,精选文本,相对肾上腺功能不全较高的皮质醇水平较低,区分相对,肾上腺功能不全和肾上腺功能不全,ACTH test,post-corticotropin plasma,cortisol levels 18 g/dL,2.an increase in plasma,cortisol level 18 g/dL,(excluding adrenal insufficiency),hydrocortisone (100 mg i.v. three times daily 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, 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 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 groups,JAMA,.,2002, Djillali Annane, Placebo-controlled, randomized, double-blind, 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,17,精选文本,并不一致的治疗结果Cri,所有的脓毒性休克患者需要激素吗,patients who responded normally to corticotropin displayed a trend,for higher mortality with hydrocortisone therapy (61% vs 53%,in the placebo group).,18,精选文本,所有的脓毒性休克患者需要激素吗patients wh,等 待,新的循证医学依据：CORTICUS,我们自己的探索,19,精选文本,等 待新的循证医学依,感谢亲观看此幻灯片，此课件部分内容来源于网络，,如有侵权请及时联系我们删除，谢谢配合！,感谢亲观看此幻灯片，此课件部分内容来源于网络，,