1、伴发相对肾上腺皮质功能不全周围抵抗GC相对不足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-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SymptomsWeakness and fatigueAnorexia,nausea,vomitingAbdominal painMyalgia or arthralgiaPostural dizzinessCraving for saltHeadachesMemory impairmentDepressionFindings on physic
2、al examinationIncreased pigmentationHypotension(postural)TachycardiaFeverDecreased body hairVitiligoFeatures of hypopituitarismAmenorrheaIntolerance of coldClinical problemsHemodynamic instabilityHyperdynamic(common)Hypodynamic(rare)Ongoing inflammation with no obvious sourceMutiple-organ dysfunctio
3、nHypoglycemiaLaboratory findingsHyponatremiaHyperkalemiaHypoglycemiaEosinophiliaElevated thyrotropin levelsLancet.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 corticotr
4、opin 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
5、,septic shock,229/299(77%),rise less than 250 nmol/l(9ug/dl)to corticotropin 较高的皮质醇水平较低的ACTH反应高死亡率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 daily for 5 days),a signifi
6、cant 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
7、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 s
8、hock.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,parallel-group trial performed in 19 intensive
9、 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 patients who responded normally to corticotropin displayed a trend for higher mortality with hydrocortisone therapy(61%vs 53%in the placebo group).
