中华急诊医学杂志
中華急診醫學雜誌
중화급진의학잡지
CHINESE JOURNAL OF EMERGENCY MEDICINE
2014年
5期
543-548
,共6页
袁光雄%付林%孙卫平%许俊%龙臣%朱云龙
袁光雄%付林%孫衛平%許俊%龍臣%硃雲龍
원광웅%부림%손위평%허준%룡신%주운룡
慢性阻塞性肺疾病%急性加重%糖皮质激素%危重症疾病%皮质醇不足%患病率%预后%炎症
慢性阻塞性肺疾病%急性加重%糖皮質激素%危重癥疾病%皮質醇不足%患病率%預後%炎癥
만성조새성폐질병%급성가중%당피질격소%위중증질병%피질순불족%환병솔%예후%염증
Chronic obstructive pulmonary disease%Acute exacerbation glucocorticoid%Critical illness%Corticosteroid insufficiency%Prevalence rate%Prognosis%Inflammation
目的 探讨小剂量糖皮质激素对慢性阻塞性肺病急性加重期(AECOPD)患者合并危重症疾病相关性皮质醇不足(CIRCI)的治疗效果.方法 采用前瞻性随机对照临床试验.收集2010年1月至2012年12月入住湘潭市中心医院重症医学科慢性阻塞性肺病急性加重期患者385例.入住重症医学科12 h内行促肾上腺皮质激素刺激试验,对筛查出合并危重症疾病相关性皮质醇不足的AECOPD患者(63例),采用随机数字法分为治疗组(n=32)和对照组(n=31),分别予以静脉注射氢化可的松150 mg/d和生理盐水,连续7d.对比28 d病死率、非休克时间、入住重症监护单元时间以及非机械通气时间等方面的差异,并观察人住时以及治疗7d后炎症指标C反应蛋白、白介素6、肿瘤坏死因子α和降钙素原的变化.使用SPSS 18.0数据包进行分析,两组间比较使用t检验或非参数检验,两组间率的比较采用x2检验,生存分析采用Kaplan-Meier检验.结果 ①共筛查了385例AECOPD患者,合并CIRCI的患病率为16.4％,合并CIRCI的AECOPD患者休克的发生率为23.8％,未合并CIRCI的AECOPD患者休克的患病率为8.7％;②治疗组患者28 d病死率为2/32,明显低于对照组8/31 (P ＜0.05),并且治疗组28 d非休克时间平均为(25.8±4.1)d,明显长于对照组(18.2±9.5)d(P＜0.05),但是,28 d休克发生率、入住重症监护单元时间以及非机械通气时间两组之间差异无统计学意义;③糖皮质激素治疗7d后,对照组和治疗组炎症指标C反应蛋白分别为(13.2±5.5) mg/Lvs.(8.3±3.1)mg/L,(13.5 ±5.9)mg/L vs.(5.1±2.3)mg/L;肿瘤坏死因子α分别为(26.1±16.2)μg/L vs.(17.5±11.7) μg/L,(25.0±14.8)μg/L vs.(10.4±7.8) μg/L;降钙素原分别为3.88 (0.25,8.5) μg/L vs.2.03 (0.15,5.1) μg/L,3.77 (0.21,8.0)μg/L vs.1.26 (0.10,3.2)μg/L,均明显下降(P＜0.01),且治疗组下降更明显,其差异具有统计学意义(P＜0.01).结论 AECOPD患者合并CIRCI的患病率较高,对合并CIRCI的AECOPD患者小剂量糖皮质激素能降低病死率和休克时间,以及有利于炎症和感染控制.
目的 探討小劑量糖皮質激素對慢性阻塞性肺病急性加重期(AECOPD)患者閤併危重癥疾病相關性皮質醇不足(CIRCI)的治療效果.方法 採用前瞻性隨機對照臨床試驗.收集2010年1月至2012年12月入住湘潭市中心醫院重癥醫學科慢性阻塞性肺病急性加重期患者385例.入住重癥醫學科12 h內行促腎上腺皮質激素刺激試驗,對篩查齣閤併危重癥疾病相關性皮質醇不足的AECOPD患者(63例),採用隨機數字法分為治療組(n=32)和對照組(n=31),分彆予以靜脈註射氫化可的鬆150 mg/d和生理鹽水,連續7d.對比28 d病死率、非休剋時間、入住重癥鑑護單元時間以及非機械通氣時間等方麵的差異,併觀察人住時以及治療7d後炎癥指標C反應蛋白、白介素6、腫瘤壞死因子α和降鈣素原的變化.使用SPSS 18.0數據包進行分析,兩組間比較使用t檢驗或非參數檢驗,兩組間率的比較採用x2檢驗,生存分析採用Kaplan-Meier檢驗.結果 ①共篩查瞭385例AECOPD患者,閤併CIRCI的患病率為16.4％,閤併CIRCI的AECOPD患者休剋的髮生率為23.8％,未閤併CIRCI的AECOPD患者休剋的患病率為8.7％;②治療組患者28 d病死率為2/32,明顯低于對照組8/31 (P ＜0.05),併且治療組28 d非休剋時間平均為(25.8±4.1)d,明顯長于對照組(18.2±9.5)d(P＜0.05),但是,28 d休剋髮生率、入住重癥鑑護單元時間以及非機械通氣時間兩組之間差異無統計學意義;③糖皮質激素治療7d後,對照組和治療組炎癥指標C反應蛋白分彆為(13.2±5.5) mg/Lvs.(8.3±3.1)mg/L,(13.5 ±5.9)mg/L vs.(5.1±2.3)mg/L;腫瘤壞死因子α分彆為(26.1±16.2)μg/L vs.(17.5±11.7) μg/L,(25.0±14.8)μg/L vs.(10.4±7.8) μg/L;降鈣素原分彆為3.88 (0.25,8.5) μg/L vs.2.03 (0.15,5.1) μg/L,3.77 (0.21,8.0)μg/L vs.1.26 (0.10,3.2)μg/L,均明顯下降(P＜0.01),且治療組下降更明顯,其差異具有統計學意義(P＜0.01).結論 AECOPD患者閤併CIRCI的患病率較高,對閤併CIRCI的AECOPD患者小劑量糖皮質激素能降低病死率和休剋時間,以及有利于炎癥和感染控製.
목적 탐토소제량당피질격소대만성조새성폐병급성가중기(AECOPD)환자합병위중증질병상관성피질순불족(CIRCI)적치료효과.방법 채용전첨성수궤대조림상시험.수집2010년1월지2012년12월입주상담시중심의원중증의학과만성조새성폐병급성가중기환자385례.입주중증의학과12 h내행촉신상선피질격소자격시험,대사사출합병위중증질병상관성피질순불족적AECOPD환자(63례),채용수궤수자법분위치료조(n=32)화대조조(n=31),분별여이정맥주사경화가적송150 mg/d화생리염수,련속7d.대비28 d병사솔、비휴극시간、입주중증감호단원시간이급비궤계통기시간등방면적차이,병관찰인주시이급치료7d후염증지표C반응단백、백개소6、종류배사인자α화강개소원적변화.사용SPSS 18.0수거포진행분석,량조간비교사용t검험혹비삼수검험,량조간솔적비교채용x2검험,생존분석채용Kaplan-Meier검험.결과 ①공사사료385례AECOPD환자,합병CIRCI적환병솔위16.4％,합병CIRCI적AECOPD환자휴극적발생솔위23.8％,미합병CIRCI적AECOPD환자휴극적환병솔위8.7％;②치료조환자28 d병사솔위2/32,명현저우대조조8/31 (P ＜0.05),병차치료조28 d비휴극시간평균위(25.8±4.1)d,명현장우대조조(18.2±9.5)d(P＜0.05),단시,28 d휴극발생솔、입주중증감호단원시간이급비궤계통기시간량조지간차이무통계학의의;③당피질격소치료7d후,대조조화치료조염증지표C반응단백분별위(13.2±5.5) mg/Lvs.(8.3±3.1)mg/L,(13.5 ±5.9)mg/L vs.(5.1±2.3)mg/L;종류배사인자α분별위(26.1±16.2)μg/L vs.(17.5±11.7) μg/L,(25.0±14.8)μg/L vs.(10.4±7.8) μg/L;강개소원분별위3.88 (0.25,8.5) μg/L vs.2.03 (0.15,5.1) μg/L,3.77 (0.21,8.0)μg/L vs.1.26 (0.10,3.2)μg/L,균명현하강(P＜0.01),차치료조하강경명현,기차이구유통계학의의(P＜0.01).결론 AECOPD환자합병CIRCI적환병솔교고,대합병CIRCI적AECOPD환자소제량당피질격소능강저병사솔화휴극시간,이급유리우염증화감염공제.
Objective To investigate the effect of low-dose glucocorticoid on prognosis of critical illness-related corticosteroid insufficient (CIRCI) patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD).Methods A total of 385 eligible patients met the criteria of AECOPD were admitted from January 2010 to December 2012.The AECOPD patients co-morbid with CIRCI screened by an adrenal corticotrophic hormone test within 12 hours after admission were randomly divided into treatment group (n =32) and control group (n =31) for prospective,randomized (random number) and controlled clinical study.Hydrocortison (150mg/d) for treatment group or normal saline instead for control group was injected intravenously for 7 days.The 28-day mortality,shock-free days,length of ICU stay within 28 days and ventilator-free days were evaluated.And the markers of inflammation C-reactive protein,tumor necrosis factor-α,interleukin 6 and procalcitonin were measured before and 7 days after treatment.The variables were analyzed by Student' s t-test,non-parametric statistical test,Chi-square test or KaplanMeier test with SPSS 18.0 statistic software.P ＜ 0.05 was considered statistically significant.Results A cohort of 385 patients with AECOPD was screened,and the prevalence rate of CIRCI was 16.4％.The shock rate was higher in the AECOPD patients co-morbid with CIRCI than that in the AECOPD patients without CIRCI (23.8％ vs 8.7％,P ＜0.01).Compared with the control group,the 28-day mortality was significantly lower in treatment group (2/32 vs 8/31,P ＜ 0.05),and shock-free days within 28 days longer in the treatment group (18.2 ± 9.5 vs 25.8 ± 4.1,P ＜ 0.05).However,there was no difference in the shock rate,days of ICU stay and ventilator-free days between the two groups.After treatment,the levels of infection markers were decreased and obviously lower than those in control group (P ＜ 0.01),such as Creactive protein (13.2 ± 5.5 mg/L vs 8.3 ± 3.1 mg/L for control group; 13.5 ± 5.9 mg/L vs 5.1 ± 2.3mg/L for treatment group),tumor necrosis factor-α (26.1 ± 16.2 μg/L vs 17.5 ± 11.7 μg/L for control group ; 25.0 ± 14.8 μg/L vs 10.4 ± 7.8 μg/L for treatment group) and procalcitonin [3.88 (0.25,8.5) μg/L vs 2.03 (0.15,5.1) μg/L for control group; 3.77 (0.21,8.0) μg/L vs 1.26 (0.10,3.2) μg/L for treatment group],furthermore,the levels of infection markers were decrease more obviously in the treatment group than those in the control group (P ＜ 0.01).Conclusions There was high prevalence rate of CIRCI in the patients with AECOPD in the department of critical medicine,and low-dose glucocorticoid reduced 28-day mortality,shock days and markers of infection and inflammation.
