2018年更新:危重病相关皮质醇不足的诊断和管理指南

在《2008年成人和儿童患者危重病相关皮质醇不足（critical illness-related corticosteroid insufficiency, CIRCI）诊断和管理共识》基础上，2018年1月和4月在Crit Care Med和Intensive Care Med上正式发表了《2017SCCM和ESICM：危重病相关皮质醇不足的诊断和管理指南》，分I、II两部分。

一、CIRCI的症状和体征

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二、CIRCI的诊断

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1. Is total cortisol response to synthetic adrenocorti-cotropic hormone (ACTH; cosyntropin) superior to random plasma or serum totalcortisol for the diag- nosis of CIRCI?

Recommendation: The task force makes no recommen- dationregarding whether to use delta cortisol (change in baseline cortisol at 60 minof <9 μg/dl) after cosyntropin (250 μg) administration or a random plasmacortisol of <10 μg/dl for the diagnosis of CIRCI.

1.采用总皮质醇对合成促肾上腺皮质激素（ACTH，二十四肽促皮质素）的反应诊断CIRCI是否优于随机血浆或血清总皮质醇？

推荐：关于是否采用给予二十四肽促皮质素后Δ皮质醇（60分钟时基线皮质醇的变化<9 ug/dl）或采用随机血浆皮质醇<10 ug/dl诊断CIRCI，工作组无推荐意见

2. Is plasma or serum free cortisol level superior toplasma total cortisol level for the diagnosis of CIRCI?

Recommendation: We suggest against using plasma freecortisol level rather than plasma total cortisol for the diagnosis of CIRCI(conditional recommendation, very low quality of evidence).

2.采用血浆或血清游离皮质醇水平诊断CIRCI是否优于血浆总皮质醇水平？

推荐：建议不要采用血浆游离皮质醇水平，而应采用血浆总皮质醇诊断CIRCI（有条件推荐，非常低质量证据）

3. Is salivary free cortisol level superior to plasmatotal cortisol level for the diagnosis of CIRCI?

Recommendation: We suggest against using salivary ratherthan serum cortisol for diagnosing CIRCI (conditional recommendation, verylow quality of evidence).

3.采用唾液游离皮质醇水平诊断CIRCI是否优于血浆总皮质醇水平？

推荐：建议不要采用唾液，而应采用血清皮质醇诊断CIRCI（有条件推荐，非常低质量证据）

4. Is the 1-μg ACTH stimulation test superior to the250-μg ACTH test for the diagnosis of CIRCI?

Recommendation: We suggest that the high-dose (250- μg)rather than the low-dose (1-μg) ACTH stimulation test be used for the diagnosisof CIRCI (conditional recommendation, low quality of evidence).

4.采用1-ug ACTH刺激试验诊断CIRCI是否优于250-ug ACTH试验？

推荐：建议采用高剂量（250-ug）而不是低剂量（1-ug）ACTH刺激试验用于诊断CIRCI（有条件推荐，低质量证据）

5. Is hemodynamic response to hydrocortisone (50– 300 mg)superior to the 250-μg ACTH stimulation test for the diagnosis of CIRCI?

Recommendation: We suggest the use of the 250-μg ACTHstimulation test rather than the hemodynamic response to hydrocortisone (50–300mg) for the diagnosis of CIRCI (conditional recommendation, very low quality of evidence).

5.采用血流动力学对氢化可的松（50-300 mg）反应诊断CIRCI是否优于250-ug ACTH刺激试验？

推荐：建议采用250-ug ACTH刺激试验诊断CIRCI，而不是采用血流动力学对氢化可的松（50-300 mg）的反应性（有条件推荐，非常低质量证据）

6. Is corticotropin level superior to the 250-μg ACTHstimulation test for the diagnosis of CIRCI?

Recommendation: We suggest against using corticotro－pinlevels for the routine diagnosis of CIRCI (conditional recommendation, lowquality of evidence).

6.采用促皮质素水平诊断CIRCI是否优于250-ug ACTH刺激试验？

推荐：建议不应采用促皮质素水平作为常规诊断CIRCI的方案（有条件推荐，低质量证据）

三、危重病情况下使用皮质醇的推荐意见

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1、Sepsis

A. Should corticosteroids be administered among hos-pitalized adult patients with sepsis without shock?

Recommendation: We suggest against corticoster- oidadministration in adult patients with sepsis without shock (conditionalrecommendation, moderate quality of evidence).

B. Should corticosteroids be administered among hospi-talized adult patients with septic shock?

Recommendation: We suggest using corticosteroids inpatients with septic shock that is not responsive to fluid and moderate- tohigh-dose vasopressor therapy (condi- tional recommendation, low quality ofevidence).

C. What is the recommended dose and duration of treat-ment among hospitalized adult patients with septic shock treated withcorticosteroids?

Recommendation: If using corticosteroids for septicshock, we suggest using long course and low dose (e.g., IV hydrocortisone<400 mg/day for at ≥3 days at full dose) rather than high dose and shortcourse in adult patients with septic shock (conditional recommendation, lowquality of evidence).

1.脓毒症

A.不合并休克的脓毒症成人住院患者是否可以给予皮质醇？

推荐：对于不合并休克的脓毒症成人患者，建议不要使用皮质醇（有条件推荐，中等质量证据）

B.脓毒性休克住院成人患者是否应该给予皮质醇？

推荐：对液体和中-高-剂量升压药物无反应的脓毒性休克患者，建议给予皮质醇（有条件推荐，低质量证据）

C.对于住院成人脓毒性休克患者，使用皮质醇的剂量和持续时间是多少？

推荐：如果使用皮质醇治疗成人脓毒性休克，建议采用长程和低剂量（比如，IV氢化可的松<400 mg/d，持续>=3天）而不是高剂量和短程皮质醇（有条件推荐，低质量证据）

2、Acute respiratory distress syndrome

Should corticosteroids be administered among hos-pitalized adult patients with acute respiratory distress syndrome?

Recommendation: We suggest use of corticosteroids inpatients with early moderate to severe acute respira- tory distress syndrome(PaO /FiO of < 200 and within 14 days of onset) (conditional recommendation,moder- ate quality of evidence).

2.急性呼吸窘迫综合征

住院成人急性呼吸窘迫综合征患者是否给予皮质醇？

推荐：建议皮质醇可以用于早期中-重度急性呼吸窘迫综合征（PaO2/FiO2<200，发病14天内）（有条件推荐，中等治疗证据）

3、Major trauma

Should corticosteroids be administered among hospital-ized adult patients with major trauma?

Recommendation: We suggest against the use of cor-ticosteroids in major trauma (conditional recommenda- tion, low quality ofevidence).

3.严重创伤

住院成人严重创伤患者是否给予皮质醇？

推荐：建议皮质醇不要用于严重创伤的患者（有条件推荐，低质量证据）

4、Community‐acquired pneumonia

Should corticosteroids be administered to hospitalizedadults with community‐acquired pneumonia (CAP)?

Recommendation: We suggest the use of corticoster- oidsfor 5–7 days at a daily dose < 400 mg i.v. hydrocortisone or equivalent inhospitalized patients with CAP (conditional recommendation, moderate quality ofevidence)

4.社区获得性肺炎

住院成人社区获得性肺炎患者是否应该给予皮质醇？

推荐：对于住院社区获得性肺炎患者，建议给予皮质醇5-7天，IV氢化可的松<400 mg/d或其他等量皮质醇（有条件推荐，中等质量证据）

5、Influenza

Should corticosteroids be administered to hospitalizedadults with influenza?

Recommendation: We suggest against the use of corticosteroids in adults with influenza (conditional recommendation, very lowquality of evidence)

5.流感

住院成人流感患者是否应给予皮质醇？

推荐：建议成人流感患者不要使用皮质醇（有条件推荐，非常低质量证据）

6、Meningitis

Should corticosteroids be administered to hospitalizedadults with bacterial meningitis?

Recommendation: We recommend use of corticosteroids inpatients with bacterial meningitis (strong recommendation, low quality ofevidence)

6.脑膜炎

住院成人细菌性脑膜炎患者是否应给予皮质醇？

推荐：推荐细菌性脑膜炎患者给予皮质醇（强烈推荐，低质量证据）

7、Cardiopulmonary bypass surgery

Should corticosteroids be administered in adultsundergoing cardiopulmonary bypass surgery?

Recommendation: We suggest use of corticosteroids inpatients undergoing cardiopulmonary bypass surgery (conditionalrecommendation, moderate quality of evidence)

7.心肺旁路手术

成人心肺旁路手术的患者是否应给予皮质醇？

推荐：建议进行心肺旁路手术者给予皮质醇（有条件推荐，中等质量证据）

8、Cardiac arrest

Should corticosteroids be administered to adults whosuffer a cardiacarrest?

Recommendation: We suggest use of corticosteroids in thesetting of cardiac arrest (conditional recommendation, very low quality ofevidence)

8.心脏骤停

成人心脏骤停患者是否给予皮质醇？

推荐：建议心脏骤停者给予皮质醇（有条件推荐，非常低质量证据）

四、文献出处

来源：全景看重症