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摘要: 脓毒症是全球性的重大公共卫生挑战，其高发病率和病死率引发广泛关注。这一疾病通常由感染触发的免疫应答失衡引起，严重者可演变为脓毒性休克。糖皮质激素作为治疗脓毒性休克的抗炎药物，其有效性存在争议。本文对近5年关于糖皮质激素治疗脓毒性休克的研究文献进行综述，包括总结其治疗观点、作用机制、药物种类与剂量的选择、最佳给药时机以及实验室检查指导糖皮质激素治疗脓毒性休克的文献案例，同时也分析相关不良反应。我们发现，许多文献认为糖皮质激素治疗是有效的，推荐使用氢化可的松，常用剂量为200~400 mg/d，治疗周期通常为4~7 d。治疗过程中可能会出现胃肠道出血、二次感染等不良反应。针对治疗效果不佳的患者，可考虑应用实验室检查方法(如炎症因子、基因检测等)指导治疗。本结论可为临床医生提供参考。但此结论存在一定的局限性，一方面由于部分参考文献未将脓毒症和脓毒性休克区分开来，另一方面关于糖皮质激素种类、最佳给药时机和实验室检查的方法指导脓毒性休克治疗相关的发表文献较少，需要更多的研究来进一步验证。Abstract: Sepsis poses a significant global public health challenge, drawing widespread attention due to its high morbidity and mortality rates. It typically arises from an immune response imbalance triggered by infection, which can progress to septic shock in severe cases. The efficacy of glucocorticoids as anti-inflammatory drugs for treating septic shock remains controversial. This article reviews the research literature on glucocorticoid treatment for septic shock over the past five years, encompassing perspectives on treatment approaches, mechanisms of action, selection of drug types and dosages, optimal timing of administration, laboratory tests guiding glucocorticoid therapy for septic shock management, and analysis of associated adverse reactions. Our findings indicate that a considerable portion of the literature leans towards considering glucocorticoid therapy effective and recommends using hydrocortisone at doses ranging from 200 to 400 mg per day for treatment cycles lasting typically 4 to 7 days. Adverse reactions such as gastrointestinal bleeding and secondary infections may occur during treatment. For patients with inadequate therapeutic response, laboratory tests(such as inflammatory factors and genetic testing) could be considered to guide further management decisions. The conclusion of this article can offer valuable insights for clinicians. However, it is important to acknowledge the limitations of this conclusion. Firstly, some references fail to differentiate between sepsis and septic shock. Secondly, there is a scarcity of publications addressing the types of glucocorticoids, optimal timing for administration, and laboratory tests that can guide the treatment of septic shock. Therefore, additional research is necessary to further validate the conclusions drawn in this study.
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Key words:
- septic shock /
- sepsis /
- glucocorticoids /
- therapy
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表 1 糖皮质激素在脓毒症或脓毒性休克患者治疗中的争议
作者 观点 年份 诊断 病例数或研究例数 分组 评价指标 结果 Wu等[1] 反对 2020 脓毒症和脓毒性休克 5 009例 使用糖皮质激素组和未使用糖皮质激素组 住院病死率 差异无统计学意义 Dequin等[2] 反对 2020 重症
COVID-19149例 治疗组即予氢化可的松200 mg/d持续治疗7 d，随后逐渐减量，共治疗14 d；对照组即未予氢化可的松治疗 第21日时的治疗失败(定义为死亡或持续呼吸支持)天数 差异无统计学意义 Edalatifard等[3] 反对 2022 重症
COVID-19304例 治疗组即予甲泼尼龙1 g/d持续治疗3 d，联合地塞米松6 mg/d持续治疗10 d；对照组即予地塞米松6 mg/d持续治疗10 d 住院时长和病死率 差异无统计学意义 Tomazini等[4] 支持 2020 COVID-19相关性ARDS 299例 使用地塞米松组和未使用地塞米松组 入院后28 d内不使用机械通气的天数 治疗组入院后28 d内不使用机械通气的天数显著增多 Edalatifard等[5] 支持 2020 重症
COVID-1962例 治疗组即予甲泼尼龙250 mg/d，持续治疗3 d；对照组即未予甲泼尼龙治疗 病死率、生存时间 治疗组病死率显著降低，生存时间显著延长 Kalimouttou等[6] 支持 2023 脓毒症和脓毒性休克 42 735例 使用糖皮质激素组和未使用糖皮质激素组 28 d病死率 发现使用糖皮质激素与28 d全因病死率显著相关 注：COVID-19表示新型冠状病毒肺炎；ARDS表示急性呼吸窘迫综合征。 
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表 2 脓毒性休克治疗中氢化可的松的替换方案[20]
激素名称 等效用量 氢化可的松200 mg qd ivgtt 甲基强的松龙40 mg qd ivgtt+氟化可的松50 μg qd po 氢化可的松200 mg qd ivgtt 地塞米松8 mg qd ivgtt+氟化可的松50 μg qd po 氢化可的松50 mg q6 h ivgtt 甲基强的松龙10 mg q6h ivgtt+氟化可的松50 μg qd po 氢化可的松50 mg q6 h ivgtt 地塞米松2 mg q6 h ivgtt+氟化可的松50 μg qd po 注：“qd”表示每日给药1次；“q 6 h”表示每6小时给药1次；“ivgtt”表示静脉滴注；“po”表示口服。
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| 引用本文: |
张跃, 王添骁. 脓毒性休克患者的糖皮质激素治疗[J]. 临床急诊杂志, 2024, 25(2): 93-98. doi: 10.13201/j.issn.1009-5918.2024.02.008
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| Citation: |
ZHANG Yue, WANG Tianxiao. Glucocorticoid therapy in patients with sepsis shock[J]. J Clin Emerg, 2024, 25(2): 93-98. doi: 10.13201/j.issn.1009-5918.2024.02.008
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