创伤性脑损伤急性期危重症相关皮质类固醇不足及其对预后的影响

Incidence of critical illness-related corticosteroid insufficiency after severe traumatic brain injury and its correlations with prognosis

目的探讨重型创伤性脑损伤（sTBI）急性期危重症相关皮质类固醇不足（CIRCI）的发生率及其对预后的影响。方法采用前瞻性队列研究分析2014年6月-2015年12月伤后24h内收治的格拉斯哥昏迷评分（GCS）≤8分的sTBI患者89例，其中男68例，女21例；年龄15—80岁。伤后36h内行促。野上腺皮质激素（ACTH）刺激试验，筛选出CIRCI患者，同时将患者分为CIRCI组（50例）和非CIRCI组（39例），并以患者是否生存分为生存组（62例）和死亡组（27例）。比较两组患者GCS、机械通气时间、28d内脑疝发生情况、患者生存时间及病死率。结果sTBI患者CIRCI的发生率高达56％（50／89）。与非CIRCI组比较，CIRCI组患者GCS更低[（5．3±1．7）分：（6．1±1．4）分]（P〈0．05），机械通气时间更长[（9．9±2．8）d：（7．5±1．6）d]（P〈0．05），28d内脑疝发生率更高（58％：21％）（P〈0．01）。28d总病死率为30％（27／89），其中CIRCI组病死率为40％（20／50），明显高于非CIRCI组的18％（7／39）（P〈0．05）；CIRCI组患者生存时间明显低于非CIRCI组（P〈0．05）。死亡组CIRCI发生率为74％（20／27），明显高于生存组的48％（30／62）（P〈0．05）。结论sTBI患者CIRCI发生率较高，脑疝发生率增加，机械通气时间延长，患者的生存时间明显缩短，病死率明显升高。

Objective To observe the incidence of critical illness-related corticosteroid insufficiency （CIRCI） after severe traumatic brain injury （sTBI） and investigate the relationship between CIRCI and prognosis. Methods This prospective cohort study enrolled 89 sTBI patients （68 males and 21 females; at age range of 15-80 years） hospitalized within 24 hours after sTBI from June 2014 to December 2015. The Glasgow coma scale （GCS） was≤8 points. The causes of injury included extensive contusion of brain （44 cases）, subdural hematoma （21 cases） , epidural hematoma （11 cases） , primary brain stem injury （8 cases） and diffuse axonal injury （5 cases）. Adrenocorticotropic hormone （ACTH） stimulation tests were done within 36 hours after sTBI to identify CIRCI patients. The patients were divided into CIRCI group （50 cases） and non-CIRCI group （39 cases）. Moreover, the patients were categorized into survival group （62 cases） and death group （27 cases） based on survival status. The GCS score, mechanical ventilation time, cerebral hernia, survival time and mortality within 28 days were observed in two groups. Results The incidence of CIRCI in sTBI patients was as high as 56% （50/89）.Compared with the non-CIRCI group, the CIRCI group had lower GCS [ （5.3 ± 1.7） points vs. （6.1 ± 1.4 ） points, P 〈 0.05 ] , and sTBI patients with CIRCI were mechanically ventilated for a longer period of time [ （9.9 ±2.8） days vs. （7.5 ±1.6） days, P 〈 0. 05 ]. In comparison with non-CIRCI patients, the incidence of brain herniation in sTBI patients with CIRCI was higher （58% vs. 21% , P 〈0.01 ）. The total fatality rate within 28 days was 30% （27/89）. The smvival time of CIRCI group was significantly shorter than that of non-CIRCI group （P 〈 0.05 ）. The fatality rate in the CIRCI group was significantly higher than that of the non-CIRCI group [40% （20/50） vs. 18% （7/39） , P 〈0.051- The incidence of CIRCI in death group was significantly higher than that of the survival group [74% （20/27） vs. 48% （30/62）, P 〈 0.05 ]. Conclusions The incidence of CIRCI in STBI patients is high. The sTBI patients with CIRCI has significantly higher incidence of brain hernia, longer mechanical ventilation time, higher 28-day mortality and shorter survival time compared with non-CIRCI patients.