每日一题_2022.4.14

A 35-year-old woman with a history of diabetes, hypertension, and lupus is admitted to the ICU with concern for pneumonia and severe sepsis. Her home medications include methotrexate, hydroxychloroquine, prednisone, esomeprazole, lisinopril, and metformin. Her initial lactate level in the emergency department is 5 mmol/L. She is started on broad-spectrum antibiotics and given 3 liters of IV normal saline. Despite continued aggressive fluid resuscitation in the ICU, her blood pressure decreases and she is started on norepinephrine and low-dose vasopressin. She is on 6 L nasal cannula with oxygen saturations of 95%, blood pressure 80/40 mm Hg, pulse 120 beats/min, respiratory rate 22 breaths/min, and is afebrile. Laboratory assessment shows a lactate of 3 mmol/L, hemoglobin 10, and a central venous oxygen saturation of 70. Central venous pressure is 12 mm Hg and urine output is adequate.

Which of the following is the best next step in management?

A. Order an additional 2L IV crystalloid bolus. 

B. Add antifungal coverage.

C. Start IV stress-dose steroids.

D. Start epinephrine.

答案解析：

重症相关皮质类固醇不足(CIRCI)在ICU中遇到。该患者在住院前接受泼尼松治疗狼疮，下丘脑-垂体-肾上腺轴受到抑制，阻止了对重度感染的适当反应。因此，尽管进行了适当的液体复苏、抗生素和血管加压药支持，但患者仍处于难治性休克状态，需要IV应激剂量类固醇以支持其血压。

CIRCI是相对肾上腺功能不全的一种形式，血液皮质类固醇水平不足以应对危重疾病期间施加的压力。特征包括难治性休克以及电解质异常，包括低血糖、高钾血症和低钠血症。基于实验室检验参数，诊断通常具有挑战性，文献中无一致值。Annane和CORTICUS研究等试验的结果相互矛盾（尽管患者人群不同），导致脓毒症存活指南建议，如果怀疑CIRCI，仅根据临床依据治疗CIRCI。类固醇的确切剂量和持续时间尚不明确，但通常使用较低的间歇性IV氢化可的松给药，并在休克消退后停药。

可以考虑增加抗真菌覆盖范围，尽管在这种情况下不太可能有益。患者接受了充分复苏，不符合开始肾上腺素治疗的任何硬标准。

正确答案：C