Sepsis adrenal fonksiyonlar ve prognoz üzerine etkileri

Abstract

44 ÖZET Bu çalışmada 49 sepsisli hasta ve kontrol grubu olarak da 30 sağlıklı kişi değerlendirmeye alındı. Her iki gruptaki hastalarda bazal kortizol seviye tayini ve ACTH stimülasyon testi yapıldı. Hastalarda yaş ortalaması 42.8±18.6, kontrol grubunda ise 41.4±12.1 olarak bulundu. Kırkdokuz hastanın 15 (% 30.6)' inde hastane infeksiyonu, 34 (% 69.4)' ünde hastane dışı infeksiyon saptandı. Hastaların 35 (% 71)' inde etyolojik ajan (% 57.1 gram-negatif, % 34.3 gram-pozitif ve % 8.6 miks bakteri) izole edildi. Kırkdokuz hastanın 14 (% 28.6)'ü öldü. Ortalama bazal kortizol seviyesi hastalarda 597.1±304.6 (217.8-1667.9) nmol/1, kontrol grubunda ise 460.2±180.8 (253.6-988.9) nmol/1 bulundu. Hastaların bazal korti zol ortalaması kontrol grubuna göre anlamlı olarak yüksek bulundu (p<0.01).Ortalama bazal kortizol seviyesi ölen hastalarda 725.5+448.9 nmol/1, iyileşen hastalarda 545.8+21019 nmol/1 idi ve aradaki fark anlamlı bulundu (p<0.05). Kırküç hastada ACTH stimülasyon testi yapıldı. Hastaların kortizol cevabı orta laması (277.7±216.9 nmol/1) kontrol grubunun kortizol cevabı ortalamasından45 (519.6±279.2 nmol/1) anlamlı olarak daha düşük bulundu (p<0.01). Kortizol cevabı ortalaması ölen hastalarda 227.2±224.6 nmol/1 iyileşen hastalarda 302.1±212.7 nmol/1 sap tandı. Ölen hastaların ACTH stimülasyon testine kortizol cevabı iyileşen hastalara göre daha düşüktü fakat aradaki fark anlamlı değildi (p>0.05). Şoku olan hastaların bazal kortizol ortalaması (732.0±449.3 nmol/1) şoku olmayan hastaların bazal kortizol ortalamasından (566.8±260.1 nmol/1) yüksek olmasına karşın aradaki fark anlamlı değildi (p>0.05). Gram-negatif sepsisi olan hastaların bazal kortizol ortalaması (494.5±198.8 nmol/1) gram-pozitif sepsisi olan hastaların bazal kortizol orta lamasından (736.2±329.5 nmol/1) anlamlı olarak daha düşük bulundu (p<0.01). Hastalarımızın 7 (% 16.3)' sinde bazal kortizol ve/veya ACTH stimülasyonu ile el de edilen kortizol değeri 500 nmol/1'nin altında bulundu ve bu durum adrenokortikal ce- vapsızlık olarak değerlendirildi. Bu hastalardan 3 (% 42.9)'ü öldü. Sonuç olarak, sepsisli hastalarda yüksek bazal kortizol seviyesi ve ACTH'a düşük kortizol cevabı kötü prognozu gösterebilir.

46 SUMMARY In this study, 49 patients with sepsis and 30 healty persons as control were evaluated. The basal Cortisol level in both group was assessed and ACTH stimulation test was carried out. The mean age was 42±18 years in the study group and 41± 12 years in the control group. Fifteen of 49(30.6 %) patients had hospital acquired and 34 (69.4 %) patients community acquired sepsis. Etiological agent was isolated in 35 (71%) patients (57.1 % gram-negative bacteria, 34.3 % gram-positive bacteria and 8.6 % polimicrobial ). Fourteen of 49 (28.6 %) patients died. Mean basal Cortisol level was 597±304 nmol/1 ( range 217.8-1667) in the study group and 460.2+180.8 nmol/1 (range 253.6-988.9) in the control group. Mean basal Cortisol level in the study group was significantly higher than the level of the control group (p<0.01). Mean basal Cortisol level was found to be 725.5±448.9 nmol/1 in the patients who died and 545. 8±2 10.9 nmol/1 in the patients who recovered. The difference between the two groups was significant (p <0.05). ACTH stimulation test was performed in 43 patients. Cortisol response was significantly lower in the patients (mean 277.7+216.9 nmol/1) than the control group47 (mean 519.6±279.2) (p<0.01). Mean Cortisol response level in the patients who died was 227.2±224.6 nmol/1 and 302. 1±2 12.7 nmol/l in the patients who recovered. The Cortisol response to ACTH stimulation in the patients who died was lower than the response in the patients who recovered but the difference was not significant(p> 0.05). Mean basal Cortisol level of patients with shock (732.0+449.3 nmol/1) was higher than the patients without shock (566.8+260.1) but the difference was not significant (p>0.05).Mean basal kortisol level of patients with gram-negative sepsis (494.5±198.8 nmol/1) was significantly lower than the patients with gram-positive sepsis (p<0.01). Basal Cortisol and/or peak level of Cortisol to ACTH stimulation was lower than 500 nmol/1 in 7 (16.3 %) patients and this stituation was assessed as adrenocortical unresponsiveness. Three (42.9 %) of these patients were died. In conclusion, high basal Cortisol level and lower Cortisol response to ACTH stimulation in the patients with sepsis may show poor prognosis.