Case 9-2004: An 18-Year-Old Man with Respiratory Symptoms and Shock
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《新英格兰医药杂志》
To the Editor: In the case of influenza presented by Todres and discussed by Gerberding et al. (March 18 issue),1 there are two points that need further examination. First, the obese patient had received at least 20 liters of fluid in 32 hours before he died from unremitting shock, yet no mention is made of measurement of the intraabdominal pressure. There is a growing body of evidence that suggests that the body-mass index and massive fluid resuscitation are the main independent causes of intraabdominal hypertension.2,3
Second, the patient received hydrocortisone after he was found to have a baseline cortisol level of 27.1 μg per deciliter (748 nmol per liter) that increased to 41.5 μg per deciliter (1145 nmol per liter) after the administration of cosyntropin. According to a study by Annane et al.,4 this patient would be classified in the lowest risk group — patients who are considered to have "adequate" activation of the hypothalamic–pituitary–adrenal axis and who would probably not benefit from the administration of corticosteroids.
Petros Kopterides, M.D.
Attikon University Hospital
12462 Athens, Greece
petkop@ath.forthnet.gr
References
Case Records of the Massachusetts General Hospital (Case 9-2004). N Engl J Med 2004;350:1236-1247.
Malbrain ML. Abdominal pressure in the critically ill: measurement and clinical relevance. Intensive Care Med 1999;25:1453-1458.
Malbrain ML. Is it wise not to think about intraabdominal hypertension in the ICU? Curr Opin Crit Care 2004;10:132-145.
Annane D, Sebille V, Troche G, Raphael JC, Gajdos P, Bellissant E. A 3-level prognostic classification in septic shock based on cortisol levels and cortisol response to corticotropin. JAMA 2000;283:1038-1045.
The discussant replies: Measurement of the intraabdominal pressure was not performed in this patient. However, it is unlikely that a clinically significant increase in abdominal pressure was present because mechanical ventilation was effectively carried out with relatively low peak inspiratory pressures and positive end-expiratory pressures. With regard to the administration of hydrocortisone, testing for the cortisol response was performed before the administration of the drug, which was then continued until the test showed a positive result, thus no longer indicating that the drug was needed in this patient.
I. David Todres, M.D.
MassGeneral Hospital for Children
Boston, MA 02114
Second, the patient received hydrocortisone after he was found to have a baseline cortisol level of 27.1 μg per deciliter (748 nmol per liter) that increased to 41.5 μg per deciliter (1145 nmol per liter) after the administration of cosyntropin. According to a study by Annane et al.,4 this patient would be classified in the lowest risk group — patients who are considered to have "adequate" activation of the hypothalamic–pituitary–adrenal axis and who would probably not benefit from the administration of corticosteroids.
Petros Kopterides, M.D.
Attikon University Hospital
12462 Athens, Greece
petkop@ath.forthnet.gr
References
Case Records of the Massachusetts General Hospital (Case 9-2004). N Engl J Med 2004;350:1236-1247.
Malbrain ML. Abdominal pressure in the critically ill: measurement and clinical relevance. Intensive Care Med 1999;25:1453-1458.
Malbrain ML. Is it wise not to think about intraabdominal hypertension in the ICU? Curr Opin Crit Care 2004;10:132-145.
Annane D, Sebille V, Troche G, Raphael JC, Gajdos P, Bellissant E. A 3-level prognostic classification in septic shock based on cortisol levels and cortisol response to corticotropin. JAMA 2000;283:1038-1045.
The discussant replies: Measurement of the intraabdominal pressure was not performed in this patient. However, it is unlikely that a clinically significant increase in abdominal pressure was present because mechanical ventilation was effectively carried out with relatively low peak inspiratory pressures and positive end-expiratory pressures. With regard to the administration of hydrocortisone, testing for the cortisol response was performed before the administration of the drug, which was then continued until the test showed a positive result, thus no longer indicating that the drug was needed in this patient.
I. David Todres, M.D.
MassGeneral Hospital for Children
Boston, MA 02114