皮質類固醇在外科手術前後及重症醫學上的實證應用

An Evidence-based Review on the Use of Corticosteroids in Peri-operative and Critical Care

皮質類固醇的藥理作用複雜且廣泛，在臨床上的使用情形很多。我們針對麻醉科醫師在外科手術前後及重症醫學領域上，可能會遇到的皮質類固醇適應症作一完整的文獻回顧，並依所收集到的證據支持度，將其適應症整理如下列建議。有強烈證據支持的絕對適應症包括：腎上腺功能不足、哮喘、過敏反應、急性脊髓受傷、腦瘤併腦壓升高。一般來說效果不錯，而建議使用的情況包括：手術後止吐、某些特定的呼吸衰竭（如急性呼吸窘迫症候群、脂肪栓塞、慢性阻塞性肺病）、腦膿瘍併腦壓升高、甲狀腺風暴和難控制的低體溫症。大劑量的皮質類固醇，在敗血性休克的治療上可能有助益，但仍需進一步的驗證。而在心臟停止、腦部外傷和梗塞所伴隨的腦壓升高、拔除氣管內管後的呼吸道水腫及吸入性肺炎，則不建議給予，因為效果不彰，甚至會進一步惡化病情。使用皮質類固醇的絕對禁忌有：全身性的黴菌感染、病患對皮質類固醇過敏、原因不明的血小板缺乏性紫斑症患者施行肌肉注射給藥，以及近期接受活病毒疫苗的患者。

With complex and extensive pharmacological effects, corticosteroids are widely used in many clinical situations. A survey conducted to define the role of corticosteroids in various settings of peri-operative and critical care gave strong evidence to support that the use of corticosteroid is absolutely indicated in patients with adrenal insufficiency, asthma, anaphylaxis, acute spinal cord injury, and increased ICP resulting from brain tumors. As the benefits of corticosteroids are much in evidence, their uses are recommended to extend to postoperative antiemesis, acute respiratory failure (such as ARDS, COPD, and fat embolism), increased ICP associated with brain abscess, thyroid storm, and refractory hypothermia. Beneficial effect could be expected in septic shock with high-dose corticosteroids. Despite extensive reports on their versatile usefulness, evidence-based review did not recommend the use of corticosteroids in increased ICP associated with traumatic head injury and cerebral infarct, cardiac arrest, post-extubation airway edema, and aspiration pneumonia due to poor effectiveness let alone further worsening of the conditions. Great caution must be taken in clinical situations where administration of corticosteroids is considered contraindicated such as systemic fungal infection, hypersensitivity to the drug, intramuscular injection in idiopathic thrombocytopenia purpura, vaccination with live virus.