\u0110\u00e3 g\u1ea7n 20 n\u0103m, c\u00e1c b\u00e1c s\u0129 v\u1eabn tranh lu\u1eadn v\u1ec1 vi\u1ec7c c\u00f3 n\u00ean s\u1eed d\u1ee5ng corticosteroid \u0111i\u1ec1u tr\u1ecb cho b\u1ec7nh nh\u00e2n shock nhi\u1ec5m khu\u1ea9n hay kh\u00f4ng.<\/strong>Trong \u1ea5n b\u1ea3n NEJM Journal Watch (General Meidicne) Year in Review 2018, c\u00e1c Editor c\u1ee7a t\u1ea1p ch\u00ed \u0111\u00e3 \u0111i\u1ec3m l\u1ea1i k\u1ebft qu\u1ea3 c\u1ee7a nh\u1eefng nghi\u00ean c\u1ee9u m\u1edbi v\u1ec1 v\u1ea5n \u0111\u1ec1 n\u00e0y. D\u1eef li\u1ec7u ghi nh\u1eadn \u0111\u01b0\u1ee3c ch\u01b0a th\u1ef1c s\u1ef1 \u0111\u1ed3ng nh\u1ea5t v\u1edbi nhau, tuy nhi\u00ean l\u1ee3i \u00edch c\u00f3 th\u1ec3 v\u01b0\u1ee3t qu\u00e1 nguy c\u01a1 tr\u00ean m\u1ed9t s\u1ed1 \u0111\u1ed1i t\u01b0\u1ee3ng b\u1ec7nh nh\u00e2n nh\u1ea5t \u0111\u1ecbnh<\/p>\n \u0110\u00e3 g\u1ea7n 20 n\u0103m, v\u1ea5n \u0111\u1ec1 s\u1eed d\u1ee5ng corticosteroid<\/strong> \u0111i\u1ec1u tr\u1ecb cho b\u1ec7nh nh\u00e2n shock nhi\u1ec5m khu\u1ea9n v\u1eabn t\u1ed3n t\u1ea1i nhi\u1ec1u \u00fd ki\u1ebfn tranh lu\u1eadn. N\u0103m 2018, hai th\u1eed nghi\u1ec7m l\u1edbn \u0111\u00e3 \u0111\u01b0\u1ee3c th\u1ef1c hi\u1ec7n v\u00e0 ti\u1ebfp t\u1ee5c g\u00e2y ra tranh c\u00e3i do k\u1ebft qu\u1ea3 c\u1ee7a ch\u00fang c\u00f3 ph\u1ea7n kh\u00e1c nhau.<\/p>\n Trong th\u1eed nghi\u1ec7m APROCCHSS, t\u1ec9 l\u1ec7 t\u1eed vong trong 90 ng\u00e0y c\u1ee7a nh\u00f3m b\u1ec7nh nh\u00e2n \u0111\u01b0\u1ee3c \u0111i\u1ec1u tr\u1ecb b\u1eb1ng c\u1ea3 glucocorticoid hydrocortison (li\u1ec1u 50 mg m\u1ed7i 6 ti\u1ebfng trong v\u00f2ng 1 tu\u1ea7n) v\u00e0 mineralocorticoid fludrocortison (50 \u03bcg\/ ng\u00e0y) th\u1ea5p h\u01a1n c\u00f3 \u00fd ngh\u0129a so v\u1edbi gi\u1ea3 d\u01b0\u1ee3c (43% so v\u1edbi 49%). Nh\u00f3m b\u1ec7nh nh\u00e2n \u0111\u01b0\u1ee3c \u0111i\u1ec1u tr\u1ecb t\u00edch c\u1ef1c c\u0169ng \u0111\u01b0\u1ee3c d\u1eebng th\u1edf m\u00e1y v\u00e0 d\u1eebng s\u1eed d\u1ee5ng thu\u1ed1c v\u1eadn m\u1ea1ch s\u1edbm h\u01a1n r\u00f5 r\u1ec7t (NEJM JW Gen Med ng\u00e0y 15\/4 and N Engl J Med ng\u00e0y 1\/3; 378:809).<\/p>\n M\u1eb7t kh\u00e1c, th\u1eed nghi\u1ec7m ADRENAL ch\u1ec9 so s\u00e1nh gi\u1eefa hydrocortison v\u1edbi gi\u1ea3 d\u01b0\u1ee3c, k\u1ebft qu\u1ea3 cho th\u1ea5y t\u1ec9 l\u1ec7 t\u1eed vong l\u00e0 nh\u01b0 nhau \u1edf c\u1ea3 2 nh\u00f3m, kho\u1ea3ng 28%. Th\u1eddi gian \u0111i\u1ec1u tr\u1ecb ngo\u00e0i khoa h\u1ed3i s\u1ee9c t\u00edch c\u1ef1c ho\u1eb7c kh\u00f4ng th\u1edf m\u00e1y kh\u00f4ng c\u00f3 s\u1ef1 kh\u00e1c bi\u1ec7t gi\u1eefa 2 nh\u00f3m. Tuy nhi\u00ean c\u0169ng nh\u01b0 k\u1ebft qu\u1ea3 c\u1ee7a th\u1eed nghi\u1ec7m APROCCHSS, th\u1eddi gian \u0111i\u1ec1u tr\u1ecb shock nhi\u1ec5m khu\u1ea9n ng\u1eafn h\u01a1n \u1edf nh\u00f3m b\u1ec7nh nh\u00e2n s\u1eed d\u1ee5ng steroid. (NEJM JW Gen Med ng\u00e0y 1\/3 v\u00e0 N Engl J Med ng\u00e0y 1\/3; 378:797). T\u00e1c d\u1ee5ng kh\u00f4ng mong mu\u1ed1n c\u1ee7a thu\u1ed1c ch\u1ed1ng vi\u00eam steroid \u0111\u1ec1u c\u00f3 t\u1ec9 l\u1ec7 r\u1ea5t nh\u1ecf \u1edf c\u1ea3 2 nghi\u00ean c\u1ee9u.<\/p>\n M\u1ed9t ph\u00e2n t\u00edch g\u1ed9p \u0111\u00e3 \u0111\u01b0\u1ee3c ti\u1ebfn h\u00e0nh tr\u00ean 42 th\u1eed nghi\u1ec7m l\u00e2m s\u00e0ng ph\u00e2n nh\u00f3m ng\u1eabu nhi\u00ean c\u00f3 ki\u1ec3m so\u00e1t (RCT) tr\u00ean 10194 b\u1ec7nh nh\u00e2n. K\u1ebft qu\u1ea3 cho th\u1ea5y s\u1eed d\u1ee5ng corticosteroid c\u00f3 th\u1ec3 l\u00e0m gi\u1ea3m nh\u1eb9 ho\u1eb7c kh\u00f4ng l\u00e0m gi\u1ea3m nguy c\u01a1 t\u1eed vong trong th\u1eddi gian ng\u1eafn (28-31 ng\u00e0y) (m\u1ee9c \u0111\u1ed9 ch\u1eafc ch\u1eafn th\u1ea5p), v\u00e0 c\u00f3 hi\u1ec7u qu\u1ea3 th\u1ea5p trong th\u1eddi gian d\u00e0i (60 ng\u00e0y – 1 n\u0103m) (m\u1ee9c \u0111\u1ed9 ch\u1eafc ch\u1eafn trung b\u00ecnh).<\/p>\n T\u01b0\u01a1ng t\u1ef1 c\u00e1c nghi\u00ean c\u1ee9u tr\u00ean, corticosteroid c\u00f3 th\u1ec3 r\u00fat ng\u1eafn th\u1eddi gian \u0111i\u1ec1u tr\u1ecb t\u1ea1i khoa ICU v\u00e0 th\u1eddi gian n\u1eb1m vi\u1ec7n, \u0111\u1ed3ng th\u1eddi c\u00f3 t\u1ec9 l\u1ec7 h\u1ed3i ph\u1ee5c sau shock cao h\u01a1n v\u00e0 \u0111i\u1ec3m SOFA (thang \u0111i\u1ec3m \u0111\u00e1nh gi\u00e1 suy t\u1ea1ng) th\u1ea5p h\u01a1n v\u00e0o ng\u00e0y \u0111i\u1ec1u tr\u1ecb th\u1ee9 7 (m\u1ee9c \u0111\u1ed9 ch\u1eafc ch\u1eafn cao). M\u1eb7t kh\u00e1c, corticosteroid c\u00f3 th\u1ec3 l\u00e0m t\u0103ng nguy c\u01a1 t\u0103ng natri m\u00e1u, t\u0103ng \u0111\u01b0\u1eddng huy\u1ebft (m\u1ee9c \u0111\u1ed9 ch\u1eafc ch\u1eafn trung b\u00ecnh) v\u00e0 nguy c\u01a1 suy nh\u01b0\u1ee3c th\u1ea7n kinh c\u01a1 (m\u1ee9c \u0111\u1ed9 ch\u1eafc ch\u1eafn th\u1ea5p), ngo\u00e0i ra kh\u00f4ng c\u00f3 t\u00e1c d\u1ee5ng ph\u1ee5 n\u00e0o \u0111\u01b0\u1ee3c t\u00ecm th\u1ea5y (m\u1ee9c \u0111\u1ed9 ch\u1eafc ch\u1eafn th\u1ea5p ho\u1eb7c r\u1ea5t th\u1ea5p). Ph\u00e2n t\u00edch d\u01b0\u1edbi nh\u00f3m kh\u00f4ng cho ra \u0111\u01b0\u1ee3c xu h\u01b0\u1edbng \u0111\u00e1ng tin c\u1eady n\u00e0o \u1edf m\u1ecdi ch\u1ec9 ti\u00eau \u0111\u00e1nh gi\u00e1.<\/p>\n T\u1ea1p ch\u00ed JAMA International Medicine ng\u00e0y 21\/12\/2018 \u0111\u00e3 \u0111\u0103ng t\u1ea3i k\u1ebft qu\u1ea3 ph\u00e2n t\u00edch g\u1ed9p 37 RCT th\u1ef1c hi\u1ec7n tr\u00ean 9564 b\u1ec7nh nh\u00e2n, k\u1ebft qu\u1ea3 thu \u0111\u01b0\u1ee3c t\u01b0\u01a1ng t\u1ef1 c\u00e1c nghi\u00ean c\u1ee9u tr\u00ean.<\/p>\n V\u1eabn ch\u01b0a r\u00f5 li\u1ec7u c\u00e1c corticosteroid c\u00f3 l\u00e0m gi\u1ea3m t\u1ec9 l\u1ec7 t\u1eed vong \u1edf b\u1ec7nh nh\u00e2n shock nhi\u1ec5m khu\u1ea9n hay kh\u00f4ng, nh\u01b0ng nh\u1eefng th\u1eed nghi\u1ec7m tr\u00ean \u0111\u00e3 ch\u1ee9ng minh c\u00e1c corticosteroid c\u00f3 th\u1ec3 r\u00fat ng\u1eafn th\u1eddi gian \u0111i\u1ec1u tr\u1ecb shock nhi\u1ec5m khu\u1ea9n. N\u1ebfu l\u00e0m gi\u1ea3m \u0111\u01b0\u1ee3c th\u1eddi gian \u0111i\u1ec1u tr\u1ecb t\u1ea1i ICU (nghi\u00ean c\u1ee9u ADRENAL) th\u00ec s\u1eed d\u1ee5ng steroid s\u1ebd gi\u00fap b\u1ec7nh nh\u00e2n ti\u1ebft ki\u1ec7m \u0111\u01b0\u1ee3c chi ph\u00ed v\u00e0 h\u1ea1n ch\u1ebf \u0111\u01b0\u1ee3c c\u00e1c nguy c\u01a1, k\u1ec3 c\u1ea3 khi steroid kh\u00f4ng l\u00e0m gi\u1ea3m t\u1ec9 l\u1ec7 t\u1eed vong. Do \u0111\u00f3, v\u1eabn n\u00ean ti\u1ebfp t\u1ee5c s\u1eed d\u1ee5ng c\u00e1c glucocorticoid cho nh\u1eefng b\u1ec7nh nh\u00e2n shock nhi\u1ec5m khu\u1ea9n c\u1ea7n \u0111i\u1ec1u tr\u1ecb b\u1eb1ng nhi\u1ec1u thu\u1ed1c v\u1eadn m\u1ea1ch ho\u1eb7c c\u1ea7n t\u0103ng li\u1ec1u nhanh. Li\u1ec1u fludrocortison trong nghi\u00ean c\u1ee9u APROCCHSS qu\u00e1 th\u1ea5p khi\u1ebfn m\u1ed9t s\u1ed1 ng\u01b0\u1eddi \u0111\u00e3 nghi ng\u1edd t\u00e1c d\u1ee5ng sinh l\u00ed c\u1ee7a n\u00f3 trong khi \u0111\u00e3 s\u1eed d\u1ee5ng glucocorticoid li\u1ec1u cao. Tuy v\u1eady, fludrocortison kh\u00f4ng t\u1ed1n k\u00e9m v\u00e0 vi\u1ec7c d\u00f9ng th\u00eam fludrocortison c\u00f3 v\u1ebb kh\u00f4ng g\u00e2y t\u1ed5n h\u1ea1i g\u00ec, do \u0111\u00f3 s\u1eed d\u1ee5ng ph\u00e1c \u0111\u1ed3 \u0111i\u1ec1u tr\u1ecb nh\u01b0 APROCCHSS (hydrocortison 50 mg m\u1ed7i 6 ti\u1ebfng trong v\u00f2ng 1 tu\u1ea7n v\u00e0 fludrocortison 50 \u03bcg\/ ng\u00e0y) c\u00f3 v\u1ebb kh\u00e1 h\u1ee3p l\u00fd.<\/p>\n