Incidence of Adrenal Insufficiency and Impact of Corticosteroid Supplementation in Critically Ill Children with Systemic Inflammatory Syndrome and Vasopressor-Dependent Shock: Hebbar KB, Stockwell JA, Leong T, Fortenberry JD. Crit Care Med 2011;39:1145–50.

Abstract

The importance of diagnosing adrenal insufficiency in pediatric patients with the Systemic Inflammatory Response Syndrome (SIRS) has not been validated, nor has the subsequent treatment with corticosteroids. This study was a retrospective review of 78 patients with a median age of 84 months, who were treated at the Atlanta Pediatric Intensive Care Unit (PICU) with a protocol for steroid supplementation in patients meeting SIRS criteria. The primary outcome was decrease in vasopressor requirements after initiation of steroid treatment. All PICU patients requiring intravenous fluids and vasopressors for treatment of shock were tested for adrenal insufficiency with a standardized corticotrophin stimulation test. Patients were then classified as having absolute adrenal insufficiency (AAI) if a basal cortisol level < 18 mg/dL was measured vs. relative adrenal insufficiency (RAI) if the corticotrophin stimulation test induced a change in measured cortisol levels. Of the initial 78 patients, 44 (56%) had AAI and 39 (50%) had RAI, for a total of 69 (88%) with some degree of adrenal dysfunction. These patients were then treated with weight-based doses of hydrocortisone, with the addition of enteral 9-alpha-fludricortisone at the discretion of the treating physician. A diagnosis of AAI was shown to be associated with increased patient age, higher incidence of Staphylococcus aureus bacteremia, increased mechanical ventilation requirements, and higher vasopressor requirements. A statistically significant decrease in duration of vasopressor use was found in those treated with steroids. Dopamine use decreased from 24 h to 8 h (p < 0.01), norepinephrine from 27.5 h to 8 h, (p = 0.0001). There was no difference found between steroids being initiated before or after 12 h of vasopressor initiation. Overall, 98% (43/44) of patients with AAI and 92% (36/39) with RAI showed a > 50% reduction in vasopressor dosage within 4 h of initiating corticosteroids. Importantly, the study found no incidence of catheter-associated bloodstream infections, ventilator-associated pneumonias, gastric bleeding, or critical illness myopathy/polyneuropathy, some of the often-reported side effects of steroids, although 14 patients (18%) had rebound hypotension after steroid discontinuation requiring additional fluid boluses. Mortality was very low in the entire cohort (5%), so comparisons could not be made between the groups.