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Incidence of adrenal insufficiency and impact of corticosteroid supplementation in critically ill children with systemic inflammatory syndrome and vasopressor-dependent shock*

Hebbar, Kiran B. MD, FAAP; Stockwell, Jana A. MD, FCCM; Leong, Traci PhD; Fortenberry, James D. MD, FCCM

doi: 10.1097/CCM.0b013e31820eb4e4
Pediatric Critical Care

Introduction: Adrenal insufficiency may be common in adults and children with vasopressor-resistant shock. We developed a protocolized approach to low-dose adrenocorticotropin testing and empirical low-dose glucocorticoid/mineralocorticoid supplementation in children with systemic inflammatory response syndrome and persistent hypotension following fluid resuscitation and vasopressor infusion.

Hypothesis: We hypothesized that absolute and relative adrenal insufficiency was common in children with systemic inflammatory response syndrome requiring vasopressor support and that steroid administration would be associated with decreased vasopressor need.

Methods: Retrospective review of pediatric patients with systemic inflammatory response syndrome and vasopressor-dependent shock receiving protocol-based adrenocorticotropin testing and low-dose steroid supplementation. The incidence of absolute and relative adrenal insufficiency was determined using several definitions. Vasopressor dose requirements were evaluated before, and following, initiation of corticosteroids.

Results: Seventy-eight patients met inclusion criteria for systemic inflammatory response syndrome and shock; 40 had septic shock. Median age was 84 months (range, 0.5–295). By adrenocorticotropin testing, 44 (56%) had absolute adrenal insufficiency, 39 (50%) had relative adrenal insufficiency, and 69 (88%) had either form of adrenal insufficiency. Adrenal insufficiency incidence was significantly higher in children >2 yrs (p = .0209). Therapeutic interventions included median 80-mL/kg fluid resuscitation; 65% of patients required dopamine, 58% norepinephrine, and 49% dopamine plus norepinephrine. With steroid supplementation, median dopamine dose decreased from 10 to 4 μg/kg/min at 4 hrs (p = .0001), and median dose of norepinephrine decreased from 0.175 μg/kg/min to 0.05 μg/kg/min at 4 hrs (p = .039).

Conclusions: Absolute and relative adrenal insufficiency was prevalent in this cohort of children with systemic inflammatory response syndrome and vasopressor-dependent shock and increased with age. Introduction of steroids produced a significant reduction in vasopressor duration and dosage. Use of low-dose adrenocorticotropin testing may help further delineate populations who require steroid supplementation.

From the Critical Care Division (KBH, JAS, JDF), Department of Pediatrics, Emory University School of Medicine, and Children's Healthcare of Atlanta at Egleston, Atlanta, GA; and Department of Biostatistics and Bioinformatics (TL), School of Public Health, Emory University, Atlanta, GA.

Supported, in part, by a grant from the Friends Research Fund, Children's Healthcare of Atlanta (JDF, KBH).

The authors have not disclosed any potential conflicts of interest.

For information regarding this article, E-mail: Dr. Kiran B. Hebbar, MD, Critical Care Division, Children's Healthcare of Atlanta at Egleston, 1405 Clifton Road NE, Atlanta, GA 30322. E-mail: kiran.hebbar@choa.org

© 2011 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins