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A retrospective cohort study of prognostic factors associated with outcome in pediatric severe sepsis: What is the role of steroids?*

Markovitz, Barry P. MD, MPH; Goodman, Denise M. MD, MSc; Watson, R Scott MD, MPH; Bertoch, David MHA; Zimmerman, Jerry MD, PhD

Pediatric Critical Care Medicine: May 2005 - Volume 6 - Issue 3 - p 270-274
doi: 10.1097/01.PCC.0000160596.31238.72
Continuing Medical Education

Objective: Systemic corticosteroids remain controversial in the treatment of pediatric patients with severe sepsis. Recent studies in septic adults have shown decreased mortality with the use of hydrocortisone in patients with relative adrenal insufficiency. We conducted this large retrospective cohort study to further characterize severe sepsis in infants and children and correlates of outcome, including the use of steroids.

Design: Retrospective cohort study.

Setting: The Pediatric Health Information System (PHIS), an administrative database of the Child Health Corporation of America (CHCA), was queried for inpatients 0–17 yrs of age with severe sepsis (defined here as an International Classification of Disease 9th edition code for infection with use of simultaneous mechanical ventilation and vasoactive infusions) from 2001 to 2002. In addition to demographic information, use of systemic corticosteroids (hydrocortisone, methylprednisolone, or dexamethasone) concurrent with the ventilatory and vasoactive support was collected.

Subjects: Data from PHIS.

Interventions: None.

Measurements and Main Results: Patients (n = 6693) were identified at 27 PHIS-participating CHCA member hospitals. Overall mortality was 24%; univariate predictors of death included use of steroids (odds ratio [OR], 1.9; 95% confidence interval (CI), 1.7, 2.2), older age (e.g., 13–17 yrs vs. neonates; OR, 1.6; 95% CI, 1.3, 2.0), a hematologic-oncologic diagnosis (OR, 5.87; 95% CI, 4.19, 8.23), and moderate vs. high case volume (OR, 1.25; 95% CI, 1.09, 1.44). Age, hematologic-oncologic diagnosis, case volume, and use of steroids remained independent predictors of mortality in multivariable analysis.

Conclusions: From this administrative database analysis, there is no evidence that steroids are associated with improved outcome in critically ill infants and children with sepsis. Although steroids may be given preferentially to more severely ill children, their use was associated with increased mortality. Clinicians should maintain equipoise on this topic pending prospective randomized clinical trials.

Associate Professor of Anesthesiology and Pediatrics, Washington University School of Medicine, St. Louis Children’s Hospital, St. Louis, MO (BPM); Associate Professor, Feinberg School of Medicine, Northwestern University, Division of Critical Care Medicine, Children’s Memorial Hospital, Chicago, IL (DMG); Assistant Professor, Critical Care Medicine and Pediatrics, University of Pittsburgh School of Medicine, Associate Director, Pediatric Intensive Care Unit, Children’s Hospital of Pittsburgh, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Laboratory, Pittsburgh, PA (RSW); Vice President, Applied Information, Child Health Corporation of America, Shawnee Mission, KS (DB); and Professor of Pediatrics and Anesthesiology, University of Washington School of Medicine, Director, Pediatric Critical Care Medicine, Children’s Hospital and Regional Medical Center, Seattle, WA (JZ).

*See also p. 370.

©2005The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies