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Corticosteroid Therapy in Critically Ill Pediatric Asthmatic Patients*

Giuliano, John S. Jr MD1; Faustino, Edward Vincent S. MD1; Li, Simon MD2; Pinto, Matthew G. MD2; Canarie, Michael F. MD3; Carroll, Christopher L. MD4

Pediatric Critical Care Medicine: June 2013 - Volume 14 - Issue 5 - p 467–470
doi: 10.1097/PCC.0b013e31828a7451
Feature Articles

Objectives: IV corticosteroids are routinely prescribed to treat critically ill children with asthma. However, no specific dosing recommendations have been made for children admitted to the PICU. We aim to determine current asthma corticosteroid dosing preferences in PICUs within North America.

Design: Cross-sectional, self-administered survey.

Setting: North American PICUs.

Subjects: Pediatric intensivists working in the United States and Canada.

Interventions: None.

Measurements and Main Results: A total of 104 intensivists completed the survey. Of these, 70% worked in the United States, 67% attended in PICUs with at most 20 beds, and 79% had more than 10 years of PICU experience. The majority of asthmatics were admitted to PICUs based on clinical asthma examination/score or because the patient was receiving continuous albuterol. IV methylprednisolone is prescribed by a large majority of intensivists (96%). Of those who prescribe methylprednisolone, 66% use a starting dose of 4 mg/kg/d, whereas 31% use a starting dose of 2 mg/kg/d, and only 3% use 1 mg/kg/d. The large majority of respondents (85%) use “clinical experience” as their rationale for their preferred dosage. In multivariate logistic regression analysis, only knowledge of the National Heart, Lung, and Blood Institute guidelines was an independent predictor of prescribing an initial corticosteroid dose of 4 mg/kg/d (odds ratio, 3.69 [95% CI, 1.26–10.80]; p = 0.017). Country of practice, years of experience, and PICU size were not associated with corticosteroid dosing preference.

Conclusions: Most intensivists administer methylprednisolone to critically ill asthmatics at doses 2 to 4 times higher than recommended by the National Heart, Lung, and Blood Institute guidelines for hospitalized asthmatic children. The rationale for these decisions is likely multifactorial, but in the absence of evidence-based data, most of them cite clinical experience as their deciding factor. Future research is needed to determine the most appropriate corticosteroid dosage in this critically ill patient population.

1Department of Pediatrics, Division of Critical Care Medicine, Yale University School of Medicine, New Haven, CT.

2Department of Pediatrics, Division of Critical Care Medicine, New York Medical College, Valhalla, NY.

3Department of Pediatrics, Division of Critical Care Medicine, Baystate Medical Center, Springfield, MA.

4Department of Pediatrics, Division of Critical Care Medicine, Connecticut Children’s Medical Center, Hartford, CT.

*See also p. 544.

The authors have disclosed that they do not have any potential conflicts of interest.

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©2013The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies