[Adrenal insufficiency in children with septic shock].
OBJECTIVE
To review the criteria for diagnosing and treating adrenal insufficiency in patients with septic shock.


METHODS
Articles published in Brazilian and foreign journals selected through these publicationś websites and Medline, as well as references cited in key articles.


RESULTS
The literature reports a range betwen 17 and 54% for the finding of adrenal insufficiency in patients with septic shock. There is no consensus for diagnosing adrenal insufficiency in patients suffering from critical diseases, particularly in patients with septic shock. The presence of volume-refractory and catecholamine-resistant septic shock suggests this condition, while basal cortisol under 25 micro g/dl is a diagnostic criterion indicating adrenal insufficiency. The adrenal stimulation test is a useful resource for identifying patients with relative adrenal insufficiency. Our testing option for adrenal stimulation in children is the use of corticotropin in low doses (0.5 micro g/1,73 m(2)). An increase of less than 9 micro g/dl in the value of postcorticotropin-stimulated cortisol suggests the presence of occult (relative) adrenal insufficiency. In patients with septic shock presenting adrenal insufficiency, either suspected or confirmed, the administration of hydrocortisone in shock or stress doses can be vital for a favorable clinical outcome.


CONCLUSIONS
The existing data, although controversial, already provides a basis to determine when to begin hormone replacement therapy, the serum level of cortisol accepted as adequate, and the choice of corticotropin doses for performing the adrenal stimulation test and diagnosing occult or relative adrenal insufficiency in patients with septic shock.
Casartelli
Carlos H
CH
Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, RS, Brazil. gtelli@terra.com
Garcia
Pedro Celiny Ramos
PC
Piva
Jefferson Pedro
JP
Branco
Ricardo Garcia
RG
D000304:Adrenal Cortex Function Tests; D000309:Adrenal Insufficiency / Q000175:diagnosis* / Q000188:drug therapy / Q000209:etiology; D000324:Adrenocorticotropic Hormone; D000893:Anti-Inflammatory Agents / Q000627:therapeutic use; D002648:Child; D006801:Humans; D006854:Hydrocortisone / Q000097:blood / Q000627:therapeutic use; D007030:Hypothalamo-Hypophyseal System; D010913:Pituitary-Adrenal System; D012680:Sensitivity and Specificity; D012772:Shock, Septic / Q000150:complications* / Q000188:drug therapy
D000893:Anti-Inflammatory Agents; D000324:Adrenocorticotropic Hormone; D006854:Hydrocortisone