title: Absolute and relative adrenal insufficiency in children with septic shock.
abstract: OBJECTIVE
  Corticosteroid replacement improves outcome in adults with relative adrenal insufficiency and catecholamine-resistant septic shock. We evaluated the relationship of absolute and relative adrenal insufficiency to catecholamine-resistant septic shock in children.
  
  
  METHODS
  Prospective cohort study.
  
  
  METHODS
  University hospital pediatric intensive care unit in Brazil.
  
  
  METHODS
  Fifty-seven children with septic shock. Children with HIV infection, those with a history of adrenal insufficiency, and those submitted to any steroid therapy or etomidate within the week before diagnosis of septic shock were excluded.
  
  
  METHODS
  None.
  
  
  RESULTS
  A short corticotropin test (250 microg) was performed, and cortisol levels were measured at baseline and 30 and 60 mins posttest. Adrenal insufficiency was defined by a response < or =9 microg/dL. Absolute adrenal insufficiency was further defined by a baseline cortisol <20 microg/dL and relative adrenal insufficiency by a baseline cortisol >20 microg/dL. Absolute adrenal insufficiency was observed in 18% of children, all of whom had catecholamine-resistant shock. Relative adrenal insufficiency was observed in 26% of children, of whom 80% had catecholamine-resistant and 20% had dopamine/dobutamine-responsive shock. All children with fluid-responsive shock had a cortisol response >9 microg/dL. Children with adrenal insufficiency had an increased risk of catecholamine-resistant shock (relative risk, 1.88; 95% confidence interval, 1.26-2.79). However, mortality was independently predicted by chronic illness or multiple organ failure (p < .05), not adrenal insufficiency.
  
  
  CONCLUSIONS
  Absolute and relative adrenal insufficiency is common in children with catecholamine-resistant shock and absent in children with fluid-responsive shock. Studies are warranted to determine whether corticosteroid therapy has a survival benefit in children with relative adrenal insufficiency and catecholamine-resistant septic shock.
authors.affiliation: Pediatric Intensive Care Unit, Department of Pediatrics, Instituto da Criança Pedro de Alcântra, Faculdade de Medicina. Universidade de São Paulo, São Paulo-SP 01238-000, Brazil. troster@einstein.br
authors.forename: Cristiane F
authors.initials: CF
authors.lastname: Pizarro
authors.forename: Eduardo J
authors.initials: EJ
authors.lastname: Troster
authors.forename: Durval
authors.initials: D
authors.lastname: Damiani
authors.forename: Joseph A
authors.initials: JA
authors.lastname: Carcillo
mesh_terms: D000293:Adolescent; D000309:Adrenal Insufficiency / Q000175:diagnosis / Q000453:epidemiology* / Q000628:therapy*; D000324:Adrenocorticotropic Hormone / Q000008:administration & dosage*; D017677:Age Distribution; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D015897:Comorbidity; D004351:Drug Resistance; D005260:Female; D005440:Fluid Therapy; D006801:Humans; D006854:Hydrocortisone / Q000378:metabolism; D015994:Incidence; D007223:Infant; D015278:Intensive Care Units, Pediatric / Q000706:statistics & numerical data; D008297:Male; D009102:Multiple Organ Failure / Q000453:epidemiology; D011446:Prospective Studies; D012044:Regression Analysis; D018570:Risk Assessment; D012772:Shock, Septic / Q000453:epidemiology* / Q000628:therapy*; D015996:Survival Rate
chemical_list: D000324:Adrenocorticotropic Hormone; D006854:Hydrocortisone