title: Clinical effects of adding fludrocortisone to a hydrocortisone-based shock protocol in hypotensive critically ill children.
abstract: BACKGROUND
  Adult studies evaluating corticosteroids have found varied efficacy. One study showing mortality benefit utilized fludrocortisone (FLU) and hydrocortisone (HC) (Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA 288:862-871, 2002). Use of FLU in children has not been described. We developed a protocol using HC for systemic inflammatory response syndrome (SIRS) and shock with optional addition of FLU.
  
  
  OBJECTIVE
  Addition of FLU to a HC-based steroid protocol is associated with decreased vasopressor duration without adverse effects in hypotensive children with SIRS.
  
  
  METHODS
  Retrospective review of low-dose HC and FLU supplementation in children with SIRS and fluid refractory shock. Patients receiving FLU in addition to HC were compared with patients receiving HC alone.
  
  
  RESULTS
  Ninety-seven children with SIRS and shock received steroids. Sixty of 97 (62%) received FLU in addition to HC. Seventy-three children required dopamine (DA) infusion, and 56 received norepinephrine (NE). Overall mortality was 7/97 (7%), with 5/7 (71%) nonsurvivors receiving HC + FLU. Fifty of 97 (52%) children with SIRS met definition for sepsis. Septic children who received HC + FLU required NE for significantly shorter duration than those receiving HC alone (p = 0.011). Nineteen of 60 HC + FLU patients (32%) developed nonsymptomatic hypokalemia. Hypokalemia was significantly more common in HC + FLU patients compared with those receiving HC alone (p = 0.05).
  
  
  CONCLUSIONS
  Overall, addition of FLU in children with SIRS was not associated with decreased vasopressor duration or vasopressor score. However, HC + FLU was associated with shorter duration of NE support in the septic subgroup. Hypokalemia was a frequent adverse finding with HC + FLU (p = 0.05). Use of FLU should be considered in further studies evaluating the role of steroids in refractory pediatric septic shock.
authors.affiliation: Division of Critical Care, Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta at Egleston, Atlanta, GA 30322, USA. kiran.hebbar@choa.org
authors.forename: Kiran B
authors.initials: KB
authors.lastname: Hebbar
authors.forename: Jana A
authors.initials: JA
authors.lastname: Stockwell
authors.forename: James D
authors.initials: JD
authors.lastname: Fortenberry
mesh_terms: D000309:Adrenal Insufficiency; D000893:Anti-Inflammatory Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D002648:Child; D002675:Child, Preschool; D002985:Clinical Protocols; D016638:Critical Illness / Q000451:nursing*; D004359:Drug Therapy, Combination; D005438:Fludrocortisone / Q000008:administration & dosage / Q000627:therapeutic use*; D005845:Georgia; D006801:Humans; D006854:Hydrocortisone / Q000008:administration & dosage / Q000627:therapeutic use*; D007022:Hypotension; D007223:Infant; D007231:Infant, Newborn; D012189:Retrospective Studies; D012720:Severity of Illness Index; D012772:Shock, Septic / Q000188:drug therapy* / Q000401:mortality; D016896:Treatment Outcome
chemical_list: D000893:Anti-Inflammatory Agents; D005438:Fludrocortisone; D006854:Hydrocortisone