title: Incidence of adrenal insufficiency and impact of corticosteroid supplementation in critically ill children with systemic inflammatory syndrome and vasopressor-dependent shock.
abstract: BACKGROUND
  Adrenal insufficiency may be common in adults and children with vasopressor-resistant shock. We developed a protocolized approach to low-dose adrenocorticotropin testing and empirical low-dose glucocorticoid/mineralocorticoid supplementation in children with systemic inflammatory response syndrome and persistent hypotension following fluid resuscitation and vasopressor infusion.
  
  
  OBJECTIVE
  We hypothesized that absolute and relative adrenal insufficiency was common in children with systemic inflammatory response syndrome requiring vasopressor support and that steroid administration would be associated with decreased vasopressor need.
  
  
  METHODS
  Retrospective review of pediatric patients with systemic inflammatory response syndrome and vasopressor-dependent shock receiving protocol-based adrenocorticotropin testing and low-dose steroid supplementation. The incidence of absolute and relative adrenal insufficiency was determined using several definitions. Vasopressor dose requirements were evaluated before, and following, initiation of corticosteroids.
  
  
  RESULTS
  Seventy-eight patients met inclusion criteria for systemic inflammatory response syndrome and shock; 40 had septic shock. Median age was 84 months (range, 0.5-295). By adrenocorticotropin testing, 44 (56%) had absolute adrenal insufficiency, 39 (50%) had relative adrenal insufficiency, and 69 (88%) had either form of adrenal insufficiency. Adrenal insufficiency incidence was significantly higher in children >2 yrs (p = .0209). Therapeutic interventions included median 80-mL/kg fluid resuscitation; 65% of patients required dopamine, 58% norepinephrine, and 49% dopamine plus norepinephrine. With steroid supplementation, median dopamine dose decreased from 10 to 4 μg/kg/min at 4 hrs (p = .0001), and median dose of norepinephrine decreased from 0.175 μg/kg/min to 0.05 μg/kg/min at 4 hrs (p = .039).
  
  
  CONCLUSIONS
  Absolute and relative adrenal insufficiency was prevalent in this cohort of children with systemic inflammatory response syndrome and vasopressor-dependent shock and increased with age. Introduction of steroids produced a significant reduction in vasopressor duration and dosage. Use of low-dose adrenocorticotropin testing may help further delineate populations who require steroid supplementation.
authors.affiliation: Critical Care Division, Department of Pediatrics, Emory University School of Medicine, and Children's Healthcare of Atlanta at Egleston, Atlanta, GA, 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: Traci
authors.initials: T
authors.lastname: Leong
authors.forename: James D
authors.initials: JD
authors.lastname: Fortenberry
mesh_terms: D000305:Adrenal Cortex Hormones / Q000008:administration & dosage*; D000309:Adrenal Insufficiency / Q000175:diagnosis / Q000188:drug therapy* / Q000401:mortality; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D003422:Critical Care / Q000379:methods; D016638:Critical Illness / Q000401:mortality / Q000628:therapy; D004305:Dose-Response Relationship, Drug; D004334:Drug Administration Schedule; D005260:Female; D005440:Fluid Therapy / Q000379:methods; D005500:Follow-Up Studies; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D015278:Intensive Care Units, Pediatric; D008297:Male; D012189:Retrospective Studies; D018570:Risk Assessment; D018805:Sepsis / Q000175:diagnosis / Q000401:mortality / Q000628:therapy; D016019:Survival Analysis; D018746:Systemic Inflammatory Response Syndrome / Q000175:diagnosis / Q000188:drug therapy* / Q000401:mortality; D016896:Treatment Outcome; D014662:Vasoconstrictor Agents / Q000008:administration & dosage*
chemical_list: D000305:Adrenal Cortex Hormones; D014662:Vasoconstrictor Agents