Adrenal insufficiency and response to corticosteroids in hypotensive critically ill children with cancer.
BACKGROUND
Assessment and treatment of adrenal axis function in critically ill pediatric patients with oncologic disorders have not been well elucidated. Critically ill children with oncologic disorders may be at increased risk for adrenal insufficiency (AI).


OBJECTIVE
The aim of the present study was to evaluate the incidence of AI in a cohort of hypotensive patients with oncologic disorders and the correlation of AI with hemodynamic response to corticosteroids.


METHODS
This is a retrospective review of pediatric oncology patients with systemic inflammatory response syndrome and vasopressor-dependent shock receiving protocol-based adrenocorticotropin testing and steroid supplementation. Vasopressor dose requirements were evaluated before and after the initiation of corticosteroids. Absolute AI (AAI) was defined as baseline cortisol less than 18 μg/dL. Relative AI (RAI) was defined as δ-cortisol less than 9 μg/dL.


RESULTS
Twenty patients received adrenocorticotropin testing; primary diagnoses were 13 hematologic malignancies and 7 solid tumors. The median age was 132 months (range, 4-224 months). The median fluid resuscitation was 80 mL/kg (range, 60-120 mL/kg), with 10 (50%) of 20 patients requiring mechanical ventilation for a median of 12 days. Overall, 10 (50%) of 20 patients met the definition for RAI, 15 (75%) of 20 met the definition for AAI, and 18 (90%) of 20 had either AAI or RAI. All patients received steroids: 18 (90%) of 20 on dopamine and 17 (85%) of 20 on norepinephrine. After the introduction of steroids, dosage of norepinephrine and dopamine was significantly reduced in 4 hours (P = .0001).


CONCLUSIONS
Both RAI and AAI were common in this cohort of critically ill pediatric patients with oncologic disorders. Introduction of steroids was associated with a significant reduction in vasopressors dose.
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
Kiran B
KB
Hebbar
Toni
T
Petrillo
James D
JD
Fortenberry
D000293:Adolescent; D000305:Adrenal Cortex Hormones / Q000627:therapeutic use*; D000309:Adrenal Insufficiency / Q000175:diagnosis / Q000188:drug therapy*; D000324:Adrenocorticotropic Hormone / Q000627:therapeutic use; D002648:Child; D002675:Child, Preschool; D016638:Critical Illness; D006801:Humans; D006854:Hydrocortisone / Q000627:therapeutic use; D007022:Hypotension / Q000188:drug therapy / Q000453:epidemiology; D007223:Infant; D009369:Neoplasms / Q000453:epidemiology*; D012189:Retrospective Studies; D018746:Systemic Inflammatory Response Syndrome / Q000188:drug therapy* / Q000453:epidemiology*; D014662:Vasoconstrictor Agents / Q000627:therapeutic use
D000305:Adrenal Cortex Hormones; D014662:Vasoconstrictor Agents; D000324:Adrenocorticotropic Hormone; D006854:Hydrocortisone