title: A Cohort Study of Pediatric Shock: Frequency of Corticosteriod Use and Association with Clinical Outcomes.
abstract: BACKGROUND
  Pediatric shock is associated with significant morbidity and limited evidence suggests treatment with corticosteroids. The objective of this study was to describe practice patterns and outcomes associated with corticosteroid use in children with shock.
  
  
  METHODS
  We conducted a retrospective, cohort study in four pediatric intensive care units (PICU) in Canada. Patients aged newborn to 17 years admitted to PICU with shock between January 2010 and June 2011 were eligible.
  
  
  RESULTS
  364 patients were included. The frequency of hydrocortisone administration was 22.3% overall (95% CI: 18.0, 26.5) and 59.4% in patients who received at least 60 cc/kg of fluid and were on two or more vasoactive agents. Patients administered hydrocortisone had higher PRISM scores (19, IQR 11-24 versus 9, IQR 5-16; P < 0.0001), higher inotrope scores (15, IQR 10-25 versus 7.5, IQR 3.3-10.6, P < 0.0001) and were more likely to have received 60 cc/kg of fluid resuscitation (59.3% versus 33.6%, OR 2.88, 95% CI: 2.09, 3.96). In an adjusted analysis, patients who received hydrocortisone spent more time on vasoactive infusions (64 versus 34  hours, hazard ratio 0.72, 95% CI: 0.62, 0.84) and had a higher incidence of positive cultures between day 4 and day 28 post admission (24.7% versus 14.5%, OR 1.79, 95% CI: 1.58, 2.04).
  
  
  CONCLUSIONS
  Hydrocortisone administration was associated with longer time on vasopressors and increased incidence of positive cultures even after correcting for illness severity. Caution should be exercised in administering hydrocortisone for shock until there is clear evidence for benefit in this patient population.
authors.affiliation: *Children's Hospital of Eastern Ontario, University of Ottawa †McMaster Children's Hospital, McMaster University ‡Ottawa Hospital Research Institute, University of Ottawa §Cincinnati Children's Hospital Medical Center, University of Cincinnati.
authors.forename: Kusum
authors.initials: K
authors.lastname: Menon
authors.forename: J Dayre
authors.initials: JD
authors.lastname: McNally
authors.forename: Karen
authors.initials: K
authors.lastname: Choong
authors.forename: Margaret L
authors.initials: ML
authors.lastname: Lawson
authors.forename: Tim
authors.initials: T
authors.lastname: Ramsay
authors.forename: James S
authors.initials: JS
authors.lastname: Hutchison
authors.forename: Jennifer
authors.initials: J
authors.lastname: Foster
authors.forename: Hector R
authors.initials: HR
authors.lastname: Wong
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D004363:Drug Utilization / Q000706:statistics & numerical data; D005260:Female; D005938:Glucocorticoids / Q000008:administration & dosage* / Q000009:adverse effects / Q000627:therapeutic use; D017052:Hospital Mortality; D006801:Humans; D006854:Hydrocortisone / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use; D007223:Infant; D007231:Infant, Newborn; D015278:Intensive Care Units, Pediatric; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D009864:Ontario / Q000453:epidemiology; D009894:Opportunistic Infections / Q000139:chemically induced; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D012769:Shock / Q000188:drug therapy* / Q000401:mortality; D016896:Treatment Outcome; D014662:Vasoconstrictor Agents / Q000008:administration & dosage
chemical_list: D005938:Glucocorticoids; D014662:Vasoconstrictor Agents; D006854:Hydrocortisone