Cortisol Correlates with Severity of Illness and Poorly Reflects Adrenal Function in Pediatric Acute Respiratory Distress Syndrome.
To test the association between random cortisol and severity of illness in a "real-world" application of current guidelines.



We performed a secondary analysis of a prospective observational cohort of acute respiratory distress syndrome (ARDS). Children with ARDS and vasopressor-dependent shock were identified and random cortisol levels before potential hydrocortisone initiation recorded. The cohort was dichotomized to cortisol < 18 and ≥ 18 μg/dL, and hydrocortisone use and outcomes compared.



Of 357 children with ARDS, 155 (15 nonsurvivors; 10%) had vasopressors initiated with cortisol drawn before possible hydrocortisone use. Patients with cortisol < 18 μg/dL had lower severity of illness scores, fewer organ failures, and lower vasopressor scores (all rank-sum P < .05). No benefit was seen with hydrocortisone in either the entire cohort, or when dichotomized by a cortisol cutoff of 18 μg/dL. In patients with cortisol ≥ 18 μg/dL, hydrocortisone was associated with increased mortality after adjustment for either organ dysfunction or vasopressor score.



In children with ARDS with vasopressor-dependent shock, low cortisol correlated with lower severity of illness. Random cortisol was a poor method of diagnosing adrenal insufficiency, and a strategy of hydrocortisone replacement for cortisol < 18 μg/dL did not target a population likely to benefit from hydrocortisone. Future guidelines should reconsider using random cortisol levels alone for assessing adrenal function.
Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA. Electronic address: yehyan@email.chop.edu.
Nadir
N
Yehya
Division of Endocrinology, Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA.
Maria G
MG
Vogiatzi
Division of Pediatric Critical Care Medicine, Department of Pediatrics and Public Health Science, Penn State Hershey Children's Hospital, Hershey, PA.
Neal J
NJ
Thomas
Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA.
Vijay
V
Srinivasan
D000293:Adolescent; D000309:Adrenal Insufficiency / Q000097:blood* / Q000175:diagnosis*; D002648:Child; D002675:Child, Preschool; D006801:Humans; D006854:Hydrocortisone / Q000097:blood* / Q000627:therapeutic use*; D007223:Infant; D011446:Prospective Studies; D012128:Respiratory Distress Syndrome / Q000097:blood* / Q000175:diagnosis / Q000188:drug therapy* / Q000503:physiopathology; D012720:Severity of Illness Index
D006854:Hydrocortisone
ARDS; acute respiratory distress syndrome; cortisol; pediatric acute respiratory distress syndrome; shock