The use of steroids in children with septicemia: review of the literature and assessment of current practice in PICUs in the UK

Evaluation of Early Corticosteroid Therapy in Management of Pediatric Septic Shock in Pediatric Intensive Care Patients: A Randomized Clinical Study

BACKGROUND

Septic shock is a major healthcare problem. Adrenal insufficiency (AI) in children with septic shock is a recognized complication, yet is controversial regarding its management and effect on mortality. According to the current guidelines, children with risk factors for AI should receive a stress dose of steroids in step 3 of treatment. This study aimed to evaluate and compare early corticosteroid therapy with the traditional use of steroids among pediatric septic shock patients.

METHODS

This prospective randomized interventional clinical study included 3 groups of patients (32 each) and was conducted in Alexandria University pediatric intensive care unit. By protocol, the first group received steroids in step 3 of the treatment according to the current international guidelines (group A), and the second group was managed as group A and was tested for AI by adrenal stimulation test using intramuscular adrenocorticotropic hormone (cosyntropin) (group B). The third group received steroids at the start of fluid therapy (group C). A fourth group (group D) was created by adding patients from groups A and B who needed corticosteroids in the third stage of therapy according to the international protocol in 1 group. All patients were evaluated for basal serum cortisol and plasma adrenocorticotropic hormone concentrations.

RESULTS

The data showed a statistically significant shorter shock reversal time among patients receiving corticosteroids at the start of treatment compared with those who received it at the third step of treatment (P = 0.046); however, mortality was not statistically different among the groups. In addition, there was no superinfection in cases receiving early steroid therapy.

CONCLUSIONS

Early use of corticosteroid in patients with septic shock might shorten the shock reversal time without increase in mortality or superinfection.

Research as a Standard of Care in the PICU

OBJECTIVES

Excellence in clinical care coupled with basic and applied research reflects the maturation of a medical subspecialty, advances that field, and provides objective data for identifying best practices. PICUs are uniquely suited for conducting translational and clinical research. In addition, multiple investigations have reported that a majority of parents are interested in their children's participation in clinical research, even when the research offers no direct benefit to their child. However, such activity may generate ethical conflict with bedside care providers trying to acutely identify the best approach for an individual critically ill child. Ultimately, this conflict may diminish enthusiasm for the generation of scientific evidence that supports the application of evidence-based medicine into PICU clinical standard work. Accordingly this review endeavors to provide an overview of current state PICU clinical research strengths, liabilities, opportunities, and barriers and contrast this with an established pediatric hematology-oncology iterative research model that constitutes a learning healthcare system.

DATA SOURCES, DATA EXTRACTION, AND DATA SYNTHESIS

Narrative review of medical literature published in English.

CONCLUSIONS

Currently, most PICU therapy is not evidence based. Developing a learning healthcare system in the PICU integrates clinical research into usual practice and fosters a culture of evidence-based learning and continual care improvement. As PICU mortality has significantly decreased, identification and validation of patient-centered, clinically relevant research outcome measures other than mortality is essential for future clinical trial design. Because most pediatric critical illness may be classified as rare diseases, participation in research networks will facilitate iterative, collaborative, multiinstitutional investigations that over time identify the best practices to improve PICU outcomes. Despite real ethical challenges, critically ill children and their families should have the opportunity to participate in translational/clinical research whenever feasible.

A survey of stated physician practices and beliefs on the use of steroids in pediatric fluid and/or vasoactive infusion-dependent shock

OBJECTIVE

Limited evidence exists on the use of corticosteroids in pediatric shock. We sought to determine physicians' practices and beliefs with regard to the management of pediatric shock.

DESIGN

Cross-sectional, Internet-based survey.

SETTING

Canada.

SUBJECTS

Physicians identified as practicing pediatric intensive care in any of 15 academic centers.

MEASUREMENTS AND MAIN RESULTS

Seventy of 97 physicians (72.2%) responded. Physicians stated that they were more likely to prescribe steroids for septic shock than for shock following cardiac surgery (odds ratio, 1.9 [95% CI, 0.9-4.3]) or trauma (odds ratio, 11.46 [95% CI, 2.5-51.2]), and 91.4% (64/70) would administer steroids to patients who had received 60 cc/kg of fluid and two or more vasoactive medications. Thirty-five percent of respondents (25/70) reported that they rarely or never conducted adrenal axis testing before giving steroids to patients in shock. Eighty-seven percent of respondents (61/70) stated that the role of steroids in the treatment of fluid and/or vasoactive drug-dependent shock needed to be clarified and that 84.3% would be willing to randomize patients into a trial of steroid efficacy who were fluid resuscitated and on one high-dose vasoactive medication. However, 74.3% stated that they would start open-label steroids in patients who required two high-dose vasoactive medications.

CONCLUSIONS

This survey provides information on the stated beliefs and practices of pediatric critical care physicians with regard to the use of steroids in fluid and/or vasoactive drug-dependent shock. Clinicians feel that the role of steroids in shock still requires clarification and that they would be willing to randomize patients into a trial. This survey may be useful as an initial framework for the development of a future trial on the use of steroids in pediatric shock.

Clinical course of sepsis in children with acute leukemia admitted to the pediatric intensive care unit

OBJECTIVE

To describe the clinical course, resource use, and mortality of patients with leukemia admitted to the pediatric intensive care unit with sepsis and nonsepsis diagnoses over a 10-yr period.

DESIGN

Retrospective analysis.

SETTING

Tertiary medical-surgical pediatric intensive care unit at C.S. Mott Children's Hospital, University of Michigan.

PATIENTS

All patients with leukemia admitted to the pediatric intensive care unit from January 1, 1998, to December 31, 2008.

INTERVENTIONS

None; chart review.

MEASUREMENTS AND MAIN RESULTS

Clinical course was characterized by demographics, leukemia diagnosis, phase of therapy, leukocyte count on admission, presence of sepsis, steroid administration, intensity of care, and Pediatric Risk of Mortality score on admission to the pediatric intensive care unit. The primary outcome was survival to pediatric intensive care unit discharge. Among 68 single admissions to the pediatric intensive care unit with leukemia during the study period, 33 (48.5%) were admitted with sepsis. Admission to the pediatric intensive care unit for sepsis was associated with greater compromise of hemodynamic and renal function and use of stress dose steroids (p = .016), inotropic and/or vasopressor drugs (p = .01), and renal replacement therapy (p = .028) than nonsepsis admission. There was higher mortality among children with sepsis than other diagnoses (52% vs. 17%, p = .004). Also, mortality among children with sepsis was higher among those with acute lymphoblastic leukemia (60% vs. 44%) compared with acute myelogenous leukemia. Administration of stress dose steroids was associated with higher mortality (50% vs. 17%, p = .005) and neutropenia. Patients with acute lymphoblastic leukemia and sepsis showed the greatest mortality and resource use.

CONCLUSIONS

Patients with acute leukemia and sepsis had a much higher mortality rate compared with previously described sepsis mortality rates for the general pediatric intensive care unit patient populations. Patients who received steroids had an increased mortality rate, but given the retrospective nature of this study, we maintain a position of equipoise with regard to this association. Variation in mortality and resource use by leukemia type suggests further research is needed to develop targeted intervention strategies to enhance patient outcomes.

A Single-Center Review of Prescribing Trends and Outcomes of Corticosteroid Replacement Therapy in Critically Ill Children with Septic Shock

Recently published consensus treatment guidelines for pediatric sepsis recommend initiating corticosteroid replacement therapy (CRT) for those critically ill children with adrenal insufficiency and refractory shock. The data to support this recommendation is limited, and multiple studies have demonstrated significant variation in both the diagnosis and treatment of adrenal insufficiency and refractory shock in children. In order to better define the variation in practice at our institution, we retrospectively reviewed the experience with CRT in critically ill children with refractory septic shock over a 1-year-period. In addition, as a secondary aim we compared outcomes in critically ill children treated with CRT for variable lengths of time. We found that the initiation of CRT at our center is relatively consistent. However, we noted significant variation in the duration of CRT and whether CRT was gradually tapered or stopped abruptly. The majority of the patients in our cohort received less than the currently recommended duration of 7 days of CRT. There were a higher number of treatment failures in those patients who received CRT for greater than 7 days, suggesting that CRT should be tapered gradually in these patients. There is significant variation in prescribing trends for CRT at our institution, which are likely to be compounded in any multi-center cohort study of CRT in critically ill children with septic shock. Practice variation in CRT should be standardized to address the impact of CRT in this population.

Practice variability in the assessment and treatment of critical illness-related corticosteroid insufficiency

PURPOSE

Little is known about how published evidence regarding use of steroids in septic shock has been incorporated into clinical practice.

MATERIALS AND METHODS

All patients admitted to an intensive care unit at a single, tertiary-care, academic medical center from November 1, 2004, through February 28, 2005, were screened using the hospital's computerized pharmacy database to determine if they had received at least 1 qualifying medication: cosyntropin, fludrocortisone, hydrocortisone, or dopamine, epinephrine, or norepinephrine as a vasopressor infusion.

RESULTS

Only 58% (95% confidence interval, 47%-69%) of the 81 patients who met criteria for vasopressor-dependent septic shock (VDSS) were evaluated for critical illness-related corticosteroid insufficiency. Forty-seven percent of the 81 patients who met the criteria for VDSS and 49% of the 47 patients who did not meet the criteria for VDSS were treated with corticosteroids. Nearly all (85%; 95% confidence interval, 72%-94%) patients who did not meet the criteria for VDSS received an adrenocorticotropic hormone test.

CONCLUSIONS

Treatment and evaluation of critical illness-related corticosteroid insufficiency in critically ill patients at our institution are inconsistent. Many patients with VDSS do not receive either treatment or evaluation for critical illness-related corticosteroid insufficiency, and patients who do not meet the current criteria are being evaluated and/or treated for critical illness-related corticosteroid insufficiency.

A history of adjunctive glucocorticoid treatment for pediatric sepsis: moving beyond steroid pulp fiction toward evidence-based medicine

OBJECTIVES

To review the history of clinical use of corticosteroids with particular reference to adjunctive therapy for severe pediatric sepsis and, in this context, to provide an overview of what is known, what is not known, and what research questions are particularly relevant at this time.

DATA SOURCE

Literature review using PubMed, cross-referenced article citations, and the Internet.

CONCLUSIONS

The history of corticosteroid use in clinical medicine has been colorful, noisy, and always controversial. Therapeutic corticosteroid indications that initially seemed rational have frequently been refuted on closer, rigorous clinical trial inspection. Although it may be prudent to provide stress-dose steroids to children with septic shock who are clinically at risk for adrenal insufficiency (chronic or recent steroid use, purpura fulminans, etomidate or ketoconazole administration, hypothalamic, pituitary, adrenal disease), the safety and efficacy of stress-dose steroids as general adjunctive therapy for pediatric septic shock have not been established. Glucocorticoid administration does add potential risk to critically ill children. In particular, although adjunctive corticosteroids may hasten resolution of unstable hemodynamics in septic shock, this may occur at the metabolic cost of hyperglycemia. Clinical practice that fosters innovative therapy (off-label use) over research probably represents bad medical and social policy. Accordingly, pediatric critical care researchers have a responsibility to generate pediatric-specific evidence-based medicine for adjunctive corticosteroid therapy for severe sepsis in children.

[Steroids in the critical care children with septic shock and other conditions]

Steroids are indicated in paediatric intensive care as anti-inflammatory drugs or for substitutive treatment. During septic shock, the incidence of adrenal insufficiency (AI) varies between 18 à 52%, depending on the relative or absolute nature of the AI. Contrary to adults, for whom long courses of low doses of corticosteroids were shown to reduce mortality and increased shock reversibility, particularly in those with a negative synacthene test, no study provided sufficient evidence to show a benefit of steroids in terms of outcome in children with septic shock. In neonates, AI occurs frequently after cardiac surgery and the administration of steroids can improve haemodynamic condition. The recommended dose of hydrocortisone during septic shock or after cardiac surgery is 30 to 100 mg/m(2)/d. Dexamethasone is efficient to reduce postextubation stridor in children and neonate and the rate of reintubations in neonate. During croup, oral or parenteral steroids reduce clinical symptoms. Dexamethasone also reduces the incidence of severe chronic lung disease and the duration of tracheal intubation in premature infants. However the high incidence of side effects, particularly on the central nervous system, makes steroids currently not recommended for bronchopulmonary dysplasia. At last, steroids are indicated for severe asthma and for bacterial meningitis. In this latter indication, dexamethasone was shown to improve neurological outcome, indeed mortality in Haemophilus influenzae and Streptococcus pneumoniae meningitis.

Identification of adrenal insufficiency in pediatric critical illness

OBJECTIVE

To determine physicians' beliefs and practices regarding adrenal dysfunction in pediatric critical illness.

DESIGN

Cross-sectional mail survey.

SETTING

Canada.

PARTICIPANTS

All members of the Canadian Pediatric Endocrine Group and all physicians identified as practicing pediatric intensive care medicine in any of 16 tertiary care teaching centers in Canada.

INTERVENTIONS

Three pediatric intensive care physicians and three pediatric endocrinologists reviewed the questionnaire before administration to ensure clarity. We asked participants to report their views on the following: a) the frequency of adrenal insufficiency in pediatric critical illness; b) diagnosis/definition of adrenal insufficiency in pediatric critical illness; and c) the use of empirical glucocorticoids in fluid/vasopressor-resistant hypotension in pediatric critical illness.

MEASUREMENTS AND MAIN RESULTS

Forty-six of 57 (80.7%) endocrinologists responded, with 43 participating (75.4%). Among intensivists, 59 of 70 (84.3%) responded with no refusals. Of intensivists, 81.4% believe that adrenal insufficiency occurs sometimes or often in critically ill pediatric intensive care unit patients, whereas 41.8% of endocrinologists believe adrenal insufficiency occurs never or rarely in these patients. Six definitions of adrenal insufficiency were proposed (varying cortisol level vs. peak/increment of cortisol in response to corticotropin), with no consensus on the definition of adrenal insufficiency from the endocrinologists or intensivists. Half (50.9%) of intensivists said they would sometimes or often empirically treat hypotensive pediatric patients with glucocorticoids, whereas 81.0% of endocrinologists would occasionally or never recommend glucocorticoids on this basis.

CONCLUSIONS

There is no consensus among pediatric intensivists or endocrinologists as to how often adrenal insufficiency occurs in pediatric critical illness or how to diagnose this condition. Despite this lack of consensus, however, many pediatric intensivists would empirically treat hypotensive patients who they suspect may have adrenal insufficiency. Prospective studies are required to determine the definition, frequency, and appropriate treatment of adrenal insufficiency in critically ill pediatric patients.