A Prospective Multicenter Study of Adrenal Function in Critically Ill Children

Abstract

Rationale-Adrenal insufficiency is a clinical condition associated with fluid-and catecholamine-resistant hypotension.Objectives-The objectives of this study were to determine the prevalence of adrenal insufficiency, risk factors and potential mechanisms for its development, and its association with clinically important outcomes in critically ill children.Correspondence and requests for reprints should be addressed to Kusum Menon, M.Sc., Pediatric Intensive Care Unit, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1S 3H2 Canada. menon@cheo.on.ca. * Canadian Critical Care Trials AIP Study Group: Institutions, site investigators, research coordinators, and research assistants (numbers of enrolled patients are shown in parentheses): British Columbia Children's and Women's Hospital, Vancouver, BC, Canada Conflict of Interest Statement:None of the authors has a financial relationship with a commercial entity that has an interest in the subject of this manuscript.The CIHR and CHEORI had no role in the design and conduct of the study, in the collection, analysis and interpretation of the data, or in the preparation of the manuscript. Assistance in the design of the study was provided by the Canadian Critical Care Trials Group. This article has an online supplement, which is accessible from this issue's CIHR Author Manuscript CIHR Author Manuscript CIHR Author ManuscriptMethods-A prospective, cohort study was conducted from 2005 to 2008 in seven tertiary-care, pediatric intensive care units in Canada on patients up to 17 years of age with existing vascular access. Adrenocorticotropic hormone stimulation tests (1 μg) were performed and adrenocorticotropic hormone levels measured in all participants. Measurements and MainResults-A total of 381 patients had adrenal testing on admission. The prevalence of adrenal insufficiency was 30.2% (95% confidence interval, 25.9-35.1). Patients with adrenal insufficiency had higher baseline cortisol levels (28.6 μg/dl vs. 16.7 μg/dl, P < 0.001) and were significantly older (11.5 yr vs. 2.3 yr, P < 0.001) than those without adrenal insufficiency. Adrenal insufficiency was associated with an increased need for catecholamines (P <0.001) and more fluid boluses (P = 0.026). The sensitivity and specificity of the low-dose adrenocorticotropic hormone stimulation test were 100% and 84%, respectively.Conclusions-Adrenal insufficiency occurs in many disease conditions in critically ill children and is associated with an increased use of catecholamines and fluid boluses. It is likely multifactorial in etiology and is associated with high baseline cortisol levels. Further research is necessary to determine which of these critically ill children are truly cortisol deficient before any treatment recommendations can be made. Keywords adrenal gland; adrenal function; adrenocorticotropic hormoneAdrenal insufficiency is a clinical condition associated with hypotension that can be resistant to fluid and catecholamine therapy and, if untreated, can result in increased morta...

Factors affecting consent in pediatric critical care research

“…In this large, multicenter observational study in six Canadian PICUs, we found that the overall consent rate for pediatric critical care research was 80.2% which is higher than what has been previously reported in several studies [4,6,7,20]. Many pediatric critical care studies have, in fact, not reported the consent rate in their manuscripts [21,22] making it difficult for researchers to obtain this information.…”

“…When compared with parents of children admitted to the PICU for all other reasons, parents of children undergoing anticipated or minor surgery were more likely to consent whereas legal guardians of children undergoing cardiac surgery were less likely to provide consent for research. The lower consent rate of cardiac surgery patients is important as these patients comprise 20-40% of participants recruited into previous pediatric critical care research studies [6,7] and 50% of the participants in this study. It will be important for researchers using the cardiac surgery population to incorporate the lower consent rate into their sample size estimation, recruitment processes, and anticipated trial duration.…”

“…However, a single-center pediatric intensive care unit (PICU) study evaluating factors that may influence consent rates [13] found that the presence of pre-existing medical conditions was associated with a lower parental consent rate, whereas patient illness severity was not. A recent large trial in PICU [7] also did not find a difference in illness severity between those in whom consent was and was not obtained. Furthermore, studies suggest that the PICU is a unique environment [14], and that PICU families prioritize their needs differently than those in NICU families [15].…”

“…Obtaining informed consent for research in critically ill patients involves a complex interplay between patient, legal guardian, consent process, and study-related factors. A review of the literature showed limited data on the consent process and consent rates in pediatric critical care research which have varied from 42 to 94% in recent large trials [4][5][6][7][8]. The factors that affect these consent rates are poorly understood and may lead to delays in trial completion and obtaining results that may influence patient care [6], difficulty with planning and financing of clinical studies [4], and questions about the reliability and generalizability of trial results [7].…”

Corticosteroids in septic shock: What should the decision in pediatrics be?

“…Menon et al conducted a very comprehensive work of relative adrenal insufficiency in critically ill children (n=381), not necessarily in shock, in seven pediatric tertiary intensive care units in Canada, supporting the concept of relative adrenal insufficiency in critical conditions. 22 In 2011, the RE-SOLVE trial 23 examined children with severe sepsis who received corticosteroids and showed that disease progression was similar to those who did not receive them. The results (mortality, time using inotropes, mechanical ventilation time, organ failure resolution, changes in mortality score, and hospitalization) were similar in children who were treated with and without steroids.…”