Adrenal insufficiency in septic shock

Abstract

Background-Functional adrenal insuYciency has been documented in critically ill adults. Objective-To document the incidence of adrenal insuYciency in children with septic shock, and to evaluate its eVect on catecholamine requirements, duration of intensive care, and mortality. Setting-Sixteen-bed paediatric intensive care unit in a university hospital. Methods-Thirty three children with septic shock were enrolled. Adrenal function was assessed by the maximum cortisol response after synthetic adrenocorticotropin stimulation (short Synacthen test). InsuYciency was defined as a post-Synacthen cortisol increment < 200 nmol/l. Results-Overall mortality was 33%. The incidence of adrenal insuYciency was 52% and children with adrenal insuYciency were significantly older and tended to have higher paediatric risk of mortality scores. They also required higher dose vasopressors for haemodynamic stability. In the survivor group, those with adrenal insuYciency needed a longer period of inotropic support than those with normal function (median, 3 v 2 days), but there was no significant diVerence in duration of ventilation (median, 4 days for each group) or length of stay (median, 5 v 4 days). Mortality was not significantly greater in children with adrenal insuYciency than in those with adequate adrenal function (6 of 17 v 5 of 16, respectively). Conclusion-Adrenal insuYciency is common in children with septic shock. It is associated with an increased vasopressor requirement and duration of shock. (Arch Dis Child 1999;80:51-55)

Niño con cardiopatía congénita controlada y muerte inesperada

“…pero como comentó el Dr. Raúl Calzada en una Sesión Anatomoclínica reciente, aun sin este recurso, el uso de dosis fisiológicas de hidrocortisona podría estar indicado en estos casos. [4][5][6] institución, y su precaria condición clínica en franca caída libre, el desenlace fatal era inexorable. Sin embargo, en distintos momentos algunas intervenciones pediátricas pudieron haber modificado dicha evolución.…”

Insuficiência adrenal na criança com choque séptico

“…In this age group work by Hatheril et al, 16 Menon and Clarson, 19 Bone et al, 18 and Pizarro 27 deserve prominence -the last carried out in Brazil (Table 1). The study by Hatheril et al 16 was performed with children with an average age of 48 months (varying from 01 to 192) and with a diagnosis of septic shock. For this study the primary criteria for a diagnosis of supra-renal insufficiency was defined as increased serum cortisol in relation to the baseline, after stimulation with a 145 µg/m² dose of synthetic ACTH.…”

“…In pediatrics, authors prefer to use the standard test (high dosage) and have also used variable doses: Hatheril et al 16 used 145 µg/m², Menon and Clarson 19 fixed doses of 125 µg for children less than 10 kg and 250 µg for children above this weight. Bone et al 18 opted to test with low dosages and used 0.5 µg (500 ng) of 1-24 corticotropin/m².…”

“…The incidence of adrenal insufficiency reported in literature for patients in septic shock, suffers from a strong influence from the criteria adopted to define the diagnosis oscillating from 17% to 54%. 12,14,16,18,19,22 With respect of adults work proliferates on adrenal insufficiency in severe cases, particularly sepsis patients. Work by Annane et al 12 performed at an intensive care unit in France merits prominence as does work by Marik and Zaloga 26 carried out in Washington.…”

“…These studies have found an incidence of insufficient renal function of from 17% to 54% and some of them established an association with the severity of the disease. [12][13][14][15][16][17][18][19] In 2002, the American Institute of Medicine requested the development of directives and clinical practice parameters for the hemodynamic support of newborns and children in septic shock in an attempt to, once implemented, improve the outcome of these patients. Specialists affiliated to the Society of Critical Care Medicine, evaluated the literature, selected specific recommendations and reviewed the compiled recommendations.…”