Adrenal Insufficiency With Sepsis And Septic Shock In Children

Objective: Sepsis and septic shock remain commonly problems that result in significant mortality and morbidity in pediatric and adult intensive care units(PICU/ICU). In this regard, the role of corticosteroid therapy in the management of septic shock has been extensively debated for many years. Recently, investigators have reported hemodynamic and survival benefits associated with the use of more physiologic steroid replacement therapy in adult patients with relative adrenal insufficiency and catecholamine-resistant septic shock. However, there is paucity of data on the magnitude of adrenal insufficiency in septic shock, especially in children. The incidence, importance, and therapeutic approach to adrenal insufficiency with sepsis and septic shock in children are less understood than that in adults. The major criticism of the 250μg ACTH stimulation test is its use of a pharmacologic dosage that results in supraphysiologic stimulation, especially in children, thus potentially inducing a cortisol response in patients with inadequate adrenal reserve. An alternative is the more physiologic 1μg ACTH stimulation test. The aim of our current study conducted a prospective study to determine the prevalence of adrenal insufficiency with sepsis and septic shock using a low-dose adrenocorticotropic hormone(ACTH) stimulation test (1 ug/1.73m2) in children.Methods: Prospective study. We performed cortisol estimation at baseline and after low-dose (1 ug/1.73m2) stimulation at 30 mins in children on the first 24 hours with sepsis or septic shock admitted to our pediatric intensive care unit. The children were classified in four groups according to adrenal function:①Absolute adrenal insufficiency: baseline cortisol <20μg/dl and increment≤9μg/dl.②Relative adrenal insufficiency: baseline cortisol≥20μg/dl and an increment≤9μg/dl.③Adequate adrenal response without an elevated baseline cortisol : baseline cortisol <20μg/dL and an increment >9μg/dl.④Adequate adrenal response: baseline cortisol≥20μg/dl and an increment >9μg/dl.Results:Sixty-two cases with sepsis and septic shock in consecutive admitted to PICU of Shanghai Jiaotong university affiliated Children's hospital during the years from April, 2006 to March, 2007. The median age was 23.4±35.3 months (range, 2–168 months), and their gender distribution was 42cases( 67.7%) male and 20(32.3%)female. 53cases were sepsis ( 85.5%) and 9 with septic shock(14.5%) . The mean pediatric critical illness score(PCIS) was 79.27±9.21 and Median Pediatric Risk of Mortality III (PRISM III) 11.98±8.25, respectively . Overall mortality of sepsis and septic shock was 27.42%. The evaluation of adrenal insufficiency describes as follow:①The mean (95% confidence interval) cortisol levels at baseline(To) and 30 mins after ACTH stimulation(T1) were(31.86±23.04)ug/dl,(45.23±23.07)ug/dl and(45.47±21.27)ug/dl,(57.93±23.19)ug/dl in patients with sepsis and septic shock group, respectively. There were no significantly difference in two groups (p>0.05).②The incidence of adrenal insufficiency in our study population was 40.32% (95% confidence interval) as defined by a response≤9μg/dl post test. The incidence of adrenal insufficiency in sepsis and septic shock were 39.6% and 44.4% , respectively. And there is no significantly difference(X2=0.074,P=1.000).③The serum To and T1 levels were (32.05±22.39)ug/dl(,46.23±21.20)ug/dl and(38.43±25.83)ug/dl, (50.07±23.81)ug/dl , respectively ;And incidence of adrenal insufficiency were 37.78% and 47.06% in patients with survivors and dead groups. There were no significantly difference in two groups (p>0.05).The levels of To and T1 were related to the PCIS(p<0.05). The morbidity of adrenal insufficiency was not related to the PCIS, PRISMⅢ, and amounts of organ insufficiency(p>0.05).④There were not side-effects been observed and not aggravated the disease induced by ACTH injection.Conclusions :①Adrenal insufficiency may occur on patients with sepsis and septic shock in children.②ACTH stimulation test may be helpful to determine whether corticosteroid therapy has a survival benefit with relative adrenal insufficiency. And a low-dose (1ug/1.73m2) ACTH stimulation test can be used to evaluate the adrenal function status of severe sepsis and septic shock in children.