There is insufficient evidence to determine whether inhaled nitric oxide is beneficial or harmful for acute hypoxemic respiratory failure in children and adults. While awaiting further studies to prove its benefit, inhaled nitric oxide should not either be recommended as a standard management or excluded for the treatment of acute hypoxemic respiratory failure.
Adrenal insufficiency is a frequent finding in children with septic shock. The low-dose corticotrophin stimulation test seems to be an important tool to distinguish between a normal cortisol response to stress and evidence of adrenal failure. Mortality was significantly higher in children that failed to respond to a corticotrophin stimulation test.
ResumoObjetivo: Revisar os critérios para o diagnóstico e o tratamento da insuficiência adrenal nos pacientes com choque séptico. Fontes dos dados:Artigos publicados em revistas nacionais e internacionais, selecionados nas suas páginas eletrônicas e através do Medline, bem como referências citadas em artigos chaves. Sínteses dos dados:Nos trabalhos publicados na literatura, o achado de insuficiência adrenal em pacientes com choque séptico tem variado entre 17% a 54%. Os dados publicados até a presente data, na literatura consultada, revelam a inexistência de um consenso para o diagnóstico da insuficiência adrenal em pacientes com doenças críticas, particularmente naqueles com choque séptico. A presença de choque refratário a volume e resistente a catecolaminas pode ser aceito como sugestivo, enquanto que um cortisol basal inferior a 25 µg/dl é um critério diagnóstico indicativo de insuficiência adrenal. O teste de estimulação adrenal é um recurso útil na identificação dos pacientes com insuficiência adrenal relativa. Nossa opção de teste para estimulação adrenal em pediatria é a utilização de corticotropina em baixas doses (0,5 µg/ 1,73 m²). Um aumento inferior a 9 µg/dl no valor do cortisol pós-teste sugere a presença de insuficiência adrenal oculta (relativa). Nos pacientes com choque séptico apresentando insuficiência adrenal, suspeita ou confirmada, a utilização de hidrocortisona em dose de choque ou de estresse pode ser vital na sua evolução favorável. Conclusões:Os dados existentes na literatura, embora controversos, já nos permitem especular sobre quando iniciar o tratamento de reposição hormonal, sobre qual o nível sérico de cortisol aceito como adequado e em relação à escolha da dose de corticotropina, para a realização do teste de estimulação adrenal e diagnóstico de insuficiência adrenal oculta ou relativa nos pacientes com choque séptico.J Pediatr (Rio J) 2003;79(Supl.2):S169-S176: Sepse, choque séptico, córtex supra-renal, hipofunção das glândulas supra-renais, glucocorticóides, testes de função do córtex supra-renal. AbstractObjective: To review the criteria for diagnosing and treating adrenal insufficiency in patients with septic shock. Sources of data:Articles published in Brazilian and foreign journals selected through these publications' websites and Medline, as well as references cited in key articles. Summary of the findings:The literature reports a range betwen 17 and 54 % for the finding of adrenal insufficiency in patients with septic shock. There is no consensus for diagnosing adrenal insufficiency in patients suffering from critical diseases, particularly in patients with septic shock. The presence of volume-refractory and catecholamine-resistant septic shock suggests this condition, while basal cortisol under 25 µg/dl is a diagnostic criterion indicating adrenal insufficiency. The adrenal stimulation test is a useful resource for identifying patients with relative adrenal insufficiency. Our testing option for adrenal stimulation in children is the use of corticotropin in low doses (0.5 ...
Objective: To review the criteria for diagnosing and treating adrenal insufficiency in patients with septic shock. Sources of data:Articles published in Brazilian and foreign journals selected through these publications' websites and Medline, as well as references cited in key articles Summary of the findings:The literature reports a range betwen 17 and 54 % for the finding of adrenal insufficiency in patients with septic shock. There is no consensus for diagnosing adrenal insufficiency in patients suffering from critical diseases, particularly in patients with septic shock. The presence of volumerefractory and catecholamine-resistant septic shock suggests this condition, while basal cortisol under 25 µg/dl is a diagnostic criterion indicating adrenal insufficiency. The adrenal stimulation test is a useful resource for identifying patients with relative adrenal insufficiency. Our testing option for adrenal stimulation in children is the use of corticotropin in low doses (0.5 µg/1,73 m²). An increase of less than 9 µg/dl in the value of postcorticotropin-stimulated cortisol suggests the presence of occult (relative) adrenal insufficiency. In patients with septic shock presenting adrenal insufficiency, either suspected or confirmed, the administration of hydrocortisone in shock or stress doses can be vital for a favorable clinical outcome. Conclusions:The existing data, although controversial, already provides a basis to determine when to begin hormone replacement therapy, the serum level of cortisol accepted as adequate, and the choice of corticotropin doses for performing the adrenal stimulation test and diagnosing occult or relative adrenal insufficiency in patients with septic shock. J Pediatr (Rio J) 2003;79(Suppl 2):S169-S76: Sepsis, septic shock, adrenal cortex, adrenal gland hypofunction, glucocorticoids, adrenal cortex function tests.
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