A retrospective cohort study of prognostic factors associated with outcome in pediatric severe sepsis: What is the role of steroids?*

Markovitz, Barry P.; Goodman, Denise M.; Watson, R. Scott; Bertoch, David; Zimmerman, Jerry J.

doi:10.1097/01.pcc.0000160596.31238.72

Cited by 100 publications

(46 citation statements)

References 9 publications

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“…Markovitz et al studied over 6,000 subjects using the Pediatric Health Information System administrative database and reported that corticosteroids were associated with increased mortality, although they were not able to account for illness severity [13]. Zimmerman et al analyzed the results of the largest interventional clinical trial in pediatric sepsis and found that corticosteroids were not associated with improved outcomes [14].…”

Section: Discussionmentioning

confidence: 99%

“…However, a meta-analysis of small trials showed no benefit attributable to corticosteroids [12]. In addition, two large retrospective observational studies did not show any survival benefit with corticosteroid use in children with septic shock [13], [14]. One of these studies normalized for illness severity and organ failure burden, but did not specifically conduct a risk-stratified analysis [14].…”

Section: Introductionmentioning

confidence: 99%

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Corticosteroids and Pediatric Septic Shock Outcomes: A Risk Stratified Analysis

et al. 2014

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BackgroundThe potential benefits of corticosteroids for septic shock may depend on initial mortality risk.ObjectiveWe determined associations between corticosteroids and outcomes in children with septic shock who were stratified by initial mortality risk.MethodsWe conducted a retrospective analysis of an ongoing, multi-center pediatric septic shock clinical and biological database. Using a validated biomarker-based stratification tool (PERSEVERE), 496 subjects were stratified into three initial mortality risk strata (low, intermediate, and high). Subjects receiving corticosteroids during the initial 7 days of admission (n = 252) were compared to subjects who did not receive corticosteroids (n = 244). Logistic regression was used to model the effects of corticosteroids on 28-day mortality and complicated course, defined as death within 28 days or persistence of two or more organ failures at 7 days.ResultsSubjects who received corticosteroids had greater organ failure burden, higher illness severity, higher mortality, and a greater requirement for vasoactive medications, compared to subjects who did not receive corticosteroids. PERSEVERE-based mortality risk did not differ between the two groups. For the entire cohort, corticosteroids were associated with increased risk of mortality (OR 2.3, 95% CI 1.3–4.0, p = 0.004) and a complicated course (OR 1.7, 95% CI 1.1–2.5, p = 0.012). Within each PERSEVERE-based stratum, corticosteroid administration was not associated with improved outcomes. Similarly, corticosteroid administration was not associated with improved outcomes among patients with no comorbidities, nor in groups of patients stratified by PRISM.ConclusionsRisk stratified analysis failed to demonstrate any benefit from corticosteroids in this pediatric septic shock cohort.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Corticosteroids and Pediatric Septic Shock Outcomes: A Risk Stratified Analysis

et al. 2014

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“…In a larger survey, the PHIS database was analysed and use of steroids was associated with increased mortality. 55 Adrenal function was not assessed in this study. On the basis of these findings of lack of benefit, we suggest that it is both ethical and prudent to further study the role of hydrocortisone treatment in paediatric patients with relative adrenal insufficiency.…”

Section: Recommendationsmentioning

confidence: 97%

What is the rationale for hydrocortisone treatment in children with infection-related adrenal insufficiency and septic shock?

Aneja

Carcillo

2006

Archives of Disease in Childhood

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Recent studies show that children who die from fulminant meningococcaemia have very low cortisol:adrenocorticotrophic hormone (ACTH) ratios within the first 8 h of presentation to emergency facilities compared with survivors. This observation supports the possibility that adrenal insufficiency may contribute to rapid cardiovascular collapse in these children. In recent years, the use of hydrocortisone treatment has become increasingly popular in the care of adult and paediatric patients with septic shock. In this review, the classical adrenal insufficiency literature is presented and the existing rationale for using titrated hydrocortisone treatment (2-50 mg/kg/day) to reverse catecholamine-resistant shock in children who have absolute adrenal insufficiency (defined by peak cortisol level ,18 mg/dl after ACTH challenge) or pituitary, hypothalamic or adrenal axis insufficiency is provided. In addition, the concept of relative adrenal insufficiency (basal cortisol .18 mg/dl but a peak response to ACTH ,9 mg/dl) is reviewed. Although there is a good rationale supporting the use of 7 days of low-dose hydrocortisone treatment (about 5 mg/kg/day) in adults with this condition and catecholamine resistant septic shock, the paediatric literature suggests that it is prudent to conduct more studies before recommending this approach in children.

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“…On day 4 post admission, low-dose intravenous methylprednisolone was started due to persistent hypoalbuminaemia, increased oxygen requirements and risk of septic shock 8. On day 6, the patient became tachycardiac and hypotensive and the blood results showed neutropaenia (WBC 3.25 × 10 3 ), thrombocytopaenia (82 × 10 3 ), anaemia (haemoglobin 8 g/dl) and coagulopathy (D-dimer elevated to 2055 ug/l, prothrombin time rose to 16 s and partial prothrombin time went up to 53 s).…”

Section: Case Presentationmentioning

confidence: 99%

A 10-month-old with rotavirus gastroenteritis, seizures, anasarca and systemic inflammatory response syndrome and complete recovery

Bharwani¹,

Shaukat

Basak

2011

Case Reports

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This report describes a 10-month-old infant who presented with generalised tonic clonic seizures following 2 days of vomiting, diarrhoea and a low-grade fever. The patient was moderately dehydrated and the blood investigations were remarkable for hyponatraemia (126 mEq/l), leukocytosis (19.4 × 10(3)/l (46% lymphocytes)), thrombocytosis (637 × 10(3)/l), hypoalbuminaemia (albumin 1.9 g/dl) and elevated C reactive protein (96 mg/l). Stool was positive for white and red blood cells but the cultures for bacteria were negative. Rotavirus antigen in stool was positive. There was microscopic haematuria without proteinuria and the nasogastric aspirate was coffee ground. Generalised oedema with pleural and peritoneal effusions ensued requiring drainage, correction of fluid and electrolytes imbalance and albumin infusions. Over the next 72 h, the patient descended into shock and disseminated intravascular coagulopathy which required packed red blood cells and fresh frozen plasma transfusions. By day 12 the patient was clinically and biochemically normal.

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A retrospective cohort study of prognostic factors associated with outcome in pediatric severe sepsis: What is the role of steroids?*

Cited by 100 publications

References 9 publications

Corticosteroids and Pediatric Septic Shock Outcomes: A Risk Stratified Analysis

Corticosteroids and Pediatric Septic Shock Outcomes: A Risk Stratified Analysis

What is the rationale for hydrocortisone treatment in children with infection-related adrenal insufficiency and septic shock?

A 10-month-old with rotavirus gastroenteritis, seizures, anasarca and systemic inflammatory response syndrome and complete recovery

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