Cross-sectional study.
SETTING: Pediatric intensive care unit in a tertiary care hospital in northern India.
PATIENTS: None.
MEASUREMENTS AND MAIN RESULTS: We performed
cortisol estimation at baseline and after low-dose Synacthen (1 microg) stimulation at 30 and 60 mins in children with fluid refractory
septic shock admitted to our pediatric intensive care unit. Basal
cortisol levels <7 microg/dL and peak
cortisol level <18 microg/dL were used to define
adrenal insufficiency. An increment of <9 microg/dL after stimulation was used to diagnose relative
adrenal insufficiency. As there is lack of consensus on the cutoffs for defining relative
adrenal insufficiency using the low-dose
adrenocorticotropic hormone test, we evaluated different cutoff values (increment at 30 mins, increment at 60 mins, greater of the two increments) and evaluated their association with the incidence of
catecholamine refractory
shock and outcomes. Children with
sepsis but without
septic shock were sampled for baseline
cortisol levels as a comparison. Thirty children (15 girls) with
septic shock were included; median age (95% confidence interval) was 36.5 (9.39- 58.45) months. Median Pediatric Risk of Mortality score was 22.5 (14.13-24.87). Fifteen (50%) children survived. The median (95% confidence interval)
cortisol values at baseline and 30 mins and 60 mins after stimulation were 71 (48.74-120.23) microg/dL, 78.1 (56.9-138.15) microg/dL, and 91 (56.17-166.44) microg/dL, respectively. The median baseline
cortisol value in age- and gender-matched children with
sepsis was 11.5 microg/dL. None of the children with
septic shock fulfilled the criteria for absolute
adrenal insufficiency. However, nine (30%) patients had relative
adrenal insufficiency (increment in
cortisol <9 microg/dL). Of these nine patients, five (56%) died; of the 21 patients with a greater increment in
cortisol after stimulation, ten died (p = .69). Compared with patients in
septic shock with normal adrenal reserve, those with relative
adrenal insufficiency had a higher incidence of
catecholamine refractory
shock (p = .019) but no difference in mortality rate (p = .69). On the sensitivity and specificity analysis using various cutoffs of increment, the best discrimination for
catecholamine refractory
shock was obtained with a peak increment <6 microg/dL.
CONCLUSIONS: