Carmean Amanda, Fortenberry James D, McCracken Courtney, Hebbar Kiran B
From the *Division of Critical Care, Department of Pediatrics, Memorial Hospital for Children, University of Colorado, Colorado Springs; †Rocky Vista University College of Osteopathic Medicine, Parker, CO; ‡Division of Critical Care, Department of Pediatrics, Emory University School of Medicine; §Division of Critical Care, Children's Healthcare of Atlanta at Egleston; and §§Department of Pediatrics, Emory University School of Medicine, Atlanta, GA.
Pediatr Emerg Care. 2015 Oct;31(10):694-8. doi: 10.1097/PEC.0000000000000561.
Although corticosteroid (CS) supplementation for pediatric septic shock (PSS) is recommended by American College of Critical Care Medicine sepsis guidelines, most data are based on adult trials. Standardized protocols for stimulation testing for adrenal insufficiency (AI) and CS treatment in children have been reported, but the current state of CS use and protocols have not been evaluated in pediatric intensive care units in the United States. We surveyed a group of pediatric intensivists to assess current approaches.
An electronic survey with 54 questions on attitudes and current use of CSs was distributed to 49 pediatric critical care and 49 pediatric endocrinology fellowship program directors.
Twenty-one (43%) of 49 critical care recipients completed the survey. Eleven (52%) were from medical/surgical units and 10 (48%) were from medical/surgical/cardiac units, with a median of 24 beds and 1614 annual admissions. Thirteen (62%) of 21 recipients rated the importance of steroids in the management of PSS as greater than 4 or 5, with 1 being of no importance and 5 of critical importance. Nineteen (90%) of 21 recipients thought AI occurs "sometimes" or "often" in septic shock. Adrenocorticotropin stimulation testing was frequently used (19 of 21; 90%) but not in protocol. Eighteen (85%) of 21 recipients agreed that "some should" receive "steroids as it improves outcome" and 9% agreed that "most should…" Fourteen (66%) of 21 recipients reported that more than 50% of patients with vasopressor-refractory PSS receive CSs. Hydrocortisone was used in 21 (100%) of 21 recipients, but dosing and duration were variable. Concerns to limit/avoid CSs included hyperglycemia (38%), superinfections (81%), and critical illness myopathy (57%). Only 3 (14%) of 21 recipients reported that they used a CS protocol for PSS. Sixteen (76%) of 21 recipients were not comfortable drawing conclusions from adult studies for PSS. Nineteen (90%) of 21 recipients agreed that it would be important to perform a randomized trial for CS use in PSS.
Corticosteroids are used at most centers for treatment of PSS, but significant variation in attitudes and use exists. Most centers identify AI as frequent; most report variable use of stimulation testing and dosing of CSs. Few centers currently use a standard protocol for diagnosis and treatment. Interest in performing a randomized trial for CSs remains because in part of reluctance to accept adult trial data.
尽管美国危重病医学会脓毒症指南推荐对儿童脓毒性休克（PSS）补充皮质类固醇（CS），但大多数数据基于成人试验。已有关于儿童肾上腺功能不全（AI）刺激试验和CS治疗的标准化方案的报道，但美国儿科重症监护病房中CS的使用现状和方案尚未得到评估。我们对一组儿科重症监护医师进行了调查，以评估当前的治疗方法。
向49名儿科重症监护和49名儿科内分泌 fellowship项目主任分发了一份包含54个关于CS态度和当前使用问题的电子调查问卷。
49名重症监护受访者中有21名（43%）完成了调查。其中11名（52%）来自内科/外科病房，10名（48%）来自内科/外科/心脏病房，平均床位为24张，年入院人数为1614人。21名受访者中有13名（62%）将类固醇在PSS管理中的重要性评为大于4或5，1表示不重要，5表示至关重要。21名受访者中有19名（90%）认为AI在脓毒性休克中“有时”或“经常”发生。促肾上腺皮质激素刺激试验经常被使用（21名中的19名；90%），但并非按照方案进行。21名受访者中有18名（85%）同意“一些患者应该”接受“类固醇，因为它能改善预后”，9%同意“大多数患者应该……”。21名受访者中有14名（66%）报告称，超过50%的血管升压药难治性PSS患者接受了CS治疗。21名受访者中有21名（100%）使用了氢化可的松，但剂量和疗程各不相同。限制/避免使用CS的担忧包括高血糖（38%）、二重感染（81%）和危重病性肌病（57%）。21名受访者中只有3名（14%）报告称他们对PSS使用了CS方案。21名受访者中有16名（76%）对从成人研究中得出PSS的结论不满意。21名受访者中有19名（90%）同意对PSS使用CS进行随机试验很重要。
大多数中心使用皮质类固醇治疗PSS，但态度和使用情况存在显著差异。大多数中心认为AI很常见；大多数报告称刺激试验和CS剂量的使用各不相同。目前很少有中心使用诊断和治疗的标准方案。对进行CS随机试验仍有兴趣，部分原因是不愿接受成人试验数据。
