Rulli Immacolata, Carcione Angelo Mattia, D'Amico Federica, Quartarone Giuseppa, Chimenz Roberto, Gitto Eloisa
Neonatal and Pediatric Intensive Care Unit, University Hospital of Messina, 98124 Messina, Italy.
Pediatric Nephrology with Dialysis Unit, Maternal-Infantile Department, University Hospital of Messina, 98124 Messina, Italy.
J Pers Med. 2024 Dec 17;14(12):1155. doi: 10.3390/jpm14121155.
A controversial aspect of pediatric septic shock management is corticosteroid therapy. Current guidelines do not recommend its use in forms responsive to fluids and inotropes but leave the decision to physicians in forms refractory to the first steps of therapy. Review of literature from January 2013 to December 2023 from online libraries Pubmed, Medline, Cochrane Library, and Scopus. The keywords "septic shock", "steroids" and "children" were used. Of 399 articles, 63 were selected. Regarding mortality, although the 2019 Cochrane review supports reduced mortality, benefits on long-term mortality and in patients with CIRCI (critical illness-related corticosteroid insufficiency) are not clear. Yang's metanalysis and retrospective studies of Nichols and Atkinson show no difference or even an increase in mortality. Regarding severity, the Cochrane review claims that hydrocortisone seems to reduce the length of intensive care hospitalization but influences the duration of ventilatory and inotropic support, and the degree of multi-organ failure appears limited. Further controversies exist on adrenal function evaluation: according to literature, including the Surviving Sepsis Campaign guidelines, basal or stimulated hormonal dosages do not allow the identification of patients who could benefit from hydrocortisone therapy (poor reproducibility). Regarding side effects, muscle weakness, hypernatremia, and hyperglycemia are the most observed. The literature does not give certainties about the efficacy of corticosteroids in pediatric septic shock, as their influence on primary outcomes (mortality and severity) is controversial. A subgroup of patients suffering from secondary adrenal insufficiency could benefit from it, but it remains to be defined how to identify and what protocol to use to treat them.
小儿感染性休克治疗中一个存在争议的方面是皮质类固醇疗法。当前指南不建议在对液体和血管活性药物有反应的情况下使用皮质类固醇，但对于对初始治疗步骤无反应的情况，则由医生自行决定是否使用。回顾了2013年1月至2023年12月在线图书馆PubMed、Medline、Cochrane图书馆和Scopus中的文献。使用了关键词“感染性休克”“类固醇”和“儿童”。在399篇文章中，筛选出63篇。关于死亡率，尽管2019年Cochrane综述支持降低死亡率，但对长期死亡率以及患有危重病相关皮质类固醇功能不全（CIRCI）的患者的益处尚不清楚。Yang的荟萃分析以及Nichols和Atkinson的回顾性研究显示死亡率没有差异甚至有所增加。关于严重程度，Cochrane综述称氢化可的松似乎可缩短重症监护住院时间，但会影响通气和血管活性药物支持的持续时间，多器官衰竭的程度似乎有限。在肾上腺功能评估方面还存在进一步的争议：根据包括《拯救脓毒症运动》指南在内的文献，基础或刺激后的激素剂量无法识别可能从氢化可的松治疗中获益的患者（再现性差）。关于副作用，最常观察到的是肌肉无力、高钠血症和高血糖。皮质类固醇在小儿感染性休克中的疗效尚无定论，因为它们对主要结局（死亡率和严重程度）的影响存在争议。患有继发性肾上腺功能不全的亚组患者可能会从中受益，但如何识别以及使用何种方案治疗他们仍有待确定。
