PEDIATRIC SPECIAL SECTION
In The Literature
Systemic Steroid Use in Pediatric Sepsis Patients
Review by Julia Simmons, MD
Markovitz BP, Goodman DM, Watson RS, et al. A retrospective cohort study of prognostic factors associated with outcome in pediatric severe sepsis: what is the role of steroids? Pediatr Crit Care Med. 2005:6:270-274.
The use of systemic steroids in septic adults with relative adrenal insufficiency has recently been shown to decrease mortality. The use of systemic steroids in the septic pediatric population remains a topic of debate and research focus. The goal of this retrospective cohort study was to determine factors associated with mortality in pediatric patients with severe sepsis treated with systemic steroids.
The authors searched the Pediatric Health Information System for their data. This system is a database for 35 pediatric hospitals within the Child Heath Corporation of America, a children’s hospital consortium. The International Classification Disease Codes for infection were used to search the database for patients from birth through 17 with sepsis during a one-year period.
Severe sepsis was defined as one or more organ dysfunction secondary to an infectious etiology during which the patient required mechanical ventilation and vasoactive medications. The primary outcome variable was mortality. Other variables analyzed included duration of hospitalization, duration of mechanical ventilatory support and vasoactive medications. Predictor variable was the use of parenteral systemic steroids given at least one day during which the patient required artificial ventilation and vasoactive medications.
There were 6,693 participants in the study. Mean days of ventilation was 24.4 +/- 37.3, median 13. Mean number of days hospitalized was 46.8 +/- 51.3 with a median of 30. The mean number of days requiring cardiac supportive medications was 7.8 +/- 9.9 with a median of five. The use of systemic steroids (hydrocortisone, dexamethasone, or methylprednisolone) with increased age, decreased hospital volume, and a history of a hematological/oncological disease were associated with an increased mortality. Even after controlling for the variables, steroids were a strong predictor of mortality. The overall mortality rate in the study was 24%.
In summary, there was an increase in mortality associated with systemic steroid use in the severely septic pediatric patient. As noted by the authors, the study was limited because there was no stratification for disease severity. Further, the rationale for giving the steroids was not known. Overall, larger prospective studies with controlled protocols are necessary in order to make recommendations regarding the use of systemic steroids in septic pediatric patients. TH