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A 3 year old boy is admitted to a paediatric intensive care unit with a history of fever, non-blanching petechial rash, decreased conscious level, and grunting; capillary refill is poor. After screening for sepsis, antibiotics are started. He is intubated, receives fluid resuscitation (total of 100 ml/kg), and a central catheter is placed, showing a central venous pressure of 12 mm Hg. Despite dopamine infusion the attending physician is unable to stabilise his blood pressure, and he requires noradrenaline infusion to achieve and maintain his haemodynamic state.
Structured clinical question
In a child with meningococcal shock [patient group] does steroid replacement therapy [intervention] decrease mortality [outcome]?
Search strategy and outcome
Secondary (Cochrane library, 2004) and primary (Medline, Embase, Scielo) sources were included in the search. MeSH terms were used in Medline and Embase.
Search strategies: “meningococcal” AND “steroid replacement”; “meningococcal” AND “steroids” (limited to “all children” from 1984 to 2004); “shock, septic” AND “steroids” (limited to “randomised controlled trials” from 1992 to 2004).
Search outcome: 68 hits (3; 52; 13; each search respectively), of which 6 (0; 3; 3) studies were directly relevant to the question. See tables 1 and 2.
The use of steroids in septic shock has been discussed for decades. The use of high dose steroids (30 mg/kg of methylprednisolone or equivalent) for a short period has been proven not to improve outcome.1 However, the use of low doses (200–300 mg of hydrocortisone in adults; around 2–5 mg/kg/day in children) for longer periods (replacement therapy) has shown very promising results in adults.2–4 Table 1 summarises the main randomised controlled trials testing the use of steroids in low dose for septic shock. Although there is a discrepancy in the populations (and on the criteria for adrenal insufficiency), replacement therapy with steroids showed either significant reduction in the duration of inotrope requirement and 28 day mortality, or a tendency towards improvement. Although no studies have evaluated the use of steroids in paediatric septic shock, expert opinion (for example, the Society of Critical Care Medicine clinical practice parameters8) recommends the use of hydrocortisone in children with septic shock requiring catecholamines for blood pressure support and adrenal insufficiency, as evidenced by total cortisol lower than 18 mg/dl.
Meningococcal septic shock presents with an early, massive inflammatory response. Although absolute adrenal failure due to adrenal haemorrhage is rare, partial adrenal insufficiency has been described in these children even in the absence of adrenal haemorrhage.5–7 Table 2 summarises the main studies that have evaluated adrenal function in children with meningococcal disease. The incidence of adrenal insufficiency varied from 10.3% to 16.9% in children with shock. Of note, children with very severe disease had lower cortisol levels than children with a moderate presentation.5–7 Moreover, after a low dose Synacthen test, cortisol levels did not increase as much in the more severely affected children as they did in children with mild disease.5 These data support the hypothesis that children with meningococcal shock, particularly the more severely affected, can present with reduced adrenal response.
In summary, children with meningococcal shock have increased incidence of abnormal adrenal response, and extrapolation of data from adult septic shock and expert opinion supports the use of hydrocortisone replacement therapy in children with meningococcal shock dependent on catecholamines.
CLINICAL BOTTOM LINE
Adrenal insufficiency is frequent in adults with septic shock, and there is good evidence to support steroid replacement therapy in this group. (Grade A)
There is no direct evidence regarding the use of steroid replacement therapy in children with meningococcal shock.
There is evidence of suppressed adrenal response (adrenal insufficiency) in children with meningococcal shock. (Grade B)
Steroid replacement is a rational therapy that is likely to be of benefit in children with meningococcal shock. (Grade B)
This case is based on experience from several cases. Details have been altered to ensure patient anonymity
Edited by Bob Phillips
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