Background: The cosyntropin stimulation study (CSS) measures the patient’s ability to adequately mount a cortisol response. Clinically, CSS results may not be used to guide hydrocortisone use. The objective of this study was to examine how the CSS results are associated with clinical parameters, mortality/disease severity, and use of glucocorticoids in pediatric patients with catecholamine- and fluid-resistant shock. Methods: This was a retrospective cohort study of patients who had a CSS during 2009–2014 in the intensive care unit at a children’s hospital. Data collected included clinical variables, mortality, biochemical studies, and glucocorticoid use. PRISM III scores were used to determine the association between CSS results and disease severity. Adequate response to cosyntropin was defined as peak cortisol of 18 µg/dL or higher. Results: Of the 76 patients that underwent CSS, 68 (89%) had an adequate response to cosyntropin. There was a positive correlation between peak cortisol and PRISM III score (r = 0.45, r2 = 0.2). Glucocorticoid was administered in 52/76 (68%) despite several patients with normal CSS results. Conclusions: Sicker patients were more likely to have an adequate response to CSS. Clinically, glucocorticoid supplementation was not based on CSS results. Further prospective studies are needed to elucidate if CSS is a valuable clinical tool.

Keywords:
Cosyntropin, Shock, Pediatric patients, Intensive care unit, Cortisol
1.
Zimmerman JJ: A history of adjunctive glucocorticoid treatment for pediatric sepsis: moving beyond steroid pulp fiction toward evidence-based medicine. Pediatr Crit Care Med 2007; 8: 530–539.
2.
Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, Sevransky JE, Sprung CL, Douglas IS, Jaeschke R, Osborn TM, Nunnally ME, Townsend SR, Reinhart K, Kleinpell RM, Angus DC, Deutschman CS, Machado FR, Rubenfeld GD, Webb SA, Beale RJ, Vincent JL, Moreno R; Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup: Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013; 41: 580–637.
3.
Carmean A, Fortenberry JD, McCracken C, Hebbar KB: A survey of attitudes and practices regarding the use of steroid supplementation in pediatric sepsis. Pediatr Emerg Care 2015; 31: 694–698.
4.
Robert SM, Borasino S, Dabal RJ, Cleveland DC, Hock KM, Alten JA: Postoperative hydrocortisone infusion reduces the prevalence of low cardiac output syndrome after neonatal cardiopulmonary bypass. Pediatr Crit Care Med 2015; 16: 629–636.
5.
Sasser WC, Robert SM, Carlo WF, Borasino S, Dabal RJ, Kirklin JK, Alten JA: Postoperative serum cortisol concentration and adrenal insufficiency in neonates undergoing open-heart surgery. World J Pediatr Congenit Heart Surg 2012; 3: 214–220.
6.
Schiller O, Dagan O, Birk E, Bitan S, Amir G, Frenkel G, Nahum E: Adrenal insufficiency in children undergoing heart surgery does not correlate with more complex postoperative course. Pediatr Cardiol 2013; 34: 1860–1867.
7.
Verweij EJ, Hogenbirk K, Roest AA, van Brempt R, Hazekamp MG, de Jonge E: Serum cortisol concentration with exploratory cut-off values do not predict the effects of hydrocortisone administration in children with low cardiac output after cardiac surgery. Interact Cardiovasc Thorac Surg 2012; 15: 685–689.
8.
Pollack MM, Patel KM, Ruttimann UE: PRISM III: an updated Pediatric Risk of Mortality score. Crit Care Med 1996; 24: 743–752.
9.
Loriaux DL, Fleseriu M: Relative adrenal insufficiency. Curr Opin Endocrinol Diabetes Obes 2009; 16: 392–400.
10.
Annane D, Sebille V, Troche G, Raphael JC, Gajdos P, Bellissant E: A 3-level prognostic classification in septic shock based on cortisol levels and cortisol response to corticotropin. JAMA 2000; 283: 1038–1045.
11.
Pizarro CF, Troster EJ, Damiani D, Carcillo JA: Absolute and relative adrenal insufficiency in children with septic shock. Crit Care Med 2005; 33: 855–859.
12.
Boonen E, Van den Berghe G: Mechanisms in endocrinology: new concepts to further unravel adrenal insufficiency during critical illness. Eur J Endocrinol 2016; 175:R1–R9.
13.
Menon K, McNally JD, Choong K, Ward RE, Lawson ML, Ramsay T, Wong HR: A survey of stated physician practices and beliefs on the use of steroids in pediatric fluid and/or vasoactive infusion-dependent shock. Pediatr Crit Care Med 2013; 14: 462–466.
14.
Kehlet H, Blichert-Toft M, Lindholm J, Rasmussen P: Short ACTH test in assessing hypothalamic-pituitary-adrenocortical function. Br Med J 1976; 1: 249–251.
15.
Fleseriu M, Loriaux DL: “Relative” adrenal insufficiency in critical illness. Endocr Pract 2009; 15: 632–640.
16.
Marcin JP, Pollack MM, Patel KM, Ruttimann UE: Combining physician’s subjective and physiology-based objective mortality risk predictions. Crit Care Med 2000; 28: 2984–2990.
17.
Zimmerman JJ, Williams MD: Adjunctive corticosteroid therapy in pediatric severe sepsis: observations from the RESOLVE study. Pediatr Crit Care Med 2011; 12: 2–8.
18.
Yehya N, Vogiatzi MG, Thomas NJ, Srinivasan V: Cortisol correlates with severity of illness and poorly reflects adrenal function in pediatric acute respiratory distress syndrome. J Pediatr 2016; 177: 212–218.e211.
19.
Onishi S, Miyazawa G, Nishimura Y, Sugiyama S, Yamakawa T, Inagaki H, Katoh T, Itoh S, Isobe K: Postnatal development of circadian rhythm in serum cortisol levels in children. Pediatrics 1983; 72: 399–404.
20.
Rivkees SA: The development of circadian rhythms: from animals to humans. Sleep Med Clin 2007; 2: 331–341.
21.
Checchia PA, Bronicki RA, Costello JM, Nelson DP: Steroid use before pediatric cardiac operations using cardiopulmonary bypass: an international survey of 36 centers. Pediatr Crit Care Med 2005; 6: 441–444.
22.
Crawford JH, Hull MS, Borasino S, Steenwyk BL, Hock KM, Wall K, Alten JA: Adrenal insufficiency in neonates after cardiac surgery with cardiopulmonary bypass. Paediatr Anaesth 2017; 27: 77–84.
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2017
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