Adrenal insufficiency and response to corticosteroids in hypotensive critically ill children with cancer

BackgroundAssessment and treatment of adrenal axis function in critically ill pediatric patients with oncologic disorders have not been well elucidated. Critically ill children with oncologic disorders may be at increased risk for adrenal insufficiency (AI).ObjectiveThe aim of the present study was to evaluate the incidence of AI in a cohort of hypotensive patients with oncologic disorders and the correlation of AI with hemodynamic response to corticosteroids.Design/MethodsThis is a retrospective review of pediatric oncology patients with systemic inflammatory response syndrome and vasopressor-dependent shock receiving protocol-based adrenocorticotropin testing and steroid supplementation. Vasopressor dose requirements were evaluated before and after the initiation of corticosteroids. Absolute AI (AAI) was defined as baseline cortisol less than 18 μg/dL. Relative AI (RAI) was defined as δ-cortisol less than 9 μg/dL.ResultsTwenty patients received adrenocorticotropin testing; primary diagnoses were 13 hematologic malignancies and 7 solid tumors. The median age was 132 months (range, 4-224 months). The median fluid resuscitation was 80 mL/kg (range, 60-120 mL/kg), with 10 (50%) of 20 patients requiring mechanical ventilation for a median of 12 days. Overall, 10 (50%) of 20 patients met the definition for RAI, 15 (75%) of 20 met the definition for AAI, and 18 (90%) of 20 had either AAI or RAI. All patients received steroids: 18 (90%) of 20 on dopamine and 17 (85%) of 20 on norepinephrine. After the introduction of steroids, dosage of norepinephrine and dopamine was significantly reduced in 4 hours (P = .0001).ConclusionsBoth RAI and AAI were common in this cohort of critically ill pediatric patients with oncologic disorders. Introduction of steroids was associated with a significant reduction in vasopressors dose.