SAN FRANCISCO – Adjunctive corticosteroid therapy for pediatric septic shock was associated with increased risks for a complicated course or death within 28 days in a retrospective study of data on 496 patients.
The investigators hypothesized that any potential benefit from adjunctive corticosteroids might depend on the patient’s initial risk of death, but they found no significant differences in outcomes between subgroups of patients that were rated as low risk, intermediate risk, or high risk at baseline using the Pediatric Sepsis Biomarker Risk Model (PERSEVERE) and received corticosteroids.
Among the 252 patients who received corticosteroids, 17% died within 38 days and 32% had a complicated course, defined as persistence of two or more organ failures at day 7 of septic shock or death within 28 days. Those rates were significantly higher than among the 244 patients who did not get corticosteroids, 8% of whom died within 28 days and 22% of whom had a complicated course, Dr. Sarah J. Atkinson and her associates reported.
Dr. Sarah J. Atkinson
The PERSEVERE-based mortality probability at baseline did not differ significantly between patients who did or did not get corticosteroids, though those who got corticosteroids had higher risk scores at baseline when assessed using the Pediatric Risk of Mortality score (PRISM).
Patients who got corticosteroids were twice as likely to die and nearly twice as likely to have a complicated course, compared with the no-corticosteroid group, she said at the annual clinical congress of the American College of Surgeons. The risks of death or complicated course did not differ significantly based on steroid use, however, in the 323 patients deemed to be low risk, the 117 intermediate-risk patients, or the 56 high-risk patients as rated by PERSEVERE. “Even in high-risk patients, the sickest patients, we do not even see a trend for benefit” from the use of corticosteroids, she said.
Because the corticosteroid group had a higher rate of comorbidity (42%), compared with the no-corticosteroid group (29%), the investigators conducted a sensitivity analysis of data on a subset of 321 patients without any comorbidities. Steroid use was associated with a 2.6 odds ratio for dying within 28 days and a doubling in odds for a complicated course, reported Dr. Atkinson of the University of Cincinnati.
“Risk-stratified analysis failed to demonstrate any benefit associated with corticosteroid use as adjunctive therapy for pediatric septic shock and suggests the possibility for harm in some patients,” Dr. Atkinson said. A randomized, controlled trial would be needed to identify any efficacy of corticosteroids as adjunct therapy in children with septic shock, she added.
Use of steroids in septic shock remains heavily debated, with no consensus and varying practices among physicians, she said. The 2012 update of Surviving Sepsis guidelines suggests “timely hydrocortisone therapy in children with fluid-refractory, catecholamine-resistant shock and suspected or proven absolute [classic] adrenal insufficiency,” Dr. Atkinson noted.
The current study analyzed data from a database of 27 pediatric centers on children who received corticosteroids within 7 days of ICU admission. In the corticosteroid group, 79% received hydrocortisone, 15% got methylprednisolone, and 6% received dexamethasone. Fluticasone, budesonide, or less than 48 hours of dexamethasone were classified as no steroids. Corticosteroids were administered for a median of 5 days starting on the day patients met criteria for septic shock.
Dr. Atkinson reported having no financial disclosures.
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