Clinical Endocrinology (2014) 81, 559–565
doi: 10.1111/cen.12444
ORIGINAL ARTICLE
Evaluation of adrenal function in critically ill children ~o*, Marcela M. A. Costa*, Margaret Castro† and Ana P. C. P. Carlotti* Viviane M. P. Balba *Department of Paediatrics, Division of Paediatric Critical Care, Ribeir~ao Preto Medical School, University of S~ao Paulo, and †Department of Internal Medicine, Division of Endocrinology, Ribeir~ao Preto Medical School, University of S~ao Paulo, Ribeir~ao Preto, Brazil
Summary Objective There is no consensus on adequate adrenal response to critical illness. We aimed to evaluate adrenal function in critically ill children and its association with clinical outcome. We hypothesized that salivary cortisol would be a more appropriate tool to evaluate adrenal function in critically ill children. Methods This was a prospective cohort study. The concentrations of serum total and salivary cortisol were measured in 34 critically ill children before and after stimulation with 250 lg adrenocorticotropic hormone (ACTH), and values were compared to a control group of healthy children (n = 15). Association between outcome and adrenal insufficiency defined by an increment in serum cortisol ≤250 nM (9 lg/dl) post-ACTH was assessed. Results Serum total and salivary cortisol concentrations pre- and post-ACTH were significantly higher in patients, and they were correlated at baseline (r = 067; P < 00001) and after ACTH (r = 041; P = 002). The incidence of adrenal insufficiency was 323%. This group had higher Paediatric Risk of Mortality III score (P = 004) but Paediatric Logistic Organ Dysfunction and vasoactive inotropic scores, duration of mechanical ventilation and length of paediatric intensive care unit and hospital stay were not significantly different compared with those with an increment >250 nM (9 lg/dl) post-ACTH. An inverse correlation between salivary cortisol post-ACTH and vasoactive inotropic score (r = 056; P = 00008) was observed. A salivary cortisol concentration post-ACTH of ≤226 nM (82 lg/dl) had a sensitivity of 79% and a specificity of 62% to discriminate need for vasoactive or inotropic support (area under receiver operating characteristic (ROC) curve 074). Conclusion Adrenal insufficiency defined by the ‘delta criterion’ was not associated with outcome. A post-ACTH salivary cortisol of ≤226 nM (82 lg/dl) may be suggestive of an insufficient adrenal response to critical illness.
Correspondence: Ana P.C.P. Carlotti, Department of Paediatrics, Hospital das Clınicas, Ribeir~ao Preto Medical School, University of S~ao Paulo, Avenida dos Bandeirantes, 3900, 14049-900 Ribeir~ao Preto, SP, Brazil. Tel.: 55 16 3602 2479; Fax: 55 16 3602 2700; E-mail: [email protected] The study was performed at the Department of Paediatrics of Ribeir~ao Preto Medical School, University of S~ao Paulo © 2014 John Wiley & Sons Ltd
(Received 17 December 2013; returned for revision 3 January 2014; finally revised 9 February 2014; accepted 25 February 2014)
Introduction The activation of the hypothalamic-pituitary-adrenal axis in response to critical illness and the resulting release of cortisol from the adrenal cortex are essential to stress adaptation and maintenance of cardiovascular homeostasis.1,2 However, the adequacy of glucocorticoid response to stressful situations in critically ill patients has not been established yet. Several criteria have been used to define adrenal insufficiency in this population, including a low basal serum total cortisol [
doi: 10.1111/cen.12444
ORIGINAL ARTICLE
Evaluation of adrenal function in critically ill children ~o*, Marcela M. A. Costa*, Margaret Castro† and Ana P. C. P. Carlotti* Viviane M. P. Balba *Department of Paediatrics, Division of Paediatric Critical Care, Ribeir~ao Preto Medical School, University of S~ao Paulo, and †Department of Internal Medicine, Division of Endocrinology, Ribeir~ao Preto Medical School, University of S~ao Paulo, Ribeir~ao Preto, Brazil
Summary Objective There is no consensus on adequate adrenal response to critical illness. We aimed to evaluate adrenal function in critically ill children and its association with clinical outcome. We hypothesized that salivary cortisol would be a more appropriate tool to evaluate adrenal function in critically ill children. Methods This was a prospective cohort study. The concentrations of serum total and salivary cortisol were measured in 34 critically ill children before and after stimulation with 250 lg adrenocorticotropic hormone (ACTH), and values were compared to a control group of healthy children (n = 15). Association between outcome and adrenal insufficiency defined by an increment in serum cortisol ≤250 nM (9 lg/dl) post-ACTH was assessed. Results Serum total and salivary cortisol concentrations pre- and post-ACTH were significantly higher in patients, and they were correlated at baseline (r = 067; P < 00001) and after ACTH (r = 041; P = 002). The incidence of adrenal insufficiency was 323%. This group had higher Paediatric Risk of Mortality III score (P = 004) but Paediatric Logistic Organ Dysfunction and vasoactive inotropic scores, duration of mechanical ventilation and length of paediatric intensive care unit and hospital stay were not significantly different compared with those with an increment >250 nM (9 lg/dl) post-ACTH. An inverse correlation between salivary cortisol post-ACTH and vasoactive inotropic score (r = 056; P = 00008) was observed. A salivary cortisol concentration post-ACTH of ≤226 nM (82 lg/dl) had a sensitivity of 79% and a specificity of 62% to discriminate need for vasoactive or inotropic support (area under receiver operating characteristic (ROC) curve 074). Conclusion Adrenal insufficiency defined by the ‘delta criterion’ was not associated with outcome. A post-ACTH salivary cortisol of ≤226 nM (82 lg/dl) may be suggestive of an insufficient adrenal response to critical illness.
Correspondence: Ana P.C.P. Carlotti, Department of Paediatrics, Hospital das Clınicas, Ribeir~ao Preto Medical School, University of S~ao Paulo, Avenida dos Bandeirantes, 3900, 14049-900 Ribeir~ao Preto, SP, Brazil. Tel.: 55 16 3602 2479; Fax: 55 16 3602 2700; E-mail: [email protected] The study was performed at the Department of Paediatrics of Ribeir~ao Preto Medical School, University of S~ao Paulo © 2014 John Wiley & Sons Ltd
(Received 17 December 2013; returned for revision 3 January 2014; finally revised 9 February 2014; accepted 25 February 2014)
Introduction The activation of the hypothalamic-pituitary-adrenal axis in response to critical illness and the resulting release of cortisol from the adrenal cortex are essential to stress adaptation and maintenance of cardiovascular homeostasis.1,2 However, the adequacy of glucocorticoid response to stressful situations in critically ill patients has not been established yet. Several criteria have been used to define adrenal insufficiency in this population, including a low basal serum total cortisol [
