Cortisol Correlates with Severity of Illness and Poorly Reflects Adrenal Function in Pediatric Acute Respiratory Distress Syndrome

• Published in: The Journal of pediatrics Vol. 177; pp. 212 - 218.e1
• Main Authors: Yehya, Nadir, Vogiatzi, Maria G., Thomas, Neal J., Srinivasan, Vijay
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.10.2016
• Subjects: acute respiratory distress syndrome; Adolescent; Adrenal Insufficiency - blood; Adrenal Insufficiency - diagnosis; ARDS; Child; Child, Preschool; cortisol; Humans; Hydrocortisone - blood; Hydrocortisone - therapeutic use; Infant; pediatric acute respiratory distress syndrome; Pediatrics; Prospective Studies; Respiratory Distress Syndrome, Adult - blood; Respiratory Distress Syndrome, Adult - diagnosis; Respiratory Distress Syndrome, Adult - drug therapy; Respiratory Distress Syndrome, Adult - physiopathology; Severity of Illness Index; shock; cortisol; VFD; shock; acute respiratory distress syndrome; ACTH; PRISM; ARDS; PICU; pediatric acute respiratory distress syndrome; Pediatric Risk of Mortality; Ventilator-free days; Adrenocorticotropic hormone; Pediatric intensive care unit
• ISSN: 0022-3476; 1097-6833; 1097-6833
• DOI: 10.1016/j.jpeds.2016.05.020

To test the association between random cortisol and severity of illness in a “real-world” application of current guidelines. We performed a secondary analysis of a prospective observational cohort of acute respiratory distress syndrome (ARDS). Children with ARDS and vasopressor-dependent shock were identified and random cortisol levels before potential hydrocortisone initiation recorded. The cohort was dichotomized to cortisol < 18 and ≥ 18 μg/dL, and hydrocortisone use and outcomes compared. Of 357 children with ARDS, 155 (15 nonsurvivors; 10%) had vasopressors initiated with cortisol drawn before possible hydrocortisone use. Patients with cortisol < 18 μg/dL had lower severity of illness scores, fewer organ failures, and lower vasopressor scores (all rank-sum P < .05). No benefit was seen with hydrocortisone in either the entire cohort, or when dichotomized by a cortisol cutoff of 18 μg/dL. In patients with cortisol ≥ 18 μg/dL, hydrocortisone was associated with increased mortality after adjustment for either organ dysfunction or vasopressor score. In children with ARDS with vasopressor-dependent shock, low cortisol correlated with lower severity of illness. Random cortisol was a poor method of diagnosing adrenal insufficiency, and a strategy of hydrocortisone replacement for cortisol < 18 μg/dL did not target a population likely to benefit from hydrocortisone. Future guidelines should reconsider using random cortisol levels alone for assessing adrenal function.