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Clinical effects of adding fludrocortisone to a hydrocortisone-based shock protocol in hypotensive critically ill
Kiran B Hebbar1, Jana A Stockwell, James D Fortenberry
1Division of Critical Care, Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta at Egleston, Atlanta, GA 30322, USA. kiran.hebbar@choa.org
Insights
Adding fludrocortisone (FLU) to hydrocortisone (HC) in pediatric systemic inflammatory response syndrome (SIRS) did not reduce vasopressor duration overall. However, it shortened norepinephrine (NE) use in septic children but increased hypokalemia risk.
Area of Science:
- Pediatric critical care medicine
- Pharmacology
- Endocrinology
Background:
- Corticosteroid efficacy in adult sepsis varies; fludrocortisone (FLU) and hydrocortisone (HC) showed mortality benefit in one adult study.
- The use of FLU in pediatric patients with systemic inflammatory response syndrome (SIRS) and shock has not been previously described.
- A protocol using HC with optional FLU was developed for pediatric SIRS and shock.
Purpose of the Study:
- To evaluate the safety and efficacy of adding FLU to a HC-based steroid protocol in pediatric patients with SIRS.
- To determine if FLU addition impacts vasopressor duration and adverse events in hypotensive children with SIRS.
Main Methods:
- Retrospective review of pediatric patients with SIRS and fluid-refractory shock treated with low-dose HC and optional FLU.
- Comparison of outcomes between patients receiving HC plus FLU and those receiving HC alone.
Main Results:
- Sixty-two percent of 97 pediatric patients received HC + FLU. Septic children receiving HC + FLU had a significantly shorter duration of norepinephrine (NE) support (p=0.011).
- Overall, HC + FLU was not associated with decreased vasopressor duration. Hypokalemia occurred more frequently in the HC + FLU group (32% vs. HC alone, p=0.05).
- Five of seven non-survivors (71%) received HC + FLU, although overall mortality was low (7%).
Conclusions:
- Addition of FLU to HC in pediatric SIRS was not linked to reduced overall vasopressor duration but showed benefit in the septic subgroup for NE duration.
- Hypokalemia is a notable adverse effect of combining HC and FLU in pediatric SIRS patients.
- Further research is warranted to explore the role of FLU in refractory pediatric septic shock management.
Background:
Adult studies evaluating corticosteroids have found varied efficacy. One study showing mortality benefit utilized fludrocortisone (FLU) and hydrocortisone (HC) (Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA 288:862-871, 2002). Use of FLU in children has not been described. We developed a protocol using HC for systemic inflammatory response syndrome (SIRS) and shock with optional addition of FLU.
Hypothesis:
Addition of FLU to a HC-based steroid protocol is associated with decreased vasopressor duration without adverse effects in hypotensive children with SIRS.
Methods:
Retrospective review of low-dose HC and FLU supplementation in children with SIRS and fluid refractory shock. Patients receiving FLU in addition to HC were compared with patients receiving HC alone.
Results:
Ninety-seven children with SIRS and shock received steroids. Sixty of 97 (62%) received FLU in addition to HC. Seventy-three children required dopamine (DA) infusion, and 56 received norepinephrine (NE). Overall mortality was 7/97 (7%), with 5/7 (71%) nonsurvivors receiving HC + FLU. Fifty of 97 (52%) children with SIRS met definition for sepsis. Septic children who received HC + FLU required NE for significantly shorter duration than those receiving HC alone (p = 0.011). Nineteen of 60 HC + FLU patients (32%) developed nonsymptomatic hypokalemia. Hypokalemia was significantly more common in HC + FLU patients compared with those receiving HC alone (p = 0.05).
Conclusions:
Overall, addition of FLU in children with SIRS was not associated with decreased vasopressor duration or vasopressor score. However, HC + FLU was associated with shorter duration of NE support in the septic subgroup. Hypokalemia was a frequent adverse finding with HC + FLU (p = 0.05). Use of FLU should be considered in further studies evaluating the role of steroids in refractory pediatric septic shock.
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