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Evaluation of adrenal function in critically ill children.

Viviane M P Balbão1, Marcela M A Costa, Margaret Castro

  • 1Department of Paediatrics, Division of Paediatric Critical Care, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil.

Clinical Endocrinology
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Salivary cortisol may help assess adrenal function in critically ill children, though the standard definition of adrenal insufficiency did not correlate with outcomes. A specific salivary cortisol level may indicate an insufficient adrenal response to critical illness.

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Area of Science:

  • Pediatric Critical Care Medicine
  • Pediatric Endocrinology
  • Clinical Chemistry

Background:

  • The assessment of adrenal function in critically ill children lacks a standardized approach.
  • Adrenal insufficiency is a potential complication in critically ill pediatric patients.
  • The clinical significance of adrenal response to critical illness requires further investigation.

Purpose of the Study:

  • To evaluate adrenal function in critically ill children using both serum and salivary cortisol measurements.
  • To determine the association between adrenal function and clinical outcomes in this population.
  • To investigate the utility of salivary cortisol as a more appropriate marker for adrenal response compared to serum cortisol.

Main Methods:

  • Prospective cohort study involving 34 critically ill children and 15 healthy controls.
  • Measurement of serum and salivary cortisol concentrations before and after adrenocorticotropic hormone (ACTH) stimulation.
  • Adrenal insufficiency defined by a serum cortisol increment ≤250 nm (9 μg/dL) post-ACTH; association with outcomes assessed.

Main Results:

  • Serum and salivary cortisol levels were significantly higher in critically ill children compared to controls, with strong correlations between serum and salivary measurements.
  • The incidence of adrenal insufficiency, by the defined criterion, was 32.3% and was associated with a higher Pediatric Risk of Mortality III score.
  • A post-ACTH salivary cortisol level ≤226 nm (8.2 μg/dL) showed 79% sensitivity and 62% specificity for predicting the need for vasoactive or inotropic support.

Conclusions:

  • Adrenal insufficiency, as defined by the 'delta criterion' in serum cortisol, was not significantly associated with major clinical outcomes.
  • Salivary cortisol levels post-ACTH stimulation demonstrated an inverse correlation with the need for vasoactive/inotropic support.
  • A post-ACTH salivary cortisol threshold of ≤226 nm (8.2 μg/dL) may serve as an indicator of insufficient adrenal response in critically ill children.