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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.
Insights
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.
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.
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 μg 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 μg/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 = 0·67; P < 0·0001) and after ACTH (r = 0·41; P = 0·02). The incidence of adrenal insufficiency was 32·3%. This group had higher Paediatric Risk of Mortality III score (P = 0·04) 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 μg/dl) post-ACTH. An inverse correlation between salivary cortisol post-ACTH and vasoactive inotropic score (r = -0·56; P = 0·0008) was observed. A salivary cortisol concentration post-ACTH of ≤226 nm (8·2 μg/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 0·74).
Conclusion:
Adrenal insufficiency defined by the 'delta criterion' was not associated with outcome. A post-ACTH salivary cortisol of ≤226 nm (8·2 μg/dl) may be suggestive of an insufficient adrenal response to critical illness.
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