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Pediatric Cardiac Intensive Care Society 2014 Consensus Statement: Pharmacotherapies in Cardiac Critical Care Hormone
Carmen L Soto-Rivera1, Michael S D Agus, Jaclyn E Sawyer
11Divisions of Endocrinology and Medicine Critical Care, Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA. 2Division of Pharmacy, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH. 3Paediatric Critical Care Unit, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom.
Insights
Routine hormone replacement therapies are not recommended for children after cardiac surgery. Evidence is insufficient for tight glycemic control, thyroid hormone replacement, and corticosteroid use in various scenarios. Individual patient assessment is crucial.
Area of Science:
- Pediatric Critical Care Medicine
- Pediatric Cardiology
- Pediatric Endocrinology
Background:
- Hormone replacement therapies (HRT) are increasingly considered in pediatric cardiac critical care.
- This review synthesizes current literature on HRT use in this vulnerable population.
- Key areas explored include glycemic control, thyroid hormone replacement, and corticosteroid administration.
Framework:
- A comprehensive literature search was conducted across PubMed, EMBASE, and Cochrane Library.
- Studies focused on pediatric patients (0-18 years), with adult data considered if pediatric evidence was sparse.
- All relevant clinical studies were reviewed for data extraction and synthesis.
Implementation:
- Glycemic control: Routine tight glycemic control is not recommended post-cardiac surgery despite potential benefits for some children.
- Thyroid hormone replacement: Current evidence does not support routine thyroid hormone replacement to normalize levels after cardiac surgery.
- Corticosteroids: Evidence is insufficient to recommend routine corticosteroid use during cardiopulmonary bypass, for refractory hypotension, or for critical illness-related corticosteroid insufficiency post-cardiac surgery.
Implications:
- Current evidence does not support the routine use of tight glycemic control, thyroid hormone replacement, or corticosteroids in pediatric cardiac critical care.
- Further high-quality randomized controlled trials are needed to establish evidence-based recommendations.
- Therapeutic decisions regarding HRT in these patients should be individualized based on specific clinical circumstances and evolving evidence.
Objective:
To provide an overview of the current literature on the use of hormone replacement therapies in pediatric cardiac critical care.
Data Sources:
PubMed, EMBASE, and the Cochrane Library were searched using keywords relevant to the hormonal therapy, with no limits on language but restricting the search to children 0-18 years old.
Study Selection:
All clinical studies believed to have relevance were considered. Where studies in children were sparse, additional evidence was sought from adult studies.
Data Extraction:
All relevant studies were reviewed, and the most relevant data were incorporated in this review.
Data Synthesis:
All authors of this review contributed to the appraisal of the data extracted. Challenges and revisions by the authors were conducted by group e-mail debate.
Conclusions:
Glycemic control: although it is likely that some children could benefit, the routine use of tight glycemic control cannot be recommended in children after cardiac surgery. Thyroid hormone replacement: routine use of thyroid hormone replacement to normalize levels after cardiac surgery cannot be recommended on current evidence. Until further evidence from adequately powered studies is available, therapeutic decisions should be based on individual patient circumstances. Corticosteroids: 1) cardiopulmonary bypass: although studies seem to favor steroid administration during surgery with cardiopulmonary bypass, a large randomized controlled trial is required before strong recommendations can be made; 2) refractory hypotension: the evidence for the use of steroid replacement in refractory hypotension is poor, and no firm recommendations can be made; and 3) abnormal adrenal function after cardiac surgery: there is inadequate evidence on which to make recommendations on the use of corticosteroid replacement in children with critical illness-related corticosteroid insufficiency in children following cardiac surgery.
