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Prescription of Steroids in General Pediatric Intensive Care Patients-A Two-Center Retrospective Observational Study
Rebecca Mitting1, Elizabeth J A Fitchett1,2, Mark J Peters3,4
1Pediatric Intensive Care Unit. St. Mary's Hospital, Imperial College Healthcare National Health Service Trust, London, United Kingdom.
Insights
Steroid use in pediatric intensive care units (PICUs) is common, with administration linked to higher mortality. Specific steroid types and delayed timing increased death risk, necessitating further trials.
Area of Science:
- Pediatric Critical Care Medicine
- Pharmacology
- Clinical Trial Design
Background:
- Steroid administration is frequent in critically ill children, complicating randomized trials on optimal use.
- Understanding current steroid prescribing patterns is essential for designing future pediatric critical care studies.
Purpose of the Study:
- To describe steroid utilization, including type, dose, and timing, in pediatric intensive care units (PICUs).
- To investigate the association between steroid administration and mortality in critically unwell children.
Main Methods:
- Retrospective observational study of 5,483 admissions across two general PICUs from 2016-2019.
- Analysis of parenteral or enteral steroid prescriptions, recording steroid type, frequency, timing, and peak daily doses.
- Multilevel logistic regression modeling to assess the association between steroid use and mortality.
Main Results:
- 33% of admissions involved steroid prescriptions; 42.3% of non-surviving children received steroids.
- Steroid administration was associated with increased mortality (OR, 1.37).
- Hydrocortisone, methylprednisolone, and delayed steroid initiation (>2 days) were linked to significantly higher mortality risks.
Conclusions:
- Steroid use is prevalent in pediatric critical illness and associated with increased mortality.
- The observed association may be influenced by steroid class and timing, reflecting underlying indications.
- Prospective trials are needed to clarify the complex risks and benefits of steroid therapy in pediatric critical care.
Objectives:
Designing randomized trials to determine utility, dose, and timing of steroid administration in the management of critically unwell children may be difficult owing to a high proportion of patients who receive steroid as part of current care. We aimed to describe steroid use among all patients on two general PICUs.
Design:
Retrospective observational study using a multilevel logistic regression model.
Setting:
Two tertiary, general mixed medical and surgical PICUs.
Patients:
All admissions between 2016 and 2019. All parenteral or enteral steroid prescriptions were identified, and steroid type, frequency, timing, and peak daily doses were recorded. The outcome measure was mortality prior to PICU discharge.
Interventions:
None.
Measurements And Main Results:
There were 5,483 admissions during the study period, and 1,804 (33%) of these involved prescription of at least one steroid. Among patients prescribed steroids, the median peak daily dose when steroids were prescribed was 2.4 mg/kg/d prednisolone equivalent (interquartile range, 1.6-3.6), and the median time to peak steroid doses was 2 days (1-5 d). Administration of steroid was associated with increased risk-adjusted mortality odds ratio (OR) of 1.37 (95% CI, 1.04-1.79). Steroids were prescribed in 42.3% of admissions, in which the child did not survive to PICU discharge. Among children who were prescribed steroids, use of hydrocortisone (OR, 6.75; 95% CI, 3.79-12.27) and methylprednisolone (OR, 7.85; 95% CI, 4.21-14.56), or starting steroids later than 2 days after PICU admission were associated with an increased mortality (OR, 1.93; 95% CI, 1.15-3.25).
Conclusions:
Steroids are widely used in pediatric critical illness and nonsurvival associated with increased frequency of use. This association appears to be related to steroid class and timing of dose, both likely to reflect indication for steroid prescription. Prospective trials are required to estimate these complex risks and benefits, and study design will need to consider these patterns.
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