Do Cortisol Levels Predict the Outcome of Pediatric Oncology Patients Admitted to the PICU for Concerns of Sepsis?

Introduction Sepsis is the leading cause of death in children worldwide and the diagnosis and treatment of sepsis in pediatric patients are often guided by studies of adult patients. Sepsis is a leading cause of morbidity and mortality in febrile pediatric oncology patients, with shock demonstrating even poorer outcomes. Steroid supplementation with hydrocortisone is recommended in patients with septic shock not responsive to fluid and vasopressors, despite the unknown underlying pathophysiological mechanism for this treatment. This recommendation is based on the results of a systematic review that demonstrated reduced mortality when low dose steroids were administered to severely ill adult patients. Steroids are heavily utilized in several pediatric oncologic treatment protocols putting patients at increased risk for adrenal insufficiency. Therefore they may benefit from hydrocortisone early on in their clinical course when admitted for concern of sepsis. Purpose To identify whether or not hydrocortisone supplementation in pediatric oncology patients with low cortisol levels and concern for septic shock results in improved clinical outcomes. Methods We performed a retrospective EMR review of all oncology patients admitted to the pediatric ICU for fever from 2010-2015. Basic demographics, vital signs on admission to the PICU, laboratory data (presenting CBC, cortisol level and absolute neutrophil count), use of pressers, and interventions in the emergency room prior to transfer to the PICU were recorded. Results Each patient who presented with an oncologic diagnosis, fever, and hypotension received at least three 20ml/kg boluses of normal saline in the emergency room. All patients who did not clinically respond to aggressive fluid resuscitation were admitted to the PICU for further management. Not all patients received pressers in the PICU, and the subsequent management varied. Most patients did not receive a cortisol level. In patients with cortisol levels, those with low levels were all given stress dose hydrocortisone at 2mg/kg. Those with high cortisol levels did not receive stress dose steroids. Length of stay in the PICU did not vary between patients who received steroids and those who did not. Conclusion Further prospective studies will need to be performed to assess the utility of steroid use in febrile septic patients. This may also lead to the ability to coordinate care and management of adrenal insufficiency.