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Submitted on May 18, 2005
Accepted on June 22, 2005
Department of Pediatrics, Division of Endocrinology, Division of Pediatric Intensive Care, Erasmus Medical Center - Sophia Children's Hospital, Department of Internal Medicine, and Department of Epidemiology and Biostatistics, Erasmus Medical Center, The Netherlands
* To whom correspondence should be addressed. E-mail: m.denbrinker{at}erasmusmc.nl.
Context: Adequate adrenal function is pivotal to survive meningococcal sepsis. Objectives: To evaluated adrenocortical function in meningococcal disease. Design: Observational cohort study. Setting: University-affiliated pediatric intensive care unit (PICU). Patients: Sixty children with meningococcal sepsis or septic shock. Main outcome measures: Differences in adrenal function between nonsurvivors (n = 8), shock-survivors (n = 43) and sepsis-survivors (n = 9) on PICU admission. Results: Nonsurvivors had significantly lower median cortisol/ACTH ratio than shock-survivors and sepsis-survivors. Since cortisol binding globulin and albumin levels did not significantly differ between the groups, bio-available cortisol levels were also significantly lower in nonsurvivors than in sepsis-survivors. Nonsurvivors had significantly lower cortisol/11-deoxycortisol ratios, but not lower 11-deoxycortisol/17-OHP ratios than survivors. Using multiple regression analysis, decreased cortisol/ACTH ratio was significantly related to higher IL-6 levels and intubation with etomidate (one single bolus), whereas decreased cortisol/11-deoxycortisol ratio was only significantly related to intubation with etomidate. Aldosterone levels tended to be higher in nonsurvivors than in shock-survivors, whereas plasma renin activity did not significantly differ. Conclusions: Our study shows that the most severely ill children with septic shock had signs of adrenal insufficiency. Bio-available cortisol levels were not more informative on adrenal function than total cortisol levels. Besides disease severity, one single bolus of etomidate during intubation was related to decreased adrenal function and 11
-hydroxylase activity. Decreased adrenal function was not related to decreased 21-hydroxylase activity. Based on our results it seems of vital importance to take considerable caution using etomidate and to consider combining its administration with glucocorticoids during intubation of children with septic shock.
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