Comparação de duas doses do teste ACTH para diagnóstico de insuficiência de corticoesteróides durante choque séptico em crianças

• Autor(a) principal: Amoretti, Carolina Friedrich
• Data de Publicação: 2009
• Tipo de documento: Dissertação
• Idioma: por
• Título da fonte: Repositório Institucional PUCRS
• Texto Completo: http://hdl.handle.net/10923/4689
• topic: MEDICINA; PEDIATRIA; DIAGNÓSTICO; CHOQUE SÉPTICO; CORTICOSTERÓIDES; CRIANÇAS; UNIDADES DE TERAPIA INTENSIVA PEDIÁTRICA; HORMÔNIOS; HIDROCORTISONA; HORMÔNIO ADRENOCORTICOTRÓPICO

Objectives: To review the literature about steroid insufficiency during septic shock; including its definition, clinical presentation, diagnosis and treatment. Then, we aimed to compare the results of ACTH adrenal stimulation test in a dose of 1 mcg/1. 73 m2 against the standart aldult dose of of 250 mcg/1. 73 m2 to identify corticosteroid insufficiency of adrenal gland cause in pediatric patients with septic shock. Method: Initially, we reviewed relevant literature from PubMed searching for pituitary-adrenal function tests, adrenocorticotropic hormone, hydrocortisone, critical illness, sepsis e shock. Based on these findings, we designed a transversal study including children admitted to the Pediatric Intensive Care Unit at Hospital São Lucas (HSL – PUCRS, Brazil), from Jun/ 2008 to Jun/ 2009; who were diagnosed with volume refractory septic shock. Basal cortisol level was determined and, then, both ACTH tests were performed. Tests were performed 4 hours apart. Study protocol was approved by the HSL ethics committee. Results: The 2008 Consensus about corticosteroid insufficiency suggest the approach to this clinical picture as Corticosteroid Insufficiency during Critical Illness, further suggesting the corticosteroid replacement to be done in symptomatic patients, with or without adrenal stimulation tests. Pediatric population studies need improvement but results so far seem similar to those found in adults. However, the pediatric population who could benefit from this replacement is not well defined, and ACTH doses used in adult population may not be adequate in children. So, we studied the relation between the ACTH stimulation test in a dose of 1 mcg/ 1,73 m2 and 250 mcg/1,73 m2 in 27 children with volume refractory septic shock. We found a positive correlation between tests of r=0,72 (r2=0,51), p=0,001 in this population. The Bland & Altman analysis also showed good agreement between tests. Five patients had an inadequate response to tests, but 3 of them were only identified by the low dose test. Conclusions: Although good number and quality of studies about this issue, the final results related to primary endpoints are controversial. Eventhough, initial data in the pediatric population seems to correlate to adult data. In our study, the low dose test was an adequate alternative to the adult standard dose test, and might be more sensible. Bigger studies are necessary to confirm these results.