Stress Dosing of Steroid Third QPEM Conference 11-13 th of January 2019 Dr. Mahmoud Alrifaai Consultant pediatrics . PEC. Alsadd
DISCLOSURE I do not have any relevant financial relationship with commercial interest to disclose.
Learning Objective Assess the need for steroid stress dose in different situations.
Examples • Case -1 : 12 years old male with CAH . Acute vomiting, abdominal pain, temperature of 38.5, hypotensive .
Examples • Case -1 : 12 years old male with CAH . Acute vomiting, abdominal pain, temperature of 38.5, hypotensive . • Case -2 : 4 months old male with congenital hypopituitarism . URTI and fever of 38.3C. , no vomiting , normal V.S . Usual medication hydrocortisone total is 5 mg/day.
Examples • Case -1 : 12 years old male with CAH . Acute vomiting, abdominal pain, temperature of 38.5, hypotensive . • Case -2 : 4 months old male with congenital hypopituitarism . URTI and fever of 38.3C. , no vomiting , normal V.S . Usual medication hydrocortisone total is 5 mg/day. • Case -3 : 3 years old female with nephrotic syndrome , wt. 15 kg , on prednisolone 5mg every other day . Loose motion and fever 39c ,no vomiting . Normal V.S .
Introduction Alamy Stock Photo Image ID: D9NTJ7
Introduction • GLUCOCORTICOIDS (CORTISOL ) : • Stress hormone secreted by adrenal cortex .It causes : Ø Gluconeogenesis : Increase glucose level in blood . Ø Proteolysis : increase of amino acids in the blood. Ø Lipolysis : increase fatty acid in the blood. Ø Anti-inflammatory: reduce pain . Ø Immuno-suppressive Ø Maintains cardiovascular system as well as kidney function.
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Patients at risk for adrenal crisis
Suppressed (HPAA) by Exogenous glucocorticoids . Oral glucocorticoid : § Maintenance daily dose 7-12 mg/m 2 of hydrocortisone or equivalent . § Administration of higher daily dose for >4 wks. may suppress HPAA. § Alternative daily doses do not affect HPAA. Inhaled glucocorticoid : High doses fluticasone >800mcg/day >4 wks. need HPAA evaluation Local application : Reported cases of Cushing syndrome and adrenal insufficiency after of high potency topical corticosteroids (clopitasole ) .
Management principles Ø ABC,D , bed side RBS , electrolytes … Ø Hydrocortisone steroid of choice as a stress dose , why ? 1- Short acting 6-8 hrs. duration 2- Reach therapeutic level after 10-20 min of IV/IM inj. 3- Mineralocorticoid effect ,Hydrocortisone 20 mg = 0.1 mg fludrocortisone. v Dexamethasone not recommended (mineralcorticoid effect =0) Ø All children at risk of adrenal insufficiency should be discussed with/and admitted under the Pediatric Endocrinology Team . Ø Treat underling cause
Hydrocortisone Patient ’ s condition 75-100 mg/m 2 bolus + followed by cont. infusion vs. Severely ill +/ - shock divided doses 50-100 mg/ m 2 /day until stable 50 mg/m 2 / day PO. or give 5x (times) the daily dose; Moderately ill or 50 mg/m 2 / day IV/IM, divided 6 hourly Cont. normal maintenance doses of steroid. Mildly ill ( URTI) , no fever 50 mg/m 2 PO. at the onset of ‘NPO’ , or same dose Brief surgery IV prior to anesthesia 50 mg/m 2 bolus IV followed by 50 - 100 mg/m 2 /day Prolonged surgery divided doses or cont. infusion. The following days 3- 4 times the patient's usual dose.
Rapid Estimates of steroid dose if Weight or BSA not available Age Hydrocortisone stress dose IV/IM 0-3 years 25 mg 3-12 years 50 mg ≥ 12 years 100 mg
In the management Septic shock in previously healthy child IS stress steroid dose recommended ?? Ø Glucocorticoids should not be routinely used in septic shock . • Their use was associated with increased mortality. Ø Refractory catecholamine resistant septic shock : stress steroid dose is recommended . • Adrenal insufficiency occurs in many conditions in critically ill children .
Examples • Case -1 : 12 year ,CAH, febrile, and hypotensive . - 100 mg hydrocortisone IM/IV followed by a cont. infusion of 100 mg/m 2 /day until clinically stable. • Case -2 : 4 month ,congenital hypopituitarism URTI & febrile . Usual daily hydrocortisone dose 5 mg/day. - 25 mg hydrocortisone /day PO. until fever resolves. • Case -3 : 3 years ,nephrotic synd. on prednisolone 5mg every other day + GE. - Continue same dose of prednisolone unless patient in relapse .
Take home messages All children at risk of adrenal insufficiency should be discussed with/and admitted under the Pediatric Endocrinology Team. Increased Cortisol is needed in times of stress to avoid adrenal crisis. Hydrocortisone is the steroid of choice as stress dose . Dexamethasone not recommended. Steroids not routinely recommended in septic shock in previously healthy child.
References Markovitz BP , Goodman DM, Watson RS, et al. A retrospective cohort study of prognostic factors associated with outcome • in pediatric severe sepsis: what is the role of steroids? Pediatr Crit Care Med 2005; 6:270 Brandon DD, Isabelle LM, Samuels MH, et al. Cortisol production rate measurement by stable isotope dilution using gas • chromatography-negative ion chemical ionization mass spectrometry. Steroids 1999; 64:372. Linder BL, Esteban NV, Yergey AL, et al. Cortisol production rate in childhood and adolescence. J Pediatr 1990; 117:892. • Charmandari E, Johnston A, Brook CG, Hindmarsh PC. Bioavailability of oral hydrocortisone in patients with congenital • adrenal hyperplasia due to 21-hydroxylase deficiency. J Endocrinol 2001; 169:65. Bornstein SR, Allolio B, Arlt W, et al. Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society • Clinical Practice Guideline. J Clin Endocrinol Metab 2016; 101:364 Uptodate •
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