Stress Dosing of Steroid Third QPEM Conference 11-13 th of January - - PowerPoint PPT Presentation

• Dr. Mahmoud Alrifaai

Consultant pediatrics . PEC. Alsadd

Third QPEM Conference 11-13th of January 2019

Stress Dosing of Steroid

I do not have any relevant financial relationship with commercial interest to disclose.

DISCLOSURE

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

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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/m2

• f 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

Patient’s condition Hydrocortisone Severely ill +/- shock

75-100 mg/m2 bolus + followed by cont. infusion vs. divided doses 50-100 mg/m2/day until stable

Moderately ill

50 mg/m2/day PO. or give 5x (times) the daily dose;

• r 50 mg/m2/day IV/IM, divided 6 hourly

Mildly ill ( URTI) , no fever

• Cont. normal maintenance doses of steroid.

Brief surgery

50 mg/m2 PO. at the onset of ‘NPO’ , or same dose IV prior to anesthesia

Prolonged surgery

50 mg/m2 bolus IV followed by 50 - 100 mg/m2/day 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/m2/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
• ther 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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