RAMB - Julho 2016

armaros

482

ssoc

ras

2016; 62(6):482-484

POINT OF VIEW

Corticosteroids in septic shock: What should the decision in

pediatrics be?

orticosteroides

choque

séptico

que

decisão

tomar

pediatria

aura

onseca

armaros

*, A

rtur

igueiredo

elgado

, W

erther

runow

arvalho

Assistant ICU Physician, Instituto da Criança, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HC-FMUSP), São Paulo, SP, Brazil

Professor, Habilitation (BR: Livre-docência), Department of Pediatrics, FMUSP, São Paulo, SP, Brazil

Full Professor of Intensive Care/Neonatology, Department of Pediatrics, FMUSP, São Paulo, SP, Brazil

Study conducted at Centro de Terapia Intensiva Pediátrica, Instituto da Criança, Hospital das Clínicas, Faculdade de Medicina,

Universidade de São Paulo (HC-FMUSP), São Paulo, SP, Brazil

Article received:

6/29/2016

Accepted for publication:

7/26/2016

*Correspondence:

Instituto da Criança

Address: Av. Dr. Enéas de Carvalho Aguiar, 647

São Paulo, SP – Brazil

Postal code: 05403-000

laurafondar@yahoo.com.br http://dx.doi.org/10.1590/1806-9282.62.06.482

Severe sepsis and septic shock are major global causes of

morbidity and mortality in children. In this context, con-

sensuses and guidelines were created for early and effec-

tive identification and therapeutic approach. As with

adults, the guidelines for septic shock in pediatrics sug-

gest the use of corticosteroids in cases that are refracto-

ry to vasoactive drugs.

However, there are no pediatric

clinical studies supporting the recommendation satisfac-

torily, and it is important to remember the fact that chil-

dren are not small adults and that the steroid metabo-

lism in both differs.

The use of corticosteroids in septic shock has a long

history in medicine and continues to generate great con-

troversy. Its history began in the 1950s, in an attempt to

treat adrenal insufficiency allegedly caused by menin-

gococcemia in pediatric patients.

In 1963, a study in-

volving adults and children showed no benefit from the

use of hydrocortisone in severe infections.

However, sup-

ported by studies by Schumer

in the 1970s, the use of

corticosteroids in high doses and for short periods of

time became widespread in the treatment of sepsis un-

til the 1980s. In 1987, in turn, two large randomized con-

trolled studies failed to confirm its effect on mortality

reduction.

6,7

In 1995, two meta-analyzes (Lefering et al.

and Cronin et al.) concluded there was no impact on

mortality and the results could even be adverse.

8,9

In the

late 1990s, it was speculated that lower doses (stress-

dose) could reduce vasopressor doses in critically ill pa-

tients.

10-12

The article that reinforced this thesis and made

an immediate impact on clinical practice was published

by Annane et al.

and proposed the use of low doses over

a longer period of time. This approach produced very in-

consistent results in many randomized trials, which end-

ed up concluding that this conduct not only did not re-

duce mortality but also could be associated with increased

morbidity.

14,15

The PROGRESS trial (n=8,960)

revealed

the widespread adoption of steroids in sepsis worldwide

(Brazil was the country with greater use) and significant

variations as to its use. In 2012, Casserly et al.

exam-

ined the use of low doses of corticosteroids in septic shock

based on data from the Surviving Sepsis Campaign and

concluded that these drugs were used indiscriminately

and were associated with increased mortality. Their study

had the advantage of deriving from a multicenter data-

base, and of having examined a very large population

(n=17,847). Recent meta-analyzes have concluded that

corticosteroids appear to improve the hemodynamics of

patients in shock, but without significant results on mor-

tality.

Currently, several studies stand out on the sub-

ject in various areas, such as the suppression of adaptive

immunity

and the resistance of tissues to stimulation

by corticosteroids.

The studies on corticosteroids in pediatric sepsis are

not as scarce as before; however, there are no large con-

trolled clinical trials on its use. Since 2005, based on a

study by Markowitz et al.,

it has been discussed whether

pediatric patients with septic shock would benefit from

treatment with corticosteroids. Markowitz’s work used

data from the Pediatric Health Information System

(n=6,693) and showed there is no evidence to indicate bet-