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C
orticosteroids
in
septic
shock
: W
hat
should
the
decision
in
pediatrics
be
?
R
ev
A
ssoc
M
ed
B
ras
2016; 62(6):482-484
483
ter results in children. But the assessment was limited by
lack of data related to the severity of the analyzed popu-
lation. In that same year, Pizarro et al.
21
concluded that
absolute and relative adrenal insufficiency was common
in children with catecholamine-resistant shock, and with
shock not responsive to fluid resuscitation. Menon et al.
conducted a very comprehensive work of relative adrenal
insufficiency in critically ill children (n=381), not neces-
sarily in shock, in seven pediatric tertiary intensive care
units in Canada, supporting the concept of relative adre-
nal insufficiency in critical conditions.
22
In 2011, the RE-
SOLVE trial
23
examined children with severe sepsis who
received corticosteroids and showed that disease progres-
sion was similar to those who did not receive them. The
results (mortality, time using inotropes, mechanical ven-
tilation time, organ failure resolution, changes in mor-
tality score, and hospitalization) were similar in children
who were treated with and without steroids. Recent stud-
ies, including those conducted in developing countries
and involving specific pathologies, emphasize the reduc-
tion of inotropic agents, without impact on mortality.
24,25
In 2013, a meta-analysis of trials with a small number of
patients showed no benefit attributable to corticoste-
roids.
26
Atkins et al.
27
proposed the lack of evidence of im-
provement could be due to the fact that children who re-
ceived corticosteroids had a higher initial mortality risk
than those who did not receive them. But in this exact
multicentric and retrospective study (n=496), based on
severity stratifications (PERSEVERE and PRISM), no ben-
efits were observed from its use.
Since the first guidelines for the diagnosis and treat-
ment of severe sepsis and septic shock in the 1990s, one
of the most controversial issues is the use of corticoste-
roids as a treatment option, especially in cases of cate-
cholamines resistance. This subject has produced multi-
ple randomized controlled trials in adults, but results are
conflicting and a consensus has not been reached. In pe-
diatrics, studies are less abundant, but hydrocortisone is
currently recommended for children with septic shock,
although there is no clear evidence of its effectiveness.
The guidelines of the Surviving Sepsis Campaign 2012
1
stipulated that the use of hydrocortisone should be con-
sidered for adult and pediatric septic shock when hypo-
tension does not respond to adequate fluid resuscitation
and vasopressors (level 2C of evidence in adults and 1A
in pediatrics). The recommendation is also suggested by
the American College of Critical Care Medicine.
28
We must
bear in mind that, despite the absence of large random-
ized controlled trials in children, some information is
available from several small studies in the literature, al-
though the results are still very unsatisfactory. Thus, in
addition to children receiving chronic steroids and chil-
dren with “classic” adrenal insufficiency, the accumulat-
ed evidence does not support a routine use of corticoste-
roids in children with septic shock.
Guidelines have emerged to standardize the treat-
ment of sepsis and septic shock around the world, also
in countries with few resources, reducing costs, morbid-
ity, and mortality. Considering the results of current pe-
diatric studies on the subject, we believe there is a press-
ing need to update the guidelines, based on the most
consistent clinical results. This point-of-view article shows
the very limited evidence that is the basis for current
guidelines, and thus the need for well-designed studies
on the use of corticosteroids in pediatric shock to up-
date future guidance.
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