High dose methylprednisolone may lessen severity of septic shock in pediatric cancer patients
Intensive Care Units, Pediatric
Introduction: Indwelling silastic central venous catheters (CVCs) are used in the treatment of pediatric cancer patients. These devices are a potential source of systemic infection and septic shock (SS). Removal of an infected CVC may lead to the release of proinflammatoty mediators. High dote corticosteroids may modify the come of SS if administered during this proinflammatory phase. A retrospective study was conducted to analyze the effect of MP on the PICU course of these patients. Methods: Medical records of pediatric cancer patients admitted to the PICU from 1992 through 1994 with SS associated with an indwelling CVC were reviewed. During this period, high dose (30 mg/kg) methylprednisolone (MP) was administered, at the discretion of the attending physician, to patients with septic shock prior to the removal of putatively infected indwelling CVCs and 6 hours later. Data collected included age, underlying malignancy and PRISM score; volume of bolus fluids (ml/kg) prior to PICU admission and in the PICU; urine output and CVP in the PICU; need for dopamine prior to PICU admission, mean and peak dopamine dosages for the first 24 hours in the PICU, time on dopamine and need for other vasoactive agents; length of PICU stay and outcome. Sixty-three cancer patients were admitted with catheter associated SS. Forty-eight charts were complete and available for review. Six patients received a steroid other than high dose MP, leaving 42 patients to evaluate. Data were analyzed by two-tailed Student t-test and Fisher's exact test. Results: Twenty-six patients received MP while 16 did not. All patients were treated with broad spectrum antimicrobials and catheter removal. The 2 groups were similar (p=ns, MP listed first) in: age (10±6 v 10±6 yrs), underlying diagnoses and PRISM scores (12±11 v 5±5); volume of bolus fluid (42±15 v 36±18 ml/kg) prior to PICU admission and in the PICU (19±19 v 15±10 ml/kg); urine output (3.7±1.9 v 3.8±1.6 ml/kg/hr) and CVP (11±5 v 9±3 mmHg); need for dopamine prior to admission (22/26 v 14/16), mean dopamine dosage (6±3 v 6±3 mcg/kg/min) and peak dopamine dosage (11±4 v 12±6 mcg/kg/min). The two groups differed with respect to time on dopamine (10.6±6.8 v 20±6.7 hrs, p<0.05) and frequency of PICU admission <24 noun (13/26 v 2/16, p<0.05). Three patients in each group required a second vasoactive agent. There were two deaths in each group (7.7% v 12.5%, p=ns). Conclusions: High dose MP may improve the course and decrease length of PICU stay for pediatric cancer patients with catheter associated SS. A placebo controlled study is required.