A History of Adjunctive Glucocorticoid Treatment for Pediatric Sepsis: Moving Beyond Steroid Pulp Fiction Toward Evidence-based Medicine

Jerry J. Zimmerman, MD, PhD, FCCM

Disclosures

Pediatr Crit Care Med. 2007;8(6):530-539. 

In This Article

Abstract and Introduction

Objectives: To review the history of clinical use of corticosteroids with particular reference to adjunctive therapy for severe pediatric sepsis and, in this context, to provide an overview of what is known, what is not known, and what research questions are particularly relevant at this time.
Data Source: Literature review using PubMed, cross-referenced article citations, and the Internet.
Conclusions: The history of corticosteroid use in clinical medicine has been colorful, noisy, and always controversial. Therapeutic corticosteroid indications that initially seemed rational have frequently been refuted on closer, rigorous clinical trial inspection. Although it may be prudent to provide stress-dose steroids to children with septic shock who are clinically at risk for adrenal insufficiency (chronic or recent steroid use, purpura fulminans, etomidate or ketoconazole administration, hypothalamic, pituitary, adrenal disease), the safety and efficacy of stress-dose steroids as general adjunctive therapy for pediatric septic shock have not been established. Glucocorticoid administration does add potential risk to critically ill children. In particular, although adjunctive corticosteroids may hasten resolution of unstable hemodynamics in septic shock, this may occur at the metabolic cost of hyperglycemia. Clinical practice that fosters innovative therapy (off-label use) over research probably represents bad medical and social policy. Accordingly, pediatric critical care researchers have a responsibility to generate pediatric-specific evidence-based medicine for adjunctive corticosteroid therapy for severe sepsis in children.

Novels written for the mass market, intended to be a good read,-often exciting, titillating, thrilling. Historically they have been very popular but critically sneered at as being of subliterary quality. The earliest ones were the dime novels of the nineteenth century, printed on newsprint (hence pulp fiction) and sold for ten cents. Westerns, stories of adventure, even the Horatio Alger novels, all were forms of pulp fiction.-R Harris, A Glossary of Literary Terms, 1997

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