Change in vasoactive inotropic score following hydrocortisone administration in the pediatric intensive care unit: a PICU data collaborative study, 2010–2022

Objective: Hydrocortisone (HCT) is an ancillary therapy for children with refractory hypotension. Current guidelines for HCT use are non-specific due to limited evidence of efficacy. We evaluated practice patterns and the association of HCT with the vasoactive inotropic score (VIS) in children admitted to the pediatric intensive care unit (PICU). Materials and methods: This was a retrospective observational cohort study using the PICU Data Collaborative (PDC). Our cohort consisted of PDC encounters receiving at least one of the six vasoactive medications included in the VIS calculation (epinephrine, norepinephrine, dopamine, dobutamine, vasopressin, or milrinone). We calculated hourly VIS for the first 7 days of ICU admission. We conducted a propensity score-matched comparison of change in VIS from hours 24–48 between encounters receiving HCT within the first 24 h of ICU admission and controls who did not receive HCT. Measurements and main results: The cohort included 10,244 encounters from three institutions. Of these, 1,915 (18.7%) received HCT. Encounters receiving HCT were older [5.4 (0.8–13.8) years vs. 4.3 (0.6–13.3) years, respectively] and had a higher maximum VIS [15.0 (10.0–20.2) vs. 8.0 (5.0–13.0)]. The PICU cohort had a significantly greater decrease in VIS from 24 to 48 h after admission compared with the cardiovascular intensive care unit (CVICU) cohort [82.2% (−40% to 100%) vs. 16.2% (−4.0% to 100%); p < 0.01]. In the matched PICU cohort, there was no difference in the 24-h reference VIS; however, there was a greater decrease in percentage of VIS from the 24-h reference to 48 h for those who received HCT [100.0 (50.0–100.0) vs. 86.6 (0.0–100.0); p = 0.03]. In the matched CVICU cohort, the HCT group had a higher VIS at 24 h [7.7 (1.0–11.0) vs. 6.0 (0.0–10.0); p = 0.02], with smaller decreases in VIS percent from reference at 48 h [9.3 (−13.2 to 58.7) vs. 18.2 (0.0–80.0); p = 0.01]. Conclusions: The use of HCT was associated with greater improvement in VIS between 24 and 48 h after admission for children in the PICU, but not for children in the CVICU. Further research is needed to determine the optimal patient selection and timing of HCT use.