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305: CRITICAL CARE TRANSPORT OF PEDIATRIC DIABETIC KETOACIDOSIS DOES IT SHORTEN INTENSIVE CARE STAY?

Learning Objectives: The lack of definitive guidelines on the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in children has resulted in varying practices among institutions and providers. The SCCM and ECIM 2017 guidelines for CIRCI recommend stress dose hydrocortisone (HCT) for patients refractory to fluid and vasopressor therapy or who have adrenal insufficiency (change in baseline cortisol at 60 minutes of <9 mCg/dL or a random cortisol level of <10 mCg/dL). The aim of this study is to assess the utilization of ACTH stimulation testing prior to initiation of stress dose HCT therapy, the interpretation of results, and the dose and duration of HCT therapy for pediatric patients in the intensive care unit. Methods: A single center, retrospective chart review was conducted in a mixed PICU from January-April 2018. Data obtained from the medical record included bolus dose and initial maintenance dose of HCT, the total days of HCT therapy, and the number of days of therapy prior to tapering. Completion of ACTH stimulation testing and interpretation of response were also collected. Descriptive statistics were utilized to assess results. Results: There were 48 bolus administrations of HCT in 28 patients, with a median dose of 50 mg/m2. Of these occurrences, 25.0% (12/48) received a dose of cosyntropin for ACTH stimulation testing prior to administration of the bolus. Of those that received stimulation testing, 83.3% (10/12) were initiated on stress dose HCT appropriately based on guideline definitions. The remaining two patients that responded appropriately to ACTH stimulation testing received HCT therapy due to persistent hypotension despite support with multiple vasoactive agents. Maintenance therapy was initiated on 37 occasions with a median dose of 12.5 mg/m2 every 6 hours. The mean duration of HCT therapy was 7.4 days (range of 3–18.5, excluding those deceased). Of those that received maintenance dosing, 8.1% (3/37) required a taper lasting >7 days. Conclusions: Stress dose HCT therapy is commonly utilized in critically ill children, without diagnostic testing of adrenal insufficiency. These results support development of institutional protocols to standardize practice and provide consistent care for all critically ill children.