Thyroid hormone profile and PELOD score in children with sepsis

Agung G. Tanurahardja; Antonius H. Pudjiadi; Pramita G. Dwipoerwantoro; Aman Pulungan

doi:10.14238/pi54.4.2014.245-50

Agung G. Tanurahardja Child Health Department, University of Indonesia Medical School/Dr. Cipto Mangunkusumo Hospital
Antonius H. Pudjiadi Child Health Department, University of Indonesia Medical School/Dr. Cipto Mangunkusumo Hospital
Pramita G. Dwipoerwantoro Child Health Department, University of Indonesia Medical School/Dr. Cipto Mangunkusumo Hospital
Aman Pulungan Child Health Department, University of Indonesia Medical School/Dr. Cipto Mangunkusumo Hospital

DOI: https://doi.org/10.14238/pi54.4.2014.245-50

Keywords: euthyroid sick syndrome, nonthyroidal illness, sepsis, procalcitonin, thyroid, PELOD, PICU

Abstract

Background Thyroid hormonal dysfunction, also known as
euthyroid sick syndrome or nonthyroidal illness, can be seen
in sepsis. There have been few studies on thyroid hormone
dysfunction in septic children, as well as on a relationship
between their thyroid hormone profiles and pediatric logistic
organ dysfunction (PELOD) scores. Procakitonin (PCT) is one
of the sepsis biomarker.
Objective To evaluate the thyroid hormone profile in children
with sepsis as well as to assess for a correlation between the thyroid
levels and PELOD scores, PCT levels, and patient outcomes.
Methods This cross-sectional study included children aged 1- 18
years admitted to the pediatric intensive care unit (PICU) with a
primary diagnosis of sepsis. PELOD scores and thyroid hormonal
levels were assessed once during the first 24 hours after PICU
admission.
Results Thirty subjects were included in the study. The median
values ofT3, free T4, and TSH were 45 (range 17 -133) ng/dL,
0.81 (range 0.3-1.57) ng/dL, and 1.36 (range 0.05-7.78) Î¼IU/L,
respectively. The T3, free T4, and TSH levels were decreased in
97%, 50% and 40% of the subjects. There were no significant
differences between low and normal to high TSH with regards to
the PELOD score (P=0.218), PCT level (P=0.694), or patient
outcomes (P=0.55). The risk of death increased by 15 times
among the subjects with PELOD score ~20 compared to those
with PELOD score <20 (OR 15; 95%CI: 1.535 to 146.545;
P=0.012).
Conclusion Thyroid hormones are decreased in septic children
with the majority having low T3. A high PELOD score is strongly
correlated with mortality and can be used as a prognostic parameter
for septic children in the PICU, but there is no correlation with
decreased TSH.

References

Baldwin KM, Cheek DJ, Mortis SE. Shock, multiple organ dysfunction syndrome, and bums in adults. In: McCance KL, Huether SE, editors. Pathophysiology: the biologic basis for disease in adults and children. 5th ed. Missouri: Elsevier; 2006. p. 1632.

Bone RC. Let's agree on terminology: definitions of sepsis. Crit Care Med. 1991;19:973-6.

Goldstein B, Giroir B, Randolph A International pediattic sepsis consensus conference: definitions for sepsis and organ dysfunction in pediattics. Pediatr Crit Care Med. 2005;6:2-8.

Ture M, Memis D, Kurt I, Pamukcu Z. Predictive value of thyroid hormones on the first day in adult respiratory distress syndrome patients admitted to ICU: comparison with SOFA and APACHE II scores. Ann Saudi Med. 2005;25:466-72.

Kaptein E, Weiner JM, Robinson WJ. Relationship of altered thyroid hormones indices to survival in nonthyroidal illnesses. Clin Endocrinol. 1982;16:565-74.

Slag MF, Morley JE, Elson MK, Crowson Tw, Nuttall FQ, Shafer RB. Hypothyroxinemia in critically ill patients as a predictor of high mortality. JAMA. 1981;245:43-5.

Chopra IJ. Euthyroid sick syndrome: is it a misnomer? J Clin Endocrinol Metab. 1997;82:329-34.

Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, et al. 2001 SCCM/ESICM/ACCP/ATS;SIS International sepsis definitions conference. Crit Care Med. 2003;31:1250-6.

Leteurtre S, Martinat A, Duhamel A, Proulx F, Grandbastien B, Cotting J, et al. Validation of the paediattic logistic organ dysfunction (PELOD) score: prospective, observational, multicentre study. Lancet. 2003;362:192-7.

Lacroix J, Cotting J. Severity of illness and organ dysfunction scoring in children. Pediatr Crit Care Med. 2005;6:s126-34.

Pesce MA, Reference ranges for laboratory tests and procedures. In: Kligman RM, Behrman RE, Jenson HB, Stanton BF. Nelson textbook of pediatrics. 18th ed. Philadelphia: Saunders Elsevier; 2007. p. 2948-9.

Madiyono B, Moeslichan S, Sastroasmoro S, Budiman I, Purwanto SH. Perkiraan besar sampel. Dasar-dasar metodologi penelitian klinis. 3rd ed. Jakarta: Sagung Seto; 2008. p. 313.

den Brinker M, Joosten KF, Visser TJ, Hop WCJ, de Rijke YB, Hazelzet JA, et al. Euthyroid sick syndrome in meningococcal sepsis: the impact of peripheral thyroid hormone metabolism and binding proteins. J Clin Endocrinol Metab. 2005;90:5613-20.

Aatif S, Qamar R, Ahmed I, Imran K. Sick euthyroid syndrome: Thyroid function abnormalities in patients with nonthyroidal illness. J of Liaquat University of Medical & Health Sciences. 2008;7:83-6.

Thukral A, Kohli U, Lodha R, Kabra SK, Kabra NK. Validation of the PEL OD score for multiple organ dysfunction in children. Indian Pediatr. 2007;44:683-6.

Hebbar K, Rigby MR, Feiner EI, Easley KA, Fortenberry JD. N euroendocrine dysfucntion in pediattic critical illness. Pediatr Crit Care Med. 2009;10:35-40.

Ray DC, Macduff A, Drummond GB, Wilkinson E, Adams B, Beckett GJ. Endocrine measurement in survivors and non-survivors from critical illness. Intensive Care Med. 2002;28:1301-8.

Arkader R, Troster EJ, Lopes MR, Junior RR, Carcillo JA, Leone C, et al. Procalcitonin does discriminate between sepsis and systemic inflammatory response syndrome. Arch Dis Child. 2006;91:117-20.

Fioretto JR, Borin FC, Bonatto RC, Ricchetti SMQ, Kurokawa CS, de Moraes MA, et al. Procalcitonin in children with sepsis and septic shock. J Pediatr. 2007;83:323-8.

Casado-Flores J, Blanco-Quiros A, Nieto M, Asensio J, Fernandez C. Prognostic utility of the semi-quantitative procalcitonin test, neutrophil count and C-reactive protein in meningococcal infection in children. Eur J Pediatr. 2006:165:26-9.

Haas NA, Camphausen CK, Kececioglu D. Clinical review: thyroid hormone replacement in children after cardiac surgery-is it worth a try? Crit Care. 2006;10:213-20.

Monig H, Arendt T, Meyer M, Kloehn S, Bewig B. Activation of the hypothalamo-pituitary-adrenal axis in response to septic or non-septic diseases - implications for the euthyroid sick syndrome. Intensive Care Med. 1999;25:1402-6.

Zargar AH, Ganie MA, Masoodi SR, Laway BA, Bashir MI, Wani AL, et al. Prevalence and pattern of sick euthyroid sick syndrome in acute and chronic non-thyroidal illness:its relationship with severity and outcome of the disorder. J Assoc Physicians India. 2004;52:27-31.