Adrenal Insufficiency in Hemodynamically Unstable Neonatesafter Open-Heart Surgery

Garcia, Xiomara; Bhutta, Adnan T.; Dyamenahalli, Umesh; Imamura, Michiaki; Jaquiss, Robert D.B.; Prodhan, Parthak

doi:10.1111/j.1747-0803.2010.00447.x

Cited by 13 publications

(22 citation statements)

References 37 publications

(74 reference statements)

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“…Depending on definition, AI may occur in up to 45.7% of infants after cardiac surgery (13); 33% of subjects in our trial developed AI after CPB. Low serum total or free cortisol, inadequate response to adrenocorticotropic hormone (ACTH) stimulation test, high ACTH/cortisol ratio, and improvement in hemodynamics after corticosteroid administration have all been proposed for AI diagnosis in other studies, with inconsistent incidence and correlation with outcomes (4,5,14). Of these definitions, we found only post-CPB ACTH stimulation testing (1 mcg) was associated with clinical outcomes in the immediate postoperative period.…”

Section: Discussionmentioning

confidence: 79%

“…SIRS may disrupt the hypothalamic–pituitary–adrenal (HPA) axis leading to relative adrenal insufficiency (AI) after neonatal CPB . Emerging evidence supports the association of AI with morbidity after cardiac surgery , and that prophylactic postoperative steroid supplementation may improve hemodynamic outcomes via modulation of post‐CPB SIRS, prevention of AI, and/or supplementation of endogenous cortisol levels. However, AI lacks a clear definition and controversy still surrounds the utility of steroid administration in the critically ill neonate .…”

Section: Introductionmentioning

confidence: 99%

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Adrenal insufficiency in neonates after cardiac surgery with cardiopulmonary bypass

Crawford

Hull

Borasino

et al. 2016

Pediatric Anesthesia

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Neonatal cardiac surgery with CPB and preoperative methylprednisolone leads to AI as determined by low-dose ACTH stimulation test in one-third of patients. AI is associated with increased serum lactate and colloid resuscitation in OR. Impact of preoperative methylprednisolone on results is not defined. Benefit of postoperative steroid administration in neonates with post-CPB AI warrants further investigation.

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Section: Discussionmentioning

confidence: 79%

Section: Introductionmentioning

confidence: 99%

Adrenal insufficiency in neonates after cardiac surgery with cardiopulmonary bypass

Crawford

Hull

Borasino

et al. 2016

Pediatric Anesthesia

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“…The patients that had a significant serum cortisol increase after ACTH test (>50 mg/dL) also had a higher mean arterial blood pressure at 48 h postoperatively. All patients included in the study had dexamethasone 0.5 mg/kg midnight before surgery and at induction [ 54 ]. In 38 neonates undergoing complex heart surgery, Mackie et al measured serum cortisol at 3 time-points: preoperatively, at 24 and 48 h postoperatively.…”

Section: Resultsmentioning

confidence: 99%

Corticosteroids in Pediatric Heart Surgery: Myth or Reality

et al. 2018

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Background: Corticosteroids have been administered prophylactically for more than 60 years in pediatric heart surgery, however, their use remains a matter of debate. There are three main indications for corticosteroid use in pediatric heart surgery with the use of cardiopulmonary bypass (CPB): (1) to blunt the systemic inflammatory response (SIRS) induced by the extracorporeal circuit; (2) to provide perioperative supplementation for presumed relative adrenal insufficiency; (3) for the presumed neuroprotective effect during deep hypothermic circulatory arrest operations. This review discusses the current evidence behind the use of corticosteroids in these three overlapping areas.Materials and Methods: We conducted a structured research of the literature using PubMed and MEDLINE databases to November 2017 and additional articles were identified by cross-referencing.Results: The evidence suggests that there is no correlation between the effect of corticosteroids on inflammation and their effect on clinical outcome. Due to the limitations of the available evidence, it remains unclear if corticosteroids have an impact on early post-operative outcomes or if there are any long-term effects. There is a limited understanding of the hypothalamic-pituitary-adrenal axis function during cardiac surgery in children. The neuroprotective effect of corticosteroids during deep hypothermic circulatory arrest surgery is controversial.Conclusions: The utility of steroid administration for pediatric heart surgery with the use of CPB remains a matter of debate. The effect on early and late outcomes requires clarification with a large multicenter randomized trial. More research into the understanding of the adrenal response to surgery in children and the effect of corticosteroids on brain injury is warranted.

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“…Hydrocortisone is instituted if baseline cortisol is G 20 [20]. Adrenocorticotropic hormone (ACTH) stimulation test rarely used due to time it takes to perform test.…”

Section: Hydrocortisonementioning

confidence: 99%

Perioperative Care of a Child with Transposition of the Great Arteries

Lorts

Krawczeski

2011

Curr Treat Options Cardio Med

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Because a minority of patients with D-transposition of the great arteries are diagnosed in utero by ultrasound, most present after delivery with cyanosis. In the absence of apparent lung disease, cyanotic neonates suspected of having a cardiac lesion should be immediately transferred to an intensive care unit at a pediatric tertiary care center for monitoring, resuscitation, and to define the cardiac anatomy and physiology. A prostaglandin E-1 infusion is usually initiated to maintain ductal patency and promote intra-cardiac mixing. In the past, balloon atrial septostomy (BAS) was routinely performed to enlarge the atrial septal defect and improve intra-cardiac mixing while the infants awaited surgery. Recent literature has reported an increase risk of stroke in neonates who undergo BAS, although more recent studies refute this. Our current practice is to perform BAS in neonates who have both echocardiographic evidence of a restrictive atrial septum and hypoxia or instability that is unresponsive to other interventions. The occasional patient who does not respond to initial management may have elevated pulmonary vascular resistance and may stabilize with pulmonary vasodilators, such as inhaled nitric oxide. Rarely, a child does not respond to interventional and pharmacologic resuscitation and requires mechanical support pre-operatively with extracorporeal membrane oxygenation (ECMO). In our experience, ECMO has been a successful bridge to corrective surgery with excellent outcomes. After pre-operative stabilization, arterial switch procedure is typically performed in the first week of life with very favorable early results.

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Adrenal Insufficiency in Hemodynamically Unstable Neonatesafter Open-Heart Surgery

Cited by 13 publications

References 37 publications

Adrenal insufficiency in neonates after cardiac surgery with cardiopulmonary bypass

Adrenal insufficiency in neonates after cardiac surgery with cardiopulmonary bypass

Corticosteroids in Pediatric Heart Surgery: Myth or Reality

Perioperative Care of a Child with Transposition of the Great Arteries

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