Cardiovascular instability after patent ductus arteriosus ligation in preterm infants: the role of hydrocortisone

Abstract

Objective: Following patent ductus arteriosus (PDA) ligation, preterm infants may develop profound hypotension and respiratory failure. Prophylactic stress hydrocortisone (HC) has emerged as a therapy to prevent complications, postulating these infants do not synthesize steroids because of an immature hypothalamic-pituitary-adrenal axis. The purpose of this study was to compare outcomes in infants who received stress HC before their PDA ligations to those who did not.Study Design: A retrospective chart review was performed of infants who underwent PDA ligations at our institution's neonatal intensive care unit. Data were collected on treatment with HC, and respiratory and cardiovascular support.Result: Gestational age (GA) and birth weight were lower in the HC group (24 vs 25 weeks, 632 vs 790 g), but age at time of surgery was similar (26 vs 21 days). Cardiorespiratory support was comparable between the groups pre-and post-operatively. In regression models that adjusted for GA, HC treatment was not independently related to respiratory support postoperatively, but was associated with a decrease in postoperative dopamine (2.2 mcg kg À1 min À1 ; P ¼ 0.03). Respiratory support postoperatively was predicted by preoperative respiratory support. GA and age at surgery were not independently associated with outcome.Conclusion: Preoperative stress HC was not associated with improved cardiorespiratory stability, regardless of GA. Further investigation is needed to identify infants who may benefit from this therapy.

Adrenal Function in Preterm Infants Undergoing Patent Ductus Arteriosus Ligation

“…In spite of lack of evidence, some centers routinely prescribe prophylactic hydrocortisone preoperatively. A recently published retrospective study of preterm infants undergoing ligation found no difference in postoperative outcomes between infants treated with and without prophylactic hydrocortisone preoperatively [18]. That study differs from ours as none of the infants were treated with milrinone or underwent ACTH stimulation testing.…”

Respiratory Trajectory after Invasive Interventions for Patent Ductus Arteriosus of Preterm Infants

“…[ 48 ]. Third, cardiovascular instability after patent ductus arteriosus ligation (i.e., post-ligation cardiac syndrome, PLCS) in preterm infants has been reported [ 49 ], as it has a tendency toward a higher risk of long-term neurodevelopmental impairment [ 50 ].…”

Anticipatory perioperative management for patent ductus arteriosus surgery: Understanding postligation cardiac syndrome

“…7 The use of postoperative cortisol, however, may lead to delay in treatment, random serum cortisol levels do not predict PLCS 28 and prophylactic stress dose hydrocortisone for all infants is not associated with improved outcomes. 29 Preoperative serum cortisol following adrenocorticotropic hormone (ACTH) stimulation of less than 750 nmol/L, however, has been associated with PLCS 26 and preoperative assessment of adrenal performance may facilitate early administration to appropriately selected patients. Stress dose hydrocortisone should be considered for infants already receiving preoperative steroids for lung disease or hypotension 29 as well as for symptomatic patients particularly in the setting of a failed ACTH stimulation test.…”

“…Developmental immaturity of the hypothalamic‐pituitary‐adrenal axis and adrenal hypoperfusion due to chronic ductal steal are potential contributors to early postoperative hypotension (0‐4 h) and poor response to catecholamine therapy is associated with low postoperative serum cortisol . The use of postoperative cortisol, however, may lead to delay in treatment, random serum cortisol levels do not predict PLCS and prophylactic stress dose hydrocortisone for all infants is not associated with improved outcomes . Preoperative serum cortisol following adrenocorticotropic hormone (ACTH) stimulation of less than 750 nmol/L, however, has been associated with PLCS and preoperative assessment of adrenal performance may facilitate early administration to appropriately selected patients.…”