1
|
Agakidou E, Chatziioannidis I, Kontou A, Stathopoulou T, Chotas W, Sarafidis K. An Update on Pharmacologic Management of Neonatal Hypotension: When, Why, and Which Medication. CHILDREN (BASEL, SWITZERLAND) 2024; 11:490. [PMID: 38671707 PMCID: PMC11049273 DOI: 10.3390/children11040490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 03/30/2024] [Accepted: 04/15/2024] [Indexed: 04/28/2024]
Abstract
Anti-hypotensive treatment, which includes dopamine, dobutamine, epinephrine, norepinephrine, milrinone, vasopressin, terlipressin, levosimendan, and glucocorticoids, is a long-established intervention in neonates with arterial hypotension (AH). However, there are still gaps in knowledge and issues that need clarification. The main questions and challenges that neonatologists face relate to the reference ranges of arterial blood pressure in presumably healthy neonates in relation to gestational and postnatal age; the arterial blood pressure level that potentially affects perfusion of critical organs; the incorporation of targeted echocardiography and near-infrared spectroscopy for assessing heart function and cerebral perfusion in clinical practice; the indication, timing, and choice of medication for each individual patient; the limited randomized clinical trials in neonates with sometimes conflicting results; and the sparse data regarding the potential effect of early hypotension or anti-hypotensive medications on long-term neurodevelopment. In this review, after a short review of AH definitions used in neonates and existing data on pathophysiology of AH, we discuss currently available data on pharmacokinetic and hemodynamic effects, as well as the effectiveness and safety of anti-hypotensive medications in neonates. In addition, data on the comparisons between anti-hypotensive medications and current suggestions for the main indications of each medication are discussed.
Collapse
Affiliation(s)
- Eleni Agakidou
- 1st Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Ippokrateion General Hospital, 54642 Thessaloniki, Greece; (I.C.); (A.K.); (T.S.); (K.S.)
| | - Ilias Chatziioannidis
- 1st Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Ippokrateion General Hospital, 54642 Thessaloniki, Greece; (I.C.); (A.K.); (T.S.); (K.S.)
| | - Angeliki Kontou
- 1st Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Ippokrateion General Hospital, 54642 Thessaloniki, Greece; (I.C.); (A.K.); (T.S.); (K.S.)
| | - Theodora Stathopoulou
- 1st Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Ippokrateion General Hospital, 54642 Thessaloniki, Greece; (I.C.); (A.K.); (T.S.); (K.S.)
| | - William Chotas
- Department of Neonatology, University of Vermont, Burlington, VT 05405, USA
| | - Kosmas Sarafidis
- 1st Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Ippokrateion General Hospital, 54642 Thessaloniki, Greece; (I.C.); (A.K.); (T.S.); (K.S.)
| |
Collapse
|
2
|
Duignan SM, Lakshminrusimha S, Armstrong K, de Boode WP, El-Khuffash A, Franklin O, Molloy EJ. Neonatal sepsis and cardiovascular dysfunction I: mechanisms and pathophysiology. Pediatr Res 2024; 95:1207-1216. [PMID: 38044334 DOI: 10.1038/s41390-023-02926-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 09/22/2023] [Accepted: 10/02/2023] [Indexed: 12/05/2023]
Abstract
The highest incidence of sepsis across all age groups occurs in neonates leading to substantial mortality and morbidity. Cardiovascular dysfunction frequently complicates neonatal sepsis including biventricular systolic and/or diastolic dysfunction, vasoregulatory failure, and pulmonary arterial hypertension. The haemodynamic response in neonatal sepsis can be hyperdynamic or hypodynamic and the underlying pathophysiological mechanisms are heterogeneous. The diagnosis and definition of both neonatal sepsis and cardiovascular dysfunction complicating neonatal sepsis are challenging and not consensus-based. Future developments in neonatal sepsis management will be facilitated by common definitions and datasets especially in neonatal cardiovascular optimisation. IMPACT: Cardiovascular dysfunction is common in neonatal sepsis but there is no consensus-based definition, making calculating the incidence and designing clinical trials challenging. Neonatal cardiovascular dysfunction is related to the inflammatory response, which can directly target myocyte function and systemic haemodynamics.
Collapse
Affiliation(s)
- Sophie M Duignan
- Department of Paediatric Cardiology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | | | - Kathryn Armstrong
- Children's Heart Centre, BC Children's Hospital, Vancouver, BC, Canada
| | - Willem P de Boode
- Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Afif El-Khuffash
- School of Medicine, Department of Paediatrics, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Orla Franklin
- Department of Paediatric Cardiology, Children's Health Ireland at Crumlin, Dublin, Ireland
- Discipline of Paediatrics, Trinity College, The University of Dublin, Trinity Research in Childhood (TRiCC) & Trinity Translational Medicine Institute (TTMI), Dublin, Ireland
| | - Eleanor J Molloy
- Discipline of Paediatrics, Trinity College, The University of Dublin, Trinity Research in Childhood (TRiCC) & Trinity Translational Medicine Institute (TTMI), Dublin, Ireland.
- Department of Neonatology, Children's Health Ireland at Crumlin, Dublin, Ireland.
- Department of Neonatology, Coombe Women and Infants University Hospital, Dublin, Ireland.
- Paediatric Neurodisability, Children's Health Ireland at Tallaght, Dublin, Ireland.
| |
Collapse
|
3
|
Kharrat A, Diambomba Y, Jain A. Corticosteroid use in neonatal hypotension: A survey of Canadian neonatologists. Pediatr Neonatol 2024:S1875-9572(24)00005-6. [PMID: 38388227 DOI: 10.1016/j.pedneo.2023.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 08/17/2023] [Accepted: 09/08/2023] [Indexed: 02/24/2024] Open
Abstract
OBJECTIVE To assess prescribing practices and perspectives regarding the use of corticosteroids in the management of neonatal hypotension. METHODS Cross-sectional questionnaire-based electronic survey of neonatologists (n = 206) practicing at tertiary neonatal intensive care units across 30 academic centres in Canada. RESULTS The overall response rate was 33% (72/206), with a completion rate was 94%. Most (48/72, 64%) worked in a unit that covered both inborn and outborn infants, and 53% (37/70) worked in units with >100 very low birth weight infants admitted annually. Among the 72 respondents, 39% use a loading dose, of whom most (57%) use 2 mg/kg. Dosing ranges were variable, most using either 0.5 mg/kg or 1 mg/kg, q6h. Among the 56% (40/72) of neonatologists who reported measuring cortisol before initiation of hydrocortisone, cut-offs for initiation of hydrocortisone varied from <100 to <500 nmol/L, most of whom (48%) used <100 nmol/L. Of 71 respondents, 92% (65) indicated that a randomized control trial examining the use of corticosteroids in neonatal hypotension is needed, of whom 52% (37) indicated that the intervention group should receiving hydrocortisone after one vasopressor/inotrope. CONCLUSIONS This survey provides insight into the prescribing practices of tertiary neonatologists with regards to the use of corticosteroids in neonatal hypotension. While corticosteroids are frequently prescribed, there is variability in the indication, dosing, and duration of corticosteroid use. The findings from this survey can be used to inform further research, including a clinical trial, regarding the practice in the management of neonatal hypotension.
Collapse
Affiliation(s)
- Ashraf Kharrat
- Department of Paediatrics, Mount Sinai Hospital, Toronto, ON, Canada; Department of Paediatrics, University of Toronto, Toronto, ON, Canada.
| | - Yenge Diambomba
- Department of Paediatrics, Mount Sinai Hospital, Toronto, ON, Canada; Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Amish Jain
- Department of Paediatrics, Mount Sinai Hospital, Toronto, ON, Canada; Department of Paediatrics, University of Toronto, Toronto, ON, Canada; Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada
| |
Collapse
|
4
|
Weaver LJ, Travers CP, Ambalavanan N, Askenazi D. Neonatal fluid overload-ignorance is no longer bliss. Pediatr Nephrol 2023; 38:47-60. [PMID: 35348902 PMCID: PMC10578312 DOI: 10.1007/s00467-022-05514-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 01/26/2022] [Accepted: 02/21/2022] [Indexed: 01/10/2023]
Abstract
Excessive accumulation of fluid may result in interstitial edema and multiorgan dysfunction. Over the past few decades, the detrimental impact of fluid overload has been further defined in adult and pediatric populations. Growing evidence highlights the importance of monitoring, preventing, managing, and treating fluid overload appropriately. Translating this knowledge to neonates is difficult as they have different disease pathophysiologies, and because neonatal physiology changes rapidly postnatally in many of the organ systems (i.e., skin, kidneys, and cardiovascular, pulmonary, and gastrointestinal). Thus, evaluations of the optimal targets for fluid balance need to consider the disease state as well as the gestational and postmenstrual age of the infant. Integration of what is known about neonatal fluid overload with individual alterations in physiology is imperative in clinical management. This comprehensive review will address what is known about the epidemiology and pathophysiology of neonatal fluid overload and highlight the known knowledge gaps. Finally, we provide clinical recommendations for monitoring, prevention, and treatment of fluid overload.
Collapse
Affiliation(s)
| | - Colm P Travers
- University of Alabama at Birmingham, Birmingham, AL, USA.
| | | | - David Askenazi
- University of Alabama at Birmingham, Birmingham, AL, USA
| |
Collapse
|
5
|
Cooper DS, Hill KD, Krishnamurthy G, Sen S, Costello JM, Lehenbauer D, Twite M, James L, Mah KE, Taylor C, McBride ME. Acute Cardiac Care for Neonatal Heart Disease. Pediatrics 2022; 150:189882. [PMID: 36317971 DOI: 10.1542/peds.2022-056415j] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 11/07/2022] Open
Abstract
This manuscript is one component of a larger series of articles produced by the Neonatal Cardiac Care Collaborative that are published in this supplement of Pediatrics. In this review article, we summarize the contemporary physiologic principles, evaluation, and management of acute care issues for neonates with complex congenital heart disease. A multidisciplinary team of authors was created by the Collaborative's Executive Committee. The authors developed a detailed outline of the manuscript, and small teams of authors were assigned to draft specific sections. The authors reviewed the literature, with a focus on original manuscripts published in the last decade, and drafted preliminary content and recommendations. All authors subsequently reviewed and edited the entire manuscript until a consensus was achieved. Topics addressed include cardiopulmonary interactions, the pathophysiology of and strategies to minimize the development of ventilator-induced low cardiac output syndrome, common postoperative physiologies, perioperative bleeding and coagulation, and common postoperative complications.
Collapse
Affiliation(s)
- David S Cooper
- Department of Pediatrics, University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kevin D Hill
- Division of Cardiology, Duke Children's Hospital, Durham, North Carolina
| | - Ganga Krishnamurthy
- Division of Neonatology, Columbia University Medical Center, New York, New York
| | - Shawn Sen
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - John M Costello
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina
| | - David Lehenbauer
- Department of Pediatrics, University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Mark Twite
- Department of Anesthesia, Colorado Children's Hospital, Aurora, Colorado
| | - Lorraine James
- Department of Pediatrics, Children's Hospital of Los Angeles, Los Angeles, California
| | - Kenneth E Mah
- Department of Pediatrics, University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Carmen Taylor
- Department of Pediatric Cardiothoracic Surgery, The Children's Hospital, Oklahoma City, Oklahoma
| | - Mary E McBride
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| |
Collapse
|
6
|
Blood pressure values and hypotension management in extremely preterm infants: a multi-center study. J Perinatol 2022; 42:1169-1175. [PMID: 35715600 DOI: 10.1038/s41372-022-01425-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 05/10/2022] [Accepted: 06/07/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To describe high/low daily blood pressures (BP) and variability in BP management with vasoactive infusions (VI) and/or hydrocortisone (HC) in extremely preterm infants. STUDY DESIGN Analysis of data from 24-27 weeks' gestation infants in the Preterm Erythropoietin Neuroprotection (PENUT) Trial. Daily high/low BPs, the use of VI and/or HC, and adverse outcomes were compared descriptively and using regression models. RESULTS 936 infants were included; 64% untreated, 20% VI, 3% HC, and 13% VI + HC. BP ranges are described for the 602 untreated infants. Considerable inter- and intra-center variability was demonstrated in the rate of VI and/or HC use and the lowest BP on the day of VI or HC initiation. CONCLUSIONS Despite published expert opinion guidance regarding BP management in extremely preterm infants, our results suggest a continued lack of consensus result in both inter- and intra-center variability in practice. Well-designed studies in the field are urgently needed.
Collapse
|
7
|
Elsayed Y, Abdul Wahab MG. A new physiologic-based integrated algorithm in the management of neonatal hemodynamic instability. Eur J Pediatr 2022; 181:1277-1291. [PMID: 34748080 DOI: 10.1007/s00431-021-04307-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 10/27/2021] [Accepted: 10/28/2021] [Indexed: 10/19/2022]
Abstract
Physiologic-based management of hemodynamic instability is proven to guide the logical selection of cardiovascular support and shorten the time to clinical recovery compared to an empiric approach that ignores the heterogeneity of the hemodynamic instability related mechanisms. In this report, we classified neonatal hemodynamic instability, circulatory shock, and degree of compensation into five physiologic categories, based on different phenotypes of blood pressure (BP), other clinical parameters, echocardiography markers, and oxygen indices. This approach is focused on hemodynamic instability in infants with normal cardiac anatomy.Conclusion: The management of hemodynamic instability is challenging due to the complexity of the pathophysiology; integrating different monitoring techniques is essential to understand the underlying pathophysiologic mechanisms and formulate a physiologic-based medical recommendation and approach. What is Known: • Physiologic-based assessment of hemodynamics leads to targeted and pathophysiologic-based medical recommendations. What is New: • Hemodynamic instability in neonates can be categorized according to the underlying mechanism into five main categories, based on blood pressure phenotypes, systemic vascular resistance, and myocardial performance. • The new classification helps with the targeted management and logical selection of cardiovascular support.
Collapse
Affiliation(s)
- Yasser Elsayed
- Division of Neonatology, Department of Pediatrics and Child Health, Rady Faculty of Health Sciences, University of Manitoba, Women's Hospital, 820 Sherbrook Street, Winnipeg, MB, R2016, R3A0L8, Canada.
| | - Muzafar Gani Abdul Wahab
- Division of Neonatology, Department of Pediatrics and Child Health, McMaster University, Hamilton, Canada
| |
Collapse
|
8
|
Tomotaki S, Iwanaga K, Hanaoka S, Tomotaki H, Matsukura T, Niwa F, Kawai M. Antenatal Glucocorticoids Reduce the Incidence of Refractory Hypotension in Low Birthweight Infants during the Early Neonatal Period, but Do Not Affect It beyond This Time. Am J Perinatol 2021; 38:1057-1061. [PMID: 32069485 DOI: 10.1055/s-0040-1701608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE This study aimed to clarify the effect of antenatal glucocorticoids (AGs) on the incidence of refractory hypotension (RH) in very low birthweight (VLBW) infants after the first week of life. STUDY DESIGN We included VLBW infants born at a gestational age of <30 weeks and divided them into three groups: the complete group (born within 7 days of completing a single course [two doses] of AGs), the incomplete group (born without complete course), and the late delivery group (born at ≥8 days after a single course). We compared the incidence and period of onset of RH among the three groups. RESULTS A total of 115 infants were enrolled. The incidence of RH in the first week of life was significantly lower in the complete group than in the other groups. However, there was no significant difference in the incidence of RH after the first week of life among the groups. CONCLUSION AGs contribute to circulatory stabilization during the first week of life, but this effect does not last after 1 or 2 weeks of administration. In infants who receive AGs, physicians should consider that the risk of RH after the first week of life is not low.
Collapse
Affiliation(s)
- Seiichi Tomotaki
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kougoro Iwanaga
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shintaro Hanaoka
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hiroko Tomotaki
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takashi Matsukura
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Fusako Niwa
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Masahiko Kawai
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| |
Collapse
|
9
|
Masumoto K, Kusuda S. Hemodynamic support of the micropreemie: Should hydrocortisone never be left out? Semin Fetal Neonatal Med 2021; 26:101222. [PMID: 33692008 DOI: 10.1016/j.siny.2021.101222] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Hemodynamic support for a micropreemie is critically important for preventing mortality and morbidity. An essential consideration in hemodynamic support is insufficient transition from fetal to neonatal circulation and inadequate cortisol production. The first 72 h of life are the most critical, especially when myocardial function is immature and impaired. Therefore, there is a need to determine and adjust preload, myocardial contractility, and afterload appropriately using repeated functional echocardiography. In addition, if myocardial function is not responsive to these attempts at hemodynamic management, hydrocortisone must be used to minimize the suboptimal perfusion burden. Fetal cortisol production is supported by a supply of progesterone from the placenta, and postnatally, adrenal cortisol production in the extremely preterm infant may be inadequate if the infant is placed under excessive stress. This leads to relative adrenal insufficiency which may last for up to several weeks after birth and lead to late-onset circulatory collapse, necessitating treatment with physiological doses of hydrocortisone.
Collapse
Affiliation(s)
- Kenichi Masumoto
- Department of Neonatology, Maternal and Perinatal Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Satoshi Kusuda
- Department of Pediatrics, Kyorin University, Tokyo, Japan.
| |
Collapse
|
10
|
Aziz KB, Boss RD, Yarborough CC, Raisanen JC, Neubauer K, Donohue PK. Intensity of Vasopressor Therapy and In-Hospital Mortality for Infants and Children: An Opportunity for Counseling Families. J Pain Symptom Manage 2021; 61:763-769. [PMID: 32942009 DOI: 10.1016/j.jpainsymman.2020.09.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 09/07/2020] [Accepted: 09/09/2020] [Indexed: 11/24/2022]
Abstract
CONTEXT Most pediatric deaths occur in an intensive care unit, and treatment specific predictors of mortality could help clinicians and families make informed decisions. OBJECTIVE To investigate whether the intensity of vasopressor therapy for pediatric patients, regardless of diagnosis, predicts in-hospital mortality. METHODS Single-center, retrospective medical chart review of children aged 0-17 who were admitted between 2005 and 2015 at a pediatric tertiary care center in the U.S. and received any vasopressor medication-dopamine, dobutamine, epinephrine, vasopressin, norepinephrine, or hydrocortisone. RESULTS During the 10-year period, 1654 patients received at least one vasopressor medication during a hospitalization. Median age at the time of hospitalization was three months, and the median duration of hospitalization was 23 days; 8% of patients had two to five hospitalizations in which they received vasopressors. There were 176 total patients who died while receiving vasopressors; most (93%) died during their first hospitalization. The most common diagnosis was sepsis (34%), followed by congenital heart disease (17%). Dopamine was the most commonly prescribed first-line vasopressor (70%), and hydrocortisone was the most commonly prescribed second-line vasopressor (49%) for all pediatric patients. The incidence of mortality rose sequentially with escalating vasopressor support, increasing from under 10% with the first vasopressor to 48% at the maximum number of agents. The odds of death almost doubled with the addition of each new vasopressor. CONCLUSIONS The intensity of vasopressor therapy for pediatric patients, regardless of diagnosis, is associated with in-hospital mortality; vasopressor escalation should trigger intensive palliative care supports.
Collapse
Affiliation(s)
- Khyzer B Aziz
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
| | - Renee D Boss
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Johns Hopkins Berman Institute of Bioethics, Baltimore, Maryland, USA
| | | | | | - Kathryn Neubauer
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Pamela K Donohue
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| |
Collapse
|
11
|
Abstract
Several limitations and controversies surround the definition of hypotension; however, it remains one of the most common problems faced by neonates. Approximately 15% to 30% of neonates with hypotension fail to respond to volume and/or vasopressor or inotropes. They are considered to have refractory hypotension. Although it is thought to have multiple causes, absolute and relative adrenal insufficiency is considered as the main reason for refractory hypotension. This article focuses on the role of adrenal insufficiency in causing refractory hypotension in preterm and term infants, the different options of corticosteroids available, and their risk/benefit profiles.
Collapse
Affiliation(s)
- Neha Kumbhat
- Division of Neonatology, Fetal and Neonatal Institute, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Shahab Noori
- Division of Neonatology, Fetal and Neonatal Institute, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.
| |
Collapse
|
12
|
Iijima S. Late-onset glucocorticoid-responsive circulatory collapse in premature infants. Pediatr Neonatol 2019; 60:603-610. [PMID: 31564521 DOI: 10.1016/j.pedneo.2019.09.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 07/16/2019] [Accepted: 09/06/2019] [Indexed: 12/20/2022] Open
Abstract
Late-onset glucocorticoid-responsive circulatory collapse (LGCC) in infants is characterized by sudden onset of hypotension and/or oliguria, which is resistant to volume expanders and inotropes but responds rapidly to intravenous glucocorticoids. LGCC occurs after the first week of life mainly in relatively stable very low birth weight (VLBW) infants. In Japan, the incidence of LGCC is reported to be 8%. Relative adrenal insufficiency (AI) is considered the most likely cause of LGCC, but its detailed pathophysiology remains unclear. Intrinsic and extrinsic factors may affect the pathophysiological mechanism. LGCC should be recognized as one of the high-risk complications in VLBW infants and managed promptly and properly, because if it is not, it may cause life-long neurological problems. To diagnose relative AI, an accurate evaluation of adrenal function is necessary; however, the interpretation of basal serum cortisol levels is difficult in preterm infants after 7 days of life. To recognize LGCC, it is recommended that blood pressure and urine volume be carefully monitored, even outside of the transitional period. If no underlying causes are documented or volume expansion and inotropic support fail, intravenous hydrocortisone should be initiated, and an additional dose of hydrocortisone is required when the response is inadequate. There are few reports to verify or characterize LGCC and this phenomenon has not been recognized worldwide to date. This review summarizes the current knowledge about LGCC in premature infants and evaluates the most significant new findings regarding its pathophysiology, treatment, and prognosis.
Collapse
Affiliation(s)
- Shigeo Iijima
- Department of Pediatrics, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, Shizuoka 431-3192, Japan.
| |
Collapse
|
13
|
Cortisol production in preterm infants with or without late-onset adrenal insufficiency of prematurity: A prospective observational study. Pediatr Neonatol 2019; 60:504-511. [PMID: 30670349 DOI: 10.1016/j.pedneo.2018.12.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 08/02/2018] [Accepted: 12/18/2018] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Immature adrenocortical function in preterm infants may cause inadequate production of cortisol under stress, resulting in adrenal insufficiency of prematurity (AOP). The objective of this study is to compare cortisol production in preterm infants with and without late-onset AOP. METHODS Of 27 preterm infants born at less than 32 weeks gestation, cortisol production was analyzed in those who did (patients, group P) and did not (controls, group C) eventually develop late-onset AOP. Blood samples were prospectively collected every two weeks after birth, and steroid hormone concentrations in the pathway to cortisol production were measured retrospectively. RESULTS We restricted the initial subjects to infants with gestation less than 29 weeks to adjust for confounding factors, culminating in matched infants in groups P (n = 8) and C (n = 11). The cortisol concentrations did not differ between the groups before AOP onset (P = 0.20), but the total concentrations of precursors for cortisol were higher in group P (P < 0.0001). The total concentrations of precursors in group C were inversely correlated with postmenstrual age (ρ = -0.38, P < 0.01). The pattern of changes in total concentrations of precursors differed between the groups (P < 0.05). CONCLUSION Adrenal cortex maturity in preterm infants develops in parallel with postmenstrual age. Infants with late-onset AOP have undeveloped maturation of adrenocortical function after birth. CLINICAL TRIAL REGISTRATION UMIN000022453.
Collapse
|
14
|
Jang JH, Shin J, Jung YH, Choi CW, Kim BI. Clinical Features of Late-Onset Circulatory Collapse in Preterm Infants. NEONATAL MEDICINE 2019. [DOI: 10.5385/nm.2019.26.3.128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
|
15
|
Kovacs K, Szakmar E, Meder U, Szakacs L, Cseko A, Vatai B, Szabo AJ, McNamara PJ, Szabo M, Jermendy A. A Randomized Controlled Study of Low-Dose Hydrocortisone Versus Placebo in Dopamine-Treated Hypotensive Neonates Undergoing Hypothermia Treatment for Hypoxic-Ischemic Encephalopathy. J Pediatr 2019; 211:13-19.e3. [PMID: 31155392 DOI: 10.1016/j.jpeds.2019.04.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 03/10/2019] [Accepted: 04/05/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To investigate whether hydrocortisone supplementation increases blood pressure and decreases inotrope requirements compared with placebo in cooled, asphyxiated neonates with volume-resistant hypotension. STUDY DESIGN A double-blind, randomized, placebo-controlled clinical trial was conducted in a Level III neonatal intensive care unit in 2016-2017. Thirty-five asphyxiated neonates with volume-resistant hypotension (defined as a mean arterial pressure [MAP] < gestational age in weeks) were randomly assigned to receive 0.5 mg/kg/6 hours of hydrocortisone or placebo in addition to standard dopamine treatment during hypothermia. RESULTS More patients reached the target of at least 5-mm Hg increment of MAP in 2 hours after randomization in the hydrocortisone group, compared with the placebo group (94% vs 58%, P = .02, intention-to-treat analysis). The duration of cardiovascular support (P = .001) as well as cumulative (P < .001) and peak inotrope dosage (P < .001) were lower in the hydrocortisone group. In a per-protocol analysis, regression modeling predicted that a 4-mm Hg increase in MAP in response to hydrocortisone treatment was comparable with the effect of 15 μg/kg/min of dopamine in this patient population. Serum cortisol concentrations were low before randomization in both the hydrocortisone and placebo groups (median 3.5 and 3.3 μg/dL, P = .87; respectively), suggesting inappropriate adrenal function. Short-term clinical outcomes were similar in the 2 groups. CONCLUSIONS Hydrocortisone administration was effective in raising the blood pressure and decreasing inotrope requirement in asphyxiated neonates with volume-resistant hypotension during hypothermia treatment. TRIAL REGISTRATION ClinicalTrials.gov: NCT02700828.
Collapse
Affiliation(s)
- Kata Kovacs
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Eniko Szakmar
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Unoke Meder
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | | | - Anna Cseko
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Barbara Vatai
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Attila J Szabo
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary; MTA-SE Pediatric and Nephrology Research Group, Budapest, Hungary
| | | | - Miklos Szabo
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Agnes Jermendy
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary.
| |
Collapse
|
16
|
Krishnamurthy G. Cardiopulmonary Bypass in Premature and Low Birth Weight Neonates - Implications for Postoperative Care From a Neonatologist/Intensivist Perspective. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2019; 22:2-9. [PMID: 31027559 DOI: 10.1053/j.pcsu.2019.02.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 02/26/2019] [Indexed: 11/11/2022]
Abstract
Prematurity and low weight remain significant risk factors for mortality after neonatal cardiac surgery despite steady gains in survival. Newer and lower weight thresholds for operability are constantly generated as surgeons gather proficiency, technical mastery, and experience in performing complex procedures on extremely small infants. Relationship between birth weight and survival after cardiac surgery is nonlinear with 2 kg being an inflection point below which marked decline in survival occurs. If strides toward improved survival in this weight category are to be made, understanding the inherent vulnerabilities of the premature and low birth weight infant is important in addition to acknowledging the vulnerabilities of the system in which care is delivered.
Collapse
Affiliation(s)
- Ganga Krishnamurthy
- Division of Neonatology, Columbia University Medical Center, New York, New York.
| |
Collapse
|
17
|
Lee ES, Sohn JA, Kim HS, Heo JS, Lee JA. Risk Factors for Brain Damage in Preterm Infants After Late-Onset Circulatory Collapse Events. NEONATAL MEDICINE 2019. [DOI: 10.5385/nm.2019.26.1.55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
|
18
|
Cerebral Circulation and Hypotension in the Premature Infant. Neurology 2019. [DOI: 10.1016/b978-0-323-54392-7.00001-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
|
19
|
Abrantes MA, Valencia AM, Bany-Mohammed F, Aranda JV, Beharry KD. Dose response effects of postnatal hydrocortisone on growth and growth factors in the neonatal rat. Steroids 2018; 140:1-10. [PMID: 30142369 DOI: 10.1016/j.steroids.2018.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 08/08/2018] [Accepted: 08/13/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND PURPOSE Hydrocortisone (HC), at different dosages, is used in critically ill newborns for lung stability, blood pressure support, and prevention of chronic lung disease (CLD). Its long-term effects on postnatal growth are not well studied. We hypothesized that early exposure to high doses of HC adversely affects growth, growth factors, metabolic hormones, and neurological outcomes, persisting in adulthood. EXPERIMENTAL DESIGN Rat pups received a single daily intramuscular dose of HC (1 mg/kg/day, 5 mg/kg/day, or 10 mg/kg/day on days 3, 4 & 5 postnatal age (P3, P4, P5). Age-matched controls received equivalent volume saline. Body weight, linear growth, and neurological outcomes were monitored. Animals were sacrificed at P21, P45, and P70 for blood glucose, insulin, IGF-I, GH, leptin, and corticosterone levels. Liver mRNA expression of IGFs and IGFBPs were determined at P21 and P70. Memory and learning abilities were tested using the Morris water maze test at P70. RESULTS HC suppressed body weight and length at P12, P21 and P45, but by P70 there was catchup overgrowth in the 5 and 10 mg/kg/day groups. At P70 blood insulin, IGF-I, GH, and leptin levels were low, whereas blood glucose, and liver IGFs and IGFBPs were high in the high dose groups. High HC also caused delayed memory and learning abilities at P70. CONCLUSIONS These data demonstrate that while higher doses of HC may be required for hemodynamic stability and prevention of CLD, these doses may result in growth deficits, as well as neurological and metabolic sequelae in adulthood.
Collapse
Affiliation(s)
- Maria A Abrantes
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Long Beach Memorial Medical Center, Long Beach, CA 90806, USA; Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of California, Irvine Medical Center, Orange, CA 92868, USA; Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Kaiser Permanente, Anaheim, CA 92806, USA
| | - Arwin M Valencia
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Long Beach Memorial Medical Center, Long Beach, CA 90806, USA; Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of California, Irvine Medical Center, Orange, CA 92868, USA; Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Saddleback Memorial Medical Center, Laguna Hills, CA 92653, USA
| | - Fayez Bany-Mohammed
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of California, Irvine Medical Center, Orange, CA 92868, USA.
| | - Jacob V Aranda
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, USA; Department of Ophthalmology, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, USA.
| | - Kay D Beharry
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Long Beach Memorial Medical Center, Long Beach, CA 90806, USA; Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of California, Irvine Medical Center, Orange, CA 92868, USA; Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, USA; Department of Ophthalmology, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, USA.
| |
Collapse
|
20
|
Ogasawara K, Sato M, Hashimoto K, Imamura T, Go H, Hosoya M. A polymorphism in the glucocorticoid receptor gene is associated with refractory hypotension in premature infants. Pediatr Neonatol 2018; 59:251-257. [PMID: 29033349 DOI: 10.1016/j.pedneo.2017.04.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 03/19/2017] [Accepted: 04/17/2017] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Glucocorticoids play an important role in endocrine control. The association of glucocorticoid receptor (GR) gene polymorphisms with altered sensitivity to glucocorticoid therapy has been reported in adults. However, there are few such reports in infants. The present study analyzed the prevalence of four GR polymorphisms in preterm infants born before 30 weeks of gestation and determined the associations between these polymorphisms and clinical outcomes in the infants. METHODS Totally, 41 preterm infants born at two hospitals in Fukushima were retrospectively screened for the presence of four GR gene polymorphisms, using a TaqMan single-nucleotide polymorphism genotyping assay. The effect of GR gene polymorphisms on clinical outcomes during hospitalization was evaluated. The following primary clinical outcomes were assessed: refractory hypotension in the acute phase and/or severe bronchopulmonary dysplasia, maximum dopamine and dobutamine doses administered, and total hydrocortisone dose administered in the first 48 h of life. Multivariate analysis with logistic regression was used to assess the association between clinical factors and refractory hypotension. RESULTS Of the four GR polymorphisms, only the BclI polymorphism was detected. The genotype distribution was as follows: C/C, 33; C/G, 8; and G/G, 0 infants. Significant differences were observed between the C/C and C/G genotypes with respect to the following variables: refractory hypotension (6% vs. 50%), dopamine dose [3.0 (2.0-4.0) vs. 4.8 (4.0-7.5) μg/kg/min], dobutamine dose [2.4 (0.0-3.6) vs. 4.0 (0-10.0) μg/kg/min], and total hydrocortisone dose administered in the first 48 h of life [2.0 (0-10.0) vs. 6.0 (0-12.0) mg/kg]. Multivariate analysis showed that the BclI genotype (C/C) was significantly less associated with refractory hypotension in the acute phase (odds ratio, 0.008; 95% confidence interval, 0.000-0.371; p = 0.013). CONCLUSION The incidence of refractory hypotension in infants with the C/C genotype was initially expected to be higher than that in infants with the C/G genotype. However, the results of this study were rather different from what we originally expected. The suppressive effect of antenatal steroid use on the HPA axis of the preterm infants with the BclI variant may be associated with refractory hypotension in the acute phase.
Collapse
Affiliation(s)
- Kei Ogasawara
- Department of Pediatrics, Fukushima Medical University School of Medicine, Hikarigaoka 1, Fukushima City, Fukushima Prefecture 960-1295, Japan.
| | - Maki Sato
- Department of Pediatrics, Fukushima Medical University School of Medicine, Hikarigaoka 1, Fukushima City, Fukushima Prefecture 960-1295, Japan.
| | - Koichi Hashimoto
- Department of Pediatrics, Fukushima Medical University School of Medicine, Hikarigaoka 1, Fukushima City, Fukushima Prefecture 960-1295, Japan.
| | - Takashi Imamura
- Department of Pediatrics, Ohta Nishinouchi Hospital, Nishinouchi 2-16-8, Kooriyama City, Fukushima Prefecture 963-8588, Japan.
| | - Hayato Go
- Department of Pediatrics, Fukushima Medical University School of Medicine, Hikarigaoka 1, Fukushima City, Fukushima Prefecture 960-1295, Japan.
| | - Mitsuaki Hosoya
- Department of Pediatrics, Fukushima Medical University School of Medicine, Hikarigaoka 1, Fukushima City, Fukushima Prefecture 960-1295, Japan.
| |
Collapse
|
21
|
Ok YJ, Lim JY, Jung SH. Critical Illness-Related Corticosteroid Insufficiency in Patients with Low Cardiac Output Syndrome after Cardiac Surgery. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2018; 51:109-113. [PMID: 29662808 PMCID: PMC5894574 DOI: 10.5090/kjtcs.2018.51.2.109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 10/19/2017] [Accepted: 10/19/2017] [Indexed: 01/20/2023]
Abstract
Background Low cardiac output syndrome (LCOS) after cardiac surgery usually requires inotropes. In this setting, critical illness-related corticosteroid insufficiency (CIRCI) may develop. We aimed to investigate the clinical features of CIRCI in the presence of LCOS and to assess the efficacy of steroid treatment. Methods We reviewed 28 patients who underwent a rapid adrenocorticotropic hormone (ACTH) test due to the suspicion of CIRCI between February 2010 and September 2014. CIRCI was diagnosed by a change in serum cortisol of <9 μg/dL after the ACTH test or a random cortisol level of <10 μg/dL. Results Twenty of the 28 patients met the diagnostic criteria. The patients with CIRCI showed higher Sequential Organ Failure Assessment (SOFA) scores than those without CIRCI (16.1±2.3 vs. 11.4±3.5, p=0.001). Six of the patients with CIRCI (30%) received glucocorticoids. With an average elevation of the mean blood pressure by 22.2±8.7 mm Hg after steroid therapy, the duration of inotropic support was shorter in the steroid group than in the non-steroid group (14.1±2.3 days versus 30±22.8 days, p=0.001). Three infections (15%) developed in the non-steroid group, but this was not a significant between-group difference. Conclusion CIRCI should be suspected in patients with LCOS after cardiac surgery, especially in patients with a high SOFA score. Glucocorticoid replacement therapy may be considered to reduce the use of inotropes without posing an additional risk of infection.
Collapse
Affiliation(s)
- You Jung Ok
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Ju Yong Lim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Sung-Ho Jung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine
| |
Collapse
|
22
|
Singh Y, Katheria AC, Vora F. Advances in Diagnosis and Management of Hemodynamic Instability in Neonatal Shock. Front Pediatr 2018; 6:2. [PMID: 29404312 PMCID: PMC5780410 DOI: 10.3389/fped.2018.00002] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Accepted: 01/05/2018] [Indexed: 01/20/2023] Open
Abstract
Shock in newborn infants has unique etiopathologic origins that require careful assessment to direct specific interventions. Early diagnosis is key to successful management. Unlike adults and pediatric patients, shock in newborn infants is often recognized in the uncompensated phase by the presence of hypotension, which may be too late. The routine methods of evaluation used in the adult and pediatric population are often invasive and less feasible. We aim to discuss the pathophysiology in shock in newborn infants, including the transitional changes at birth and unique features that contribute to the challenges in early identification. Special emphasis has been placed on bedside focused echocardiography/focused cardiac ultrasound, which can be used as an additional tool for early, neonatologist driven, ongoing evaluation and management. An approach to goal oriented management of shock has been described and how bed side functional echocardiography can help in making a logical choice of intervention (fluid therapy, inotropic therapy or vasopressor therapy) in infants with shock.
Collapse
Affiliation(s)
- Yogen Singh
- Department of Pediatric Cardiology and Neonatal Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- University of Cambridge Clinical School of Medicine, Cambridge, United Kingdom
| | - Anup C. Katheria
- Department of Neonatology, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, United States
- Department of Neonatology, Loma Linda University School of Medicine, Loma Linda, CA, United States
| | - Farha Vora
- Department of Neonatology, Loma Linda University School of Medicine, Loma Linda, CA, United States
| |
Collapse
|
23
|
Verma RP, Dasnadi S, Zhao Y, Chen HH. A comparative analysis of ante- and postnatal clinical characteristics of extremely premature neonates suffering from refractory and non-refractory hypotension: Is early clinical differentiation possible? Early Hum Dev 2017; 113:49-54. [PMID: 28750269 DOI: 10.1016/j.earlhumdev.2017.07.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 06/19/2017] [Accepted: 07/02/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND About 25% of hypotensive ELBW infants are refractory to intravascular volume expansion and inotropic drugs (VI) and require hydrocortisone (HC). Such neonates suffer from complications of prolonged hypotension and extended therapy with VI. ELBW infants with refractory hypotension (RH) are clinically and biochemically indistinguishable from those who respond to VI. OBJECTIVE Early identification and differentiation of ELBW infants susceptible to steroid dependent hypotension from those who respond to inotropic medications. METHODS In a retrospective study the ante- and postnatal clinical characteristics of ELBW infants who received hydrocortisone (HC) for refractory hypotension (RH) were compared to those who responded to volume-inotropes (VI). RESULTS Infants in HC group had lower birth weight (BW, 675±121g) and gestational age (GA, 25.1±1.3weeks) and higher mean airway pressure and oxygen requirements, all independent of antenatal steroid (ANS) exposure. The receipt of ANS (p 0.01) and occurrences of maternal diabetes mellitus (GDM, p 0.01) were lower in HC group. ANS (OR 0.5, 95% CI 0.2-0.9, p 0.01) and GDM (OR 0.3, 95% CI 0.09-0.9, p 0.04) reduced the risk for RH. HC group had higher risk for IVH (OR 2.1, 95% CI 1.02-4.2 p=0.04) which declined in the multivariate analysis. A trend towards lower risk of ventriculomegaly (VM) was noted in HC group (OR 0.3, 95% CI 0.1-1.1), which became significant after controlling for BW (OR 0.2 95% CI 0.07-0.9, p 0.04). Similar trend was noted for maternal hypertension. CONCLUSION Hypotension in ELBW infants who are ≤25wks of GA and unexposed to ANS and GDM is refractory to VI therapy. Such neonates may benefit from an initial therapy with, or earlier institution of hydrocortisone. The trend towards a higher risk for VM with VI therapy needs validation in future studies.
Collapse
Affiliation(s)
- Rita P Verma
- Nassau University Medical Center, Department of Pediatrics, Division of Neonatology, 2201 Hempstead Turnpike, East Meadow, NY 11554, United States.
| | - Shaeequa Dasnadi
- Houston Methodist Sugarland Nurseries, Department of Pediatrics Section of Neonatology, Baylor College of Medicine, 6621 Fannin Street # B 06104, Houston, TX 77030, United States.
| | - Yuan Zhao
- Department of Applied Mathematics and Statistics, Stony Brook University, Stony Brook, NY 11794, United States.
| | - Hegang H Chen
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, 113 Howard Hall, 660 W. Redwood Street, Baltimore, MD 21201, United States.
| |
Collapse
|
24
|
Abstract
PURPOSE Guidelines for diagnosis and treatment of adrenal insufficiency (AI) in newborns with congenital diaphragmatic hernia (CDH) are poorly defined. METHODS From 2002 to 2016, 155 infants were treated for CDH at our institution. Patients with shock refractory to vasopressors (clinically diagnosed AI) were treated with hydrocortisone (HC). When available, random cortisol levels <10 μg/dL were considered low. Outcomes were compared between groups. RESULTS Hydrocortisone was used to treat AI in 34% (53/155) of patients. That subset of patients was demonstrably sicker, and mortality was expectedly higher for those treated with HC (37.7 vs. 17.6%, p = 0.0098). Of the subset of patients with random cortisol levels measured before initiation of HC, 67.7% (21/31) had low cortisol levels. No significant differences were seen in survival between the high and low groups, but mortality trended higher in patients with high cortisol levels that received HC. After multivariate analysis, duration of HC stress dose administration was associated with increased risk of mortality (OR 1.11, 95% CI 1.02-1.2, p = 0.021), and total duration of HC treatment was associated with increased risk of sepsis (OR 1.04, 95% CI 1.005-1.075, p = 0.026). CONCLUSION AI is prevalent amongst patients with CDH, but prolonged treatment with HC may increase risk of mortality and sepsis.
Collapse
|
25
|
Peeples ES. An evaluation of hydrocortisone dosing for neonatal refractory hypotension. J Perinatol 2017; 37:943-946. [PMID: 28518133 DOI: 10.1038/jp.2017.68] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 02/28/2017] [Accepted: 04/12/2017] [Indexed: 11/09/2022]
Abstract
OBJECTIVE The objective of the study was to compare blood pressure, vasoactive medication requirements and adverse outcomes after administration of high- versus low-dose hydrocortisone (HC) in preterm infants. STUDY DESIGN This is a retrospective analysis of 106 infants ⩽28 weeks gestational age with hypotension requiring vasoactive infusions and high-dose (4 mg kg-1 per day, n=50), low-dose (1 to 3 mg kg-1 per day, n=20) or no HC (n=36) from 2011 to 2015. Groups were compared by two-tailed t-test or χ2, and correlation estimated by multivariable logistic regression. RESULTS There were no differences in measured efficacy between the low- and high-dose groups. Infants with pre-treatment cortisol >15 mcg dl-1 who received HC therapy showed less improvement in vasoactive burden, increased hyperglycemia (P=0.015) and increased death independent of HC dose (odds ratio 26.3, 3.5 to 198.3, P=0.002). CONCLUSION These results support using the lowest effective HC dose in preterm infants. In addition, HC therapy should likely be avoided in infants who are not cortisol deficient.
Collapse
Affiliation(s)
- E S Peeples
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA, USA
| |
Collapse
|
26
|
Abstract
Hypotension is a common problem in neonates with complex underlying pathophysiology. Although treatment of low blood pressure is common, clinicians must use all available information to target neonates with compromised perfusion. Pharmacotherapy should be tailored to the specific physiologic perturbations of the individual neonate. Dopamine is the most commonly utilized agent and may be the most appropriate agent for septic shock with low diastolic blood pressure. However, alternative therapies should be considered for other etiologies of hypotension, including milrinone and vasopressin for persistent pulmonary hypertension of the newborn and dobutamine for patent ductus arteriosus. Additional studies are required to refine the approach to neonatal hypotension and document the long-term outcomes of treated neonates.
Collapse
|
27
|
Khashana A, Ahmed H, Ahmed A, Abdelwahab A, Saarela T, Rämet M, Hallman M. Cortisol precursors in neonates with vasopressor-resistant hypotension in relationship to demographic characteristics. J Matern Fetal Neonatal Med 2017. [PMID: 28629239 DOI: 10.1080/14767058.2017.1344966] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To correlate between cortisol precursors in neonates with vasopressor resistant hypotension and demographic characteristics. METHODS We investigated 48 neonates with vasopressor-resistant hypotension. Gestation at birth ranged from 34 to 42 weeks and postnatal age from 4 to 14 days. Cortisol and precursor steroids were measured soon after the onset of volume expansion and inotropes for treatment of shock. Their concentrations were determined using liquid chromatography/mass spectrometry. RESULTS In neonates with vasopressor-resistant hypotension, the serum levels of cortisol were within normal nonstress range. There was a strong negative linear association between postnatal age and dehydroepiandrosterone level (r = -0.50, p < .01), which decreased with neonatal age. In addition, there was a significant positive association between gestational age at birth and 17-hydroxy-pregnenolone (r = 0.33, p = .02). No further significant associations were evident between the neonatal weight, duration of gestation or gender and of the levels of cortisol or the other steroids (p > .05). The cause of therapy-resistant hypotension did not appear to influence the steroid levels. CONCLUSIONS Cortisol stress response is absent in these severely ill late preterm and term infants. This may be due to inhibition of the distal pathway of cortisol synthesis.
Collapse
Affiliation(s)
- Abdelmoneim Khashana
- a Medical Research Center Oulu, PEDEGO Research Unit, University of Oulu , Oulu , Finland.,b Department of Children and Adolescents , Oulu University Hospital , Oulu , Finland.,c Department of Pediatrics and Neonatology , Suez Canal University Hospital , Ismailia , Egypt
| | - Hoda Ahmed
- c Department of Pediatrics and Neonatology , Suez Canal University Hospital , Ismailia , Egypt
| | - Amal Ahmed
- d Department of Clinical Pathology , Suez Canal University Hospital , Ismailia , Egypt
| | - Amina Abdelwahab
- c Department of Pediatrics and Neonatology , Suez Canal University Hospital , Ismailia , Egypt
| | - Timo Saarela
- a Medical Research Center Oulu, PEDEGO Research Unit, University of Oulu , Oulu , Finland.,b Department of Children and Adolescents , Oulu University Hospital , Oulu , Finland
| | - Mika Rämet
- a Medical Research Center Oulu, PEDEGO Research Unit, University of Oulu , Oulu , Finland.,b Department of Children and Adolescents , Oulu University Hospital , Oulu , Finland
| | - Mikko Hallman
- a Medical Research Center Oulu, PEDEGO Research Unit, University of Oulu , Oulu , Finland.,b Department of Children and Adolescents , Oulu University Hospital , Oulu , Finland
| |
Collapse
|
28
|
Abstract
Congenital Diaphragmatic hernia (CDH) is a condition characterized by a defect in the diaphragm leading to protrusion of abdominal contents into the thoracic cavity interfering with normal development of the lungs. The defect may range from a small aperture in the posterior muscle rim to complete absence of diaphragm. The pathophysiology of CDH is a combination of lung hypoplasia and immaturity associated with persistent pulmonary hypertension of newborn (PPHN) and cardiac dysfunction. Prenatal assessment of lung to head ratio (LHR) and position of the liver by ultrasound are used to diagnose and predict outcomes. Delivery of infants with CDH is recommended close to term gestation. Immediate management at birth includes bowel decompression, avoidance of mask ventilation and endotracheal tube placement if required. The main focus of management includes gentle ventilation, hemodynamic monitoring and treatment of pulmonary hypertension followed by surgery. Although inhaled nitric oxide is not approved by FDA for the treatment of PPHN induced by CDH, it is commonly used. Extracorporeal membrane oxygenation (ECMO) is typically considered after failure of conventional medical management for infants ≥ 34 weeks’ gestation or with weight >2 kg with CDH and no associated major lethal anomalies. Multiple factors such as prematurity, associated abnormalities, severity of PPHN, type of repair and need for ECMO can affect the survival of an infant with CDH. With advances in the management of CDH, the overall survival has improved and has been reported to be 70-90% in non-ECMO infants and up to 50% in infants who undergo ECMO.
Collapse
|
29
|
Abstract
Newborns, and especially premature newborns, are at significant risk for developing hypotension in the first week or two after birth. The etiology of hypotension in the newborn may vary, but the very low birth weight and extremely low birth weight preterm infants are less likely to respond to conventional cardiovascular support when they develop hypotension. This article reviews the least conventional treatment using hydrocortisone for hypotension that is refractory to conventional volume replacement and/or vasopressor medications with the underlying assumption that sick and premature newborns have a relative or measured adrenal insufficiency. The addition of hydrocortisone in the treatment of hypotension in the newborn is becoming more common but is not universally advocated. However, the supportive evidence is growing, and, as reviewed, use of hydrocortisone requires judicious and cautious regard.
Collapse
|
30
|
|
31
|
Giesinger RE, McNamara PJ. Hemodynamic instability in the critically ill neonate: An approach to cardiovascular support based on disease pathophysiology. Semin Perinatol 2016; 40:174-88. [PMID: 26778235 DOI: 10.1053/j.semperi.2015.12.005] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Hemodynamic disturbance in the sick neonate is common, highly diverse in underlying pathophysiology and dynamic. Dysregulated systemic and cerebral blood flow is hypothesized to have a negative impact on neurodevelopmental outcome and survival. An understanding of the physiology of the normal neonate, disease pathophysiology, and the properties of vasoactive medications may improve the quality of care and lead to an improvement in survival free from disability. In this review we present a modern approach to cardiovascular therapy in the sick neonate based on a more thoughtful approach to clinical assessment and actual pathophysiology. Targeted neonatal echocardiography offers a more detailed insight into disease processes and offers longitudinal assessment, particularly response to therapeutic intervention. The pathophysiology of common neonatal conditions and the properties of cardiovascular agents are described. In addition, we outline separate treatment algorithms for various hemodynamic disturbances that are tailored to clinical features, disease characteristics and echocardiographic findings.
Collapse
Affiliation(s)
- Regan E Giesinger
- Division of Neonatology, The Hospital for Sick Children, 555 University Ave, Toronto, ON, Canada M5G 1X8; Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Patrick J McNamara
- Division of Neonatology, The Hospital for Sick Children, 555 University Ave, Toronto, ON, Canada M5G 1X8; Department of Paediatrics, University of Toronto, Toronto, ON, Canada; Department of Physiology, University of Toronto, Toronto, ON, Canada.
| |
Collapse
|
32
|
Yuerek M, Rossano JW, Mascio CE, Shaddy RE. Postoperative management of heart failure in pediatric patients. Expert Rev Cardiovasc Ther 2015; 14:201-15. [PMID: 26560361 DOI: 10.1586/14779072.2016.1117388] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Low cardiac output syndrome (LCOS) is a well-described entity occurring in 25-65% of pediatric patients undergoing open-heart surgery. With judicious intensive care management of LCOS, most patients have an uncomplicated postoperative course, and within 24 h after cardiopulmonary bypass, the cardiac function returns back to baseline. Some patients have severe forms of LCOS not responsive to medical management alone, requiring temporary mechanical circulatory support to prevent end-organ injury and to decrease myocardial stress and oxygen demand. Occasionally, cardiac function does not recover and heart transplantation is necessary. Long-term mechanical circulatory support devices are used as a bridge to transplantation because of limited availability of donor hearts. Experience in usage of continuous flow ventricular assist devices in the pediatric population is increasing.
Collapse
Affiliation(s)
- Mahsun Yuerek
- a Division of Cardiac Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine , Children's Hospital of Philadelphia , Philadelphia , PA , USA
| | - Joseph W Rossano
- b Division of Cardiology, Department of Pediatrics , University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia , Philadelphia , PA , USA
| | - Christopher E Mascio
- c Division of Pediatric Cardiothoracic Surgery, Department of Surgery , University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia , Philadelphia , PA , USA
| | - Robert E Shaddy
- b Division of Cardiology, Department of Pediatrics , University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia , Philadelphia , PA , USA
| |
Collapse
|
33
|
Postoperative Hydrocortisone Infusion Reduces the Prevalence of Low Cardiac Output Syndrome After Neonatal Cardiopulmonary Bypass. Pediatr Crit Care Med 2015; 16:629-36. [PMID: 25901540 DOI: 10.1097/pcc.0000000000000426] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Neonatal cardiac surgery with cardiopulmonary bypass is often complicated by morbidity associated with inflammation and low cardiac output syndrome. Hydrocortisone "stress dosing" is reported to provide hemodynamic benefits in some patients with refractory shock. Development of cardiopulmonary bypass-induced adrenal insufficiency may provide further rationale for postoperative hydrocortisone administration. We sought to determine whether prophylactic, postoperative hydrocortisone infusion could decrease prevalence of low cardiac output syndrome after neonatal cardiac surgery with cardiopulmonary bypass. DESIGN Double-blind, randomized control trial. SETTING Pediatric cardiac ICU and operating room in tertiary care center. PATIENTS Forty neonates undergoing cardiac surgery with cardiopulmonary bypass were randomized (19 hydrocortisone and 21 placebo). Demographics and known risk factors were similar between groups. INTERVENTIONS After cardiopulmonary bypass separation, bolus hydrocortisone (50 mg/m²) or placebo was administered, followed by continuous hydrocortisone infusion (50 mg/m²/d) or placebo tapered over 5 days. Adrenocorticotropic hormone stimulation testing (1 μg) was performed before and after cardiopulmonary bypass, prior to steroid administration. Blood was collected for cytokine analysis before and after cardiopulmonary bypass. MEASUREMENTS AND MAIN RESULTS Subjects receiving hydrocortisone were less likely to develop low cardiac output syndrome (5/19, 26% vs 12/21, 57%; p = 0.049). Hydrocortisone group had more negative net fluid balance at 48 hours (-114 vs -64 mL/kg; p = 0.01) and greater urine output at 0-24 hours (2.7 vs 1.2 mL/kg/hr; p = 0.03). Hydrocortisone group weaned off catecholamines and vasopressin sooner than placebo, with a difference in inotrope-free subjects apparent after 48 hours (p = 0.033). Five placebo subjects (24%) compared with no hydrocortisone subjects required rescue steroids (p = 0.02). Thirteen (32.5%) had adrenal insufficiency after cardiopulmonary bypass. Patients with adrenal insufficiency randomized to receive hydrocortisone had lower prevalence of low cardiac output syndrome compared with patients with adrenal insufficiency randomized to placebo (1/6 vs 6/7, respectively; p = 0.02). Hydrocortisone significantly reduced proinflammatory cytokines. Ventilator-free days, hospital length of stay, and kidney injury were similar. CONCLUSIONS Prophylactic, postoperative hydrocortisone reduces low cardiac output syndrome, improves fluid balance and urine output, and attenuates inflammation after neonatal cardiopulmonary bypass surgery. Further studies are necessary to show if these benefits lead to improvements in more important clinical outcomes.
Collapse
|
34
|
Noori S, Seri I. Evidence-based versus pathophysiology-based approach to diagnosis and treatment of neonatal cardiovascular compromise. Semin Fetal Neonatal Med 2015; 20:238-45. [PMID: 25823937 DOI: 10.1016/j.siny.2015.03.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
With the advances in biomedical research and neonatal intensive care, our understanding of cardiovascular developmental physiology and pathophysiology has significantly improved during the last few decades. Despite this progress, the current management of circulatory compromise depends primarily on experts' opinions rather than high level of evidence. The lack of reliable, accurate, continuous and preferably non-invasive monitoring techniques has further limited our ability to collect the information needed for the design and execution of more sophisticated clinical trials with a better chance to provide the evidence we need. Given the lack of randomized, placebo-controlled trials investigating clinically relevant outcomes of novel treatments of neonatal cardiovascular compromise, we must now use the available lower level of evidence and our present understanding of developmental physiology and pathophysiology when providing cardiovascular supportive care to critically ill neonates. However, with recent advances in cardiovascular monitoring capabilities, direct and more objective assessment of the changes in cardiovascular function, organ blood flow, and tissue oxygenation have become possible. These advances have helped in our clinical assessment and enabled us to start designing more sophisticated interventional clinical trials using clinically relevant endpoints.
Collapse
Affiliation(s)
- Shahab Noori
- Division of Neonatology and the Center for Fetal and Neonatal Medicine, Department of Pediatrics, Children's Hospital Los Angeles and the LAC+USC Medical Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| | - Istvan Seri
- Sidra Medical and Research Center, Doha, Qatar
| |
Collapse
|
35
|
Rodríguez-Castaño M, Corredera A, Aleo E, Arruza L. Prenatal Exposure to Angiotensin II Receptor Blockers and Hemodynamic Effects on the Newborn. Fetal Pediatr Pathol 2015; 34:117-9. [PMID: 25394297 DOI: 10.3109/15513815.2014.976685] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Angiotensin II receptor blockers (ARBs) are potent antihypertensive agents that block the renin angiotensin aldosterone system (RAS). Their use in pregnancy may cause malformations, oligoanuria, hypotension, and death. Hypotension is observed up to 15% of cases and is described as refractory to volume and inotropic support, although its pathophysiology is unknown. We present a case of prenatal exposure to ARBs in order to characterize the hemodynamic compromise in the newborn, help in decision-making, and guide the therapeutic approach to these patients.
Collapse
|
36
|
Neunhoeffer F, Renk H, Hofbeck M, Grenz C, Haller C, Heimberg E, Gerbig I, Schlensak C, Kumpf M. Safety, efficacy and response to a hydrocortisone rescue therapy protocol in children with refractory hypotension after cardiopulmonal bypass. Pediatr Cardiol 2015; 36:640-5. [PMID: 25380964 DOI: 10.1007/s00246-014-1059-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 10/31/2014] [Indexed: 11/25/2022]
Abstract
Little is known about which paediatric patients respond to hydrocortisone rescue therapy (HRT) with improvement of haemodynamic stability in refractory hypotension after cardiopulmonal bypass. Data were gathered retrospectively from children who received HRT in refractory hypotension after cardiopulmonary bypass in the period from 2000 to 2010. One hundred and sixty-six out of 1,273 children, 150 <1 year and 16 >1 year were enrolled. HRT improved haemodynamics significantly, increased blood pressure, decreased the vasoactive-inotropic score and plasma lactate concentrations in all children >1 year and in 82 % (123 out of 150) of the infants <1 year. Non-responders <1 year were significantly younger, lighter, mostly male infants and had longer cardiopulmonary bypass support time. Serum lactate and paediatric risk of mortality score were significantly higher in non-responders at time of initiation of HRT. Mortality was significantly higher in non-responders versus responders (2.44 vs. 13.5 %; p = 0.0008). HRT caused no adverse effects like electrolyte disturbances or hyperglycaemia. HRT in refractory hypotension after paediatric cardiac surgery is safe but not all infants <1 year show haemodynamic response to HRT. Non-response to HRT is associated with significantly higher mortality.
Collapse
Affiliation(s)
- F Neunhoeffer
- Department of Paediatric Cardiology, Pulmology and Paediatric Intensive Care Medicine, University Children's Hospital, Hoppe-Seyler-Str. 1, 72076, Tübingen, Germany,
| | | | | | | | | | | | | | | | | |
Collapse
|
37
|
Affiliation(s)
- Hye Rim Chung
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Korea
| |
Collapse
|
38
|
Chung HR. Adrenal and thyroid function in the fetus and preterm infant. KOREAN JOURNAL OF PEDIATRICS 2014; 57:425-33. [PMID: 25379042 PMCID: PMC4219944 DOI: 10.3345/kjp.2014.57.10.425] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 08/14/2014] [Indexed: 02/04/2023]
Abstract
Adrenal and thyroid hormones are essential for the regulation of intrauterine homeostasis, and for the timely differentiation and maturation of fetal organs. These hormones play complex roles during fetal life, and are believed to underlie the cellular communication that coordinates maternal-fetal interactions. They serve to modulate the functional adaptation for extrauterine life during the perinatal period. The pathophysiology of systemic vasopressor-resistant hypotension is associated with low levels of circulating cortisol, a result of immaturity of hypothalamic-pituitary-adrenal axis in preterm infants under stress. Over the past few decades, studies in preterm infants have shown abnormal clinical findings that suggest adrenal or thyroid dysfunction, yet the criteria used to diagnose adrenal insufficiency in preterm infants continue to be arbitrary. In addition, although hypothyroidism is frequently observed in extremely low gestational age infants, the benefits of thyroid hormone replacement therapy remain controversial. Screening methods for congenital hypothyroidism or congenital adrenal hyperplasia in the preterm neonate are inconclusive. Thus, further understanding of fetal and perinatal adrenal and thyroid function will provide an insight into the management of adrenal and thyroid function in the preterm infant.
Collapse
Affiliation(s)
- Hye Rim Chung
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Korea
| |
Collapse
|
39
|
Trends in pharmacotherapy for neonatal hypotension. J Pediatr 2014; 165:697-701.e1. [PMID: 25039051 DOI: 10.1016/j.jpeds.2014.06.009] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Revised: 05/20/2014] [Accepted: 06/03/2014] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To determine trends in pharmacotherapy for neonatal hypotension in all infants and in extremely low birth weight (ELBW, birth weight 300-1000 g) infants. STUDY DESIGN We queried the Pediatric Health Information System database for all infants ≤28 days with a diagnosis code for hypotension that were discharged between January 2001 and December 2012. Patients were excluded if they had complex congenital heart disease or cardiac surgery, sepsis or meningitis, or had extracorporeal membrane oxygenation. We determined trends in pharmacotherapy for hypotension in all infants and ELBW infants, an especially vulnerable group. RESULTS A total of 8019 hypotensive infants met study criteria. The 2 most prescribed medications were dopamine (65.3%) and dobutamine (19.9%). For 1487 hypotensive ELBW infants, the 2 most prescribed medications were dopamine (83.4%) and hydrocortisone (33%). During the study period, the use of dobutamine decreased, and hydrocortisone and vasopressin use increased for all infants and for ELBW infants. CONCLUSIONS Treatment of neonatal hypotension varies widely between institutions and individual practitioners, and pharmacotherapy for neonatal hypotension has changed over the past decade. Although dopamine and dobutamine were the most frequently used agents, their use has declined and the uses of hydrocortisone and vasopressin have increased.
Collapse
|
40
|
A role for H2S in the microcirculation of newborns: the major metabolite of H2S (thiosulphate) is increased in preterm infants. PLoS One 2014; 9:e105085. [PMID: 25121737 PMCID: PMC4133363 DOI: 10.1371/journal.pone.0105085] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2014] [Accepted: 07/20/2014] [Indexed: 11/19/2022] Open
Abstract
Excessive vasodilatation during the perinatal period is associated with cardiorespiratory instability in preterm neonates. Little evidence of the mechanisms controlling microvascular tone during circulatory transition exists. We hypothesised that hydrogen sulphide (H2S), an important regulator of microvascular reactivity and central cardiac function in adults and animal models, may contribute to the vasodilatation observed in preterm newborns. Term and preterm neonates (24–43 weeks gestational age) were studied. Peripheral microvascular blood flow was assessed by laser Doppler. Thiosulphate, a urinary metabolite of H2S, was determined by high performance liquid chromatography as a measure of 24 hr total body H2S turnover for the first 3 days of postnatal life. H2S turnover was greatest in very preterm infants and decreased with increasing gestational age (p = 0.0001). H2S turnover was stable across the first 72 hrs of life in older neonates. In very preterm neonates, H2S turnover increased significantly from day 1 to 3 (p = 0.0001); and males had higher H2S turnover than females (p = 0.04). A significant relationship between microvascular blood flow and H2S turnover was observed on day 2 of postnatal life (p = 0.0004). H2S may play a role in maintaining microvascular tone in the perinatal period. Neonates at the greatest risk of microvascular dysfunction characterised by inappropriate peripheral vasodilatation - very preterm male neonates - are also the neonates with highest levels of total body H2S turnover suggesting that overproduction of this gasotransmitter may contribute to microvascular dysfunction in preterms. Potentially, H2S is a target to selectively control microvascular tone in the circulation of newborns.
Collapse
|
41
|
Adding hydrocortisone as 1st line of inotropic treatment for hypotension in very low birth weight infants. Indian J Pediatr 2014; 81:808-10. [PMID: 23904065 DOI: 10.1007/s12098-013-1151-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Accepted: 06/17/2013] [Indexed: 10/26/2022]
Abstract
In this pilot study the authors demonstrate the feasibility, effectiveness and safety of the combined early treatment with hydrocortisone and dopamine for refractory hypotension in preterm newborns. Very low birth weight infants born at gestational age < 30 wk or birth weight < 1250 g in the first 48 h of life with hypotension after receiving 10-20 mL/kg bolus of normal saline, were randomized to receive concurrently with the initiation of dopamine, intravenous hydrocortisone (11 infants) or an equivalent volume of placebo (11 infants). Despite no significant clinical difference between the groups including gestational age, birth weight, prevalence of chorioamnionitis, prenatal steroid treatment, cord PH, baseline cortisol level, there was a trend towards lower incidence of bronchopulmonary dysplasia (BPD), and higher survival without BPD rate in the hydrocortisone group. In this very sick small group of infants, hydrocortisone was not associated with more adverse effects, but rather showed a trend toward association with better outcome, including survival without BPD.
Collapse
|
42
|
Salas G, Travaglianti M, Leone A, Couceiro C, Rodríguez S, Fariña D. Hidrocortisona para el tratamiento de hipotensión refractaria: ensayo clínico controlado y aleatorizado. An Pediatr (Barc) 2014; 80:387-93. [DOI: 10.1016/j.anpedi.2013.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Revised: 07/07/2013] [Accepted: 08/26/2013] [Indexed: 10/26/2022] Open
|
43
|
Hydrocortisone for the treatment of refractory hypotension: a randomised controlled trial. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2014. [DOI: 10.1016/j.anpede.2014.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
|
44
|
Abstract
Successful transition from intrauterine to extrauterine life involves significant physiologic changes. The majority of these changes occur relatively quickly during those first moments following delivery; however, transition for the extremely preterm infant occurs over a longer period of time. Careful assessment and perceptive interventions on the part of neonatal care providers is essential as the extremely preterm infant adjusts to life outside the womb. This article will focus on respiratory, cardiovascular, gastrointestinal, and neurologic transitional events experienced by the extremely premature infant.
Collapse
|
45
|
Poon CY, Edwards MO, Kotecha S. Long term cardiovascular consequences of chronic lung disease of prematurity. Paediatr Respir Rev 2013; 14:242-9. [PMID: 24209460 DOI: 10.1016/j.prrv.2012.08.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Pulmonary arterial (PA) hypertension in preterm infant is an important consequence of chronic lung disease of prematurity (CLD) arising mainly due to impaired alveolar development and dysregulated angiogenesis of the pulmonary circulation. Although PA pressure and resistance in these children normalise by school age, their pulmonary vasculature remains hyper-reactive to hypoxia until early childhood. Furthermore, there is evidence that systemic blood pressure in preterm born children with or without CLD is mildly increased at school age and in young adulthood when compared to term-born children. Arterial stiffness may be increased in CLD survivors due to increased smooth muscle tone of the pre-resistance and resistance vessels rather than the loss of elasticity in the large arteries. This review explores the long term effects of CLD on the pulmonary and systemic circulations along with their clinical correlates and therapeutic approaches.
Collapse
Affiliation(s)
- Chuen Yeow Poon
- Department of Child Health, School of Medicine, Cardiff University, University Hospital of Wales, Heath Park, Cardiff CF14 4XN, UK.
| | | | | |
Collapse
|
46
|
Krishnamurthy G, Ratner V, Bacha E. Neonatal cardiac care, a perspective. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2013; 16:21-31. [PMID: 23561814 DOI: 10.1053/j.pcsu.2013.01.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Every year in the United States approximately 40,000 infants are born with congenital heart disease. Several of these infants require corrective or palliative surgery in the neonatal period. Mortality rates after cardiac surgery are highest amongst neonates, particularly those born prematurely. There are several reasons for the increased surgical mortality risk in neonates. This review outlines these risks, with particular emphasis on the relative immaturity of the organ systems in the term and preterm neonate.
Collapse
Affiliation(s)
- Ganga Krishnamurthy
- Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York, NY 10032, USA.
| | | | | |
Collapse
|
47
|
Minette MS, Hoyer AW, Pham PP, DeBoer MD, Reller MD, Boston BA. Cardiac function in congenital adrenal hyperplasia: a pattern of reversible cardiomyopathy. J Pediatr 2013; 162:1193-8, 1198.e1. [PMID: 23337094 DOI: 10.1016/j.jpeds.2012.11.086] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Revised: 10/10/2012] [Accepted: 11/29/2012] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To evaluate cardiac function in infants with congenital adrenal hyperplasia (CAH) before and after corticosteroid replacement therapy. STUDY DESIGN This prospective, case-control study included 9 infants with CAH. Cardiac function was assessed by echocardiography at presentation and after corticosteroid replacement therapy. Six term infants underwent 2 echocardiograms each and served as the control group. Data on fractional shortening (FS), rate-corrected velocity of circumferential fiber shortening (Vcf), wall stress, tissue Doppler indices, myocardial performance index, left ventricular mass, and Vcf/wall stress were obtained. RESULTS The infants with CAH exhibited myocardial dysfunction at baseline and lower systolic blood pressure (SBP) compared with the control group. FS, a measure of systolic contractility, differed significantly from before to after corticosteroid treatment (mean, 32.3%±4.7% pretreatment, 39.9%±5.0% posttreatment). Vcf, a preload-independent measure of cardiac contractility, also differed significantly before and after treatment (mean, 1.23±0.16 circumferences/second pretreatment, 1.45±0.22 circumferences/second posttreatment). SBP was also lower (mean, 84±9.3 mmHg) and improved with treatment (mean, 95±4.8 mmHg). The control group demonstrated no statistically significant changes in FS, Vcf, or SBP. There was a change in left ventricular mass in the control group between the 2 studies. CONCLUSION Newborns with CAH have evidence for cardiac dysfunction at baseline that reverses with corticosteroid replacement therapy. These data suggest that corticosteroids play a direct role in modulating cardiac function in the newborn.
Collapse
Affiliation(s)
- Mary S Minette
- Division of Pediatric Cardiology, Department of Pediatrics, Oregon Health & Science University, Portland, OR 97239, USA.
| | | | | | | | | | | |
Collapse
|
48
|
Niwa F, Kawai M, Kanazawa H, Iwanaga K, Matsukura T, Shibata M, Hasegawa T, Heike T. Limited response to CRH stimulation tests at 2 weeks of age in preterm infants born at less than 30 weeks of gestational age. Clin Endocrinol (Oxf) 2013; 78:724-9. [PMID: 23009353 DOI: 10.1111/cen.12049] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Revised: 09/02/2012] [Accepted: 09/12/2012] [Indexed: 11/26/2022]
Abstract
BACKGROUND The high incidence of glucocorticoid-responsive complications in extremely preterm infants suggests the immaturity of their adrenal function; however, knowledge of the hypothalamus-pituitary-adrenal (HPA) axis in extremely preterm infants is limited. METHODS To clarify the characteristics of the HPA axis in preterm very low birthweight (VLBW) infants, we performed CRH tests repeatedly: at about 2 weeks of age and at term (37-41 weeks of postmenstrual age) for 21 VLBW infants with a gestational age (GA) <30 weeks at birth. RESULTS Basal cortisol values at 2 weeks of age were significantly higher than those at term in VLBW infants < 30 weeks of gestation at birth (304·1 ± 146·3 nmol/l vs 184·7 ± 108·2 nmol/l). Response to corticotropin-releasing hormone (CRH) stimulation tests at 2 weeks of age was significantly lower than at term (delta cortisol 148·3 ± 90·7 nmol/l vs 271·8 ± 167·0 nmol/l, delta ACTH 3·9 ± 3·2 pmol/l vs 12·3 ± 9·2 pmol/l, respectively). We found that earlier GA contributed to the higher basal cortisol values, and antenatal glucocorticoid (AG) contributed to the lower response of cortisol to CRH tests at 2 weeks of age. CONCLUSIONS VLBW infants showed a characteristic pattern in the HPA axis at 2 weeks of age: higher basal cortisol values and lower response to CRH tests. This study suggested that AG was related to the lower response to CRH tests, at least partly.
Collapse
Affiliation(s)
- Fusako Niwa
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
| | | | | | | | | | | | | | | |
Collapse
|
49
|
Drury PP, Booth LC, Bennet L, Davidson JO, Wibbens B, Gunn AJ. Dopamine infusion for postresuscitation blood pressure support after profound asphyxia in near-term fetal sheep. Exp Physiol 2012; 98:699-709. [DOI: 10.1113/expphysiol.2012.069989] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
50
|
Lee SR, Kim HK, Youm JB, Dizon LA, Song IS, Jeong SH, Seo DY, Ko KS, Rhee BD, Kim N, Han J. Non-genomic effect of glucocorticoids on cardiovascular system. Pflugers Arch 2012; 464:549-59. [PMID: 23001133 DOI: 10.1007/s00424-012-1155-2] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Accepted: 09/05/2012] [Indexed: 01/01/2023]
Abstract
Glucocorticoids (GCs) are essential steroid hormones for homeostasis, development, metabolism, and cognition and possess anti-inflammatory and immunosuppressive actions. Since glucocorticoid receptor II (GR) is nearly ubiquitous, chronic activation or depletion of GCs leads to dysfunction of diverse organs, including the heart and blood vessels, resulting predominantly from changes in gene expression. Most studies, therefore, have focused on the genomic effects of GC to understand its related pathophysiological manifestations. The nongenomic effects of GCs clearly differ from well-known genomic effects, with the former responding within several minutes without the need for protein synthesis. There is increasing evidence that the nongenomic actions of GCs influence various physiological functions. To develop a GC-mediated therapeutic target for the treatment of cardiovascular disease, understanding the genomic and nongenomic effects of GC on the cardiovascular system is needed. This article reviews our current understanding of the underlying mechanisms of GCs on cardiovascular diseases and stress, as well as how nongenomic GC signaling contributes to these conditions. We suggest that manipulation of GC action based on both GC and GR metabolism, mitochondrial impact, and the action of serum- and glucocorticoid-dependent kinase 1 may provide new information with which to treat cardiovascular diseases.
Collapse
Affiliation(s)
- Sung Ryul Lee
- National Research Laboratory for Mitochondrial Signaling, Department of Physiology, College of Medicine, Cardiovascular and Metabolic Disease Center, Inje University, 633-165 Gaegeum-Dong, Busanjin-Gu, Busan, Korea
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|