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Pediatric Surgery International

, Volume 33, Issue 9, pp 981–987 | Cite as

Steroid use for refractory hypotension in congenital diaphragmatic hernia

  • Jason O. Robertson
  • Cory N. Criss
  • Lily B. Hsieh
  • Niki Matsuko
  • Josh S. Gish
  • Rodrigo A. Mon
  • Kevin N. Johnson
  • Samir K. Gadepalli
Original Article

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.

Keywords

Adrenal insufficiency Stress dose Congenital diaphragmatic hernia Steroids 

Notes

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

References

  1. 1.
    Annane D, Sebille V, Bellissant E (2006) Ger-Inf-05 Study G. Effect of low doses of corticosteroids in septic shock patients with or without early acute respiratory distress syndrome. Crit Care Med 34(1):22–30CrossRefPubMedGoogle Scholar
  2. 2.
    Annane D, Sebille V, Charpentier C, Bollaert PE, Francois B, Korach JM et al (2002) Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA 288(7):862–871CrossRefPubMedGoogle Scholar
  3. 3.
    Fernandez E, Schrader R, Watterberg K (2005) Prevalence of low cortisol values in term and near-term infants with vasopressor-resistant hypotension. J Perinatol 25(2):114–118CrossRefPubMedGoogle Scholar
  4. 4.
    Hanna CE, Keith LD, Colasurdo MA, Buffkin DC, Laird MR, Mandel SH et al (1993) Hypothalamic pituitary adrenal function in the extremely low birth weight infant. J Clin Endocrinol Metab 76(2):384–387PubMedGoogle Scholar
  5. 5.
    Johnson PJ (2015) Hydrocortisone for treatment of hypotension in the newborn. Neonatal Netw 34(1):46–51CrossRefPubMedGoogle Scholar
  6. 6.
    Ng PC (2016) Adrenocortical insufficiency and refractory hypotension in preterm infants. Arch Dis Child Fetal Neonatal Ed. doi: 10.1136/archdischild-2016-311289 Google Scholar
  7. 7.
    Scott SM, Watterberg KL (1995) Effect of gestational age, postnatal age, and illness on plasma cortisol concentrations in premature infants. Pediatr Res 37(1):112–116CrossRefPubMedGoogle Scholar
  8. 8.
    Seri I, Tan R, Evans J (2001) Cardiovascular effects of hydrocortisone in preterm infants with pressor-resistant hypotension. Pediatrics 107(5):1070–1074CrossRefPubMedGoogle Scholar
  9. 9.
    Ng PC, Lam CW, Lee CH, Ma KC, Fok TF, Chan IH et al (2002) Reference ranges and factors affecting the human corticotropin-releasing hormone test in preterm, very low birth weight infants. J Clin Endocrinol Metab 87(10):4621–4628CrossRefPubMedGoogle Scholar
  10. 10.
    Ng PC, Lee CH, Lam CW, Ma KC, Fok TF, Chan IH et al (2004) Transient adrenocortical insufficiency of prematurity and systemic hypotension in very low birthweight infants. Arch Dis Child Fetal Neonatal Ed 89(2):F119–F126CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Watterberg KL, Gerdes JS, Cook KL (2001) Impaired glucocorticoid synthesis in premature infants developing chronic lung disease. Pediatr Res 50(2):190–195CrossRefPubMedGoogle Scholar
  12. 12.
    Kamath BD, Fashaw L, Kinsella JP (2010) Adrenal insufficiency in newborns with congenital diaphragmatic hernia. J Pediatr 156(3):495–7 e1Google Scholar
  13. 13.
    Pittinger TP, Sawin RS (2000) Adrenocortical insufficiency in infants with congenital diaphragmatic hernia: a pilot study. J Pediatr Surg 35(2):223–225 (discussion 5–6) CrossRefPubMedGoogle Scholar
  14. 14.
    Levy-Shraga Y, Pinhas-Hamiel O (2013) Critical illness-related corticosteroid insufficiency in children. Horm Res Paediatr 80(5):309–317CrossRefPubMedGoogle Scholar
  15. 15.
    Baker CF, Barks JD, Engmann C, Vazquez DM, Neal CR Jr, Schumacher RE et al (2008) Hydrocortisone administration for the treatment of refractory hypotension in critically ill newborns. J Perinatol 28(6):412–419CrossRefPubMedGoogle Scholar
  16. 16.
    Ng PC, Lee CH, Bnur FL, Chan IH, Lee AW, Wong E et al (2006) A double-blind, randomized, controlled study of a “stress dose” of hydrocortisone for rescue treatment of refractory hypotension in preterm infants. Pediatrics 117(2):367–375CrossRefPubMedGoogle Scholar
  17. 17.
    Brodde OE, Michel MC, Gordon EP, Sandoval A, Gilbert EM, Bristow MR (1989) Beta-adrenoceptor regulation in the human heart: can it be monitored in circulating lymphocytes? Eur Heart J 10(Suppl B):2–10CrossRefPubMedGoogle Scholar
  18. 18.
    Davies AO, Lefkowitz RJ (1980) Corticosteroid-induced differential regulation of beta-adrenergic receptors in circulating human polymorphonuclear leukocytes and mononuclear leukocytes. J Clin Endocrinol Metab 51(3):599–605CrossRefPubMedGoogle Scholar
  19. 19.
    Hui KK, Conolly ME, Tashkin DP (1982) Reversal of human lymphocyte beta-adrenoceptor desensitization by glucocorticoids. Clin Pharmacol Ther 32(5):566–571CrossRefPubMedGoogle Scholar
  20. 20.
    Segar JL, Bedell K, Page WV, Mazursky JE, Nuyt AM, Robillard JE (1995) Effect of cortisol on gene expression of the renin-angiotensin system in fetal sheep. Pediatr Res 37(6):741–746CrossRefPubMedGoogle Scholar
  21. 21.
    Metzger DL, Wright NM, Veldhuis JD, Rogol AD, Kerrigan JR (1993) Characterization of pulsatile secretion and clearance of plasma cortisol in premature and term neonates using deconvolution analysis. J Clin Endocrinol Metab 77(2):458–463PubMedGoogle Scholar
  22. 22.
    Venkatesh B, Mortimer RH, Couchman B, Hall J (2005) Evaluation of random plasma cortisol and the low dose corticotropin test as indicators of adrenal secretory capacity in critically ill patients: a prospective study. Anaesth Intensive Care 33(2):201–209PubMedGoogle Scholar
  23. 23.
    Agus MS, Jaksic T (2004) Critically low hormone and catecholamine concentrations in the primed extracorporeal life support circuit. ASAIO J 50(1):65–67CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Anand KJ, Aynsley-Green A (1988) Measuring the severity of surgical stress in newborn infants. J Pediatr Surg 23(4):297–305CrossRefPubMedGoogle Scholar
  25. 25.
    Hindmarsh KW, Tan L, Sankaran K, Laxdal VA (1989) Diurnal rhythms of cortisol, ACTH, and beta-endorphin levels in neonates and adults. West J Med 151(2):153–156PubMedPubMedCentralGoogle Scholar
  26. 26.
    Baud O, Maury L, Lebail F, Ramful D, El Moussawi F, Nicaise C et al (2016) Effect of early low-dose hydrocortisone on survival without bronchopulmonary dysplasia in extremely preterm infants (PREMILOC): a double-blind, placebo-controlled, multicentre, randomised trial. Lancet 387(10030):1827–1836CrossRefPubMedGoogle Scholar
  27. 27.
    Mastropietro CW, Barrett R, Davalos MC, Zidan M, Valentine KM, Delius RE et al (2013) Cumulative corticosteroid exposure and infection risk after complex pediatric cardiac surgery. Ann Thorac Surg 95(6):2133–2139CrossRefPubMedGoogle Scholar
  28. 28.
    Rohr SB, Sauer H, Gottschling S, Abdul-Khaliq H, Gortner L, Nunold H et al (2014) Non-neurological, steroid-related adverse events in very low birth weight infants: a prospective audit. Swiss Med Wkly 144:w13954PubMedGoogle Scholar
  29. 29.
    Hanna CE, Jett PL, Laird MR, Mandel SH, LaFranchi SH, Reynolds JW (1997) Corticosteroid binding globulin, total serum cortisol, and stress in extremely low-birth-weight infants. Am J Perinatol 14(4):201–204CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany 2017

Authors and Affiliations

  • Jason O. Robertson
    • 1
  • Cory N. Criss
    • 1
  • Lily B. Hsieh
    • 1
  • Niki Matsuko
    • 1
  • Josh S. Gish
    • 1
  • Rodrigo A. Mon
    • 1
  • Kevin N. Johnson
    • 1
  • Samir K. Gadepalli
    • 1
  1. 1.Section of Pediatric Surgery, C.S. Mott Children’s HospitalUniversity of MichiganAnn ArborUSA

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