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Hydrocortisone Dosing for Hypotension in Newborn Infants: Less Is More

2016; Elsevier BV; Volume: 174; Linguagem: Inglês

10.1016/j.jpeds.2016.04.005

1097-6833

Kristi L. Watterberg,

Congenital Diaphragmatic Hernia Studies

Debate surrounds all aspects of hypotension in newborn infants, including the definition, the questions of whether and when to treat it, the choice of treatments, and their possible benefits and risks. 1 Barrington K.J. Janaillac M. Treating hypotension in extremely preterm infants. The pressure is mounting. Arch Dis Child Fetal Neonatal Ed. 2016; 101: F188-F189 Crossref Scopus (7) Google Scholar , 2 Cox D.J. Groves A.M. Inotropes in preterm infants—evidence for and against. Acta Paediatr. 2012; 101: 17-23 Crossref Scopus (17) Google Scholar To date, no randomized trials have evaluated the long-term risks and benefits of any of these treatment strategies. Despite this, hydrocortisone has become widely used to treat hypotension in critically ill newborn infants. 3 Rios D.R. Moffett B.S. Kaiser J.R. Trends in pharmacotherapy for neonatal hypotension. J Pediatr. 2014; 165: 697-701 Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar Low cortisol concentrations in critically ill newborns have been associated with several markers of illness, including the use of surfactant, positive pressure ventilation, and vasopressors, as well as with vasopressor-resistant hypotension. 4 Scott S.M. Watterberg K.L. Effect of gestational age, postnatal age, and illness on plasma cortisol concentrations in premature infants. Pediatr Res. 1995; 37: 112-116 Crossref PubMed Scopus (150) Google Scholar , 5 Ng P.C. Lam C.W. Fok T.F. Lee C.H. Ma K.C. Chan I.H. et al. Refractory hypotension in preterm infants with adrenocortical insufficiency. Arch Dis Child Fetal Neonatal Ed. 2001; 84: F122-F124 Crossref PubMed Google Scholar , 6 Fernandez E.F. Montman R. Watterberg K.L. ACTH and cortisol response to critical illness in term and late preterm newborns. J Perinatol. 2008; 28: 797-802 Crossref PubMed Scopus (69) Google Scholar , 7 Noori S. McNamara P. Jain A. Lavoie P.M. Wickremasinghe A. Merritt T.A. et al. PDA Ligation/Hypotension Trial InvestigatorsCatecholamine-resistant hypotension and myocardial performance following patent ductus arteriosus ligation. J Perinatol. 2015; 35: 123-127 Crossref PubMed Scopus (24) Google Scholar Furthermore, hydrocortisone treatment of newborn infants with hypotension results in an increase in blood pressure, suggesting that one etiology of hypotension in these infants may be relative adrenal insufficiency. 7 Noori S. McNamara P. Jain A. Lavoie P.M. Wickremasinghe A. Merritt T.A. et al. PDA Ligation/Hypotension Trial InvestigatorsCatecholamine-resistant hypotension and myocardial performance following patent ductus arteriosus ligation. J Perinatol. 2015; 35: 123-127 Crossref PubMed Scopus (24) Google Scholar , 8 Ng P.C. Lee C.H. Bnur F.L. Chan I.H. Lee A.W. Wong E. et al. A double-blind, randomized, controlled study of a "stress dose" of hydrocortisone for rescue treatment of refractory hypotension in preterm infants. Pediatrics. 2006; 117: 367-375 Crossref PubMed Scopus (172) Google Scholar , 9 Efird M.M. Heerens A.T. Gordon P.V. Bose C.L. Young D.A. A randomized-controlled trial of prophylactic hydrocortisone supplementation for the prevention of hypotension in extremely low birth weight infants. J Perinatol. 2005; 25: 119-124 Crossref PubMed Scopus (87) Google Scholar , 10 Watterberg K.L. Gerdes J.S. Cole C.H. Aucott S.W. Thilo E.H. Mammel M.C. et al. Prophylaxis of early adrenal insufficiency to prevent bronchopulmonary dysplasia: a multicenter trial. Pediatrics. 2004; 114: 1649-1657 Crossref PubMed Scopus (341) Google Scholar If so, hydrocortisone would be a more suitable treatment for these patients than vasopressors. Whether or not that is the case, hydrocortisone has been shown to increase the blood pressure of most patients in this population, particularly in patients with vasopressor-resistant hypotension. 8 Ng P.C. Lee C.H. Bnur F.L. Chan I.H. Lee A.W. Wong E. et al. A double-blind, randomized, controlled study of a "stress dose" of hydrocortisone for rescue treatment of refractory hypotension in preterm infants. Pediatrics. 2006; 117: 367-375 Crossref PubMed Scopus (172) Google Scholar , 9 Efird M.M. Heerens A.T. Gordon P.V. Bose C.L. Young D.A. A randomized-controlled trial of prophylactic hydrocortisone supplementation for the prevention of hypotension in extremely low birth weight infants. J Perinatol. 2005; 25: 119-124 Crossref PubMed Scopus (87) Google Scholar , 10 Watterberg K.L. Gerdes J.S. Cole C.H. Aucott S.W. Thilo E.H. Mammel M.C. et al. Prophylaxis of early adrenal insufficiency to prevent bronchopulmonary dysplasia: a multicenter trial. Pediatrics. 2004; 114: 1649-1657 Crossref PubMed Scopus (341) Google Scholar Despite uncertainties about long-term benefits and risks, the demonstrated efficacy of hydrocortisone has been a strong stimulus for its use.