Department of Paediatrics, Rotunda Hospital, Dublin, Ireland.
Neonatology. 2013;104(1):28-33. doi: 10.1159/000350017. Epub 2013 Apr 25.
Targeted milrinone treatment for low left ventricular output (LVO) reduces the incidence of acute cardiorespiratory instability following ligation of patent ductus arteriosus (PDA) in preterm infants. Despite this, some infants continue to experience postoperative deterioration. Adrenal insufficiency related to prematurity has been postulated as a possible mechanism.
To describe adrenal function in premature infants undergoing PDA ligation and to investigate its association with pre- and postoperative clinical and echocardiography-derived indices of disease severity.
A retrospective cohort study was conducted over a 2-year period on infants who underwent PDA ligation and had preoperative adrenocorticotropic hormone (ACTH) stimulation. All infants were screened by echocardiography for low LVO at 1 h after surgery and treated with intravenous milrinone if LVO <200 ml/kg/min. The primary outcome evaluated was low LVO at 1 h after surgery. Secondary outcomes included hypotension and oxygenation and ventilation failure occurring within 24 h.
A total of 35 infants at a median gestation of 25.4 (24.5-26.4) weeks and weight at birth of 700 (600-810) g were included. Baseline median cortisol measured preoperatively was 202 (137-403) nmol/l. Following the ACTH stimulation test, 3 infants had cortisol ≤500 nmol/l while 15 had ≤750 nmol/l. There was no association seen between any cortisol value and low LVO postoperatively. Post-ACTH cortisol ≤750 nmol/l was significantly associated with hypotension (p = 0.03) and oxygenation (p = 0.04) and ventilation (p = 0.008) failure. Receiver-operator characteristic curve showed a high predictive value of post-ACTH cortisol for all clinical outcomes.
Post-ACTH cortisol (≤750 nmol/l) may be associated with clinical indices of postoperative cardiorespiratory instability. Relative adrenal insufficiency may play a role in the etiology of post-PDA ligation hemodynamic and respiratory instability.
靶向米力农治疗左心室输出量（LVO）降低了早产儿动脉导管未闭（PDA）结扎后急性心肺不稳定的发生率。尽管如此，一些婴儿仍继续出现术后恶化。与早产有关的肾上腺功能不全被认为是一种可能的机制。
描述行 PDA 结扎术的早产儿的肾上腺功能，并探讨其与术前和术后疾病严重程度的临床和超声心动图指标的相关性。
对 2 年内接受 PDA 结扎且术前接受促肾上腺皮质激素（ACTH）刺激的婴儿进行回顾性队列研究。所有婴儿在术后 1 小时通过超声心动图筛查 LVO，如 LVO < 200 ml/kg/min，则给予静脉注射米力农。主要结局评估为术后 1 小时的 LVO 低。次要结局包括术后 24 小时内发生的低血压和氧合及通气失败。
共纳入 35 名中位胎龄为 25.4（24.5-26.4）周，出生体重为 700（600-810）g 的婴儿。术前皮质醇中位值为 202（137-403）nmol/L。ACTH 刺激试验后，3 名婴儿皮质醇≤500 nmol/L，15 名婴儿皮质醇≤750 nmol/L。术后任何皮质醇值与 LVO 低均无相关性。术后 ACTH 皮质醇≤750 nmol/L 与低血压（p = 0.03）、氧合（p = 0.04）和通气（p = 0.008）失败显著相关。受试者工作特征曲线显示，术后 ACTH 皮质醇对所有临床结局均具有较高的预测价值。
术后 ACTH 皮质醇（≤750 nmol/L）可能与术后心肺不稳定的临床指标相关。相对肾上腺功能不全可能在 PDA 结扎后血流动力学和呼吸不稳定的发病机制中发挥作用。
