Robert Stephen M, Borasino Santiago, Dabal Robert J, Cleveland David C, Hock Kristal M, Alten Jeffrey A
1Department of Pediatric Critical Care, University of Alabama at Birmingham, Birmingham, AL. 2Department of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, AL.
Pediatr Crit Care Med. 2015 Sep;16(7):629-36. doi: 10.1097/PCC.0000000000000426.
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.
Double-blind, randomized control trial.
Pediatric cardiac ICU and operating room in tertiary care center.
Forty neonates undergoing cardiac surgery with cardiopulmonary bypass were randomized (19 hydrocortisone and 21 placebo). Demographics and known risk factors were similar between groups.
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.
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.
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.
新生儿体外循环心脏手术常并发与炎症和低心排血量综合征相关的疾病。据报道，氢化可的松“应激剂量”给药对一些难治性休克患者有血流动力学益处。体外循环诱发的肾上腺功能不全的发生可能为术后给予氢化可的松提供进一步的理论依据。我们试图确定预防性术后输注氢化可的松是否能降低新生儿体外循环心脏手术后低心排血量综合征的发生率。
双盲随机对照试验。
三级医疗中心的儿科心脏重症监护病房和手术室。
40例接受体外循环心脏手术的新生儿被随机分组（19例接受氢化可的松，21例接受安慰剂）。两组的人口统计学和已知危险因素相似。
体外循环结束后，给予氢化可的松推注（50mg/m²）或安慰剂，随后持续输注氢化可的松（50mg/m²/d）或安慰剂，持续5天。在体外循环前后、给予类固醇之前进行促肾上腺皮质激素刺激试验（1μg）。在体外循环前后采集血样进行细胞因子分析。
接受氢化可的松治疗的受试者发生低心排血量综合征的可能性较小（5/19，26% 对比 12/21，57%；p = 0.049）。氢化可的松组在48小时时的净液体平衡更负（-114对比-64mL/kg；p = 0.01），在0 - 24小时时尿量更多（2.7对比1.2mL/kg/hr；p = 0.03）。氢化可的松组比安慰剂组更快停用儿茶酚胺和血管加压素，48小时后无血管活性药物支持的受试者差异明显（p = 0.033）。5例安慰剂受试者（24%）与无氢化可的松受试者相比需要抢救性使用类固醇（p = 0.02）。13例（32.5%）在体外循环后出现肾上腺功能不全。随机接受氢化可的松治疗的肾上腺功能不全患者与随机接受安慰剂治疗的肾上腺功能不全患者相比，低心排血量综合征的发生率更低（分别为1/6对比6/7；p = 0.02）。氢化可的松显著降低促炎细胞因子水平。无呼吸机天数、住院时间和肾损伤情况相似。
预防性术后使用氢化可的松可降低新生儿体外循环心脏手术后低心排血量综合征的发生率，改善液体平衡和尿量，并减轻炎症反应。需要进一步研究以确定这些益处是否能改善更重要的临床结局。
