新生儿休克氢化可的松治疗的时机：系统评价、荟萃分析及临床实践指南
Timing of hydrocortisone therapy in neonates with shock: a systematic review, meta-analysis, and clinical practice guideline.
作者信息
Ramaswamy Viraraghavan Vadakkencherry, Kumar Gunjana, Pullattayil S Abdul Kareem, Aradhya Abhishek S, Suryawanshi Pradeep, Sahni Mohit, Khurana Supreet, Saini Shiv Sajan, K Ravishankar, Dhir Shashi Kant, Chawla Deepak, Kumar Praveen, More Kiran
机构信息
Department of Neonatology, Ankura Hospital for Women and Children, Hyderabad, India.
Department of Neonatology, National Institute of Medical Sciences, Jaipur, India.
出版信息
Front Pediatr. 2025 Mar 12;13:1491976. doi: 10.3389/fped.2025.1491976. eCollection 2025.
BACKGROUND
The effect of the timing of initiation of hydrocortisone in neonatal shock has not been evaluated. The objective of this systematic review was to compare the effect of earlier vs. later initiation of hydrocortisone in neonatal shock.
METHODS
Medline, Embase, and CENTRAL were searched from inception until 15 May 2024. Randomized controlled trials (RCTs) and non-RCTs were eligible for inclusion. A random effects meta-analysis was used to synthesize the data. The evidence certainty was evaluated according to Grading of Recommendations Assessment, Development, and Evaluation (GRADE). A clinical practice guideline was formulated as recommended by the GRADE group.
RESULTS
Of the 3,757 titles and abstracts screened, 20 studies were included: 7 RCTs and 13 non-RCTs. While clinical benefit or harm could not be ruled out for the outcome of mortality from the meta-analysis of the RCTs [early initiation risk ratio (RR): 0.46, 95% confidence interval (CI): 0.03-7.92; late initiation RR: 0.43, 95% CI: 0.12-1.47], the non-RCTs included in the narrative review suggested that late hydrocortisone initiation might be associated with increased risk of mortality. The meta-analysis indicated that early and late hydrocortisone administration may be associated with an increased response to treatment therapy (early initiation RR: 1.85, 95% CI: 1.26-2.71; late initiation RR: 2.50, 95% CI: 1.16-5.39). Late hydrocortisone initiation may increase the risk of necrotizing enterocolitis (NEC) ≥ stage 2 (RR: 2.46, 95% CI: 1.19-5.08). The evidence certainty was very low for most of the outcomes evaluated.
CONCLUSION
The early use of hydrocortisone in neonates with shock requiring vasopressors is associated with better outcomes and no major adverse effects. Later institution of hydrocortisone therapy in neonatal shock may improve the response to therapy but may be associated with adverse outcomes including mortality and NEC. The results are to be interpreted with caution as the evidence certainty was predominantly very low.
SYSTEMATIC REVIEW REGISTRATION
https://www.crd.york.ac.uk/PROSPERO/view/CRD42023432169, identifier: CRD42023432169.
背景
氢化可的松在新生儿休克中的起始使用时机的影响尚未得到评估。本系统评价的目的是比较氢化可的松在新生儿休克中早期与晚期起始使用的效果。
方法
检索Medline、Embase和CENTRAL数据库，检索时间从建库至2024年5月15日。随机对照试验（RCT）和非RCT均符合纳入标准。采用随机效应荟萃分析来综合数据。根据推荐分级的评估、制定和评价（GRADE）对证据确定性进行评估。按照GRADE小组的建议制定临床实践指南。
结果
在筛选的3757篇标题和摘要中，纳入了20项研究：7项RCT和13项非RCT。虽然从RCT的荟萃分析中无法排除死亡率结局的临床益处或危害（早期起始风险比（RR）：0.46，95%置信区间（CI）：0.03 - 7.92；晚期起始RR：0.43，95%CI：0.12 - 1.47），但叙述性综述中纳入的非RCT表明，晚期起始氢化可的松可能与死亡风险增加相关。荟萃分析表明，早期和晚期给予氢化可的松可能与治疗反应增加相关（早期起始RR：1.85，95%CI：1.26 - 2.71；晚期起始RR：2.50，95%CI：1.16 - 5.39）。晚期起始氢化可的松可能增加≥2期坏死性小肠结肠炎（NEC）的风险（RR：2.46，95%CI：1.19 - 5.08）。对于评估的大多数结局，证据确定性非常低。
结论
对于需要血管升压药的休克新生儿，早期使用氢化可的松与更好的结局相关且无重大不良反应。在新生儿休克中较晚开始氢化可的松治疗可能改善治疗反应，但可能与包括死亡和NEC在内的不良结局相关。由于证据确定性主要非常低，对结果的解释应谨慎。
系统评价注册
https://www.crd.york.ac.uk/PROSPERO/view/CRD42023432169，标识符：CRD42023432169。
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