Hydrocortisone and Vasopressor-Resistant Shock in Preterm Neonates

Abstract

Because systemic hypotension and significant fluctuations in blood pressure in the immediate postnatal period are associated with increased mortality and major adverse outcomes in preterm neonates, most neonatologists attempt to maintain blood pressure in the perceived gestational- and postnatal-age–dependent “normal” range. Many very low birth weight (VLBW) neonates respond to medium-to-high doses of dopamine, epinephrine, and/or dobutamine and are able to wean off the medications within a few days. However, more than half of them become dependent on medium-to-high–dose vasopressor/inotrope support beyond the first few postnatal days or do not respond at all. Findings of a few observational and retrospective studies have suggested that these neonates respond to relatively low doses of hydrocortisone, with normalization of their cardiovascular status and decreasing vasopressor/inotrope requirement.1–3 Despite the limited information provided by these publications on safety and efficacy and despite the lack of appropriately designed prospective clinical trials, hydrocortisone has now become the choice of treatment of preterm neonates with vasopressor-resistant hypotension. The study by Ng et al,4 published in this issue of Pediatrics , is indeed the first prospective randomized clinical trial that assessed the effectiveness of relatively low doses of hydrocortisone in the treatment of refractory hypotension of VLBW neonates during the immediate postnatal period. The findings of this prospective, double-blind, randomized, controlled trial indicate that a 5-day course of 3 mg/kg per day of hydrocortisone started on the first postnatal day decreases the cumulative doses of vasopressors/inotropes and volume expanders as well as the number of patients who require vasopressor/inotrope support by 72 hours of the drug administration. In addition, mean arterial blood pressure was significantly and consistently higher in the hydrocortisone-treated group. These beneficial cardiovascular effects were not accompanied by apparent adverse effects such as an increased incidence of hyperglycemia, systemic infections, or intestinal perforation. … Address correspondence to Istvan Seri, MD, PhD, Childrens Hospital Los Angeles, 4650 Sunset Blvd, MS 31, Los Angeles, CA 90027. E-mail: iseri{at}chla.usc.edu