2-021 | Additional Comments | Previous Article | Next Article | List of Articles | Submit Comments | Index | FSN Home Page
Hydrocortisone for Hypotension
Cardiovascular Effects of Hydrocortisone in Preterm Infants with Pressor-Resistant Hypotension. Seri I, Tan R, and Evans J. Pediatrics 2001;107:1070-4.
The study design was a retrospective review of the cardiovascular response to 23 courses of hydrocortisone administration during the first day of treatment in 21 preterm infants (EGA 26.9 +/- 3.9 weeks; postnantal age 11.3 +/- 13.1 days). Hydrocortisone (2-6 mg/kg/d) was administered when dopamine (22.2 +/- 11 mcg/kg/min) alone (n=16) or in combination with dobutamine (8.4 +/- 4.9 mcg/kg/min, n=7) and/or epinephrine (0.38 +/- 0.56 mcg/kg/min, n=4) failed to normalize blood pressure.
Results: Mean blood pressure increased from 29.3 +/- 4.1 to 34.1 +/- 5.2, 38.0 +/- 8.0, and 41.8 +/- 6.6 mm Hg by 2, 4, and 6 hours of hydrocortisone administration respectively, and remained stable thereafter. The dose of dopamine and the number of patients receiving dobutamine and/or epinephrine also decreased during the same period. 18 or the 21 patients survived.
Comment: The dose of hydrocortisone used in this study is similar to that used for physiologic replacement therapy, and much lower that the dose used to treat shock (25-50 mg/kg/d). This study reminds us that much of the hypotension that we see in premature babies is reflective of their adreno-cortical insufficiency. This seems to be especially true when the hypotension is refractory to treatment with volume and pressors. I wonder whether we could predict which preterm babies might be at risk for this problem by screening cortisol levels from their cord blood. We then might be able to prevent this refractory hypotension by providing hydrocortisone replacement therapy to those determined to be cortisol deficient. Alternatively, a low cortisol level at the time of a hypotensive episode might suggest that hydrocortisone would be a more appropriate first-line treatment than either volume or pressors. Of course, the safety and efficacy of this approach needs to be studied.