Hypotension following patent ductus arteriosus ligation: the role of adrenal hormones.

Clyman RI, Wickremasinghe A, Merritt TA, Solomon T, McNamara P, Jain A, Singh J, Chu A, Noori S, Sekar K, Lavoie PM, Attridge JT, Swanson JR, Gillam-Krakauer M, Reese J, DeMauro S, Poindexter B, Aucott S, Satpute M, Fernandez E, Auchus RJ, Patent Ductus Arteriosus Ligation/Hypotension Trial Investigators
J Pediatr. 2014 164 (6): 1449-55.e1

PMID: 24636853 · PMCID: PMC4035426 · DOI:10.1016/j.jpeds.2014.01.058

OBJECTIVE - To test the hypothesis that an impaired adrenal response to stress might play a role in the hypotension that follows patent ductus arteriosus (PDA) ligation.

STUDY DESIGN - We performed a multicenter study of infants born at <32 weeks' gestation who were about to undergo PDA ligation. Serum adrenal steroids were measured 3 times: before and after a cosyntropin (1.0 μg/kg) stimulation test (performed before the ligation), and at 10-12 hours after the ligation. A standardized approach for diagnosis and treatment of postoperative hypotension was followed at each site. A modified inotrope score (1 × dopamine [μg/kg/min] + 1 × dobutamine) was used to monitor the catecholamine support an infant received. Infants were considered to have catecholamine-resistant hypotension if their greatest inotrope score was >15.

RESULTS - Of 95 infants enrolled, 43 (45%) developed hypotension and 14 (15%) developed catecholamine-resistant hypotension. Low postoperative cortisol levels were not associated with the overall incidence of hypotension after ligation. However, low cortisol levels were associated with the refractoriness of the hypotension to catecholamine treatment. In a multivariate analysis: the OR for developing catecholamine-resistant hypotension was OR 36.6, 95% CI 2.8-476, P = .006. Low cortisol levels (in infants with catecholamine-resistant hypotension) were not attributable to adrenal immaturity or impairment; their cortisol precursor concentrations were either low or unchanged, and their response to cosyntropin was similar to infants without catecholamine-resistant hypotension.

CONCLUSION - Infants with low cortisol concentrations after PDA ligation are likely to develop postoperative catecholamine-resistant hypotension. We speculate that decreased adrenal stimulation, rather than an impaired adrenal response to stimulation, may account for the decreased production.

Copyright © 2014 Elsevier Inc. All rights reserved.

MeSH Terms (21)

Adrenocorticotropic Hormone Cardiac Surgical Procedures Catecholamines Cohort Studies Drug Resistance Ductus Arteriosus, Patent Female Follow-Up Studies Humans Hydrocortisone Hypotension Infant, Newborn Infant, Premature Ligation Male Postoperative Care Postoperative Complications Preoperative Care Retrospective Studies Risk Assessment Survival Rate

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