Cardiovascular effects of hydrocortisone in preterm infants with pressor-resistant hypotension.

Objectivt'. To study the cardiovascular effects of hydrocortisone in pretenn infants with hypo- tension unresponsive to volume and pressor administra- tion. Shldy Dt'sign. Retrospective review of the cardiovas- cular response to 23 courses of hydrocortisone adminis- tration during the first day of treatment in 21 pretenn infants (gestational age: 26.9 ~ 3.9 weeks; postnatal age: 11.3 ~ 13.1 days). Hydrocortisone (2 mg/kg/d in 16 pa- tients and 3-6 mg/kg/d in 5 patients) was administered when dopamine (22.2 ~ 111J.g/kg/min, range: 8-60) alone (n = 16) or in combination with dobutamine (8.4 :!: 4.9 1J.g/kg/min, range: 5-20, n = 7) and/or epinephrine (0.38 ~ 0.56 1J.g/kg/min, range: 0.01-1-2. n = 4) failed to normalize blood pressure. Resu!ts. 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. respec- tively, and remained stable thereafter. Urine output in- creased despite a decrease in fluid administration during the first day of hydrocortisone treatment. The dose of dopamine and the number of patients receiving dobut- amine and/or epinephrine also decreased during the same period. Eighteen of the 21 patients survived. Conclusions. Preterm infants with volume- and pres- sor-resistant hypotension respond to hydrocortisone with rapid normalization of the cardiovascular status and sustained decreases in volume and pressor requirement Pediatrics 2001;107:1070-1074; blood pressure, dopamine, hydrocortisone, hypotension, pretenn infant. long-term central nervous system morbidity in thi~ patient population. In most hypotensive preterm in- fants, cautious and limited \'olume administration and the early use of dopamine are effecti\'e in im- proving the cardiovascular status and renal func- tion.1.6 However, a subgroup of hypotensive preterm infants does not respond even when treatment is escalated and aggressive \'olume resuscitation and dopamine doses well beyond the conventional (2-20 ILg/kg/min) dose range are used.l.7 In these patients with volume- and pressor-resistant hypotension, several therapeutic approaches have been attempted including additional escalation of dopamine treat- ment,S addition of, epinephrine9.10 or norepineph- rine} 1 and more recently, initiation of steroid admin- istration.7.12-15 Although steroid administration may be effective in improving blood pressure and stabilizing cardio- vascular status,7.U-15 the number of patients in the peer-reviewed literature that comprise the popula- tion reported to benefit from steroid treatment of hypotension is srnall.7.12.13.15 In addition, the time course of the improvement in blood pressure in re- sponse to steroid treatment has not been systemati- cally investigated. Therefore, in the present stud~', we report the changes in mean arterial blood pres, sure, heart rate, urine output, and fluid intake after the initiation of hydrocortisone (HC) treatment, with special attention to the timing of the cardiovascular changes in response to steroid administration in 21 pretenn infants with volume- and pressor-resistant