title: Hypotension following patent ductus arteriosus ligation: the role of adrenal hormones.
abstract: 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.
  
  
  METHODS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Pediatric, Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA. Electronic address: clymanr@peds.ucsf.edu.
authors.forename: Ronald I
authors.initials: RI
authors.lastname: Clyman
authors.affiliation: Department of Pediatric, Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA.
authors.forename: Andrea
authors.initials: A
authors.lastname: Wickremasinghe
authors.affiliation: Department of Pediatrics, Loma Linda University, Loma Linda, CA.
authors.forename: T Allen
authors.initials: TA
authors.lastname: Merritt
authors.affiliation: Department of Pediatrics, Loma Linda University, Loma Linda, CA.
authors.forename: Tabitha
authors.initials: T
authors.lastname: Solomon
authors.affiliation: Department of Pediatrics, Hospital for Sick Children, Toronto, Canada.
authors.forename: Patrick
authors.initials: P
authors.lastname: McNamara
authors.affiliation: Department of Pediatrics, Hospital for Sick Children, Toronto, Canada.
authors.forename: Amish
authors.initials: A
authors.lastname: Jain
authors.affiliation: Department of Pediatrics, University of Chicago, Chicago, IL.
authors.forename: Jaideep
authors.initials: J
authors.lastname: Singh
authors.affiliation: Department of Pediatrics, University of Chicago, Chicago, IL.
authors.forename: Alison
authors.initials: A
authors.lastname: Chu
authors.affiliation: Department of Pediatrics, University of Oklahoma, Oklahoma City, OK.
authors.forename: Shahab
authors.initials: S
authors.lastname: Noori
authors.affiliation: Department of Pediatrics, University of Oklahoma, Oklahoma City, OK.
authors.forename: Krishnamurthy
authors.initials: K
authors.lastname: Sekar
authors.affiliation: Department of Pediatrics, Children's & Women's Health Center of British Columbia, Vancouver, Canada.
authors.forename: Pascal M
authors.initials: PM
authors.lastname: Lavoie
authors.affiliation: Department of Pediatrics, University of Virginia, Charlottesville, VA.
authors.forename: Joshua T
authors.initials: JT
authors.lastname: Attridge
authors.affiliation: Department of Pediatrics, University of Virginia, Charlottesville, VA.
authors.forename: Jonathan R
authors.initials: JR
authors.lastname: Swanson
authors.affiliation: Department of Pediatrics, Vanderbilt University, Nashville, TN.
authors.forename: Maria
authors.initials: M
authors.lastname: Gillam-Krakauer
authors.affiliation: Department of Pediatrics, Vanderbilt University, Nashville, TN.
authors.forename: Jeff
authors.initials: J
authors.lastname: Reese
authors.affiliation: Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
authors.forename: Sara
authors.initials: S
authors.lastname: DeMauro
authors.affiliation: Department of Pediatrics, Indiana University, Indianapolis, IN.
authors.forename: Brenda
authors.initials: B
authors.lastname: Poindexter
authors.affiliation: Department of Pediatrics, Johns Hopkins University, Baltimore, MD.
authors.forename: Sue
authors.initials: S
authors.lastname: Aucott
authors.affiliation: Department of Pediatrics, Johns Hopkins University, Baltimore, MD.
authors.forename: Monique
authors.initials: M
authors.lastname: Satpute
authors.affiliation: Department of Pediatrics, University of New Mexico, Albuquerque, NM.
authors.forename: Erika
authors.initials: E
authors.lastname: Fernandez
authors.affiliation: Department of Medicine, University of Michigan, Ann Arbor, MI.
authors.forename: Richard J
authors.initials: RJ
authors.lastname: Auchus
mesh_terms: D000324:Adrenocorticotropic Hormone / Q000378:metabolism; D006348:Cardiac Surgical Procedures / Q000009:adverse effects* / Q000379:methods; D002395:Catecholamines / Q000008:administration & dosage*; D015331:Cohort Studies; D004351:Drug Resistance; D004374:Ductus Arteriosus, Patent / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D006854:Hydrocortisone / Q000097:blood*; D007022:Hypotension / Q000188:drug therapy / Q000209:etiology* / Q000503:physiopathology; D007231:Infant, Newborn; D007234:Infant, Premature; D008026:Ligation / Q000009:adverse effects / Q000379:methods; D008297:Male; D011182:Postoperative Care / Q000379:methods; D011183:Postoperative Complications / Q000175:diagnosis / Q000188:drug therapy; D011300:Preoperative Care / Q000379:methods; D012189:Retrospective Studies; D018570:Risk Assessment; D015996:Survival Rate
chemical_list: D002395:Catecholamines; D000324:Adrenocorticotropic Hormone; D006854:Hydrocortisone