title: Postoperative Hydrocortisone Infusion Reduces the Prevalence of Low Cardiac Output Syndrome After Neonatal Cardiopulmonary Bypass.
abstract: OBJECTIVE
  Neonatal cardiac surgery with cardiopulmonary bypass is often complicated by morbidity associated with inflammation and low cardiac output syndrome. Hydrocortisone "stress dosing" is reported to provide hemodynamic benefits in some patients with refractory shock. Development of cardiopulmonary bypass-induced adrenal insufficiency may provide further rationale for postoperative hydrocortisone administration. We sought to determine whether prophylactic, postoperative hydrocortisone infusion could decrease prevalence of low cardiac output syndrome after neonatal cardiac surgery with cardiopulmonary bypass.
  
  
  METHODS
  Double-blind, randomized control trial.
  
  
  METHODS
  Pediatric cardiac ICU and operating room in tertiary care center.
  
  
  METHODS
  Forty neonates undergoing cardiac surgery with cardiopulmonary bypass were randomized (19 hydrocortisone and 21 placebo). Demographics and known risk factors were similar between groups.
  
  
  METHODS
  After cardiopulmonary bypass separation, bolus hydrocortisone (50 mg/m²) or placebo was administered, followed by continuous hydrocortisone infusion (50 mg/m²/d) or placebo tapered over 5 days. Adrenocorticotropic hormone stimulation testing (1 μg) was performed before and after cardiopulmonary bypass, prior to steroid administration. Blood was collected for cytokine analysis before and after cardiopulmonary bypass.
  
  
  RESULTS
  Subjects receiving hydrocortisone were less likely to develop low cardiac output syndrome (5/19, 26% vs 12/21, 57%; p = 0.049). Hydrocortisone group had more negative net fluid balance at 48 hours (-114 vs -64 mL/kg; p = 0.01) and greater urine output at 0-24 hours (2.7 vs 1.2 mL/kg/hr; p = 0.03). Hydrocortisone group weaned off catecholamines and vasopressin sooner than placebo, with a difference in inotrope-free subjects apparent after 48 hours (p = 0.033). Five placebo subjects (24%) compared with no hydrocortisone subjects required rescue steroids (p = 0.02). Thirteen (32.5%) had adrenal insufficiency after cardiopulmonary bypass. Patients with adrenal insufficiency randomized to receive hydrocortisone had lower prevalence of low cardiac output syndrome compared with patients with adrenal insufficiency randomized to placebo (1/6 vs 6/7, respectively; p = 0.02). Hydrocortisone significantly reduced proinflammatory cytokines. Ventilator-free days, hospital length of stay, and kidney injury were similar.
  
  
  CONCLUSIONS
  Prophylactic, postoperative hydrocortisone reduces low cardiac output syndrome, improves fluid balance and urine output, and attenuates inflammation after neonatal cardiopulmonary bypass surgery. Further studies are necessary to show if these benefits lead to improvements in more important clinical outcomes.
authors.affiliation: 1Department of Pediatric Critical Care, University of Alabama at Birmingham, Birmingham, AL. 2Department of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, AL.
authors.forename: Stephen M
authors.initials: SM
authors.lastname: Robert
authors.forename: Santiago
authors.initials: S
authors.lastname: Borasino
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Dabal
authors.forename: David C
authors.initials: DC
authors.lastname: Cleveland
authors.forename: Kristal M
authors.initials: KM
authors.lastname: Hock
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Alten
mesh_terms: D000893:Anti-Inflammatory Agents / Q000008:administration & dosage*; D002303:Cardiac Output, Low / Q000209:etiology / Q000517:prevention & control*; D002315:Cardiopulmonary Bypass; D016207:Cytokines / Q000097:blood; D004311:Double-Blind Method; D006439:Hemodynamics; D006801:Humans; D006854:Hydrocortisone / Q000008:administration & dosage*; D007223:Infant; D007231:Infant, Newborn; D007262:Infusions, Intravenous; D007263:Infusions, Parenteral; D015278:Intensive Care Units, Pediatric; D011184:Postoperative Period; D015995:Prevalence
chemical_list: D000893:Anti-Inflammatory Agents; D016207:Cytokines; D006854:Hydrocortisone