Steroid supplementation: a legitimate pharmacotherapy after neonatal open heart surgery

Abstract

Background: An inflammatory response together with multiple organ failure subsequent to cardiopulmonary bypass is especially prominent in neonates. The behavior of glucocorticoids during this period in these patients is not known. If adrenal insufficiency should exist, it could considerably compromise postoperative recovery.

Methods: Twenty neonates undergoing biventricular repair were enrolled. Ten patients were assigned to receive hydrocortisone treatment and the other 10 to receive placebo. The treatment group received stress-dose hydrocortisone sodium succinate after discontinuation of cardiopulmonary bypass: 0.18 mg.kg(-1).hr(-1) for 3 days, 0.09 mg.kg(-1).hr(-1) for 2 days, and 0.045 mg.kg(-1).hr(-1) for 2 days. The placebo was 5% glucose solution.

Results: Patients had adrenal insufficiency (cortisol < 5 microg/dL) from 24 to 72 hours in the placebo group. This was associated with a simultaneous reduction of left ventricular shortening fraction (p < 0.0001, analysis of variance; p = 0.0203, Student's t test), the necessity to increase inotropic agents (p = 0.043, analysis of variance), and an increase in serum lactate level (p = 0.049, Student's t test). During this period, serum cortisol level was maintained above the normal level (> 23 microg/dL) in the hydrocortisone group. The placebo group had a greater positive fluid balance (p = 0.027, Student's t test) and greater total body edema in the immediate postoperative period (p = 0.065, Student's t test). Blood oxygenation constantly improved, and the duration on mechanical ventilation was shorter (83.5 +/- 42.1 versus 138.2 +/- 89.7 hours; p = 0.098) in the hydrocortisone group.

Conclusions: Adrenal insufficiency may occur after neonatal open heart surgery. Stress-dose hydrocortisone supplementation blunts other organ dysfunction and can be considered a legitimate pharmacotherapy in this cohort.