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Erschienen in: Pediatric Cardiology 3/2007

01.06.2007 | ORIGINAL ARTICLE

Glucocorticoid Therapy for Hypotension in the Cardiac Intensive Care Unit

verfasst von: K. J. Millar, R. R. Thiagarajan, P. C. Laussen

Erschienen in: Pediatric Cardiology | Ausgabe 3/2007

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Abstract

In recent years, it has been our practice to treat persistent hypotension in the cardiac intensive care unit with glucocorticoids. We undertook a retrospective review in an attempt to identify predictors of a hemodynamic response to steroids and of survival in these patients. Patients who had received glucocorticoids for hypotension over a 2-year period were identified retrospectively. Summary measures of blood pressure, heart rate, urine output, inotrope score, and volume of infused fluid were calculated for the 12 hours before and the 24 hours following initiation of glucocorticoid therapy. A hemodynamic response was defined as a ≥20% increase in mean blood pressure without an increase in inotrope score following initiation of steroid therapy. Fifty-one patients were included, of whom 6 (11.8%) died. Serum cortisol was measured in 43 patients (84.3%) and was below the lower limit of normal (<5 μg/dl) in 20 of these (46.5%). Following initiation of steroid therapy, blood pressure and urine output increased, whereas heart rate, inotrope score, and infused volume decreased. There were 21 (41.1%) hemodynamic responders, all of whom survived, whereas 6 of 30 (20%) nonresponders died (p = 0.036). No predictors of a hemodynamic response to steroid were identified. Some critically ill children with cardiac disease and inotrope refractory hypotension demonstrated hemodynamic improvement following glucocorticoid administration. An improvement in blood pressure following administration of glucocorticoid was associated with survival, but we were unable to identify predictors of that response.
Literatur
1.
Zurück zum Zitat Almawi WY, Melemedjian OK (2002) Negative regulation of nuclear factor-kappaB activation and function by glucocorticoids. J Mol Endocrinol 28:69–78PubMedCrossRef Almawi WY, Melemedjian OK (2002) Negative regulation of nuclear factor-kappaB activation and function by glucocorticoids. J Mol Endocrinol 28:69–78PubMedCrossRef
2.
Zurück zum Zitat Anand KJ, Hansen DD, Hickey PR (1990) Hormonal-metabolic stress responses in neonates undergoing cardiac surgery. Anesthesiology 73:661–670PubMedCrossRef Anand KJ, Hansen DD, Hickey PR (1990) Hormonal-metabolic stress responses in neonates undergoing cardiac surgery. Anesthesiology 73:661–670PubMedCrossRef
3.
Zurück zum Zitat Anand KJ, Hickey PR (1992) Halothane-morphine compared with high-dose sufentanil for anesthesia and postoperative analgesia in neonatal cardiac surgery. N Engl J Med 326:1–9PubMedCrossRef Anand KJ, Hickey PR (1992) Halothane-morphine compared with high-dose sufentanil for anesthesia and postoperative analgesia in neonatal cardiac surgery. N Engl J Med 326:1–9PubMedCrossRef
4.
Zurück zum Zitat Annane D, Sebille V, Charpentier C, et al. (2002) Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA 288:862–871PubMedCrossRef Annane D, Sebille V, Charpentier C, et al. (2002) Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA 288:862–871PubMedCrossRef
5.
Zurück zum Zitat Barnes PJ (1995) Beta-adrenergic receptors and their regulation. Am J Respir Crit Care Med 152:838–860PubMed Barnes PJ (1995) Beta-adrenergic receptors and their regulation. Am J Respir Crit Care Med 152:838–860PubMed
6.
Zurück zum Zitat Barquist E, Kirton O (1997) Adrenal insufficiency in the surgical intensive care unit patient. J Trauma-Injury Infect Crit Care 42:27–31CrossRef Barquist E, Kirton O (1997) Adrenal insufficiency in the surgical intensive care unit patient. J Trauma-Injury Infect Crit Care 42:27–31CrossRef
7.
Zurück zum Zitat Briegel J, Forst H, Haller M, et al. (1999) Stress doses of hydrocortisone reverse hyperdynamic septic shock: a prospective, randomized, double-blind, single-center study. Crit Care Med 27:723–732PubMedCrossRef Briegel J, Forst H, Haller M, et al. (1999) Stress doses of hydrocortisone reverse hyperdynamic septic shock: a prospective, randomized, double-blind, single-center study. Crit Care Med 27:723–732PubMedCrossRef
8.
Zurück zum Zitat Chen YZ, Qiu J (1999) Pleiotropic signaling pathways in rapid, nongenomic action of glucocorticoid. Mol Cell Biol Res Commun 2:145–149PubMedCrossRef Chen YZ, Qiu J (1999) Pleiotropic signaling pathways in rapid, nongenomic action of glucocorticoid. Mol Cell Biol Res Commun 2:145–149PubMedCrossRef
9.
Zurück zum Zitat Connell JM, Whitworth JA, Davies DL, et al. (1987) Effects of ACTH and cortisol administration on blood pressure, electrolyte metabolism, atrial natriuretic peptide and renal function in normal man. J Hypertens 5:425–433PubMedCrossRef Connell JM, Whitworth JA, Davies DL, et al. (1987) Effects of ACTH and cortisol administration on blood pressure, electrolyte metabolism, atrial natriuretic peptide and renal function in normal man. J Hypertens 5:425–433PubMedCrossRef
10.
Zurück zum Zitat Cooper MS, Stewart PM (2003) Corticosteroid insufficiency in acutely ill patients. N Engl J Med 348:727–734PubMedCrossRef Cooper MS, Stewart PM (2003) Corticosteroid insufficiency in acutely ill patients. N Engl J Med 348:727–734PubMedCrossRef
11.
Zurück zum Zitat Dasgupta SJ, Gill AB (2003) Hypotension in the very low birthweight infant: the old, the new, and the uncertain. Arch Dis Child Fetal Neonatal Ed 88:F450PubMedCrossRef Dasgupta SJ, Gill AB (2003) Hypotension in the very low birthweight infant: the old, the new, and the uncertain. Arch Dis Child Fetal Neonatal Ed 88:F450PubMedCrossRef
12.
Zurück zum Zitat Elmlinger MW, Kuhnel W, Ranke MB (2002) Reference ranges for serum concentrations of lutropin (LH), follitropin (FSH), estradiol (E2), prolactin, progesterone, sex hormone-binding globulin (SHBG), dehydroepiandrosterone sulfate (DHEAS), cortisol and ferritin in neonates, children and young adults. Clin Chem Lab Med 40:1151–1160PubMedCrossRef Elmlinger MW, Kuhnel W, Ranke MB (2002) Reference ranges for serum concentrations of lutropin (LH), follitropin (FSH), estradiol (E2), prolactin, progesterone, sex hormone-binding globulin (SHBG), dehydroepiandrosterone sulfate (DHEAS), cortisol and ferritin in neonates, children and young adults. Clin Chem Lab Med 40:1151–1160PubMedCrossRef
13.
Zurück zum Zitat Fishel RS, Eisenberg S, Shai SY, et al. (1995) Glucocorticoids induce angiotensin-converting enzyme expression in vascular smooth muscle. Hypertension 25:343–349PubMed Fishel RS, Eisenberg S, Shai SY, et al. (1995) Glucocorticoids induce angiotensin-converting enzyme expression in vascular smooth muscle. Hypertension 25:343–349PubMed
14.
Zurück zum Zitat Hatherill M, Tibby SM, Hilliard T, Turner C, Murdoch IA (1999) Adrenal insufficiency in septic shock. Arch Dis Child 80:51–55PubMed Hatherill M, Tibby SM, Hilliard T, Turner C, Murdoch IA (1999) Adrenal insufficiency in septic shock. Arch Dis Child 80:51–55PubMed
15.
Zurück zum Zitat Heckmann M, Wudy SA, Haack D, Pohlandt F (1999) Reference range for serum cortisol in well preterm infants. Arch Dis Child Fetal Neonatal Ed 81:F171–F174PubMedCrossRef Heckmann M, Wudy SA, Haack D, Pohlandt F (1999) Reference range for serum cortisol in well preterm infants. Arch Dis Child Fetal Neonatal Ed 81:F171–F174PubMedCrossRef
16.
Zurück zum Zitat Hoffman TM, Wernovsky G, Atz AM, et al. (2003) Efficacy and safety of milrinone in preventing low cardiac output syndrome in infants and children after corrective surgery for congenital heart disease. Circulation 107:996–1002PubMedCrossRef Hoffman TM, Wernovsky G, Atz AM, et al. (2003) Efficacy and safety of milrinone in preventing low cardiac output syndrome in infants and children after corrective surgery for congenital heart disease. Circulation 107:996–1002PubMedCrossRef
17.
Zurück zum Zitat Jenkins KJ, Gauvreau K, Newburger JW, et al. (2002) Consensus-based method for risk adjustment for surgery for congenital heart disease. J Thorac Cardiovasc Surg 123:110–118PubMedCrossRef Jenkins KJ, Gauvreau K, Newburger JW, et al. (2002) Consensus-based method for risk adjustment for surgery for congenital heart disease. J Thorac Cardiovasc Surg 123:110–118PubMedCrossRef
18.
Zurück zum Zitat Keh D, Boehnke T, Weber-Cartens S, et al. (2003) Immunologic and hemodynamic effects of “low-dose” hydrocortisone in septic shock: a double-blind, randomized, placebo-controlled, crossover study. Am J Respir Crit Care Med 167:512–520PubMedCrossRef Keh D, Boehnke T, Weber-Cartens S, et al. (2003) Immunologic and hemodynamic effects of “low-dose” hydrocortisone in septic shock: a double-blind, randomized, placebo-controlled, crossover study. Am J Respir Crit Care Med 167:512–520PubMedCrossRef
19.
Zurück zum Zitat Knighton JD, Woodock TE, Hough M (1999) Adrenal failure in the critically ill. Br J Anaesth 82:152–153PubMed Knighton JD, Woodock TE, Hough M (1999) Adrenal failure in the critically ill. Br J Anaesth 82:152–153PubMed
20.
Zurück zum Zitat Li H, Wallerath T, Münzel T, Föstermann U (2002) Regulation of endothelial-type NO synthase expression in pathophysiology and in response to drugs. Nitric Oxide 7:149–164PubMedCrossRef Li H, Wallerath T, Münzel T, Föstermann U (2002) Regulation of endothelial-type NO synthase expression in pathophysiology and in response to drugs. Nitric Oxide 7:149–164PubMedCrossRef
21.
Zurück zum Zitat Malatinsky J, Vigas M, Jezova D, et al. (1984) The effects of open heart surgery on growth hormone, cortisol and insulin levels in man. Hormone levels during open heart surgery. Resuscitation 11:57–68PubMedCrossRef Malatinsky J, Vigas M, Jezova D, et al. (1984) The effects of open heart surgery on growth hormone, cortisol and insulin levels in man. Hormone levels during open heart surgery. Resuscitation 11:57–68PubMedCrossRef
22.
Zurück zum Zitat Masterson GR, Mostafa SM (1998) Adrenocortical function in critical illness. Br J Anaesth 81:308–310PubMed Masterson GR, Mostafa SM (1998) Adrenocortical function in critical illness. Br J Anaesth 81:308–310PubMed
23.
Zurück zum Zitat Menon K, Clarson C (2002) Adrenal function in pediatric critical illness. Pediatr Crit Care Med 3:112–116PubMedCrossRef Menon K, Clarson C (2002) Adrenal function in pediatric critical illness. Pediatr Crit Care Med 3:112–116PubMedCrossRef
24.
Zurück zum Zitat Pirpiris M, Sudhir K, Yeung S, Jennings G, Whitworth JA (1992) Pressor responsiveness in corticosteroid-induced hypertension in humans. Hypertension 19:567–574PubMed Pirpiris M, Sudhir K, Yeung S, Jennings G, Whitworth JA (1992) Pressor responsiveness in corticosteroid-induced hypertension in humans. Hypertension 19:567–574PubMed
25.
Zurück zum Zitat Pittinger TP, Sawin RS (2000) Adrenocortical insufficiency in infants with congenital diaphragmatic hernia: a pilot study. J Pediatr Surg 35:223–225PubMedCrossRef Pittinger TP, Sawin RS (2000) Adrenocortical insufficiency in infants with congenital diaphragmatic hernia: a pilot study. J Pediatr Surg 35:223–225PubMedCrossRef
26.
Zurück zum Zitat Pollock EM, Pollock JC, Jamieson MP, et al. (1988) Adrenocortical hormone concentrations in children during cardiopulmonary bypass with and without pulsatile flow. Br J Anaesth 60:536–541PubMedCrossRef Pollock EM, Pollock JC, Jamieson MP, et al. (1988) Adrenocortical hormone concentrations in children during cardiopulmonary bypass with and without pulsatile flow. Br J Anaesth 60:536–541PubMedCrossRef
27.
Zurück zum Zitat Rivers EP, Gaspari M, Saad GA, et al. (2001) Adrenal insufficiency in high-risk surgical ICU patients. Chest 119:889–896PubMedCrossRef Rivers EP, Gaspari M, Saad GA, et al. (2001) Adrenal insufficiency in high-risk surgical ICU patients. Chest 119:889–896PubMedCrossRef
28.
Zurück zum Zitat Roth-Isigkeit AK, Dibbelt L, Schmucker P (2000) Blood levels of corticosteroid-binding globulin, total cortisol and unbound cortisol in patients undergoing coronary artery bypass grafting surgery with cardiopulmonary bypass. Steroids 65:513–520PubMedCrossRef Roth-Isigkeit AK, Dibbelt L, Schmucker P (2000) Blood levels of corticosteroid-binding globulin, total cortisol and unbound cortisol in patients undergoing coronary artery bypass grafting surgery with cardiopulmonary bypass. Steroids 65:513–520PubMedCrossRef
29.
Zurück zum Zitat Shenker Y, Skatrud JB (2001) Adrenal insufficiency in critically ill patients. Am J Respir Crit Care Med 163:1520–1523PubMed Shenker Y, Skatrud JB (2001) Adrenal insufficiency in critically ill patients. Am J Respir Crit Care Med 163:1520–1523PubMed
30.
Zurück zum Zitat Shore S, Nelson DP, Pearl JM, et al. (2001) Usefulness of corticosteroid therapy in decreasing epinephrine requirements in critically ill infants with congenital heart disease. Am J Cardiol 88:591–594PubMedCrossRef Shore S, Nelson DP, Pearl JM, et al. (2001) Usefulness of corticosteroid therapy in decreasing epinephrine requirements in critically ill infants with congenital heart disease. Am J Cardiol 88:591–594PubMedCrossRef
31.
Zurück zum Zitat Spijkstra JJ, Girbes AR (2000) The continuing story of corticosteroids in the treatment of septic shock. Int Care Med 26:496–500CrossRef Spijkstra JJ, Girbes AR (2000) The continuing story of corticosteroids in the treatment of septic shock. Int Care Med 26:496–500CrossRef
32.
Zurück zum Zitat Streeten DH (1999) What test for hypothalamic–pituitary–adrenocortical insufficiency? Lancet 354:179–180PubMedCrossRef Streeten DH (1999) What test for hypothalamic–pituitary–adrenocortical insufficiency? Lancet 354:179–180PubMedCrossRef
33.
Zurück zum Zitat Suominen PK, Dickerson HA, Moffett BS, et al. (2005) Hemodynamic effects of rescue protocol hydrocortisone in neonates with low cardiac output syndrome after cardiac surgery. Pediatr Crit Care Med 6:655–659PubMedCrossRef Suominen PK, Dickerson HA, Moffett BS, et al. (2005) Hemodynamic effects of rescue protocol hydrocortisone in neonates with low cardiac output syndrome after cardiac surgery. Pediatr Crit Care Med 6:655–659PubMedCrossRef
34.
Zurück zum Zitat Ullian ME (1999) The role of corticosteriods in the regulation of vascular tone. Cardiovasc Res 41:55–64PubMedCrossRef Ullian ME (1999) The role of corticosteriods in the regulation of vascular tone. Cardiovasc Res 41:55–64PubMedCrossRef
35.
Zurück zum Zitat Unverferth DA, Blanford M, Kates RE, Leier CV (1980) Tolerance to dobutamine after a 72 hour continuous infusion. Am J Med 69:262–266PubMedCrossRef Unverferth DA, Blanford M, Kates RE, Leier CV (1980) Tolerance to dobutamine after a 72 hour continuous infusion. Am J Med 69:262–266PubMedCrossRef
36.
Zurück zum Zitat Voerman HJ, Strack van Schijndel RJ, Groeneveld AB, et al. (1992) Pulsatile hormone secretion during severe sepsis: accuracy of different blood sampling regimens. Metabolism 41:934–940PubMedCrossRef Voerman HJ, Strack van Schijndel RJ, Groeneveld AB, et al. (1992) Pulsatile hormone secretion during severe sepsis: accuracy of different blood sampling regimens. Metabolism 41:934–940PubMedCrossRef
37.
Zurück zum Zitat Wan S, LeClerc JL, Vincent JL (1997) Inflammatory response to cardiopulmonary bypass: mechanisms involved and possible therapeutic strategies. Chest 112:676–692PubMed Wan S, LeClerc JL, Vincent JL (1997) Inflammatory response to cardiopulmonary bypass: mechanisms involved and possible therapeutic strategies. Chest 112:676–692PubMed
Metadaten
Titel
Glucocorticoid Therapy for Hypotension in the Cardiac Intensive Care Unit
verfasst von
K. J. Millar
R. R. Thiagarajan
P. C. Laussen
Publikationsdatum
01.06.2007
Erschienen in
Pediatric Cardiology / Ausgabe 3/2007
Print ISSN: 0172-0643
Elektronische ISSN: 1432-1971
DOI
https://doi.org/10.1007/s00246-006-0053-9

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