Hypotension following patent ductus arteriosus ligation

The role of adrenal hormones

Ronald I. Clyman, Andrea Wickremasinghe, T. Allen Merritt, Tabitha Solomon, Patrick McNamara, Amish Jain, Jaideep Singh, Alison Chu, Shahab Noori, Krishnamurthy Sekar, Pascal M. Lavoie, Joshua T. Attridge, Jonathan R. Swanson, Maria Gillam-Krakauer, Jeff Reese, Sara Demauro, Brenda Poindexter, Sue Aucott, Monique Satpute, Erika Fernandez & 1 others Richard J. Auchus

Research output: Contribution to journalArticle

28 Citations (Scopus)

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. Study design 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. Conclusion 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.

Original languageEnglish
JournalJournal of Pediatrics
Volume164
Issue number6
DOIs
StatePublished - 2014

Fingerprint

Patent Ductus Arteriosus
Hypotension
Ligation
Hormones
Catecholamines
Hydrocortisone
Cosyntropin
Multicenter Studies
Multivariate Analysis
Incidence

ASJC Scopus subject areas

  • Pediatrics, Perinatology, and Child Health

Cite this

Clyman, R. I., Wickremasinghe, A., Merritt, T. A., Solomon, T., McNamara, P., Jain, A., ... Auchus, R. J. (2014). Hypotension following patent ductus arteriosus ligation: The role of adrenal hormones. Journal of Pediatrics, 164(6). https://doi.org/10.1016/j.jpeds.2014.01.058

Hypotension following patent ductus arteriosus ligation : The role of adrenal hormones. / Clyman, Ronald I.; Wickremasinghe, Andrea; Merritt, T. Allen; Solomon, Tabitha; McNamara, Patrick; Jain, Amish; Singh, Jaideep; Chu, Alison; Noori, Shahab; Sekar, Krishnamurthy; Lavoie, Pascal M.; Attridge, Joshua T.; Swanson, Jonathan R.; Gillam-Krakauer, Maria; Reese, Jeff; Demauro, Sara; Poindexter, Brenda; Aucott, Sue; Satpute, Monique; Fernandez, Erika; Auchus, Richard J.

In: Journal of Pediatrics, Vol. 164, No. 6, 2014.

Research output: Contribution to journalArticle

Clyman, RI, Wickremasinghe, A, Merritt, TA, Solomon, T, McNamara, P, Jain, A, Singh, J, Chu, A, Noori, S, Sekar, K, Lavoie, PM, Attridge, JT, Swanson, JR, Gillam-Krakauer, M, Reese, J, Demauro, S, Poindexter, B, Aucott, S, Satpute, M, Fernandez, E & Auchus, RJ 2014, 'Hypotension following patent ductus arteriosus ligation: The role of adrenal hormones', Journal of Pediatrics, vol. 164, no. 6. https://doi.org/10.1016/j.jpeds.2014.01.058
Clyman, Ronald I. ; Wickremasinghe, Andrea ; Merritt, T. Allen ; Solomon, Tabitha ; McNamara, Patrick ; Jain, Amish ; Singh, Jaideep ; Chu, Alison ; Noori, Shahab ; Sekar, Krishnamurthy ; Lavoie, Pascal M. ; Attridge, Joshua T. ; Swanson, Jonathan R. ; Gillam-Krakauer, Maria ; Reese, Jeff ; Demauro, Sara ; Poindexter, Brenda ; Aucott, Sue ; Satpute, Monique ; Fernandez, Erika ; Auchus, Richard J. / Hypotension following patent ductus arteriosus ligation : The role of adrenal hormones. In: Journal of Pediatrics. 2014 ; Vol. 164, No. 6.
@article{ff18f809af4e4e08a832957d5283ad76,
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. Study design 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. Conclusion 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.",
author = "Clyman, {Ronald I.} and Andrea Wickremasinghe and Merritt, {T. Allen} and Tabitha Solomon and Patrick McNamara and Amish Jain and Jaideep Singh and Alison Chu and Shahab Noori and Krishnamurthy Sekar and Lavoie, {Pascal M.} and Attridge, {Joshua T.} and Swanson, {Jonathan R.} and Maria Gillam-Krakauer and Jeff Reese and Sara Demauro and Brenda Poindexter and Sue Aucott and Monique Satpute and Erika Fernandez and Auchus, {Richard J.}",
year = "2014",
doi = "10.1016/j.jpeds.2014.01.058",
language = "English",
volume = "164",
journal = "Journal of Pediatrics",
issn = "0022-3476",
publisher = "Mosby Inc.",
number = "6",

}

TY - JOUR

T1 - Hypotension following patent ductus arteriosus ligation

T2 - The role of adrenal hormones

AU - Clyman, Ronald I.

AU - Wickremasinghe, Andrea

AU - Merritt, T. Allen

AU - Solomon, Tabitha

AU - McNamara, Patrick

AU - Jain, Amish

AU - Singh, Jaideep

AU - Chu, Alison

AU - Noori, Shahab

AU - Sekar, Krishnamurthy

AU - Lavoie, Pascal M.

AU - Attridge, Joshua T.

AU - Swanson, Jonathan R.

AU - Gillam-Krakauer, Maria

AU - Reese, Jeff

AU - Demauro, Sara

AU - Poindexter, Brenda

AU - Aucott, Sue

AU - Satpute, Monique

AU - Fernandez, Erika

AU - Auchus, Richard J.

PY - 2014

Y1 - 2014

N2 - 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. Study design 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. Conclusion 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.

AB - 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. Study design 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. Conclusion 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.

UR - http://www.scopus.com/inward/record.url?scp=84901498254&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=84901498254&partnerID=8YFLogxK

U2 - 10.1016/j.jpeds.2014.01.058

DO - 10.1016/j.jpeds.2014.01.058

M3 - Article

VL - 164

JO - Journal of Pediatrics

JF - Journal of Pediatrics

SN - 0022-3476

IS - 6

ER -