Three Part Question
In [hypotensive preterm infants] does [treatment with dexamethasone] [increase blood pressure]?
A 25 week gestation baby, birth weight 695g is ventilated for respiratory distress syndrome. Invasive blood pressure monitoring at 2 hours of age showed a mean of 23-25 mmHg. The blood pressure did not improve over the next 24 hours, in spite of three intravenous boluses of 0.9% saline and concurrent infusions of dopamine and dobutamine at 15 ug/kg/min. A colleague suggests that dexamethasone might help to improve the baby's blood pressure.
3 articles found, 2 of which were relevant. The two papers are shown in the table.
|Author, date and country
||Study type (level of evidence)
|Bourchier D and Weston PJ,|
|40 hypotensive preterm babies||Randomised, open trial of hydrocortisone vs dopamine (1b)||Hypotension despite treatment: dopamine 0/19; hydrocortisone 4/21||Absolute risk increase (ARI) was 20% for hydrocortisone and NNT=5 (95% CI 3-45)||Method of BP measurement not stated in this paper|
|Gaissmaier RE and Pohlandt F,|
|20 preterm babies (mean body weight 690g) hypotensive in spite of volume support and inotropes||Randomised, double blind, placebo controlled trial (1b)||Discontinuation of adrenaline at 12 hours||Absolute risk reduction (ARR) for withdrawal of adrenaline was 52% and NNT=2 (95% CI 1-8)||All blood pressure readings measured invasively|
The study by Gassaier and Pohlandt was well constructed in terms of randomisation, blinding and intention to treat analysis. Dexamethasone administration after treatment with volume boluses, dopamine and adrenaline infusion improved BP such that adrenaline was discontinued in 63% of babies (compared with 11% of placebo group).
The paper by Bouchier and Weston supports the idea that bolus steroids are a useful adjunct to conventional treatments for hypotension in sick, ventilated preterm infants. Dopamine and hydrocortisone both appeared to be effective (p = 0.108) in the treatment of hypotension refractory to treatment with fluid bolus. However, if five babies received hydrocortisone, 1 additional baby remained hypotensive, compared with similar babies who received dopamine. Confidence intervals for this NNT are wide (3, 45), suggesting a larger study would show statistical difference at the 5% level.
Dexamethasone appears to be a useful adjunct to the commonly used pathway for treating hypotension in neonates (fluid bolus +/- dopamine +/- dobutamine).
Although no adverse events related to steroid use are reported in either paper, no long term follow up is reported and caution is warranted as there is emerging evidence of increased risk of cerebal palsy following postnatal dexamethasone use in babies at risk for chronic lung disease (3), without improvement in mortality (4).
Clinical Bottom Line
Dexamethasone improved blood pressure in ill, ventilated neonates.
- Bourchier D, Weston PJ. Randomised trial of dopamine compared with hydrocortisone for the treatment of hypotensive very low birthweight infants. Arch Dis Child Fetal Neonatal Ed 1997;76(3):F174-8.
- Gaissmaier RE, Pohlandt F. Single-dose dexamethasone treatment of hypotension in preterm infants. J Pediatr 1999;134(6):701-5.
- Shinwell ES, Karplus M, Reich D et al. Early postnatal dexamethasone treatment and increased incidence of cerebral palsy. Archives of Disease in Childhood: Fetal & Neonatal Edition 2000;83(3):F177-81.
- Halliday HL, Ehrenkranz RA. Early postnatal (<96 hours) corticosteroids for preventing chronic lung disease in preterm infants. Cochrane Database of Systematic Reviews Issue 1, 2001.