Steroids and Vasopressor-Resistant Hypotension in Preterm Infants
Despite our inability to appropriately define the gestational- and postnatal-age dependent normative values of
blood pressure, hypotension is often been diagnosed and treated in preterm neonates especially during the transitional period.
Although the perceived normal blood pressure values can be restored in the majority of preterm neonates by administration
of volume and vasopressor-inotropes, some patients will not respond even to higher doses of vasoactive medications.
In these neonates with so-called “vasopressor-resistant hypotension”, steroid administration is usually effective in
increasing the blood pressure to the perceived normal range and decreasing vasopressor requirement. The etiology of
vasopressor-resistant hypotension is thought to be a combination of transient adrenocortical insufficiency of prematurity
and downregulation of the cardiovascular adrenergic receptors. In the clinical practice, hydrocortisone is used most frequently
for the management of vasopressor-resistance. Importantly, low-dose hydrocortisone appears to improve blood
pressure without compromising cardiac function or systemic perfusion in these patients. However, caution must be exercised
when hydrocortisone is administered during the first postnatal week as significant side effects including gastrointestinal
perforation may occur especially in infants co-exposed to indomethacin. In addition, although the available data on
the lack of a documented impact of early low-dose hydrocortisone administration on brain development are encouraging,
more and appropriately powered studies are needed to put this concern to rest.
Keywords: Vasopressor-resistant hypotension, preterm neonate, hydrocortisone, relative adrenal insufficiency of prematurity,
adrenergic receptor downregulation
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