Association between plasma cortisol and death or vasopressor refractory hypotension in preterm neonates: a prospective, cohort study

Management Practices for Hemodynamic Impairment in Neonates Born Prematurely: A Quality Improvement Project

Background: No consensus exists on the management of hemodynamic impairment in very premature neonates. At level 3 NICU, the protocol involves an initial infusion of crystalloids, followed by a cardiac ultrasound if the infusion fails to restore appropriate hemodynamics. Based on the ultrasound findings, a decision is then made regarding a second infusion or the prescription of vasopressor amines. The aim of the present study was to assess the effect of and compliance with this management practice in neonates born prematurely between 26 and 31 completed weeks of gestation following a plan-do-study-act design. Methods: Data were collected retrospectively from patient records for all neonates who were managed for hemodynamic impairment within the first 24 h of life. Results: Of 604 neonates born during the study period, 68 were included in this study, but only eight cases followed the protocol. Reasons for non-compliance were the absence of cardiac ultrasound and variations in the duration and dosage of fluid administration. There was a significant relationship between blood pressure and positive inspiratory pressure levels at the time of management and compliance with the protocol. Conclusions: A revision of the protocol will emphasize the importance of echocardiography assessment, as all neonates responded to the ultrasound-guided therapy. As a quality improvement measure, attending neonatologists will be trained to thoroughly adhere to the protocol before the next evaluation.

Influence of innate immune activation on endocrine and metabolic pathways in infancy

Prematurity is the leading cause of neonatal morbidity and mortality worldwide. Premature infants often require extended hospital stays, with increased risk of developing infection compared with term infants. A picture is emerging of wide-ranging deleterious consequences resulting from innate immune system activation in the newborn infant. Those who survive infection have been exposed to a stimulus that can impose long-lasting alterations into later life. In this review, we discuss sepsis-driven alterations in integrated neuroendocrine and metabolic pathways and highlight current knowledge gaps in respect of neonatal sepsis. We review established biomarkers for sepsis and extend the discussion to examine emerging findings from human and animal models of neonatal sepsis that propose novel biomarkers for early identification of sepsis. Future research in this area is required to establish a greater understanding of the distinct neonatal signature of early and late-stage infection, to improve diagnosis, curtail inappropriate antibiotic use, and promote precision medicine through a biomarker-guided empirical and adjunctive treatment approach for neonatal sepsis. There is an unmet clinical need to decrease sepsis-induced morbidity in neonates, to limit and prevent adverse consequences in later life and decrease mortality.

Absence of relationship between serum cortisol and critical illness in premature infants

BACKGROUND

Inadequate cortisol production in response to critical illness in extremely preterm infants may exacerbate poor outcomes. Despite commonly measuring cortisol concentration and administering hydrocortisone for presumed adrenal insufficiency, the relationship between serum cortisol concentration and illness severity remains unclear in this unique population.

OBJECTIVE

To determine the relationship between cortisol concentrations and illness severity as measured by the Score for Neonatal Acute Physiology II, neonatal Sequential Organ Failure Assessment and Vasoactive-Inotropic Score in premature infants.

DESIGN/METHODS

This retrospective, single-center cohort study included preterm infants born <30 weeks gestational age admitted to a level IV neonatal intensive care unit (NICU) between June 2011 and July 2018, who had a serum cortisol obtained for clinical indications before 36 weeks PMA. Demographic data were collected on infants and mothers. Nine clinical variables were identified a priori that could potentially modify cortisol concentration including critical illness. Univariate and multivariable analyses determined the relationship between cortisol concentration and each of these variables.

RESULTS

A total of 224 preterm infants with pretreatment serum cortisol concentration met criteria for inclusion. The median (IQR) gestational age at birth was 25 weeks (24, 26) and at cortisol measurement was 26 weeks (25, 28). The median cortisol was 13.3 ug/dL. Non-survivors had the highest values. Cortisol concentration did not correlate with any of the selected illness severity scores.

CONCLUSIONS

Cortisol concentrations in extremely preterm infants did not correlate with illness severity regardless of gestational age. Further studies are needed to identify clinically useful mediators of adrenal dysfunction and to guide clinical management.