111 - Use of Hydrocortisone (HC): A Retrospective Look at Relative Adrenal Insufficiency (RAI) of Prematurity

Publication Number: 2106.111

Prima Das, Albany Medical College, Northfield, NJ, United States; Priya Kabaria. Patel, Albany Medical College, Albany, NY, United States; Joaquim Pinheiro, Albany Medical College, Albany, NY, United States; Jennifer Cerone, Albany Medical College, Albany, NY, United States; Megan Reyes-Wangh, Albany Medical College, Albany, NY, United States; Upender Munshi, Albany Medical College, Albany, NY, United States

Background: Relative Adrenal Insufficiency (RAI) occurs when preterm infants cannot make enough cortisol, needed for stress response and supporting cardiovascular function. Due to a lack of standardized lab values to define RAI of Prematurity, diagnosis is based on clinical presentation which may include refractory hypotension unresponsive to volume resuscitation and/or vasopressor/inotropic support, low urine output (UOP), and rising serum creatinine (CR) levels.

Objective: To evaluate if HC improved RAI clinical markers [mean arterial pressure (MAP) < 10%tile for gestational age, UOP < 2 ml/kg/h, CR≥1 mg/dL] within 48 hours. Secondary outcomes: time of onset, hyperglycemia, and spontaneous intestinal perforation (SIP).

Design/Methods: Retrospective chart review of HC use in infants < 30 weeks gestational age (GA) or birth weight (BW) < 1250 g treated for presumed RAI in 2021-2024 at Level 4 NICU. Exclusions: death within 48h of HC, necrotizing enterocolitis (NEC)/SIP before HC, surgical prophylaxis, or genetic/metabolic errors. Data: demographics, RAI onset, and evaluation of clinical markers. Secondary outcomes: NEC/SIP during or after HC, intraventricular hemorrhage (IVH), retinopathy of prematurity (ROP), and bronchopulmonary dysplasia (BPD defined as O2 requirement at 36 weeks (wk.) corrected gestational age (CGA). Analysis: repeated-measures analysis of variance (ANOVA) and Dunnett's test (p < 0.05).

Results: Of 415 infants, 96 received HC; 66 met inclusion criteria, and 56 survived. Mean GA 25±2 wk, BW 743±220 g; 85% C-section; median 5-min Apgar 6 (4-8); 76% had antenatal steroids. Figure 1 shows HC starting criteria. RAI onset: 17% in 1-3 days of life (DOL), 12% DOL 4-7, 56% DOL 8-28, and 15% >28 DOL (peak DOL 8-28). Pre-HC glucose 144±67, Na 137±5.5, and K⁺ 4.0±0.9. Post-HC glucose within 24h was 129±51.3. 2 infants had HC d/c'ed due to hyperglycemia and 3 pts received HC as transition from dexamethasone.

Interventions prior to HC: 9% volume, 29% vasopressors, 17% both, and 45% HC alone. HC dose was 0.5-1.5 mg/kg/day, duration 28±30d. MAP, UOP, and CR significantly improved within 24-48 h (Table 1). For major comorbidities: 12% NEC/SIP during or after HC, 17% had severe IVH, and 59% had BPD, see Table 2.

Conclusion(s): RAI occurred in 17% within 3 DOL, most often (56%) at 8-28 DOL. HC significantly improved cardiovascular and renal function within 24 to 48 hours of initiation. Compared with existing comorbidities in our unit, HC treatment did not have a significant effect. For future direction, we are reviewing the neurodevelopmental outcomes of this cohort.

Criteria for Starting Hydrocortisone
Venn diagram showing the reasoning for starting hydrocortisone

Effect of Hydrocortisone
Table 1: MAP, UOP, and Creatinine 24-48 hour before and after starting hydrocortisone

Secondary Outcomes/Comorbidities