No abstract

No abstract

High dose steroids have been used frequently in the management of ventilator dependent premature infants. Several studies have shown that such treatment accelerates weaning from assisted ventilation and improves pulmonary compliance, and the reported complication rates have been low.1-5 Over a 2 5 year period, we have treated 80 ventilator dependent infants with high doses of dexamethasone. Among these infants three have had major complications associated with steroid usage: a perforated duodenal ulcer, a perforated gastric ulcer, and an upper gastrointestinal haemorrhage. Two infants died, resulting in a mortality of 66%. In contrast to the experience of others, then, our experience suggests that significant complications can occur when dexamethasone is used in infants at risk for bronchopulmonary dysplasia.Dexamethasone is a synthetic steroid having a glucocorticoid effect about 30 times more potent than endogenous cortisol.6 Most protocols start dexamethasone at an initial dose of 0 5 mg/kg/day given either enterally or parenterally. [1][2][3][4][5] The patient is weaned from the dexamethasone on all protocols, but the times and rates vary. At our institution we use the dexamethasone protocol described by Cummings et al: initial treatment with a dose of 0 5 mg/kg/day, which is decreased to 0-3 mg/kg/day after three days, and thereafter reduced by 10% every three days until 0-1 mg/kg/day is reached.5 At that point, the drug is given every other day until day 42. The dosage is not changed in the presence of sepsis. Body weight, blood pressure, blood glucose values, and triglyceride concentrations are monitored. Case reports CASE 1A girl weighing 700 g born after 25 weeks' gestation was immediately intubated for respiratory distress. After 3 5 weeks of mechanical ventilation, high dose intravenous dexamethasone treatment (0 5 mg/kg/day) was begun. On the fourth day of steroid treatment at that dose she developed hypoxia, tachycardia, and abdominal distention; an abdominal radiograph showed free intraperitoneal air. Enteral feeding had not been initiated. At exploratory surgery, a perforated duodenal ulcer was found and repaired. Before H2 receptor antagonist treatment was started, her gastric pH was 1'7 and her non-fasting serum gastrin concentration was 224 ng/l (normal range for non-fasting serum gastrin in infants: 100-225 ng/17).The postoperative course was otherwise uneventful. She was weaned from steroid treatment over several days and extubated on postoperative day 7. CASE 2 A boy weighing 860 g born after 28 weeks' gestation was intubated immediately and remained ventilator dependent for three weeks. High dose intravenous dexamethasone (0 5 mg/kg/day) was begun, and 10 days later free intraperitoneal air was seen on a routine chest radiograph. The dexamethasone dose at this point was 0-2 mg/kg/day. At operation, a perforated ulcer was found on the lesser curvature of the stomach proximal to the pylorus. During repair of the ulcer the patient became hypotensive and died. CASE 3 A boy weighing 900 g was...