The use of an early ACTH test to identify hypoadrenalism-related hypotension in low birth weight infants

Abstract

Objective: To investigate if in preterm newborns, an early adrenocorticotropin hormone (ACTH) test can identify possible transient adrenal insufficiency (TAI), using significant hypotension as a clinical marker.Study Design: We studied 40 premature newborns born 24 to 29 weeks gestational age (GA) before 8 h of life. Serum cortisol levels were obtained before and 40 min after administration of 1.0 mcg kg À1 cosyntropin.Inotropes were used to treat hypotension based on clinical assessment following no response to fluid boluses. Functional echocardiogram was used to support the clinical diagnosis of hypotension. The accuracy of the ACTH test was evaluated using receiver operating characteristic (ROC) curve.Result: Study patients had mean GA of 26.6 weeks and birth weight of 876 g. In all, 30% required inotropes. The area under the ROC curve for the ACTH test was 87%. Using a cutoff of an increase in cortisol below 12% from baseline had 75% sensitivity and 93% specificity for detecting hypotension. This cutoff was associated with bronchopulmonary dysplasia (8/12 vs 7/28, 95% CI: 0.1 to 0.72), but not with other morbidities or death.Conclusion: An early ACTH test using the above cutoff has high specificity for detecting hypotension, and thus, can serve as a marker for potential TAI in preterm newborns. Future studies should focus on identifying those newborns for which steroid supplementation would be most beneficial.

Adrenocortical sensitivity to ACTH in neonatal rats: correlation of corticosterone responses and adrenal cAMP content

“…In particular, it is now established that transient, relative adrenal insufficiency is a significant clinical entity in the premature and low-birth weight human infant and may be associated with hypotension, respiratory failure, and increased morbidity (15,20,21,34,35,43,50). Furthermore, an altered adrenocortical response to physiological and pharmacological doses of exogenous ACTH is useful in the evaluation of adrenal function in the premature and low-birth weight infant (1,13,20,22,24,43,44). ACTH stimulation is an important diagnostic test of human adrenal function, the results of which can influence the implementation of glucocorticoid therapy (35,44).…”

Hypotension following Patent Ductus Arteriosus Ligation: The Role of Adrenal Hormones

“…These findings suggest that the premature adrenal gland might not respond appropriately to elevated ACTH levels (15, 20, 21). Sick preterm infants have high circulating concentrations of 17-hydroxyprogesterone, 11-deoxycortisol, and cortisone.…”

Adding Hydrocortisone as 1st Line of Inotropic Treatment for Hypotension in Very Low Birth Weight Infants: Authors’ Reply

“…This study, and other studies mentioned by Hakan et al used a higher cumulative doses and a longer course compared to our study [4]. Furthermore, recent study demonstrated relation between hypoadrenalism and hypotension in hypotensive premature newborns [5]. This suggests the potential importance and benefit of using steroids as replacement therapy and not only as vasopressor in this group.…”