Cardiac Output, Low
Conditions
Keywords
Congenital heart disease., Low cardiac output syndrome., Corticosteroids., Hydrocortisone., Blood pressure., Inotropes.
Brief summary
Babies having heart surgery often have problems after surgery with their blood pressure and getting enough blood to their bodies. To treat this they require medicines to keep their blood pressure high enough to get blood to their bodies. The side effects of these medicines include fast heart rates and increasing the amount of work the heart has to do. Corticosteroids are made by the body and help to use the energy in the food people eat, control the chemicals in their blood and maintain their blood pressure. Corticosteroids made by the body may be decreased in patients that have major surgery. Corticosteroids help to increase blood pressure and can decrease the amount of blood pressure medicines a patient requires. Corticosteroids have been shown to increase blood pressure in patients with bacterial infections and in very small, premature babies but have only been studied in a few babies who have had heart surgery. The way corticosteroids work is unknown but may involve decreasing the body's response to being on a heart-lung machine or give steroids not being made by the patient. Corticosteroids have been shown to be helpful in treating many diseases. The purpose of this study is to look at the effects of corticosteroids in babies who have had heart surgery and need blood pressure medicines in the intensive care unit after surgery. Our idea is that getting corticosteroids will allow us to decrease the amount of blood pressure medicines each patient needs and improve how they do after surgery. We also plan to do blood tests to help determine how the corticosteroids are working. It will be randomly determined if the subject receives corticosteroids or salt water. The subject will receive a corticosteroid or salt water once a day for five days. Their vital signs will be monitored, especially blood pressure and their need for medicines to increase their blood pressure. Blood work will also be obtained to determine their body's ability to make steroids.
Detailed description
The study will be prospective. Patients who meet entry criteria will be randomized to receive corticosteroids versus placebo. Randomization will take into account biventricular versus univentricular repairs/palliations and whether the patients received intraoperative steroids. Patients will be compared with matched controls based on: diagnosis, +/- intraoperative steroids/phenoxybenzamine, cardiopulmonary bypass/cross clamp/circulatory arrest times and inotrope requirements. Those in the treatment arm will be dosed with hydrocortisone - stress dose (100mg/m2/dose daily x2, then taper with two days at half the original dose and one day at one quarter of the original dose) and then the steroids will be discontinued. Outcome data will include: heart rate, blood pressure, mixed venous oxygen saturation to assess cardiac output, blood cultures/infection/antibiotics (antibiotics as deemed necessary by the primary cardiologist), +/- gastrointestinal bleeding, time to discontinuing inotropic agents, time to extubation, length of intensive care unit admission and survival. Laboratory studies will be assessed before and 24 hours after the institution of steroids. The following labs are standard of care in the unit and will be assessed: glucose, electrolytes, blood urea nitrogen/creatinine, complete blood counts, lactate, arterial blood gases, cultures and stool guaiac. The following labs will be assessed in addition to regular monitoring: cortisol, adrenocorticotropin hormone and C reactive protein.
Interventions
DRUGHydrocortisone
Hydrocortisone taper (100mg/m2/day --\> 25mg/m2/day) over 5 days intravenously.
DRUGPlacebo
Placebo for 5 days intravenously.
Sponsors
Baylor College of Medicine
Study design
Allocation
RANDOMIZED
Intervention model
SINGLE_GROUP
Primary purpose
TREATMENT
Masking
TRIPLE (Subject, Caregiver, Investigator)
Eligibility
Sex/Gender
ALL
Age
No minimum to 1 Months
Healthy volunteers
No
Inclusion criteria
* Age \< 1 month * Postoperative * Inotrope score \> 20 x \> 4 hrs \[epinephrine: (mcg/kg/min) x 100 + norepinephrine: (mcg/kg/min) x 100 + phenylephrine: (mcg/kg/min) x 100 + vasopressin: (units/kg/hr) x 100 + milrinone: (mcg/kg/min) x 15 + dopamine: (mcg/kg/min) x 1 + dobutamine: (mcg/kg/min) x 1 + calcium chloride: (mg/kg/hr) x 1\]
Exclusion criteria
* Age \> 1 month * Documented sepsis * Preoperative use of steroids \> 1 wk
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Blood Pressure. | 2 days | Change in mean blood pressure recorded prior to (15 minutes prior to study drug) and subsequent to medication/placebo administration (at 2 days post drug administration). |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Change in Inotrope Score. This is the Change in the Inotrope Score Between 15 Minutes Prior to Drug Administration and at 2 Days After Drug Administration. | 2 days | Inotrope score: epinephrine (mcg/kg/min x 100) + norepinephrine (mcg/kg/min x 100) + phenylephrine (mcg/kg/min x 100) + dopamine (mcg/kg/min x1) + dobutamine (mcg/kg/min x 1) + milrinone (mcg/kg/min x15). A lower inotrope score is better with the minimum being 0 and the maximum being 85. |
Countries
United States
Participant flow
Participants by arm
| Arm | Count |
|---|---|
| Hydrocortisone Subjects in this arm will receive a 5 day tapering course of hydrocortisone. Hydrocortisone: Hydrocortisone taper (100mg/m2/day --\> 25mg/m2/day) over 5 days intravenously. | 9 |
| Placebo Subjects in this arm will receive 5 days of placebo. Placebo: Placebo for 5 days intravenously. | 9 |
| Total | 18 |
Baseline characteristics
| Characteristic | Hydrocortisone | Placebo | Total |
|---|---|---|---|
| Age, Categorical <=18 years | 9 Participants | 9 Participants | 18 Participants |
| Age, Categorical >=65 years | 0 Participants | 0 Participants | 0 Participants |
| Age, Categorical Between 18 and 65 years | 0 Participants | 0 Participants | 0 Participants |
| Age, Continuous | 10 days STANDARD_DEVIATION 10.58 | 7 days STANDARD_DEVIATION 4.12 | 8.5 days STANDARD_DEVIATION 7.94 |
| Inotrope score | 23.46 units on a scale STANDARD_DEVIATION 3.79 | 22.11 units on a scale STANDARD_DEVIATION 2.31 | 22.78 units on a scale STANDARD_DEVIATION 3.12 |
| Region of Enrollment United States | 9 participants | 9 participants | 18 participants |
| Sex: Female, Male Female | 5 Participants | 4 Participants | 9 Participants |
| Sex: Female, Male Male | 4 Participants | 5 Participants | 9 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| deaths Total, all-cause mortality | — / — | — / — |
| other Total, other adverse events | 0 / 9 | 0 / 9 |
| serious Total, serious adverse events | 0 / 9 | 1 / 9 |
Outcome results
Primary
Blood Pressure.
Change in mean blood pressure recorded prior to (15 minutes prior to study drug) and subsequent to medication/placebo administration (at 2 days post drug administration).
Time frame: 2 days
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Hydrocortisone | Blood Pressure. | 6 mmHg | Standard Deviation 7.86 |
| Placebo | Blood Pressure. | 5.89 mmHg | Standard Deviation 9.24 |
Secondary
Change in Inotrope Score. This is the Change in the Inotrope Score Between 15 Minutes Prior to Drug Administration and at 2 Days After Drug Administration.
Inotrope score: epinephrine (mcg/kg/min x 100) + norepinephrine (mcg/kg/min x 100) + phenylephrine (mcg/kg/min x 100) + dopamine (mcg/kg/min x1) + dobutamine (mcg/kg/min x 1) + milrinone (mcg/kg/min x15). A lower inotrope score is better with the minimum being 0 and the maximum being 85.
Time frame: 2 days
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Hydrocortisone | Change in Inotrope Score. This is the Change in the Inotrope Score Between 15 Minutes Prior to Drug Administration and at 2 Days After Drug Administration. | 8.83 units on a scale | Standard Deviation 9.61 |
| Placebo | Change in Inotrope Score. This is the Change in the Inotrope Score Between 15 Minutes Prior to Drug Administration and at 2 Days After Drug Administration. | 7.17 units on a scale | Standard Deviation 4.8 |