Related Experiment Video
Updated: May 11, 2026
Hemodynamic Precision in the Neonatal Intensive Care Unit using Targeted Neonatal Echocardiography
Published on: January 27, 2023
Adrenal function in preterm infants undergoing patent ductus arteriosus ligation
Afif EL-Khuffash1, Patrick J McNamara, Anie Lapointe
1Department of Paediatrics, Rotunda Hospital, Dublin, Ireland.
Insights
Adrenal insufficiency may contribute to cardiorespiratory instability after patent ductus arteriosus (PDA) ligation in preterm infants. Post-ACTH cortisol levels below 750 nmol/l were linked to hypotension and ventilation failure, suggesting a role for relative adrenal insufficiency.
Area of Science:
- Neonatalogy
- Pediatric Cardiology
- Endocrinology
Background:
- Targeted milrinone therapy for low left ventricular output (LVO) after patent ductus arteriosus (PDA) ligation in preterm infants aims to reduce cardiorespiratory instability.
- Despite treatment, some infants experience postoperative deterioration, prompting investigation into potential underlying mechanisms like adrenal insufficiency.
- Prematurity-related adrenal insufficiency has been postulated as a contributing factor to postoperative complications in these vulnerable infants.
Purpose of the Study:
- To assess adrenal function in premature infants undergoing PDA ligation.
- To investigate the association between adrenal function (cortisol levels) and clinical/echocardiographic indicators of disease severity before and after surgery.
- To explore the predictive value of adrenal response to adrenocorticotropic hormone (ACTH) stimulation for postoperative outcomes.
Main Methods:
- A retrospective cohort study included 35 preterm infants who underwent PDA ligation and received preoperative ACTH stimulation testing.
- Infants were assessed for LVO via echocardiography 1 hour post-surgery, with milrinone administered if LVO <200 ml/kg/min.
- Primary outcome was LVO; secondary outcomes included hypotension, and oxygenation/ventilation failure within 24 hours.
Main Results:
- No significant association was found between preoperative or post-ACTH cortisol levels and postoperative low LVO.
- However, post-ACTH cortisol levels ≤750 nmol/l were significantly associated with increased risk of hypotension (p=0.03) and oxygenation/ventilation failure (p=0.04, p=0.008).
- Receiver-operator characteristic analysis indicated a high predictive value of post-ACTH cortisol for clinical outcomes.
Conclusions:
- Post-ACTH cortisol levels ≤750 nmol/l may indicate a higher risk of cardiorespiratory instability following PDA ligation.
- Relative adrenal insufficiency could be a significant factor in the hemodynamic and respiratory complications observed after PDA ligation in preterm infants.
- Adrenal function assessment may aid in identifying infants at risk for postoperative instability.
Background:
Targeted milrinone treatment for low left ventricular output (LVO) reduces the incidence of acute cardiorespiratory instability following ligation of patent ductus arteriosus (PDA) in preterm infants. Despite this, some infants continue to experience postoperative deterioration. Adrenal insufficiency related to prematurity has been postulated as a possible mechanism.
Objectives:
To describe adrenal function in premature infants undergoing PDA ligation and to investigate its association with pre- and postoperative clinical and echocardiography-derived indices of disease severity.
Methods:
A retrospective cohort study was conducted over a 2-year period on infants who underwent PDA ligation and had preoperative adrenocorticotropic hormone (ACTH) stimulation. All infants were screened by echocardiography for low LVO at 1 h after surgery and treated with intravenous milrinone if LVO <200 ml/kg/min. The primary outcome evaluated was low LVO at 1 h after surgery. Secondary outcomes included hypotension and oxygenation and ventilation failure occurring within 24 h.
Results:
A total of 35 infants at a median gestation of 25.4 (24.5-26.4) weeks and weight at birth of 700 (600-810) g were included. Baseline median cortisol measured preoperatively was 202 (137-403) nmol/l. Following the ACTH stimulation test, 3 infants had cortisol ≤500 nmol/l while 15 had ≤750 nmol/l. There was no association seen between any cortisol value and low LVO postoperatively. Post-ACTH cortisol ≤750 nmol/l was significantly associated with hypotension (p = 0.03) and oxygenation (p = 0.04) and ventilation (p = 0.008) failure. Receiver-operator characteristic curve showed a high predictive value of post-ACTH cortisol for all clinical outcomes.
Conclusions:
Post-ACTH cortisol (≤750 nmol/l) may be associated with clinical indices of postoperative cardiorespiratory instability. Relative adrenal insufficiency may play a role in the etiology of post-PDA ligation hemodynamic and respiratory instability.
