Timing of hydrocortisone therapy in neonates with shock: a systematic review, meta-analysis, and clinical practice guideline.

IF 2 3区医学 Q2 PEDIATRICS Frontiers in Pediatrics Pub Date : 2025-03-12 eCollection Date: 2025-01-01 DOI:10.3389/fped.2025.1491976

Viraraghavan Vadakkencherry Ramaswamy, Gunjana Kumar, Abdul Kareem Pullattayil S, Abhishek S Aradhya, Pradeep Suryawanshi, Mohit Sahni, Supreet Khurana, Shiv Sajan Saini, Ravishankar K, Shashi Kant Dhir, Deepak Chawla, Praveen Kumar, Kiran More

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Abstract

Background: The effect of the timing of initiation of hydrocortisone in neonatal shock has not been evaluated. The objective of this systematic review was to compare the effect of earlier vs. later initiation of hydrocortisone in neonatal shock.

Methods: Medline, Embase, and CENTRAL were searched from inception until 15 May 2024. Randomized controlled trials (RCTs) and non-RCTs were eligible for inclusion. A random effects meta-analysis was used to synthesize the data. The evidence certainty was evaluated according to Grading of Recommendations Assessment, Development, and Evaluation (GRADE). A clinical practice guideline was formulated as recommended by the GRADE group.

Results: Of the 3,757 titles and abstracts screened, 20 studies were included: 7 RCTs and 13 non-RCTs. While clinical benefit or harm could not be ruled out for the outcome of mortality from the meta-analysis of the RCTs [early initiation risk ratio (RR): 0.46, 95% confidence interval (CI): 0.03-7.92; late initiation RR: 0.43, 95% CI: 0.12-1.47], the non-RCTs included in the narrative review suggested that late hydrocortisone initiation might be associated with increased risk of mortality. The meta-analysis indicated that early and late hydrocortisone administration may be associated with an increased response to treatment therapy (early initiation RR: 1.85, 95% CI: 1.26-2.71; late initiation RR: 2.50, 95% CI: 1.16-5.39). Late hydrocortisone initiation may increase the risk of necrotizing enterocolitis (NEC) ≥ stage 2 (RR: 2.46, 95% CI: 1.19-5.08). The evidence certainty was very low for most of the outcomes evaluated.

Conclusion: The early use of hydrocortisone in neonates with shock requiring vasopressors is associated with better outcomes and no major adverse effects. Later institution of hydrocortisone therapy in neonatal shock may improve the response to therapy but may be associated with adverse outcomes including mortality and NEC. The results are to be interpreted with caution as the evidence certainty was predominantly very low.

Systematic review registration: https://www.crd.york.ac.uk/PROSPERO/view/CRD42023432169, identifier: CRD42023432169.

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新生儿休克时氢化可的松治疗的时机：系统回顾、荟萃分析和临床实践指南。

背景：氢化可的松起始时间对新生儿休克的影响尚未得到评估。本系统综述的目的是比较较早和较晚使用氢化可的松治疗新生儿休克的效果。方法：检索Medline、Embase和CENTRAL数据库，检索时间为建站至2024年5月15日。随机对照试验（rct）和非rct均符合纳入条件。随机效应荟萃分析用于综合数据。根据推荐评估、发展和评价分级（GRADE）对证据确定性进行评估。根据GRADE组的建议制定了临床实践指南。结果：在筛选的3757篇标题和摘要中，纳入了20项研究：7项随机对照试验和13项非随机对照试验。然而，从rct的荟萃分析中，不能排除临床益处或危害对死亡率结果的影响[早期起始风险比（RR）： 0.46, 95%置信区间（CI）： 0.03-7.92；较晚的起始RR: 0.43, 95% CI: 0.12-1.47]，叙述性综述中纳入的非rct提示，较晚的氢化可的松起始可能与死亡风险增加有关。荟萃分析表明，早期和晚期氢化可的松给药可能与治疗反应的增加有关(早期起始RR: 1.85, 95% CI: 1.26-2.71；发病晚期RR: 2.50, 95% CI: 1.16-5.39)。延迟使用氢化可的松可能增加坏死性小肠结肠炎(NEC)≥2期的风险（RR: 2.46, 95% CI: 1.19-5.08）。大多数评估结果的证据确定性非常低。结论：早期应用氢化可的松治疗需要血管加压药物的休克新生儿可获得较好的预后，且无重大不良反应。后来在新生儿休克中采用氢化可的松治疗可以改善对治疗的反应，但可能与包括死亡率和NEC在内的不良后果相关。结果应谨慎解释，因为证据确定性非常低。系统综述注册：https://www.crd.york.ac.uk/PROSPERO/view/CRD42023432169，标识符：CRD42023432169。

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来源期刊

Frontiers in Pediatrics Medicine-Pediatrics, Perinatology and Child Health

CiteScore

3.60

自引率

7.70%

发文量

2132

审稿时长

14 weeks

期刊介绍： Frontiers in Pediatrics (Impact Factor 2.33) publishes rigorously peer-reviewed research broadly across the field, from basic to clinical research that meets ongoing challenges in pediatric patient care and child health. Field Chief Editors Arjan Te Pas at Leiden University and Michael L. Moritz at the Children''s Hospital of Pittsburgh are supported by an outstanding Editorial Board of international experts. This multidisciplinary open-access journal is at the forefront of disseminating and communicating scientific knowledge and impactful discoveries to researchers, academics, clinicians and the public worldwide. Frontiers in Pediatrics also features Research Topics, Frontiers special theme-focused issues managed by Guest Associate Editors, addressing important areas in pediatrics. In this fashion, Frontiers serves as an outlet to publish the broadest aspects of pediatrics in both basic and clinical research, including high-quality reviews, case reports, editorials and commentaries related to all aspects of pediatrics.