Sketchy Benefits With Corticosteroids Persist in Children’s Heart Surgery

For children undergoing cardiac surgery with cardiopulmonary bypass (CPB), perioperative corticosteroids have not reduced mortality and, at best, may shorten hospital stays, according to the bulk of the randomized data.

A meta-analysis found that rates of all-cause mortality tended to favor those who received methylprednisolone or dexamethasone, but with a difference that fell short of reaching statistical significance, reported Daliu Chen, MD, of Chunzhou County Hospital, and Yongchun Du, MD, of Huai’an Maternal and Child Health Care Hospital, both in Huai’an, China.

The evidence was more persuasive for perioperative corticosteroids reducing duration of hospitalization, the authors suggested in Clinical Cardiology.

Chen and Du noted that corticosteroids have been used prophylactically in pediatric heart surgery for decades but are controversial in practice.

Methylprednisolone or dexamethasone are thought to reduce the inflammatory response that occurs during CPB due to exposure to the artificial interface of CPB circuits — important especially during childhood.

“Children were thought to be more at risk for this kind of SIRS [systemic inflammatory response syndrome] because they experience more severe hemodilution, have a reduced circulation volume, and experience more challenging surgical procedures than adults,” Chen and Du wrote.

Corticosteroids are also believed to offer perioperative supplementation for anticipated relative adrenal insufficiency, and neuroprotection during hypothermia, they noted.

Yet all these benefits have failed to translate into consistently improved clinical outcomes in the limited literature. What’s more, documented side effects from corticosteroid use include infection and hyperglycemia requiring insulin treatment.

Last year, the STRESS group reported that perioperative methylprednisolone did not help outcomes after elective cardiac surgery for congenital heart disease in a relatively large trial of 1,200 infants randomized to the steroid or placebo.

The secondary analyses were more hopeful as there were borderline-positive results on clinical analysis lacking full adjustment and a Bayesian win ratio analysis. Subgroups with greater potential for benefit were identified as babies undergoing less complex heart procedures, those with a longer duration of CPB, and those who were born premature.

Glucose levels in the methylprednisolone group did rise to the 200-300 mg/dL range in the STRESS study. To reduce the likelihood of hyperglycemia, the lead author had suggested lower-dose steroids instead of the 30 mg/kg methylprednisolone dose used in the trial.

For now, the guidelines still do not provide firm recommendations for or against perioperative corticosteroids in pediatric heart surgery.

Chen and Du conducted a meta-analysis of STRESS and other randomized trials comparing perioperative corticosteroids with other therapeutic therapies, placebo, or no treatment. Children pooled from 10 trials (n=7,798) who were undergoing surgery to correct congenital heart problems were included.

In these studies, methylprednisolone or dexamethasone were administered beginning 4 hours before the start of CPB and continuing for days after surgery. There was a wide range of corticosteroid doses and administration frequencies across the studies, according to the authors.

They also cautioned that they were unable to separate the physiological differences between neonates and older children, so “the findings cannot be applied to the population as a whole.”