Perioperative use of steroids in neonatal heart surgery: Evidence based practice or tradition?

• Prophylactic glucocorticoids are widely used to modulate the inflammatory response and treat presumed relative adrenal insufficiency in children undergoing heart surgery.
• There is wide variability between centre and physician's preference in the timing, dose, route or type of steroid to be administered.
• There is an intense debate about prophylactic steroid use and their effect on the clinical outcomes.
• The weight of the current evidence for prophylactic, perioperative steroid administration suggests they do not unequivocally improve clinical endpoints.
• A large, multicentre prospective randomized controlled trial is needed to clarify the role of steroids in paediatric heart surgery.

A best evidence topic was written according to a structured protocol. The question addressed was: Is the use of prophylactic, perioperative steroids associated with better clinical outcomes following heart surgery in neonates? Altogether, 194 papers were found using the reported search, of which 8 represented the best evidence to answer the clinical question. One study found improved hospital survival in the group without steroids. Steroids increased infection in one large retrospective study. Incidence of hyperglycaemia was increased in the steroid group in 2 out of 5 studies. Use of steroids was associated with a shorter duration of ventilation and better oxygenation in one study. Postoperative steroid infusion was associated with reduced low cardiac output syndrome, inotrope requirement and less fluid retention in two controlled trials in which all patients received preoperative steroid. High dose steroid was associated with renal dysfunction in one study, comparing single versus double dose steroid prophylaxis. Steroid non-recipients had a shorter intensive care length of stay in 2 out of 7 studies. We conclude that use of steroids perioperatively does not unequivocally improve clinical outcome in neonatal heart surgery. A large, multicentre prospective randomized controlled trial is needed to clarify the role of steroids in paediatric heart surgery.