Steroid Treatment - How many times is too many?

[ali 28]

Hi 99ers,

May I plant a hypothetical scenario to prompt a discussion around the number of steroid courses (DART/Durand etc) to promote extubation. An ex 23 weeker, now 6 weeks old, extubated onto FDCPAP (FiO2 0.7) following second DART regime, but O2 now climbing and now consistently > 0.9 (3 days post end of previous DART). Gaining weight, Diuretics, Ureaplasma -ve,  Azithromycin trialled, compensated gases and evolving PIE. 

Would you reduce your saturation limits and tolerate the high FiO2 requirement, commence a third course of steroid prior to intubation, intubate and then start a 3rd course. Would you ever consider a fourth trial of steroids?

Thank you in advance

Alistair

[Nathan Sundgren 40]

Tough question, but something we see in various shades of similar. I would personally try the 2 rounds of steroids as in the scenario, but I would strongly hesitate for a third. I would probably tolerate a lower sat goal to keep the baby off 100% oxygen, fluid restrict more, and then wait. Grow, grow, grow. If I had to intubate (for whatever reason I "had to") I think I would focus on growth for several weeks before possibly trying the third round of steroids to extubate again. This is, of course, based on as little EBM as I can imagine, and faced with the actual circumstance I would probably actually do something completely different each time.