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American College of Critical Care Medicine Clinical Practice Parameters for Hemodynamic Support of Pediatric and Neonatal Septic Shock. Crit Care Med 2017; 45:1061-1093. [PMID: 28509730 DOI: 10.1097/ccm.0000000000002425] [Citation(s) in RCA: 381] [Impact Index Per Article: 54.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES The American College of Critical Care Medicine provided 2002 and 2007 guidelines for hemodynamic support of newborn and pediatric septic shock. Provide the 2014 update of the 2007 American College of Critical Care Medicine "Clinical Guidelines for Hemodynamic Support of Neonates and Children with Septic Shock." DESIGN Society of Critical Care Medicine members were identified from general solicitation at Society of Critical Care Medicine Educational and Scientific Symposia (2006-2014). The PubMed/Medline/Embase literature (2006-14) was searched by the Society of Critical Care Medicine librarian using the keywords: sepsis, septicemia, septic shock, endotoxemia, persistent pulmonary hypertension, nitric oxide, extracorporeal membrane oxygenation, and American College of Critical Care Medicine guidelines in the newborn and pediatric age groups. MEASUREMENTS AND MAIN RESULTS The 2002 and 2007 guidelines were widely disseminated, translated into Spanish and Portuguese, and incorporated into Society of Critical Care Medicine and American Heart Association/Pediatric Advanced Life Support sanctioned recommendations. The review of new literature highlights two tertiary pediatric centers that implemented quality improvement initiatives to improve early septic shock recognition and first-hour compliance to these guidelines. Improved compliance reduced hospital mortality from 4% to 2%. Analysis of Global Sepsis Initiative data in resource rich developed and developing nations further showed improved hospital mortality with compliance to first-hour and stabilization guideline recommendations. CONCLUSIONS The major new recommendation in the 2014 update is consideration of institution-specific use of 1) a "recognition bundle" containing a trigger tool for rapid identification of patients with septic shock, 2) a "resuscitation and stabilization bundle" to help adherence to best practice principles, and 3) a "performance bundle" to identify and overcome perceived barriers to the pursuit of best practice principles.
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Abstract
Failure of the normal circulatory adaptation to extrauterine life results in persistent pulmonary hypertension of the newborn (PPHN). Although this condition is most often secondary to parenchymal lung disease or lung hypoplasia, it may also be idiopathic. PPHN is characterized by elevated pulmonary vascular resistance with resultant right-to-left shunting of blood and hypoxemia. Although the preliminary diagnosis of PPHN is often based on differential cyanosis and labile hypoxemia, the diagnosis is confirmed by echocardiography. Management strategies include optimal lung recruitment and use of surfactant in patients with parenchymal lung disease, maintaining optimal oxygenation and stable blood pressures, avoidance of respiratory and metabolic acidosis and alkalosis, and pulmonary vasodilator therapy. Extracorporeal membrane oxygenation is considered when medical management fails. Although mortality associated with PPHN has decreased significantly with improvements in medical care, there remains the potential risk for neurodevelopmental disability which warrants close follow-up of affected infants after discharge.
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Affiliation(s)
- Mamta Fuloria
- Department of Pediatrics, Albert Einstein College of Medicine and the Children's Hospital at Montefiore, Bronx, NY, USA
| | - Judy L Aschner
- Departments of Pediatrics and Obstetrics, Gynecology and Women's Health, Albert Einstein College of Medicine and the Children's Hospital at Montefiore, Bronx, NY, USA.
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Abstract
Hypotension is a common problem in neonates with complex underlying pathophysiology. Although treatment of low blood pressure is common, clinicians must use all available information to target neonates with compromised perfusion. Pharmacotherapy should be tailored to the specific physiologic perturbations of the individual neonate. Dopamine is the most commonly utilized agent and may be the most appropriate agent for septic shock with low diastolic blood pressure. However, alternative therapies should be considered for other etiologies of hypotension, including milrinone and vasopressin for persistent pulmonary hypertension of the newborn and dobutamine for patent ductus arteriosus. Additional studies are required to refine the approach to neonatal hypotension and document the long-term outcomes of treated neonates.
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Giaccone A, Zuppa AF, Sood B, Cohen MS, O’Byrne ML, Moorthy G, Mathur A, Kirpalani H. Milrinone Pharmacokinetics and Pharmacodynamics in Neonates with Persistent Pulmonary Hypertension of the Newborn. Am J Perinatol 2017; 34:749-758. [PMID: 28099979 PMCID: PMC6342009 DOI: 10.1055/s-0036-1597996] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Objective To describe the pharmacokinetics and pharmacodynamics of milrinone in infants with persistent pulmonary hypertension of the newborn (PPHN) and to explore the impact of age on milrinone disposition. Design Randomized, open label pilot study. Setting Multicenter; level 3 and level 4 neonatal intensive care units. Patients Six infants ≥34 weeks' gestational age and <10 days of life with persistent hypoxemia receiving inhaled nitric oxide. Intervention Intravenous milrinone lactate in one of two dosing regimens: (1) low dose, 20 mcg/kg bolus followed by 0.2 mcg/kg/minute, and (2) standard dose, 50 mcg/kg bolus followed by 0.5 mcg/kg/minute. Measurements and Main Results The final structural model was a two-compartment disposition model with interindividual variability estimated on clearance (CL). The estimated value of CL is 7.65 mL/minute/3.4 kg (3.05 mL/minute/kg). The addition of age improved the precision of the CL estimate, and CL increased with chronological age in days. The oxygenation index was highly variable within each participant and improved with time. There were no observed safety concerns in either dosing group. Conclusion The CL of milrinone in newborns with PPHN is reduced and increases with age. In this pilot study, we did not see significant pharmacodynamic or safety effects associated with drug exposure.
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Affiliation(s)
- Annie Giaccone
- Department of Pediatrics, The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania,Section of Neonatology, Reading Hospital, West Reading, Pennsylvania
| | - Athena F. Zuppa
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Beena Sood
- Department of Pediatrics, Children’s Hospital of Michigan and Wayne State University School of Medicine, Detroit, Michigan
| | - Meryl S. Cohen
- Department of Pediatrics, The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael L. O’Byrne
- Department of Pediatrics, The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania,Department of Pediatrics, Children’s National Health System and George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Ganesh Moorthy
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amit Mathur
- Department of Pediatrics, St. Louis Children’s Hospital and Washington University School of Medicine, St. Louis, Missouri
| | - Haresh Kirpalani
- Department of Pediatrics, The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Luecke C, McPherson C. Treatment of Persistent Pulmonary Hypertension of the Newborn: Use of Pulmonary Vasodilators in Term Neonates. Neonatal Netw 2017; 36:160-168. [PMID: 28494828 DOI: 10.1891/0730-0832.36.3.160] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Persistent pulmonary hypertension of the newborn (PPHN) represents a challenging condition associated with significant morbidity. A successful transition from intrauterine to extrauterine life is contingent on adequate pulmonary vasodilation. Several pathophysiologies contribute to the failure of this cascade and may result in life-threatening hypoxia and acidosis in the newborn. Management includes optimal respiratory support, adequate sedation and analgesia, and support of vascular tone and cardiac function. Pulmonary vasodilation has the potential to overcome the cycle of hypoxia and acidosis, improving outcome in these infants. Oxygen and inhaled nitric oxide represent the foundation of therapy. Tertiary pulmonary vasodilators represent a greater challenge, selecting between therapies that include prostanoids, sildenafil, and milrinone. Variable levels of evidence exist for each agent. Thorough review of available data informing efficacy and adverse effects contributes to the development of an informed approach to neonates with refractory PPHN.
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Abstract
Congenital Diaphragmatic hernia (CDH) is a condition characterized by a defect in the diaphragm leading to protrusion of abdominal contents into the thoracic cavity interfering with normal development of the lungs. The defect may range from a small aperture in the posterior muscle rim to complete absence of diaphragm. The pathophysiology of CDH is a combination of lung hypoplasia and immaturity associated with persistent pulmonary hypertension of newborn (PPHN) and cardiac dysfunction. Prenatal assessment of lung to head ratio (LHR) and position of the liver by ultrasound are used to diagnose and predict outcomes. Delivery of infants with CDH is recommended close to term gestation. Immediate management at birth includes bowel decompression, avoidance of mask ventilation and endotracheal tube placement if required. The main focus of management includes gentle ventilation, hemodynamic monitoring and treatment of pulmonary hypertension followed by surgery. Although inhaled nitric oxide is not approved by FDA for the treatment of PPHN induced by CDH, it is commonly used. Extracorporeal membrane oxygenation (ECMO) is typically considered after failure of conventional medical management for infants ≥ 34 weeks’ gestation or with weight >2 kg with CDH and no associated major lethal anomalies. Multiple factors such as prematurity, associated abnormalities, severity of PPHN, type of repair and need for ECMO can affect the survival of an infant with CDH. With advances in the management of CDH, the overall survival has improved and has been reported to be 70-90% in non-ECMO infants and up to 50% in infants who undergo ECMO.
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Considerations in the management of hypoxemic respiratory failure and persistent pulmonary hypertension in term and late preterm neonates. J Perinatol 2016; 36 Suppl 2:S12-9. [PMID: 27225960 DOI: 10.1038/jp.2016.44] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Revised: 02/10/2016] [Accepted: 02/16/2016] [Indexed: 01/12/2023]
Abstract
Recent advances in our understanding of neonatal pulmonary circulation and the underlying pathophysiology of hypoxemic respiratory failure (HRF)/persistent pulmonary hypertension of the newborn (PPHN) have resulted in more effective management strategies. Results from animal studies demonstrate that low alveolar oxygen tension (PAO2) causes hypoxic pulmonary vasoconstriction, whereas an increase in oxygen tension to normoxic levels (preductal arterial partial pressure of oxygen (PaO2) between 60 and 80 mm Hg and/or preductal peripheral capillary oxygen saturation between 90% and 97%) results in effective pulmonary vasodilation. Hyperoxia (preductal PaO2 >80 mm Hg) does not cause further pulmonary vasodilation, and oxygen toxicity may occur when high concentrations of inspired oxygen are used. It is therefore important to avoid both hypoxemia and hyperoxemia in the management of PPHN. In addition to oxygen supplementation, therapeutic strategies used to manage HRF/PPHN in term and late preterm neonates may include lung recruitment with optimal mean airway pressure and surfactant, inhaled and intravenous vasodilators and 'inodilators'. Clinical evidence suggests that administration of surfactant or inhaled nitric oxide (iNO) therapy at a lower acuity of illness can decrease the risk of extracorporeal membrane oxygenation/death, progression of HRF and duration of hospital stay. Milrinone may be beneficial as an inodilator and may have specific benefits following prolonged exposure to iNO plus oxygen owing to inhibition of phosphodiesterase (PDE)-3A. Additionally, sildenafil, and, in selected cases, hydrocortisone may be appropriate options after hyperoxia and oxidative stress owing to their effects on PDE-5 activity and expression. Continued investigation into these and other interventions is needed to optimize treatment and improve outcomes.
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Abstract
Inhaled nitric oxide (iNO) is approved for use in persistent pulmonary hypertension of the newborn (PPHN) but does not lead to sustained improvement in oxygenation in one-third of patients with PPHN. Inhaled NO is less effective in the management of PPHN secondary to congenital diaphragmatic hernia (CDH), extreme prematurity, and bronchopulmonary dysplasia (BPD). Intravenous pulmonary vasodilators such as prostacyclin, alprostadil, sildenafil, and milrinone have been successfully used in PPHN resistant to iNO. Oral pulmonary vasodilators such as endothelin receptor antagonist bosentan and phosphodiesterase-5 inhibitors such as sildenafil and tadalafil are used both during acute and chronic phases of PPHN. In the absence of infection, glucocorticoids may also be effective in PPHN. Many of these pharmacologic agents are not approved for use in PPHN and our knowledge is based on case reports and small trials. Large multicenter randomized controlled trials with long-term follow-up are required to evaluate alternate pharmacologic strategies in PPHN.
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Affiliation(s)
| | - Bobby Mathew
- Department of Pediatrics, University at Buffalo, Buffalo, NY
| | - Corinne L Leach
- Department of Pediatrics, University at Buffalo, Buffalo, NY
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Abstract
Pulmonary hypertension in the perinatal period can present acutely (persistent pulmonary hypertension of the newborn) or chronically. Clinical and echocardiographic diagnosis of acute pulmonary hypertension is well accepted but there are no broadly validated criteria for echocardiographic diagnosis of pulmonary hypertension later in the clinical course, although there are significant populations of infants with lung disease at risk for this diagnosis. Contributing cardiovascular comorbidities are common in infants with pulmonary hypertension and lung disease. It is not clear who should be treated without confirmation of pulmonary vascular disease by cardiac catheterization, with concurrent evaluation of any contributing cardiovascular comorbidities.
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Affiliation(s)
- Roberta L Keller
- Neonatology, Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, Box 0734, 550 16th Street, 5th Floor, San Francisco, CA 94143, USA.
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The effect of milrinone on right and left ventricular function when used as a rescue therapy for term infants with pulmonary hypertension. Cardiol Young 2016; 26:90-9. [PMID: 25599873 DOI: 10.1017/s1047951114002698] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Milrinone may be an appropriate adjuvant therapy for infants with persistent pulmonary hypertension of the newborn. We aimed to describe the effect of milrinone administration on right and left ventricular function in infants with persistent pulmonary hypertension not responding to inhaled nitric oxide after 4 hours of administration. MATERIALS AND METHODS This is a retrospective review of infants born after or at 34 weeks of gestation with persistent pulmonary hypertension who received milrinone treatment. The primary endpoint was the effect of milrinone on myocardial performance and haemodynamics, including right and left ventricular outputs, tissue Doppler velocities, right ventricle and septal strain, and strain rate. Secondary endpoints examined included duration of inhaled nitric oxide and oxygen support. RESULTS A total of 17 infants with a mean (standard deviation) gestation and birth weight of 39.8 (2.0) weeks and 3.45 (0.39) kilograms, respectively, were included in the study. The first echocardiogram was performed 15 hours after the commencement of nitric oxide inhalation. Milrinone treatment was started at a median time of 1 hour after the echocardiogram and was associated with an increase in left ventricular output (p=0.04), right ventricular output (p=0.004), right ventricle strain (p=0.01) and strain rate (p=0.002), and left ventricle s` (p<0.001) and a` (p=0.02) waves. There was a reduction in nitric oxide dose and oxygen requirement over the subsequent 72 hours (all p<0.05). CONCLUSION The use of milrinone as an adjunct to nitric oxide is worth further exploration, with preliminary evidence suggesting an improvement in both oxygenation and myocardial performance in this group of infants.
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Kraemer U, Cochius-den Otter S, Snoek KG, Tibboel D. Pharmacodynamic considerations in the treatment of pulmonary hypertension in infants: challenges and future perspectives. Expert Opin Drug Metab Toxicol 2015; 12:1-19. [DOI: 10.1517/17425255.2016.1116520] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Puligandla PS, Grabowski J, Austin M, Hedrick H, Renaud E, Arnold M, Williams RF, Graziano K, Dasgupta R, McKee M, Lopez ME, Jancelewicz T, Goldin A, Downard CD, Islam S. Management of congenital diaphragmatic hernia: A systematic review from the APSA outcomes and evidence based practice committee. J Pediatr Surg 2015; 50:1958-70. [PMID: 26463502 DOI: 10.1016/j.jpedsurg.2015.09.010] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 09/06/2015] [Accepted: 09/09/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Variable management practices complicate the identification of optimal strategies for infants with congenital diaphragmatic hernia (CDH). This review critically appraises the available evidence to provide recommendations. METHODS Six questions regarding CDH management were generated. English language articles published between 1980 and 2014 were compiled after searching Medline, Cochrane, Embase and Web of Science. Given the paucity of literature on the subject, all studies irrespective of their rank in the levels of evidence hierarchy were included. RESULTS Gentle ventilation with permissive hypercapnia provides the best outcomes. Initial high frequency ventilation may be considered but its overall efficacy is unproven. Routine inhaled nitric oxide (iNO) or other medical adjuncts for acute, severe pulmonary hypertension demonstrate no benefit. Evidence does not support routine administration of pre- or postnatal glucocorticoids. Mode of extracorporeal membrane oxygenation (ECMO) has little bearing on outcomes. While the overall timing of repair does not impact outcomes, early repair on ECMO has benefits. Open repair leads to significantly fewer recurrences. Polytetrafluoroethylene (PTFE) is the most durable patch repair material. CONCLUSIONS Limited high-level evidence prevents the development of robust management guidelines for CDH. Prospective, multi-institutional studies are needed to identify best practices and optimize outcomes.
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Affiliation(s)
| | | | - Mary Austin
- The University of Texas Medical School at Houston
| | | | | | | | - Regan F Williams
- University of Tennessee Health Science Center, Le Bonheur Children's Hospital
| | | | | | | | | | - Tim Jancelewicz
- University of Tennessee Health Science Center, Le Bonheur Children's Hospital
| | - Adam Goldin
- Seattle Children's Hospital, University of Washington
| | - Cynthia D Downard
- Kosair Children's Hospital, University of Louisville, Louisville, KY
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63
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Abstract
Congenital diaphragmatic hernia (CDH) in the newborn poses challenges to the multi-disciplinary teams involved in its management. Mortality remains significantly high, despite growing understanding and treatment options. Early intubation of antenatally diagnosed cases is crucial in preventing deterioration and persistent pulmonary hypertension. Early recognition of cases not diagnosed on antenatal scan, with appreciation of differential diagnosis, requires an index of suspicion and imaging. Increasing options and modalities are available, with only modest, if any, survival advantage. Permissive hypercapnea and minimal ventilation have made the most significant impact on survival in modern era. High-frequency oscillatory ventilation (HFOV), inhaled nitric oxide (iNO), treatment of pulmonary hypertension, and ECMO are used in a somewhat stepwise manner for stabilisation. Delayed surgery has become established later in management plan. The impact of individual therapies (e.g. HFOV, iNO, ECMO) on outcome is difficult to ascertain. Little level 1 or 2 evidence exists. Randomised studies and reviews on the role of ECMO have not yet proven any long-term survival benefit. One pilot randomised study of thoracoscopic repair suggests increased acidosis; intraoperative blood gases and CO2 levels should be closely monitored. Monitoring tissue oxygenation should be considered. There is no evidence to suggest the best patch material.
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Affiliation(s)
- Merrill McHoney
- Royal Hospital for Sick Children Edinburgh, Sciennes Road, Edinburgh, EH9 1LF, UK.
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64
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Jain A, McNamara PJ. Persistent pulmonary hypertension of the newborn: Advances in diagnosis and treatment. Semin Fetal Neonatal Med 2015; 20:262-71. [PMID: 25843770 DOI: 10.1016/j.siny.2015.03.001] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Persistent pulmonary hypertension of the newborn (PPHN) is a frequent cause for admission to the neonatal intensive care unit and is associated with mortality and variable morbidities. It is primarily a state of oxygenation failure representing a failure of the normal postnatal decline in pulmonary vascular resistance that may be associated with right ventricular dysfunction. Enhanced knowledge of the pathophysiologic contributors to this syndrome helps clinicians understand its phenotypic expression and facilitates more focused intensive care decision-making. The approach to treatment should be based on alleviation of the elevation in pulmonary vascular resistance and should include optimization of lung recruitment and judicious use of pulmonary vasodilators. When response to inhaled nitric oxide is suboptimal, the physiologic contributors to impaired oxygenation need further investigation. Targeted neonatal echocardiography provides novel physiologic insights; in particular, it may help assess the adequacy of right ventricular performance, the relative contribution of the fetal shunts and the magnitude of the overall impairment to cardiac output. This information may facilitate therapeutic next steps and whether adjunctive vasodilators or drugs to augment ventricular function are preferable. This article provides a comprehensive overview of the pathological contributors to PPHN, the physiologic constituents of its phenotypic expression, standard approach to therapeutic intervention, and the role of bedside echocardiography in enhancing the decision-making process.
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Affiliation(s)
- Amish Jain
- Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Patrick J McNamara
- Division of Neonatology, Hospital for Sick Children, Toronto, Ontario, Canada; Departments of Pediatrics and Physiology, University of Toronto, Toronto, Canada.
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Dempsey EM. Challenges in Treating Low Blood Pressure in Preterm Infants. CHILDREN-BASEL 2015; 2:272-88. [PMID: 27417363 PMCID: PMC4928758 DOI: 10.3390/children2020272] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 06/05/2015] [Indexed: 01/02/2023]
Abstract
Whilst the prevalence of low blood pressure in preterm infants seems to have fallen over the last number of years, the problem is still frequently encountered in the neonatal intensive care unit and many babies continue to receive intervention. Great variability in practice persists, with a significant number of extremely low gestational age newborns in some institutions receiving some form of intervention, and in other units substantially less. A great degree of this variability relates to the actual criteria used to define hypotension, with some using blood pressure values alone to direct therapy and others using a combination of clinical, biochemical and echocardiography findings. The choice of intervention remains unresolved with the majority of centres continuing to administer volume followed by dopamine as a first line inotrope/vasopressor agent. Despite over 40 years of use there is little evidence that dopamine is of benefit both in the short term and long-term. Long-term follow up is available in only two randomised trials, which included a total of 99 babies. An under recognized problem relates to the administration of inotrope infusions in very preterm infants. There are no pediatric specific inotrope formulations available and so risks of errors in preparation and administration remain. This manuscript outlines these challenges and proposes some potential solutions.
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Affiliation(s)
- Eugene M Dempsey
- Department of Paediatrics and Child Health, University College Cork, Cork City post code, Ireland.
- Irish Centre for Fetal and Neonatal Translational Research (INFANT), Cork, Ireland.
- Department of Paediatrics and Child Health, Cork University Maternity Hospital, Wilton Cork, Ireland.
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Sharma V, Berkelhamer S, Lakshminrusimha S. Persistent pulmonary hypertension of the newborn. Matern Health Neonatol Perinatol 2015; 1:14. [PMID: 27057331 PMCID: PMC4823682 DOI: 10.1186/s40748-015-0015-4] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 04/27/2015] [Indexed: 01/18/2023] Open
Abstract
Persistent pulmonary hypertension of the newborn (PPHN) is characterized by elevated pulmonary vascular resistance resulting in right-to-left shunting of blood and hypoxemia. PPHN is often secondary to parenchymal lung disease (such as meconium aspiration syndrome, pneumonia or respiratory distress syndrome) or lung hypoplasia (with congenital diaphragmatic hernia or oligohydramnios) but can also be idiopathic. The diagnosis of PPHN is based on clinical evidence of labile hypoxemia often associated with differential cyanosis. The diagnosis is confirmed by the echocardiographic demonstration of - (a) right-to-left or bidirectional shunt at the ductus or foramen ovale and/or, (b) flattening or leftward deviation of the interventricular septum and/or, (c) tricuspid regurgitation, and finally (d) absence of structural heart disease. Management strategies include optimal oxygenation, avoiding respiratory and metabolic acidosis, blood pressure stabilization, sedation and pulmonary vasodilator therapy. Failure of these measures would lead to consideration of extracorporeal membrane oxygenation (ECMO); however decreased need for this rescue therapy has been documented with advances in medical management. While trends also note improved survival, long-term neurodevelopmental disabilities such as deafness and learning disabilities remain a concern in many infants with severe PPHN. Funded by: 1R01HD072929-0 (SL).
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Affiliation(s)
- Vinay Sharma
- Department of Pediatrics (Neonatology), Hennepin County Medical Center, 701 Park Avenue, Shapiro Building, Minneapolis, MN 55415 USA
| | - Sara Berkelhamer
- Department of Pediatrics, Women and Children's Hospital of Buffalo, 219 Bryant St, Buffalo, New York 14222 USA
| | - Satyan Lakshminrusimha
- Department of Pediatrics, Women and Children's Hospital of Buffalo, 219 Bryant St, Buffalo, New York 14222 USA
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Bendapudi P, Rao GG, Greenough A. Diagnosis and management of persistent pulmonary hypertension of the newborn. Paediatr Respir Rev 2015; 16:157-61. [PMID: 25765845 DOI: 10.1016/j.prrv.2015.02.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 02/04/2015] [Indexed: 10/24/2022]
Abstract
Persistent pulmonary hypertension of new born (PPHN) is associated with mortality and morbidity; it may be idiopathic or secondary to a number of conditions. The mainstay of diagnosis and to exclude structural abnormalities is echocardiography. Brain type natriuretic peptide (BNP) levels are elevated in PPHN, but are insufficiently sensitive to contribute to routine diagnosis. Management includes improving oxygenation by optimising lung volume by ventilatory techniques and/or surfactant and administering pulmonary vasodilator agents. Inhaled nitric oxide (iNO), a selective pulmonary vasodilator, reduces the need for extracorporeal membrane oxygenation in term infants; it does not, however, improve mortality or have any long term positive effects in prematurely born infants or infants with congenital diaphragmatic hernia. Other pulmonary vasodilators have been reported in case series to be efficacious alone or in combination with iNO. Randomised trials with long term follow up are required to identify the optimum therapeutic strategies in PPHN.
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Affiliation(s)
- Perraju Bendapudi
- Division of Asthma, Allergy and Lung Biology, MRC Centre for Allergic Mechanisms in Asthma, King's College London
| | - Gopinath Gangadhara Rao
- Division of Asthma, Allergy and Lung Biology, MRC Centre for Allergic Mechanisms in Asthma, King's College London
| | - Anne Greenough
- Division of Asthma, Allergy and Lung Biology, MRC Centre for Allergic Mechanisms in Asthma, King's College London.
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de Waal K, Kluckow M. Prolonged rupture of membranes and pulmonary hypoplasia in very preterm infants: pathophysiology and guided treatment. J Pediatr 2015; 166:1113-20. [PMID: 25681201 DOI: 10.1016/j.jpeds.2015.01.015] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Revised: 11/19/2014] [Accepted: 01/06/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Koert de Waal
- Department of Newborn Care, John Hunter Children's Hospital & University of Newcastle, NSW, Australia.
| | - Martin Kluckow
- Department of Neonatology, Royal North Shore Hospital & University of Sydney, NSW, Australia
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James AT, Bee C, Corcoran JD, McNamara PJ, Franklin O, El-Khuffash AF. Treatment of premature infants with pulmonary hypertension and right ventricular dysfunction with milrinone: a case series. J Perinatol 2015; 35:268-73. [PMID: 25429380 DOI: 10.1038/jp.2014.208] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Revised: 09/22/2014] [Accepted: 10/14/2014] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Milrinone has been proposed as an effective treatment for pulmonary hypertension (PH) and right ventricular (RV) dysfunction. We aimed to determine the effect of milrinone therapy on clinical and echocardiography parameters of PH in preterm infants with elevated pulmonary pressures. STUDY DESIGN A retrospective case review was conducted on infants <32 weeks gestation who received milrinone for the treatment of PH and reduced RV function. Echocardiographic data were collected before and after treatment with milrinone, and serial clinical parameters were recorded over a 72h period. RESULT Seven infants met the inclusion criteria with a median gestation and birth weight of 27.3 weeks and 1140 g, respectively. Four infants had a diagnosis of pulmonary hypoplasia with PH, and three infants were recipients in twin-to-twin transfusion syndrome who also developed PH. Nitric oxide was used in six infants before commencement of milrinone. Milrinone was commenced at a dose of 0.33 μg kg(-1) min(-1) to 0.5 μg kg(-1) min(-1) and continued for a median duration of 70 h. Use of milrinone was associated with a fall in oxygenation index and inhaled nitric oxide dose. Following an initial fall in blood pressure over the first 6 h, there was an increase in blood pressure over the subsequent 72 h. Echocardiographic data demonstrated an increase in indicators of myocardial performance and PH. One infant died before discharge. CONCLUSION This case series suggests that milrinone may be a useful therapy for premature infants with echocardiography findings of PH and/or RH dysfunction. This data support the need for a randomised control trial to confirm its efficacy.
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Affiliation(s)
- A T James
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland
| | - C Bee
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland
| | - J D Corcoran
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland
| | - P J McNamara
- 1] Physiology and Experimental Medicine, Hospital for Sick Children, Toronto, Canada [2] Department of Neonatology, The Hospital for Sick Children, Toronto, Canada
| | - O Franklin
- Department of Paediatric Cardiology, Our Lady's Children's Hospital Crumlin, Dublin, Ireland
| | - A F El-Khuffash
- 1] Department of Neonatology, The Rotunda Hospital, Dublin, Ireland [2] Department of Paediatrics, Royal College of Surgeons in Ireland, Dublin, Ireland
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Choudhary M, Meena MK, Chhangani N, Sharma D, Choudhary JS, Choudhary SK. To study prevalence of persistent pulmonary hypertension in newborn with meconium aspiration syndrome in western Rajasthan, India: a prospective observational study. J Matern Fetal Neonatal Med 2015; 29:324-7. [DOI: 10.3109/14767058.2014.1000296] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Mukesh Choudhary
- Department of Medical and Paediatric Oncology, GCRI, Ahmedabad, Gujarat, India,
| | - Mahesh Kumar Meena
- Department of Pediatrics, Govt HBK District Hospital, Jaipur, Rajasthan, India,
| | - Narendra Chhangani
- Department of Paediatrics, Umaid Hospital, S.N. Medical College, Jodhpur, Rajasthan, India,
| | - Deepak Sharma
- Department of Neonatology, Fernandez hospital, Hyderabad, Telangana, India,
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Lee EH, Choi BM. Clinical Application of Inhaled Nitric Oxide Therapy in Persistent Pulmonary Hypertension of the Newborn. NEONATAL MEDICINE 2015. [DOI: 10.5385/nm.2015.22.2.61] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Eun Hee Lee
- Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
| | - Byung Min Choi
- Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
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Samiee-Zafarghandy S, Raman SR, van den Anker JN, McHutchison K, Hornik CP, Clark RH, Smith PB. Safety of milrinone use in neonatal intensive care units. Early Hum Dev 2015; 91:31-5. [PMID: 25460254 PMCID: PMC4302030 DOI: 10.1016/j.earlhumdev.2014.10.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Revised: 10/21/2014] [Accepted: 10/27/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Milrinone use in the neonatal intensive care unit has increased over the last 10 years despite a paucity of published safety data in infants. We sought to determine the safety of milrinone therapy among infants in the neonatal intensive care unit. METHODS We conducted a retrospective data analysis, identifying all infants who were exposed to milrinone and discharged from 322 neonatal intensive care units managed by the Pediatrix Medical Group from 1997-2010. We identified adverse events (AEs) during milrinone exposure. The unit of observation for clinical AEs was the first course of milrinone and for laboratory AEs it was an infant-day of exposure to milrinone. RESULTS Overall, 1446 of 716,821 (0.2%) infants received milrinone for a total of 6894 infant-days. The proportion of infants exposed to milrinone increased from 0 in 1997 to 4/1000 infant cases in 2010. Persistent pulmonary hypertension (40%) was the most commonly reported diagnosis at the start of milrinone administration. Overall, 606/1446 (42%) of infants had at least 1 clinical AE recorded during milrinone therapy. Hypotension requiring pressors and thrombocytopenia (<100,000/mm(3)) were the most commonly reported clinical and laboratory AEs, respectively. Death was reported in 8% of infants during the first course of milrinone therapy. CONCLUSION Among infants hospitalized in the neonatal intensive care unit, there was an increase in the use of milrinone over the past 13 years. The safety, dosing, and efficacy of milrinone in infants should be determined in prospective clinical trials.
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Affiliation(s)
- Samira Samiee-Zafarghandy
- Center for Translational Science, Children’s National Medical Center, Washington, DC
- Division of Clinical Pharmacology, Children’s National Medical Center, Washington, DC
- Division of Neonatology, McMaster University, Hamilton, Ontario, Canada
| | - Sudha R. Raman
- Duke Clinical Research Institute, Duke University, Durham, NC
| | - John N. van den Anker
- Center for Translational Science, Children’s National Medical Center, Washington, DC
- Division of Clinical Pharmacology, Children’s National Medical Center, Washington, DC
| | | | - Christoph P. Hornik
- Duke Clinical Research Institute, Duke University, Durham, NC
- Department of Pediatrics, Duke University, Durham, NC
| | - Reese H. Clark
- Pediatrix-Obstetrix Center for Research and Education, Sunrise, FL
| | - P. Brian Smith
- Duke Clinical Research Institute, Duke University, Durham, NC
- Department of Pediatrics, Duke University, Durham, NC
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Malikiwi A, Sasi A, Tan K, Sehgal A. Vasopressin as an adjunct therapy for pulmonary hypertension: a case report. Eur J Pediatr 2014; 173:1651-4. [PMID: 24297672 DOI: 10.1007/s00431-013-2225-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Accepted: 11/21/2013] [Indexed: 11/25/2022]
Abstract
UNLABELLED Vasopressin is emerging as a therapeutic adjunct option towards treatment of shock states in the pediatric population. Its effects on pulmonary vasculature are less well understood. This report describes a 5-month-old infant with nitric oxide-unresponsive pulmonary hypertension, oxygenation failure, and systemic hypotension. Vasopressin therapy improved oxygenation and blood pressure and biventricular function, allowing weaning of nitric oxide and inotropic support. No decrease in coronary flow was noted. CONCLUSIONS Vasopressin could be considered as an adjunct option in infants with pulmonary hypertension and systemic hypotension. Echocardiographic monitoring during treatment is recommended.
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Affiliation(s)
- Andra Malikiwi
- Monash Newborn, Monash Children's Hospital, Melbourne, Australia
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Rossor T, Greenough A. Advances in paediatric pulmonary vascular disease associated with bronchopulmonary dysplasia. Expert Rev Respir Med 2014; 9:35-43. [PMID: 25426585 DOI: 10.1586/17476348.2015.986470] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Pulmonary hypertension (PH) is a common finding in infants with bronchopulmonary dysplasia (BPD). The aim of this review is to describe recent advances in the diagnosis and treatment of PH and discuss whether they will benefit infants and children with BPD related PH. Echocardiography remains the mainstay of diagnosis but has limitations, further developments in diagnostic techniques and identification of biomarkers are required. There are many potential therapies for PH associated with BPD. Inhaled nitric oxide has been shown to improve short term outcomes only. Sidenafil in resource limited settings was shown in three randomized trials to significantly reduce mortality. The efficacy of other therapies including prostacyclin, PDE3 inhibitors and endothelin receptor blockers has only been reported in case reports or case series. Randomized controlled trials with long term follow up are required to appropriately assess the efficacy of therapies aimed at improving the outcome of children with PH.
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Affiliation(s)
- Thomas Rossor
- Division of Asthma, Allergy and Lung Biology, MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, England, UK
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A Specific and Sensitive HPLC–MS/MS Micromethod for Milrinone Plasma Levels Determination After Inhalation in Cardiac Patients. Ther Drug Monit 2014; 36:663-8. [DOI: 10.1097/ftd.0000000000000072] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Park JH, Kwon MA, Kim DH, Kim SK, Jeon DG, Song J, Ji SH, Lee GW, Kang BJ. Effectiveness of milrinone for cardiogenic shock due to massive pulmonary aspiration: a case report. Korean J Anesthesiol 2014; 66:476-80. [PMID: 25006374 PMCID: PMC4085271 DOI: 10.4097/kjae.2014.66.6.476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Revised: 05/20/2013] [Accepted: 05/22/2013] [Indexed: 11/10/2022] Open
Abstract
Pulmonary aspiration of gastric contents is one of the most frightening complications during anesthesia. Although pulmonary aspiration of gastric contents in general surgical patients is not common and resulting long-term morbidity and mortality are rare, severe hypoxemia and other sequelae of pulmonary aspiration continue to be reported. We report a case of massive aspiration of gastric contents during induction of general anesthesia, resulting in cardiac arrest due to severe pulmonary hypertension and myocardial infarction. Sustained cardiac arrest and shock that did not respond the conventional resuscitation was successfully treated using milrinone. The patient was discharged without complications in 20 days.
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Affiliation(s)
- Jeong Heon Park
- Department of Anesthesiology and Pain Medicine, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea
| | - Min A Kwon
- Department of Anesthesiology and Pain Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - Dong Hee Kim
- Department of Anesthesiology and Pain Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - Seok-Kon Kim
- Department of Anesthesiology and Pain Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - Dae Geun Jeon
- Department of Anesthesiology and Pain Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - Jaegyok Song
- Department of Anesthesiology and Pain Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - Seung Heon Ji
- Department of Anesthesiology and Pain Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - Gwan Woo Lee
- Department of Anesthesiology and Pain Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - Bong Jin Kang
- Department of Anesthesiology and Pain Medicine, Dankook University College of Medicine, Cheonan, Korea
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Azevedo MF, Faucz FR, Bimpaki E, Horvath A, Levy I, de Alexandre RB, Ahmad F, Manganiello V, Stratakis CA. Clinical and molecular genetics of the phosphodiesterases (PDEs). Endocr Rev 2014; 35:195-233. [PMID: 24311737 PMCID: PMC3963262 DOI: 10.1210/er.2013-1053] [Citation(s) in RCA: 196] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Accepted: 11/06/2013] [Indexed: 12/31/2022]
Abstract
Cyclic nucleotide phosphodiesterases (PDEs) are enzymes that have the unique function of terminating cyclic nucleotide signaling by catalyzing the hydrolysis of cAMP and GMP. They are critical regulators of the intracellular concentrations of cAMP and cGMP as well as of their signaling pathways and downstream biological effects. PDEs have been exploited pharmacologically for more than half a century, and some of the most successful drugs worldwide today affect PDE function. Recently, mutations in PDE genes have been identified as causative of certain human genetic diseases; even more recently, functional variants of PDE genes have been suggested to play a potential role in predisposition to tumors and/or cancer, especially in cAMP-sensitive tissues. Mouse models have been developed that point to wide developmental effects of PDEs from heart function to reproduction, to tumors, and beyond. This review brings together knowledge from a variety of disciplines (biochemistry and pharmacology, oncology, endocrinology, and reproductive sciences) with emphasis on recent research on PDEs, how PDEs affect cAMP and cGMP signaling in health and disease, and what pharmacological exploitations of PDEs may be useful in modulating cyclic nucleotide signaling in a way that prevents or treats certain human diseases.
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Affiliation(s)
- Monalisa F Azevedo
- Section on Endocrinology Genetics (M.F.A., F.R.F., E.B., A.H., I.L., R.B.d.A., C.A.S.), Program on Developmental Endocrinology Genetics, Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD), National Institutes of Health (NIH), Bethesda, Maryland 20892; Section of Endocrinology (M.F.A.), University Hospital of Brasilia, Faculty of Medicine, University of Brasilia, Brasilia 70840-901, Brazil; Group for Advanced Molecular Investigation (F.R.F., R.B.d.A.), Graduate Program in Health Science, Medical School, Pontificia Universidade Catolica do Paraná, Curitiba 80215-901, Brazil; Cardiovascular Pulmonary Branch (F.A., V.M.), National Heart, Lung, and Blood Institute, NIH, Bethesda, Maryland 20892; and Pediatric Endocrinology Inter-Institute Training Program (C.A.S.), NICHD, NIH, Bethesda, Maryland 20892
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Abstract
Persistent pulmonary hypertension of the newborn (PPHN) is a syndrome of failed circulatory adaptation at birth, seen in about 2/1000 live born infants. While it is mostly seen in term and near-term infants, it can be recognized in some premature infants with respiratory distress or bronchopulmonary dysplasia. Most commonly, PPHN is secondary to delayed or impaired relaxation of the pulmonary vasculature associated with diverse neonatal pulmonary pathologies, such as meconium aspiration syndrome, congenital diaphragmatic hernia, and respiratory distress syndrome. Gentle ventilation strategies, lung recruitment, inhaled nitric oxide, and surfactant therapy have improved outcome and reduced the need for extracorporeal membrane oxygenation (ECMO) in PPHN. Newer modalities of treatment discussed in this article include systemic and inhaled vasodilators like sildenafil, prostaglandin E1, prostacyclin, and endothelin antagonists. With prompt recognition/treatment and early referral to ECMO centers, the mortality rate for PPHN has significantly decreased. However, the risk of potential neurodevelopmental impairment warrants close follow-up after discharge for infants with PPHN.
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Affiliation(s)
- Jayasree Nair
- Center for Developmental Biology of the Lung, State University of New York, Buffalo, NY
| | - Satyan Lakshminrusimha
- Center for Developmental Biology of the Lung, State University of New York, Buffalo, NY; Division of Neonatology, Department of Pediatrics, Women and Children's Hospital of Buffalo, 219 Bryant St, Buffalo, NY 14222.
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Abstract
Controversy surrounds the assessment of perfusion and the methods currently utilised to define hypotension, especially blood pressure. There is growing agreement to assess heart function when selecting inotropic therapy and use bedside tools such as echocardiography for assessing at-risk infants. Both dopamine and dobutamine have comparative efficacy, and in certain disease states with immature myocardium there could be potential advantages in using dobutamine. The concomitant use of hydrocortisone has been shown to be beneficial when escalating doses of first-line inotropes are used. Other inotropes require further study through randomised trials for their safety and efficacy to be established.
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Affiliation(s)
- Samir Gupta
- Department of Paediatrics, University Hospital of North Tees and University of Durham, Stockton-on-Tees, UK.
| | - Steven M Donn
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, C.S. Mott Children's Hospital, University of Michigan Health System, Ann Arbor, MI, USA
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van der Horst IWJM, Reiss I, Tibboel D. Therapeutic targets in neonatal pulmonary hypertension: linking pathophysiology to clinical medicine. Expert Rev Respir Med 2014; 2:85-96. [DOI: 10.1586/17476348.2.1.85] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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81
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Abstract
Normal pulmonary vascular development in infancy requires maintenance of low pulmonary vascular resistance after birth, and is necessary for normal lung function and growth. The developing lung is subject to multiple genetic, pathological and/or environmental influences that can adversely affect lung adaptation, development, and growth, leading to pulmonary hypertension. New classifications of pulmonary hypertension are beginning to account for these diverse phenotypes, and or pulmonary hypertension in infants due to PPHN, congenital diaphragmatic hernia, and bronchopulmonary dysplasia (BPD). The most effective pharmacotherapeutic strategies for infants with PPHN are directed at selective reduction of PVR, and take advantage of a rapidly advancing understanding of the altered signaling pathways in the remodeled vasculature.
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Affiliation(s)
- Robin H Steinhorn
- Department of Pediatrics, University of California Davis Children's Hospital, Sacramento, CA, United States.
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Craciun EM, Altfelder F, Kuss N, Poeschl J, Ruef P. Anti-inflammatory effects of selected drugs on activated neonatal and adult neutrophils. Scandinavian Journal of Clinical and Laboratory Investigation 2013; 73:407-13. [PMID: 23713554 DOI: 10.3109/00365513.2013.796591] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
AIM In view of the central role of granulocytic neutrophils in the context of inflammatory reactions, the present study focuses on anti-inflammatory effects of drugs on activated neutrophils in neonates and adults. METHODS Sixteen blood samples of neonates and adults were investigated in a prospective study. Loss of deformability, morphological changes, and increases in neutrophil elastase were determined as measures of neutrophil activation due to incubation with the pro-inflammatory cytokine interleukin-8. For inhibition experiments, the blood samples were also incubated with the phosphodiesterase inhibitors milrinone and piclamilast, the protease inhibitor urinastatin, ketamine, protein C concentrate, and the nitric oxide donor FK 409. Changes in deformability were investigated with a cell transit analyzer, morphological changes by microscopic observation, and the extent of neutrophil elastase release with an enzyme immunoassay. RESULTS The drugs milrinone, piclamilast, urinastatin, ketamine, protein C concentrate and FK 409 showed deactivating effects on activated neutrophils in recommended clinical doses. They improved deformability as well as reduced pseudopod formation and the release of neutrophil elastase. The effects on neutrophils did not differ between neonates and adults despite their functional differences. CONCLUSION We conclude that these drugs may reduce the inflammatory response and improve microcirculation in neonates and adults during inflammation.
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Affiliation(s)
- Eugenia M Craciun
- Clinic of Neonatology, Department of Pediatrics, University of Heidelberg, Heidelberg, Germany
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83
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Cabral JE, Belik J. Persistent pulmonary hypertension of the newborn: Recent advances in pathophysiology and treatment. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2013. [DOI: 10.1016/j.jpedp.2012.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Cabral JEB, Belik J. Persistent pulmonary hypertension of the newborn: recent advances in pathophysiology and treatment. J Pediatr (Rio J) 2013; 89:226-42. [PMID: 23684454 DOI: 10.1016/j.jped.2012.11.009] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Accepted: 11/08/2012] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES Although recognized for decades, little is known about the etiology, physiopathology, and prevention of persistent pulmonary hypertension of the newborn (PPHN), and its treatment remains a major challenge for neonatologists. In this review, the clinical features and physiopathology of the syndrome will be addressed, as well as its general and specific treatments. DATA SOURCE A review was carried out in PubMed, Cochrane Library, and MRei consult databases, searching for articles related to the syndrome and published between 1995 and 2011. DATA SYNTHESIS Risk factors and the physiopathological mechanisms of the syndrome are discussed. The clinical presentation depends on the different factors involved. These are related to the etiology and physiopathology of the different forms of the disease. In addition to the measures used to allow for the decrease in pulmonary vascular resistance after birth, in some instances pulmonary vasodilators will be required. Although inhaled nitric oxide has proved effective, other vasodilators have been recently used, but clinical evidence is still lacking to demonstrate their benefits in the treatment of PPHN. CONCLUSIONS Despite recent technological advances and new physiopathological knowledge of this disease, mortality associated with PPHN remains at 10%. More clinical research and evidence-based experimental results are needed to prevent, treat, and reduce the morbidity/mortality associated with this neonatal syndrome.
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85
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Effectiveness and safety of intravenous iloprost for severe persistent pulmonary hypertension of the newborn. Indian Pediatr 2013; 50:934-8. [PMID: 23798625 DOI: 10.1007/s13312-013-0263-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2012] [Accepted: 03/30/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The aims of this study were to determine the effectiveness (oxygenation), safety (hemodynamic status) and short term outcomes of intravenous iloprost (IVI) administration as a rescue therapy in severe persistent pulmonary hypertension of the newborn (PPHN). DESIGN Retrospective medical records review. SETTING Tertiary neonatal intensive care unit at Songklanagarind Hospital, Songkhla Province, Hat Yai, Thailand. PARTICIPANTS Newborns who received IVI as an adjunctive therapy for treatment of severe PPHN, as defined by an oxygen index (OI) of >20 and without response to conventional therapies. MAIN OUTCOME MEASURES The change of OI and alveolar-arterial oxygen difference before and after commencement of IVI. RESULTS 33 neonates with severe PPHN at a median gestation of 39 weeks and a baseline OI of 40 (range, 21-101) received IVI. The median OI and alveolar-arterial oxygen difference had a statistically significant decrease after 2 hours of treatment and continued to decline thereafter (P<0.05). All infants received one or more inotropic medications and volume expanders to provide blood pressure support with no statistically significant difference of blood pressure and heart rate before and after IVI treatment. The mortality rate was 15.2%, all of them had initially severe hypoxemia with a median OI of 53.6. CONCLUSION Triglyceride and non-high-density lipoprotein cholesterol are better than low-density lipoprotein cholesterol as predictors of cardiovascular disease risk factors in Chinese Han children and adolescents.
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Abstract
BACKGROUND Inodilators are routinely used in cardiovascular surgery with cardiopulmonary bypass (CPB). Information regarding safety and tolerability of the novel molecule, levosimendan (LEVO), in newborns is anecdotal; no pharmacokinetic data in this population are available. METHODS This was a phase I, randomized, and blinded study. Neonates undergoing surgical repair for congenital heart defects received stepwise dose increases of milrinone (MR; 0.5-1 μg/kg/min, n = 9) or LEVO (0.1-0.2 μg/kg/min, n = 11) as an i.v. continuous infusion, starting before CPB. Infants had continuous, time-locked, physiological, and near-infrared spectroscopy (NIRS) (cerebral and peripheral) recordings during the first 24 h, and at 48 and 96 h postsurgery. Serial biochemistry and pharmacokinetic studies were performed. RESULTS During the first 24 h postsurgery, patients showed time-related, group-independent increased cerebral tissue oxygenation and decreased diastolic blood pressure; in addition, group-dependent differences in heart rate and peripheral perfusion were found. Early postsurgery, MR-treated infants showed lower pH, higher glycemia, and higher inotrope score. The groups differed in cerebral NIRS-derived variables from 24 to 96 h. Study drug withdrawal at 96 h was more frequent with LEVO. LEVO intermediate metabolites were detected in plasma at day 14 after surgery. CONCLUSION LEVO is well tolerated in critically ill neonates. LEVO may have advantages over MR in terms of the dosing regimen.
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Pharmacology of milrinone in neonates with persistent pulmonary hypertension of the newborn and suboptimal response to inhaled nitric oxide. Pediatr Crit Care Med 2013; 14:74-84. [PMID: 23132395 DOI: 10.1097/pcc.0b013e31824ea2cd] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Persistent pulmonary hypertension of the newborn is a common problem with significant morbidity and mortality. Inhaled nitric oxide is the standard care, but up to 40% of neonates are nonresponders. Milrinone is a phosphodiesterase III inhibitor which increases the bioavailability of cyclic adenosine monophosphate and has been shown to improve pulmonary hemodynamics in animal experimental models. The primary objective was to investigate the pharmacological profile of milrinone in persistent pulmonary hypertension of the newborn. Secondary objectives were to delineate short-term outcomes and safety profile. SUBJECTS AND METHODS An open label study of milrinone in neonates with persistent pulmonary hypertension of the newborn was conducted. Patients received an intravenous loading dose of milrinone (50 μg/kg) over 60 mins followed by a maintenance infusion (0.33-0.99 μg/kg/min) for 24-72 hrs. Physiologic indices of cardiorespiratory stability and details of cointerventions were recorded. Serial blood milrinone levels were collected after the bolus, following initiation of the maintenance infusion to determine steady state levels, and following discontinuation of the drug to determine clearance. Echocardiography was performed before and after (1, 12 hrs) milrinone initiation. INTERVENTIONS Milrinone. MEASUREMENTS AND MAIN RESULTS Eleven neonates with a diagnosis of persistent pulmonary hypertension of the newborn who met eligibility criteria were studied. The median (SD) gestational age and weight at birth were 39.2 ± 1.3 wks and 3481 ± 603 g. The mean (± sd) half-life, total body clearance, volume of distribution, and steady state concentration of milrinone were 4.1 ± 1.1 hrs, 0.11 ± 0.01 L/kg/hr, 0.56 ± 0.19 L/kg, and 290.9 ± 77.7 ng/mL. The initiation of milrinone led to an improvement in PaO2 (p = 0.002) and a sustained reduction in FIO2 (p < 0.001), oxygenation index (p < 0.001), mean airway pressure (p = 0.03), and inhaled nitric oxide dose (p < 0.001). Although a transient reduction in systolic arterial pressure (p < 0.001) was seen following the bolus, there was overall improvement in base deficit (p = 0.01) and plasma lactate (p = 0.04) with a trend towards lower inotrope score. Serial echocardiography revealed lower pulmonary artery pressure, improved right and left ventricular output, and reduced bidirectional or right-left shunting (p < 0.05) after milrinone treatment. CONCLUSIONS The pharmacokinetics of milrinone in persistent pulmonary hypertension of the newborn is consistent with published data. The administration of intravenous milrinone led to better oxygenation and improvements in pulmonary and systemic hemodynamics in patients with suboptimal response to inhaled nitric oxide. These data support the need for a randomized controlled trial in neonates.
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89
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Abstract
Pulmonary arterial hypertension is a serious disease with significant morbidity and mortality. Although it can occur idiopathically, it is more commonly associated with other cardiac or lung diseases. While most of the available therapies have been tested in adult populations and most therapies in children remain off-label, new reports and randomized trials are emerging that inform the treatment of pediatric populations. This review discusses currently available therapies for pediatric pulmonary hypertension, their biological rationales, and evidence for their clinical effectiveness.
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Affiliation(s)
- Robin H Steinhorn
- Department of Pediatrics, The Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University, 225 East Chicago Avenue, Chicago, IL 60611, USA.
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90
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Abstract
The pulmonary circulation rapidly adapts at birth to establish lungs as the site of gas exchange. Abnormal transition at birth and/or parenchymal lung disease can result in neonatal hypoxemic respiratory failure. This article reviews the functional changes in pulmonary hemodynamics and structural changes in pulmonary vasculature secondary to (1) normal and abnormal transition at birth, and (2) diseases associated with neonatal hypoxemic respiratory failure. Various management strategies to correct respiratory failure are also discussed.
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Affiliation(s)
- Satyan Lakshminrusimha
- Division of Neonatology, Women and Children's Hospital of Buffalo, State University of New York at Buffalo, 219 Bryant Street, Buffalo, NY 14222, USA.
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91
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Abstract
PURPOSE OF REVIEW Congenital diaphragmatic hernia (CDH) is a rare developmental defect resulting in variable degrees of lung and pulmonary vasculature hypoplasia. Whereas many high-volume centers have recently reported increased survival rates, this has not been the collective trend. One potential explanation for this is inconsistent perinatal care among centers. RECENT FINDINGS Significant efforts have been made to identify prenatally those fetuses that will be most severely affected. A number of radiologic features have shown promise for achieving this goal as well as identifying fetuses that may benefit from prenatal intervention. When CDH is antenatally diagnosed, early referral to a tertiary center is recommended. Centers that routinely use postnatal management protocols have demonstrated improved overall survival rates including increased survival in high-risk CDH patients. SUMMARY As a result of advancements in perinatal care, more severely affected newborns with CDH are now surviving. These patients may experience a number of associated morbidities which affect not only their health but overall quality of life. A multidisciplinary approach to the long-term care of these patients will allow early identification and management of these morbidities.
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92
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Sehgal A, Athikarisamy SE, Adamopoulos M. Global myocardial function is compromised in infants with pulmonary hypertension. Acta Paediatr 2012; 101:410-3. [PMID: 22181690 DOI: 10.1111/j.1651-2227.2011.02572.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIM Persistent pulmonary hypertension of the newborn is a serious clinical entity with significant mortality and long-term morbidity. The objective was to study the profile of myocardial function, especially diastolic function, in term infants with pulmonary hypertension treated with nitric oxide. METHODS Unit electronic database was accessed to identify infants ≥34 weeks gestation who were administered nitric oxide for pulmonary hypertension over the last 6 years. Medical records and archived echocardiographic images were retrieved. Those with no echocardiogram on the day of administration of nitric oxide, concomitant congenital heart disease or ≥2 weeks of age at the time of nitric administration were excluded. RESULTS Low biventricular outputs were noted in >2/3rd infants. Tricuspid regurgitation was noted in 20/25 (80%) infants, and ductal shunt was bidirectional in the majority of cases. Right ventricular diastolic function was assessed by systolic to diastolic duration ratio; dysfunction was widely prevalent. CONCLUSIONS A large percentage of infants were haemodynamically severely compromised. This is the first study to detail right ventricular diastolic dysfunction in infants with pulmonary hypertension and highlights the therapeutic role of milrinone, a lusitropic drug with myocardial relaxation properties. Comprehensive evaluation of cardiovascular haemodynamics can optimize clinical care.
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Affiliation(s)
- Arvind Sehgal
- Monash Newborn, Monash Medical Centre, Melbourne, Australia.
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93
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Pulmonary vasodilator therapy in the NICU: inhaled nitric oxide, sildenafil, and other pulmonary vasodilating agents. Clin Perinatol 2012; 39:149-64. [PMID: 22341543 PMCID: PMC3562500 DOI: 10.1016/j.clp.2011.12.006] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The perinatal transition from fetal to extrauterine life requires a dramatic change in the circulatory pattern as the organ of gas exchange switches from the placenta to the lungs. Pulmonary hypertension can occur during early newborn life, and present as early respiratory failure or as a complication of more chronic diseases, such as bronchopulmonary dysplasia. The most effective pharmacotherapeutic strategies for infants with persistent pulmonary hypertension of the newborn are directed at selective reduction of pulmonary vascular resistance. This article discusses currently available therapies for pulmonary hypertension, their biologic rationales, and evidence for their clinical effectiveness.
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94
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Milrinone is preferred to levosimendan for mesenteric perfusion in hypoxia-reoxygenated newborn piglets treated with dopamine. Pediatr Res 2012; 71:241-6. [PMID: 22337258 PMCID: PMC4972574 DOI: 10.1038/pr.2011.48] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION There is little information regarding the comparative hemodynamic effects of adding milrinone or levosimendan to dopamine infusion in hypoxia-reoxygenated (H-R) newborns. RESULTS Severely hypoxic piglets had cardiogenic shock with depressed cardiac index (CI) and mean arterial pressure (MAP). The hemodynamics deteriorated gradually after initial recovery upon reoxygenation. Heart rate and CI improved with milrinone (D+M) and levosimendan (D+L) administration (P < 0.05 vs. control). Both regimens improved carotid arterial flow and carotid vascular resistance; D+M additionally improved superior mesentric arterial flow (all P < 0.05 vs. control). No effect was found on renal arterial flow or elevated lactate state with either regimen. D+M piglets also had a lower myocardial oxidized/reduced glutathione ratio (P < 0.05 vs. control). DISCUSSION In conclusion, adding milrinone or levosimendan to dopamine similarly improved systemic hemodynamics in H-R newborn piglets. Milrinone also improved mesenteric perfusion and attenuated myocardial oxidative stress. METHODS Twenty-eight piglets (1-4 d, 1.5-2.5 kg) were instrumented for continuous monitoring of systemic MAP and pulmonary arterial pressure (PAP), CI, and carotid, superior mesenteric, and renal arterial flows. Piglets were randomized with blinding to sham-operated, H-R control (saline), and H-R dopamine (10 μg/kg/min) with D+M or D+L groups. H-R piglets underwent H-R followed by 2 h of drug infusion after reoxygenation. Tissue was collected for biochemical/oxidative stress testing and histological analysis.
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95
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Noori S, Seri I. Neonatal blood pressure support: the use of inotropes, lusitropes, and other vasopressor agents. Clin Perinatol 2012; 39:221-38. [PMID: 22341548 DOI: 10.1016/j.clp.2011.12.010] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
A solid understanding of the mechanisms of action of cardiovascular medications used in clinical practice along with efforts to develop comprehensive hemodynamic monitoring systems to improve the ability to accurately identify the underlying pathophysiology of cardiovascular compromise are essential in the management of neonates with shock. This article reviews the mechanisms of action of the most frequently used cardiovascular medications in neonates. Because of paucity of data from controlled clinical trials, evidence-based recommendations for the clinical use of these medications could not be made. Careful titration of the given medication with close monitoring of the cardiovascular response might improve the effectiveness and decrease the risks associated with administration of these medications.
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Affiliation(s)
- Shahab Noori
- Center for Fetal and Neonatal Medicine and the USC Division of Neonatal Medicine, Children's Hospital Los Angeles and the LAC+USC Medical Center, Keck School of Medicine, University of Southern California, 4650 Sunset Boulevard, Los Angeles, CA 90027, USA
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96
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Patel N. Use of milrinone to treat cardiac dysfunction in infants with pulmonary hypertension secondary to congenital diaphragmatic hernia: a review of six patients. Neonatology 2012; 102:130-6. [PMID: 22710735 DOI: 10.1159/000339108] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2012] [Accepted: 04/10/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND Pulmonary hypertension and secondary cardiac dysfunction are important contributors of morbidity and mortality in infants with congenital diaphragmatic hernia (CDH). Milrinone, a phosphodiesterase-3 inhibitor, may be useful in this setting for its combined actions as a pulmonary vasodilator and to improve systolic and diastolic function. OBJECTIVES This study aimed to assess the effects of milrinone on cardiac function and pulmonary artery pressure in infants with CDH. METHODS A retrospective review of echocardiograms performed on infants with CDH who received milrinone was performed. Tissue Doppler imaging velocities were used to assess systolic and diastolic function. Pulmonary artery pressure was assessed from the pattern and velocity of ductal shunting. RESULTS Six infants with CDH and severe pulmonary hypertension were identified. Systolic and diastolic myocardial velocities were reduced in the right ventricle (RV) and interventricular septum (IVS) at baseline. In the 72 h after commencement of milrinone, there was a significant increase in early diastolic myocardial velocities in the RV, accompanied by increasing systolic velocities in the RV and IVS. Oxygenation index was significantly reduced, blood pressure unchanged, and ductal shunt velocity minimally altered over the same time period. CONCLUSIONS Milrinone use was associated with an improvement in systolic and diastolic function in the RV, corresponding to an improvement in clinical status.
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Affiliation(s)
- Neil Patel
- Royal Children's Hospital, Melbourne, Vic., Australia.
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97
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Šebková S, Tomek V, Zemanová P, Janota J. Heart Failure Treated with Low-dose Milrinone in a Full-term Newborn. Prague Med Rep 2012; 113:58-65. [DOI: 10.14712/23362936.2015.38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
A term newborn with a hypocontractile myocardium complicating persistent pulmonary hypertension of the newborn was successfully treated with a low-dose phosphodiesterase III inhibitor milrinone. Echocardiography diagnosed heart failure with a left ventricular ejection fraction of 35% and a left ventricular shortening fraction of 18% and severe persistent pulmonary hypertension of the newborn with oxygenation index of 28. Milrinone was started at an initial dose of 50 mcg/kg, followed by continuous infusion of 0.20 mcg/kg/min. With lowdose milrinone oxygenation index decreased to 3 within 6 hours, left ventricular ejection fraction and left ventricular shortening fraction increased to 57%, and 30%, respectively. Low doses of milrinone might be promising in the treatment of heart failure and persistent pulmonary hypertension of the newborn in term newborns.
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98
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Giaccone A, Kirpalani H. Judgment often impossible without randomized trials. Commentary on N. Patel: use of milrinone to treat cardiac dysfunction in infants with pulmonary hypertension secondary to congenital diaphragmatic hernia: a review of six patients (Neonatology 2012;102:130-136). Neonatology 2012; 102:137-8. [PMID: 22710761 DOI: 10.1159/000339112] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Accepted: 04/10/2012] [Indexed: 11/19/2022]
Affiliation(s)
- Annie Giaccone
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
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99
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Santhosh KT, Elkhateeb O, Nolette N, Outbih O, Halayko AJ, Dakshinamurti S. Milrinone attenuates thromboxane receptor-mediated hyperresponsiveness in hypoxic pulmonary arterial myocytes. Br J Pharmacol 2011; 163:1223-36. [PMID: 21385177 DOI: 10.1111/j.1476-5381.2011.01306.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND AND PURPOSE Neonatal pulmonary hypertension (PPHN) is characterized by pulmonary vasoconstriction, due in part to dysregulation of the thromboxane prostanoid (TP) receptor. Hypoxia induces TP receptor-mediated hyperresponsiveness, whereas serine phosphorylation mediates desensitization of TP receptors. We hypothesized that prostacyclin (IP) receptor activity induces TP receptor phosphorylation and decreases ligand affinity; that TP receptor sensitization in hypoxic myocytes is due to IP receptor inactivation; and that this would be reversible by the cAMP-specific phosphodiesterase inhibitor milrinone. EXPERIMENTAL APPROACH We examined functional regulation of TP receptors by serine phosphorylation and effects of IP receptor stimulation and protein kinase A (PKA) activity on TP receptor sensitivity in myocytes from neonatal porcine resistance pulmonary arteries after 72 h hypoxia in vitro. Ca(2+) response curves to U46619 (TP receptor agonist) were determined in hypoxic and normoxic myocytes incubated with or without iloprost (IP receptor agonist), forskolin (adenylyl cyclase activator), H8 (PKA inhibitor) or milrinone. TP and IP receptor saturation binding kinetics were measured in presence of iloprost or 8-bromo-cAMP. KEY RESULTS Ligand affinity for TP receptors was normalized in vitro by IP receptor signalling intermediates. However, IP receptor affinity was compromised in hypoxic myocytes, decreasing cAMP production. Milrinone normalized TP receptor sensitivity in hypoxic myocytes by restoring PKA-mediated regulatory TP receptor phosphorylation. CONCLUSIONS AND IMPLICATIONS TP receptor sensitivity and EC(50) for TP receptor agonists was regulated by PKA, as TP receptor serine phosphorylation by PKA down-regulated Ca(2+) mobilization. Hypoxia decreased IP receptor activity and cAMP generation, inducing TP receptor hyperresponsiveness, which was reversed by milrinone.
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Affiliation(s)
- K T Santhosh
- Departments of PhysiologyPediatrics, University of Manitoba, Winnipeg, Canada
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100
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The n-3 polyunsaturated fatty acids: another option in the management of persistent pulmonary hypertension of the newborn? Crit Care Med 2011; 39:1587-9. [PMID: 21610639 DOI: 10.1097/ccm.0b013e31821a3f74] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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