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Agakidou E, Chatziioannidis I, Kontou A, Stathopoulou T, Chotas W, Sarafidis K. An Update on Pharmacologic Management of Neonatal Hypotension: When, Why, and Which Medication. CHILDREN (BASEL, SWITZERLAND) 2024; 11:490. [PMID: 38671707 PMCID: PMC11049273 DOI: 10.3390/children11040490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 03/30/2024] [Accepted: 04/15/2024] [Indexed: 04/28/2024]
Abstract
Anti-hypotensive treatment, which includes dopamine, dobutamine, epinephrine, norepinephrine, milrinone, vasopressin, terlipressin, levosimendan, and glucocorticoids, is a long-established intervention in neonates with arterial hypotension (AH). However, there are still gaps in knowledge and issues that need clarification. The main questions and challenges that neonatologists face relate to the reference ranges of arterial blood pressure in presumably healthy neonates in relation to gestational and postnatal age; the arterial blood pressure level that potentially affects perfusion of critical organs; the incorporation of targeted echocardiography and near-infrared spectroscopy for assessing heart function and cerebral perfusion in clinical practice; the indication, timing, and choice of medication for each individual patient; the limited randomized clinical trials in neonates with sometimes conflicting results; and the sparse data regarding the potential effect of early hypotension or anti-hypotensive medications on long-term neurodevelopment. In this review, after a short review of AH definitions used in neonates and existing data on pathophysiology of AH, we discuss currently available data on pharmacokinetic and hemodynamic effects, as well as the effectiveness and safety of anti-hypotensive medications in neonates. In addition, data on the comparisons between anti-hypotensive medications and current suggestions for the main indications of each medication are discussed.
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Affiliation(s)
- Eleni Agakidou
- 1st Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Ippokrateion General Hospital, 54642 Thessaloniki, Greece; (I.C.); (A.K.); (T.S.); (K.S.)
| | - Ilias Chatziioannidis
- 1st Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Ippokrateion General Hospital, 54642 Thessaloniki, Greece; (I.C.); (A.K.); (T.S.); (K.S.)
| | - Angeliki Kontou
- 1st Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Ippokrateion General Hospital, 54642 Thessaloniki, Greece; (I.C.); (A.K.); (T.S.); (K.S.)
| | - Theodora Stathopoulou
- 1st Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Ippokrateion General Hospital, 54642 Thessaloniki, Greece; (I.C.); (A.K.); (T.S.); (K.S.)
| | - William Chotas
- Department of Neonatology, University of Vermont, Burlington, VT 05405, USA
| | - Kosmas Sarafidis
- 1st Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Ippokrateion General Hospital, 54642 Thessaloniki, Greece; (I.C.); (A.K.); (T.S.); (K.S.)
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Kharrat A, Diambomba Y, Jain A. Corticosteroid use in neonatal hypotension: A survey of Canadian neonatologists. Pediatr Neonatol 2024:S1875-9572(24)00005-6. [PMID: 38388227 DOI: 10.1016/j.pedneo.2023.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 08/17/2023] [Accepted: 09/08/2023] [Indexed: 02/24/2024] Open
Abstract
OBJECTIVE To assess prescribing practices and perspectives regarding the use of corticosteroids in the management of neonatal hypotension. METHODS Cross-sectional questionnaire-based electronic survey of neonatologists (n = 206) practicing at tertiary neonatal intensive care units across 30 academic centres in Canada. RESULTS The overall response rate was 33% (72/206), with a completion rate was 94%. Most (48/72, 64%) worked in a unit that covered both inborn and outborn infants, and 53% (37/70) worked in units with >100 very low birth weight infants admitted annually. Among the 72 respondents, 39% use a loading dose, of whom most (57%) use 2 mg/kg. Dosing ranges were variable, most using either 0.5 mg/kg or 1 mg/kg, q6h. Among the 56% (40/72) of neonatologists who reported measuring cortisol before initiation of hydrocortisone, cut-offs for initiation of hydrocortisone varied from <100 to <500 nmol/L, most of whom (48%) used <100 nmol/L. Of 71 respondents, 92% (65) indicated that a randomized control trial examining the use of corticosteroids in neonatal hypotension is needed, of whom 52% (37) indicated that the intervention group should receiving hydrocortisone after one vasopressor/inotrope. CONCLUSIONS This survey provides insight into the prescribing practices of tertiary neonatologists with regards to the use of corticosteroids in neonatal hypotension. While corticosteroids are frequently prescribed, there is variability in the indication, dosing, and duration of corticosteroid use. The findings from this survey can be used to inform further research, including a clinical trial, regarding the practice in the management of neonatal hypotension.
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Affiliation(s)
- Ashraf Kharrat
- Department of Paediatrics, Mount Sinai Hospital, Toronto, ON, Canada; Department of Paediatrics, University of Toronto, Toronto, ON, Canada.
| | - Yenge Diambomba
- Department of Paediatrics, Mount Sinai Hospital, Toronto, ON, Canada; Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Amish Jain
- Department of Paediatrics, Mount Sinai Hospital, Toronto, ON, Canada; Department of Paediatrics, University of Toronto, Toronto, ON, Canada; Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada
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Grau J, Moreno-Guzmán M, Arruza L, López MÁ, Escarpa A, Chisvert A. Analysis of microsamples by miniaturized magnetic-based pipette tip microextraction: determination of free cortisol in serum and urine from very low birth weight preterm newborns. Analyst 2023; 148:1050-1057. [PMID: 36723348 DOI: 10.1039/d2an02085h] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Miniaturized magnetic-based pipette tip microextraction is presented as a sample preparation approach for microsamples. It involves quick dispersion of a diminutive amount of a magnetic sorbent material in a low-volume sample (10 μL) to entrap the target analytes. Next, the dispersion is aspirated using a (semi)automatic pipette through a pipette tip with a small cubic neodymium magnet inside, which retrieves the magnetic sorbent containing the analytes. After discarding the rest of the sample, the sorbent is properly rinsed by aspirating/dispensing deionized water, and then, the analytes are eluted by aspirating/dispensing an appropriate solvent. This approach was employed for the determination of free cortisol in serum and urine from very low birth weight preterm newborns, a vulnerable patient group who present low availability for sampling biological fluids. A magnetic immunosorbent made of a cortisol antibody was employed for the selective extraction, followed by liquid chromatography-tandem mass spectrometry. Good analytical features were obtained, such as limits of detection and quantification of 0.08 and 0.27 ng mL-1, respectively, linearity up to 50 ng mL-1 (R2 > 0.999), RSD values under 15% and relative recoveries between 91 and 111%. The cross-reactivity with other glucocorticoids (i.e., cortisone and prednisolone) was evaluated to show the selectivity of the extraction. Finally, the method applicability was demonstrated towards the determination of free cortisol in the serum and urine samples from low birth weight preterm newborns.
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Affiliation(s)
- José Grau
- GICAPC Research Group, Department of Analytical Chemistry, University of Valencia, 46100 Burjassot, Valencia, Spain.
| | - María Moreno-Guzmán
- Department of Chemistry in Pharmaceutical Sciences, Analytical Chemistry, Faculty of Pharmacy, Complutense University of Madrid, Plaza Ramón y Cajal s/n, 28040 Madrid, Spain
| | - Luis Arruza
- Division of Neonatology, Child and Teenager Institute, Clínico San Carlos Hospital IdISCC, Madrid, Spain
| | - Miguel Ángel López
- Department of Analytical Chemistry, Physical Chemistry and Chemical Engineering, University of Alcala, Ctra. Madrid-Barcelona, Km. 33.600, Alcalá de Henares, 28802 Madrid, Spain. .,Chemical Research Institute "Andres M. Del Río", University of Alcala, Ctra. Madrid-Barcelona, Km. 33.600, Alcala de Henares, 28802 Madrid, Spain
| | - Alberto Escarpa
- Department of Analytical Chemistry, Physical Chemistry and Chemical Engineering, University of Alcala, Ctra. Madrid-Barcelona, Km. 33.600, Alcalá de Henares, 28802 Madrid, Spain. .,Chemical Research Institute "Andres M. Del Río", University of Alcala, Ctra. Madrid-Barcelona, Km. 33.600, Alcala de Henares, 28802 Madrid, Spain
| | - Alberto Chisvert
- GICAPC Research Group, Department of Analytical Chemistry, University of Valencia, 46100 Burjassot, Valencia, Spain.
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Weaver LJ, Travers CP, Ambalavanan N, Askenazi D. Neonatal fluid overload-ignorance is no longer bliss. Pediatr Nephrol 2023; 38:47-60. [PMID: 35348902 PMCID: PMC10578312 DOI: 10.1007/s00467-022-05514-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 01/26/2022] [Accepted: 02/21/2022] [Indexed: 01/10/2023]
Abstract
Excessive accumulation of fluid may result in interstitial edema and multiorgan dysfunction. Over the past few decades, the detrimental impact of fluid overload has been further defined in adult and pediatric populations. Growing evidence highlights the importance of monitoring, preventing, managing, and treating fluid overload appropriately. Translating this knowledge to neonates is difficult as they have different disease pathophysiologies, and because neonatal physiology changes rapidly postnatally in many of the organ systems (i.e., skin, kidneys, and cardiovascular, pulmonary, and gastrointestinal). Thus, evaluations of the optimal targets for fluid balance need to consider the disease state as well as the gestational and postmenstrual age of the infant. Integration of what is known about neonatal fluid overload with individual alterations in physiology is imperative in clinical management. This comprehensive review will address what is known about the epidemiology and pathophysiology of neonatal fluid overload and highlight the known knowledge gaps. Finally, we provide clinical recommendations for monitoring, prevention, and treatment of fluid overload.
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Affiliation(s)
| | - Colm P Travers
- University of Alabama at Birmingham, Birmingham, AL, USA.
| | | | - David Askenazi
- University of Alabama at Birmingham, Birmingham, AL, USA
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Sushko K, Al-Rawahi N, Watterberg K, Van Den Anker J, Litalien C, Lacroix J, Razak A, Samiee-Zafarghandy S. Efficacy and safety of low-dose versus high-dose hydrocortisone to treat hypotension in neonates: a protocol for a systematic review and meta-analysis. BMJ Paediatr Open 2021; 5:10.1136/bmjpo-2021-001200. [PMID: 35404836 PMCID: PMC8671989 DOI: 10.1136/bmjpo-2021-001200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 11/18/2021] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Impaired adrenal function is a well-described entity in critically ill term and preterm neonates with systemic hypotension. The standard treatment for neonatal hypotension includes volume expanders and vasopressors. Recent evidence supports the use of glucocorticoids for the primary or rescue treatment of neonatal hypotension associated with impaired adrenal function. However, inconsistency regarding the prescribed dosing regimen to provide the best balance between efficacy and safety in this vulnerable population remains an area of concern. METHODS We will conduct a systematic review and meta-analysis to evaluate low-dosing compared with high-dosing regimens of hydrocortisone for the treatment of hypotension in critically ill term, preterm and very low birth weight neonates. Ovid MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials and Web of Science will be searched from inception to November 2021. Study screening and selection will be completed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. Our primary outcomes will be (1) an improvement in end-organ perfusion, defined as an increase in blood pressure along with an increase in urine output or a reduction in serum lactate and (2) mortality prior to discharge. Our secondary outcomes will be the development of (1) major neurosensory abnormality, (2) bronchopulmonary dysplasia and (3) the occurrence of adverse events. DISCUSSION Hydrocortisone may be beneficial in the treatment of hypotension associated with impaired adrenal function among critically ill neonates. However, its optimal dosing to balance desired efficacy with the risk of adverse events is yet to be determined. Our systematic review and meta-analysis aims to address this evidence gap, providing valuable knowledge for a large audience, including guideline developers, policy-makers and clinicians. PROSPERO REGISTRATION NUMBER This protocol is submitted for registration to the international database of prospectively registered systematic reviews (PROSPERO, awaiting registration number).
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Affiliation(s)
- Katelyn Sushko
- Faculty of Health Sciences, School of Nursing, McMaster University, Hamilton, Ontario, Canada
| | - Nada Al-Rawahi
- Faculty of Health Sciences, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Kristi Watterberg
- Department of Pediatrics, School of Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - John Van Den Anker
- University Children's Hospital Basel, Division of Paediatric Pharmacology and Pharmacokinetics, University of Basel, Basel, Basel-Stadt, Switzerland
| | - Catherine Litalien
- Division of General Pediatrics, Department of Pediatrics, and the Rosalind & Morris Goodman Family Paediatric Foundations Centre, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Québec, Canada
| | - Jacques Lacroix
- Division of Paediatric Critical Care Medicine, Department of Pediatrics, University of Montreal, Montreal, Québec, Canada
| | - Abdul Razak
- Division of Neonatology, Department of Pediatrics, King Abdullah Bin Abdulaziz University Hospital, Riyadh, Riyadh Province, Saudi Arabia
| | - Samira Samiee-Zafarghandy
- Faculty of Health Sciences, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
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A Neonate With Vertical Transmission of COVID-19 and Acute Respiratory Failure: A Case Report. Adv Neonatal Care 2021; 21:482-492. [PMID: 34596092 DOI: 10.1097/anc.0000000000000954] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND This case describes a case of vertical transmission of COVID-19 from a mother to her neonate. The neonate subsequently developed acute respiratory failure consistent with adult symptoms of COVID-19. CLINICAL FINDINGS This preterm neonate was born at 33 4/7 weeks' gestational age to a COVID-19-positive mother and admitted to the neonatal intensive care unit (NICU) for prematurity and respiratory distress. The neonate developed acute respiratory failure with severe persistent pulmonary hypertension of newborn (PPHN) and required intubation and maximum respiratory and cardiovascular support. The neonate subsequently tested positive for COVID-19 at 24 hours of life. PRIMARY DIAGNOSIS Acute respiratory failure related to COVID-19 infection. INTERVENTIONS The neonate was admitted to the NICU on CPAP. At 11 hours of life, the neonate began to exhibit signs of worsening respiratory distress requiring intubation, mechanical, and high frequency ventilation. An echocardiogram revealed severe PPHN. The neonate required dopamine to manage hypotension and was treated with steroids to decrease inflammation associated with airway edema noted during intubation. Pharmaceutically induced paralysis, analgesia, and sedation was used to manage persistent hypoxia. OUTCOMES The neonate fully recovered from acute respiratory failure and was discharged home with the mother. PRACTICE RECOMMENDATIONS Newborns born to mothers who are positive for COVID-19 are at risk for vertical transmission of COVID-19 and should be monitored closely for acute respiratory failure. Respiratory medical management should include supportive care. Staff should also encourage parents to consider receiving the COVID-19 vaccine to protect their newborn from the possibility of developing acute respiratory failure.
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Wu TW, Noori S. Recognition and management of neonatal hemodynamic compromise. Pediatr Neonatol 2021; 62 Suppl 1:S22-S29. [PMID: 33485823 DOI: 10.1016/j.pedneo.2020.12.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 12/09/2020] [Indexed: 01/22/2023] Open
Abstract
Hemodynamic compromise of the neonate can occur in various clinical situations, including but not limited to maladaptation during the early transitional period, sepsis, congenital heart anomalies, hemodynamically significant patent ductus arteriosus, persistent pulmonary hypertension of the newborn, systemic inflammatory diseases such as necrotizing enterocolitis, and dehydration. Despite the handful of advances in neonatal care through ground-breaking clinical trials, the management of neonatal shock is often dependent on the bedside clinician's experience and training without the aid of high-level evidence. However, the recognition for the importance of comprehensive and serial hemodynamic assessment is growing. There is now a wealth of literature investigating the use of functional echocardiography, near-infrared spectroscopy, and noninvasive impedance-based cardiometry to complement common bedside hemodynamic measures such as blood pressure and heart rate measurement. In this review article, the pathophysiology of neonatal hemodynamic compromise is outlined, and concomitant best-evidence management for hemodynamic compromise in the neonate is proposed.
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Affiliation(s)
- Tai-Wei Wu
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Shahab Noori
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
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