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Abstract
Neonatal hypertension is uncommon but is becoming increasingly recognized. Normative blood pressure data are limited, as is research regarding the risks, treatment, and long-term outcomes. Therefore, there are no clinical practice guidelines and management is based on clinical judgment and expert opinion. Recognition of neonatal hypertension requires proper blood pressure measurement technique. When hypertension is present there should be a thorough clinical, laboratory, and imaging evaluation to promptly diagnose causes needing medical or surgical management. This review provides a practical overview for the practicing clinician regarding the identification, evaluation, and management of neonatal hypertension.
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Affiliation(s)
- Rebecca Hjorten
- Department of Pediatrics, Division of Nephrology, Seattle Children's Hospital, 4800 Sand Point Way NE, OC.9.820 - Nephrology, Seattle, WA 98105, USA
| | - Joseph T Flynn
- Department of Pediatrics, Division of Nephrology, Seattle Children's Hospital, 4800 Sand Point Way NE, OC.9.820 - Nephrology, Seattle, WA 98105, USA.
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2
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Tobias JD, Naguib A, Simsic J, Krawczeski CD. Pharmacologic Control of Blood Pressure in Infants and Children. Pediatr Cardiol 2020; 41:1301-1318. [PMID: 32915293 DOI: 10.1007/s00246-020-02448-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 08/30/2020] [Indexed: 01/04/2023]
Abstract
Alterations in blood pressure are common during the perioperative period in infants and children. Perioperative hypertension may be the result of renal failure, volume overload, or activation of the sympathetic nervous system. Concerns regarding end-organ effects or postoperative bleeding may mandate regulation of blood pressure. During the perioperative period, various pharmacologic agents have been used for blood pressure control including sodium nitroprusside, nitroglycerin, β-adrenergic antagonists, fenoldopam, and calcium channel antagonists. The following manuscript outlines the commonly used pharmacologic agents for perioperative BP including dosing regimens and adverse effect profiles. Previously published clinical trials are discussed and efficacy in the perioperative period reviewed.
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Affiliation(s)
- Joseph D Tobias
- Departments of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University, 700 Children's Drive, Columbus, OH, 43205, USA.
| | - Aymen Naguib
- Departments of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University, 700 Children's Drive, Columbus, OH, 43205, USA
| | - Janet Simsic
- Department of Pediatrics and Division of Pediatric Cardiology, Nationwide Children's Hospital and The Ohio State University, Columbus, OH, USA
| | - Catherine D Krawczeski
- Department of Pediatrics and Division of Pediatric Cardiology, Nationwide Children's Hospital and The Ohio State University, Columbus, OH, USA
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3
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Abstract
Hypertension in neonates is increasingly recognized because of improvements in neonatal intensive care that have led to improved survival of premature infants. Although normative data on neonatal blood pressure remain limited, several factors appear to be important in determining blood pressure levels in neonates, especially gestational age, birth weight and maternal factors. Incidence is around 1% in most studies and identification depends on careful blood pressure measurement. Common causes of neonatal hypertension include umbilical catheter associated thrombosis, renal parenchymal disease, and chronic lung disease, and can usually be identified with careful diagnostic evaluation. Given limited data on long-term outcomes and use of antihypertensive medications in these infants, clinical expertise may need to be relied upon to decide the best approach to treatment. This review will discuss these concepts and identify evidence gaps that should be addressed.
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Affiliation(s)
- Joseph T Flynn
- Department of Pediatrics, University of Washington School of Medicine, And Division of Nephrology, Seattle Children's Hospital, Seattle, WA, USA.
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4
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Starr MC, Flynn JT. Neonatal hypertension: cases, causes, and clinical approach. Pediatr Nephrol 2019; 34:787-799. [PMID: 29808264 PMCID: PMC6261698 DOI: 10.1007/s00467-018-3977-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 04/12/2018] [Accepted: 05/01/2018] [Indexed: 12/24/2022]
Abstract
Neonatal hypertension is increasingly recognized as dramatic improvements in neonatal intensive care, advancements in our understanding of neonatal physiology, and implementation of new therapies have led to improved survival of premature infants. A variety of factors appear to be important in determining blood pressure in neonates, including gestational age, birth weight, and postmenstrual age. Normative data on neonatal blood pressure values remain limited. The cause of hypertension in an affected neonate is often identified with careful diagnostic evaluation, with the most common causes being umbilical catheter-associated thrombosis, renal parenchymal disease, and chronic lung disease. Clinical expertise may need to be relied upon to decide the best approach to treatment in such patients, as data on the use of antihypertensive medications in this age group are extremely limited. Available data suggest that long-term outcomes are usually good, with resolution of hypertension in most infants. In this review, we will take a case-based approach to illustrate these concepts and to point out important evidence gaps that need to be addressed so that management of neonatal hypertension may be improved.
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Affiliation(s)
- Michelle C. Starr
- Division of Nephrology, Department of Pediatrics, Seattle Children’s Hospital and University of Washington School of Medicine, Seattle, WA, USA
| | - Joseph T. Flynn
- Division of Nephrology, Department of Pediatrics, Seattle Children’s Hospital and University of Washington School of Medicine, Seattle, WA, USA
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5
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Deliu AG, Sanneerappa PBJ, Franklin O, Letshwiti J. Sodium nitroprusside, a lifesaving treatment for neonatal hypertension: an Irish experience. BMJ Case Rep 2018; 2018:bcr-2017-221856. [PMID: 29592974 DOI: 10.1136/bcr-2017-221856] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We present a 30+2-weeks-old (30 weeks and 2 days) male, twin 1, born by emergency caesarean section due to twin-twin transfusion syndrome (absent end-diastolic flow and cardiac anomaly in twin 2) presenting with hypertensive crisis on day 3. He was already on milrinone and propranolol. His echocardiogram showed poor left ventricular contractility and after cardiology consultation received sodium nitroprusside, which eventually saved his life by decreasing his blood pressure and improving cardiac function. As sodium nitroprusside is very rarely used for hypertensive crisis in neonates, we would like to share our experiences on dosage, challenges in administration due to its fast onset of action, criteria for monitoring for complications and finally weaning. Baby developed severe bilateral periventricular leukomalacia as a potential complication of hypertensive crisis, preceded by bilateral periventricular flare secondary to twin-twin transfusion.
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Affiliation(s)
- Alina Gina Deliu
- Department of Neonatology, Rotunda Hospital, Dublin, Dublin, Ireland
| | | | - Orla Franklin
- Department of Cardiology, Our Lady's Children's Hospital, Crumlin, Dublin, Ireland
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6
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Dionne JM, Flynn JT. Management of severe hypertension in the newborn. Arch Dis Child 2017; 102:1176-1179. [PMID: 28739634 DOI: 10.1136/archdischild-2015-309740] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 05/29/2017] [Accepted: 06/12/2017] [Indexed: 11/04/2022]
Abstract
Blood pressure is considered a vital sign, as values too low or too high can be related with serious morbidity and mortality. In neonates, normal blood pressure values undergo rapid changes, especially in premature infants, making the recognition of abnormal blood pressures more challenging. Severe hypertension can occur in neonates and infants and is a medical emergency, often manifesting with congestive heart failure or other life-threatening complications. The cause or risk factors for the hypertension can usually be identified and may guide management. Most classes of antihypertensive medications have been used in the neonatal population. For severe hypertension, intravenous short-acting medications are preferred for a controlled reduction of blood pressure. In this article, we focus on identification, aetiology and management of severe hypertension in the newborn.
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Affiliation(s)
- Janis M Dionne
- Department of Pediatrics, Division of Nephrology, University of British Columbia, BC Children's Hospital, Vancouver, Canada
| | - Joseph T Flynn
- Department of Pediatrics, Division of Nephrology, University of Washington, Seattle Children's Hospital, Washington, USA
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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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Yuerek M, Rossano JW, Mascio CE, Shaddy RE. Postoperative management of heart failure in pediatric patients. Expert Rev Cardiovasc Ther 2015; 14:201-15. [PMID: 26560361 DOI: 10.1586/14779072.2016.1117388] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Low cardiac output syndrome (LCOS) is a well-described entity occurring in 25-65% of pediatric patients undergoing open-heart surgery. With judicious intensive care management of LCOS, most patients have an uncomplicated postoperative course, and within 24 h after cardiopulmonary bypass, the cardiac function returns back to baseline. Some patients have severe forms of LCOS not responsive to medical management alone, requiring temporary mechanical circulatory support to prevent end-organ injury and to decrease myocardial stress and oxygen demand. Occasionally, cardiac function does not recover and heart transplantation is necessary. Long-term mechanical circulatory support devices are used as a bridge to transplantation because of limited availability of donor hearts. Experience in usage of continuous flow ventricular assist devices in the pediatric population is increasing.
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Affiliation(s)
- Mahsun Yuerek
- a Division of Cardiac Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine , Children's Hospital of Philadelphia , Philadelphia , PA , USA
| | - Joseph W Rossano
- b Division of Cardiology, Department of Pediatrics , University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia , Philadelphia , PA , USA
| | - Christopher E Mascio
- c Division of Pediatric Cardiothoracic Surgery, Department of Surgery , University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia , Philadelphia , PA , USA
| | - Robert E Shaddy
- b Division of Cardiology, Department of Pediatrics , University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia , Philadelphia , PA , USA
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Topf HG, Rauh M, Rascher W, Dötsch J, Klinge JM. Endothelial cells influence the sodium nitroprusside mediated inhibition of platelet aggregation by an as yet unkown pathway. Thromb J 2012; 10:6. [PMID: 22564812 PMCID: PMC3528661 DOI: 10.1186/1477-9560-10-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2011] [Accepted: 03/13/2012] [Indexed: 01/22/2023] Open
Abstract
The clinical use of Sodium nitroprusside (SNP) may be associated with an alteration of platelet function. The main focus of this study was the effect of SNP on platelet aggregation in the absence or presence of endothelial cells. Methods: Platelets were incubated with different concentrations of SNP with and without endothelial cells. Platelet aggregation was induced by ADP. Results: Platelet aggregation was significantly inhibited by all concentrations of SNP. Endothelial cells significantly increased this inhibitory effect of SNP. Time course studies showed an inverse correlation of incubation time to platelet aggregation inhibition in the absence of endothelial cells, and a direct correlation in the presence of endothelial cells. Blocking platelet and endothelial cell guanylate cyclase with 1 H-(1,2,4)-oxadiazolo(4,3-a) quinoxalin-1-one (ODQ), or pretreatment of the endothelial cells with cyclooxygenase – inhibitors, had no influence on the increased inhibitory effect of the endothelial cells. Cyanide reversed the inhibitory effect of SNP completely. Conclusion: Endothelial cells play an important role in the SNP mediated inhibition of platelet aggregation. The effect is reversible only by cyanide, not by blocking classical NO signal transduction.
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Affiliation(s)
- Hans-Georg Topf
- Klinik für Kinder und Jugendliche, University of Erlangen-Nuremberg, Loschgestr 15, 91054, Erlangen, Germany.
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Dionne JM, Abitbol CL, Flynn JT. Hypertension in infancy: diagnosis, management and outcome. Pediatr Nephrol 2012; 27:17-32. [PMID: 21258818 DOI: 10.1007/s00467-010-1755-z] [Citation(s) in RCA: 120] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2010] [Revised: 12/16/2010] [Accepted: 12/20/2010] [Indexed: 10/18/2022]
Abstract
Advances in the ability to identify, evaluate, and care for infants with hypertension, coupled with advances in the practice of Neonatology, have led to an increased awareness of hypertension in modern neonatal intensive care units. This review will present updated data on blood pressure values in neonates, with a focus on the changes that occur over the first days and weeks of life in both term and preterm infants. Optimal blood pressure measurement techniques as well as the differential diagnosis of hypertension in the neonate and older infants will be discussed. Recommendations for the optimal immediate and long-term evaluation and treatment, including potential treatment parameters, will be presented. We will also review additional information on outcome that has become available over the past decade.
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Affiliation(s)
- Janis M Dionne
- Division of Nephrology, Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver, BC, Canada
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11
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Abstract
Hypertensive crisis is a relatively rare event and is associated with significant morbidity and mortality in adults and pediatric patients alike. Rapid, safe, and effective treatment is imperative to alleviate immediate presenting clinical symptoms, prevent devastating morbidity, preserve long-term quality of life, and prevent mortality. Many medications in the hypertensive crisis arsenal have been used for nearly half a century. Nearly all treatment options have been utilized in children for decades, yet reliable data and sound clinical literature remain elusive. Every agent considered to be a first-line, second-line, or adjunctive option has yet to be evaluated in a randomized controlled trial in pediatric patients. With a paucity of clinical data to form evidence-based decisions, the clinician must rely entirely on the extrapolation from adult data and small retrospective studies, case series, and case reports of medication use in pediatric patients. Although more research in the treatment of pediatric hypertensive crisis is desperately needed, current practice demands a sharp knowledge of the pediatric clinical literature and pharmacology in this area as an essential tool to consistently improve patient outcomes with respect to morbidity and mortality.
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Affiliation(s)
- Christopher A Thomas
- Department of Pharmacy, Riley Hospital for Children - Indiana University Health, Indianapolis, IN 46202, USA.
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12
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Baek JG, Jeong HL, Park JS, Seo JH, Park ES, Lim JY, Park CH, Woo HO, Youn HS, Yeom JS. Successful treatment by exchange transfusion of a young infant with sodium nitroprusside poisoning. KOREAN JOURNAL OF PEDIATRICS 2010; 53:805-8. [PMID: 21189979 PMCID: PMC3004497 DOI: 10.3345/kjp.2010.53.8.805] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2010] [Revised: 04/19/2010] [Accepted: 05/25/2010] [Indexed: 11/27/2022]
Abstract
Although sodium nitroprusside (SNP) is often used in pediatric intensive care units, cyanide toxicity can occur after SNP treatment. To treat SNP-induced cyanide poisoning, antidotes such as amyl nitrite, sodium nitrite, sodium thiosulfate, and hydroxycobalamin should be administered immediately after diagnosis. Here, we report the first case of a very young infant whose SNP-induced cyanide poisoning was successfully treated by exchange transfusion. The success of this alternative method may be related to the fact that exchange transfusion not only removes the cyanide from the blood but also activates detoxification systems by supplying sulfur-rich plasma. Moreover, exchange transfusion replaces cyanide-contaminated erythrocytes with fresh erythrocytes, thereby improving the blood's oxygen carrying capacity more rapidly than antidote therapy. Therefore, we believe that exchange transfusion might be an effective therapeutic modality for critical cases of cyanide poisoning.
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Affiliation(s)
- Jong Geun Baek
- Department of Pediatrics, Gyeongsang National University School of Medicine, Jinju, Korea
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13
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Thomas C, Svehla L, Moffett BS. Sodium-nitroprusside-induced cyanide toxicity in pediatric patients. Expert Opin Drug Saf 2009; 8:599-602. [PMID: 19645589 DOI: 10.1517/14740330903081717] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Sodium nitroprusside (SNP) is often used as a continuous infusion intravenous vasodilator in pediatric patients. However, cyanide toxicity can occur with SNP therapy. Scant literature is available determining the safety of SNP therapy, the incidence of cyanide toxicity or the risk factors for cyanide toxicity in pediatric patients. OBJECTIVE To review the literature concerning the safety of intravenous SNP with regard to cyanide toxicity in the pediatric patient population. METHODS A MedLine search was used to identify articles pertaining to SNP therapy and cyanide toxicity in pediatric patients. CONCLUSIONS Sodium nitroprusside seems to be safe when used in critically ill pediatric patients. Cyanide toxicity may occur in patients with specific risk factors. Routine monitoring of cyanide levels may not be warranted.
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Affiliation(s)
- Christopher Thomas
- Texas Children's Hospital, Department of Pharmacy, 6621 Fannin Street, MC 2-2510, Houston, TX 77030, USA.
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14
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Brierley J, Carcillo JA, Choong K, Cornell T, Decaen A, Deymann A, Doctor A, Davis A, Duff J, Dugas MA, Duncan A, Evans B, Feldman J, Felmet K, Fisher G, Frankel L, Jeffries H, Greenwald B, Gutierrez J, Hall M, Han YY, Hanson J, Hazelzet J, Hernan L, Kiff J, Kissoon N, Kon A, Irazuzta J, Irazusta J, Lin J, Lorts A, Mariscalco M, Mehta R, Nadel S, Nguyen T, Nicholson C, Peters M, Okhuysen-Cawley R, Poulton T, Relves M, Rodriguez A, Rozenfeld R, Schnitzler E, Shanley T, Kache S, Skache S, Skippen P, Torres A, von Dessauer B, Weingarten J, Yeh T, Zaritsky A, Stojadinovic B, Zimmerman J, Zuckerberg A. Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine. Crit Care Med 2009; 37:666-88. [PMID: 19325359 PMCID: PMC4447433 DOI: 10.1097/ccm.0b013e31819323c6] [Citation(s) in RCA: 647] [Impact Index Per Article: 43.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND The Institute of Medicine calls for the use of clinical guidelines and practice parameters to promote "best practices" and to improve patient outcomes. OBJECTIVE 2007 update of the 2002 American College of Critical Care Medicine Clinical Guidelines for Hemodynamic Support of Neonates and Children with Septic Shock. PARTICIPANTS Society of Critical Care Medicine members with special interest in neonatal and pediatric septic shock were identified from general solicitation at the Society of Critical Care Medicine Educational and Scientific Symposia (2001-2006). METHODS The Pubmed/MEDLINE literature database (1966-2006) was searched using the keywords and phrases: sepsis, septicemia, septic shock, endotoxemia, persistent pulmonary hypertension, nitric oxide, extracorporeal membrane oxygenation (ECMO), and American College of Critical Care Medicine guidelines. Best practice centers that reported best outcomes were identified and their practices examined as models of care. Using a modified Delphi method, 30 experts graded new literature. Over 30 additional experts then reviewed the updated recommendations. The document was subsequently modified until there was greater than 90% expert consensus. RESULTS The 2002 guidelines were widely disseminated, translated into Spanish and Portuguese, and incorporated into Society of Critical Care Medicine and AHA sanctioned recommendations. Centers that implemented the 2002 guidelines reported best practice outcomes (hospital mortality 1%-3% in previously healthy, and 7%-10% in chronically ill children). Early use of 2002 guidelines was associated with improved outcome in the community hospital emergency department (number needed to treat = 3.3) and tertiary pediatric intensive care setting (number needed to treat = 3.6); every hour that went by without guideline adherence was associated with a 1.4-fold increased mortality risk. The updated 2007 guidelines continue to recognize an increased likelihood that children with septic shock, compared with adults, require 1) proportionally larger quantities of fluid, 2) inotrope and vasodilator therapies, 3) hydrocortisone for absolute adrenal insufficiency, and 4) ECMO for refractory shock. The major new recommendation in the 2007 update is earlier use of inotrope support through peripheral access until central access is attained. CONCLUSION The 2007 update continues to emphasize early use of age-specific therapies to attain time-sensitive goals, specifically recommending 1) first hour fluid resuscitation and inotrope therapy directed to goals of threshold heart rates, normal blood pressure, and capillary refill 70% and cardiac index 3.3-6.0 L/min/m.
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15
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Moffett BS, Price JF. Evaluation of Sodium Nitroprusside Toxicity in Pediatric Cardiac Surgical Patients. Ann Pharmacother 2008; 42:1600-4. [DOI: 10.1345/aph.1l192] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background: Sodium nitroprusside (SNP) is often used in postoperative pediatric cardiac surgical patients. Cyanide toxicity may occur with the use of SNP. There is a paucity of literature describing dosing parameters or physical signs and symptoms of toxicity with SNP. Objective: To determine the incidence of cyanide toxicity in postoperative pediatric cardiac surgical patients treated with SNP and identify dosing parameters and physical signs and symptoms that may predict elevated cyanide concentrations. Methods: Medical records of patients who received SNP in the pediatric cardiac intensive care unit from January 2002 through December 2002 were identified and evaluated for cyanide and thiocyanate levels, dosing, and signs and symptoms of toxicity. Patients were included if they had received SNP after cardiac surgery, were 18 years of age or less, and had at least one cyanide or thiocyanate level determined while receiving therapy. Patients were excluded if they had received sodium thiosulfate. The Mann-Whitney U test was used to determine significant differences in mean dose, duration of infusion, renal function, serum lactate, and acid-base status between groups with elevated or nonelevated levels. Logistic regression and receiver operator curve were used to determine variables associated with elevated levels. Relationships between signs and symptoms of toxicity and elevated levels were evaluated with Fisher's exact test. Results: Cyanide concentrations were in the toxic range in 7 of 63 (11%) patients. Patients with elevated concentrations had significantly higher mean dose, cumulative dose, and acid-base excess values. Elevated cyanide levels were independently predicted by mean dose, cumulative dose, and acid-base excess values, and a dose of 1.8 μg/kg/min predicted an elevated cyanide concentration with 89% sensitivity and 88% specificity. Adverse events were not reliable predictors of elevated cyanide levels. Conclusions: Mean dose of SNP is the best predictor of elevated cyanide levels. Adverse events commonly associated with cyanide toxicity may not be reliable indicators of elevated cyanide concentrations.
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Affiliation(s)
| | - Jack F Price
- Lillie Frank Abercrombie Section of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Houston
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16
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López-Herce J, Borrego R, Bustinza A, Carrillo A. Elevated carboxyhemoglobin associated with sodium nitroprusside treatment. Intensive Care Med 2005; 31:1235-8. [PMID: 16041521 DOI: 10.1007/s00134-005-2718-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2005] [Accepted: 06/21/2005] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To report four cases of carboxyhemoglobinemia associated with high doses of sodium nitroprusside after cardiac transplant in children. PATIENTS Four children in the pediatric care unit of a university hospital aged 6 months-4 years. Carboxyhemoglonemia developed at levels of 5.5-7.7% in patients receiving high doses of sodium nitroprusside (7-16 microg/kg per minute and no other medication that could caused elevated carboxyhemoglobin). One patient died, and three recovered with no sequelae after discontinuation of sodium nitroprusside. CONCLUSIONS High doses of sodium nitroprusside can induce carboxyhemoglobinemia in children after heart transplant, probably by inducing hemeoxygenase, with no other secondary effects.
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Affiliation(s)
- Jesús López-Herce
- Pediatric Critical Care Unit, Gregorio Marañón University Hospital, Dr. Castelo 47, 28009 Madrid, Spain.
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17
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Tweddell JS, Hoffman GM. Postoperative management in patients with complex congenital heart disease. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2004; 5:187-205. [PMID: 11994879 DOI: 10.1053/pcsu.2002.31499] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Life-threatening problems occur in the neonate and infant after cardiac surgery because of the interplay of diminished cardiac output (CO), increased metabolic demand, inflammatory responses to cardiopulmonary bypass, and maladaptive responses to stress. Therefore, the postoperative management of patients with complex congenital heart defects is directed at optimization of oxygen delivery to maintain end-organ function and promote wound healing. Traditionally, assessment of circulation in the postoperative congenital heart patient has depended on indirect assessment of CO using parameters such as blood pressure, pulses, capillary refill, and urine output. Because of the limitations of indirect and observer-dependent assessment of CO, we rely on objective measures of tissue oxygen levels for the complex postoperative patient. We have found that continuous monitoring of the mixed venous saturation (SvO2) allows for identification of acute changes in systemic oxygen delivery and frequently precedes other indicators of decreased CO. The postoperative patient can be expected to have a period of decreasing CO, and the need for intervention should be anticipated because critical low output syndrome will develop in a subset of patients. Strategies for postoperative care are developed based on the diagnosis and procedure, but optimizing SvO2 is a consistent goal. A uniform approach to airway maintenance, vascular access, and drug infusions, all universal concerns during the perioperative period, minimizes the potential for these predictable and necessary interventions to result in morbidity or mortality. Management of the postoperative single ventricle patient targets stabilization of the systemic vascular resistance through the use of vasodilators to improve systemic perfusion and simplify ventilator management. Management of any individual patient should be driven by objective analysis of available data and must include efforts to re-evaluate the treatment plan as well as to identify unanticipated problems.
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Affiliation(s)
- James S Tweddell
- Divisions of Cardiothoracic Surgery, Pediatric Anesthesia, and Critical Care, The Children's Hospital of Wisconsin, Milwaukee, WI 53226, USA
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Mestan KKL, Carlson AD, White M, Powers JA, Morgan S, Meadow W, Schreiber MD. Cardiopulmonary effects of nebulized sodium nitroprusside in term infants with hypoxic respiratory failure. J Pediatr 2003; 143:640-3. [PMID: 14615737 DOI: 10.1067/s0022-3476(03)00533-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To study whether nebulized nitroprusside (neb-NP) improves oxygenation in term infants with hypoxic respiratory failure (HRF). STUDY DESIGN We studied 22 newborn term infants (gestational age, 39.7+/-0.4 weeks [mean+/-SEM]; birth weight, 3.6+/-0.1 kg) with hypoxia (Pao2<100 mm Hg) during mechanical ventilation (Fio2=1.0). Sodium nitroprusside (5 mg followed by 25 mg) was nebulized into the inspiratory arm of the ventilator circuit. Vital signs and arterial blood gas values were recorded after 20 minutes at each dose and before and after initiation of inhaled nitric oxide (iNO). RESULTS Pao2 increased significantly with 5 mg neb-NP (from 64.6+/-5.6 to 90.1+/-15.3 mm Hg, P=.04) and with 25 mg neb-NP (113.2+/-20.4 mm Hg, P=.009). Differences between mean Pao2 at 5 mg versus 25 mg neb-NP were also statistically significant (P=.03). When comparing the effect of neb-NP to iNO, the treatment-induced increases in Pao2 were similar (52.1+/-18.7 vs 62.2+/-18.2 mm Hg, respectively, P=not significant). CONCLUSIONS Neb-NP causes a dose-dependent increase in oxygenation in term infants with HRF, similar in magnitude to iNO* Neb-NP may be beneficial in infants with HRF when iNO is not readily available.
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Affiliation(s)
- Karen K L Mestan
- Department of Pediatrics, the University of Chicago Children's Hospital, Chicago, Illinois, USA
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19
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Abstract
In the last 5 years, the understanding of the epidemiology and pathogenesis of pediatric sepsis, septic shock, and multiple organ failure has expanded greatly. There has also been a substantial increase in the number of successful randomized trials in which success has been measured as reduction in mortality in adults, children, and newborns. This article discusses these advances, updating the 1997 article on septic shock written by the author and by Dr. Robert E. Cunnion and following the format of the 1997 article.
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Affiliation(s)
- Joseph A Carcillo
- Division of Critical Care Medicine, Children's Hospital of Pittsburgh, 3705 5th Avenue, Pittsburgh, PA 15123, USA.
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Carcillo JA, Fields AI. Clinical practice parameters for hemodynamic support of pediatric and neonatal patients in septic shock. Crit Care Med 2002; 30:1365-78. [PMID: 12072696 DOI: 10.1097/00003246-200206000-00040] [Citation(s) in RCA: 360] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The Institute of Medicine has called for the development of clinical guidelines and practice parameters to develop "best practice" and potentially improve patient outcome. OBJECTIVE To provide American College of Critical Care Medicine clinical guidelines for hemodynamic support of neonates and children with septic shock. SETTING Individual members of the Society of Critical Care Medicine with special interest in neonatal and pediatric septic shock were identified from literature review and general solicitation at Society of Critical Care Medicine Educational and Scientific Symposia (1998-2001). METHODS The MEDLINE literature database was searched with the following age-specific keywords: sepsis, septicemia, septic shock, endotoxemia, persistent pulmonary hypertension, nitric oxide, and extracorporeal membrane oxygenation. More than 30 experts graded literature and drafted specific recommendations by using a modified Delphi method. More than 30 more experts then reviewed the compiled recommendations. The task-force chairman modified the document until <10% of experts disagreed with the recommendations. RESULTS Only four randomized controlled trials in children with septic shock could be identified. None of these randomized trials led to a change in practice. Clinical practice has been based, for the most part, on physiologic experiments, case series, and cohort studies. Despite relatively low American College of Critical Care Medicine-graded evidence in the pediatric literature, outcomes in children have improved from 97% mortality in the 1960s to 60% in the 1980s and 9% mortality in 1999. U.S. hospital survival was three-fold better in children compared with adults (9% vs. 27% mortality) in 1999. Shock pathophysiology and response to therapies is age specific. For example, cardiac failure is a predominant cause of death in neonates and children, but vascular failure is a predominant cause of death in adults. Inotropes, vasodilators (children), inhaled nitric oxide (neonates), and extracorporeal membrane oxygenation can be more important contributors to survival in the pediatric populations, whereas vasopressors can be more important contributors to adult survival. CONCLUSION American College of Critical Care Medicine adult guidelines for hemodynamic support of septic shock have little application to the management of pediatric or neonatal septic shock. Studies are required to determine whether American College of Critical Care Medicine guidelines for hemodynamic support of pediatric and neonatal septic shock will be implemented and associated with improved outcome.
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Affiliation(s)
- Joseph A Carcillo
- Children's Hospital of Pittsburgh, Division of Critical Care Medicine, 15213, USA.
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21
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Ong W, Guignard J, Sharma A, Aranda J. Pharmacological approach to the management of neonatal hypertension. ACTA ACUST UNITED AC 1998. [DOI: 10.1016/s1084-2756(98)80033-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Pérez-Vizcaíno F, Villamor E, Moro M, Tamargo J. Pulmonary versus systemic effects of vasodilator drugs: an in vitro study in isolated intrapulmonary and mesenteric arteries of neonatal piglets. Eur J Pharmacol 1996; 314:91-8. [PMID: 8957223 DOI: 10.1016/s0014-2999(96)00548-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The ability of several vasodilators to inhibit the responses to noradrenaline and U46619 (a thromboxane A2 analog) in isolated pulmonary and mesenteric arteries of neonatal piglets was compared. In pulmonary arteries, acetylcholine produced endothelium-dependent relaxations (pIC50 = about 6.8) while, in mesenteric arteries, a relaxant (< or = 10(-7) M) or a contractile response (> or = 10(-6) M) was observed. Sodium nitroprusside produced relaxant effects in pulmonary and mesenteric arteries contracted by noradrenaline (pIC50 = 6.6 and 6.0, respectively) and U46619 (pIC50 = 5.4 and 6.7, respectively). ATP induced an endothelium-independent relaxation in pulmonary arteries (pIC50 = about 4) but in mesenteric arteries it produced weak relaxant effects. In resting mesenteric arteries, ATP induced a concentration-dependent contraction which was not observed in pulmonary arteries. Prostaglandin E1 induced a contractile effect whereas, at higher concentrations, a relaxant response was observed. The alpha-adrenoceptor antagonist tolazoline had no effect on arteries contracted by U46619 but relaxed arteries contracted by noradrenaline being slightly more potent in mesenteric than in pulmonary arteries (pIC50 = 5.1 and 4.8, respectively). Nifedipine (> 10(-7) M) relaxed both arteries, mesenteric being more sensitive than pulmonary arteries and noradrenaline more sensitive than U46619-induced contractions. In conclusion, differences in the relaxant effects for all vasodilators were found depending on the artery, the vasoconstrictor used or both. However, ATP was the only drug which, regardless of the concentration or vasoconstrictor used, produced greater relaxant effects in pulmonary than in mesenteric arteries.
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Affiliation(s)
- F Pérez-Vizcaíno
- Department of Pharmacology, School of Medicine, Universidad Complutense, Madrid, Spain
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23
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Williams RS, Mickell JJ, Young ES, Shapiro JH, Lofland GK. Methemoglobin levels during prolonged combined nitroglycerin and sodium nitroprusside infusions in infants after cardiac surgery. J Cardiothorac Vasc Anesth 1994; 8:658-62. [PMID: 7880995 DOI: 10.1016/1053-0770(94)90198-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Nitroglycerin (NTG) and sodium nitroprusside (SNP) are routinely used perioperatively in infants with congenital heart defects. In this study, NTG and SNP were infused in the operating room to increase venous capacitance, reduce systemic and pulmonary afterload, facilitate weaning off cardiopulmonary bypass, stabilize hemodynamics for transport to the intensive care unit (ICU), and reduce the fluid resuscitation needed upon arrival in the ICU. Because of the risk for accumulation of methemoglobin (MetHb) and cyanmethemoglobin (cyan-MetHb) during prolonged continuous infusion of NTG and SNP, it was decided to (1) quantify ICU use, (2) measure % MetHb at 12-hour intervals, and (3) look indirectly for the accumulation of cyan-MetHb by comparing simultaneous pulse oximetry (SpO2) (Nellcor N-100 [Nellcor, Haywood, CO]) and CO-oximetry (SaO2) (Corning 270 [Corning, Medfield, MA]). A total of 69 arterial samples were obtained from 16 infants (median age 4.4 months) following cardiac surgery with bypass. Median doses of NTG, 6.0 mg/kg (range 0.7 to 27.5), and SNP, 3.3 mg/kg (range 0.6 to 33.4), were infused over a median of 64.5 hours (range 12 to 183) (N = 16 patients). The median MetHb was 0.6% (range 0.0 to 1.5) after infusions of NTG, 1.8 micrograms/kg/min (range 0.5 to 4), and SNP, 1.3 micrograms/kg/min (range 0.3 to 8.4) (N = 69 measurements). Regression analysis of oximetry data yielded the equation: SpO2 = 1.04 SaO2 - 3.7%, r = 0.97. The mean difference between SpO2 and SaO2 data pairs was 0.0% (bias) with a SD (precision) of +/- 2.3%.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- R S Williams
- Department of Pediatrics, Children's Medical Center, Medical College of Virginia, Virginia Commonwealth University, Richmond
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Abstract
Despite an association with meconium and blood aspiration, pneumonia, sepsis, pneumothorax, prematurity, and congenital diaphragmatic hernia, no cause for persistent pulmonary hypertension of the newborn can be found in many cases. This article discusses the advances in current therapies including the promising new therapy of inhaled nitric oxide.
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Affiliation(s)
- J D Roberts
- Department of Anesthesia, Harvard Medical School, Boston, Massachusetts
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Affiliation(s)
- V Y Yu
- Department of Paediatrics, Monash Medical Centre, Clayton, Melbourne, Victoria, Australia
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Geggel RL. Inhalational nitric oxide: a selective pulmonary vasodilator for treatment of persistent pulmonary hypertension of the newborn. J Pediatr 1993; 123:76-9. [PMID: 8320629 DOI: 10.1016/s0022-3476(05)81540-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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27
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Affiliation(s)
- Y K Abu-Osba
- Paediatric Department, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
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28
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Park JW. Formation of nitrosamines from sodium nitroprusside and physiological amines. Arch Pharm Res 1989. [DOI: 10.1007/bf02911052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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29
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Abstract
Severe pre-eclampsia is a state of acute afterload increase where compensation may be total by use of the Frank-Starling mechanism and/or increased adrenergic drive, or may be uncompensated in a patient with limited or exhausted preload reserve. As such, we are presented with a diverse group of patients and antihypertensive therapy ideally should be individualized. In reality we are dealing with a complex situation because of the presence of the fetus raising concerns about direct effects on the fetus as well as on uteroplacental blood flow. This limits our choice of agents to those with extensive use in pregnancy except in complicated or resistant cases. For these reasons, hydralazine is the antihypertensive agent of choice for treatment of acute hypertensive emergencies in pregnancy. In the complicated case other agents such as sodium nitroprusside or nitroglycerin may be more appropriate and, in these cases, hemodynamic monitoring should be performed to allow not only greater safety, but also to tailor therapy to the individual hemodynamic profile.
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Affiliation(s)
- H M Silver
- Department of Obstetrics and Gynecology, University of California-Davis, Sacramento
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Kunathai S, Sholler GF, Celermajer JM, O'Halloran M, Cartmill TB, Nunn GR. Nitroprusside in children after cardiopulmonary bypass: a study of thiocyanate toxicity. Pediatr Cardiol 1989; 10:121-4. [PMID: 2798186 DOI: 10.1007/bf02081673] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Thiocyanate levels, an indicator of nitroprusside toxicity, were studied in 22 children after repair of structural heart disease during cardiopulmonary bypass. At the total dose (2.6 +/- 2.3 mg/kg) and time (34.4 +/- 19 h) ranges of this study, no evidence of toxicity was detected, despite this total dose exceeding recommended maximum in some patients. Nitroprusside infusion, as described, in children with normal hepatic and renal function is safe and may not warrant routine assessment of thiocyanate levels.
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Affiliation(s)
- S Kunathai
- Adolph Basser Institute of Cardiology, Children's Hospital, Camperdown, Sydney, Australia
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31
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Affiliation(s)
- L G Feld
- Children's Hospital of Buffalo, New York
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32
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ALVERSON DALEC. Pulsed-Doppler Assessment of Ascending Aortic Flow Velocity in Newborns and Infants: Clinical Applications. Echocardiography 1988. [DOI: 10.1111/j.1540-8175.1988.tb00230.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Benitz WE, Stevenson DK. Refractory neonatal hypoxemia: diagnostic evaluation and pharmacologic management. Resuscitation 1988; 16:49-64. [PMID: 2831603 DOI: 10.1016/0300-9572(88)90018-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Hypoxemia refractory to oxygen administration and assisted ventilation is found in many clinical conditions and results from a variety of pathophysiologic disorders. Recent clinical and laboratory experience has demonstrated that the choice of therapy for an infant with refractory hypoxemia depends upon identification of the underlying etiologic and pathophysiologic conditions. The ideal therapies for many of these conditions have not yet been defined. We have provided, based on our experience, guidelines for selection of the most appropriate of the currently available therapies for many of these patients.
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Affiliation(s)
- W E Benitz
- Department of Pediatrics, Stanford University School of Medicine, CA 94305
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34
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Abstract
After describing the particular features of the fetal circulation, changes in the pattern of blood flow at the time of birth and during early neonatal life are explained. From animal studies it is wellknown that during the first hours and weeks after birth newborns are characterized by an extremely high cardiac output due to high metabolic demands. In order to meet this marked volume loading, already under resting conditions the neonatal heart appears to be operating nearly at its full capacity without reserves in contractility, preload and afterload. Consequently the newborn heart has less ability to cope with additional acute afterload and/or preload stress. Few investigations on cardiac output and myocardial performance in healthy human newborns provide presumptive evidence that the postnatal human heart performs probably as well as the heart of other species. These observations may influence the therapeutic approach in clinical situations with additional alterations in loading conditions.
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Affiliation(s)
- H Stopfkuchen
- Universitäts-Kinderklinik, Mainz, Federal Republic of Germany
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35
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Stevenson DK, Benitz WE. A practical approach to diagnosis and immediate care of the cyanotic neonate. Stabilization and preparation for transfer to level III nursery. Clin Pediatr (Phila) 1987; 26:325-31. [PMID: 3595037 DOI: 10.1177/000992288702600701] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The diagnostic and therapeutic strategies described above have been presented sequentially for the sake of clarity, but in practice should be performed as quickly as possible in any infant who remains cyanotic despite receiving 100% oxygen. The practitioner must proceed with emergent stabilization of the infant with specific therapies for identified problems and nonspecific therapies for suspected problems, recognizing that the coexistence of two or more pathophysiologic entities is not uncommon. By the time of transport, the practitioner may have laid the groundwork for further diagnostic procedures and therapies by having already classified the infant into one of four primary pathophysiologic categories, as outlined in Table 4. Although congenital heart disease may be highly suspected, confirmation may not be possible without echocardiography. The practitioner, however, should not be discouraged by failure to achieve a specific etiologic diagnosis, despite careful analysis of all the information obtained from diagnostic evaluations prior to transport. Hypoxemia refractory to oxygen administration and assisted ventilation is found in many clinical conditions and results from a variety of pathophysiological disorders. The pediatrician caring for such an infant has primary responsibility for stabilization and preparation for transport of the infant to a Level III facility, and for communicating information about diagnostic procedures and therapeutic maneuvers that might facilitate extended resuscitative efforts by the neonatologist accepting responsibility for the transport and subsequent care of the infant.
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Butt W, Bohn D, Whyte H. Clinical experience with systemic vasodilator therapy in the newborn infant. AUSTRALIAN PAEDIATRIC JOURNAL 1986; 22:117-20. [PMID: 3089210 DOI: 10.1111/j.1440-1754.1986.tb00201.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Newborn infants with impaired myocardial performance may not respond to inotropic drugs and volume loading. Vasodilator therapy was tried in 10 such patients and in most there was improvement in peripheral perfusion, blood pH, arterial oxygenation, blood pressure and urine output. No complications of these drugs were detected. Vasodilator therapy has a role in the management of the acutely sick newborn infant with clinical signs of low cardiac output.
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