Effects of terlipressin on pulmonary artery pressure in a septic cooled infant: an echocardiographic assessment

Utility of Low Dose Vasopressin for Persistent Pulmonary Hypertension of Newborn with Catecholamine Refractory Shock

OBJECTIVE

To evaluate the effect of low dose vasopressin on the hemodynamics of neonates with persistent pulmonary hypertension and catecholamine refractory shock.

METHODS

This retrospective study was conducted in a level III NICU of a tertiary care teaching hospital, south India. Eighteen neonates with hypoxemic respiratory failure due to persistent pulmonary hypertension of newborn with catecholamine refractory shock were studied. Neonates were managed for hypotension with conventional inotropic support with the additional use of low dose vasopressin (LDV). Effect of vasopressin on oxygenation index (OI), blood pressure, duration of inotropic usage and survival was evaluated.

RESULTS

Mean OI was 38.2 ± 4.9, and mean blood pressure was 30.7 ± 5.3 mmHg before the start of vasopressin. Initiation of LDV (0.0003 ± 0.0001 IU/kg/min) for a median duration 36.4 ± 17.9 h was followed by a reduction in OI (p < 0.001), control of hypotension (p < 0.001), reduction in lactic acidosis (p < 0.001) and decline in inotropic support.

CONCLUSIONS

In resource-restricted settings, LDV may be useful as a rescue therapy for persistent pulmonary hypertension of newborn with catecholamine refractory shock.

Severe neonatal pulmonary artery hypertension rescued with vasopressin

An inborn term neonate weighing 2600 g developed meconium aspiration syndrome at birth. Baby had respiratory failure requiring high-frequency oscillatory ventilation support at 15 hours of life. He additionally developed hypotension with left ventricular dysfunction noted on point-of-care echocardiography (POCE), which required dopamine and epinephrine infusions. At 28 hours of life, he was started on inhaled nitric oxide (iNO), followed by milrinone due to hypoxaemic respiratory failure and the POCE revealed severe pulmonary artery hypertension (PAH). As PAH was refractory to iNO and milrinone, vasopressin was added which resulted in rapid improvement in oxygenation and normalisation of pulmonary artery pressures. Baby was weaned off from vasoactive support in the next 120 hours. Vasopressin proved to be the rescue agent in this case of iNO refractory PAH without any side effects during therapy. Baby was successfully extubated on day 18 and was discharged with a normal neurological examination finding.

American College of Critical Care Medicine Clinical Practice Parameters for Hemodynamic Support of Pediatric and Neonatal Septic Shock

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.

Vasopressin in Pediatric Critical Care

Vasopressin is a unique hormone with complex receptor physiology and numerous physiologic functions beyond its well-known vascular actions and osmoregulation. While vasopressin has in the past been primarily used in the management of diabetes insipidus and acute gastrointestinal bleeding, an increased understanding of the physiology of refractory shock, and the role of vasopressin in maintaining cardiovascular homeostasis prompted a renewed interest in the therapeutic roles for this hormone in the critical care setting. Identifying vasopressin-deficient individuals for the purposes of assessing responsiveness to exogenous hormone and prognosticating outcome has expanded research into the evaluation of vasopressin and its precursor, copeptin as useful biomarkers. This review summarizes the current evidence for vasopressin in critically ill children, with a specific focus on its use in the management of shock. We outline important considerations and current guidelines, when considering the use of vasopressin or its analogues in the pediatric critical care setting.

Vasopressin as an adjunct therapy for pulmonary hypertension: a case report

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.

Vasopressin improves hemodynamic status in infants with congenital diaphragmatic hernia

OBJECTIVE

To assess the ability of vasopressin to stabilize hemodynamics in infants with systemic hypotension secondary to congenital diaphragmatic hernia (CDH).

STUDY DESIGN

A retrospective chart review was performed to identify 13 patients with CDH treated with vasopressin for refractory hypotension to assess the effect of vasopressin on pulmonary and systemic hemodynamics and gas exchange in this setting. Data collected included demographics, respiratory support, inotropic agents, pulmonary and systemic hemodynamics, urine output, and serum and urine sodium levels during vasopressin therapy.

RESULTS

Vasopressin therapy increased mean arterial pressure and decreased pulmonary/systemic pressure ratio, heart rate, and fraction of inspired oxygen. In 6 of 13 patients, extracorporeal membrane oxygenation therapy was no longer indicated after treatment with vasopressin. Improvement in left ventricular function and oxygenation index after vasopressin initiation was associated with a decreased need for extracorporeal membrane oxygenation therapy. Prolonged vasopressin treatment was associated with hyponatremia, increased urine output, and increased urine sodium.

CONCLUSIONS

Vasopressin stabilized systemic hemodynamics without adverse effects on pulmonary hemodynamics in a subset of infants with CDH. Our results suggest a potential role for vasopressin therapy in patients with CDH with catecholamine-resistant refractory hypotension.