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Ramaswamy VV, Kumar G, Abdul Kareem P, Somasekhara Aradhya A, Suryawanshi P, Sahni M, Khurana S, Sharma D, More K. Comparative efficacy of volume expansion, inotropes and vasopressors in preterm neonates with probable transitional circulatory instability in the first week of life: a systematic review and network meta-analysis. BMJ Paediatr Open 2024; 8:e002500. [PMID: 38769048 PMCID: PMC11110579 DOI: 10.1136/bmjpo-2024-002500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 03/12/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND There exists limited agreement on the recommendations for the treatment of transitional circulatory instability (TCI) in preterm neonates OBJECTIVE: To compare the efficacy of various interventions used to treat TCI METHODS: Medline and Embase were searched from inception to 21st July 2023. Two authors extracted the data independently. A Bayesian random effects network meta-analysis was used. Recommendations were formulated using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework. INTERVENTIONS Dopamine, dobutamine, epinephrine, hydrocortisone, vasopressin, milrinone, volume and placebo. MAIN OUTCOME MEASURES Mortality, major brain injury (MBI) (intraventricular haemorrhage > grade 2 or cystic periventricular leukomalacia), necrotising enterocolitis (NEC) ≥stage 2 and treatment response (as defined by the author). RESULTS 15 Randomized Controlled Trials (RCTs) were included from the 1365 titles and abstracts screened. Clinical benefit or harm could not be ruled out for the critical outcome of mortality. For the outcome of MBI, epinephrine possibly decreased the risk when compared to dobutamine and milrinone (very low certainty). Epinephrine was possibly associated with a lesser risk of NEC when compared with dopamine, dobutamine, hydrocortisone and milrinone (very low certainty). Dopamine was possibly associated with a lesser risk of NEC when compared with dobutamine (very low certainty). Vasopressin possibly decreased the risk of NEC compared with dopamine, dobutamine, hydrocortisone and milrinone (very low certainty). Clinical benefit or harm could not be ruled out for the outcome response to treatment. CONCLUSIONS Epinephrine may be used as the first-line drug in preterm neonates with TCI, the evidence certainty being very low. We suggest future trials evaluating the management of TCI with an emphasis on objective criteria to define it.
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Affiliation(s)
| | - Gunjana Kumar
- Neonatology, National Institute of Medical Sciences and Research, Jaipur, Rajasthan, India
| | | | | | - Pradeep Suryawanshi
- Neonatology, Bharati Vidyapeeth University Medical College & Hospital, Pune, Maharashtra, India
| | - Mohit Sahni
- Neonatology, Surat Kids Hospital, Surat, Gujarat, India
| | | | - Deepak Sharma
- Neonatology, National Institute of Medical Sciences and Research, Jaipur, Rajasthan, India
| | - Kiran More
- Neonatology, MRR Children's Hospital, Thane, Maharashtra, India
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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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Mullaly R, El-Khuffash AF. Haemodynamic assessment and management of hypotension in the preterm. Arch Dis Child Fetal Neonatal Ed 2024; 109:120-127. [PMID: 37173119 DOI: 10.1136/archdischild-2022-324935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 05/02/2023] [Indexed: 05/15/2023]
Abstract
The management of low blood flow states in premature neonates is fraught with many challenges. We remain over-reliant on regimented stepwise protocols that use mean blood pressure as a threshold for intervention to guide treatment, without giving due consideration to the underlying pathophysiology. The current available evidence does not reflect the need to concentrate on the unique pathophysiology of the preterm infant and thus leads to widespread misuse of vasoactive agents that often do not provide the desired clinical effect. Therefore, understanding the underlying pathophysiological underpinnings of haemodynamic compromise may better guide choice of agent and assess physiological response to the selected intervention.
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Affiliation(s)
- Rachel Mullaly
- Department of Paediatrics, Royal College of Surgeons in Ireland, Dublin, Ireland
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Kallimath A, Garegrat R, Patnaik S, Singh Y, Soni NB, Suryawanshi P. Hemodynamic effects of noradrenaline in neonatal septic shock: a prospective cohort study. J Trop Pediatr 2024; 70:fmae001. [PMID: 38324898 DOI: 10.1093/tropej/fmae001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
BACKGROUND The incidence of neonatal septic shock in low-income countries is 26.8% with a mortality rate of 35.4%. The evidence of the hemodynamic effects of noradrenaline in neonates remains sparse. This study was carried out to evaluate the effects of noradrenaline in neonates with septic shock. METHODS This was a single-center prospective cohort study in a tertiary care hospital's level III neonatal intensive care unit. Neonates with septic shock and those who received noradrenaline as a first-line vasoactive agent were included. Clinical and hemodynamic parameters were recorded before and after one hour of noradrenaline infusion. The primary outcomes were: response at the end of one hour after starting noradrenaline infusion and mortality rate. RESULTS A total of 21 babies were analyzed. The cohort comprised 17 preterm neonates. The mean age of presentation with septic shock was 74.3 h. Resolution of shock at one hour after starting noradrenaline was achieved in 76.2% of cases. The median duration of hospital stay was 14 days. The mean blood pressure improved after the initiation of noradrenaline from 30.6 mm of Hg [standard deviation (SD) 6.1] to 37.8 mm of Hg (SD 8.22, p < 0.001). Fractional shortening improved after noradrenaline initiation from 29% (SD 13.5) to 45.1% (SD 21.1, p < 0.001). The mortality rate was 28.6% in our study. CONCLUSION Noradrenaline is a potential drug for use in neonatal septic shock, with improvement in mean blood pressure and fractional shortening; however, further studies with larger sample sizes are needed to confirm our findings before it can be recommended as first-line therapy in neonatal septic shock.
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Affiliation(s)
- Aditya Kallimath
- Department of Neonatology, Bharati University Medical College, Pune 411043, India
| | - Reema Garegrat
- Department of Neonatology, Bharati University Medical College, Pune 411043, India
| | - Suprabha Patnaik
- Department of Neonatology, Bharati University Medical College, Pune 411043, India
| | - Yogen Singh
- Division of Neonatology, Loma Linda University School of Medicine, Loma Linda, CA 92345, USA
| | - Naharmal B Soni
- Department of Neonatology, Sidra Medicine, 26999 Doha, Qatar
| | - Pradeep Suryawanshi
- Department of Neonatology, Bharati University Medical College, Pune 411043, India
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Foote HP, Benjamin DK, Greenberg RG, Clark RH, Hornik CP. Use of vasopressors for septic shock in the neonatal intensive care unit. J Perinatol 2023; 43:1274-1280. [PMID: 37055478 DOI: 10.1038/s41372-023-01667-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 03/21/2023] [Accepted: 03/24/2023] [Indexed: 04/15/2023]
Abstract
OBJECTIVE To describe outcomes for infants in the neonatal intensive care unit with septic shock based on the vasopressor administered. METHODS This is a multicenter cohort study of infants with an episode of septic shock. We evaluated the primary outcomes of mortality and pressor-free days alive in the first week after shock using multivariable logistic and Poisson regressions. RESULTS We identified 1592 infants. Mortality was 50%. Dopamine was the most used vasopressor (92% of episodes) and hydrocortisone was co-administered with a vasopressor in 38% of episodes. Compared to infants treated with dopamine alone, adjusted odds of mortality were significantly higher for those treated with epinephrine alone (aOR 4.7 [95% CI: 2.3-9.2]). Adjuvant hydrocortisone was associated with significantly lower adjusted odds of mortality (aOR 0.60 [0.42-0.86]) CONCLUSIONS: The use of epinephrine as either a solo agent or in combination therapy was associated with significantly worse outcomes, while adjuvant hydrocortisone was associated with decreased mortality.
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Affiliation(s)
- Henry P Foote
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | | | - Rachel G Greenberg
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | | | - Christoph P Hornik
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA.
- Duke Clinical Research Institute, Durham, NC, USA.
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Willems A, Havaux R, Schmartz D, Fils JF, DE Pooter F, VAN DER Linden P. The choice of perioperative inotropic support impacts the outcome of small infants undergoing complex cardiac surgery: an observational study. Minerva Anestesiol 2023; 89:753-761. [PMID: 37676176 DOI: 10.23736/s0375-9393.23.16622-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/08/2023]
Abstract
BACKGROUND Vaso-inotropic agents are frequently used to prevent and/or treat low cardiac output syndrome in infants undergoing surgery for congenital heart disease. Due to the lack of comparative studies, their use is largely dependent on physician- and center preferences. The aim was to assess the impact of two different inotropic regimens, milrinone-epinephrine versus dobutamine on postoperative morbi-mortality in young children undergoing complex cardiac surgery. METHODS All consecutive children younger than one year of age admitted for complex cardiac surgery (Risk Adjustment in Congenital Heart Surgery-1 [RACHS-1] score ≥3) with cardiopulmonary bypass (CPB) from January 2008 to December 2018 were included. Children received either milrinone in association with low dose epinephrine (milrinone-epinephrine group) or dobutamine (dobutamine group) groups were matched and compared using a propensity score. Our primary outcome was a composite measure including either hospital death and/or the presence of at least two of the following events: respiratory failure, prolonged inotropic support, or renal failure. RESULTS Two hundred and fifty patients were included in the analysis. Children in the milrinone-epinephrine group (N.=184) suffered more frequently from a cyanotic heart disease and had longer surgery, CPB, and aortic cross clamp times than those in the dobutamine group (N.=66). After matching, children in the milrinone-epinephrine group had a higher incidence of severe postoperative morbidity or mortality compared to those in the dobutamine group (27.4 versus 13.9%; P=0.016). Respiratory failure (28% vs. 12%), prolonged inotropic support (71% vs. 35%) and in-hospital death (3 vs. 0%) were more frequent in the milrinone-epinephrine group. CONCLUSIONS In young infants undergoing complex cardiac surgery, milrinone combined with epinephrine is associated with a higher incidence of postoperative morbidity or mortality compared to dobutamine for perioperative inotropic support. Further prospective randomized studies are required to confirm this finding.
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Affiliation(s)
- Ariane Willems
- Pediatric Intensive Care Unit, Department of Pediatrics, Queen Fabiola University Children's Hospital, Brussels, Belgium -
| | - Renaud Havaux
- Department of Anesthesiology, University Hospital Brugmann and Queen Fabiola University Children's Hospital, Brussels, Belgium
| | - Denis Schmartz
- Department of Anesthesiology, University Hospital Brugmann and Queen Fabiola University Children's Hospital, Brussels, Belgium
| | | | - Françoise DE Pooter
- Department of Anesthesiology, University Hospital Brugmann and Queen Fabiola University Children's Hospital, Brussels, Belgium
| | - Philippe VAN DER Linden
- Department of Anesthesiology, University Hospital Brugmann and Queen Fabiola University Children's Hospital, Brussels, Belgium
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Ishiguro A, Kabe K. Effects of Catecholamines on Blood Flow in Preterm Infants: A Subanalysis of PICC-MBF Trial. Neonatology 2023; 120:673-680. [PMID: 37660690 DOI: 10.1159/000532017] [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: 05/13/2023] [Accepted: 07/06/2023] [Indexed: 09/05/2023]
Abstract
INTRODUCTION This study evaluated the correlation between skin blood flow and systemic blood flow and whether skin blood flow can determine the circulatory effects of dopamine and dobutamine on blood flow in very low birth weight (VLBW) infants. METHODS This study was a subanalysis of the PICC-MBF randomized controlled trial. The correlation between skin blood flow and echocardiographic findings was examined. Changes in skin blood flow and blood pressure before and after initiation or dose increase of dopamine and dobutamine were also evaluated. RESULTS Two hundred and thirty-four participants underwent echocardiography. Skin blood flow was significantly correlated with supra vena cava (SVC) flow (r = 0.31, p < 0.001). Receiver operator characteristic analysis revealed that skin blood flow <17 mL/min effectively detected SVC flow <41 mL/min (area under the curve = 0.83, p < 0.001). Dobutamine significantly increased skin blood flow after initiation or dose increase (p = 0.033) without increasing blood pressure. However, dopamine significantly increased both skin blood flow (p = 0.010) and blood pressure (p < 0.001). CONCLUSIONS Our findings indicated that skin blood flow could be used as a surrogate marker of systemic blood flow in VLBW infants and revealed differences in the effects of dopamine and dobutamine on circulation.
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Affiliation(s)
- Akio Ishiguro
- Division of Neonatal Medicine, Center for Maternal, Fetal and Neonatal Medicine, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
| | - Kazuhiko Kabe
- Division of Neonatal Medicine, Center for Maternal, Fetal and Neonatal Medicine, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
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Aladangady N, Sinha A, Banerjee J, Asamoah F, Mathew A, Chisholm P, Kempley S, Morris J. Comparison of clinical outcomes between active and permissive blood pressure management in extremely preterm infants. NIHR OPEN RESEARCH 2023; 3:7. [PMID: 37881469 PMCID: PMC10593335 DOI: 10.3310/nihropenres.13357.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/02/2023] [Indexed: 10/27/2023]
Abstract
Background There remains uncertainty about the definition of normal blood pressure (BP), and when to initiate treatment for hypotension for extremely preterm infants. To determine the short-term outcomes of extremely preterm infants managed by active compared with permissive BP support regimens during the first 72 hours of life. Method This is a retrospective medical records review of 23 +0-28 +6 weeks' gestational age (GA) infants admitted to neonatal units (NNU) with active BP support (aimed to maintain mean arterial BP (MABP) >30 mmHg irrespective of the GA) and permissive BP support (used medication only when babies developed signs of hypotension) regimens. Babies admitted after 12 hours of age, or whose BP data were not available were excluded. Results There were 764 infants admitted to the participating hospitals; 671 (88%) were included in the analysis (263 active BP support and 408 permissive BP support). The mean gestational age, birth weight, admission temperature, clinical risk index for babies (CRIB) score and first haemoglobin of infants were comparable between the groups. Active BP support group infants had consistently higher MABP and systolic BP throughout the first 72 hours of life (p<0.01). In the active group compared to the permissive group 56 (21.3%) vs 104 (25.5%) babies died, and 21 (8%) vs 51 (12.5%) developed >grade 2 intra ventricular haemorrhage (IVH). Death before discharge (adjusted OR 1.38 (0.88 - 2.16)) or IVH (1.38 (0.96 - 1.98)) was similar between the two groups. Necrotising enterocolitis (NEC) ≥stage 2 was significantly higher in permissive BP support group infants (1.65 (1.07 - 2.50)). Conclusions There was no difference in mortality or IVH between the two BP management approaches. Active BP support may reduce NEC. This should be investigated prospectively in large multicentre randomised studies.
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Affiliation(s)
- Narendra Aladangady
- Department of Neonatology, Homerton University Hospital, Homerton Healthcare NHS Foundation Trust, London, E9 6SR, UK
- Centre for Paediatrics, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Ajay Sinha
- Centre for Paediatrics, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Department of Neonatology, The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Jayanta Banerjee
- Department of Neonatology, Imperial College Healthcare NHS Trust, London, UK
- Institute of Reproductive and Developmental Biology, Imperial College London, London, UK
| | - Felix Asamoah
- Department of Statistics, NHS England and Improvement, London, UK
| | - Asha Mathew
- Department of Neonatology, Homerton University Hospital, Homerton Healthcare NHS Foundation Trust, London, E9 6SR, UK
| | - Phillippa Chisholm
- Department of Neonatology, Homerton University Hospital, Homerton Healthcare NHS Foundation Trust, London, E9 6SR, UK
| | - Steven Kempley
- Centre for Paediatrics, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Department of Neonatology, The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Joan Morris
- Environment, Prevention & Health Care, Population Health Research Institute, St George’s University of London, London, UK
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Zaveri PG, Walker AM, Upadhyay K, Talati AJ. Use of Vasopressors in Extremely Preterm Infants in First Week of Life. Am J Perinatol 2023; 40:513-518. [PMID: 33990125 DOI: 10.1055/s-0041-1729558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE A significant variability exists for diagnosis and treatment of hypotension in extremely preterm infants. Benefits of the use of vasopressors remain unclear. We wanted to identify the risk factors associated with use of vasopressors in the first week of life and their impact on outcomes of extremely preterm infants. STUDY DESIGN Retrospective review of all newborns ≤28 weeks of gestational age (GA) admitted in neonatal intensive care unit from October 1, 2012, to October 31, 2015, done. Data regarding antenatal and neonatal characteristics and outcomes were recorded. Study infants were divided into two cohorts and compared based on vasopressor use. Chi-square, t-test, and multiple logistic regression were performed as appropriate and significance set at p <0.05. RESULTS Of 213 extremely preterm infants, 90 (42.3%) received vasopressors in first week of life. The mean arterial pressure (MAP) at admission in these infants was significantly lower than that of infants who did not require vasopressors (27 ± 8 vs. 30 ± 6 mm Hg, p < 0.05). Vasopressors were initiated within 24 hours in 91% of babies. After controlling for other variables, use of vasopressors was significantly higher in infants with lower birth weight (odds ratio [OR]: 3.2, 95% confidence interval [CI]: 1.6-8.3), 5-minute Apgar's score ≤5 (OR: 1.8, 95% CI: 1.2-3.12), and admission hypothermia (OR: 2.7, 95% CI: 1.3-4.9). The use of vasopressors was significantly associated with severe intraventricular hemorrhage (IVH), even after controlling for other significant variables (OR: 5.9, 95% CI: 1.6-9.3). CONCLUSION Lower birth weight, low 5-minute Apgar's score, and admission hypothermia are characteristics associated with early use of vasopressors in extremely preterm infants. Infants treated with vasopressors are at a higher risk of developing severe IVH. KEY POINTS · Low systemic blood pressure is a very common problem in the extremely preterm population.. · In clinical practice, mean arterial blood pressure (BP) less than the infants GA in week is typically considered to be "low BP.". · About 50% of infants born at <29 weeks of GA received very preterm in the first week of life.. · Use of vasopressors is associated with a higher incidence of intraventricular hemorrhage in extremely preterm population..
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Affiliation(s)
- Parul G Zaveri
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee
- Division of Neonatology, Regional One Health, Memphis, Tennessee
| | - Amanda M Walker
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Kirtikumar Upadhyay
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | - Ajay J Talati
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee
- Division of Neonatology, Regional One Health, Memphis, Tennessee
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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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11
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Fletcher KL, Chapman R. Update on pre-ECMO evaluation and treatment for term infants in respiratory failure. Semin Fetal Neonatal Med 2022; 27:101401. [PMID: 36450631 DOI: 10.1016/j.siny.2022.101401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The epidemiology, diagnostic and management approach to severe hypoxemic respiratory failure in the term and near-term neonate has evolved over time, as has the need for extracorporeal membrane oxygenation (ECMO) support in this patient population. Many patients who historically would have required ECMO support now respond to less invasive therapies, with patients requiring ECMO generally representing a higher risk and more heterogenous group of underlying diagnoses. This review will highlight these changes over time and the current available evidence for the diagnosis and management of these infants, as well as the current indications and relative contraindications to ECMO support when oxygen delivery cannot meet demand with less invasive management.
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Affiliation(s)
- Kathryn L Fletcher
- Division of Perinatal Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT, 333 Cedar Street, LMP, 4085, USA.
| | - Rachel Chapman
- Department of Pediatrics, USC Keck School of Medicine, Fetal & Neonatal Institute, Children's Hospital Los Angeles, 4650 Sunset Blvd, Los Angeles, CA, 90027, USA.
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12
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Cooper DS, Hill KD, Krishnamurthy G, Sen S, Costello JM, Lehenbauer D, Twite M, James L, Mah KE, Taylor C, McBride ME. Acute Cardiac Care for Neonatal Heart Disease. Pediatrics 2022; 150:189882. [PMID: 36317971 DOI: 10.1542/peds.2022-056415j] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 11/07/2022] Open
Abstract
This manuscript is one component of a larger series of articles produced by the Neonatal Cardiac Care Collaborative that are published in this supplement of Pediatrics. In this review article, we summarize the contemporary physiologic principles, evaluation, and management of acute care issues for neonates with complex congenital heart disease. A multidisciplinary team of authors was created by the Collaborative's Executive Committee. The authors developed a detailed outline of the manuscript, and small teams of authors were assigned to draft specific sections. The authors reviewed the literature, with a focus on original manuscripts published in the last decade, and drafted preliminary content and recommendations. All authors subsequently reviewed and edited the entire manuscript until a consensus was achieved. Topics addressed include cardiopulmonary interactions, the pathophysiology of and strategies to minimize the development of ventilator-induced low cardiac output syndrome, common postoperative physiologies, perioperative bleeding and coagulation, and common postoperative complications.
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Affiliation(s)
- David S Cooper
- Department of Pediatrics, University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kevin D Hill
- Division of Cardiology, Duke Children's Hospital, Durham, North Carolina
| | - Ganga Krishnamurthy
- Division of Neonatology, Columbia University Medical Center, New York, New York
| | - Shawn Sen
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - John M Costello
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina
| | - David Lehenbauer
- Department of Pediatrics, University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Mark Twite
- Department of Anesthesia, Colorado Children's Hospital, Aurora, Colorado
| | - Lorraine James
- Department of Pediatrics, Children's Hospital of Los Angeles, Los Angeles, California
| | - Kenneth E Mah
- Department of Pediatrics, University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Carmen Taylor
- Department of Pediatric Cardiothoracic Surgery, The Children's Hospital, Oklahoma City, Oklahoma
| | - Mary E McBride
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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13
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McNamara PJ, Giesinger RE, Lakshminrusimha S. Dopamine and Neonatal Pulmonary Hypertension-Pressing Need for a Better Pressor? J Pediatr 2022; 246:242-250. [PMID: 35314154 DOI: 10.1016/j.jpeds.2022.03.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 02/07/2022] [Accepted: 03/15/2022] [Indexed: 02/07/2023]
Affiliation(s)
- Patrick J McNamara
- Division of Neonatology, Department of Pediatrics, University of Iowa, Iowa City, IA.
| | - Regan E Giesinger
- Division of Neonatology, Department of Pediatrics, University of Iowa, Iowa City, IA
| | - Satyan Lakshminrusimha
- Division of Neonatology, Department of Pediatrics, University of California Davis, Sacramento, CA
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14
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Sarafidis K, Verykouki E, Nikopoulos S, Apostolidou-Kiouti F, Diakonidis T, Agakidou E, Kontou A, Haidich AB. Systematic Review and Meta-Analysis of Cardiovascular Medications in Neonatal Hypotension. Biomed Hub 2022; 7:70-79. [PMID: 35950013 PMCID: PMC9251481 DOI: 10.1159/000525133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 04/20/2022] [Indexed: 11/19/2022] Open
Abstract
Background Comparative studies among the various cardiovascular medications used for the treatment of neonatal hypotension are lacking. Methods This systematic review and pairwise meta-analysis of the anti-hypotensive treatments in preterm and term infants was conducted to evaluate efficacy and impact on outcome. Electronic databases were searched up to February 2021 for relevant articles. As an extension of the current approach for study selection, a machine learning technique was used. Only randomized controlled trials (RCTs) of inotropes, pressors, volume therapy, and corticosteroids were included. Response to treatment was the primary outcome while secondary outcomes included mortality and common morbidities. Results Nineteen RCTs involving 758 preterm and term neonates were found, and 8 treatments were evaluated. Most studies involved subjects with early hypotension associated with prematurity. Pairwise meta-analysis among treatments showed that dopamine was more effective than dobutamine regarding the response to treatment (restoration of normotension or normalization of blood pressure) (7 trials, 286 neonates, odds ratio, 3.06 [95% CI = 1.06–8.87]; I<sup>2</sup> = 49%, very low quality of the evidence per GRADE). Comparisons of other treatments were not significant. No differences were found among regimens regarding survival and other secondary outcomes. Conclusion In this systematic review and pairwise meta-analysis, only the comparison of dopamine versus dobutamine provided evidence for efficacy of treatment and favored dopamine. No safe conclusions could be reached in regard to other treatments. Data regarding the management of arterial hypotension in conditions other than transition after birth in preterm newborns are sparse both in preterm and term infants.
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Affiliation(s)
- Kosmas Sarafidis
- 1st Department of Neonatology, School of Medicine, Aristotle University of Thessaloniki, Hppokrateion General Hospital, Thessaloniki, Greece
- *Kosmas Sarafidis,
| | - Eleni Verykouki
- Department of Hygiene, Social-Preventive Medicine & Medical Statistics, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Stefanos Nikopoulos
- 1st Department of Neonatology, School of Medicine, Aristotle University of Thessaloniki, Hppokrateion General Hospital, Thessaloniki, Greece
| | - Fani Apostolidou-Kiouti
- Department of Hygiene, Social-Preventive Medicine & Medical Statistics, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Theodoros Diakonidis
- Department of Hygiene, Social-Preventive Medicine & Medical Statistics, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleni Agakidou
- 1st Department of Neonatology, School of Medicine, Aristotle University of Thessaloniki, Hppokrateion General Hospital, Thessaloniki, Greece
| | - Aggeliki Kontou
- 1st Department of Neonatology, School of Medicine, Aristotle University of Thessaloniki, Hppokrateion General Hospital, Thessaloniki, Greece
| | - Anna-Bettina Haidich
- Department of Hygiene, Social-Preventive Medicine & Medical Statistics, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
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15
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Goldsmith JP, Keels E. Recognition and Management of Cardiovascular Insufficiency in the Very Low Birth Weight Newborn. Pediatrics 2022; 149:184900. [PMID: 35224636 DOI: 10.1542/peds.2021-056051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The measurement of blood pressure in the very low birth weight newborn infant is not simple and may be erroneous because of numerous factors. Assessment of cardiovascular insufficiency in this population should be based on multiple parameters and not only on numeric blood pressure readings. The decision to treat cardiovascular insufficiency should be made after considering the potential complications of such treatment. There are numerous potential strategies to avoid or mitigate hypoperfusion states in the very low birth weight infant.
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Affiliation(s)
- Jay P Goldsmith
- Department of Pediatrics, Division of Newborn Medicine, Tulane University, New Orleans, Louisiana
| | - Erin Keels
- Neonatal Practitioner Program, Neonatal Services, Nationwide Children's Hospital, Columbus, Ohio
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16
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Vasoactive medications in extremely low gestational age neonates during the first postnatal week. J Perinatol 2021; 41:2330-2336. [PMID: 33758384 PMCID: PMC9204669 DOI: 10.1038/s41372-021-01031-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 02/16/2021] [Accepted: 02/24/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The management of early hypotension in extremely low gestational age neonates (ELGANs) varies greatly between centers. The objective of this study was to provide updated data on the use of vasoactive medications in ELGANs during the first postnatal week. STUDY DESIGN We identified ELGANs (22-27 weeks gestational age) cared for at Pediatrix neonatal intensive care units from 2009 to 2018. We evaluated the frequency of exposure to vasoactive medications by gestational age, and compared use of vasoactive medications between two epochs (2009-2013 and 2014-2018). RESULTS A total of 10,070/34,234 (29%) ELGANs received ≥1 vasoactive medication. Dopamine was the most frequently used vasoactive medication. The majority (83%) of treated ELGANs initiated therapy on postnatal days 0-1. Overall use of vasoactive medications was slightly lower in 2014-2018 than 2009-2013 (28 vs 31%, p < 0.001). CONCLUSION A substantial proportion of ELGANs were exposed to vasoactive medications during the first postnatal week.
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17
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Siefkes HM, Lakshminrusimha S. Management of systemic hypotension in term infants with persistent pulmonary hypertension of the newborn: an illustrated review. Arch Dis Child Fetal Neonatal Ed 2021; 106:446-455. [PMID: 33478959 PMCID: PMC8217132 DOI: 10.1136/archdischild-2020-319705] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 12/22/2020] [Accepted: 12/29/2020] [Indexed: 01/03/2023]
Abstract
In persistent pulmonary hypertension of the newborn (PPHN), the ratio of pulmonary vascular resistance to systemic vascular resistance is increased. Extrapulmonary shunts (patent ductus arteriosus and patent foramen value) allow for right-to-left shunting and hypoxaemia. Systemic hypotension can occur in newborns with PPHN due to variety of reasons, such as enhanced peripheral vasodilation, impaired left ventricular function and decreased preload. Systemic hypotension can lead to end organ injury from poor perfusion and hypoxaemia in the newborn with PPHN. Thus, it must be managed swiftly. However, not all newborns with PPHN and systemic hypotension can be managed the same way. Individualised approach based on physiology and echocardiographic findings are necessary to improve perfusion to essential organs. Here we present a review of the physiology and mechanisms of systemic hypotension in PPHN, which can then guide treatment.
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Affiliation(s)
- Heather M. Siefkes
- Department of Pediatrics, University of California, Davis, Sacramento, California, United States of America
| | - Satyan Lakshminrusimha
- Department of Pediatrics, University of California, Davis, Sacramento, California, United States of America
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18
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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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19
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Lee G, Kaiser JR, Moffett BS, Rodman E, Toy C, Rios DR. Efficacy of Low-Dose Epinephrine Continuous Infusion in Neonatal Intensive Care Unit Patients. J Pediatr Pharmacol Ther 2021; 26:51-55. [PMID: 33424500 DOI: 10.5863/1551-6776-26.1.51] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 06/09/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Although epinephrine is used in the neonatal intensive care unit, few data exist on efficacy of doses <0.05 mcg/kg/min. This study evaluates the efficacy and safety of low-dose epinephrine continuous infusion at doses <0.05 mcg/kg/min in infants. METHODS Single-center, retrospective review of hypotensive infants from 2011-2018. Charts were reviewed for initial and maximum epinephrine doses, additional vasoactive agents, short-term efficacy, and adverse effects. The primary outcome was percentage of patients initiated on low-dose epinephrine whose dose did not require titration to ≥0.05 mcg/kg/min. RESULTS A total of 115 patients met study criteria with 131 distinct occurrences of low-dose epinephrine initiation. Most patients were unresponsive to other vasopressors at the time of epinephrine initiation. The median (IQR) starting dose of low-dose epinephrine was 0.01 (0.01-0.04) mcg/kg/min and median (IQR) maximum dose was 0.04 (0.02-0.08) mcg/kg/min. Fifty-five percent were responders. Patients in this cohort demonstrated significant improvement of blood pressure and urine output (p < 0.001) without adverse effects. CONCLUSIONS Low-dose epinephrine infusion may be considered as an alternative treatment to standard starting doses in hypotensive neonatal intensive care unit patients.
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20
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Abstract
Primary function of cardiovascular system is to meet body's metabolic demands. The aim of inotrope therapy is to minimise adverse impact of cardiovascular compromise. Current use of inotropes is primarily guided by the pathophysiology of cardiovascular compromise and anticipated actions of inotropes. Lack of significant reduction in morbidity and mortality associated with cardiovascular compromise despite inotrope use, highlights major gaps in our understanding of circulatory targets, thresholds and choices of inotrope therapy. Thus far, prevention of cardiovascular compromise remains the most effective strategy to optimize outcomes. Studies of alternative design are needed for further advancement in cardiovascular therapy in neonates.
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Affiliation(s)
- Nilkant Phad
- Department of Neonatology, John Hunter Children's Hospital, Lookout Road, New Lambton Heights, New South Wales 2305, Australia; University of Newcastle, Newcastle, Australia.
| | - Koert de Waal
- Department of Neonatology, John Hunter Children's Hospital, Lookout Road, New Lambton Heights, New South Wales 2305, Australia; University of Newcastle, Newcastle, Australia
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21
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Barrington K, El-Khuffash A, Dempsey E. Intervention and Outcome for Neonatal Hypotension. Clin Perinatol 2020; 47:563-574. [PMID: 32713451 DOI: 10.1016/j.clp.2020.05.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Many observational studies have shown that infants with blood pressures (BPs) that are in the lower range for their gestational age tend to have increased complications such as an increased rate of significant intraventricular hemorrhage and adverse long-term outcome. This relationship does not prove causation nor should it create an indication for treatment. However, many continue to intervene with medication for low BP on the assumption that an increase in BP will result in improved outcome. Only adequately powered prospective randomized controlled trials can answer the question of whether individual treatments of low BP are beneficial.
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Affiliation(s)
| | - Afif El-Khuffash
- The Rotunda Hospital, Dublin and Royal College of Surgeons, Dublin, Ireland
| | - Eugene Dempsey
- Department of Paediatrics and Child Health, INFANT Centre, University College Cork, Ireland.
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22
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Göpel W, Müller M, Rabe H, Borgmann J, Rausch TK, Faust K, Kribs A, Dötsch J, Ellinghaus D, Härtel C, Roll C, Szabo M, Nürnberg P, Franke A, König IR, Turner MA, Herting E. Genetic background of high blood pressure is associated with reduced mortality in premature neonates. Arch Dis Child Fetal Neonatal Ed 2020; 105:184-189. [PMID: 31201254 PMCID: PMC7063394 DOI: 10.1136/archdischild-2019-317131] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 05/07/2019] [Accepted: 05/28/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The aim of our study was to determine if a genetic background of high blood pressure is a survival factor in preterm infants. DESIGN Prospective cohort study. SETTING Patients were enrolled in 53 neonatal intensive care units. PATIENTS Preterm infants with a birth weight below 1500 g. EXPOSURES Genetic score blood pressure estimates were calculated based on adult data. We compared infants with high genetic blood pressure estimates (>75th percentile of the genetic score) to infants with low genetic blood pressure estimates (<25th percentile of the genetic score). MAIN OUTCOME MEASURES Lowest blood pressure on the first day of life and mortality. RESULTS 5580 preterm infants with a mean gestational age of 28.1±2.2 weeks and a mean birth weight of 1022±299 g were genotyped and analysed. Infants with low genetic blood pressure estimates had significantly lower blood pressure if compared with infants with high genetic blood pressure estimates (27.3±6.2vs 27.9±6.4, p=0.009, t-test). Other risk factors for low blood pressure included low gestational age (-1.26 mm Hg/week) and mechanical ventilation (-2.24 mm Hg, p<0.001 for both variables, linear regression analysis). Mortality was significantly reduced in infants with high genetic blood pressure estimates (28-day mortality: 21/1395, 1.5% vs 44/1395, 3.2%, p=0.005, Fisher's exact test). This survival advantage was independent of treatment with catecholamines. CONCLUSIONS Our study provides first evidence that a genetic background of high blood pressure may be beneficial with regard to survival of preterm infants.
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Affiliation(s)
| | - Mirja Müller
- Paediatrics, University of Lübeck, Lübeck, Germany
| | - Heike Rabe
- Neonatology, Brighton Sussex University Hospitals NHS Trust, Brighton, UK
| | | | - Tanja K Rausch
- Institute for Medical Biometry and Statistics Lübeck, Lübeck, Germany
| | | | - Angela Kribs
- Neonatology and Pediatric Intensive Care, University Hospital of Cologne, Cologne, Germany
| | - Jörg Dötsch
- Department of Paediatrics, University of Cologne, Cologne, Germany
| | - David Ellinghaus
- Institute of Clinical Molecular Biology, Christian-Albrechts-Universitat zu Kiel, Kiel, Germany
| | | | - Claudia Roll
- Neonatology, Universitat Witten/Herdecke, Witten, Germany
| | - Miklos Szabo
- Neonatology, Semmelweis University, Budapest, Hungary
| | - Peter Nürnberg
- Cologne Center for Genomics, University Hospital of Cologne, Cologne, Germany
| | - Andre Franke
- Institute of Clinical Molecular Biology, Christian-Albrechts-Universitat zu Kiel, Kiel, Germany
| | - Inke R König
- Institute for Medical Biometry and Statistics Lübeck, Lübeck, Germany
| | - Mark A Turner
- Division of Perinatal Reproductive Medicine, University of Liverpool, Liverpool, UK
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23
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Neonatal Hypotension: What Is the Efficacy of Each Anti-Hypotensive Intervention? A Systematic Review. ACTA ACUST UNITED AC 2019. [DOI: 10.1007/s40746-019-00175-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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24
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Abstract
There is a distinct lack of age-appropriate cardiotonic drugs, and adult derived formulations continue to be administered, without evidence-based knowledge on their dosing, safety, efficacy, and long-term effects. Dopamine remains the most commonly studied and prescribed cardiotonic drug in the neonatal intensive care unit (NICU), but evidence of its effect on endorgan perfusion still remains. Unlike adult and pediatric critical care, there are significant gaps in our knowledge on the use of various cardiotonic drugs in various forms of circulatory failure in the NICU.
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Affiliation(s)
- Eugene Dempsey
- Department of Paediatrics and Child Health, Neonatal Intensive Care Unit, University College Cork, Wilton, Cork, Ireland; Irish Centre for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland.
| | - Heike Rabe
- Brighton and Sussex Medical School, University of Sussex, Brighton, UK; Department of Neonatology, Brighton & Sussex University Hospitals NHS Trust, Brighton, UK
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25
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Krishnamurthy G. Cardiopulmonary Bypass in Premature and Low Birth Weight Neonates - Implications for Postoperative Care From a Neonatologist/Intensivist Perspective. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2019; 22:2-9. [PMID: 31027559 DOI: 10.1053/j.pcsu.2019.02.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 02/26/2019] [Indexed: 11/11/2022]
Abstract
Prematurity and low weight remain significant risk factors for mortality after neonatal cardiac surgery despite steady gains in survival. Newer and lower weight thresholds for operability are constantly generated as surgeons gather proficiency, technical mastery, and experience in performing complex procedures on extremely small infants. Relationship between birth weight and survival after cardiac surgery is nonlinear with 2 kg being an inflection point below which marked decline in survival occurs. If strides toward improved survival in this weight category are to be made, understanding the inherent vulnerabilities of the premature and low birth weight infant is important in addition to acknowledging the vulnerabilities of the system in which care is delivered.
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Affiliation(s)
- Ganga Krishnamurthy
- Division of Neonatology, Columbia University Medical Center, New York, New York.
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26
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Bravo MC, López-Ortego P, Sánchez L, Madero R, Cabañas F, Koch A, Rojas-Anaya H, Rabe H, Pellicer A. Validity of Biomarkers of Early Circulatory Impairment to Predict Outcome: A Retrospective Analysis. Front Pediatr 2019; 7:212. [PMID: 31192178 PMCID: PMC6548875 DOI: 10.3389/fped.2019.00212] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 05/10/2019] [Indexed: 11/13/2022] Open
Abstract
Objectives: The definition of circulatory impairment in the premature infant is controversial. Current research suggests overdiagnosis and overtreatment. We aimed to analyse which biomarkers move clinicians to initiate cardiovascular treatment (CVT). The prognostic capacity for adverse outcome (death and/or moderate-severe brain damage by cranial ultrasound at term equivalent) of these biomarkers was evaluated. Study Design: Retrospective data analysis from preterm infants enrolled in a placebo-controlled trial on dobutamine for low superior vena cava (SVC) flow, who showed normal SVC flow within the first 24 h (not randomized). Five positive biomarkers were considered: MABP < gestational age (GA)-1 mmHg; MABP < GA-5 mmHg; lactate > 4 mmol/L; BE < -9 mmol/L; SVC flow <51 ml/kg/min. Results: Ninety eight infants formed the study cohort. Thirty six received CVT (2-95 h). Logistic regression models adjusted for gestational age showed a positive association between CVT and the risk of death or moderate-severe abnormal cranial ultrasound at term equivalent [(OR 5.2, 95%CI: 1.8-15.1) p = 0.002]. MABP < GA-1 mmHg and lactate > 4 mmol/L were the most prevalent biomarkers at start of treatment. Low BE, high serum lactate and low SVC flow at first echocardiography showed a trend toward being associated with adverse outcome, although not statistically significant. Conclusions: Low blood pressure and high lactate are the most prevalent biomarkers used for CVT prescription. Lactic acidosis and low SVC flow early after birth showed a trend toward being associated with adverse outcome. These findings support using a combination of biomarkers for inclusion in a placebo-controlled trial on CVT during transitional circulation.
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Affiliation(s)
| | | | - Laura Sánchez
- Department of Neonatology, La Paz University Hospital, Madrid, Spain
| | - Rosario Madero
- Division of Statistics, La Paz University Hospital, Madrid, Spain
| | - Fernando Cabañas
- Department of Neonatology, La Paz University Hospital, Madrid, Spain.,Department of Pediatrics and Neonatology, Quironsalud Madrid University Hospital, Madrid, Spain
| | - Armin Koch
- Medizinische Hochschule Hannover, Institut für Biometrie, Hannover, Germany
| | - Héctor Rojas-Anaya
- Academic Department of Paediatrics, Brighton and Sussex Medical School, Brighton, United Kingdom
| | - Heike Rabe
- Academic Department of Paediatrics, Brighton and Sussex Medical School, Brighton, United Kingdom
| | - Adelina Pellicer
- Department of Neonatology, La Paz University Hospital, Madrid, Spain
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27
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Lingwood BE, Eiby YA, Bjorkman ST, Miller SM, Wright IMR. Supporting preterm cardiovascular function. Clin Exp Pharmacol Physiol 2018; 46:274-279. [PMID: 30347457 DOI: 10.1111/1440-1681.13044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 09/04/2018] [Accepted: 10/15/2018] [Indexed: 11/30/2022]
Abstract
Preterm infants are at higher risk of adverse neurodevelopmental outcomes. Inadequate cerebral oxygen delivery resulting from poor cardiovascular function is likely to be a significant contributor to preterm brain injury. In this context, improved support of cardiovascular function is integral to improving preterm outcomes. Many of the treatments used to support preterm cardiovascular function are based on adult physiology and may not be appropriate for the unique physiology of the preterm infant. The preterm heart is structurally immature with reduced contractility and low cardiac output. However, there is limited evidence that inotropic support with dopamine and/or dobutamine is effective in preterm babies. Hypovolemia may also contribute to poor preterm cardiovascular function; there is evidence that capillary leakage results in considerable loss of plasma from the circulation of newborn preterm babies. In addition, the vasoconstrictor response to acute stimuli does not develop until quite late in gestation and is limited in the preterm infant. This may lead to inappropriate vasodilatation adding to functional hypovolemia. The first line treatment for hypotension in preterm infants is volume expansion with crystalloid solutions, but this has limited efficacy in the preterm infant. More effective methods of volume expansion are required. Effective support of preterm cardiovascular function requires better understanding of preterm cardiovascular physiology so that treatments can target mechanisms that are sufficiently mature to respond.
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Affiliation(s)
- Barbara E Lingwood
- UQ Centre for Clinical Research and Perinatal Research Centre, The University of Queensland, Brisbane, Australia
| | - Yvonne A Eiby
- UQ Centre for Clinical Research and Perinatal Research Centre, The University of Queensland, Brisbane, Australia
| | - Stella T Bjorkman
- UQ Centre for Clinical Research and Perinatal Research Centre, The University of Queensland, Brisbane, Australia
| | - Stephanie M Miller
- UQ Centre for Clinical Research and Perinatal Research Centre, The University of Queensland, Brisbane, Australia
| | - Ian M R Wright
- Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, Australia
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28
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Antonucci R, Antonucci L, Locci C, Porcella A, Cuzzolin L. Current Challenges in Neonatal Resuscitation: What is the Role of Adrenaline? Paediatr Drugs 2018; 20:417-428. [PMID: 29923109 DOI: 10.1007/s40272-018-0300-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Adrenaline, also known as epinephrine, is a hormone, neurotransmitter, and medication. It is the best established drug in neonatal resuscitation, but only weak evidence supports current recommendations for its use. Furthermore, the available evidence is partly based on extrapolations from adult studies, and this introduces further uncertainty, especially when considering the unique physiological characteristics of newly born infants. The timing, dose, and route of administration of adrenaline are still debated, even though this medication has been used in neonatal resuscitation for a long time. According to the most recent Neonatal Resuscitation Guidelines from the American Heart Association, adrenaline use is indicated when the heart rate remains < 60 beats per minute despite the establishment of adequate ventilation with 100% oxygen and chest compressions. The aforementioned guidelines recommend intravenous administration (via an umbilical venous catheter) of adrenaline at a dose of 0.01-0.03 mg/kg (1:10,000 concentration). Endotracheal administration of a higher dose (0.05-0.1 mg/kg) may be considered while venous access is being obtained, even if supportive data for endotracheal adrenaline are lacking. The safety and efficacy of intraosseous administration of adrenaline remain to be investigated. This article reviews the evidence on the circulatory effects and tolerability of adrenaline in the newborn, discusses literature data on adrenaline use in neonatal cardiopulmonary resuscitation, and describes international recommendations and outcome data regarding the use of this medication during neonatal resuscitation.
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Affiliation(s)
- Roberto Antonucci
- Pediatric Clinic, Department of Clinical and Experimental Medicine, University of Sassari, Sassari, Italy.
| | - Luca Antonucci
- Academic Department of Pediatrics, Children's Hospital Bambino Gesù, University of Rome "Tor Vergata", Rome, Italy
| | - Cristian Locci
- Pediatric Clinic, Department of Clinical and Experimental Medicine, University of Sassari, Sassari, Italy
| | - Annalisa Porcella
- Division of Neonatology and Pediatrics, "Nostra Signora di Bonaria" Hospital, San Gavino Monreale, Italy
| | - Laura Cuzzolin
- Department of Diagnostics and Public Health, Section of Pharmacology, University of Verona, Verona, Italy
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Baske K, Saini SS, Dutta S, Sundaram V. Epinephrine versus dopamine in neonatal septic shock: a double-blind randomized controlled trial. Eur J Pediatr 2018; 177:1335-1342. [PMID: 29936590 DOI: 10.1007/s00431-018-3195-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 06/10/2018] [Accepted: 06/12/2018] [Indexed: 12/17/2022]
Abstract
We compared epinephrine and dopamine as a first-line vasoactive drug in 40 neonates (enrolled in two gestational age strata ≤ 306/7 and ≥ 310/7 weeks) with fluid-refractory septic shock. Epinephrine or dopamine was initiated at 0.2 or 10 μg/kg/min, respectively. If shock persisted after 15 min, epinephrine or dopamine was increased to 0.3 or 15 μg/kg/min, respectively (16-30 min), and thereafter to 0.4 or 20 μg/kg/min (31-45 min). Proportion of neonates achieving 'reversal of shock' (defined as systolic and diastolic BP > fifth centile and capillary filling time < 3 s and left ventricular output ≥ 150 mL/kg/min) by 45 min [5 (25%) vs 6 (30%), RR 0.83 (95% CI 0.30, 2.29)]; haemodynamic stability (shock reversal for ≥ 120 min without escalation of vasoactive drugs) anytime during therapy [10 (50%) vs 6 (30%), RR 1.67 (95% CI 0.75, 3.71)]; and all-cause mortality by 28 days [14 (70%) vs 16 (80%), RR 0.87 (95% CI 0.61, 1.26)] were comparable in the epinephrine and dopamine groups, respectively. On stratified analysis, we observed an interaction of gestational age strata with the group of allocation favouring epinephrine in neonates ≤ 306/7 weeks.Conclusion: Epinephrine (0.2-0.4 μg/kg/min) and dopamine (10-20 μg/kg/min) had comparable efficacy and safety in neonatal septic shock.Clinical Trial registry name and registration number: The study was registered with Clinical Trial Registry of India CTRI/2015/10/006285. What is Known: • The choice of vasoactive drugs in neonatal septic shock is empirical and dopamine is the conventional first-line vasoactive drug. • There are no randomized controlled trials comparing dopamine and epinephrine in neonatal septic shock. What is New: • In this study, epinephrine and dopamine had comparable efficacy and safety as a first-line vasoactive drug in management of neonatal septic shock. • On stratified analysis in a limited sample, epinephrine was associated with better outcomes in neonates ≤ 306/7 weeks.
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Affiliation(s)
- Kishore Baske
- Division of Neonatology, Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Shiv Sajan Saini
- Division of Neonatology, Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India.
| | - Sourabh Dutta
- Division of Neonatology, Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Venkataseshan Sundaram
- Division of Neonatology, Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
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Interpretation of Cerebral Oxygenation Changes in the Preterm Infant. CHILDREN-BASEL 2018; 5:children5070094. [PMID: 29987227 PMCID: PMC6069134 DOI: 10.3390/children5070094] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 06/28/2018] [Accepted: 07/06/2018] [Indexed: 12/30/2022]
Abstract
Near-infrared spectroscopy (NIRS) allows for continuous, non-invasive monitoring of end-organ tissue oxygenation. The use of NIRS, cerebral NIRS (cNIRS) in particular, in neonatal care has increased significantly over the last few years. This dynamic monitoring technique provides real-time information on the cerebral and haemodynamic status of the neonate and has the potential to serve as an important adjunct to patient care with some centres routinely utilising cNIRS to aid decision-making at the bedside. cNIRS values may be influenced by many variables, including cardiac, respiratory and metabolic parameters, and therefore it is essential to understand the pathophysiology behind alterations in cNIRS values. Correct interpretation is required to direct appropriate patient-specific interventions. This article aims to assist clinicians in deciphering cNIRS values by providing an overview of potential causes of fluctuations in cNIRS values, illustrated by common clinical scenarios, with particular emphasis on the preterm infant.
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Splanchnic NIRS monitoring in neonatal care: rationale, current applications and future perspectives. J Perinatol 2018; 38:431-443. [PMID: 29472709 DOI: 10.1038/s41372-018-0075-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2017] [Revised: 11/22/2017] [Accepted: 11/28/2017] [Indexed: 12/29/2022]
Abstract
Near infrared spectroscopy (NIRS) provides a non-invasive, continuous monitoring of regional tissue oxygenation. NIRS assessment of neonatal splanchnic oxygenation (SrSO2) has gained increasing interest over the last decade, as local hypoxia and ischemia underlie the most feared gut complications in neonates. Current literature provides encouraging evidence in support of SrSO2 reliability in detecting mesenteric hemodynamic changes related to various physiological and pathological conditions in-term and preterm infants. Even so, while splanchnic NIRS monitoring looks promising for investigating gut physiopathology in research settings, further studies are needed to evaluate its feasibility as a routine monitoring tool in neonatal care and to investigate its potential role in clinical decision making. After a brief introduction to NIRS technical principles, this review aims to provide a complete overview of current neonatal applications for splanchnic NIRS monitoring, to discuss its possible limitations and to suggest future directions for research and clinical applications.
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Joynt C, Cheung PY. Treating Hypotension in Preterm Neonates With Vasoactive Medications. Front Pediatr 2018; 6:86. [PMID: 29707527 PMCID: PMC5908904 DOI: 10.3389/fped.2018.00086] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 03/19/2018] [Indexed: 12/23/2022] Open
Abstract
Preterm neonates often have hypotension which may be due to various etiologies. While it is controversial to define hypotension in preterm neonates, various vasoactive medications are commonly used to provide the cardiovascular support to improve the blood pressure, cardiac output, or to treat shock. However, the literature on the systemic and regional hemodynamic effects of these antihypotensive medications in neonates is deficient and incomplete, and cautious translation of findings from other clinical populations and animal studies is required. Based on a literature search on published reports, meta-analytic reviews, and selected abstracts, this review discusses the current available information on pharmacologic actions, clinical effects, and side effects of commonly used antihypotensive medications including dopamine, dobutamine, epinephrine, norepinephrine, vasopressin, and milrinone in preterm neonates.
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Affiliation(s)
- Chloe Joynt
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Po-Yin Cheung
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.,Department of Pharmacology and Surgery, University of Alberta, Edmonton, AB, Canada.,Centre for the Studies of Asphyxia and Resuscitation, Edmonton, AB, Canada
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Garvey AA, Kooi EMW, Dempsey EM. Inotropes for Preterm Infants: 50 Years on Are We Any Wiser? Front Pediatr 2018; 6:88. [PMID: 29682496 PMCID: PMC5898425 DOI: 10.3389/fped.2018.00088] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 03/20/2018] [Indexed: 12/20/2022] Open
Abstract
For almost half a century, inotropes have been administered to preterm infants with the ultimate goal of increasing their blood pressure. A number of trials, the majority of which focused on dopamine administration, have demonstrated increased blood pressure following inotrope administration in preterm infants and have led to continued use of inotropes in our neonatal units. We have also seen an increase in the number of potential agents available to the clinician. However, we now know that hypotension is a much broader concept than blood pressure alone, and our aim should instead be focused on improving end organ perfusion, specifically cerebral perfusion. Only a limited number of studies have incorporated the organ-relevant hemodynamic changes and long-term outcomes when assessing inotropic effects in neonates, the majority of which are observational studies or have a small sample size. In addition, important considerations, including the developing/maturing adrenergic receptors, polymorphisms of these receptors, and other differences in the pharmacokinetics and pharmacodynamics of preterm infants, are only recently being recognized. Certainly, there remains huge variation in practice. The lack of well-conducted randomized controlled trials addressing these relevant outcomes, along with the difficulty executing such RCTs, leaves us with more questions than answers. This review provides an overview of the various inotropic agents currently being used in the care of preterm infants, with a particular focus on their organ/cerebral hemodynamic effects both during and after transition.
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Affiliation(s)
- Aisling A Garvey
- Department of Paediatrics and Child Health, Neonatal Intensive Care Unit, University College Cork, Cork, Ireland.,INFANT, Irish Centre for Fetal and Neonatal Translational Research, University College Cork, Cork, Ireland
| | - Elisabeth M W Kooi
- Department of Paediatrics and Child Health, Neonatal Intensive Care Unit, University College Cork, Cork, Ireland.,Division of Neonatology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Eugene M Dempsey
- Department of Paediatrics and Child Health, Neonatal Intensive Care Unit, University College Cork, Cork, Ireland.,INFANT, Irish Centre for Fetal and Neonatal Translational Research, University College Cork, Cork, Ireland
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Rabe H, Rojas-Anaya H. Inotropes for preterm babies during the transition period after birth: friend or foe? Arch Dis Child Fetal Neonatal Ed 2017; 102:F547-F550. [PMID: 28818851 DOI: 10.1136/archdischild-2016-311709] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 06/28/2017] [Accepted: 07/06/2017] [Indexed: 11/04/2022]
Abstract
During the transition to extrauterine life, preterm infants are at high risk of developing circulatory failure. Currently, hypotension is used as major diagnostic criteria for starting treatments such as fluid boluses, inotropes or steroids. Most of these treatment options have not been studied in large randomised controlled trials for efficacy and safety and are under discussions. A wide variety in their use is reported in the literature and clear evidence about which inotrope or other treatment should be preferred is lacking. In addition, there is ongoing debate about the appropriate threshold values for blood pressure. Other diagnostic measures for poor circulation are functional echocardiography, near-infrared spectroscopy, capillary refill time, base excess and serum lactate. Large randomised controlled trials for the use of dopamine and dobutamine in preterm infants <32 weeks gestation are under way to fill the knowledge gaps on the assessment of circulatory compromise and on efficacy and safety of the studied age-appropriate drug formulations.
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Affiliation(s)
- Heike Rabe
- Department of Paediatrics, Brighton and Sussex Medical School, Brighton, UK.,Department of Neonatology, Brighton Sussex University Hospitals NHS Trust, Brighton, UK
| | - Hector Rojas-Anaya
- Department of Neonatology, Brighton Sussex University Hospitals NHS Trust, Brighton, UK
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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
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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37
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Cao Y. [Diagnosis and treatment of neonatal septic shock]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2017; 19. [PMID: 28202107 PMCID: PMC7389477 DOI: 10.7499/j.issn.1008-8830.2017.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Yun Cao
- Department of Neonatology, Children's Hospital, Fudan University, Shanghai 201102, China
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38
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Ledo A, Aguar M, Núñez-Ramiro A, Saénz P, Vento M. Abdominal Near-Infrared Spectroscopy Detects Low Mesenteric Perfusion Early in Preterm Infants with Hemodynamic Significant Ductus Arteriosus. Neonatology 2017; 112:238-245. [PMID: 28704836 DOI: 10.1159/000475933] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 04/21/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND The therapeutic decision to close patent ductus arteriosus in preterm infants entails great uncertainty. Near-infrared spectroscopy is a noninvasive bedside technique used to monitor mixed regional oxygen saturation. We hypothesized that near-infrared spectroscopy could identify preterm infants at risk of mesenteric hypoperfusion associated with hemodynamically significant ductus arteriosus. METHODS This is a prospective observational study including consecutively admitted preterm infants with a gestational age <32 weeks. Mesenteric regional oxygenation was blindly monitored using an INVOS 5100 device. The presence of a hemodynamically significant patent ductus arteriosus was routinely confirmed by echocardiography/Doppler. Statistical analysis including Bland-Altman plots was performed to assess near-infrared spectroscopy intraobserver repeatability. RESULTS A total of 72 preterm infants were enrolled. The daily mean regional oxygen saturation for preterm infants was determined both in mesenteric and cerebral regions and plotted against time. We identified a differential temporary baseline. Hemodynamic significant ductus arteriosus was associated with lower blood pressures and lower regional splanchnic oxygenation. There was a significant relationship between reversal diastolic flow in the descending aorta and the regional oxygen saturation, which remained significant after controlling for ductal size and nil per os. CONCLUSIONS The simultaneous monitoring of splanchnic near-infrared spectroscopy and echocardiography could identify low mesenteric perfusion in the presence of hemodynamic ductus arteriosus.
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Affiliation(s)
- Ana Ledo
- Division of Neonatology, University and Polytechnic Hospital, Valencia, Spain
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Luu Y, Thigpen J, Brown SD. Stability of sildenafil in combination with heparin and dopamine. Am J Health Syst Pharm 2017; 74:e64-e71. [PMID: 28007723 DOI: 10.2146/ajhp150853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The stability of sildenafil in combination with heparin and dopamine was evaluated. METHODS A stability-indicating high-performance liquid chromatography method with ultraviolet detection was developed for sildenafil citrate and validated. The method was applied to the investigation of sildenafil alone, sildenafil with heparin, sildenafil with dopamine, and sildenafil with heparin and with dopamine, all in 5% dextrose injection at room temperature and under refrigeration for 30 days. Samples of 100 μL were pulled from each storage bottle on each sampling day, diluted in mobile phase, and assayed in duplicate. Samples were tested on days 0, 1, 2, 3, 4, 5, 7, 9, 12, 14, 21, and 30. Each preparation was visually inspected for precipitation and color change. The percent recovery in each study sample was determined by comparing the peak area of sildenafil in the sample with the peak area of sildenafil from a freshly prepared 100-μg/mL standard in mobile phase. RESULTS The sildenafil alone, sildenafil with heparin, and sildenafil with dopamine remained within 90-110% of the expected sildenafil potency for at least 30 days at both temperatures. The preparation of sildenafil with both heparin and dopamine fell below 90% potency after 3 days at room temperature and 21 days in the refrigerator. CONCLUSION Sildenafil prepared in 5% dextrose injection alone, with heparin, and with dopamine retained over 90% potency after 30 days of storage at room temperature and under refrigeration. Sildenafil prepared with both heparin and dopamine had a potency of <90% after 3 days of storage at room temperature and 21 days of storage under refrigeration.
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Affiliation(s)
- Yao Luu
- Department of Pharmaceutical Sciences, Bill Gatton College of Pharmacy, East Tennessee State University, Johnson City, TN
| | - Jim Thigpen
- Department of Pharmacy Practice, Bill Gatton College of Pharmacy, East Tennessee State University, Johnson City, TN
| | - Stacy D Brown
- Department of Pharmaceutical Sciences, Bill Gatton College of Pharmacy, East Tennessee State University, Johnson City, TN.
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Circulatory Management Focusing on Preventing Intraventricular Hemorrhage and Pulmonary Hemorrhage in Preterm Infants. Pediatr Neonatol 2016; 57:453-462. [PMID: 26993561 DOI: 10.1016/j.pedneo.2016.01.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Revised: 12/24/2015] [Accepted: 01/08/2016] [Indexed: 11/20/2022] Open
Abstract
The goal of modern neonatal care of extremely preterm infants is to reduce mortality and long-term neurological impairments. Preterm infants frequently experience cerebral intraventricular or pulmonary hemorrhage, which usually occurs within 72 hours after birth and can lead to long-term neurological sequelae and mortality. These serious hemorrhagic complications are closely related to perinatal hemodynamic changes, including an increase in the afterload on the left ventricle of the heart after the infant is separated from the placenta, and an increased preload from a left-to-right shunt caused by a hemodynamically significant patent ductus arteriosus (PDA). The left ventricle of a preterm myocardium has limited ability to respond to such an increase in afterload and preload, and this can result in cardiac dysfunction and hemodynamic deterioration. We suggest that delayed umbilical cord clamping or umbilical cord milking to maintain optimal blood pressure and systemic blood flow (SBF), careful assessment to keep the afterload at an acceptable level, and a strategy of early targeted treatment of significant PDA to improve perfusion during this critical time period may reduce or prevent these serious complications in preterm infants.
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Inotropes do not increase cardiac output or cerebral blood flow in preterm piglets. Pediatr Res 2016; 80:870-879. [PMID: 27490740 DOI: 10.1038/pr.2016.156] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 06/10/2016] [Indexed: 01/26/2023]
Abstract
BACKGROUND The preterm newborn is at high risk of developing cardiovascular compromise during the first day of life and this is associated with increased risk of brain injury. Standard treatments are volume expansion and administration of inotropes, typically dopamine and/or dobutamine, but there is limited evidence that inotropes improve clinical outcomes. This study investigated the efficacy of dopamine and dobutamine for the treatment of cardiovascular compromise in the preterm newborn using a piglet model. METHODS Preterm and term piglets were assigned to either dopamine, dobutamine or control infusions. Heart rate, left ventricular contractility, cardiac output, blood pressure, and cerebral and regional blood flows were measured during baseline, low (10 µg/kg/h), and high (20 µg/kg/h) dose infusions. RESULTS At baseline, preterm piglets had lower cardiac contractility, cardiac output, blood pressure, and cerebral blood flow compared to term piglets. The response of preterm piglets to either dopamine or dobutamine administration was less than in term piglets. In both preterm and term piglets, cardiac output and cerebral blood flow were unaltered by either inotrope. CONCLUSION In order to provide better cardiovascular support, it may be necessary to develop treatments that target receptors with a more mature profile than adrenoceptors in the preterm newborn.
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Pharmacologie des catécholamines chez l’enfant. MEDECINE INTENSIVE REANIMATION 2016. [DOI: 10.1007/s13546-016-1216-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Vesoulis ZA, El Ters N, Foster A, Trivedi SB, Liao SM, Mathur AM. Response to dopamine in prematurity: a biomarker for brain injury? J Perinatol 2016; 36:453-8. [PMID: 26890555 PMCID: PMC4882223 DOI: 10.1038/jp.2016.5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 01/07/2016] [Accepted: 01/08/2016] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To identify factors associated with responsiveness to dopamine therapy for hypotension and the relationship to brain injury in a cohort of preterm infants. STUDY DESIGN The pharmacy database at St Louis Children's Hospital was retrospectively queried to identify infants who (a) were born <28 weeks gestation between 2012 and 2014, (b) received dopamine and (c) had blood pressure measurements from an umbilical arterial catheter. A control group was constructed from contemporaneous infants who did not receive dopamine. Mean arterial blood pressure (MABP) at baseline, 1 h and 3 h after initiating dopamine were obtained for each dopamine-exposed infant. MABP measurements at matched time points were obtained in the control group. RESULT Sixty-nine dopamine-treated and 45 control infants were included. Mean ΔMABP at 3 h was 4.5±6.3 mm of Hg for treated infants vs 1±2.9 for the control. Median dopamine starting dose was 2.5 μg kg(-1) min(-1). Dopamine-treated infants were less mature and of lower birth weight while also more likely to be intubated at 72 h, diagnosed with intraventricular hemorrhage (IVH) and to die. Failure to respond to dopamine was associated with greater likelihood of developing IVH (odds ratio (OR) 5.8, 95% confidence interval (CI) 1.1-42.3), while a strong response (ΔMABP>10 mm Hg) was associated with a reduction in risk of IVH (OR 0.1, 95% CI 0.01-0.8). CONCLUSION Low-moderate dose dopamine administration results in modest blood pressure improvements. A lack of response to dopamine is associated with a greater risk of IVH, whereas a strong response is associated with a decreased risk. Further research into underlying mechanisms and management strategies is needed.
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Affiliation(s)
- Zachary A. Vesoulis
- Division of Newborn Medicine, Edward Mallinckrodt Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Nathalie El Ters
- Division of Newborn Medicine, Edward Mallinckrodt Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Allison Foster
- Division of Newborn Medicine, Edward Mallinckrodt Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Shamik B. Trivedi
- Division of Newborn Medicine, Edward Mallinckrodt Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Steve M. Liao
- Division of Newborn Medicine, Edward Mallinckrodt Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Amit M. Mathur
- Division of Newborn Medicine, Edward Mallinckrodt Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
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Bhayat SI, Gowda HMS, Eisenhut M. Should dopamine be the first line inotrope in the treatment of neonatal hypotension? Review of the evidence. World J Clin Pediatr 2016; 5:212-222. [PMID: 27170932 PMCID: PMC4857235 DOI: 10.5409/wjcp.v5.i2.212] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 12/17/2015] [Accepted: 01/19/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine if dopamine is effective in treating neonatal hypotension and safe to use comparing to other inotropes.
METHODS: This is a review of evidence on inotropic treatment of neonatal hypotension. Databases searched were MEDLINE and the Cochrane Library, a total of 134 studies were identified. Only studies with high quality evidence (level 1a and b and 2a) were included. After review, only eight studies were included in the final analysis. Pooled risk ratios derived for each outcome [Mantel-Haenzel (M-H) fixed effect] with CI, as reported in the Cochrane reviews were plotted in forest plot form.
RESULTS: Eight articles met inclusion criteria, which all included treatment in preterm infants. Dopamine increased mean arterial blood pressure (BP) (n = 163; r = 0.88, 95%CI: 0.76 to 0.94) and systolic BP (n = 142; r = 0.81, 95%CI: 0.42 to 0.94) comparing to placebo. Dopamine has been shown overall to be statistically more effective in increasing BP than dobutamine (n = 251, r = 0.26, 95%CI: 0.20-0.32). However there were no differences in short term outcomes (periventricular leucomalacia, periventricular haemorrhage) and mortality between both drugs. There is no statistical evidence of dopamine being more effective than adrenaline or corticosteroids. There was no difference in morbidity and mortality outcomes when dopamine was compared to hydrocortisone (RR 1.81, 95%CI: 0.18 to 18.39) or adrenaline.
CONCLUSION: In preterms, dopamine is the most studied drug, and we suggest it could be used as first line treatment in hypotension.
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Giesinger RE, McNamara PJ. Hemodynamic instability in the critically ill neonate: An approach to cardiovascular support based on disease pathophysiology. Semin Perinatol 2016; 40:174-88. [PMID: 26778235 DOI: 10.1053/j.semperi.2015.12.005] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Hemodynamic disturbance in the sick neonate is common, highly diverse in underlying pathophysiology and dynamic. Dysregulated systemic and cerebral blood flow is hypothesized to have a negative impact on neurodevelopmental outcome and survival. An understanding of the physiology of the normal neonate, disease pathophysiology, and the properties of vasoactive medications may improve the quality of care and lead to an improvement in survival free from disability. In this review we present a modern approach to cardiovascular therapy in the sick neonate based on a more thoughtful approach to clinical assessment and actual pathophysiology. Targeted neonatal echocardiography offers a more detailed insight into disease processes and offers longitudinal assessment, particularly response to therapeutic intervention. The pathophysiology of common neonatal conditions and the properties of cardiovascular agents are described. In addition, we outline separate treatment algorithms for various hemodynamic disturbances that are tailored to clinical features, disease characteristics and echocardiographic findings.
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Affiliation(s)
- Regan E Giesinger
- Division of Neonatology, The Hospital for Sick Children, 555 University Ave, Toronto, ON, Canada M5G 1X8; Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Patrick J McNamara
- Division of Neonatology, The Hospital for Sick Children, 555 University Ave, Toronto, ON, Canada M5G 1X8; Department of Paediatrics, University of Toronto, Toronto, ON, Canada; Department of Physiology, University of Toronto, Toronto, ON, Canada.
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Randomized, Placebo-Controlled Trial of Dobutamine for Low Superior Vena Cava Flow in Infants. J Pediatr 2015; 167:572-8.e1-2. [PMID: 26116470 DOI: 10.1016/j.jpeds.2015.05.037] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Revised: 04/16/2015] [Accepted: 05/20/2015] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To gather information for a future confirmatory trial of dobutamine (DB) for circulatory impairment (ie, low superior vena cava [SVC] flow). STUDY DESIGN A total of 127 infants born at < 31 weeks gestational age were serially scanned from birth to 96 hours after birth. The infants were randomly assigned to 2 groups and were treated with DB (stepwise dose increase, 5-10-15-20 μg/kg/min) or placebo if they had an SVC flow < 41 mL/kg/min within the first 24 hours after birth. The primary outcome measures were the achievement and maintenance of an SVC flow ≥ 41 mL/kg/min. Secondary outcome measures were the short-term evolution of clinical and biochemical variables, near-infrared spectroscopy, cranial Doppler ultrasound, and clinical outcomes. RESULTS SVC flow increased throughout the first 96 hours for the entire cohort. All of the randomized infants (n = 28) except 2 achieved and maintained an SVC flow ≥ 41 mL/kg/min after intervention; however, the infants treated with DB (n = 16) showed a higher heart rate and improved base excess compared with those treated with placebo (n = 12). Low SVC flow was associated with low gestational age (P = .02) and poor condition at birth (P = .02). Low SVC flow significantly increased the risk of severe ischemic events (OR, 13; 95% CI, 2.4-69.2; P < .01). CONCLUSION This exploratory trial demonstrates a tendency toward improved short-term clinical and biochemical perfusion variable outcomes in infants with low SVC flow treated with DB. TRIAL REGISTRATION ClinicalTrials.gov (NCT01605279) and the European Clinical Trials Database (EurodraCT 2009-010901-35).
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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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Vasopressin versus dopamine for treatment of hypotension in extremely low birth weight infants: a randomized, blinded pilot study. J Pediatr 2015; 166:850-5. [PMID: 25641242 PMCID: PMC4380753 DOI: 10.1016/j.jpeds.2014.12.027] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2014] [Revised: 11/12/2014] [Accepted: 12/11/2014] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To evaluate vasopressin vs dopamine as initial therapy in extremely low birth weight (ELBW) infants with hypotension during the first 24 hours of life. STUDY DESIGN ELBW infants with hypertension ≤ 30 weeks' gestation and ≤ 24 hours old randomly received treatment with vasopressin or dopamine in a blinded fashion. Normotensive infants not receiving vasopressor support served as a comparison group. RESULTS Twenty ELBW infants with hypertension received vasopressin (n = 10) or dopamine (n = 10), and 50 were enrolled for comparison. Mean gestational age was 25.6 ± 1.4 weeks and birth weight 705 ± 154 g. Response to vasopressin paralleled that of dopamine in time to adequate mean blood pressure (Kaplan-Meier curve, P = .986); 90% of infants in each treatment group responded with adequate blood pressure. The vasopressin group received fewer doses of surfactant (P < .05), had lower PaCO2 values (P < .05), and were not tachycardic (P < .001) during vasopressin administration, compared with the dopamine group. CONCLUSIONS Vasopressin in ELBW infants as the initial agent for early hypotension appeared safe. This pilot study supports a larger randomized controlled trial of vasopressin vs dopamine therapy in ELBW infants with hypotension.
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Cox C, Hashem NG, Tebbs J, Bookstaver PB, Iskersky V. Evaluation of caffeine and the development of necrotizing enterocolitis. J Neonatal Perinatal Med 2015; 8:339-347. [PMID: 26757002 DOI: 10.3233/npm-15814059] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To test the association between medical or surgical necrotizing enterocolitis (NEC) and caffeine administration in premature infants. STUDY DESIGN This single-center, retrospective study evaluated patients admitted to a level 3 neonatal intensive care unit (NICU) over an 18-month period. All patients were evaluated for factors associated with the development of NEC including exposure to caffeine (dosing and duration), gestational age, birth weight, vasoactive medications and maternal illicit drug use. RESULTS There were 615 subjects included in the study; among these subjects, 7.3% (n = 45) developed NEC (35 subjects receiving caffeine and 10 subjects not receiving caffeine). The administration of caffeine (p = 0.008), birth weight (p = 0.014) and the use of vasopressors (p = 0.033) were associated with the development of NEC. When considering only infants with a birth weight less than 1500 g and less than 32 weeks gestation, the effects of caffeine and vasopressor use remained statistically significant (p = 0.047 and p = 0.045, respectively). The time to development of NEC did not differ statistically between patients receiving caffeine and those not receiving caffeine (p = 0.129). CONCLUSION A potential association between the administration of caffeine and the development of medical or surgical necrotizing enterocolitis in premature infants exists. Further investigation of dose-dependent effects and loading doses is warranted.
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Affiliation(s)
- C Cox
- Department of Clinical Pharmacy and Outcomes Sciences, South Carolina College of Pharmacy, University of South Carolina, Columbia, SC, USA
| | - N G Hashem
- Lancaster General Health, Lancaster, PA, USA
| | - J Tebbs
- Department of Statistics, University of South Carolina, Columbia, SC, USA
| | - P Brandon Bookstaver
- Department of Clinical Pharmacy and Outcomes Sciences, South Carolina College of Pharmacy, University of South Carolina, Columbia, SC, USA
| | - V Iskersky
- Department of Neonatology, Palmetto Health Richland, Columbia, SC, USA
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Abstract
Neonatal critical aortic stenosis is a rare form of CHD that often presents with cardiogenic shock. Although surgical and cardiac catheterisation-based interventions have been successful in alleviating left ventricular outflow tract obstruction, it remains associated with high morbidity and mortality. Critical aortic stenosis results in elevated left ventricular wall stress, which ultimately increases myocardial oxygen consumption and disrupts coronary artery perfusion during diastole, leading to ventricular dysfunction and cardiogenic shock. Critical care management before definitive intervention should be tailored to optimising oxygen delivery and reducing metabolic consumption of the myocardium and peripheral organ systems. This can be accomplished with prostaglandin infusion to maintain system perfusion through patency of the arterial duct, inotropic support, mechanical ventilation, and central nervous system abrogation. Management should also include a multi-specialty medical team including paediatric cardiothoracic surgeons and paediatric cardiologists with expertise in cardiac catheterisation, imaging, and transplantation.
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