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Shah S, Dhalait S, Fursule A, Khandare J, Kaul A. Use of Vasopressin as Rescue Therapy in Refractory Hypoxia and Refractory Systemic Hypotension in Term Neonates with Severe Persistent Pulmonary Hypertension-A Prospective Observational Study. Am J Perinatol 2024; 41:e886-e892. [PMID: 36302521 DOI: 10.1055/a-1969-1119] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE Persistent pulmonary hypertension of the newborn (PPHN) is a serious cardiorespiratory problem. PPHN is frequently associated with refractory hypoxia and hypotension, and optimal management has the potential to improve important clinical outcomes including mortality. The primary objective is to evaluate the efficacy and safety of rescue vasopressin (VP) therapy in the management of severe (refractory) hypoxia and refractory systemic hypotension in term neonates with severe PPHN. STUDY DESIGN Neonates with refractory hypoxia and refractory hypotension due to severe PPHN needing VP were prospectively enrolled in the study. Refractory hypoxia was defined as oxygenation index (OI) ≥ 25 for at least 4 hours after the commencement of high-frequency oscillatory ventilation and nitric oxide at 20 ppm. Refractory hypotension was defined as mean blood pressure lesser than mean gestational age lasting for more than 15 minutes in spite of dopamine infusion at 10 µg/kg/min, adrenaline infusion at 0.3 µg/kg/min, and noradrenaline infusion at 0.1 µg/kg/min. RESULTS Thirty-two neonates with PPHN were recruited. The baseline OI (mean ± standard deviation [SD]) before starting VP was 33.43 ± 16.54 which started decreasing significantly between 1 and 6 hours after the commencement of VP (p < 0.05). The mean blood pressure also increased concomitantly with a significant effect seen by 1 hour (p < 0.05). The vasoactive infusion score before the commencement of VP was mean 46.07 (SD = 25.72) and started decreasing after 12 to 24 hours of commencement of VP (p < 0.05). Lactate levels (mean ± SD) before starting VP were 7.8 ± 8.6 mmol/L and started decreasing between 6 and 12 hours (p < 0.05). Two neonates died due to refractory hypoxia and refractory hypotension (overall mortality 6.2%) CONCLUSION: Rescue VP therapy is a useful adjunct in the management of neonates with severe PPHN with refractory hypoxia and/or refractory hypotension. Improvement in oxygenation and hemodynamics with the use of VP results in reduced mortality. KEY POINTS · Rescue vasopressin is a useful adjunct in the management of neonates with severe PPHN.. · Vasopressin helps reduce OI.. · Vasopressin reduces the vasoactive inotrope score..
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Affiliation(s)
- Sachin Shah
- Department of Neonatal and Pediatric Intensive Care Services, Surya Mother & Child Superspeciality Hospital, Pune, Maharashtra, India
| | - Saleha Dhalait
- Department of Neonatal and Pediatric Intensive Care Services, Surya Mother & Child Superspeciality Hospital, Pune, Maharashtra, India
| | - Anurag Fursule
- Department of Neonatal and Pediatric Intensive Care Services, Surya Mother & Child Superspeciality Hospital, Pune, Maharashtra, India
| | - Jayant Khandare
- Department of Neonatal and Pediatric Intensive Care Services, Surya Mother & Child Superspeciality Hospital, Pune, Maharashtra, India
| | - Amita Kaul
- Department of Neonatal and Pediatric Intensive Care Services, Surya Mother & Child Superspeciality Hospital, Pune, Maharashtra, India
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Ouellet S, Drolet C, Morissette G, Pellerin A, Hébert A. Vasopressin in newborns with refractory acute pulmonary hypertension. Pediatr Res 2024; 95:1572-1577. [PMID: 38212386 DOI: 10.1038/s41390-023-02995-3] [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: 06/12/2023] [Revised: 11/20/2023] [Accepted: 12/15/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND Acute pulmonary hypertension (aPH) in newborns can be life threatening and challenging to manage. In newborns with refractory aPH, there is currently limited therapeutic agents. METHODS Retrospective single-center cohort study in newborns less than one month old who were treated with vasopressin for a minimum of one hour in the context of refractory aPH in the neonatal and pediatric intensive care units of a tertiary university center between 2016 and 2022. The objective was to evaluate the efficacy and safety of vasopressin in newborns as an adjuvant treatment for refractory aPH. RESULTS Twenty-five patients met inclusion criteria. In patients who received vasopressin, oxygenation index improved from 28.4 to 14.4 (p = 0.004) after twelve hours of continuous infusion. Oxygen requirements (FiO2) decreased from 0.91 to 0.50 (p = 0.004) and mean arterial pressure increased from 41 to 51 mmHg (p = 0.001). In our cohort, 68% of patients presented an episode of hyponatremia (serum sodium <130 mmol/L). CONCLUSIONS The use of vasopressin may be associated with improvement in oxygenation and hemodynamic status of neonatal patients with aPH refractory to initial therapy. Further prospective studies are needed to establish the safety profile of vasopressin in newborns, particularly in preterm infants. IMPACT Vasopressin may be an effective cardiotropic agent to improve oxygenation and hemodynamic status in newborns with acute pulmonary hypertension. Careful monitoring of serum sodium levels are warranted in newborns who are receiving vasopressin infusion. This provides additional evidence for the consideration of vasopressin in newborns with acute pulmonary hypertension refractory to inhaled nitric oxide.
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Affiliation(s)
- Simon Ouellet
- Department of Pediatrics, CHU de Québec, Université Laval, Quebec City, Canada
| | - Christine Drolet
- Department of Pediatrics, CHU de Québec, Université Laval, Quebec City, Canada
- Division of Neonatology, CHU de Québec, Université Laval, Quebec City, Canada
| | - Geneviève Morissette
- Department of Pediatrics, CHU de Québec, Université Laval, Quebec City, Canada
- Division of Pediatric Intensive Care, CHU de Québec, Université Laval, Quebec City, Canada
| | - Annie Pellerin
- Department of Pharmacy, CHU de Québec, Université Laval, Quebec City, Canada
| | - Audrey Hébert
- Department of Pediatrics, CHU de Québec, Université Laval, Quebec City, Canada.
- Division of Neonatology, CHU de Québec, Université Laval, Quebec City, Canada.
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Capolupo I, De Rose DU, Mazzeo F, Monaco F, Giliberti P, Landolfo F, Di Pede A, Toscano A, Conforti A, Bagolan P, Dotta A. Early vasopressin infusion improves oxygenation in infants with congenital diaphragmatic hernia. Front Pediatr 2023; 11:1104728. [PMID: 37063685 PMCID: PMC10090559 DOI: 10.3389/fped.2023.1104728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 03/14/2023] [Indexed: 04/18/2023] Open
Abstract
Objective Congenital Diaphragmatic Hernia (CDH) is a complex disease including a diaphragmatic defect, lung hypoplasia, and pulmonary hypertension. Despite its increasing use in neonates, the literature on the use of vasopressin in neonates is limited. The aim of this work is to analyze the changes in clinical and hemodynamic variables in a cohort of CDH infants treated with vasopressin. Methods Among CDH infants managed at the Neonatal Intensive Care Unit (NICU) of our hospital from May 2014 to January 2019, all infants who were treated with vasopressin, because of systemic hypotension and pulmonary hypertension, were enrolled in this retrospective study. The primary outcome was the change in oxygenation index (OI) after the start of the infusion of vasopressin. The secondary outcomes were the changes in cerebral and splanchnic fractional tissue oxygen extraction (FTOEc and FTOEs) at near-infrared spectroscopy, to understand the balance between oxygen supply and tissue oxygen consumption after the start of vasopressin infusion. We also reported as secondary outcomes the changes in ratio of arterial oxygen partial pressure (PaO2) to fraction of inspired oxygen (FiO2), heart rate, mean arterial pressure, serum pH, and serum sodium. Results We included 27 patients with isolated CDH who received vasopressin administration. OI dramatically dropped when vasopressin infusion started, with a significant reduction according to ANOVA for repeated measures (p = 0.003). A global significant improvement in FTOEc and FTOEs was detected (p = 0.009 and p = 0.004, respectively) as a significant reduction in heart rate (p = 0.019). A global significant improvement in PaO2/FiO2 ratio was observed (p < 0.001) and also at all time points: at 6 h since infusion (p = 0.015), 12 h (p = 0.009), and 24 h (p = 0.006), respectively. A significant reduction in sodium levels was observed as expected side effect (p = 0.012). No significant changes were observed in the remaining outcomes. Conclusion Our data suggest that starting early vasopressin infusion in CDH infants with pulmonary hypertension could improve oxygenation index and near-infrared spectroscopy after 12 and 24 h of infusion. These pilot data represent a background for planning future larger randomized trials to evaluate the efficacy and safety of vasopressin for the CDH population.
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Affiliation(s)
- Irma Capolupo
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus – Newborn – Infant, “Bambino Gesù” Children’s Hospital IRCCS, Rome, Italy
- Correspondence: Irma Capolupo
| | - Domenico Umberto De Rose
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus – Newborn – Infant, “Bambino Gesù” Children’s Hospital IRCCS, Rome, Italy
| | - Francesca Mazzeo
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus – Newborn – Infant, “Bambino Gesù” Children’s Hospital IRCCS, Rome, Italy
| | - Francesca Monaco
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus – Newborn – Infant, “Bambino Gesù” Children’s Hospital IRCCS, Rome, Italy
| | - Paola Giliberti
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus – Newborn – Infant, “Bambino Gesù” Children’s Hospital IRCCS, Rome, Italy
| | - Francesca Landolfo
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus – Newborn – Infant, “Bambino Gesù” Children’s Hospital IRCCS, Rome, Italy
| | - Alessandra Di Pede
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus – Newborn – Infant, “Bambino Gesù” Children’s Hospital IRCCS, Rome, Italy
| | - Alessandra Toscano
- Perinatal Cardiology, Medical and Surgical Department of Fetus – Newborn – Infant, “Bambino Gesù” Children’s Hospital IRCCS, Rome, Italy
| | - Andrea Conforti
- Neonatal Surgery Unit, Medical and Surgical Department of Fetus – Newborn – Infant, “Bambino Gesù” Children’s Hospital IRCCS, Rome, Italy
| | - Pietro Bagolan
- Neonatal Surgery Unit, Medical and Surgical Department of Fetus – Newborn – Infant, “Bambino Gesù” Children’s Hospital IRCCS, Rome, Italy
- Department of Systems Medicine, University of Tor Vergata, Rome, Italy
| | - Andrea Dotta
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus – Newborn – Infant, “Bambino Gesù” Children’s Hospital IRCCS, Rome, Italy
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Al-Saadi A, Sushko K, Bui V, van den Anker J, Razak A, Samiee-Zafarghandy S. Efficacy and Safety of Vasopressin and Terlipressin in Preterm Neonates: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:13760. [PMID: 36360641 PMCID: PMC9658127 DOI: 10.3390/ijerph192113760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 10/14/2022] [Accepted: 10/19/2022] [Indexed: 06/16/2023]
Abstract
INTRODUCTION The use of arginine vasopressin (AVP) and terlipressin to treat hypotension in preterm neonates is increasing. Our aim was to review the available evidence on the efficacy and safety of AVP and terlipressin for use in preterm neonates. METHODS MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, Web of Science, and Google Scholar from inception to September 2021 were searched for studies of AVP and terlipressin in the treatment of hypotension of any cause in preterm neonates. Primary outcomes were improvement in end-organ perfusion and mortality. The risk of bias assessment and certainty of the evidence were performed using appropriate tools. RESULTS Fifteen studies describing the use of AVP (n = 12) or terlipressin (n = 3) among 148 preterm neonates were included. Certainly, the available evidence for the primary outcome of end-organ perfusion rated as very low. AVP or terlipressin were used to treat 144 and 4 neonates, respectively. Improvement in markers of end-organ perfusion was reported in 143 (99%) neonates treated with AVP and 3 (75%) treated with terlipressin. The mortality rate was 41% (n = 59) and 50% (n = 2) for neonates who received AVP and terlipressin, respectively. Hyponatremia was the most frequently reported adverse event (n = 37, 25%). CONCLUSION AVP and terlipressin may improve measured blood pressure values and possibly end-organ perfusion among neonates with refractory hypotension. However, the efficacy-safety balance of these drugs should be assessed on an individual basis and as per the underlying cause. Studies on the optimal dosing, efficacy, and safety of AVP and terlipressin in preterm neonates with variable underlying conditions are critically needed.
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Affiliation(s)
- Abdulrahman Al-Saadi
- Division of Neonatology, Department of Pediatrics, Sultan Qaboos University, Muscat 123, Oman
| | - Katelyn Sushko
- Faculty of Health Sciences, School of Nursing, McMaster University, Hamilton, ON L8S 4L8, Canada
| | - Vivian Bui
- Department of Pharmacy, Hamilton Health Sciences, Hamilton, ON L8L 2X2, Canada
| | - John van den Anker
- Pediatric Pharmacology and Pharmacometrics, University Children’s Hospital Basel (UKBB), University of Basel, 4055 Basel, Switzerland
- Division of Clinical Pharmacology, Children’s National Hospital, Washington, DC 20010, USA
- Intensive Care and Department of Pediatric Surgery, Erasmus MC Sophia Children’s Hospital, 3000 CB Rotterdam, The Netherlands
| | - Abdul Razak
- Division of Neonatology, Department of Pediatrics, King Abdullah bin Abdulaziz University Hospital, Princess Norah Bint Abdulrahman University, Riyadh 11564, Saudi Arabia
- Department of Pediatrics, Monash University, Melbourne 3800, Australia
| | - Samira Samiee-Zafarghandy
- Division of Neonatology, Department of Pediatrics, McMaster University, Hamilton, ON L8S 4L8, Canada
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Amer R, Seshia MM, Elsayed YN. A vasoactive inotropic score predicts the severity of compromised systemic circulation and mortality in preterm infants. J Neonatal Perinatal Med 2022; 15:529-535. [PMID: 35661023 DOI: 10.3233/npm-210932] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To validate the vasoactive inotropic score as a predictor of the severity of compromised systemic circulation and mortality in preterm infants. METHODS A retrospective study was conducted on preterm infants with Compromised systemic circulation [hypotension±lactic acidosis±oliguria] who received a cardiovascular support, we calculated the vasoactive inotropic score (VIS) and cumulative exposure to cardiovascular medications over time (VISct). Receiver operator curve was constructed to predict the primary outcome which was death & refractory hypotension. RESULTS VIS had an area under the curve of 0.73 (95% CI 0.85-0.98, p < 0.001). A VIS cut off of 25 has sensitivity and specificity of 66% and 92%, and positive and negative predictive values of 78.5% and 83%, respectively. CONCLUSION High VIS predicts the severity of Compromised systemic circulation and mortality rate in preterm infants.
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Affiliation(s)
- R Amer
- McMaster University, Section of Neonatology, Pediatrics Department, Hamilton, ON, Canada
| | - M M Seshia
- University of Manitoba, Section of Neonatology, Pediatrics Department, Winnipeg, MB, Canada
| | - Y N Elsayed
- University of Manitoba, Section of Neonatology, Pediatrics Department, Winnipeg, MB, Canada
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Elsayed Y, Abdul Wahab MG. A new physiologic-based integrated algorithm in the management of neonatal hemodynamic instability. Eur J Pediatr 2022; 181:1277-1291. [PMID: 34748080 DOI: 10.1007/s00431-021-04307-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 10/27/2021] [Accepted: 10/28/2021] [Indexed: 10/19/2022]
Abstract
Physiologic-based management of hemodynamic instability is proven to guide the logical selection of cardiovascular support and shorten the time to clinical recovery compared to an empiric approach that ignores the heterogeneity of the hemodynamic instability related mechanisms. In this report, we classified neonatal hemodynamic instability, circulatory shock, and degree of compensation into five physiologic categories, based on different phenotypes of blood pressure (BP), other clinical parameters, echocardiography markers, and oxygen indices. This approach is focused on hemodynamic instability in infants with normal cardiac anatomy.Conclusion: The management of hemodynamic instability is challenging due to the complexity of the pathophysiology; integrating different monitoring techniques is essential to understand the underlying pathophysiologic mechanisms and formulate a physiologic-based medical recommendation and approach. What is Known: • Physiologic-based assessment of hemodynamics leads to targeted and pathophysiologic-based medical recommendations. What is New: • Hemodynamic instability in neonates can be categorized according to the underlying mechanism into five main categories, based on blood pressure phenotypes, systemic vascular resistance, and myocardial performance. • The new classification helps with the targeted management and logical selection of cardiovascular support.
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Affiliation(s)
- Yasser Elsayed
- Division of Neonatology, Department of Pediatrics and Child Health, Rady Faculty of Health Sciences, University of Manitoba, Women's Hospital, 820 Sherbrook Street, Winnipeg, MB, R2016, R3A0L8, Canada.
| | - Muzafar Gani Abdul Wahab
- Division of Neonatology, Department of Pediatrics and Child Health, McMaster University, Hamilton, Canada
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Zang S, Chen Q, Zhang Y, Xu L, Chen J. Comparison of the Clinical Effectiveness of AN69-oXiris versus AN69-ST Filter in Septic Patients: A Single-Centre Study. Blood Purif 2021; 51:617-629. [PMID: 34610595 DOI: 10.1159/000519166] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 08/22/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The clinical effectiveness of AN69-oXiris remains unclear. This study aimed to compare the effects of AN69-oXiris and AN69-ST filters on cytokine levels and clinical improvement in septic patients. METHODS This prospective observational study recruited septic patients who underwent blood purification in the First Affiliated Hospital of Soochow University between December 2019 and May 2020. Patients were assigned to an AN69-oXiris (oXiris) or AN69-ST (ST) group based on their preferred filter. Patients' clinical data, cytokine levels, and prognostic indicators were analysed at baseline (T0), 24 h after treatment (T1), and at the end of the treatment (T2). RESULTS Forty-four patients participated in this study (22 patients in each group). Participants in both groups showed improvements in mean arterial pressure (MAP) values, oxygenation indices, and urinary output, and decreased vasoactive-inotropic scores (VISs), heart rates, lactic acid levels, and serum creatinine levels after blood purification. Reductions in cytokine levels were observed at T1 in both groups. Improvement the haemodynamic status was higher in the oXiris group than in the ST group at T2 (MAP: 79.0 [76.0, 85.0] vs. 77.0 [72.75, 79.25] mm Hg, p = 0.04; VISs: 9.10 [0.00, 16.69] vs. 19.05 [10.60, 26.33], p = 0.03, respectively). Patients in the oXiris group also had lower cytokine levels than those in the ST group at T1 (tumour necrosis factor-α: 24.55 [16.9, 30.15] vs. 30.15 [23.38, 34.13] pg/mL, p = 0.04; interleukin (IL)-6: 66.63 [46.21, 102.20] vs. 125.48 [79.73, 167.97] pg/mL, p = 0.01; IL-8: 53.59 [35.10, 66.01] vs. 63.60 [45.58, 83.37] pg/mL, p = 0.04; IL-10: 13.50 [10.35, 18.68] vs. 17.15 [13.80, 21.95] pg/mL, p = 0.04, respectively). There were no significant differences between the 2 groups regarding hospital mortality, intensive care unit length of stay (LOS), and hospital LOS. CONCLUSION Blood purification using the AN69-oXiris or AN69-ST filter proved useful for septic patients, which was associated with reduced cytokine levels and improved clinical condition. Patients treated with AN69-oXiris had a more remarkable improvement in haemodynamic status and lower cytokine levels than those treated with AN69-ST filter, but there were no differences in clinical outcomes. Further investigations are needed to prove this finding.
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Affiliation(s)
- Shouhua Zang
- Department of Surgical Intensive Care Unit of Anesthesiology, First Hospital Affiliated to Soochow University, Suzhou, China,
| | - Qing Chen
- Department of Surgical Intensive Care Unit of Anesthesiology, First Hospital Affiliated to Soochow University, Suzhou, China
| | - Yukun Zhang
- Department of Surgical Intensive Care Unit of Anesthesiology, First Hospital Affiliated to Soochow University, Suzhou, China
| | - Li Xu
- Department of Surgical Intensive Care Unit of Anesthesiology, First Hospital Affiliated to Soochow University, Suzhou, China
| | - Jun Chen
- Department of Surgical Intensive Care Unit of Anesthesiology, First Hospital Affiliated to Soochow University, Suzhou, China
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