The use of volume expansion in preterm infants

Management of hypotension in the very low-birth-weight infant during the golden hour

Primum non nocere, a saying in Latin that means "first, do no harm," is a phrase neonatal clinicians should keep in mind when initiating or suggesting treatment. In the "golden hour" of resuscitation of the very low-birth-weight infant, team members assess multiple parameters of the infant's vital signs, with a key one being that of the cardiovascular status, specifically blood pressure. Attempts to treat a number rather than after assessment and develop a sound plan of care based on findings, will affect both short- and long-term outcomes. By understanding what neonatal hypotension is and knowing when and how to treat it, the neonatal clinician honors this charge and can safely and effectively manage the very low-birth-weight infant with hypotension shortly after birth.

Diagnostic criteria and therapeutic interventions for the hypotensive very low birth weight infant

INTRODUCTION

The diagnosis and management of hypotension in the very low birth weight (VLBW) is a controversial area.

OBJECTIVE

To establish if there is any consensus in the diagnostic criteria and therapeutic interventions in the hypotensive VLBW among neonatologists in Canada.

METHODS

A postal questionnaire was sent to neonatologists in all level II and III neonatal intensive care units throughout Canada.

RESULTS

In total, 120 questionnaires were sent. Ninety-five completed questionnaires were returned. Seventy-six percent of respondents work in units where at least 50 VLBWs and 43% where at least 100 VLBWs are cared for annually. Fifty-seven percent of the respondents have at least 10 years experience as practicing neonatologists. 25.8% rely on blood pressure values alone when intervening, the most common being a blood pressure less than gestational age in weeks. Ninety-seven percent of respondents commence therapy with a fluid bolus. Normal saline is the predominant volume administered (95%). Dopamine remains the pressor of choice. Great variation exists in starting doses and total amount administered. Similar variation exists with epinephrine, with tenfold differences in starting doses (0.01-0.1 mcg/kg/min) and tenfold differences in maximum dose (0.4-4 mc/kg/min) administered. Steroid doses used ranged from 0.1 mg/kg/dose of hydrocortisone to 5 mg/kg/dose. Bicarbonate is rarely used. Three predominant therapeutic regimes exist. These include (i) volume followed by dopamine then a steroid (32%), (ii) volume, dopamine, dobutamine (29%), (iii) volume, dopamine, epinephrine (22%).

CONCLUSION

This is the first large study of practices among neonatologists addressing hypotension in the VLBW infant. There is wide variation in practice, which is a reflection of the lack of good evidence currently available for this very common problem.