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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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Prideaux MA, Guillet R. The Use of Low-Dose Dopamine in the Neonatal Intensive Care Unit. Neoreviews 2024; 25:e207-e215. [PMID: 38556497 DOI: 10.1542/neo.25-4-e207] [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: 04/02/2024]
Abstract
Dopamine has been used for half a century in adult and pediatric patients for the treatment of hypotension, as well as for the theoretical prevention of acute kidney injury (AKI). Although activation of renal dopamine receptors leads to increased urine output, there is no evidence that low-dose dopamine reduces the incidence of AKI, need for dialysis, or death. Dopamine administration is also associated with multiple adverse effects, particularly in preterm infants. Despite the lack of evidence for its use, as well as the known adverse effects of dopamine, many neonatologists still use low-dose dopamine to prevent or treat AKI in neonates. In this review, we provide a summary of our current medical knowledge about the use of low-dose dopamine in the neonatal population.
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Affiliation(s)
- Mallory A Prideaux
- Division of Neonatology, Golisano Children's Hospital, University of Rochester, Rochester, NY
| | - Ronnie Guillet
- Division of Neonatology, Golisano Children's Hospital, University of Rochester, Rochester, NY
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3
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Prideaux MA, Guillet R. The Use of Low-Dose Dopamine in the Neonatal Intensive Care Unit. Neoreviews 2024; 25:e207-e215. [PMID: 38556488 DOI: 10.1542/neo.25-3-e207] [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: 04/02/2024]
Abstract
Dopamine has been used for half a century in adult and pediatric patients for the treatment of hypotension, as well as for the theoretical prevention of acute kidney injury (AKI). Although activation of renal dopamine receptors leads to increased urine output, there is no evidence that low-dose dopamine reduces the incidence of AKI, need for dialysis, or death. Dopamine administration is also associated with multiple adverse effects, particularly in preterm infants. Despite the lack of evidence for its use, as well as the known adverse effects of dopamine, many neonatologists still use low-dose dopamine to prevent or treat AKI in neonates. In this review, we provide a summary of our current medical knowledge about the use of low-dose dopamine in the neonatal population.
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Affiliation(s)
- Mallory A Prideaux
- Division of Neonatology, Golisano Children's Hospital, University of Rochester, Rochester, NY
| | - Ronnie Guillet
- Division of Neonatology, Golisano Children's Hospital, University of Rochester, Rochester, NY
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Dusleag M, Urlesberger B, Schwaberger B, Baik-Schneditz N, Schlatzer C, Wolfsberger CH, Pichler G. Acid base and metabolic parameters of the umbilical cord blood and cerebral oxygenation immediately after birth. Front Pediatr 2024; 12:1385726. [PMID: 38606368 PMCID: PMC11007157 DOI: 10.3389/fped.2024.1385726] [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: 02/13/2024] [Accepted: 03/13/2024] [Indexed: 04/13/2024] Open
Abstract
Objective Aim was to investigate whether acid-base and metabolic parameters obtained from arterial umbilical cord blood affect cerebral oxygenation after birth in preterm neonates with respiratory support and in term neonates without respiratory support. Study design This was a post-hoc analysis of secondary outcome parameters of a prospective observational study including preterm neonates with and term neonates without respiratory support. Non-asphyxiated neonates with cerebral oxygenation measured with near-infrared spectroscopy during the first 15 min and with blood gas analyses from arterial umbilical cord blood were included. Arterial oxygen saturation (SpO2) and heart rate (HR) were monitored with pulse oximetry. Potential correlations were investigated between acid-base and metabolic parameters (pH-value, bicarbonate, base-excess, and lactate) and crSO2/cFTOE 5 min after birth. Results Seventy-seven neonates were included: 14 preterm neonates with respiratory support (mean gestational age [GA] 31.4 ± 4.1 weeks; mean birth weight [BW] 1,690 ± 640 g) and 63 term neonates without respiratory support (GA 38.7 ± 0.8 weeks; BW 3,258 ± 443 g). Mean crSO2 5 min after birth was 44.0% ± 24.2% in preterm and 62.2% ± 20.01% in term neonates. Mean cFTOE 5 min after birth was 0.46 ± 0.06 in preterm and 0.27 ± 0.19 in term neonates. In preterm neonates with respiratory support higher lactate was significantly associated with lower crSO2 and SpO2 and tended to be associated with higher cFTOE. In term neonates without respiratory support no significant correlations were found. Conclusion In non-asphyxiated preterm neonates with respiratory support, lactate levels were negatively associated with crSO2 and SpO2, whereas in term neonates without respiratory support no associations were observed.
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Affiliation(s)
- Martin Dusleag
- Division of Neonatology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
- Research Unit for Neonatal Micro- and Macrocirculation, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Berndt Urlesberger
- Division of Neonatology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
- Research Unit for Neonatal Micro- and Macrocirculation, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Bernhard Schwaberger
- Division of Neonatology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
- Research Unit for Neonatal Micro- and Macrocirculation, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Nariae Baik-Schneditz
- Division of Neonatology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
- Research Unit for Neonatal Micro- and Macrocirculation, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Christoph Schlatzer
- Division of Neonatology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
- Research Unit for Neonatal Micro- and Macrocirculation, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Christina H Wolfsberger
- Division of Neonatology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
- Research Unit for Neonatal Micro- and Macrocirculation, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Gerhard Pichler
- Division of Neonatology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
- Research Unit for Neonatal Micro- and Macrocirculation, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
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Martini S, Thewissen L, Austin T, da Costa CS, de Boode WP, Dempsey E, Kooi E, Pellicer A, Rhee CJ, Riera J, Wolf M, Wong F. Near-infrared spectroscopy monitoring of neonatal cerebrovascular reactivity: where are we now? Pediatr Res 2023:10.1038/s41390-023-02574-6. [PMID: 36997690 DOI: 10.1038/s41390-023-02574-6] [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] [Received: 10/27/2022] [Revised: 02/09/2023] [Accepted: 02/17/2023] [Indexed: 06/19/2023]
Abstract
Cerebrovascular reactivity defines the ability of the cerebral vasculature to regulate its resistance in response to both local and systemic factors to ensure an adequate cerebral blood flow to meet the metabolic demands of the brain. The increasing adoption of near-infrared spectroscopy (NIRS) for non-invasive monitoring of cerebral oxygenation and perfusion allowed investigation of the mechanisms underlying cerebrovascular reactivity in the neonatal population, confirming important associations with pathological conditions including the development of brain injury and adverse neurodevelopmental outcomes. However, the current literature on neonatal cerebrovascular reactivity is mainly still based on small, observational studies and is characterised by methodological heterogeneity; this has hindered the routine application of NIRS-based monitoring of cerebrovascular reactivity to identify infants most at risk of brain injury. This review aims (1) to provide an updated review on neonatal cerebrovascular reactivity, assessed using NIRS; (2) to identify critical points that need to be addressed with targeted research; and (3) to propose feasibility trials in order to fill the current knowledge gaps and to possibly develop a preventive or curative approach for preterm brain injury. IMPACT: NIRS monitoring has been largely applied in neonatal research to assess cerebrovascular reactivity in response to blood pressure, PaCO2 and other biochemical or metabolic factors, providing novel insights into the pathophysiological mechanisms underlying cerebral blood flow regulation. Despite these insights, the current literature shows important pitfalls that would benefit to be addressed in a series of targeted trials, proposed in the present review, in order to translate the assessment of cerebrovascular reactivity into routine monitoring in neonatal clinical practice.
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Affiliation(s)
- Silvia Martini
- Neonatal Intensive Care Unit, IRCCS AOU S. Orsola, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
| | | | - Topun Austin
- Neonatal Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Willem P de Boode
- Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Eugene Dempsey
- Department of Paediatrics and Child Health, INFANT Centre, University College Cork, Cork, Ireland
| | - Elisabeth Kooi
- Division of Neonatology, Beatrix Children's Hospital, University Medical Center, University of Groningen, Groningen, The Netherlands
| | - Adelina Pellicer
- Department of Neonatology, La Paz University Hospital, Madrid, Spain
| | - Christopher J Rhee
- Section of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Joan Riera
- Department of Neonatology, La Paz University Hospital, Madrid, Spain
- Center for Biomedical Technology, Technical University, Madrid, Spain
| | - Martin Wolf
- Biomedical Optics Research Laboratory, Department of Neonatology, University Hospital Zurich, Zurich, Switzerland
| | - Flora Wong
- Monash Newborn, Monash Children's Hospital, Hudson Institute of Medical Research, Department of Paediatrics, Monash University, Melbourne, VIC, Australia
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Baik-Schneditz N, Schwaberger B, Bresesti I, Fuchs H, Lara I, Nakstad B, Lista G, Vento M, Binder-Heschl C, Pichler G, Urlesberger B. Fetal to neonatal transition: what additional information can be provided by cerebral near infrared spectroscopy? Pediatr Res 2022:10.1038/s41390-022-02081-0. [PMID: 35597824 DOI: 10.1038/s41390-022-02081-0] [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] [Received: 09/14/2021] [Revised: 04/04/2022] [Accepted: 04/12/2022] [Indexed: 11/09/2022]
Abstract
This narrative review focuses on the clinical use and relevance of cerebral oxygenation measured by NIRS during fetal to neonatal transition. Cerebral NIRS(cNIRS) offers the possibility of non-invasive, continuous, and objective brain monitoring in addition to the recommended routine monitoring. During the last decade, with growing interest in early and sensitive brain monitoring, many research groups worldwide have been working with cNIRS and verified the feasibility of cNIRS monitoring immediately after birth. Cerebral hypoxia during fetal to neonatal transition, defined as cerebral oxygenation values below10th percentile, seems to have an impact on neurological outcomes. Feasibility to guide clinical support using cNIRS to reduce the burden of cerebral hypoxia has been shown. It is well known that in some cases cerebral oxygenation follows different patterns than SpO2. Cerebral oxygenation does not only depend on systemic oxygenation, hemoglobin content and cerebral blood flow, but also on cardiocirculatory condition, ventilation, and metabolic parameters. Hence, measurement of cerebral oxygenation may uncover problems not detectable by standard monitoring. Therefore, applying NIRS can provide caregivers a more complete clinical overview, especially in critically ill neonates. In this review, we aim to describe the additional information which can be provided by cNIRS during fetal to neonatal transition. IMPACT: This narrative review focuses on the clinical use and relevance of cerebral oxygenation measured by near infrared spectroscopy (NIRS) during fetal to neonatal transition. During the last decade, interest on brain monitoring is growing continuously as the measurement of cerebral oxygenation may uncover problems which are not detectable by routine monitoring. Therefore, it will be crucial to have additional information to get a complete overview, especially in critically ill neonates in need of medical and respiratory support. In this review, we offer additional information which can be provided by cerebral NIRS during fetal to neonatal transition.
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Affiliation(s)
- Nariae Baik-Schneditz
- Division of Neonatology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
- Research Unit for Cerebral Development and Oximetry, Division of Neonatology, Medical University of Graz, Graz, Austria
| | - Bernhard Schwaberger
- Division of Neonatology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
- Research Unit for Cerebral Development and Oximetry, Division of Neonatology, Medical University of Graz, Graz, Austria
| | - Ilia Bresesti
- Division of Neonatology, Department of Paediatrics, "F. Del Ponte" Hospital, University of Insubria, Varese, Italy
| | - Hans Fuchs
- Division of Neonatology and Pediatric Intensive Care Medicine, Center for Pediatrics and Adolescent Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Inmaculada Lara
- Division of Neonatology, University and Polytechnic Hospital La Fe, Valencia, Spain
| | - Britt Nakstad
- Division of Pediatric and Adolescent Medicine, Institute for Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Paediatric and Adolescent Health, University of Botswana, Gaborone, Botswana
| | - Gianluca Lista
- Division of Neonatology, "V.Buzzi" Children's Hospital, ASST-FBF-Sacco, Milan, Italy
| | - Maximo Vento
- Division of Neonatology, University and Polytechnic Hospital La Fe, Valencia, Spain
| | - Corinna Binder-Heschl
- Division of Neonatology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
- Research Unit for Cerebral Development and Oximetry, Division of Neonatology, Medical University of Graz, Graz, Austria
| | - Gerhard Pichler
- Division of Neonatology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
- Research Unit for Cerebral Development and Oximetry, Division of Neonatology, Medical University of Graz, Graz, Austria
| | - Berndt Urlesberger
- Division of Neonatology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.
- Research Unit for Cerebral Development and Oximetry, Division of Neonatology, Medical University of Graz, Graz, Austria.
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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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Cerebral oxygen saturation and autoregulation during hypotension in extremely preterm infants. Pediatr Res 2021; 90:373-380. [PMID: 33879849 DOI: 10.1038/s41390-021-01483-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 02/23/2021] [Accepted: 03/04/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND The impact of the permissive hypotension approach in clinically well infants on regional cerebral oxygen saturation (rScO2) and autoregulatory capacity (CAR) remains unknown. METHODS Prospective cohort study of blinded rScO2 measurements within a randomized controlled trial of management of hypotension (HIP trial) in extremely preterm infants. rScO2, mean arterial blood pressure, duration of cerebral hypoxia, and transfer function (TF) gain inversely proportional to CAR, were compared between hypotensive infants randomized to receive dopamine or placebo and between hypotensive and non-hypotensive infants, and related to early intraventricular hemorrhage or death. RESULTS In 89 potentially eligible HIP trial patients with rScO2 measurements, the duration of cerebral hypoxia was significantly higher in 36 hypotensive compared to 53 non-hypotensive infants. In 29/36 hypotensive infants (mean GA 25 weeks, 69% males) receiving the study drug, no significant difference in rScO2 was observed after dopamine (n = 13) compared to placebo (n = 16). Duration of cerebral hypoxia was associated with early intraventricular hemorrhage or death. Calculated TF gain (n = 49/89) was significantly higher reflecting decreased CAR in 16 hypotensive compared to 33 non-hypotensive infants. CONCLUSIONS Dopamine had no effect on rScO2 compared to placebo in hypotensive infants. Hypotension and cerebral hypoxia are associated with early intraventricular hemorrhage or death. IMPACT Treatment of hypotension with dopamine in extremely preterm infants increases mean arterial blood pressure, but does not improve cerebral oxygenation. Hypotensive extremely preterm infants have increased duration of cerebral hypoxia and reduced cerebral autoregulatory capacity compared to non-hypotensive infants. Duration of cerebral hypoxia and hypotension are associated with early intraventricular hemorrhage or death in extremely preterm infants. Since systematic treatment of hypotension may not be associated with better outcomes, the diagnosis of cerebral hypoxia in hypotensive extremely preterm infants might guide treatment.
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Schranz D. Pharmacological Heart Failure Therapy in Children: Focus on Inotropic Support. Handb Exp Pharmacol 2020; 261:177-192. [PMID: 31707469 DOI: 10.1007/164_2019_267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Pediatric heart failure is a clinical syndrome, which needs to be distinctly defined and the pathophysiological consequences considered. Pharmacological treatment depends on the disease- and age-specific myocardial characteristics. Acute and chronic low cardiac output is the result of an inadequate heart rate (rhythm), myocardial contractility, preload and afterload, and also ventriculo-ventricular interaction, synchrony, atrio-ventricular and ventricular-arterial coupling. The treatment of choice is curing the cause of heart failure, if possible.Acute HF therapy is still based to the use of catecholamines and inodilators. The cornerstone of chronic HF treatment consists of blocking the endogenous, neuro-humoral axis, in particular the adrenergic and renin-angiotensin-aldosterone system.Before neprilysin inhibitors are used in young children, their potential side-effect for inducing Alzheimer disease needs to be clarified. The focus of the current review is put on the differential use of the inotropic drugs as epinephrine, norepinephrine, dopamine and dobutamine, and also the inodilators milrinone and levosimendan. Considering effects and side-effects of any cardiac stimulating treatment strategy, co-medication with ß-blockers, angiotensin converting inhibitors (ACEIs), angiotensin blockers (ARBs) and mineralocorticoid receptor antagonists (MRAs) is not a contradiction, but a senseful measure, even still during the acute inotropic treatment.Missing sophisticated clinical trials using accurate entry criteria and clinically relevant endpoints, there is especially in cardiovascular diagnosis and treatment of young children a compromise of evidence-based versus pathophysiology-based procedures. But based on the pharmacological and pathophysiological knowledge a hypothesis-driven individualized treatment is already currently possible and therefore indicated.
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Affiliation(s)
- Dietmar Schranz
- Pediatric Heart Center, Johann Wolfgang Goethe University Clinic, Frankfurt, Germany.
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Current Trends and Critical Care Considerations for the Management of Single Ventricle Neonates. CURRENT PEDIATRICS REPORTS 2020. [DOI: 10.1007/s40124-020-00227-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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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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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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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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Cerebral Circulation and Hypotension in the Premature Infant. Neurology 2019. [DOI: 10.1016/b978-0-323-54392-7.00001-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Mahdi ES, Bouyssi-Kobar M, Jacobs MB, Murnick J, Chang T, Limperopoulos C. Cerebral Perfusion Is Perturbed by Preterm Birth and Brain Injury. AJNR Am J Neuroradiol 2018; 39:1330-1335. [PMID: 29748205 DOI: 10.3174/ajnr.a5669] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Accepted: 03/23/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Early disturbances in systemic and cerebral hemodynamics are thought to mediate prematurity-related brain injury. However, the extent to which CBF is perturbed by preterm birth is unknown. Our aim was to compare global and regional CBF in preterm infants with and without brain injury on conventional MR imaging using arterial spin-labeling during the third trimester of ex utero life and to examine the relationship between clinical risk factors and CBF. MATERIALS AND METHODS We prospectively enrolled preterm infants younger than 32 weeks' gestational age and <1500 g and performed arterial spin-labeling MR imaging studies. Global and regional CBF in the cerebral cortex, thalami, pons, and cerebellum was quantified. Preterm infants were stratified into those with and without structural brain injury. We further categorized preterm infants by brain injury severity: moderate-severe and mild. RESULTS We studied 78 preterm infants: 31 without brain injury and 47 with brain injury (29 with mild and 18 with moderate-severe injury). Global CBF showed a borderline significant increase with increasing gestational age at birth (P = .05) and trended lower in preterm infants with brain injury (P = .07). Similarly, regional CBF was significantly lower in the right thalamus and midpons (P < .05) and trended lower in the midtemporal, left thalamus, and anterior vermis regions (P < .1) in preterm infants with brain injury. Regional CBF in preterm infants with moderate-severe brain injury trended lower in the midpons, right cerebellar hemisphere, and dentate nuclei compared with mild brain injury (P < .1). In addition, a significant, lower regional CBF was associated with ventilation, sepsis, and cesarean delivery (P < .05). CONCLUSIONS We report early disturbances in global and regional CBF in preterm infants following brain injury. Regional cerebral perfusion alterations were evident in the thalamus and pons, suggesting regional vulnerability of the developing cerebro-cerebellar circuitry.
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Affiliation(s)
- E S Mahdi
- From the Developing Brain Research Program (E.S.M., M.B.-K., J.M., C.L.), Department of Diagnostic Imaging and Radiology
| | - M Bouyssi-Kobar
- From the Developing Brain Research Program (E.S.M., M.B.-K., J.M., C.L.), Department of Diagnostic Imaging and Radiology
- Department of Neurology (T.C.)
| | - M B Jacobs
- Department of Epidemiology and Biostatistics (M.B.J.), Children's Research Institute, Children's National Health System, Washington, DC
| | - J Murnick
- From the Developing Brain Research Program (E.S.M., M.B.-K., J.M., C.L.), Department of Diagnostic Imaging and Radiology
| | - T Chang
- Department of Neurology (T.C.)
| | - C Limperopoulos
- From the Developing Brain Research Program (E.S.M., M.B.-K., J.M., C.L.), Department of Diagnostic Imaging and Radiology
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Rasmussen MB, Gramsbergen JB, Eriksen VR, Greisen G. Dopamine plasma clearance is increased in piglets compared to neonates during continuous dopamine infusion. Acta Paediatr 2018; 107:249-254. [PMID: 28796889 DOI: 10.1111/apa.14018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 07/13/2017] [Accepted: 08/07/2017] [Indexed: 01/26/2023]
Abstract
AIM Piglets models have often been used to study the effects of dopamine infusion on hypotension in neonates. However, piglets need higher doses of dopamine than neonates to increase blood pressure. We investigated whether this difference was due to interspecific difference in dopamine pharmacokinetics. METHODS Arterial blood samples were drawn from six neonates admitted to the neonatal intensive care unit of Copenhagen University Hospital and 20 newborn piglets during continuous dopamine infusion. Furthermore, to estimate the piglet plasma dopamine half-life, blood samples were drawn at 2.5-minute intervals after the dopamine infusion was discontinued. The plasma dopamine content was analysed by high-performance liquid chromatography with electrochemical detection. RESULTS The dopamine displayed first-order kinetics in piglets and had a half-life of 2.5 minutes, while the median plasma clearance was 627.9 mL/kg/minute (interquartile range 452.6-1914.4). Both piglets and neonates showed large interindividual variations in plasma clearance, but the median tended to be lower in neonates (384.9, interquartile range 114.2-480.2 mL/kg/minute). CONCLUSION Our results suggest that pharmacokinetic differences may explain the interspecific difference in required doses of dopamine infusion to increase blood pressure. This is important when translating the results obtained in piglet models to treating neonatal hypotension with dopamine.
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Affiliation(s)
- Martin B. Rasmussen
- Department of Neonatology; Copenhagen University Hospital - Rigshospitalet; Copenhagen Denmark
- Faculty of Health and Medical Sciences; University of Copenhagen; Copenhagen Denmark
| | - Jan Bert Gramsbergen
- Department of Neurobiology Research; Institute of Molecular Medicine; University of Southern Denmark (SDU); Odense Denmark
| | - Vibeke R. Eriksen
- Department of Neonatology; Copenhagen University Hospital - Rigshospitalet; Copenhagen Denmark
- Faculty of Health and Medical Sciences; University of Copenhagen; Copenhagen Denmark
| | - Gorm Greisen
- Department of Neonatology; Copenhagen University Hospital - Rigshospitalet; Copenhagen Denmark
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17
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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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18
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Joynt C, Cheung PY. Cardiovascular Supportive Therapies for Neonates With Asphyxia - A Literature Review of Pre-clinical and Clinical Studies. Front Pediatr 2018; 6:363. [PMID: 30619782 PMCID: PMC6295641 DOI: 10.3389/fped.2018.00363] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 11/08/2018] [Indexed: 12/13/2022] Open
Abstract
Asphyxiated neonates often have hypotension, shock, and poor tissue perfusion. Various "inotropic" medications are used to provide cardiovascular support to improve the blood pressure and to treat shock. However, there is incomplete literature on the examination of hemodynamic effects of these medications in asphyxiated neonates, especially in the realm of clinical studies (mostly in late preterm or term populations). Although the extrapolation of findings from animal studies and other clinical populations such as children and adults require caution, it seems appropriate that findings from carefully conducted pre-clinical studies are important in answering some of the fundamental knowledge gaps. Based on a literature search, this review discusses the current available information, from both clinical studies and animal models of neonatal asphyxia, on common medications used to provide hemodynamic support including dopamine, dobutamine, epinephrine, milrinone, norepinephrine, vasopressin, levosimendan, and hydrocortisone.
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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, University of Alberta, Edmonton, AB, Canada.,Centre for the Study of Asphyxia and Resuscitation, Edmonton, AB, Canada
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19
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Vesoulis ZA, Hao J, McPherson C, El Ters NM, Mathur AM. Low-frequency blood pressure oscillations and inotrope treatment failure in premature infants. J Appl Physiol (1985) 2017; 123:55-61. [PMID: 28428252 PMCID: PMC6157481 DOI: 10.1152/japplphysiol.00205.2017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 04/03/2017] [Accepted: 04/13/2017] [Indexed: 11/22/2022] Open
Abstract
The underlying mechanism as to why some hypotensive preterm infants do not respond to inotropic medications remains unclear. For these infants, we hypothesize that impaired vasomotor function is a significant factor and is manifested through a decrease in low-frequency blood pressure variability across regulatory components of vascular tone. Infants born ≤28 wk estimated gestational age underwent prospective recording of mean arterial blood pressure for 72 h after birth. After error correction, root-mean-square spectral power was calculated for each valid 10-min data frame across each of four frequency bands (B1, 0.005-0.0095 Hz; B2, 0.0095-0.02 Hz; B3, 0.02-0.06 Hz; and B4, 0.06-0.16) corresponding to different components of vasomotion control. Forty infants (twenty-nine normotensive control and eleven inotrope-exposed) were included with a mean ± SD estimated gestational age of 25.2 ± 1.6 wk and birth weight 790 ± 211 g. 9.7/11.8 Million (82%) data points were error-free and used for analysis. Spectral power across all frequency bands increased with time, although the magnitude was 20% less in the inotrope-exposed infants. A statistically significant increase in spectral power in response to inotrope initiation was noted across all frequency bands. Infants with robust blood pressure response to inotropes had a greater increase compared with those who had limited or no blood pressure response. In this study, hypotensive infants who require inotropes have decreased low-frequency variability at baseline compared with normotensive infants, which increases after inotrope initiation. Low-frequency spectral power does not change for those with inotrope treatment failure, suggesting dysfunctional regulation of vascular tone as a potential mechanism of treatment failure.NEW & NOTEWORTHY In this study, we examine patterns of low-frequency oscillations in blood pressure variability across regulatory components of vascular tone in normotensive and hypotensive infants exposed to inotropic medications. We found that hypotensive infants who require inotropes have decreased low-frequency variability at baseline, which increases after inotrope initiation. Low-frequency spectral power does not change for those with inotrope treatment failure, suggesting dysfunctional regulation of vascular tone as a potential mechanism of treatment failure.
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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, Missouri; and
| | - Jessica Hao
- Division of Newborn Medicine, Edward Mallinckrodt Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri; and
| | - Christopher McPherson
- Division of Newborn Medicine, Edward Mallinckrodt Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri; and
- St. Louis Children's Hospital, St. Louis, Missouri
| | - Nathalie M El Ters
- Division of Newborn Medicine, Edward Mallinckrodt Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri; and
| | - Amit M Mathur
- Division of Newborn Medicine, Edward Mallinckrodt Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri; and
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20
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Segar JL. Renal adaptive changes and sodium handling in the fetal-to-newborn transition. Semin Fetal Neonatal Med 2017; 22:76-82. [PMID: 27881286 DOI: 10.1016/j.siny.2016.11.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Appropriate fluid and electrolyte management is critical for optimal care of very low birth weight or sick infants. Delivery of such care requires an understanding of developmental changes in renal water and salt handling that occur with advancing gestational age as well as postnatal age. This review focuses on the principles of sodium homeostasis during fetal and postnatal life. The physiology of renal tubular transport mechanisms, as well as neurohumoral factors impacting renal tubular transport are highlighted. Clinical implications and guidelines to the provision of sodium to this vulnerable population are also discussed.
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Affiliation(s)
- Jeffrey L Segar
- Department of Pediatrics, University of Iowa Carver College of Medicine, University of Iowa Children's Hospital, Iowa City, IA, USA.
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21
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Baik N, Urlesberger B, Schwaberger B, Avian A, Mileder L, Schmölzer GM, Pichler G. Blood Pressure during the Immediate Neonatal Transition: Is the Mean Arterial Blood Pressure Relevant for the Cerebral Regional Oxygenation? Neonatology 2017; 112:97-102. [PMID: 28427056 DOI: 10.1159/000455965] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 01/06/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Measurement of mean arterial blood pressure (MABP) is feasible during neonatal transition. OBJECTIVE The objective of this study was to investigate a potential influence of MABP on the cerebral regional oxygen saturation (crSO2) in preterm and term infants during the immediate neonatal transition. MATERIALS AND METHODS Preterm and term infants were included in this observational study. The crSO2 was measured by near-infrared spectroscopy with the INVOS 5100C (Somanetics Corp., Troy, MI, USA) during the immediate neonatal transition (15 min after birth). The near-infrared spectroscopy sensor was applied to the left forehead. Furthermore, a pulse oximeter was applied to monitor arterial oxygen saturation (SpO2) and heart rate (HR). Fifteen minutes after birth, blood pressure was measured noninvasively at the left upper arm. Cerebral fraction tissue oxygen extraction (cFTOE) was calculated from SpO2 and crSO2. To investigate a potential association between crSO2/cFTOE and MABP, we performed a correlation analysis. RESULTS A total of 462 preterm and term infants (186/292) were included. Mean gestational age was 31.0 ± 3.5 weeks for preterm infants and 38.9 ± 0.8 weeks for full term infants. Mean birth weight was 1.591 ± 630 g in preterm infants and 3.331 ± 461 g in term infants. There was a significant negative correlation between MABP and cFTOE (ρ = -0.19, p = 0.03) in preterm infants but not in term infants (ρ = 0.05, p = 0.39). There was no significant correlation between MABP and crSO2 in either group. CONCLUSION MABP has an impact on cerebral oxygenation in preterm infants. Therefore, blood pressure monitoring during the immediate neonatal transition might be relevant for improving cerebral oxygenation especially in preterm infants.
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Affiliation(s)
- Nariae Baik
- Division of Neonatology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
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22
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Population Pharmacokinetics and Dosing Considerations for Gentamicin in Newborns with Suspected or Proven Sepsis Caused by Gram-Negative Bacteria. Antimicrob Agents Chemother 2016; 61:AAC.01304-16. [PMID: 27795373 DOI: 10.1128/aac.01304-16] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 10/09/2016] [Indexed: 12/13/2022] Open
Abstract
The aim of this study was to describe the population pharmacokinetics (PK) of gentamicin in neonates with suspected or proven Gram-negative sepsis and determine the optimal dosage regimen in relation to the bacterial MICs found in this population. Data were prospectively collected between October 2012 and January 2013 in the Neonatal Intensive Care Unit (NICU) at the Academic Medical Center (AMC), Amsterdam, The Netherlands. A single nonlinear mixed-effects regression analysis (NONMEM) was performed to describe the population PK of gentamicin. Dosage regimens based upon gestational age (GA) were generated using Monte Carlo simulations with the final model. Target values were based on the MIC distribution in our patient population. In total, 136 gentamicin concentrations from 65 (pre)term neonates were included. The PK was best described by an allometric 2-compartment model with postmenstrual age (PMA) as a covariate on clearance (Cl). The MIC distribution (median, 0.75 [range, 0.5 to 1.5] mg/liter) justified a gentamicin target peak concentration of 8 to 12 mg/liter. This study describes the PK of gentamicin in (pre)term neonates. Dosage regimens of 5 mg/kg of body weight every 48 h, 5 mg/kg every 36 h, and 5 mg/kg every 24 h for patients with GAs of <37 weeks, 37 to 40 weeks, and ≥40 weeks, respectively, are recommended.
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23
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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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Pandey V, Kumar D, Vijayaraghavan P, Chaturvedi T, Raina R. Non-dialytic management of acute kidney injury in newborns. J Renal Inj Prev 2016; 6:1-11. [PMID: 28487864 PMCID: PMC5414511 DOI: 10.15171/jrip.2017.01] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 10/10/2016] [Indexed: 01/04/2023] Open
Abstract
Treating acute kidney injury (AKI) in newborns is often challenging due to the functional immaturity of the neonatal kidney. Because of this physiological limitation, renal replacement therapy (RRT) in this particular patient population is difficult to execute and may lead to unwanted complications. Although fluid overload and electrolyte abnormalities, as seen in neonatal AKI, are indications for RRT initiation, there is limited evidence that RRT initiated in the first year of life improves long-term outcome. The underlying cause of AKI in a newborn patient should determine the treatment strategies to restore appropriate renal function. However, our understanding of this common clinical condition remains limited, as no standardized, evidence-based definition of neonatal AKI currently exists. Non-dialytic management of AKI in these patients may restore appropriate renal function to these patients without exposure to complications often encountered with RRT.
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Affiliation(s)
- Vishal Pandey
- Department of Pediatrics and Neonatology, University of Kansas Hospital, Kansas City, KS, USA
| | - Deepak Kumar
- Department of Pediatrics and Neonatology, MetroHealth Medical Center, Cleveland, OH, USA
| | - Prashant Vijayaraghavan
- Division of Nephrology, Department of Internal Medicine and Research Cleveland Clinic Akron General, Akron, OH, USA 4Akron Children's Hospital, Cleveland, OH, USA
| | - Tushar Chaturvedi
- Division of Nephrology, Department of Internal Medicine and Research Cleveland Clinic Akron General, Akron, OH, USA 4Akron Children's Hospital, Cleveland, OH, USA
| | - Rupesh Raina
- Division of Nephrology, Department of Internal Medicine and Research Cleveland Clinic Akron General, Akron, OH, USA 4Akron Children's Hospital, Cleveland, OH, USA.,Akron Children's Hospital, Cleveland, OH, USA
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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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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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Assessing cerebrovascular autoregulation in infants with necrotizing enterocolitis using near-infrared spectroscopy. Pediatr Res 2016; 79:76-80. [PMID: 26383883 DOI: 10.1038/pr.2015.184] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 07/15/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND We assessed cerebrovascular autoregulation (CAR) in preterm infants with definite necrotizing enterocolitis (NEC), Bell's stage 2 or 3, and infants without NEC, using near-infrared spectroscopy. We hypothesized that CAR would be more often impaired in infants with NEC compared with infants without NEC. METHODS We measured cerebral regional tissue oxygen saturation, arterial oxygen saturation, and mean arterial blood pressure (MABP) during 48 h. We calculated the correlation between cerebral fractional tissue oxygen extraction and MABP for each patient. A statistically significant negative correlation reflected impaired CAR. RESULTS We included 15 infants with definite NEC (median (range) gestational age 27.4 (25.6-34.7) wk; birth weight 1,070 (670-2,400) g) and 13 infants without NEC (gestational age 27.9 (26.3-34.7) wk; birth weight 980 (640-2,640) g). Fourteen infants had a statistically significant negative correlation (ρ -0.468 to-0.104), of whom five were infants without NEC (5/13; 38%) and nine with definite NEC (9/15; 60%). The difference in prevalence of impaired CAR was not statistically significant. CONCLUSION Impaired CAR is present in a substantial proportion of infants with definite NEC, which may predispose them to NEC-associated neurological damage.
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Abstract
Shock is characterized by inadequate oxygen delivery to the tissues, and is more frequent in very low birth weight infants, especially in the first few days of life. Shock is an independent predictor of mortality, and the survivors are at a higher risk of neurologic impairment. Understanding the pathophysiology helps to recognize and classify shock in the early compensated phase and initiate appropriate treatment. Hypovolemia is rarely the primary cause of shock in neonates. Myocardial dysfunction is especially common in extremely preterm infants, and in term infants with perinatal asphyxia. Blood pressure measurements are easy, but correlate poorly with cerebral and systemic blood flows. Point-of-care cardiac ultrasound can help in individualized assessment of problems, selecting appropriate therapy and monitoring response, but may not always be available, and long-term benefits need to be demonstrated. The use of near-infrared spectroscopy to guide treatment of neonatal shock is currently experimental. In the absence of hypovolemia, excessive administration of fluid boluses is inappropriate therapy. Dobutamine and dopamine are the most common initial inotropes used in neonatal shock. Dobutamine has been shown to improve systemic blood flow, especially in very low birth weight infants, but dopamine is better at improving blood pressure in hypotensive infants. Newer inodilators including milrinone and levosimendan may be useful in selected settings. Data on long-term survival and neurologic outcomes following different management strategies are scarce and future research efforts should focus on this.
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Affiliation(s)
- B Vishnu Bhat
- Department of Neonatology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, 605006, India.
| | - Nishad Plakkal
- Department of Neonatology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, 605006, India
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Fuchs A, Guidi M, Giannoni E, Werner D, Buclin T, Widmer N, Csajka C. Population pharmacokinetic study of gentamicin in a large cohort of premature and term neonates. Br J Clin Pharmacol 2015; 78:1090-101. [PMID: 24938850 DOI: 10.1111/bcp.12444] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Accepted: 06/09/2014] [Indexed: 12/01/2022] Open
Abstract
AIM This study aims to investigate the clinical and demographic factors influencing gentamicin pharmacokinetics in a large cohort of unselected premature and term newborns and to evaluate optimal regimens in this population. METHODS All gentamicin concentration data, along with clinical and demographic characteristics, were retrieved from medical charts in a Neonatal Intensive Care Unit over 5 years within the frame of a routine therapeutic drug monitoring programme. Data were described using non-linear mixed-effects regression analysis ( nonmem®). RESULTS A total of 3039 gentamicin concentrations collected in 994 preterm and 455 term newborns were included in the analysis. A two compartment model best characterized gentamicin disposition. The average parameter estimates, for a median body weight of 2170 g, were clearance (CL) 0.089 l h(-1) (CV 28%), central volume of distribution (Vc ) 0.908 l (CV 18%), intercompartmental clearance (Q) 0.157 l h(-1) and peripheral volume of distribution (Vp ) 0.560 l. Body weight, gestational age and post-natal age positively influenced CL. Dopamine co-administration had a significant negative effect on CL, whereas the influence of indomethacin and furosemide was not significant. Both body weight and gestational age significantly influenced Vc . Model-based simulations confirmed that, compared with term neonates, preterm infants need higher doses, superior to 4 mg kg(-1) , at extended intervals to achieve adequate concentrations. CONCLUSIONS This observational study conducted in a large cohort of newborns confirms the importance of body weight and gestational age for dosage adjustment. The model will serve to set up dosing recommendations and elaborate a Bayesian tool for dosage individualization based on concentration monitoring.
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Affiliation(s)
- Aline Fuchs
- Division of Clinical Pharmacology, Service of Biomedicine, Department of Laboratory, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
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Bighamian R, Soleymani S, Reisner AT, Seri I, Hahn JO. Prediction of Hemodynamic Response to Epinephrine via Model-Based System Identification. IEEE J Biomed Health Inform 2014; 20:416-23. [PMID: 25420273 DOI: 10.1109/jbhi.2014.2371533] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In this study, we present a system identification approach to the mathematical modeling of hemodynamic responses to vasopressor-inotrope agents. We developed a hybrid model called the latency-dose-response-cardiovascular (LDC) model that incorporated 1) a low-order lumped latency model to reproduce the delay associated with the transport of vasopressor-inotrope agent and the onset of physiological effect, 2) phenomenological dose-response models to dictate the steady-state inotropic, chronotropic, and vasoactive responses as a function of vasopressor-inotrope dose, and 3) a physiological cardiovascular model to translate the agent's actions into the ultimate response of blood pressure. We assessed the validity of the LDC model to fit vasopressor-inotrope dose-response data using data collected from five piglet subjects during variable epinephrine infusion rates. The results suggested that the LDC model was viable in modeling the subjects' dynamic responses: After tuning the model to each subject, the r (2) values for measured versus model-predicted mean arterial pressure were consistently higher than 0.73. The results also suggested that intersubject variability in the dose-response models, rather than the latency models, had significantly more impact on the model's predictive capability: Fixing the latency model to population-averaged parameter values resulted in r(2) values higher than 0.57 between measured versus model-predicted mean arterial pressure, while fixing the dose-response model to population-averaged parameter values yielded nonphysiological predictions of mean arterial pressure. We conclude that the dose-response relationship must be individualized, whereas a population-averaged latency-model may be acceptable with minimal loss of model fidelity.
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Brew N, Walker D, Wong FY. Cerebral vascular regulation and brain injury in preterm infants. Am J Physiol Regul Integr Comp Physiol 2014; 306:R773-86. [PMID: 24647591 DOI: 10.1152/ajpregu.00487.2013] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Cerebrovascular lesions, mainly germinal matrix hemorrhage and ischemic injury to the periventricular white matter, are major causes of adverse neurodevelopmental outcome in preterm infants. Cerebrovascular lesions and neuromorbidity increase with decreasing gestational age, with the white matter predominantly affected. Developmental immaturity in the cerebral circulation, including ongoing angiogenesis and vasoregulatory immaturity, plays a major role in the severity and pattern of preterm brain injury. Prevention of this injury requires insight into pathogenesis. Cerebral blood flow (CBF) is low in the preterm white matter, which also has blunted vasoreactivity compared with other brain regions. Vasoreactivity in the preterm brain to cerebral perfusion pressure, oxygen, carbon dioxide, and neuronal metabolism is also immature. This could be related to immaturity of both the vasculature and vasoactive signaling. Other pathologies arising from preterm birth and the neonatal intensive care environment itself may contribute to impaired vasoreactivity and ineffective CBF regulation, resulting in the marked variations in cerebral hemodynamics reported both within and between infants depending on their clinical condition. Many gaps exist in our understanding of how neonatal treatment procedures and medications have an impact on cerebral hemodynamics and preterm brain injury. Future research directions for neuroprotective strategies include establishing cotside, real-time clinical reference values for cerebral hemodynamics and vasoregulatory capacity and to demonstrate that these thresholds improve long-term outcomes for the preterm infant. In addition, stimulation of vascular development and repair with growth factor and cell-based therapies also hold promise.
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Affiliation(s)
- Nadine Brew
- The Ritchie Centre, Monash Institute of Medical Research-Prince Henry's Institute, Melbourne, Clayton, Victoria, Australia; and
| | - David Walker
- The Ritchie Centre, Monash Institute of Medical Research-Prince Henry's Institute, Melbourne, Clayton, Victoria, Australia; and Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Flora Y Wong
- The Ritchie Centre, Monash Institute of Medical Research-Prince Henry's Institute, Melbourne, Clayton, Victoria, Australia; and Monash Newborn, Monash Medical Centre, Melbourne, Victoria, Australia; and Department of Pediatrics, Monash University, Melbourne, Victoria, Australia
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Olhager E, Nold-Petry CA, Joshi MS, Doery JCG, Samarasinghe T, Walker AM, Wong FY. Preterm lambs given intravenous dopamine show increased dopamine in their cerebrospinal fluid. Acta Paediatr 2014; 103:337-42. [PMID: 24267481 DOI: 10.1111/apa.12520] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Revised: 10/07/2013] [Accepted: 11/20/2013] [Indexed: 11/26/2022]
Abstract
AIM Dopamine is used as an inotropic medication in preterm infants. The preterm human blood brain barrier (BBB) is permeable to intravascular dopamine, and the impact of exogenous dopamine on the preterm brain remains unknown. The preterm lamb model may be suitable for studying the cerebral impact of dopamine therapy whether its BBB permeability is similar to preterm human infants. We aimed to examine BBB permeability to exogenous dopamine in the preterm lamb, by measuring dopamine levels in the cerebrospinal fluid (CSF). METHODS Nine preterm foetal lambs (125-130 days, term = 147 days) were given either dopamine at 10 μg/kg/min (dopamine, n = 4) or saline (control, n = 5). CSF, and plasma samples were taken for dopamine assay. RESULTS The median (range) baseline CSF dopamine level for the combined control and dopamine groups (n = 9) was 0.10(0.03-0.16) ng/mL, and baseline plasma dopamine was 0.30(0.13-0.84) ng/mL. The dopamine lambs showed increase in CSF dopamine to 3.91(1.87-11.35) ng/mL with plasma dopamine increased to 14.2 (9.1-57.9) ng/mL. No change was found in the control lambs. CONCLUSION In the preterm lamb, the BBB permeability and pharmacokinetics to dopamine infusion are similar to findings in the preterm human infant, supporting applicability of the preterm lamb model for studying effects of dopamine infusion in the preterm human brain.
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Affiliation(s)
- Elisabeth Olhager
- The Ritchie Centre; Monash University; Melbourne VIC Australia
- Department of clinical and experimental medicine; Linkoping University; Linkoping Sweden
| | | | - Mandar S Joshi
- The Ritchie Centre; Monash University; Melbourne VIC Australia
| | - James CG Doery
- Department of Biochemistry; Monash Medical Centre; Melbourne VIC Australia
- Department of Medicine; Monash University; Melbourne VIC Australia
| | | | - Adrian M Walker
- The Ritchie Centre; Monash University; Melbourne VIC Australia
| | - Flora Y Wong
- The Ritchie Centre; Monash University; Melbourne VIC Australia
- Monash Newborn, Monash Medical Centre; Melbourne VIC Australia
- Department of Paediatrics; Monash University; Melbourne VIC Australia
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Abstract
Controversy surrounds the assessment of perfusion and the methods currently utilised to define hypotension, especially blood pressure. There is growing agreement to assess heart function when selecting inotropic therapy and use bedside tools such as echocardiography for assessing at-risk infants. Both dopamine and dobutamine have comparative efficacy, and in certain disease states with immature myocardium there could be potential advantages in using dobutamine. The concomitant use of hydrocortisone has been shown to be beneficial when escalating doses of first-line inotropes are used. Other inotropes require further study through randomised trials for their safety and efficacy to be established.
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Affiliation(s)
- Samir Gupta
- Department of Paediatrics, University Hospital of North Tees and University of Durham, Stockton-on-Tees, UK.
| | - Steven M Donn
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, C.S. Mott Children's Hospital, University of Michigan Health System, Ann Arbor, MI, USA
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Abstract
Ensuring adequate oxygenation of the developing brain is the cornerstone of neonatal critical care. Despite decades of clinical research dedicated to this issue of paramount importance, our knowledge and understanding regarding the physiology and pathophysiology of neonatal cerebral blood flow are still rudimentary. This review primarily focuses on currently available human clinical and experimental data on cerebral blood flow and autoregulation in the preterm and term infant. Limitations of systemic blood pressure values as surrogates for monitoring adequate cerebral oxygen delivery are discussed. Particular emphasis is placed on the high interindividual variability in cerebral blood flow values, vasoreactivity, and autoregulatory thresholds making the applications of normative values highly questionable. Technical and ethical difficulties to conduct such trials leave us with a near complete lack of knowledge on how pharmacological and surgical interventions impact on cerebral autoregulation. The ensemble of these works argues for the necessity of highly individualized care by taking advantage of continuous bedside monitoring of cerebral circulation. They also point to the urgent need for further studies addressing the exciting but difficult issue of cerebral blood flow autoregulation in the neonate.
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Affiliation(s)
- Laszlo Vutskits
- Department of Anesthesiology, Pharmacology and Intensive Care, University Hospital of Geneva, Geneva, Switzerland; Department of Fundamental Neuroscience, Geneva University Medical School, Geneva, Switzerland
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Krishnamurthy G, Ratner V, Bacha E. Neonatal cardiac care, a perspective. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2013; 16:21-31. [PMID: 23561814 DOI: 10.1053/j.pcsu.2013.01.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Every year in the United States approximately 40,000 infants are born with congenital heart disease. Several of these infants require corrective or palliative surgery in the neonatal period. Mortality rates after cardiac surgery are highest amongst neonates, particularly those born prematurely. There are several reasons for the increased surgical mortality risk in neonates. This review outlines these risks, with particular emphasis on the relative immaturity of the organ systems in the term and preterm neonate.
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Affiliation(s)
- Ganga Krishnamurthy
- Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York, NY 10032, USA.
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Lightburn MH, Gauss CH, Williams DK, Kaiser JR. Observational study of cerebral hemodynamics during dopamine treatment in hypotensive ELBW infants on the first day of life. J Perinatol 2013; 33:698-702. [PMID: 23619374 PMCID: PMC3735635 DOI: 10.1038/jp.2013.44] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Revised: 03/10/2013] [Accepted: 03/21/2013] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To evaluate cerebral hemodynamics during dopamine treatment in hypotensive (mean arterial blood pressure (MABP)<gestational age) extremely low birth weight (ELBW) infants. STUDY DESIGN Continuous monitoring of cerebral blood flow velocity (CBFv), MABP and PCO2 was performed in hypotensive ELBW infants on the first day of life, beginning with an ∼15-min baseline reading and continued during advancing dopamine infusion until MABP was optimized. Physiological variables and CBFv reactivity were compared before and after MABP was optimized. RESULT Fifteen hypotensive ELBW infants (625±174 g; 24 (23 to 24.8) weeks) were studied. Mean CBFv increased from 10.9±3.7 to 15.7±5.7 cm s(-1) (P=0.001) simultaneously as MABP increased from 22.3±2.8 to 35.2±9.7 mm Hg (P<0.001). Mean CBFv reactivity (95% confidence interval (CI)) was 3.9 (1.6 to 6.2) %mm Hg(-1). Nine infants died and/or developed severe intraventricular hemorrhage (IVH). CONCLUSION Mean CBFv increased pressure-passively as MABP was optimized by dopamine treatment in very sick hypotensive ELBW infants on the first day of life.
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Affiliation(s)
- Marla H. Lightburn
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR 72205
| | - C. Heath Gauss
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR 72205
| | - D. Keith Williams
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR 72205
| | - Jeffrey R. Kaiser
- Departments of Pediatrics and Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX 77030
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Effects of low-dose dopamine on urine output in normotensive very low birth weight neonates. J Perinatol 2013; 33:619-21. [PMID: 23448938 PMCID: PMC4028044 DOI: 10.1038/jp.2013.20] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Accepted: 01/18/2013] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To determine the effects of low-dose dopamine on urine output (UOP) in very low birth weight premature neonates. STUDY DESIGN Retrospective cohort study of all low-dose (3-5 μg kg(-1) per min) dopamine infusions >24-h duration in neonates 1500 g and 32 weeks gestation from August 2009 through September 2011. Linear regression was used to estimate the impact of covariates on UOP. RESULT We identified 91 episodes of low-dose dopamine use in 65 neonates. Increased UOP occurred in 64% of episodes. Low-dose dopamine use was associated with a 0.6 ml kg(-1) h(-1) increase in UOP (P<0.001) and a 1.3 ml kg(-1)h(-1) increase when baseline UOP was <1.5 ml kg(-1) h(-1) (P<0.001). The improvement remained statistically significant after controlling for medications (diuretics and hydrocortisone) and fluid intake. CONCLUSION Low-dose dopamine use was associated with increased UOP in very low birth weight neonates.
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Azhan A, Wong FY. Challenges in understanding the impact of blood pressure management on cerebral oxygenation in the preterm brain. Front Physiol 2012; 3:471. [PMID: 23264765 PMCID: PMC3524455 DOI: 10.3389/fphys.2012.00471] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Accepted: 11/30/2012] [Indexed: 02/01/2023] Open
Abstract
Systemic hypotension in preterm infants has been related to increased mortality, cerebrovascular lesions, and neurodevelopmental morbidity. Treatment of hypotension with inotropic medications aims at preservation of end organ perfusion and oxygen delivery, especially the brain. The common inotropic medications in preterm infants include dopamine, dobutamine, adrenaline, with adjunctive use of corticosteroids in cases of refractory hypotension. Whether maintenance of mean arterial blood pressure (MAP) by use of inotropic medication is neuroprotective or not remains unclear. This review explores the different inotropic agents and their effects on perfusion and oxygenation in the preterm brain, in clinical studies as well as in animal models. Dopamine and adrenalin, because of their α-adrenergic vasoconstrictor actions, have raised concerns of reduction in cerebral blood flow (CBF). Several studies in hypotensive preterm infants have shown that dopamine elevates CBF together with increased MAP, in keeping with limited cerebro-autoregulation. Adrenaline is also effective in raising cerebral perfusion together with MAP in preterm infants. Experimental studies in immature animals show no cerebro-vasoconstrictive effects of dopamine or adrenaline, but demonstrate the consistent findings of increased cerebral perfusion and oxygenation with the use of dopamine, dobutamine, and adrenaline, alongside with raised MAP. Both clinical and animal studies report the transitory effects of adrenaline in increasing plasma lactate, and blood glucose, which might render its use as a 2nd line therapy. To investigate the cerebral effects of inotropic agents in long-term outcome in hypotensive preterm infants, carefully designed prospective research possibly including preterm infants with permissive hypotension is required. Preterm animal models would be useful in investigating the relationship between the physiological effects of inotropes and histopathology outcomes in the developing brain.
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Affiliation(s)
- Aminath Azhan
- The Ritchie Centre, Monash UniversityMelbourne, VIC, Australia
| | - Flora Y. Wong
- The Ritchie Centre, Monash UniversityMelbourne, VIC, Australia
- Monash Newborn, Monash Medical CentreMelbourne, VIC, Australia
- Department of Pediatrics, Monash UniversityMelbourne, VIC, Australia
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Abstract
There is significant uncertainty regarding the optimal circulatory management of preterm infants, with research in the field limited by the paucity of safe, reproducible biomarkers of circulatory function. This review discusses the physiology and pathophysiology of circulatory function in preterm infants, describes the mode of action and evidence for and against commonly used and recently trialled inotropic therapies and provides recommendations for managing circulatory dysfunction in the transitional period and in the context of sepsis/necrotizing enterocolitis. We recommend a pragmatic approach of assessing multiple aspects of circulatory function (blood pressure alone correlates weakly with volume of flow) in each infant, tailoring therapy on the basis of the change in function desired and frequently reassessing response to intervention.
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Affiliation(s)
- David J Cox
- Centre for the Developing Brain, Imperial College London and MRC Clinical Sciences Centre, London, UK
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Noori S, Seri I. Neonatal blood pressure support: the use of inotropes, lusitropes, and other vasopressor agents. Clin Perinatol 2012; 39:221-38. [PMID: 22341548 DOI: 10.1016/j.clp.2011.12.010] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
A solid understanding of the mechanisms of action of cardiovascular medications used in clinical practice along with efforts to develop comprehensive hemodynamic monitoring systems to improve the ability to accurately identify the underlying pathophysiology of cardiovascular compromise are essential in the management of neonates with shock. This article reviews the mechanisms of action of the most frequently used cardiovascular medications in neonates. Because of paucity of data from controlled clinical trials, evidence-based recommendations for the clinical use of these medications could not be made. Careful titration of the given medication with close monitoring of the cardiovascular response might improve the effectiveness and decrease the risks associated with administration of these medications.
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Affiliation(s)
- Shahab Noori
- Center for Fetal and Neonatal Medicine and the USC Division of Neonatal Medicine, Children's Hospital Los Angeles and the LAC+USC Medical Center, Keck School of Medicine, University of Southern California, 4650 Sunset Boulevard, Los Angeles, CA 90027, USA
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Bonestroo HJC, Lemmers PMA, Baerts W, van Bel F. Effect of antihypotensive treatment on cerebral oxygenation of preterm infants without PDA. Pediatrics 2011; 128:e1502-10. [PMID: 22065269 DOI: 10.1542/peds.2010-3791] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Preterm infants with hypotension (mean arterial blood pressure [MABP] < gestational age [GA]) are treated with volume expansion and/or dopamine to ensure adequate cerebral perfusion/oxygenation. We used near-infrared spectroscopy to analyze the effects of volume expansion and dopamine on cerebral oxygenation in hypotensive preterm infants without patent ductus arteriosus (PDA). PATIENTS AND METHODS Among 390 infants, 71 (GA < 32 weeks) were hypotensive and eligible for inclusion. Thirty-three infants received volume expansion only (NaCl 0.9%; 20 mL/kg), and 38 received additional dopamine (5 μg/kg per minute). Nine and 11 infants initially treated with dopamine subsequently needed 7.5 and 10 μg/kg per minute, respectively. Seventy-one infants without hypotension were individually matched to serve as controls. MABP, regional cerebral oxygen saturation (rSco(2)), fractional tissue oxygen extraction (cFTOE), and arterial saturation (Sao(2)) were monitored 15 minutes before and 30 and 60 minutes after volume or dopamine and at comparable postnatal ages in controls. RESULTS No changes in MABP, rSco(2), or cFTOE were found 30 minutes after volume expansion. MABP increased 60 minutes after 5 μg/kg per minute dopamine (median [range]: 28 [19-32] vs 33 [23-46] mm Hg; P < .001). There was a small increase and decrease, respectively, in rSco(2) (63 [43-84] vs 66 [46-87]%; P < .05) and cFTOE (0.33 [0.14-0.56] vs 0.31 [0.07-0.54]1/1; P < .05). However, no differences were found at any time point between controls and infants treated with volume or additional dopamine (5, 7.5, and 10 μg/kg per minute) for rSco(2) or cFTOE. CONCLUSIONS Volume expansion and additional dopamine do not cause any significant change in rSco(2) or cFTOE in hypotensive preterm infants without PDA. We speculate that very preterm infants with hypotension but without signs of a compromised cerebral oxygenation and systemic perfusion might not be in need of antihypotensive therapy.
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Affiliation(s)
- Hilde J C Bonestroo
- Department of Neonatology, Wilhelmina Children's Hospital, AB Utrecht, Netherlands
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A meta-analysis of dopamine use in hypotensive preterm infants: blood pressure and cerebral hemodynamics. J Perinatol 2011; 31:647-55. [PMID: 21273985 DOI: 10.1038/jp.2011.2] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Dopamine administration results in variable effects on blood pressure in hypotensive preterm infants. The clinical benefits of dopamine administration in increasing cerebral blood flow (CBF) and reducing adverse neurological outcomes in hypotensive preterm neonates are unclear. The objective of this study was to examine the efficacy of dopamine for treatment of hypotension and investigate the changes in cerebral hemodynamics and central nervous system injury in hypotensive preterm infants following dopamine administration. STUDY DESIGN Standard meta-analytic techniques, including random and fixed effects models, were used to calculate combined effect size correlations and significance levels. RESULT Random effects meta-analysis found that dopamine increases mean arterial blood pressure (12 studies; N=163; r=0.88, 95% confidence interval (CI)=0.76 to 0.94) and systolic blood pressure (8 studies; N=142; r=0.81, 95% CI=0.42 to 0.94). For the increase in blood pressure, dopamine administration was associated with a significantly greater overall efficacy than dobutamine (seven studies; N=251; r=0.26; 95% CI=0.20 to 0.32), colloid (two studies; N=67; r=0.60; 95% CI=0.41 to 0.74) and hydrocortisone (one study; N=28; r=0.40; 95% CI=0.034 to 0.67). CBF increased following dopamine administration (five studies; N=75; r=0.36; 95% CI=-0.059 to 0.67) and the increase in CBF was greater in hypotensive than normotensive preterm infants (eight studies; N=153; r=0.16; 95% CI=-0.0080 to 0.32). There were no statistically significant differences in adverse neurological outcome between dopamine and dobutamine (three studies; N=118; r=-0.13; 95% CI=-0.31 to 0.059), epinephrine (two studies; N=46; r=0.06; 95% CI=-0.23 to 0.34), colloid (two studies; N=80; r=0.0070; 95% CI=-0.218 to 0.23) or hydrocortisone administration (one study; N=40; r=-0.10; 95% CI=-0.40 to 0.22). CONCLUSION Dopamine administration increases mean and systolic blood pressure in hypotensive preterm infants, and is more effective than dobutamine, colloid or hydrocortisone alone. Dopamine administration is associated with increased CBF, with greater increases in CBF in hypotensive than in normotensive preterm infants. Dopamine is not associated with a greater incidence of adverse effects than other therapies used to treat hypotension.
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New NANN Practice Guideline: the management of hypotension in the very-low-birth-weight infant. Adv Neonatal Care 2011; 11:272-8. [PMID: 22123349 DOI: 10.1097/anc.0b013e318229263c] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The Management of Hypotension in the Very-Low-Birth-Weight Infant: Guideline for Practice, developed by Lyn Vargo, PhD, RN, NNP-BC, and Istvan Seri, MD, PhD, in 2011 under the auspices of the National Association of Neonatal Nurse Practitioners, focuses on the challenging topic of clinical management of systemic hypotension in the very low-birth-weight (VLBW) infant during the first 3 days of postnatal life. The recommendations and rationale in the excerpt below from the complete online publication are based on the best evidence available through both neonatal research and consultation of experts on the subject. They suggest a conservative, evidence-based treatment approach for the management of hypotension in the VLBW infant during the first 3 days of postnatal life that is logical, safe, and physiologically sound. The insufficient fund of knowledge on transitional cardiovascular physiology in general and pathophysiology in particular makes establishment of strict guidelines on the treatment of hypotension in VLBW neonates impossible. What becomes clear when presenting the evidence is how much more we need to know. Readers are strongly encouraged to refer to the complete text of the guideline, which has been endorsed by the American Academy of Pediatrics, for further understanding of this complex topic. The guideline is available free of charge at www.nann.org (click on Guidelines in the Education section).
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Wong FY, Barfield CP, Horne RSC, Walker AM. Dopamine therapy promotes cerebral flow-metabolism coupling in preterm infants. Intensive Care Med 2009; 35:1777-82. [DOI: 10.1007/s00134-009-1602-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2009] [Accepted: 07/16/2009] [Indexed: 10/20/2022]
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Kaiser JR. The association of high-magnitude cerebral passivity and intraventricular hemorrhage in premature infants. Pediatrics 2009; 124:384-6. [PMID: 19564324 PMCID: PMC2848071 DOI: 10.1542/peds.2009-0472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Jeffrey R. Kaiser
- Departments of Pediatrics and Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
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Abstract
The complexity of postnatal cardiovascular transition has only recently been better appreciated in the very low birth weight neonate. As blood pressure in itself poorly represents systemic blood flow, especially when the fetal channels are open and the developmentally regulated vital organ assignment may not have been completed, efforts to measure systemic blood flow have resulted in a novel, yet incomplete, understanding of the principles and clinical relevance of cardiovascular adaptation during postnatal transition in this patient population. This article describes the definition of hypotension based on the principles of cardiovascular physiology, and reviews the tools available to the clinician and researcher at the bedside to examine the complex relationship among blood pressure, systemic and organ blood flow, and tissue oxygen delivery and oxygen demand in vital and non-vital organs in the very low birth weight neonate. Only after gaining an insight into these complex relationships and processes will we be able to design clinical trials of selected treatment modalities targeting relevant patient sub-populations for the management of neonatal cardiovascular compromise. Only clinical trials based on a solid understanding of developmental cardiovascular physiology tailored to the appropriate patient sub-population hold the promise of being effective and practical, and can lead to improvements in both hemodynamic parameters and clinically relevant outcome measures.
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Subramanian S, Agarwal R, Deorari AK, Paul VK, Bagga A. Acute renal failure in neonates. Indian J Pediatr 2008; 75:385-91. [PMID: 18536895 DOI: 10.1007/s12098-008-0043-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2008] [Accepted: 03/28/2008] [Indexed: 11/28/2022]
Abstract
Acute renal failure (ARF) is a common condition seen in neonatal intensive care units. It is broadly classified into prerenal, intrinsic renal and post renal failure. There is no consensus on the definition of neonatal ARF. Of utmost importance is to differentiate prerenal from intrinsic renal failure. The most common causes of neonatal ARF are hypovolemia, hypotension and, hypoxia. Among several indices that are available for differentiating prerenal failure from intrinsic renal failure, fractional excretion of sodium is the preferred index. Diagnostic fluid challenge with or without frusemide is a bed side method for differentiating prerenal failure from intrinsic renal failure. Babies with ARF have to be monitored for several metabolic derangements like hyponatremia, hyperkalemia, hypocalcemia, and acidosis and have to be managed accordingly. Fluid balance should be precise in order to avoid fluid overload. It is difficult to provide adequate calories due to fluid restriction. Dialysis has to be instituted to preempt complications. Peritoneal dialysis is the easiest and safest modality. These babies need long term follow up as they are prone for long term complications.
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Affiliation(s)
- Sreeram Subramanian
- Department of Pediatrics, Division of Neonatology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
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Filippi L, Pezzati M, Poggi C, Rossi S, Cecchi A, Santoro C. Dopamine versus dobutamine in very low birthweight infants: endocrine effects. Arch Dis Child Fetal Neonatal Ed 2007; 92:F367-71. [PMID: 17329276 PMCID: PMC2675359 DOI: 10.1136/adc.2006.098566] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To compare the endocrine effects of dopamine and dobutamine in hypotensive very low birthweight (VLBW) infants. DESIGN Non-blinded randomised prospective trial. SETTING Level III neonatal intensive care unit. PATIENTS 35 hypotensive VLBW infants who did not respond to volume loading, assigned to receive dopamine or dobutamine. MEASUREMENTS Haemodynamic variables and serum levels of thyroid stimulating hormone (TSH), total thyroxine (T(4)), prolactin (PRL) and growth hormone were assessed during the first 72 h of treatment and the first 72 h after stopping treatment. RESULTS Demographic and clinical data did not significantly differ between the two groups. Necessary cumulative and mean drug doses and maximum infusion required to normalise blood pressure were significantly higher in the dobutamine than in the dopamine group (p<0.01). Suppression of TSH, T(4) and PRL was observed in dopamine-treated newborns from 12 h of treatment onwards, whereas levels of growth hormone reduced significantly only at 12 h and 36 h of treatment (p<0.01). TSH, T(4) and PRL rebound was observed from the first day onwards after stopping dopamine. Dobutamine administration did not alter the profile of any of the hormones and no rebound was observed after stopping treatment. CONCLUSION Dopamine and dobutamine both increase the systemic blood pressure, though dopamine is more effective. Dopamine reduces serum levels of TSH, T(4) and PRL in VLBW infants but such suppression is quickly reversed after treatment is stopped. Further research is required to assess if short-term iatrogenic pituitary suppression has longer-term consequences.
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Affiliation(s)
- Luca Filippi
- Neonatal Intensive Care Unit, Department of Critical Care Medicine, Meyer University Hospital, via L. Giordano, 13 I-50132 Florence, Italy.
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Valverde E, Pellicer A, Madero R, Elorza D, Quero J, Cabañas F. Dopamine versus epinephrine for cardiovascular support in low birth weight infants: analysis of systemic effects and neonatal clinical outcomes. Pediatrics 2006; 117:e1213-22. [PMID: 16717120 DOI: 10.1542/peds.2005-2108] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Early postnatal adaptation to transitional circulation in low birth weight infants frequently is associated with low blood pressure and decreased blood flow to organs. Catecholamines have been used widely as treatment, despite remarkably little empirical evidence on the effects of vasopressor/inotropic support on circulation and on clinically important outcomes in sick newborn infants. AIMS To explore the effectiveness of low/moderate-dose dopamine and epinephrine in the treatment of early systemic hypotension in low birth weight infants, evaluate the frequency of adverse drug effects, and examine neonatal clinical outcomes of patients in relation to treatment. DESIGN/METHODS Newborns of <1501-g birth weight or <32 weeks of gestational age, with a mean blood pressure lower than gestational age in the first 24 hours of life, were assigned randomly to receive dopamine (2.5, 5, 7.5, and 10 microg/kg per minute; n = 28) or epinephrine (0.125, 0.250, 0.375, and 0.5 microg/kg per minute; n = 32) at doses that were increased stepwise every 20 minutes until optimal mean blood pressure was attained and maintained (responders). If this treatment was unsuccessful (nonresponders), sequential rescue therapy was started, consisting first of the addition of the second study drug and then hydrocortisone. OUTCOME MEASURES These included: (1) short-term changes (first 96 hours, only responders) in heart rate, mean blood pressure, acid-base status, lactate, glycemia, urine output, and fluid-carbohydrate debit; and (2) medium-term morbidity, enteral nutrition tolerance, gastrointestinal complications, severity of lung disease, patent ductus arteriosus, cerebral ultrasound diagnoses, retinopathy of prematurity, and mortality. RESULTS Patients enrolled in this trial did not differ in birth weight or gestational age (1008 +/- 286 g and 28.3 +/- 2.3 weeks in the dopamine group; 944 +/- 281 g and 27.7 +/- 2.4 weeks in the epinephrine group). Other main antenatal variables were also comparable. However, responders and nonresponders differed significantly with respect to the need for cardiorespiratory resuscitation at birth (3% vs 23%), Critical Risk Index for Babies score (3.8 +/- 3 vs 7 +/- 5), and premature rupture of membranes >24 hours (39.5% vs 13.6%), respectively. No differences were found in the rate of treatment failure (dopamine: 36%; epinephrine: 37%) or need for rescue therapy according to treatment allocation. Groups did not differ in age at initiation of therapy (dopamine: 5.3 +/- 3.9 hours; epinephrine: 5.2 +/- 3.3 hours), but withdrawal was significantly later in the dopamine group. For short-term changes, mean blood pressure showed a significant increase from baseline throughout the first 96 hours with no differences between groups. However, epinephrine produced a greater increase in heart rate than dopamine. After treatment began, epinephrine patients showed higher plasma lactate (first 36 hours) and lower bicarbonate and base excess (first 6 hours) and received more bicarbonate. Patients in the epinephrine group also had higher glycemia (first 24 hours) and needed insulin therapy more often. Groups did not differ in urine output or fluid-carbohydrate supply during the first 96 hours. For medium-term morbidity, there were no differences in neonatal clinical outcomes in responders. However, significant differences were found in the incidence of patent ductus arteriosus, bronchopulmonary dysplasia, need for high-frequency ventilation, occurrence of necrotizing enterocolitis, and death between responders and nonresponders. CONCLUSIONS Low/moderate-dose epinephrine is as effective as low/moderate-dose dopamine for the treatment of hypotension in low birth weight infants, although it is associated with more transitory adverse effects.
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Affiliation(s)
- Eva Valverde
- Department of Neonatology, La Paz University Hospital, Madrid, Spain
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