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

Abstract

Introduction:

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

Objective:

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

Methods:

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

Results:

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

Conclusion:

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

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References

  1. Al-Aweel I, Pursley DM, Rubin LP, Shah B, Weisberger S, Richardson DK . Variations in prevalence of hypotension, hypertension, and vasopressor use in NICUs. J Perinatol 2001; 21 (5): 272–278.

    Article  CAS  Google Scholar 

  2. Lee J, Rajadurai VS, Tan KW . Blood pressure standards for very low birthweight infants during the first day of life. Arch Dis Child Fetal Neonatal Ed 1999; 81 (3): F168–F170.

    Article  CAS  Google Scholar 

  3. Zubrow AB, Hulman S, Kushner H, Falkner B . Determinants of blood pressure in infants admitted to neonatal intensive care units: a prospective multicenter study. Philadelphia Neonatal Blood Pressure Study Group. J Perinatol 1995; 15 (6): 470–479.

    CAS  Google Scholar 

  4. Watkins AMC, West CR, Cooke RWI . Blood pressure and cerebral haemorrhage and ischaemia in very low birthweight infants. Early Hum Dev 1989; 19: 103.

    Article  CAS  Google Scholar 

  5. Joint Working Party of British Association of Perinatal Medicine and the Research Unit of the Royal College of Physicians. Development of audit measures and guidelines for good practice in the management of neonatal respiratory distress syndrome. Arch Dis Child 1992; 67: 1221–1227.

  6. Dasgupta SJ, Gill AB . Hypotension in the very low birthweight infant: the old, the new, and the uncertain. Arch Dis Child Fetal Neonatal Ed 2003; 88 (6): F450–F454.

    Article  CAS  Google Scholar 

  7. Subhedar N . Treatment of hypotension in newborns. Semin Neonatol 2003; 8: 413–423.

    Article  Google Scholar 

  8. Roze JC, Tohier C, Maingueneau C, Lefevre M, Mouzard A . Response to dobutamine and dopamine in the hypotensive very preterm infant. Arch Dis Child 1993; 69: 59–63.

    Article  CAS  Google Scholar 

  9. Bada HS, Korones SB, Perry EH, Arheart KL, Ray JD, Pourcyrous M et al. Mean arterial blood pressure changes in premature infants and those at risk for intraventricular hemorrhage. J Pediatr 1990; 117 (4): 607–614.

    Article  CAS  Google Scholar 

  10. Osborn DA, Evans N . Early volume expansion versus inotrope for prevention of morbidity and mortality in very preterm infants. Cochrane Database Syst Rev 2001; (2) CD002056 (Review).

  11. Dempsey EM, Al Hazzani F, Barrington K . Permissive Hypotension in The ELBW. Pediatric Research Supplement 2005.

  12. Osborn DA, Evans N, Kluckow M . Clinical detection of low upper body blood flow in very premature infants using blood pressure, capillary refill time, and central-peripheral temperature difference. Arch Dis Child Fetal Neonatal Ed 2004; 89 (2): F168–F173.

    Article  CAS  Google Scholar 

  13. Bauer K, Linderkamp O, Versmold HT . Systolic blood pressure and blood volume in preterm infants. Arch Dis Child 1993; 69: 521–522.

    Article  CAS  Google Scholar 

  14. Tammela OK, Koivisto ME . Fluid restriction for preventing bronchopulmonary dysplasia? Reduced fluid intake during the first weeks of life improves the outcome of low birth weight infants. Acta Paediatrica 1992; 81 (3): 207–212.

    Article  CAS  Google Scholar 

  15. Goldberg RN, Chung D, Goldman SL, Bancalari E . The association of rapid volume expansion and intraventricular hemorrhage in the preterm infant. J Pediatr 1980; 96 (6): 1060–1063.

    Article  CAS  Google Scholar 

  16. Ewer AK, Tyler W, Francis A, Drinkall D, Gardosi JO . Excessive volume expansion and neonatal death in preterm infants born at 27–28 weeks gestation. Paediatr Perinat Epidemiol 2003; 17 (2): 180–186.

    Article  Google Scholar 

  17. Pladys P, Wodey E, Betremieux P, Beuchee A, Ecoffey C . Effects of volume expansion on cardiac output in the preterm infant. Acta Paediatr 1997; 86 (11): 1241–1245.

    Article  CAS  Google Scholar 

  18. Barr PA, Bailey PE, Sumners J, Cassady G . Relation between arterial blood pressure and blood volume and effect of infused albumin in sick preterm infants. Pediatrics 1977; 60: 282–289.

    CAS  PubMed  Google Scholar 

  19. Evans N . Volume expansion during neonatal intensive care: do we know what we are doing? Semin Neonatol 2003; 8 (4): 315–323.

    Article  Google Scholar 

  20. Tyler W, Ewer AK . The use of volume expansion in preterm infants. Pediatr Perinat Epidemiol 2004; 18: 135–137.

    Article  CAS  Google Scholar 

  21. Zhang J, Penny DJ, Kim NS, Yu VY, Smolich JJ . Mechanisms of blood pressure increase induced by dopamine in hypotensive preterm neonates. Arch Dis Child Fetal Neonatal Ed 1999; 81: F99–F104.

    Article  CAS  Google Scholar 

  22. Phillipos EZ, Barrington K, Robertson MA . Dopamine versus epinephrine for inotropic support in the neonate: a randomized blinded trial. Ped Res 1996; 39: A238.

    Google Scholar 

  23. Seri I, Tan R, Evans J . Cardiovascular effects of hydrocortisone in preterm infants with pressor resistant hypotension. Pediatrics 2001; 107: 1070–1074.

    Article  CAS  Google Scholar 

  24. Osiovich H, Phillipos E, Lemke P . A short course of hydrocortisone in hypotensive neonates: a randomized double blind control trial. Pediatr Res 2000; 43: A422.

    Google Scholar 

  25. Ng PC, Lee CH, Bnur FL, Chan IH, Lee AW, Wong E et al. A double-blind, randomized, controlled study of a ‘stress dose’ of hydrocortisone for rescue treatment of refractory hypotension in preterm infants. Pediatrics 2006; 117 (2): 367–375.

    Article  Google Scholar 

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Acknowledgements

EMD was funded by Department of Pediatrics, McGill University, Clinical/Research Fellowship in Academic Pediatrics.

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Correspondence to E M Dempsey.

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Dempsey, E., Barrington, K. Diagnostic criteria and therapeutic interventions for the hypotensive very low birth weight infant. J Perinatol 26, 677–681 (2006). https://doi.org/10.1038/sj.jp.7211579

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