Inotrope and Vasopressor Support in Neonates

Abstract

1. There is limited knowledge regarding the optimal management of neonates with hemodynamic instability. 2. One approach to hemodynamic instability may not be efficacious for all neonates. AbstractHemodynamic instability is a common problem in neonates and has important implications for long-term outcomes. Inotropes and vasopressors are commonly used to treat low blood pressure or poor perfusion in neonatal intensive care, despite limited evidence to guide optimal management in specific clinical situations. Dopamine is the most commonly used agent in clinical practice, increasing blood pressure with limited adverse effects compared with epinephrine. Dobutamine is less commonly used but may be the optimal agent for premature neonates with poor perfusion due to immature myocardial contractility. New evidence is emerging to guide the treatment of hypotension in the setting of sepsis and persistent pulmonary hypertension. Norepinephrine and vasopressin may have utility in the setting of refractory hypotension due to sepsis. Increasing evidence supports use of norepinephrine, milrinone, and vasopressin in the setting of persistent pulmonary hypertension. Hydrocortisone should be reserved for vasopressor-resistant hypotension in preterm neonates; however, this agent may also prove useful in the treatment of persistent pulmonary hypertension in term neonates. Further clinical trials are necessary to determine the optimal treatment algorithm for neonates with hemodynamic instability. Future trials should include physiologically relevant end points and long-term follow-up. However, one approach may not be efficacious for all neonates even with a similar diagnosis. Therefore, bedside assessment techniques should continue to be explored to allow tailored therapy based on real-time assessment of underlying physiology.Objectives After completing this article, readers should be able to:1. Characterize the mechanism of action, pharmacokinetic properties, and cardiovascular effects of different inotropes. 2. Describe additional medications that can provide cardiovascular support. 3. Determine clinical factors that affect medication selection.

European Consensus Guidelines on the Management of Respiratory Distress Syndrome - 2016 Update

“…Hypovolaemia is probably overdiagnosed and can be minimized by delaying cord clamping. Dopamine is more effective than dobutamine at increasing blood pressure and can improve cerebral blood flow in hypotensive infants [149], although dobutamine may be a more rational choice during the transitional period due to its ability to increase contractility and decrease afterload [150]. Studies assessing different thresholds for intervention with dopamine to determine if inotrope therapy influences long-term outcome are ongoing [151].…”

Diagnosis and management of congenital diaphragmatic hernia: a 2023 update from the Canadian Congenital Diaphragmatic Hernia Collaborative

“…Nevertheless, although diverse phenotypes have been documented, no trials within CDH cohorts have delineated the benefits of employing specific cardiovascular management strategies for acute pulmonary hypertension, right ventricular dysfunction, left ventricular dysfunction or biventricular dysfunction in this population. Hence, clinicians should tailor their therapy based on their best assessment of the patient’s underlying physiology 61–63…”

Improving the Treatment of Neonatal Sepsis in Resource-Limited Settings: Gaps and Recommendations

“… 70 A meta-analysis found that neonates with sepsis are almost twice as likely to develop respiratory distress syndrome, almost 20 times more likely to develop multiple organ failure, and have almost double the mortality when compared to neonates without sepsis. 29 Although more intensive measures such as inotropic support 71 and even extracorporeal membrane oxygenation 72 may form part of this care in high-resource settings, we will focus on aspects applicable in the resource-limited setting: transfer to specialist hospitals, respiratory support, and nutrition.…”