Management of Neonatal Hypotension and Shock

Schwarz, Christoph E.; Dempsey, Eugene M.

doi:10.1016/j.siny.2020.101121

Cited by 22 publications

(12 citation statements)

References 57 publications

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“…NEC remains a leading cause of morbidity and death among preterm infants and requires increased hospital care and resource utilization [3][4][5][6][7][8][9]. NEC is associated with a severe systemic inflammatory response and septic shock-like presentation that can contribute to multi-organ dysfunction due to intravascular volume depletion, capillary leak syndrome and hypotension [10]. Hemodynamic changes, surgical stresses, anesthetic agents,…”

Section: Discussionmentioning

confidence: 99%

Clinical Correlates of Moderate-to-Severe Bronchopulmonary Dysplasia in Preterm Infants following Surgical Necrotizing Enterocolitis

et al. 2022

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Objective: To determine clinical correlates of moderate to severe bronchopulmonary dysplasia (BPD) in preterm infants following surgical necrotizing enterocolitis (NEC). Methods: A retrospective, single-center cohort study comparing patients with moderate to severe BPD to patients with non/mild BPD among surgical NEC infants. BPD was defined by NIH 2001 consensus definition Results: Of 92 consecutive neonates with surgical NEC, 77% (71/92) had moderate/severe BPD and 22% (21/92) had non/mild BPD. The patent ductus arteriosus (PDA) was significantly higher in those developing moderate/severe BPD (67.6% [48/71]) than non/mild BPD (28.6% [6/21]; p=0.001). Postoperatively,infants with moderate/severe BPD had more severe AKI (67.6% [48/71] vs. 28.6% [6/21]; p=0.001), were intubated longer (40.5 days [IQR 12, 59] vs. 6 days [IQR 2, 13]; p<0.001), received more parenteral nutrition (109 days [IQR 77, 147] vs. 55 days [IQR 19, 70]; p<0.001), developed higher surgical morbidity (46.5% [33/71] vs. 14.3% [3/21]; p=0.008), had more intestinal failure (62.5% vs. 13.3%; p<0.001), required a longer hospital stay (161 days [IQR 112, 186] vs. 64 days [IQR 20, 91]; p<0.001), and were more likely to need home oxygen. In a multivariable analysis, lower birth weight (OR=0.3, [95% CI 0.1-0.5]; p=0.001), patent ductus arteriosus (OR=10.3, [95%CI 1.6-65.4]; p=0.014) and longer parenteral nutritional days (OR=8.8; [95%CI 2.0 -43.0]; p=0.005) were significantly and independently associated with higher odds of moderate/severe vs. non/mild BPD. Conclusion: Development of moderate/severe BPD occurred in the majority of preterm infants with surgical NEC in this consecutive series. Preterm infants with moderate/severe BPD were more likely to have a PDA before NEC. Development of moderate/severe BPD was associated with significantly greater burden and duration of post-operative morbidity following surgical NEC. Identifying surgical NEC infants at increased risk of moderate/severe BPD and developing lung protection strategies may improve surgical NEC outcomes.

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Section: Discussionmentioning

confidence: 99%

Clinical Correlates of Moderate-to-Severe Bronchopulmonary Dysplasia in Preterm Infants following Surgical Necrotizing Enterocolitis

et al. 2022

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“…Most of the treated hypotensive infants received volume expansion, and the most frequently used inotropic drug was dopamine, as observed in an international survey contemporaneous with the EPIPAGE-2 study ( 28 ). Although volume expansion can increase blood pressure, its wide use is not supported by either long-term clinical benefits ( 22 ) or pathophysiological mechanisms ( 5 ). Similarly, dopamine is effective for increasing blood pressure but does not improve blood flow or clinical outcomes ( 21 ).…”

Section: Discussionmentioning

confidence: 99%

“…Although hypotension management remains controversial (2)(3)(4)(5), there is a consensus to promote multimodal hemodynamic assessment in premature infants, especially with the use of neonatologist-performed echocardiography (NPE) (6). By providing a more comprehensive assessment of the pathophysiological mechanisms leading to low systemic perfusion than blood pressure measurement alone, NPE could theoretically help clinicians decide whether or not to start treatment, and if yes, to choose the most appropriate treatment strategy (7).…”

Section: Introductionmentioning

confidence: 99%

In-hospital Outcomes and Early Hemodynamic Management According to Echocardiography Use in Hypotensive Preterm Infants: A National Propensity-Matched Cohort Study

Raschetti

Torchin

Gascoin

et al. 2022

Front. Cardiovasc. Med.

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BackgroundHypotension is a common condition during the first postnatal days of very preterm infants and has been associated with an increased risk of adverse outcomes but its management remains controversial. There is a consensus to promote the use of neonatologist-performed echocardiography (NPE) in hypotensive very preterm infants, although no clinical trial ever assessed this practice.MethodsWe conducted a retrospective analysis of prospectively collected data from the French national EPIPAGE-2 cohort to evaluate the association of NPE with survival, severe morbidity, and therapeutic management in very preterm infants with early hypotension. Reasons for administering antihypotensive treatments were also analyzed. We included infants born before 30 weeks of gestation with hypotension within 72 h of birth. Infants managed with (NPE group) or without (no-NPE group) NPE use were compared after matching on gestational age and a propensity score, reflecting each patient's probability of having an NPE based on his/her baseline covariates. This matching procedure intended to control for the indication bias of NPE.ResultsAmong 966 eligible infants, 809 were included (NPE group, n = 320; no-NPE group, n = 489), and 229 from each group could be matched. The NPE group did not differ significantly from the no-NPE group for survival (OR 1.01, 95% CI 0.64 to 1.60; p = 0.95) or survival without severe morbidity at discharge (OR 0.92, 95% CI 0.63 to 1.34; p = 0.66), but received more antihypotensive treatments [144/229 (62.9%) vs. 99/229 (43.0%), p < 0.001]. Isolated hypotension was the main reason for treatment in both groups. Among treated infants, volume expansion was administered at equal rates to the NPE and no-NPE groups [118/144 (82.1%) vs. 79/99 (80.1%), p = 0.67], but the NPE group received inotropic drugs more often [77/144 (53.7%) vs. 37/99 (37.8%), p = 0.023].ConclusionNPE use in hypotensive preterm infants was not associated with in-hospital outcomes and had little influence on the nature of and reasons for antihypotensive treatments. These results suggest the need to optimize NPE use.

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“…In the present meta-analysis, most studies involved very premature neonates with early cardiovascular insufficiency (online suppl. Table 3 ), apparently due to structural and developmental aspects of the cardiovascular system and the transitional changes that occur over the first weeks of life [ 51 ]. However, RCTs on the role of cardiovascular medications in other neonatal conditions are alarmingly sparse.…”

Section: Discussionmentioning

confidence: 99%

Systematic Review and Meta-Analysis of Cardiovascular Medications in Neonatal Hypotension

et al. 2022

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Background: Comparative studies among the various cardiovascular medications used for the treatment of neonatal hypotension are lacking. Methods: This systematic review and pairwise meta-analysis of the anti-hypotensive treatments in preterm and term infants was conducted to evaluate efficacy and impact on outcome. Electronic databases were searched up to February 2021 for relevant articles. As an extension of the current approach for study selection, a machine learning technique was used. Only randomized controlled trials (RCTs) of inotropes, pressors, volume therapy, and corticosteroids were included. Response to treatment was the primary outcome while secondary outcomes included mortality and common morbidities. Results: Nineteen RCTs involving 758 preterm and term neonates were found, and 8 treatments were evaluated. Most studies involved subjects with early hypotension associated with prematurity. Pairwise meta-analysis among treatments showed that dopamine was more effective than dobutamine regarding the response to treatment (restoration of normotension or normalization of blood pressure) (7 trials, 286 neonates, odds ratio, 3.06 [95% CI = 1.06–8.87]; I2 = 49%, very low quality of the evidence per GRADE). Comparisons of other treatments were not significant. No differences were found among regimens regarding survival and other secondary outcomes. Conclusion: In this systematic review and pairwise meta-analysis, only the comparison of dopamine versus dobutamine provided evidence for efficacy of treatment and favored dopamine. No safe conclusions could be reached in regard to other treatments. Data regarding the management of arterial hypotension in conditions other than transition after birth in preterm newborns are sparse both in preterm and term infants.

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Management of Neonatal Hypotension and Shock

Cited by 22 publications

References 57 publications

Clinical Correlates of Moderate-to-Severe Bronchopulmonary Dysplasia in Preterm Infants following Surgical Necrotizing Enterocolitis

Clinical Correlates of Moderate-to-Severe Bronchopulmonary Dysplasia in Preterm Infants following Surgical Necrotizing Enterocolitis

In-hospital Outcomes and Early Hemodynamic Management According to Echocardiography Use in Hypotensive Preterm Infants: A National Propensity-Matched Cohort Study

Systematic Review and Meta-Analysis of Cardiovascular Medications in Neonatal Hypotension

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