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Current Treatment of Hypotension in ELBW Infants: Complications and Controversies

Rita P. Verma

Anti-hypotensive treatments are often started in response to a low blood pressure (BP) or signs of low cardiac output (CO) in critically ill neonates. The challenge for clinicians in the neonatal intensive care unit (NICU) is to dissect out the etiology of the hemodynamic changes, decide if the changes are pathologic or transitionally appropriate, and then tailor the treatment regimen for the patient, the condition, and gestation. This process all occurs while being cognizant that a hemodynamic state evolves throughout the chronological age of the neonate and the course of illness and is affected by concurrent treatments, such as ventilation. Studies in Europe, North America, and Australia all highlight that practices are variable across countries and continents with respect to which patient, when and how to treat with cardiotonic drugs (1–6). A national Canadian database reported that 10% of neonates of <29 weeks had been treated with inotropes on days 1–3 (0–36% within the 27 NICUs). The treated neonates were less likely to have received antenatal corticosteroids, more likely have a smaller birthweight, a higher SNAPS II, TRIPS score, and need for ventilation, and had a higher mortality and incidence of intraventricular hemorrhage. Recently, a Norwegian population database study indicated that 2.7% of all NICU patients received inotropes at any point of their NICU stay; 28 and 4.1% of <28 and <36 weeks of gestation, respectively, and 13% of <1,500 g infants. These numbers are similar to those reported by Lasky et al. in American NICU . Multiple inotropes were associated with an increased mortality. Indeed, the use of inotropes was associated with an increased mortality, after adjusting for gender, gestation, and 5-min Apgar.