Shock and Hypotension in the Newborn Differential Diagnoses

  • Author: Samir Gupta, DM, MRCP, MD, FRCPCH, FRCPI; Chief Editor: Ted Rosenkrantz, MD  more...
 
Updated: Mar 27, 2014
 
 

Diagnostic Considerations

Conditions to consider in the differential diagnosis of shock and hypotension in the newborn include the following:

  • Coarctation of the aorta
  • Congenital adrenal hyperplasia
  • Consumption coagulopathy
  • Dehydration
  • Enteroviral infections
  • Escherichia coli infections
  • Hemorrhagic disease of newborn
  • Viral myocarditis
  • Necrotizing enterocolitis
  • Neonatal sepsis
  • Oliguria
  • Outflow obstructions
  • Periventricular hemorrhage–intraventricular hemorrhage

Differential Diagnoses

 
 
Contributor Information and Disclosures
Author

Samir Gupta, DM, MRCP, MD, FRCPCH, FRCPI Professor of Neonatal Medicine, Deputy Director, Research and Development, University of Durham and North Tees University Hospital, UK

Samir Gupta, DM, MRCP, MD, FRCPCH, FRCPI is a member of the following medical societies: British Medical Association, Society for Pediatric Research, European Society for Paediatric Research, Royal College of Paediatrics and Child Health, European Respiratory Society, Royal College of Physicians of Ireland

Disclosure: Nothing to disclose.

Coauthor(s)

Sunil K Sinha, MBBS, MD, MRCP, PhD, FRCP, FRCPCH Director of Neonatal Services, South Cleveland Hospital, UK

Sunil K Sinha, MBBS, MD, MRCP, PhD, FRCP, FRCPCH is a member of the following medical societies: British Medical Association, Royal College of Physicians

Disclosure: Nothing to disclose.

Chief Editor

Ted Rosenkrantz, MD Professor, Departments of Pediatrics and Obstetrics/Gynecology, Division of Neonatal-Perinatal Medicine, University of Connecticut School of Medicine

Ted Rosenkrantz, MD is a member of the following medical societies: American Academy of Pediatrics, American Pediatric Society, Eastern Society for Pediatric Research, American Medical Association, Connecticut State Medical Society, Society for Pediatric Research

Disclosure: Nothing to disclose.

Acknowledgements

David A Clark, MD Chairman, Professor, Department of Pediatrics, Albany Medical College

David A Clark, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Pediatric Society, Christian Medical & Dental Society, Medical Society of the State of New York, New York Academy of Sciences, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Pharmacy Editor, eMedicine

Disclosure: Nothing to disclose.

References
  1. Schmaltz C. Hypotension and shock in the preterm neonate. Adv Neonatal Care. 2009 Aug. 9(4):156-62. [Medline].

  2. Al-Aweel I, Pursley DM, Rubin LP, et al. Variations in prevalence of hypotension, hypertension, and vasopressor use in NICUs. J Perinatol. 2001 Jul-Aug. 21(5):272-8. [Medline].

  3. Northern Neonatal Nursing Initiative. Systolic blood pressure in babies of less than 32 weeks gestation in the first year of life. Arch Dis Child Fetal Neonatal Ed. 1999 Jan. 80(1):F38-42. [Medline].

  4. Gupta S, Wyllie J. Correlation of Non-invasive Systolic and Mean Blood pressure (BP) Measurements with Echocardiographic Haemodynamic Assessment. Third Congress of the European Academy of Paediatric Societies (EAPS). Copenhagen, Denmark. October 23-26, 2010.

  5. Laughon M, Bose C, Allred E, et al. Factors associated with treatment for hypotension in extremely low gestational age newborns during the first postnatal week. Pediatrics. 2007 Feb. 119(2):273-80. [Medline].

  6. [Guideline] Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Intensive Care Med. 2008 Jan. 34(1):17-60. [Medline].

  7. Wahab Mohamed WA, Saeed MA. Mannose-binding lectin serum levels in neonatal sepsis and septic shock. J Matern Fetal Neonatal Med. 2011 Jun 1. [Medline].

  8. Kluckow M, Evans N. Superior vena cava flow in newborn infants: a novel marker of systemic blood flow. Arch Dis Child Fetal Neonatal Ed. 2000 May. 82(3):F182-7. [Medline].

  9. Osborn DA, Evans N, Kluckow M, et al. Low superior vena cava flow and effect of inotropes on neurodevelopment to 3 years in preterm infants. Pediatrics. 2007 Aug. 120(2):372-80. [Medline].

  10. Skinner JR, Milligan DW, Hunter S, et al. Central venous pressure in the ventilated neonate. Arch Dis Child. 1992 Apr. 67(4 Spec No):374-7. [Medline].

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Table 1. Agents Used To Treat Neonatal Shock
Agent TypeAgentInitial DosageAdditional Factors
Volume expandersIsotonic sodium chloride solution10-20 mL/kg intravenous (IV)Inexpensive, available
Albumin (5%)10-20 mL/kg IVExpensive
Plasma10-20 mL/kg IVExpensive
Lactated ringer solution10-20 mL/kg IVInexpensive, available
Isotonic glucose10-20 mL/kg IVInexpensive, available
Whole blood products10-20 mL/kg IVLimited availability
Reconstituted blood products10-20 mL/kg IVUse type



O negative



Vasoactive drugsDopamine5-20 mcg/kg/min IVNever administer intra-arterially
Dobutamine5-20 mcg/kg/min IVNever administer intra-arterially
Epinephrine0.05-1 mcg/kg/min IVNever administer intra-arterially
Hydralazine0.1-0.5 mg/kg IV every 3-6 hAfterload reducer
Isoproterenol0.05-0.5 mcg/kg/min IVNever administer intra-arterially
Nitroprusside0.5-8 mcg/kg/min IVAfterload reducer
Norepinephrine0.05-1 mcg/kg/min IVNever administer intra-arterially
Phentolamine1-20 mcg/kg/min IVAfterload reducer
Milrinone22.5-45 mcg/kg/h continuous IV infusion (ie, 0.375-0.75 mcg/kg/min)Afterload reducer in cardiac dysfunction; decrease dose with renal impairment
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