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Shock and Hypotension in the Newborn Medication

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

Medication Summary

In premature infants younger than 30 weeks' gestation, poor cardiac contractility is most common; patients benefit from early institution of dobutamine.

Patients with septic shock benefit from dopamine as first-line management; it has been found to be more effective than dobutamine and albumin in correcting blood pressure for short-term treatment in these situations; however, the effect of these drugs on long-term outcome is unknown.

Although adrenaline is used for cardiovascular compromise, its effect on mortality and morbidity has not yet been evaluated.

No evidence suggests that milrinone is beneficial in prevention of low systemic blood flow in ill, very-preterm neonates during the first postnatal day.

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Alpha/Beta Adrenergic Agonists

Class Summary

Cardiovascular performance deteriorates and cardiac output falls if effective therapy is not administered. Adrenergic antagonists improve the patient’s hemodynamic status by increasing myocardial contractility and heart rate, resulting in increased cardiac output. They also increase peripheral resistance by causing vasoconstriction. Increased cardiac output and increased peripheral resistance lead to increased blood pressure.

Dopamine

 

Dopamine stimulates adrenergic and dopaminergic receptors. Its hemodynamic effect is dependent on the dose. Lower doses predominantly stimulate dopaminergic receptors that, in turn, produce renal and mesenteric vasodilation. Cardiac stimulation and peripheral vasoconstriction is produced by higher doses.

Dobutamine

 

Dobutamine produces vasodilation and increases the inotropic state. At higher dosages, it may cause increased heart rate, exacerbating myocardial ischemia.

Epinephrine (Adrenalin)

 

Epinephrine elicits alpha-agonist effects that include increased peripheral vascular resistance, reversed peripheral vasodilatation, systemic hypotension, and vascular permeability. The drug's beta-agonist effects include bronchodilatation, chronotropic cardiac activity, and positive inotropic effects.

Isoproterenol (Isuprel)

 

Isoproterenol possesses beta1- and beta2-adrenergic receptor activity. It binds to beta receptors of the heart, smooth muscle of the bronchi, skeletal muscle, vasculature, and alimentary tract. Isoproterenol elicits positive inotropic and chronotropic actions.

Norepinephrine (Levophed)

 

Norepinephrine is used to treat protracted hypotension following adequate fluid-volume replacement. It stimulates beta1- and alpha-adrenergic receptors, increasing cardiac muscle contractility and heart rate, as well as vasoconstriction; this results in systemic blood pressure and coronary blood flow increases. After obtaining a response, the rate of flow should be adjusted and maintained at a low-normal blood pressure, such as 80-100mm Hg systolic, sufficient to perfuse vital organs.

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Vasodilators

Class Summary

Preload reduction with vasodilators is thought to be helpful in acute decompensated heart failure by reducing congestion and minimizing cardiac oxygen demand. Afterload reduction is also thought to be helpful in some patients with acute decompensated heart failure by decreasing myocardial oxygen demand and improving forward flow.

Hydralazine

 

Hydralazine decreases systemic resistance through direct vasodilation of arterioles.

Nitroprusside (Nitropress)

 

Nitroprusside produces vasodilation and increases inotropic activity of the heart. At higher dosages, it may exacerbate myocardial ischemia by increasing heart rate.

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Inotropic agents

Class Summary

Inotropic agents increase cardiac contractility and may reduce vascular tone by vasodilatation.

Phentolamine (Oraverse)

 

Phentolamine has positive inotropic and chronotropic effects on the heart. Phentolamine is an alpha1- and alpha2-adrenergic blocking agent that blocks circulating epinephrine and norepinephrine action, reducing hypertension resulting from catecholamine effects on alpha receptors.

Milrinone

 

Milrinone is a bi-pyridine positive inotrope and vasodilator with little chronotropic activity. Its mode of actions differs from that of digitalis glycosides and catecholamines. Milrinone selectively inhibits phosphodiesterase type III (PDE III) in cardiac and smooth vascular muscle, resulting in reduced afterload and preload and increased inotropy.

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Volume Expanders

Class Summary

The use of crystalloid or colloid solutions is appropriate, unless the source of hypovolemia is hemorrhage, in which case whole or reconstituted blood is more appropriate.

Sodium chloride hypertonic, ophthalmic

 

Isotonic sodium chloride solution is a low-cost alternative that is readily available.

Albumin (Albuminar, Buminate)

 

Albumin is useful for plasma volume expansion and the maintenance of cardiac output.

Lactated Ringer solution with isotonic sodium chloride

 

Each fluid is essentially isotonic and has equivalent volume restorative properties. Although some differences between metabolic changes are observed with the administration of large quantities of either fluid, for practical purposes and in most situations, the differences are clinically irrelevant. Importantly, there is no demonstrable difference in hemodynamic effect, morbidity, or mortality with resuscitation.

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Antibiotics, Other

Class Summary

In early onset neonatal sepsis, ampicillin and either gentamicin or cefotaxime are the antimicrobials of choice until a specific infectious agent is identified.

Ampicillin

 

Ampicillin has bactericidal activity against susceptible organisms.

Cefotaxime (Claforan)

 

Cefotaxime is a third-generation cephalosporin that possesses antimicrobial effects on a predominantly gram-negative spectrum. Its efficacy against gram-positive organisms is lower.

Gentamicin

 

Gentamicin is an aminoglycoside antibiotic for gram-negative coverage. It is used in combination with an agent against gram-positive organisms and one that covers anaerobes. Dosing regimens are numerous; adjust the dose based on creatinine clearance (CrCl) and changes in the volume of distribution. The drug may be administered intravenously or intramuscularly.

Follow each regimen by at least a trough level drawn on the third dose (0.5h before dosing). Peak levels may be drawn 0.5 hour after a 30-minute infusion. If the trough level is greater than 2mg/L, increase the dosing interval.

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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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Determinants of cardiac function and oxygen delivery to tissues. Adapted from Strange GR. APLS: The Pediatric Emergency Medicine Course. 3rd ed. Elk Grove Village, Ill: American Academy of Pediatrics; 1998:34.
Assisted ventilation newborn –Intubation and meconium aspiration. Video courtesy of Therese Canares, MD, and Jonathan Valente, MD, Rhode Island Hospital, Brown University.
Table 1. Agents Used To Treat Neonatal Shock
Agent Type Agent Initial Dosage Additional Factors
Volume expanders Isotonic sodium chloride solution 10-20 mL/kg intravenous (IV) Inexpensive, available
Albumin (5%) 10-20 mL/kg IV Expensive
Plasma 10-20 mL/kg IV Expensive
Lactated ringer solution 10-20 mL/kg IV Inexpensive, available
Isotonic glucose 10-20 mL/kg IV Inexpensive, available
Whole blood products 10-20 mL/kg IV Limited availability
Reconstituted blood products 10-20 mL/kg IV Use type



O negative



Vasoactive drugs Dopamine 5-20 mcg/kg/min IV Never administer intra-arterially
Dobutamine 5-20 mcg/kg/min IV Never administer intra-arterially
Epinephrine 0.05-1 mcg/kg/min IV Never administer intra-arterially
Hydralazine 0.1-0.5 mg/kg IV every 3-6 h Afterload reducer
Isoproterenol 0.05-0.5 mcg/kg/min IV Never administer intra-arterially
Nitroprusside 0.5-8 mcg/kg/min IV Afterload reducer
Norepinephrine 0.05-1 mcg/kg/min IV Never administer intra-arterially
Phentolamine 1-20 mcg/kg/min IV Afterload reducer
Milrinone 22.5-45 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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