Diagnostic Considerations
Consider outflow obstructions and neonatal arrhythmias in the differential diagnosis of shock and hypotension in the newborn.
Differential Diagnoses
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Shock and Hypotension in the Newborn. 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.
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Shock and Hypotension in the Newborn. Assisted ventilation newborn – intubation and meconium aspiration. Video courtesy of Therese Canares, MD, and Jonathan Valente, MD, Rhode Island Hospital, Brown University.
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Shock and Hypotension in the Newborn. Presumed effects of commonly used cardiovascular drugs in neonatal intensive care. X-axis (effect on vascular tone): The more to the right, the more vasodilatory effects; the more to the left, the more vasoconstrictory effects. Y-axis (inotropic properties): The higher on the Y-axis, the more inotropic characteristics. The larger the size of the (semi-)circle, the more chronotropic effects. It should be noted that the effect on vascular tone depends on the used dosage that determines which adrenergic receptors are activated (e.g., dopamine and epinephrine). Courtesy of Springer Nature [de Boode WP et al. The role of neonatologist performed echocardiography in the assessment and management of neonatal shock. Pediatr Res. 2018 Jul;84(suppl 1):57-67. Online at: https://www.nature.com/articles/s41390-018-0081-1. PMID: 30072807.].
Tables
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; reduce the dose in the setting of renal impairment |
