Shock and Hypotension in the Newborn Medication

Updated: Dec 18, 2020
  • Author: Samir Gupta, MD, DM, MRCP, FRCPCH, FRCPI; Chief Editor: Ted Rosenkrantz, MD  more...
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Medication

Medication Summary

In premature infants younger than 30 weeks' gestation, poor cardiac contractility is most common; patients benefit from early institution of dobutamine. Other agents often used to manage hypotension in preterm infants include dobutamine, epinephrine, norepinephrine, vasopressin, and milrinone; clinicians should closely monitor these infants for side effects of these medications. [14]

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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