ELBW in first 72 hours Cardiovascular monitoring 

• Treatment of “isolated hypotension” is controversial (studies described increase IVH and no change in mortality). 

• GA in weeks as minimum mean blood pressure lacks strong data (but is the most conservative vs other normative tables) 

• mBP < GA should  prompt complimentary evaluations: history suggestive of volume loss assess perfusion (refill, physical exam, baseline neurological status), acid-base status, trend and clinical setting.

• Clinical diagnosis of shock difficult to establish 

• Based on exam with or without hypotension: prolonged CRT, cold extremities, ↓ urinary output, metabolic acidosis. Should assess perfusion.

References for normal blood pressure in premature newborns:

Treatment of hypotension and hypoperfusion

• Hypotension with hypoperfusion treated based on assumed etiology 

• If evidence of volume loss: Placenta praevia, abruption, blood loss from umbilical cord, fetal anemia, or fetal-maternal transfusion: administration of volume expander such as NS, or O Rh-negative blood may be used as an initial dose of 10 mL/kg. Slow infusion (over 30 minutes) or faster if clinically indicated. May be repeated. Albumin is not generally recommended.

• In absence of suspicion of hypovolemia: Use volume expansion judiciously (some data = increased mortality) 

  • First line of inotrope:  dopamine or epinephrine when assumed vasomotor dysregulation, dobutamine when assumed to be myocardial dysfunction (start at 5 and up to 15 mcg/kg/min). 

  • Hydrocortisone (30 mg/m2/day IV divided q 8h or 1 mg/kg/dose IV q 8hours) considered if: Suboptimal response to inotropes, suspected adrenal suppression, presence of severe PPHN (Vargo et al. 2011, Perez et al. 2014)

  • Consider obtaining ECHO in 24 hours after start of inotropes to guide management – consider as early as possible. Wean inotropes aggressively as soon as hemodynamic status stabilized then hydrocortisone may be weaned or stopped in case of short duration of use. Data regarding inhaled nitric oxide (iNO) in preterm infants is lacking.