Inotropes, Vasopressors, and Cardiovascular Medications

Summary Table on Cardiovascular Medications in HIE and acute PH

Populational-based blood pressure by EPIQ-CNN

Calculator here: https://neopeds.academy/bp/ 

Treatment of “isolated hypotension” of the very low birth weight (VLBW) infant is controversial as some studies indicate increase intraventricular hemorrhage (IVH) and no change in mortality (Dempsey et al. 2009). HIP trial (Dempsey et al. 2021) did not show any difference with the use dopamine but was terminated prematurely. As such, to avoid iatrogenic and without any indication that this leads to tissue ischemia, we do not recommend active interventions, but rather watchful assessments of ongoing perfusion.

Figure on cardiovascular medications (English)

Figure sur les médications cardiovasculaires (français)

Hemodynamic Considerations in Prematurity

Cardiovascular Medications in Prematurity

A big thanks to Louis Chartier - Pharmacist at the Montreal Children's Hospital for contributing his expertise in reviewing the half-life of each medications in the literature. 

Please find in french some references here regarding pharmacology in the NICU: Guide pratique des médicaments en néonatologie au CHU Sainte-Justine

Infusion rates

How to prepare certain dilutions

FINAL Standard Concentrations for Common NICU Drips UPDATED 2024.pdf

Adrenergic receptors (G-protein coupled)

Physiology reminders

Epinephrine 

α1 and β1 (slight β2)) - Vasoconstriction (α); Inotropy (β)

Side effects: Induces hyperglycemia (insulin suppression, ↑ glycogenolysis and in gluconeogenesis) and hyperlactatemia (increase in oxygen consumption)

In piglets: epinephine ↑ cardiac index with no effect on systolic arterial pressure or systemic vascular resistance

Parasternal long axis view indicating poor LV contractility. 

Parasternal long axis view indicating poor LV contractility and some mitral regurgitation. Infants with perinatal depression often have some degree of myocardial ischemia. Subendocardial ischemia may manifest as papillary muscle ischemia and mitral insufficiency.  

Biventricular dysfunction before Epinephrine initiation:

Significant improvement after epinephrine initiation:

Dopamine

No neonatal data showing different dosages have different cardiovascular impact in newborns.

Adrenergic by degradation in Norepinephrine and Epinephrine (in adrenal medulla – can be immature in premature or injured in those with asphyxia).

Theoretical impact on thyroid hormonal secretion. May increase pulmonary vascular resistance.

Initial dosage : 5-10 mcg/kg/min; Usual range: 1 à 20 mcg/kg/min

Dobutamine

Norepinephrine

Phenylephrine

Hydrocortisone

Vasopressin

Terlipressin

Milrinone

References:

Dietrichs ES, Kondratiev T, Tveita T. Milrinone ameliorates cardiac mechanical dysfunction after hypothermia in an intact rat model. Cryobiology. 2014;69(3):361-6.

McNamara PJ, Laique F, Muang-In S, Whyte HE. Milrinone improves oxygenation in neonates with severe persistent pulmonary hypertension of the newborn. Journal of critical care. 2006;21(2):217-22.

Tveita T, Sieck GC. Effects of milrinone on left ventricular cardiac function during cooling in an intact animal model. Cryobiology. 2012;65(1):27-32.

Dietrichs ES, Kondratiev T, Tveita T. Milrinone ameliorates cardiac mechanical dysfunction after hypothermia in an intact rat model. Cryobiology. 2014;69(3):361-6.

Levosimendan 

Methylene Blue

One study (RCT) in the neonate with refractory septic shock found that Methylene Blue improved the hemodynamic parameters. It seems that MB acts by vasoconstriction. There is very scarse data for this agent in the neonatal population and should be used with great caution. 

Hemodynamic instability in HIE

fped-06-00086.pdf

Presentation on Approach to hypotension by Dr Carolina Macias Michel

Approach to hypotension2.pdf

Anti-Hypertensive Medications

Giri, Priyadarshani, and Philip Roth. "Neonatal hypertension." Pediatrics in Review 41.6 (2020): 307-311.

Presentation at PAS 2024 - TARGET Shock - Targeted Agents Reducing Global hypoperfusion in Extreme preTerms

TARGET PAS - 2024.pdf

May 7, 2024 - For those who missed my talk at PAS 2024, here is a recording of the live session. TARGET Shock - Targeted Agents Reducing Global hypoperfusion in Extreme preTerms. Enjoy!

7 mai 2024 - Pour ceux qui ont raté ma conférence au PAS 2024, voici un enregistrement de la session en direct. TARGET Shock - Targeted Agents Reducing Global hypoperfusion in Extreme preTerms. Bonne écoute.

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