Inotropic support

Outside resources

Great physiology review resource: https://onepagericu.com/ Some of the high yield for hemodynamics that are applicable to newborn physiology (these are outside links for OnePagerIcu.com):

Summary Table

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

• Starting dose: 0.05 à 0.1 mcg/kg/min

•Range of treatment: 0.01 à 1 mcg/kg/min

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

•Increases pulmonary vascular resistance

•Increased Pulmonary/Systemic pressure ratio

•β1 (slightly β2): Inotropy and chronotropy (arrhythmias / tachycardia).

•Meta-analysis have been done on dopamine in the context of HIE and did not find any differences in mortality or neurodevelopmental outcomes

•Dopamine associated in observational studies with a rise in BP numbers, but no link with improved outcomes

•Few animal studies done: Apoptotic cell death ↓ in cerebral white matter of (dopamine treated fetal sheep) brains vs NS.

Dobutamine

•Synthetic agonist of β1 (slightly β2): Inotropy and chronotropy (may induce arrhythmias).

•Theoretical benefit in cardiogenic shock but can disturb diastolic function as heart rate increases (less filling time)

•↑ cardiac O2 consumption

•Initial dosage : 5-10 mcg/kg/min

•Usual range: 1 à 20 mcg/kg/min

•Some data from animal models: dose-dependent increase in cardiac index by ↑ in HR, with no effect on stroke volume. SVR ↓ but not PVR

Norepinephrine

Hydrocortisone

Vasopressin

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.

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.

Created by Gabriel Altit - Neonatologist / Créé par Gabriel Altit (néonatalogiste) - © NeoCardioLab - 2020-2024 - Contact us / Contactez-nous