Incidence, Management, and Outcomes of Cardiovascular Insufficiency in Critically Ill Term and Late Preterm Newborn Infants

Abstract

Objective The objective of this study was to characterize the incidence, management, and short-term outcomes of cardiovascular insufficiency (CVI) in mechanically ventilated newborns, evaluating four separate prespecified definitions.

Study Design Multicenter, prospective cohort study of infants ≥34 weeks gestational age (GA) and on mechanical ventilation during the first 72 hours. CVI was prospectively defined as either (1) mean arterial pressure (MAP) < GA; (2) MAP < GA + signs of inadequate perfusion; (3) any therapy for CVI; or (4) inotropic therapy. Short-term outcomes included death, days on ventilation, oxygen, and to full feedings and discharge.

Results Of 647 who met inclusion criteria, 419 (65%) met ≥1 definition of CVI. Of these, 98% received fluid boluses, 36% inotropes, and 17% corticosteroids. Of treated infants, 46% did not have CVI as defined by a MAP < GA ± signs of inadequate perfusion. Inotropic therapy was associated with increased mortality (11.1 vs. 1.3%; p < 0.05).

Conclusion More than half of the infants met at least one definition of CVI. However, almost half of the treated infants met none of the definitions. Inotropic therapy was associated with increased mortality. These findings can help guide the design of future studies of CVI in newborns.

Keywords

blood pressure - cardiovascular insufficiency - mechanical ventilation - inotrope - fluid bolus - glucocorticoid - outcomes - newborn

• References

• 1 Cayabyab R, McLean CW, Seri I. Definition of hypotension and assessment of hemodynamics in the preterm neonate. J Perinatol 2009; 29 (2, Suppl 2): S58-S62
• 2 Al-Aweel I, Pursley DM, Rubin LP, Shah B, Weisberger S, Richardson DK. Variations in prevalence of hypotension, hypertension, and vasopressor use in NICUs. J Perinatol 2001; 21 (5) 272-278
• 3 Clark RH. The epidemiology of respiratory failure in neonates born at an estimated gestational age of 34 weeks or more. J Perinatol 2005; 25 (4) 251-257
• 4 Brierley J, Carcillo JA, Choong K , et al. Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine. Crit Care Med 2009; 37 (2) 666-688
• 5 Sweet DG, Carnielli V, Greisen G , et al; European Association of Perinatal Medicine. European consensus guidelines on the management of neonatal respiratory distress syndrome in preterm infants - 2010 update. Neonatology 2010; 97 (4) 402-417
• 6 Dempsey EM, Barrington KJ. Treating hypotension in the preterm infant: when and with what: a critical and systematic review. J Perinatol 2007; 27 (8) 469-478
• 7 Nuntnarumit P, Yang W, Bada-Ellzey HS. Blood pressure measurements in the newborn. Clin Perinatol 1999; 26 (4) 981-996 , x
• 8 Efird MM, Heerens AT, Gordon PV, Bose CL, Young DA. A randomized-controlled trial of prophylactic hydrocortisone supplementation for the prevention of hypotension in extremely low birth weight infants. J Perinatol 2005; 25 (2) 119-124
• 9 Millar KJ, Thiagarajan RR, Laussen PC. Glucocorticoid therapy for hypotension in the cardiac intensive care unit. Pediatr Cardiol 2007; 28 (3) 176-182
• 10 Zubrow AB, Hulman S, Kushner H, Falkner B ; Philadelphia Neonatal Blood Pressure Study Group. Determinants of blood pressure in infants admitted to neonatal intensive care units: a prospective multicenter study. J Perinatol 1995; 15 (6) 470-479
• 11 Brierley J, Carcillo JA, Choong K , et al. Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine. Crit Care Med 2009; 37 (2) 666-688
• 12 Dempsey EM, Barrington KJ. Diagnostic criteria and therapeutic interventions for the hypotensive very low birth weight infant. J Perinatol 2006; 26 (11) 677-681
• 13 Singh BS, Clark RH, Powers RJ, Spitzer AR. Meconium aspiration syndrome remains a significant problem in the NICU: outcomes and treatment patterns in term neonates admitted for intensive care during a ten-year period. J Perinatol 2009; 29 (7) 497-503
• 14 Ng PC, Lee CH, Bnur FL , et al. A double-blind, randomized, controlled study of a “stress dose” of hydrocortisone for rescue treatment of refractory hypotension in preterm infants. Pediatrics 2006; 117 (2) 367-375
• 15 Gaissmaier RE, Pohlandt F. Single-dose dexamethasone treatment of hypotension in preterm infants. J Pediatr 1999; 134 (6) 701-705
• 16 Takci S, Yigit S, Korkmaz A, Yurdakök M. Comparison between oscillometric and invasive blood pressure measurements in critically ill premature infants. Acta Paediatr 2012; 101 (2) 132-135
• 17 Mertens L, Seri I, Marek J , et al; Writing Group of the American Society of Echocardiography (ASE); European Association of Echocardiography (EAE); Association for European Pediatric Cardiologists (AEPC). Targeted neonatal echocardiography in the neonatal intensive care unit: practice guidelines and recommendations for training. Eur J Echocardiogr 2011; 12 (10) 715-736
• 18 Greisen G. Is near-infrared spectroscopy living up to its promises?. Semin Fetal Neonatal Med 2006; 11 (6) 498-502