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Stefan Johansson

99nicu Poll: use of inotropes in preterm infants

On his 2nd day of life a ventilated 26-weeker has a blood-pressure mean of 21mmHg. What do you do?  

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The use of inotropes is a matter of discussion, and the 99nicu Poll for May 2012 is about the use inotrope use in preterm infant.

This poll is inspired by a topic at the Evidence-based neonatology (EBNEO) conference in Stockholm, June 2011. Dr Alan Groves lectured about the use of inotropes, in an excellent and thought-provoking way.

You can see this lecture in the EBNEO web cast, as the first lecture on the 2nd conference day (4 June 2011)

http://web22.abiliteam.com/ability/show/khcichp/abbott_ebneo/speed.asp

A review article by Alan Groves is also promoted as the Leading article this month.

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Firstly, I will re-calibrate my ABP transducer, secondly I will make sure that the baby is well perfused, well hydrated and not acidotic with normal serum lactate level and maintaining adequate urine out put.

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I would use first Normal saline bolus once or twice and then start Dopamine

You should never give bolus infusions to a preterm infant. The word bolus means immediately like when you slap your hands.

Infusions should be given over a graded period of time. All infants with low BP should be started on dopamine. Read article from Murphy which shows clearly that beginning dopamine preserves CBF.

thanks

charlie

Dr C Paxson

Prof Peds

Michigan State Sch Med

Marquette, MI, USA

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For Dr C Paxson

Sorry for misinterpretation. When I worte bolus, it means over 30min to one hour. No bolus can be given like Slap of hands. I will still insist on restoring blood volume first by giving Normal saline over 30min to one hour and then start dopamine. Starting dopamine right from the begining is not correct.

One thing more I want to add if your ABG is fine with no metabolic acidosis, normal lactate and no tachycardia with good perfusion, donot treat numbers, just wait and see.

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10ml per kg NS infusion two times followed by dopamine titrate the dose upwards as required; but the next step is it dobutamine or adrenaline, I prefer adrenaline but my colleagues prefer dobutamine, what is your views?

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START DOBUTAMINE TO IMPROVE BLOOD FLOW AND HENCE BLOOD PRESSURE , NO NEED FOR SALINE BOLUS AS THE PROBLEM IS NOT HYPOVOLEMIA BUT MYOCARDIAL DYSFUCTION OF THE PREMATURES

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I usually use Dobutamine after NS bolus, but frequently it'll need also dopamine after that (10 mcg each)... Never had experience with adrenaline.. Please share, in what situation we use adrenaline?

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I would rather start off with dobutamine and assess the response, adding dopamine if blood prrssure remained low. After 24 hours, dopamine would be my first choice.

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Oops!! Reread initial statement. Yes, after 24 hours dopamine is the drug of first choice.

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Is there any role of fuctional echocardiography to essess myocardic dysfuction? Dopamine is prefered after volume correction.Dobutamine can be added if there is myocardic dysfuction.Also treat cause.

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echocardiographic assesment

if PCA: dobutamine + ibuprofène

if not PCA, Lv dysfunction: dobutamine

if No PCA and good LV dysfunction : NS 10-20 ml/kg over 40-60 mn and HSHC 4-5 mg/kg/j in IV route

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Got it.. Echo assessment (if possible), NS, n dobutamine (first 24 hs) or dopamine.. Or both... But are there in any sircumstances should we use adrenaline? Or should we add adrenaline after dobu/dopa fail to give a good BP? Or after resuscitation/bradicardiac state in a previously in dobu/dopa baby?

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we can add adrenaline &\or hydrocortisone in case adreno cortical insufficiency where there no response to routine management(FLuids+dopamine+dobutamine).

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10ml per kg NS infusion two times (60 min) followed by dopamine titrate the dose upwards as required; the next step is it dobutamine, if hypotension persist, the next is adrénaline +/- hydrocortisone.

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Very interesting discussion. I personally prefer dopamine, if echo is available i might think about dobutamine. some at our department start norepinephrine (it leads to the least pulmonary hypertension) and again others believe hydrocortisone as first line is best.

What article by Murphy do you mean, Charles Paxson?

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echocardiographic assesment

if PCA: dobutamine + ibuprofène

if not PCA, Lv dysfunction: dobutamine

if No PCA and good LV dysfunction : NS 10-20 ml/kg over 40-60 mn and HSHC 4-5 mg/kg/j in IV route

I agree with this plan and we do the same.

would like to add - if ECHO assessment is not feasible or informative, we give fluid + ibup, if no improvement start with dobutamin / dopamin (as per the age), still no improvement - start adrenaline. with a shot of hydrocartisone.

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in most hospitals in my country , we use normal saline or ringer if hypotetion present in preterm and wait and see

and if still hypotensive with frequent reading and suitable cuff ,,, we start dopamine if no tachycardia +/- dobutamine with low doses

and if no response we increasind the dose gradualy

but actually we didn't make ECHO for hypotesion alone

and we didn't use adrenaline for hypotesion

and in some resistant cases we use hydrocortisone dose

but in cases of IDM with hypotesion or poor perfusion we didn't add dopa or dobut. before ECHO ........

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I don't use lv function in isolation ( you can get an FS to measure what you want). Looking at mitral inflow and aortic outflow may be of use in term sof VTI. In the end it still I think come back to using RV output / SVC flow in context with the global picture - lactate . urine output and metabolic acidosis.

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