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99nicu Poll: What is your pharmaceutical management option for PPHN of a term newborn in your institution?


selvanr4

What is your pharmaceutical management for PPHN in a term newborn? (several options allowed)  

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PPHN could be idiopathic or secondary and leads to increased pulmonary vascular resistance.There is no clear consensus on the management of PPHN. The goals of treatment are to improve oxygenation, reduce pulmonary vasoconstriction, maintain systemic Blood pressure and perfusion and pulmonary vasodilator therapy.

How do you manage a term newborn baby with PPHN in your institution?

Please note that multiple options/replies can be ticked.

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we use sildenafel with very good result and we recommend its use , its cheap easy to give and well tolerated by the baby; but with disadvantaged of its must be given orally as till now no IV sildenafel available, also there is no long term study of its effect on the baby in late stages of life, also NO still the 1st choice its very expensive instrument as compared to sildenafel but combination of both is the best.

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Too bad we still have no NO in our unit.. :(

We use sildenafil, magnesium sulphate, inotropes and high setting of conventional ventilator (sigh.. We still don't have HFOV)..

MgSO4 works though.. It's a sistemik vasodilator, dilate the pulmonary vessel too, but it need inotropes for back up, otherwise it'll drop the BP..

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References for use of Bonstan in newborn are

1) Acta Paediatr. 2009 Oct;98(10):1683-5. Epub 2009 Jun 11.

2) Eur J Pediatr. 2008 Apr;167(4):437-40. Epub 2007 Aug 15

3) Please refer to this study by its ClinicalTrials.gov identifier: NCT01389856

I hope others are also using it in severe cases.

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PPHN could be idiopathic or secondary and leads to increased pulmonary vascular resistance.There is no clear consensus on the management of PPHN. The goals of treatment are to improve oxygenation, reduce pulmonary vasoconstriction, maintain systemic Blood pressure and perfusion and pulmonary vasodilator therapy.

How do you manage a term newborn baby with PPHN in your institution?

Please note that multiple options/replies can be ticked.

We use alkali therapy with ionotropes, and once we tried sedentifil

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At our unit, or even the one I previously worked for, the initial treatment would focus on the underlying reason for PPHN, if there is one and the optimization of PH, CO2, O2, and blood pressure.

Next step would be the use of NO if available.

In addition or in the more chronic phase Sildenafil would come in probably even Illoprost would be tested.

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  • 2 weeks later...

It is very tricky to treat and stabilize resistant cases with PPHN .

Now as mentioned earlier; our targets are : a) Maintain OXYGENATION (we aim to maintain above 95%) B) to maintain systemic pressure (we aim to maintain above 55-60 of mean).

Now again as requested we are talking about term babies.

It is a big challenge; so bypassing the high pressure (which can frequentely cause air leak) and high FiO2 on conventional ventilation. Nitric is really of great help. We usually start at 20 PPM. We do not use Sildenafil that frequent.

Higher maps in HFOV can help but again with caution.

When we come to the point where Oxygenation index exceeding 45 to 50; we start to think about ECMO.

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Well as a basic principle we try to maintain oyxgenation above SpO2 95%, avoid any acidosis (use hydrogencarbonate if necessary), ascertain normothermia, and try to keep systemic blood pressure slightly above normal.

Achieving these goals may include the use of HFOV and the use of different inotropes like dobutamine, low-dose adrenaline (0.05µg/kg/min), noradrenaline or milrinone followed by hydrocortisone. We also include iNO (starting 20 ppm) if inotropes are ineffective. We rarely use sildenafil primarily.

 

I would be interested to know how you combine inotropes? Start dobutamine first? Then add noradrenaline (to what max. dosage)?

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In response to one of the above comments, we have tried IV Pulmosil in our unit a couple of times, with good results and no immediate problems. Too early to say how it compares with oral sildenafil, though, which is tried and tested, and most important, cheap!

 

IV sildenafil dosage that we used was 0.4 mg/kg over 3 hours, followed by 1.6 mg/kg/day.

 

Word of caution about concomitant use with iNO. A study by Shekerdemian et al on piglets with meconium aspiration said that combined use resulted in worsening oxygenation and hypotension. (However, a more recent, multicenter study by Steinhorn et al (2003-05) says it did not!)

 

It was a moot point for us, though, as our unit has no iNO...

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  • 10 months later...

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