dear collegues,

Some times we recieve neonates with severe hypoxemic failure due to various causes without infection and with intractable shock due to PPHN despite central venous cath., dopamine (20ug/kg/mn), dobutamine (20-30 ug/kg/mn), 4-6 fluids boluses of 10-20ml/kg, inhaled NO, sedation and effective mechanical ventilation. echocardiography shows frequently signs of PPHN. the question that i would like to answer is that what should we use after: epinephrine, norepinephrine or other thing?

Dear ammar,

difficult scenario!

We would probably add epinephrine, while decreasing dobutamine slightly.

If you have echo easily accessible one may also try to increase the NO dose, while doing doppler and see if it is possible to decrease pulm resistance.

I believe Epinephrine is the drug of choice. It works very well in most of the cases

Dear Colleague,

iNO for hypoxic resp.failure of term NB is a good therapy, but should be monitored to avoide the potential toxic effects.

The most important therapy for hypox.resp.failure of term NB includes administration of high concentration of Oxygen,hyperventilation,induction of alkalosis and neuromuscular blockade.

Infants with cong.diaphr.hernia have been shown not to benefit from iNO therapy.

Echo is necessary to rule out cong.heart.disease.

Epinephrine is the choice of therapy also with observation

Dear all that replied to my question,

thank you very much. I can affirm to you that we recieve 1-2 patients with such pathology weekly. we use monitored iNO therapy. in all cases we try to use 20-80 ppm if there is no response for < 20 ppm. but we have not a response in the majority of cases (when that does'nt work at 20 pmm, that will not work at 1000 ppm! you can be sure because we are a very big users of INO and HFOV).

we use épinephrine usually rather than norepinephrine in such situations but we are not sure that this is the best choice (neurologic outcome). so can you answer me is there any difference in neurologic outcome between epinephrine and norepinephrine use and thank you very much

Epinephrine is drug of choice. Also sometime stress doses of Hydrocortisone also works in pt with hypotention

is there anybody who used sildenafil citrate( viagra) in PPHN ? I saw some papers that it is hopefull choice.

dear cihanber,

we used it recently in one case of CDH with a sequellar PPHN after chirugical cure of the defect. the patient was on HFOV (MAP=18, FiO2=50%) and iNO at 10 ppm. we weaned up the patient at day 16 after chirurgy. Echocardiography before and after 3 days of Sildenafil was not very different. But we will begun in few days a prospective work about it. my personan opinion that if when there is not A LOOSER, we must search greatly A WINNER! I will give you further information about if you like.

thanks a lot:)I am looking forward from you...