Dear all,

We are sometime faced with this situation when the mean blood pressure is borderline for the gestational age. However, there is wide pulse pressure thereby decreasing diastolic pressure and contributing to lower mean blood pressure.

For example, in a 26 week baby a blood pressure of 35 / 22 gives a higher mean blood pressure reading (26 mm of Hg) compared to 35 / 15 (21 mm of Hg).

Would you accept lower mean blood pressure, if the systolic blood pressure is high enough (example 35 mm of Hg in the above mentioned example )

Normal’ blood pressure should be defined as the pressure, which ensures adequate organ perfusion.

The normal values will depend on gestational age, birth weight and postnatal age.

They defined hypotension as less than the 10th centile for birth weight and postnatal age

BP.

PERFUSION.

PH AND LACTIC ACID.

PULSE VOLUME QUALITY

KIDNEY FUNCTION AND URINE OUTPUT.

VENTRCULAR CONTRACTION AND CARDIAC OUTPUT.

CVP NORMAL 3-9

blood pressure less than the gestational age

does not necessarily need to be treated.

Global assessment of cardiovascular status and

intervention for hypotension restricted to infants

with poor perfusion may have good clinical

outcomes and warrants further evaluation.

The treatment of neonatal hypotension should be based on an overall assessment of cardiovascular status of the infant and not blood pressure alone.

The heart rate, peripheral perfusion and urine output should be considered in addition to blood pressure, elevated lactate concentration on blood gas analysis indicates low tissue perfusion.

Echocardiographic evaluation can serve as useful adjunct, but is not readily available in most neonatal units.

I have recently attended a symposium on neonatal haemodynamics and echocardiography. The main theme is that ideally a functional echo should be done especially in the first 12 hours as an infant can have a low mean and good cardiac output or a normal mean and reduced cardiac output. Of course this means that you need someone available that can do a functional echo round the clock which is probably unlikely.

Here comes the of importance of Functional, Bedside, Point of Care Echocardiography. Surrogates of cardiovascular function e.g BP, HR and perfusion are helpful but functional echo would give you the answer. In a situation where you have a 26 wks premature baby with a low diastolic and a wide pulse , a functional echo is helpful as a base line and on follow up. A bedside echo will show the cardiac function , left ventricular output, duct size and direction of flow as well as end organ diastolic flow in celiac , SMA or cerebral arteries. I Believe it to be a good asset for any NICU to have a neonatologist who can do functional echo. It is the Interdisciplinary politics and conflicts that may on some occasions ; hinder or "scare" Neonatologists from gaining this experience. Of course the training and "some sort "of accreditation is important as well as the collaboration and support of the paediatric cardiology services.

Even in big neonatal units , you might need an echo to be done on 1-2 patients per day. However, echo will be needed more frequently in babies with PDA post ligation. Just to intervene before they develop post-ligation cardiac syndrome at around 8hrs of ligation.

Chasing a BP "number" would not be helpful,instead, monitor perfusion,lactate, urine out put , but surely a functional echo will save you a lot of hassle if its available in the unit.

Thanks

Omer Hamud

Toronto.

Edited December 19, 201015 yr by Omer

Hi all: I'm a certified neonatologist and very much interested in learning echocardiography for neonates . are you aware of any program , courses, or classes ( on site or online) that can help me with this? I heard that if you do 300 echo( mixed adults and peds) and a cardiologist certify you as some one who can do echo's, that would be enough.. Is that right? Any way , I live in PA , USA in case you can help me with this!

There are echo courses in London, UK: check this link out:

http://www.rbht.nhs.uk/healthprofessionals/clinical-departments/paediatrics/morphology/

(I and a few colleagues used to organize ultrasound courses in Stockholm (brain+heart). Unfortunately, there is no course in pipeline...)

Thanks Stefan for your help. Unfortunately, It's hard to do it out of the U.S these days. I wish some day I will be able to attend a course for both in Stockholm

BTW: you still recommend the interactive cd of dr Evans from Australia ? 3-4 years ago you guys used to offer them for purchasing ..

Are we measuring SVC blood flow in functional echo ?