Zakariya Al-Salam

Hi all, It gives me a great pleasure to review the book entitled "Hemodynamics and Cardiology: Neonatology Questions and Controversies" published by Sauders in June 2008. It is a relatively reasonable sized-book (432 pages) with hardcover and good quality figures and printing. The two editors (Charles Kleinman and Istvan Seri) are well-known in the field of neonatology and more specifically neonatal cardiology and hemodynamics. Richard Polin was the consulting editor. I believe this book is published in response to the major controversies related to the management of PDA, hypotension/blood flow and impact of major neonatal outcomes. Of course, finding the best management to neonatal hemodynamic disturbances would need understanding of evidence related to diagnosis, treatment and outcomes. These aspects were covered very efficiently in a very unbiased format. The book was divided into two parts; hemodynamics and what I call "classical" cardiology. In order to understand clearly issues related to diagnosis and therapy, authors explained in detail the pathophysiology of shock in neonates, consequences and compensatory mechanisms based on the available literature. The area of controversies and lack of evidence were emphasized. Major part of the book was devoted for advances in the diagnosis which is probably the most important step in management of neonatal hemodynamic disturbances. New modalities such as functional echo, NIRS and even MRI were discussed in fairly to meet the purpose of this book. There was extensive review of available evidence to guide therapy. However, due to lack of evidence, there are no clear graded recommendations about best therapy to any specific condition Therefore; the main aim of this book is to highlight available, controversial and even lack of evidence which may guide you indirectly to predict the best intervention for your patients. The following conditions and interventions were covered in details: • Systemic and organ blood flow mainly cerebral blood flow • Hypotension, shock • PDA: association, diagnosis and management and outcomes • Intoropes • Adrenal insufficiency • Surgical patients with shock and SIRS This book was complemented by "classical cardiology". This is a very important to staff dealing with neonates. Nowadays, cardiac patients are kept in NICU not only preoperatively but also post-operatively. Good knowledge about presentation and management of major and life threatening cardiac malformation is essential for peri-operative stabilization. This section is relatively concise and supplemented by very nice figures to make understanding easier. Finally, I highly recommend this book. You can read any chapter in any sequence you want. It is a very nice reference for understanding the neonatal hemodynamics and cardiology but it is not a book about clinical practice guidelines. Regards, Zakariya

Hi, I will try my best to go. Hope to see some of you. Zakariya

Well, I think it is worth to try it in places where iNO is not available or if your patient is difficult to wean off iNO. So far there is only one RCT in human neonate with PPHN that suggests improvement in oxygenation indices: Baquero H et al. Oral sildenafil in infants with persistent pulmonary hypertension of the newborn: a pilot randomized blinded study. Pediatrics. 2006 Apr;117(4):1077-83. Note this study has a very limited number of subjects. There are also other case reports and case series in human neonates in addition to animal models of PPHN. In animal it was given IV, by nebulization or through endotracheal tube with surfactant. The results are encouraging. Shekerdemian L et al. Intravenous sildenafil lowers pulmonary vascular resistance in a model of neonatal pulmonary hypertension. Am J Respir Crit Care Med. 2002;165 :1098 –1102 Ichinose F et al. Nebulized sildenafil is a selective pulmonary vasodilator in lambs with acute pulmonary hypertension. Crit Care Med. 2001;29 :1000 –1005a Haase E, et al Dose response of intravenous sildenafil on systemic and regional hemodynamics in hypoxic neonatal piglets. Shock. 2006 Jul;26(1):99-106. Obaid L et al. Intratracheal administration of sildenafil and surfactant alleviates the pulmonary hypertension in newborn piglets. Resuscitation. 2006 May;69(2):287-94. Epub 2006 Feb 23. Hope this is useful Zakariya Al-Salam

Hi all, This is one of my favorite subjects. The way I look at PPHN is not far from what have been mentioned. As you know, PPHN is a complex disease characterized mainly by increased pulmonary vascular resistance that might be accompanied by systemic hypotension and myocardial dysfunction secondary to the primary or underlying disease. The main aim of therapy is to improve systemic oxygen delivery and minimize iatrogenic complications secondary to our interventions. We have made some arguments in the introduction and discussion in the article we published Al-Salam Z et al. The hemodynamic effects of dobutamine during reoxygenation after hypoxia: a dose-response study in newborn pigs. Shock. 2007 Sep;28(3):317-25. Sure! This is an animal study but the discussion was mainly about human neonates. You will find in the article why we suggest dobutamine as inotrope of choice in the condition of PPHN. In summary, although, dobutamine has less effect on systemic blood pressure, it improves cardiac output and systemic oxygen delivery. In addition, dobutamine can decrease pulmonary vascular resistance. Moreover, dopamine and epinephrine can lead to worsening of PPHN (see references in the article). It is very important to keep in mind when we give any of the inotropes/vasopressors that they do not only act on one side of the heart but on both sides (right and left; pulmonary and systemic). Therefore it is of paramount importance to maintain a good balance between the 2 circulations in the presence or absence of shunts. Thanks, Zakariya Al-Salam

Thanks a lot. I agree with you. Allow me to share with one thought. I believe CPR in the form of chest compressions is a very basic intervention aimed to pump blood to vital organs mainly the brain. It is a measure used before advanced care can be provided and be effective. Once patient is on full cardiopulmonary support (according to the standard) and arrested then I am not really sure adding chest compressions or some more epinephrine would do anything beneficial to the patient. Once again thanks for the reply and looking forward more participation to the forum.

Thanks for the reply. You know, giving standard care for premature infants means lots of things; one of them is to talk with parents and keeping them updated about the situation of their baby. With all due respect, discussing whether or not to give iNO is a diversion from the main isssue. We can discuss that in the respiratory section. Now, allow me to make it more to the point. You have an extremely premature infant with a very high mortality and poor prognosis. He is on full cardio-respiratory support and going to arrest any moment. You have nobody to coutersign the DNR form (you need 3 consultants). It is a weekend. Do you offer CRP if the baby actually arrested? Thanks Zakariya

Dear colleagues, More and more units are adopting policies and procedures related to DNR and Companionate Care. These policies and procedures, usually, depend on many factors the least of which is the scientific evidence. I personally called them consensus-based policies rather than Clinical Practice Guidelines. Having said that I still followed them and in case I believe the situation in front of me does not relate well to the policy, I write justifications and discuss the issue with other member of the team. Now, allow me to give you a brief scenario and please let me know your opinion. You are doing the round in one of the weekends and you are faced with twins who were born 2 days ago at 23 weeks' gestation (b.wt: 540 and 630 g). They required intubation and given standard care of any premature. Twin 1 on HFO very high settings and 100 oxygen and iNO, hypertensive on triple inotropes, hypoxic and pH: 6.8. He has also renal failure, anemic and DIC. He is not responsive to the standard therapy you are providing. Many of you probably believe this baby is in terminal stage and DNR and compassionate care ordered should be written after counseling the parents. Since it is weekend you are the only consultant available and there is no one else with you to counter sign DNR form. Using your clinical judgment do you believe it is right to say this patient is not responsive and if patient gets worse there is nothing we can do about it. OR you are still going to do CPR? I am looking forward hearing from you Best regards, Zakariya Al-Salam