first inotrope in premature newborn born after prolonged labour

[amitkala]

i am working in nicu as a resident. i received a preterm newborn 33 wks born after difficult and prolonged labour. patient had mean BP around 25 after birth. then my teacher asked to administer 2 bolus of normal saline of 10ml/kg. and after that she advised to add adrenaline infusion @0.1 mcg/kg/min. Is it better idea to start with adrenaline rather than dopamoine?

[Stefan Johansson]

I guess traditions vary, but we use adrenalin only if dopamin and/or dobutamine are insufficient.

[fcardona]

I agree a lot is about personal preference when treating hypotension in the newborn. The "classical" way is to use dopamin or dobutamin and use epinephrine as second line. Newer studies show epinephrine just as good in elevating blood pressure (see this (http://www.ncbi.nlm.nih.gov/pubmed/11317051)). There is some evidence that dopamin might lead to pulmonary hypertension, maybe only transient but there are no good studies on that matter or the superiority of a different inotrope (this (http://www.ncbi.nlm.nih.gov/pubmed/11953739)).
Needless to say, hypotension in the newborn is still hotly debated as probably arterial blood pressure is not a means to measure cerebral perfusion (what we really want to know) efficiently. A good read on this is this article by Gorm Greisen (link (http://www.ncbi.nlm.nih.gov/pubmed/15935919))

[Stefan Johansson]

Needless to say, hypotension in the newborn is still hotly debated as probably arterial blood pressure is not a means to measure cerebral perfusion (what we really want to know) efficiently. A good read on this is this article by Gorm Greisen (link (http://www.ncbi.nlm.nih.gov/pubmed/15935919))

Thanks for raising this issue. I have often found that many people do not consider the different concepts of (blood) pressure and (blood) flow. I would also like to recommend this review by Nick Evans (http://www.ncbi.nlm.nih.gov/pubmed/19399010).
Functional echo! That's what we need to learn, to diagnose and treat hemodynamic problems in the newborn.

[fcardona]

Functional echo! Actually I would already be satisfied to know that cerebral oxygenation/perfusion is sufficient.. Now how do we reliably measure that?

[Stefan Johansson]

Actually I would already be satisfied to know that cerebral oxygenation/perfusion is sufficient.. Now how do we reliably measure that?
Functional echo!
Just kidding. NIRS? But, measuring systemic venous return i v cava superior, gives good marker of cerebral perfusion.
http://www.ncbi.nlm.nih.gov/pubmed/10794784

[fcardona]

I am sceptical for now about SVC flow as there is poor interobserver repeatability (among others Groves et al. (2008) (http://www.ncbi.nlm.nih.gov/pubmed/17626146)) and I have seen other reports that showed great variability in results as well. Maybe in the future it will be possible to standardize measurements, definitely an interesting area.
Do you routinely measure SVC flow? I I may be relieved of my scepticism though some day...

[xemoni]

i am working in nicu as a resident. i received a preterm newborn 33 wks born after difficult and prolonged labour. patient had mean BP around 25 after birth. then my teacher asked to administer 2 bolus of normal saline of 10ml/kg. and after that she advised to add adrenaline infusion @0.1 mcg/kg/min. Is it better idea to start with adrenaline rather than dopamoine?

I would prefer dopamine to adrenaline.