Abstract
Whilst the prevalence of low blood pressure in preterm infants seems to have fallen over the last number of years, the problem is still frequently encountered in the neonatal intensive care unit and many babies continue to receive intervention. Great variability in practice persists, with a significant number of extremely low gestational age newborns in some institutions receiving some form of intervention, and in other units substantially less. A great degree of this variability relates to the actual criteria used to define hypotension, with some using blood pressure values alone to direct therapy and others using a combination of clinical, biochemical and echocardiography findings. The choice of intervention remains unresolved with the majority of centres continuing to administer volume followed by dopamine as a first line inotrope/vasopressor agent. Despite over 40 years of use there is little evidence that dopamine is of benefit both in the short term and long-term. Long-term follow up is available in only two randomised trials, which included a total of 99 babies. An under recognized problem relates to the administration of inotrope infusions in very preterm infants. There are no pediatric specific inotrope formulations available and so risks of errors in preparation and administration remain. This manuscript outlines these challenges and proposes some potential solutions.
Highlights
The decision to intervene in preterm infants with low blood pressure remains unresolved and as a result significant variability in practice remains [1,2]
In one centre almost all (98%) ELGANS admitted to the intensive care unit received volume, and in the same centre over 64% of all ELGANs received inotrope therapy
We previously described a cohort of infants who had low blood pressure, clinically appeared well and who had a good short term clinical outcome: referred to as permissive hypotension [26]
Summary
The decision to intervene in preterm infants with low blood pressure remains unresolved and as a result significant variability in practice remains [1,2]. The most consistent finding of the ELGAN study is that in the majority of circumstances intervention commenced on the first day of life (90%, 89%, 91%, and 89% of infants born at to weeks, weeks, weeks, and weeks of gestation). The most recent survey, conducted by the HIP consortium, identified that the BAPM rule was used by 75% of respondents to define a low blood pressure that may warrant intervention [4]. This is an important finding and shows that very little has changed in practice over the last 10 years. Other methods of non-invasive assessment of flow are essential to guide therapy and these will be discussed later
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