PEDIATRICS Vol. 123 No. 5 May 2009, pp. 1369-1376 (doi:10.1542/peds.2008-0673)
ARTICLE |
Early Systemic Hypotension and Vasopressor Support in Low Birth Weight Infants: Impact on Neurodevelopment
a Department of Neonatology
b Biostatistics Unit, La Paz University Hospital, Madrid, Spain
BACKGROUND. The duration and severity of systemic hypotension have been related with altered neurodevelopment. Cerebral circulation is pressure-passive in low birth weight infants with early systemic hypotension who receive cardiovascular support. The treatment of early systemic hypotension is controversial, because it has been associated with short-term and long-term morbidity in retrospective studies. However, there has been no prospective information on cardiovascular support for hypotension and morbidity.
OBJECTIVE. Our goal for this prospective study was to evaluate the effect on neurodevelopment resulting from the use of vasopressors/inotropes for early systemic hypotension.
METHODS. Low birth weight infants with early systemic hypotension (<24 hours of life; study group) were assigned randomly to receive dopamine (2.5–10 µg/kg per minute) or epinephrine (0.125–0.5 µg/kg per minute) in progressively larger doses until target blood pressure was attained (treatment-success subgroup). Hemodynamically stable patients who did not receive cardiovascular support were the control group. Outcome measures were serial cranial ultrasound up to 40 weeks, structured neurologic evaluation (every 3 months), and neurodevelopmental test at 2 to 3 years of age.
RESULTS. One hundred thirty patients were included (study = 60; treatment success = 38; controls = 70). Study-group patients had lower birth weight, gestational age, and 5-minute Apgar score, higher rates of premature rupture of membranes, need for cardiorespiratory resuscitation at birth, and sickness shortly after birth than the control group. The patients in the study group also had significantly higher serum troponin I levels at birth. Initial cranial ultrasound findings did not differ between groups, but the final cranial ultrasounds revealed higher rates of severe periventricular hemorrhage in the study group and higher rates of normal cranial ultrasounds in the control group. Only the latter remained when the treatment-success subgroup and control group were compared. Multivariate analysis did not detect any association between final cranial ultrasounds and the use of vasopressors/inotropes. Sixteen infants died and 103 were followed up (90% survival rate). No differences between groups were found in the rates of abnormal neurologic status, developmental delay, or combined adverse outcome (death or cerebral palsy or severe neurodevelopmental delay).
CONCLUSIONS. Cautious use of cardiovascular support to treat early systemic hypotension in low birth weight infants seems to be safe. The question of whether raising systemic blood pressure to within a normal range will improve outcome should be examined by using appropriate study designs.
Key Words: premature infant • hypotension • dopamine • epinephrine • developmental impairment • cerebral palsy
Abbreviations: LBW—low birth weight • IVH—intraventricular hemorrhage • PVL—periventricular leukomalacia • MBP—mean blood pressure • TnI—troponin I • CUS—cranial ultrasound • PVE—periventricular echogenicity • PROM—premature rupture of membranes • CRIB—Critical Risk Index for Babies • NS—not significant • PVHI—periventricular hemorrhagic infarction • OR—odds ratio • CI—confidence interval
Accepted Sep 9, 2008.
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