Original Article

Journal of Perinatology (2007) 27, 353–358; doi:10.1038/sj.jp.7211749; published online 19 April 2007

Is refractory hypotension in preterm infants a manifestation of early ductal shunting?

S Sarkar1, R Dechert2, R E Schumacher1 and S M Donn1

  1. 1Department of Pediatrics, Division of Neonatal-Perinatal Medicine, University of Michigan Health System, C.S. Mott Children's Hospital, Ann Arbor, MI, USA
  2. 2Department of Pediatrics, Critical Care Support Services, University of Michigan Health System, C.S. Mott Children's Hospital, Ann Arbor, MI, USA

Correspondence: Dr S Sarkar, Department of Pediatrics, Division of Neonatal–Perinatal Medicine, University of Michigan Health System, F5790 C.S. Mott Children's Hospital, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-0254, USA. E-mail: subratas@med.umich.edu

Received 29 November 2006; Revised 8 March 2007; Accepted 20 March 2007; Published online 19 April 2007.

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Abstract

Background:

 

Clinicians frequently use hydrocortisone (HC) to treat vasopressor-resistant hypotension even before establishing its cause.

Objective:

 

To identify the etiologic factors leading to development of refractory hypotension, and to assess if patent ductus arteriosus (PDA) is associated with refractory hypotension during the first week of life.

Study design:

 

The medical records of 290 consecutively born infants less than or equal to30 weeks' gestational age (GA) were reviewed to identify the escalating need for vasopressors to maintain mean arterial blood pressure (MABP) at or above a level equal to the GA in completed weeks. Refractory hypotension was defined as MABP unresponsive to fluid boluses and high-dose vasopressors (dopamine and dobutamine at doses 20 mug/kg/min each and/or epinephrine) prompting the use of HC.

Results:

 

Eighty-nine (30.7%) of 290 infants had refractory hypotension between postnatal days 2 and 7. Infants with refractory hypotension were more likely to have a lower birth weight and GA (P<0.001), been treated with surfactant (P=0.004) and received indomethacin for a symptomatic PDA (P<0.001). To identify the etiologic factors, a univariate analysis revealed that the use of high-frequency oscillatory ventilation, presence of air leaks, PDA, sepsis, hyperkalemia and intraventricular hemorrhage (IVH) were significantly associated with refractory hypotension. However, multivariate analysis confirmed the independent association of only PDA (odds ratio (OR) 7.6, 95% confidence interval (CI) 3.3–17.7, P=0.000), severe IVH (OR 2.6, 95% CI 1.1–6.4, P=0.03) and GA (OR 0.7, 95% CI 0.6–0.8, P=0.001).

Conclusions:

 

Evaluation for early ductal shunting and closure of the ductus, if patent, should be attempted before HC is considered in hypotensive infants with escalating needs for vasopressors.

Keywords:

refractory hypotension, vasopressors, hydrocortisone, patent ductus arteriosus

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