Some newborns, especially those who are very premature, are hypotensive in the first few days of life despite good general support, adequate vascular volume, good myocardial contractility, a closed or insignificant ductus arteriosus, steroid treatment, and 20 mcg/kg/min of dopamine. These babies are often presumed to be septic (or too immature), even if cultures are negative, and they usually die.

Such babies may have systemic inflammatory response syndrome without sepsis(Critical Care Clin 11:751) with pathologic vasodilation (Pediatr Res 36:25A) and distributive shock (Annals Int Med 113:227), which may respond to vigorous vasoconstriction as has been used in septic adults (Critical Care Med 17:179 and 19:1395). There have been no reports of NE infusions in newborns.

We have treated 29 such babies with NE infusion over a four year period(4/92-3/96). Four were born at 22, 10 at 23-24, 12 at 25-28, and three at 31-38 completed weeks of gestation. One baby had culture-proven sepsis (died). One baby had poor myocardial contractility (survived). Indomethacin was given if the ductus arteriosus was open. All 29 babies received 5-30 mcg/kg/min dopamine with their NE. One baby received 2 mcg/kg/min of NE (survived), but the others received less than 1.5 mcg/kg/min of NE, to keep the mean blood pressure above 25-30 torr in the babies weighing less than 1 kg (Arch Dis Child 62:1068). Only one baby's NE was continued beyond four days of age(died).

Fifteen of the 29 babies survived to discharge home. Five of the 15 survivors had grade 3 or 4 IVH or posthemorrhagic hydrocephalus (one of them died after discharge home). Four survivors had isolated bowel perforations, probably due to mesenteric vasoconstriction. Eight babies survived without either of these two lesions. No survivors had long term renal failure or cystic periventricular leukomalacia that was visible with ultrasound. Follow-up evaluations of these babies have begun.

The lack of periventricular leukomalacia in this extremely sick group of babies suggests that NE maintains adequate cerebral and myocardial blood flow despite its vasoconstrictive properties. This is consistent with studies of extreme vasoconstriction during cardiopulmonary resuscitation of piglets(Anesthesiology 75:1041) and of pressor infusions high enough to decrease the cardiac output and increase the base deficit of lambs (Pediatr Res 21:131). More research is needed in this area.