Yenidoğanda Hipotansiyon ve Tedavisi

Yıl 2013, Cilt: 11 Sayı: 2, 68 - 76, 01.09.2013

Nilay Hakan Mustafa Aydın

https://doi.org/10.4274/Jcp.11.43153

Öz

Sistemik hipotansiyon hasta prematüre bebeklerde sık görülen bir komplikasyon olup ventrikül içi kanamayı, nörogelişimsel morbiditeyi ve mortaliteyi de içeren bazı olumsuz sonuçlara neden olabilir. Neonatologlar arasında hem hipotansiyonun tanımı hem de nörolojik hasara neden olabilen sistemik arteriyel kan basıncı alt sınırı değeri bakımından bir fikir birliği yoktur. Bu nedenle bildirilen hipotansiyon prevalansları yenidoğan üniteleri arasında değişkenlik gösterir. Bununla birlikte, klinisyenlerin çoğu tarafından yenidoğanda nörolojik sonuçları ve yaşam oranlarını iyileştirdiği düşünülerek hipotansiyonun erken ve etkin tedavisi kabul görmüştür. Hipotansiyon tedavisinde amaç yeterli organ kan akımını, özellikle serebral kan akımını sağlamaktır. Tedavi kararı, serebral oksijen dağılımının yeterliliği ve organ perfüzyonunun değerlendirilmesindeki zorluklardan dolayı, klinik öngörü ile beraber gestasyonel ve postnatal yaşa göre belirlenmiş normal kan basıncı değerlerine göre verilmektedir. Günümüzde prematüre bebeklerde hipotansiyon tedavisinde hacim genişleticiler, inotrop, vazopressör ajanlar ve kortikosteroidler kullanılmaktadır. Yenidoğanda yaygın olarak kullanılan inotropik ajanlardan dopaminin kan basıncını arttırmada dobutaminden daha etkili olduğu bildirilmiştir. Bazı hipotansif prematüre bebeklerde adrenokortikal yetmezlik nedeniyle kortizol düzeyleri düşüktür ve kortikosteroidler genel olarak bu bebeklerde dirençli hipotansiyon tedavisi için bekletilir; bununla birlikte potansiyel yan etkileri nedeniyle profilaktik ya da rutin klinik kullanımı önerilmez. Bu yazıda yenidoğanda sistemik hipotansiyonun tanı ve tedavisi ile ilgili bazı tartışmalı noktalar gözden geçirilecektirr

Anahtar Kelimeler

Yenidoğan, hipotansiyon, tedavi, damar büzücü ajanlar

Hypotension in Newborn Infants and Its Treatment

Öz

Systemic hypotension is a common complication of sick premature infants and may be associated with major adverse outcomes, including intraventricular hemorrhage, neurodevelopmental morbidity, and mortality. There is no consensus among neonatologists regarding either the definition of hypotension or the lower threshold level of systemic arterial blood pressure in which neurological injury is inevitable. For this reason, there is a considerable variation in the reported prevalence of hypotension among different neonatal units. However, it is widely accepted by many of clinicians that early and aggressive treatment of hypotension in the neonates leads to improved neurologic outcome and survival. The goal of treatment of hypotension is to maintain adequate organ blood flow, particularly, cerebral blood flow. Because of difficulties in evaluating organ perfusion and adequacy of cerebral oxygen delivery, treatment decisions are based on statistically defined gestational and postnatal agedependent normative blood-pressure values combined with clinical intuition. Current treatment of hypotension in the premature infant includes the use of volume expansions, inotropes, vasopressor agents and corticosteroids. It has been reported that dopamine, as a commonly used inotropic agents in the neonatal period, is more effective than dobutamine in the raising of blood pressure. Some hypotensive premature infants have low cortisol levels because of adrenocortical insufficiency, and corticosteroids are generally reserved for treatment of refractory hypotension of these infants; however, it is not recommended for prophylaxis or routine clinical use because of its potential serious side effects. This article aims to review some of the controversies about diagnosis and management of systemic hypotension in the newborn infants

Anahtar Kelimeler

Newborn infant, hypotension, treatment, vasoconstrictor agents

Kaynakça

• 1. Watkins AM, West CR, Cooke RW. Blood pressure and cerebral haemorrhage and ischaemia in very low birthweight infants. Early Hum Dev 1989;19:103-10.
• 2. Miall-Allen VM, de Vries LS, Whitelaw AG. Mean arterial blood pressure and neonatal cerebral lesions. Arch Dis Child 1987;62:1068-9.
• 3. Pellicer A, Bravo MC, Madero R, Salas S, Quero J, Cabañas F. Early systemic hypotension and vasopressor support in low birth weight infants: impact on neurodevelopment. Pediatrics 2009;123:1369-76.
• 4. Öztürk MA, Büyükayhan D. Yenidoğanda hipotansiyon. Bakırköy Tıp Dergisi 2011;7:1-5.
• 5. Al-Aweel I, Pursley DM, Rubin LP, Shah B, Weisberger S, Richardson DK. Variations in prevalence of hypotension, hypertension, and vasopressor use in NICUs. J Perinatol 2001;21:272-8.
• 6. Jones JG, Smith SL. Shock in the critically ill neonate. J Perinat Neonatal Nurs 2009;23:346-54.
• 7. Fanaroff JM, Wilson-Costello DE, Newman NS, Montpetite MM, Fanaroff AA. Treated hypotension is associated with neonatal morbidity and hearing loss in extremely low birth weight infants. Pediatrics 2006;117:1131-5.
• 8. Fanaroff JM, Fanaroff AA. Blood pressure disorders in the neonate: hypotension and hypertension. Semin Fetal Neonatal Med 2006;11:174-81.
• 9. Seri I. Cardiovascular, renal, and endocrine actions of dopamine in neonates and children. J Pediatr 1995;126:333-44.
• 10. Seri I. Circulatory support of the sick preterm infant.Semin Neonatol 2001;6:85-95.
• 11. Perkin RM, Levin DL. Shock in the pediatric patient. Part I. J Pediatr 1982;101:163-9.
• 12. Nuntnarumit P, Yang W, Bada-Ellzey HS. Blood pressure measurements in the newborn. Clin Perinatol 1999;26:981- 96.
• 13. Kent AL, Kecskes Z, Shadbolt B, Falk MC. Blood pressure in the first year of life in healthy infants born at term. Pediatr Nephrol 2007;22:1743-9.
• 14. Kent AL, Meskell S, Falk MC, Shadbolt B. Normative blood pressure data in non-ventilated premature neonates from 28- 36 weeks gestation. Pediatr Nephrol 2009;24:141-6.
• 15. Vargo L, Seri I. New NANN Practice Guideline: the management of hypotension in the very-low-birth-weight infant. Adv Neonatal Care 2011;11:272-8.
• 16. Kluckow M, Evans N. Low systemic blood flow in the preterm infant. Semin Neonatol 2001;6:75-84.
• 17. Evans N. Assessment and support of the preterm circulation. Early Hum Dev 2006;82:803-10.
• 18. Kluckow M, Evans N. Superior vena cava flow in newborn infants: a novel marker of systemic blood flow Arch Dis Child Fetal Neonatal Ed 2000;82:182-7.
• 19. Noori S, Stavroudis TA, Seri I. Systemic and cerebral hemodynamics during the transitional period after premature birth. Clin Perinatol 2009;36:723-36.
• 20. Kehrer M, Blumenstock G, Ehehalt S, Goelz R, Poets C, Schöning M. Development of cerebral blood flow volume in preterm neonates during the first two weeks of life. Pediatr Res 2005;58:927-30.
• 21. Tyszczuk L, Meek J, Elwell C, Wyatt JS. Cerebral blood flow is independent of mean arterial blood pressure in preterm infants undergoing intensive care. Pediatrics 1998;102:337-41.
• 22. Goldstein RF, Thompson RJ Jr, Oehler JM, Brazy JE. Influence of acidosis, hypoxemia, and hypotension on neurodevelopmental outcome in very low birth weight infants. Pediatrics 1995;95:238-43.
• 23. Mattia FR, deRegnier RA. Chronic physiologic instability is associated with neurodevelopmental morbidity at one and two years in extremely premature infants. Pediatrics 1998;102:35.
• 24. Dempsey EM, Barrington KJ. Treating hypotension in the preterm infant: when and with what: a critical and systematic review J Perinatol 2007;27:469-78.
• 25. Ahn SY, Kim ES, Kim JK, Shin JH, Sung SI, Jung JM, Chang YS, Park WS. Permissive hypotension in extremely low birth weight infants (≤1000 gm). Yonsei Med J 2012;53:765-71.
• 26. Subhedar NV. Treatment of hypotension in newborns. Semin Neonatol 2003;8:413-23.
• 27. Dempsey EM, Barrington KJ. Treating hypotension in the preterm infant: when and with what: a critical and systematic review. J Perinatol 2007;27:469-78.
• 28. Pladys P, Wodey E, Beuchée A, Branger B, Betremieux P. Left ventricle output and mean arterial blood pressure in preterm infants during the 1st day of life. Eur J Pediatr 1999;158:817- 24.
• 29. Barrington KJ. Circulatory effects of dopamine in neonates. J Pediatr 1995;127:843-4.
• 30. Seri I, Evans J. Controversies in the diagnosis and management of hypotension in the newborn infant. Curr Opin Pediatr 2001;13:116-23.
• 31. So KW, Fok TF, Ng PC, Wong WW, Cheung KL. Randomised controlled trial of colloid or crystalloid in hypotensive preterm infants. Arch Dis Child Fetal Neonatal Ed 1997;76:43-6.
• 32. Sasidharan P. Role of corticosteroids in neonatal blood pressure homeostasis. Clin Perinatol 1998;25:723-40.
• 33. Göksedef D, Yalvaç EŞD, Ömeroğlu SN. İnotropik İlaçların Klinik Kullanımı. Turkiye Klinikleri J Cardiovasc Surg-Special Topics 2012;4:92-102.
• 34. Rozé JC, Tohier C, Maingueneau C, Lefèvre M, Mouzard A. Response to dobutamine and dopamine in the hypotensive very preterm infant. Arch Dis Child 1993;69:59-63.
• 35. Greenough A, Emery EF. Randomized trial comparing dopamine and dobutamine in preterm infants. Eur J Pediatr 1993;152:925-7.
• 36. Osborn D, Evans N, Kluckow M. Randomized trial of dobutamine versus dopamine in preterm infants with low systemic blood flow. J Pediatr 2002;140:183-91.
• 37. Seri I. Cardiovascular, renal, and endocrine actions of dopamine in neonates and children. J Pediatr 1995;126:333-44.
• 38. Aşılıoğlu N, Demirkol D. Vazoaktif İlaçlar. Turkiye Klinikleri J Pediatr Sci 2011;7:96-103.
• 39. DiSessa TG, Leitner M, Ti CC, Gluck L, Coen R, Friedman WF. The cardiovascular effects of dopamine in the severely asphyxiated neonate. J Pediatr 1981;99:772-6.
• 40. Cuevas L, Yeh TF, John EG, Cuevas D, Plides RS. The effect of low-dose dopamine infusion on cardiopulmonary and renal status in premature newborns with respiratory distress syndrome. Am J Dis Child 1991;145:799-803.
• 41. Hahn GH, Heiring C, Pryds O, Greisen G. Cerebral vascular effects of hypovolemia and dopamine infusions: a study in newborn piglets. Acta Paediatr 2012;101:736-42.
• 42. Sassano-Higgins S, Friedlich P, Seri I. A meta-analysis of dopamine use in hypotensive preterm infants: blood pressure and cerebral hemodynamics. J Perinatol 2011;31:647-55.
• 43. Enrico C, Kanoore Edul VS, Vazquez AR, Pein MC, Pérez de la Hoz RA, Ince C, et al. Systemic and microcirculatory effects of dobutamine in patients with septic shock. J Crit Care 2012;27:630-8.
• 44. Valverde E, Pellicer A, Madero R, Elorza D, Quero J, Cabañas F. Dopamine versus epinephrine for cardiovascular support in low birth weight infants: analysis of systemic effects and neonatal clinical outcomes. Pediatrics 2006;117:1213-22.
• 45. Scott SM, Watterberg KL. Effect of gestational age, postnatal age, and illness on plasma cortisol concentrations in premature infants. Pediatr Res 1995;37:112-6.
• 46. Moïse AA, Wearden ME, Kozinetz CA, Gest AL, Welty SE, Hansen TN. Antenatal steroids are associated with less need for blood pressure support in extremely premature infants. Pediatrics 1995;95:845-50.
• 47. Helbock HJ, Insoft RM, Conte FA. Glucocorticoid-responsive hypotension in extremely low birth weight newborns. Pediatrics 1993;92:715-7.
• 48. Higgins S, Friedlich P, Seri I. Hydrocortisone for hypotension and vasopressor dependence in preterm neonates: a metaanalysis. J Perinatol 2010;30:373-8.
• 49. Ibrahim H, Sinha IP, Subhedar NV. Corticosteroids for treating hypotension in preterm infants. Cochrane Database Syst Rev 2011;7: CD003662. doi: 10.1002/14651858.
• 50. Kawczynski P, Piotrowski A. Circulatory and diuretic effects of dopexamine infusion in low-birth-weight infants with respiratory failure. Intensive Care Med 1996;22:65-70.
• 51. Packer M, Carver JR, Rodeheffer RJ, Ivanhoe RJ, DiBianco R, Zeldis SM, et al. Effect of oral milrinone on mortality in severe chronic heart failure. The PROMISE Study Research Group. N Engl J Med 1991;325:1468-75.
• 52. Driscoll W, Thurin S, Carrion V, Steinhorn RH, Morin FC 3rd. Effect of methylene blue on refractory neonatal hypotension. J Pediatr 1996;129:904-8.
• 53. Ikegami H, Funato M, Tamai H, Wada H, Nabetani M, Nishihara M. Low-dose vasopressin infusion therapy for refractory hypotension in ELBW infants. Pediatr Int 2010;52:368-73