Early vasopressin infusion improves oxygenation in infants with congenital diaphragmatic hernia

Abstract

ObjectiveCongenital Diaphragmatic Hernia (CDH) is a complex disease including a diaphragmatic defect, lung hypoplasia, and pulmonary hypertension. Despite its increasing use in neonates, the literature on the use of vasopressin in neonates is limited. The aim of this work is to analyze the changes in clinical and hemodynamic variables in a cohort of CDH infants treated with vasopressin.MethodsAmong CDH infants managed at the Neonatal Intensive Care Unit (NICU) of our hospital from May 2014 to January 2019, all infants who were treated with vasopressin, because of systemic hypotension and pulmonary hypertension, were enrolled in this retrospective study. The primary outcome was the change in oxygenation index (OI) after the start of the infusion of vasopressin. The secondary outcomes were the changes in cerebral and splanchnic fractional tissue oxygen extraction (FTOEc and FTOEs) at near-infrared spectroscopy, to understand the balance between oxygen supply and tissue oxygen consumption after the start of vasopressin infusion. We also reported as secondary outcomes the changes in ratio of arterial oxygen partial pressure (PaO2) to fraction of inspired oxygen (FiO2), heart rate, mean arterial pressure, serum pH, and serum sodium.ResultsWe included 27 patients with isolated CDH who received vasopressin administration. OI dramatically dropped when vasopressin infusion started, with a significant reduction according to ANOVA for repeated measures (p = 0.003). A global significant improvement in FTOEc and FTOEs was detected (p = 0.009 and p = 0.004, respectively) as a significant reduction in heart rate (p = 0.019). A global significant improvement in PaO2/FiO2 ratio was observed (p < 0.001) and also at all time points: at 6 h since infusion (p = 0.015), 12 h (p = 0.009), and 24 h (p = 0.006), respectively. A significant reduction in sodium levels was observed as expected side effect (p = 0.012). No significant changes were observed in the remaining outcomes.ConclusionOur data suggest that starting early vasopressin infusion in CDH infants with pulmonary hypertension could improve oxygenation index and near-infrared spectroscopy after 12 and 24 h of infusion. These pilot data represent a background for planning future larger randomized trials to evaluate the efficacy and safety of vasopressin for the CDH population.

An Update on Pharmacologic Management of Neonatal Hypotension: When, Why, and Which Medication

“…More recent clinical studies confirmed the efficacy of AVP as a rescue treatment in neonates with PPHN and catecholamine refractory hypotension [79,85,[164][165][166][167][168]. Common findings of these studies were the increase in AP and improvement in oxygenation and requirements for inotropes following the addition of AVP to the treatment regime.…”

“…Common findings of these studies were the increase in AP and improvement in oxygenation and requirements for inotropes following the addition of AVP to the treatment regime. Additional findings included reduction in lactic acidosis [79], avoidance of extracorporeal membrane oxygenation in 50% of the patients [164], and improved NIRS findings [167].…”

Hemodynamic management of congenital diaphragmatic hernia: the role of targeted neonatal echocardiography

“…71 Capolupo et al reported a cohort of 27 patients with isolated CDH and found that early initiation of vasopressin improved OI and near-infrared spectroscopy after 12 and 24 hours of infusion. 72 Norepinephrine has been employed to improve the SVR/PVR ratio and oxygenation in infants with severe PHT. 73 Research conducted by Tourneux et al, encompassing a group of 18 neonates with severe PHT, demonstrated an increase in systemic pressure and LVO, alongside a 20% rise in mean left pulmonary artery blood flow velocity.…”