Inotropes for Preterm Infants: 50 Years on Are We Any Wiser?

Abstract

For almost half a century, inotropes have been administered to preterm infants with the ultimate goal of increasing their blood pressure. A number of trials, the majority of which focused on dopamine administration, have demonstrated increased blood pressure following inotrope administration in preterm infants and have led to continued use of inotropes in our neonatal units. We have also seen an increase in the number of potential agents available to the clinician. However, we now know that hypotension is a much broader concept than blood pressure alone, and our aim should instead be focused on improving end organ perfusion, specifically cerebral perfusion. Only a limited number of studies have incorporated the organ-relevant hemodynamic changes and long-term outcomes when assessing inotropic effects in neonates, the majority of which are observational studies or have a small sample size. In addition, important considerations, including the developing/maturing adrenergic receptors, polymorphisms of these receptors, and other differences in the pharmacokinetics and pharmacodynamics of preterm infants, are only recently being recognized. Certainly, there remains huge variation in practice. The lack of well-conducted randomized controlled trials addressing these relevant outcomes, along with the difficulty executing such RCTs, leaves us with more questions than answers. This review provides an overview of the various inotropic agents currently being used in the care of preterm infants, with a particular focus on their organ/cerebral hemodynamic effects both during and after transition.

Evolution of circulating thyroid hormone levels in preterm infants during the first week of life: perinatal influences and impact on neurodevelopment

“…Dopamine is known to suppress the TH function in preterm infants [8]. Besides positive inotropic and vasopressor effects through the stimulation of both αand β-adrenoreceptors [9], it also acts on specific dopamine type 2 receptors in the anterior pituitary, leading to the inhibition of the release of prolactin, growth hormone and TSH [8].…”

Cardiovascular Pharmacological Support Among Preterm Infants in Chinese Referral Center Neonatal Intensive Care Units

“…Our results demonstrated the highest order of magnitude variation, specifically, a 35-fold difference (1.9-65.8%) in drug use among Chinese NICUs. A lack of reliable normative blood pressure data in preterm infants, non-judicious use of cardiovascular pharmacological support, and diagnostic imprecision related to poor access to TnECHO services may contribute to variations in practice (19)(20)(21)(24)(25)(26).…”

Noradrenaline use for neonatal circulatory support

“…5 Other Australian neonatal drug manuals and published international guidelines have similarly recommend NA as an adjunct therapy in treating profound hypotension when other inotropes have failed such as in the setting of sepsis. 2,[11][12][13][14] It is largely unknown what individual factors influence the decision to use NA in neonates. The aim of this retrospective study was to determine the indications, use and effects of NA in neonates requiring circulatory support at the RBWH NICU.…”