Etiology, clinical manifestations, evaluation, and management of low blood pressure in extremely preterm infants
- Beau Batton, MD
Beau Batton, MD
- Associate Professor of Pediatrics and Chief of Neonatology
- Southern Illinois School of Medicine
Blood pressure (BP) management in the extremely preterm (EPT) infant (gestational age [GA] <28 weeks) is challenging due to the presence of multiple disease processes, unpredictable adaptation to extrauterine life, and difficulty assessing organ perfusion. Although there are data that suggest EPT infants with low BP (eg, perceived hypotension) are at an increased risk for adverse outcomes, low BP in EPT infants with adequate perfusion may not be an independent risk factor for poor outcome. Because data are insufficient regarding the efficacy and safety for antihypotensive therapy in adequately perfused EPT infants, it remains unclear how best to manage low BP in this group of patients. In contrast, the small minority (approximately 10 to 15 percent) of patients with both low BP and poor perfusion are in shock and require immediate attention to restore adequate perfusion (see "Etiology, clinical manifestations, evaluation, and management of neonatal shock", section on 'Initial stabilization').
The challenges of BP management of EPT infants with good perfusion will be discussed here. The etiology, clinical manifestations, evaluation, and management of neonatal shock are discussed separately. (See "Etiology, clinical manifestations, evaluation, and management of neonatal shock".)
●Extremely preterm (EPT) infant – Infants born <28 weeks gestational age (GA)
●Extremely low birth weight (ELBW) infant – Infants born with BW <1000 g
●Cardiac output (CO) is the volume of blood ejected by the heart each minute. It is the product of heart rate (HR) and stroke volume (SV):To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Dempsey EM, Barrington KJ. Treating hypotension in the preterm infant: when and with what: a critical and systematic review. J Perinatol 2007; 27:469.
- Laughon M, Bose C, Allred E, et al. Factors associated with treatment for hypotension in extremely low gestational age newborns during the first postnatal week. Pediatrics 2007; 119:273.
- Barrington KJ, Janaillac M. Treating hypotension in extremely preterm infants. The pressure is mounting. Arch Dis Child Fetal Neonatal Ed 2016; 101:F188.
- Dempsey EM, Al Hazzani F, Barrington KJ. Permissive hypotension in the extremely low birthweight infant with signs of good perfusion. Arch Dis Child Fetal Neonatal Ed 2009; 94:F241.
- Batton B, Li L, Newman NS, et al. Evolving blood pressure dynamics for extremely preterm infants. J Perinatol 2014; 34:301.
- Vesoulis ZA, El Ters NM, Wallendorf M, Mathur AM. Empirical estimation of the normative blood pressure in infants <28 weeks gestation using a massive data approach. J Perinatol 2016; 36:291.
- Batton B, Batton D, Riggs T. Blood pressure during the first 7 days in premature infants born at postmenstrual age 23 to 25 weeks. Am J Perinatol 2007; 24:107.
- Colan SD, Fujii A, Borow KM, et al. Noninvasive determination of systolic, diastolic and end-systolic blood pressure in neonates, infants and young children: comparison with central aortic pressure measurements. Am J Cardiol 1983; 52:867.
- Sonesson SE, Broberger U. Arterial blood pressure in the very low birthweight neonate. Evaluation of an automatic oscillometric technique. Acta Paediatr Scand 1987; 76:338.
- Baker MD, Maisels MJ, Marks KH. Indirect BP monitoring in the newborn. Evaluation of a new oscillometer and comparison of upper- and lower-limb measurements. Am J Dis Child 1984; 138:775.
- Dannevig I, Dale HC, Liestøl K, Lindemann R. Blood pressure in the neonate: three non-invasive oscillometric pressure monitors compared with invasively measured blood pressure. Acta Paediatr 2005; 94:191.
- Vain NE, Barrington KJ. Feasibility of evaluating treatment of early hypotension in extremely low birth weight infants. J Pediatr 2012; 161:4.
- Shimokaze T, Akaba K, Saito E. Oscillometric and intra-arterial blood pressure in preterm and term infants: extent of discrepancy and factors associated with inaccuracy. Am J Perinatol 2015; 32:277.
- Batton B, Li L, Newman NS, et al. Use of antihypotensive therapies in extremely preterm infants. Pediatrics 2013; 131:e1865.
- Short BL, Van Meurs K, Evans JR, Cardiology Group. Summary proceedings from the cardiology group on cardiovascular instability in preterm infants. Pediatrics 2006; 117:S34.
- Logan JW, O'Shea TM, Allred EN, et al. Early postnatal hypotension and developmental delay at 24 months of age among extremely low gestational age newborns. Arch Dis Child Fetal Neonatal Ed 2011; 96:F321.
- Batton B, Li L, Newman NS, et al. Early blood pressure, antihypotensive therapy and outcomes at 18-22 months' corrected age in extremely preterm infants. Arch Dis Child Fetal Neonatal Ed 2016; 101:F201.
- Development of audit measures and guidelines for good practice in the management of neonatal respiratory distress syndrome. Report of a Joint Working Group of the British Association of Perinatal Medicine and the Research Unit of the Royal College of Physicians. Arch Dis Child 1992; 67:1221.
- Garner RS, Burchfield DJ. Treatment of presumed hypotension in very low birthweight neonates: effects on regional cerebral oxygenation. Arch Dis Child Fetal Neonatal Ed 2013; 98:F117.
- Hall RW, Kronsberg SS, Barton BA, et al. Morphine, hypotension, and adverse outcomes among preterm neonates: who's to blame? Secondary results from the NEOPAIN trial. Pediatrics 2005; 115:1351.
- Ewer AK, Tyler W, Francis A, et al. Excessive volume expansion and neonatal death in preterm infants born at 27-28 weeks gestation. Paediatr Perinat Epidemiol 2003; 17:180.
- Durrmeyer X, Marchand-Martin L, Porcher R, et al. Abstention or intervention for isolated hypotension in the first 3 days of life in extremely preterm infants: association with short-term outcomes in the EPIPAGE 2 cohort study. Arch Dis Child Fetal Neonatal Ed 2017.
- Faust K, Härtel C, Preuß M, et al. Short-term outcome of very-low-birthweight infants with arterial hypotension in the first 24 h of life. Arch Dis Child Fetal Neonatal Ed 2015; 100:F388.
- Al Tawil KI, El Mahdy HS, Al Rifai MT, et al. Risk factors for isolated periventricular leukomalacia. Pediatr Neurol 2012; 46:149.
- Yau GS, Lee JW, Tam VT, et al. Risk factors for retinopathy of prematurity in extremely preterm Chinese infants. Medicine (Baltimore) 2014; 93:e314.
- Catenacci M, Miyagi S, Wickremasinghe AC, et al. Dopamine-resistant hypotension and severe retinopathy of prematurity. J Pediatr 2013; 163:400.
- Wong J, Shah PS, Yoon EW, et al. Inotrope use among extremely preterm infants in Canadian neonatal intensive care units: variation and outcomes. Am J Perinatol 2015; 32:9.
- Gephart SM, Spitzer AR, Effken JA, et al. Discrimination of GutCheck(NEC): a clinical risk index for necrotizing enterocolitis. J Perinatol 2014; 34:468.
- Fanaroff JM, Wilson-Costello DE, Newman NS, et al. Treated hypotension is associated with neonatal morbidity and hearing loss in extremely low birth weight infants. Pediatrics 2006; 117:1131.
- Martens SE, Rijken M, Stoelhorst GM, et al. Is hypotension a major risk factor for neurological morbidity at term age in very preterm infants? Early Hum Dev 2003; 75:79.
- Batton B, Zhu X, Fanaroff J, et al. Blood pressure, anti-hypotensive therapy, and neurodevelopment in extremely preterm infants. J Pediatr 2009; 154:351.
- Alderliesten T, Lemmers PM, van Haastert IC, et al. Hypotension in preterm neonates: low blood pressure alone does not affect neurodevelopmental outcome. J Pediatr 2014; 164:986.
- Cayabyab R, McLean CW, Seri I. Definition of hypotension and assessment of hemodynamics in the preterm neonate. J Perinatol 2009; 29 Suppl 2:S58.
- 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.
- Munro MJ, Walker AM, Barfield CP. Hypotensive extremely low birth weight infants have reduced cerebral blood flow. Pediatrics 2004; 114:1591.
- Fukuda S, Mizuno K, Kakita H, et al. Late circulatory dysfunction and decreased cerebral blood flow volume in infants with periventricular leukomalacia. Brain Dev 2008; 30:589.
- Lightburn MH, Gauss CH, Williams DK, Kaiser JR. Cerebral blood flow velocities in extremely low birth weight infants with hypotension and infants with normal blood pressure. J Pediatr 2009; 154:824.
- Nishimaki S, Iwasaki S, Minamisawa S, et al. Blood flow velocities in the anterior cerebral artery and basilar artery in asphyxiated infants. J Ultrasound Med 2008; 27:955.
- Romagnoli C, Giannantonio C, De Carolis MP, et al. Neonatal color Doppler US study: normal values of cerebral blood flow velocities in preterm infants in the first month of life. Ultrasound Med Biol 2006; 32:321.
- Papacci P, Giannantonio C, Cota F, et al. Neonatal colour Doppler ultrasound study: normal values of abdominal blood flow velocities in the neonate during the first month of life. Pediatr Radiol 2009; 39:328.
- Ilves P, Lintrop M, Talvik I, et al. Developmental changes in cerebral and visceral blood flow velocity in healthy neonates and infants. J Ultrasound Med 2008; 27:199.
- Physiological changes in BP
- BP measurement reliability
- Defining hypotension
- Assessing the impact of anti-hypotensive therapies
- Untreated low BP and outcomes
- Risk for developing shock with low BP and good perfusion
- BP alone not a sufficient measure of perfusion
- ETIOLOGIES OF LOW BLOOD PRESSURE
- MANAGEMENT APPROACH
- Poor perfusion
- Adequate perfusion
- SUMMARY AND RECOMMENDATIONS