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Adrenaline for prevention of morbidity and mortality in preterm infants with cardiovascular compromise
1RPA Newborn Care, Royal Prince Alfred Hospital, Missenden Rd, Camperdown, Sydney, Australia.
Insights
Limited data exist on adrenaline use in preterm infants with cardiovascular compromise. More research is needed to determine if adrenaline effectively reduces mortality and morbidity in these vulnerable newborns.
Area of Science:
- Neonatal Medicine
- Pediatric Cardiology
- Clinical Pharmacology
Background:
- Cardiovascular compromise is common in preterm infants, often due to circulatory adaptation issues, perinatal asphyxia, or sepsis.
- Hypotension and poor organ perfusion in preterm infants are linked to brain injury and adverse neurodevelopmental outcomes.
- Adrenaline (epinephrine) infusions are utilized for clinical cardiovascular compromise in preterm neonates.
Purpose of the Study:
- To evaluate the effectiveness and safety of adrenaline compared to no treatment or other inotropes.
- To assess adrenaline's impact on mortality and morbidity in preterm infants with cardiovascular compromise.
Main Methods:
- Systematic review of randomized controlled trials (RCTs) identified through MEDLINE, CENTRAL, and EMBASE databases.
- Inclusion criteria: RCTs involving preterm infants comparing adrenaline to no treatment or other inotropes (dopamine, dobutamine, noradrenaline, isoprenaline).
- Data extraction and analysis by two independent reviewers, assessing mortality, neurodevelopmental outcomes, brain injury, hemodynamics, and adverse effects.
Main Results:
- Only one ongoing study and one abstract-only study comparing adrenaline to dopamine were identified.
- The included study showed both adrenaline and dopamine increased heart rate and mean blood pressure but had no significant effect on ventricular outputs.
- No other clinical outcomes were reported, and no studies compared adrenaline to placebo or no treatment.
Conclusions:
- Insufficient data exist to recommend adrenaline infusions for preterm infants with cardiovascular compromise.
- Larger clinical trials are necessary to ascertain the efficacy of adrenaline in reducing morbidity and mortality in this population.
Background:
Inotropes are widely used in preterm infants to treat cardiovascular compromise, which may result from early adaptive problems of the transitional circulation, perinatal asphyxia or sepsis. Sustained hypotension and poor organ blood flow are associated with brain injury including peri/intraventricular haemorrhage and subsequent poor neurodevelopmental outcomes. Adrenaline (epinephrine) infusions are used in preterm infants with clinical cardiovascular compromise.
Objectives:
To determine the effectiveness and safety of adrenaline compared to no treatment or other inotropes in reducing mortality and morbidity in preterm infants with cardiovascular compromise.
Search Strategy:
Randomised controlled trials were identified by searching MEDLINE (1966-August 2003), The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2003) and EMBASE (1980 - 2003), supplemented with searches of reference lists of published trials and abstracts of conference proceedings.
Selection Criteria:
Randomised controlled trials of preterm newborn infants that compared adrenaline to no treatment or other inotropic agents (including dopamine, dobutamine, noradrenaline or isoprenaline).
Data Collection And Analysis:
Data were extracted and analysed independently by two reviewers. Treatment effects on the following outcomes were to be determined: mortality in the newborn period, long term neurodevelopmental outcomes, radiological evidence of brain injury, short term haemodynamic changes, adverse drug effects and short term neonatal outcomes. Study authors were contacted for additional information. Studies were analysed for methodological quality using the criteria of the Cochrane Neonatal Review Group.
Main Results:
One ongoing study (Pellicer 2003) was identified. One study comparing adrenaline with dopamine infusion was included but was published in abstract form only (Phillipos 1996). It enrolled hypotensive, predominantly preterm infants in the first 24 hours. Only infants >1750g are included in this review (report for infants <=1750g appears incomplete). The study was reported as being randomised and double blinded, but methods were not reported. Both adrenaline and dopamine significantly increased heart rate and mean BP, with no statistically significant effect on left or right ventricular outputs. No other clinical outcomes were reported. No studies were identified that compared adrenaline to other inotropes, placebo or no treatment.
Reviewer'S Conclusions:
There are insufficient data on the use of adrenaline infusions in preterm infants with cardiovascular compromise to make recommendations for practice. There is a need for larger trials to determine whether adrenaline is effective in reducing morbidity and mortality in preterm infants with cardiovascular compromise.
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