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Factors associated with treatment for hypotension in extremely low gestational age newborns during the first
Matthew Laughon1, Carl Bose, Elizabeth Allred
1School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA. matt_laughon@med.unc.edu
Insights
Treatment decisions for extremely premature infants
Area of Science:
- Neonatology
- Pediatric Critical Care
- Perinatal Medicine
Background:
- Extremely low gestational age newborns (ELGANs) often experience hypotension.
- Management of hypotension in ELGANs lacks standardized treatment thresholds.
- Interinstitutional variability exists in the treatment of hypotension in ELGANs.
Purpose of the Study:
- Identify blood pressure thresholds for intervention in ELGANs.
- Determine infant characteristics associated with hypotension treatment.
- Assess variability in hypotension treatment practices across institutions.
Main Methods:
- Retrospective cohort study of 1507 ELGANs (23-27 weeks gestation) at 14 institutions.
- Blood pressures monitored clinically; interventions categorized as any treatment or vasopressor treatment.
- Logistic regression analyses used to identify factors associated with treatment.
Main Results:
- Hypotension treatment varied significantly between institutions, independent of infant factors.
- Lower gestational age, lower birth weight, male gender, and higher illness severity scores were associated with increased treatment.
- Treatment initiation predominantly occurred within the first 24 hours of life.
Conclusions:
- Blood pressure in untreated ELGANs increases with gestational and postnatal age.
- Treatment decisions for hypotension in ELGANs are strongly influenced by the care institution, not solely by infant characteristics.
Objective:
The goals were to identify the blood pressures of extremely low gestational age newborns that prompt intervention, to identify other infant characteristics associated with receipt of therapies intended to increase blood pressure, and to assess the interinstitutional variability in the use of these therapies.
Methods:
The cohort included 1507 extremely low gestational age newborns born at 23 weeks to 27 weeks of gestation, at 14 institutions, between March 2002 and August 2004; 1387 survived the first postnatal week. Blood pressures were measured as clinically indicated. Interventions were grouped as any treatment (ie, vasopressor and/or fluid boluses of >10 mL/kg) and vasopressor treatment, and logistic regression analyses were performed.
Results:
At each gestational age, the lowest mean arterial pressures in treated and untreated infants tended to increase with advancing postnatal age. Infants who received any therapy tended to have lower mean arterial pressures than infants who did not, but uniform thresholds for treatment were not apparent. The proportion of infants receiving any treatment decreased with increasing gestational age from 93% at 23 weeks to 73% at 27 weeks. Treatment nearly always began during the first 24 hours of life. Lower gestational age, lower birth weight, male gender, and higher Score for Neonatal Acute Physiology-II values were associated with any treatment and vasopressor treatment. Institutions varied greatly in their tendency to offer any treatment and vasopressor treatment. Neither the lowest mean arterial pressure on the day of treatment nor other characteristics of the infants accounted for center differences in treatment.
Conclusions:
Blood pressure in extremely premature infants not treated for hypotension increased directly with both increasing gestational age and postnatal age. The decision to provide treatment was associated more strongly with the center where care was provided than with infant attributes.
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