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Hypotension in small preterms: what does it mean?
Manuel R G Carrapato1,2, Teresa Andrade1, Teresa Caldeira1
1São Sebastião Hospital , Santa Maria Feira , Portugal.
Insights
Hypotension in preterm infants is complex. Many extremely premature babies with low blood pressure show no signs of poor organ function, suggesting a need for less aggressive, individualized treatment protocols.
Area of Science:
- Neonatalogy
- Pediatric Cardiology
- Perinatal Medicine
Background:
- Preterm infants, particularly those with extremely low gestational age (ELGA) and extremely low birth weight (ELBW), frequently exhibit low blood pressure readings in early neonatal life.
- The definition of hypotension and the optimal management strategy, balancing aggressive intervention against potential medication side effects and the risks of undertreatment, remain debated.
- Current clinical decisions regarding hypotension management in neonates often rely on individual judgment rather than standardized evidence-based protocols.
Purpose of the Study:
- To investigate the prevalence of hypotension and its clinical significance in extremely preterm infants.
- To evaluate current management practices for hypotension in this vulnerable population.
- To propose a refined approach to managing hypotension in preterm neonates, emphasizing individualized care and permissive strategies.
Main Methods:
- Retrospective analysis of clinical data from live preterm infants born between 23 0/7 and 31 6/7 weeks gestational age.
- Data were collected from two distinct periods (2000-2004 and 2008-2012) to assess changes or consistencies in management.
- Assessment included mean arterial pressure (MAP) readings, clinical signs of impaired perfusion, and organ-specific assessments (e.g., cerebral Doppler, cardiac output).
Main Results:
- Nearly half of ELGA/ELBW neonates did not present with low MAP or clinical indicators of hypoperfusion, despite initial low blood pressure readings.
- Treatment decisions for hypotension were often individualized, lacking consistent application of evidence-based guidelines.
- Variability in treatment approaches was observed between the two study periods.
Conclusions:
- A significant proportion of preterm infants with low blood pressure readings may not require aggressive intervention, especially in the absence of clinical signs of hypoperfusion.
- Management of persistent hypotension should consider the overall clinical picture, including evidence of organ dysfunction, and utilize least aggressive measures within flexible protocols.
- The concept of 'permissive hypotension' is supported for transient episodes without signs of hypoperfusion, normal cardiac output, and normal cerebral blood flow, warranting further investigation into the long-term outcomes of treated versus untreated hypotension.
Abstract:
Introduction: Small preterms often have low blood pressure readings in the first few days of life. However, what is hypotension in preterms? Should there be an aggressive approach to its management? What are the immediate and long-term side effects of powerful medications? Alternatively, could a low blood pressure be accepted instead? Materials and methods: Data were collected from files of all live babies with gestational age (GA) between 230/7 and 316/7 weeks over two different periods: years 2000-2004 and 2008-2012. Results: Our data show that, despite extremely low gestational age (ELGA)/extremely low birth weight (ELBW) neonates, almost half of these tiny babies have neither low mean arterial pressure (MAP) readings nor clinical signs of impaired perfusion. Yet, many of them are, variously treated or not, depending on individual decisions, rather than on sound evidence. Discussion: We suggest, should it be required to treat persistent hypotension, rather than treating just a low MAP recording, to address the whole issue of hypotension in the overall picture of clinical settings; we to assess organ dysfunction caused by low output and use the least aggressive measures, preferably within written protocols, tailored to the given unit, but equally, sufficiently flexible to individual babies. Furthermore, allow for "permissive hypotension" especially if transient, in the absence of clinical signs of hypoperfusion, with normal superior vena cava (SVC) flow, normal cardiac output, and normal brain scanning with normal cerebral Doppler flows. Whether treating hypotension, by whichever definition, "per se", will make any difference to both, immediate and late outcomes; in the end, treating remains open to questioning and calls for careful follow-up of these very susceptible preterms.
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