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Permissive Hypotension
Dempsey EM, Al Hazzani F, and Barrington KJ. Permissive hypotension in the extremely low birthweight infant with signs of good perfusion. Archives of Disease in Childhood - Fetal and Neonatal Edition 2009;94:F241-F244. Full Text | Full Text (PDF)
Introduction: Many practitioners routinely treat infants whose mean arterial blood pressure in mm Hg is less than their gestational age in weeks (GA).
Objective: To assess the effectiveness of utilising a combined approach of clinical signs, metabolic acidosis and absolute blood pressure (BP) values when deciding to treat hypotension in the extremely low birthweight (ELBW) infant.
Methods: Retrospective cohort study of all live born ELBW infants admitted to our neonatal intensive care unit over a 4-year period. Patients were grouped as either normotensive (BP never less than GA), hypotensive and not treated (BP<GA but signs of good perfusion; we termed this permissive hypotension) and hypotensive treated (BP<GA with signs of poor perfusion).
Results: 118 patients were admitted during this period. Blood pressure data were available on 108 patients. 53% of patients were hypotensive (mean BP in mm Hg less than GA in weeks). Treated patients had lower birth weight and GA, and significantly lower blood pressure at 6, 12, 18 and 24 h. Normotensive patients and patients designated as having permissive hypotension had similar outcomes. Mean blood pressure in the permissive group increased from 26 mm Hg at 6 h to 31 mm Hg at 24 h. In a logistic regression model, treated hypotension is independently associated with mortality, odds ratio 8.0 (95% CI 2.3 to 28, p<0.001).
Conclusions: Blood pressure spontaneously improves in ELBW infants during the first 24 h. Infants hypotensive on GA criteria but with clinical evidence of good perfusion had as good an outcome as normotensive patients. Treated low blood pressure was associated with adverse outcome
Comments: It is noted that Mean Blood Pressure (MBP) increases with time in ELBW infants, and it is recommended not to start pressers immediately. If the baby is doing well and peripheral perfusion is good, I think it is advisable to wait in the first 24 hrs. JMK
Date: 08 Aug 2009
Time: 09:58:39
If the neonate has good perfusion(Good Oxygenation,and capillary refill < 3
secs)there is no need to treat a particular Blood Pressure No. For Decades
Neonatologists have used MBP. Physiologically the Systolic Pressure is the
determining factor for organ perfusion, I always use that for the need for fluid
boluses or pressors in addition to Clinical signs of decreased perfusion.
UserName: Ravi Agarwal
Institution: Fort Walton Beach Medical Center
telephone: 8504960855
email: neodoc1@yahoo.com
Date: 08 Sep 2009
Time: 21:52:45
JWK and RA's comments are both well taken. That being said, the truth is (and I believe K Barrington would state this) we don't know what BP a prem should have, how to really assess perfusion, and when (or whether) to treat with inotropes. A large void remains in our knowledge on this subject. A good prospective study is needed.
UserName: Gregory Moore
Institution: Children's Hospital of Eastern Ontario, Ottawa, Canada
telephone: 0011 1 613 737 8909
email:
gmoore@cheo.on.ca
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