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Inotropes in Preterm Infants
Randomized Trial of Dopamine versus Dobutamine in Preterm Infants with Low Systemic Blood Flow. Osborn D, Evans N, and Klockow M. J Pediatr (Feb 2002) 140:183-91.
Forty-two preterm infants with low superior vena cava (SVC) flow on the first day of life by echocardiography were randomized to receive 10 ml/kg of normal saline IV, followed by 10 mcg/kg/min of either dobutamine or dopamine. If low SVC flow persisted or recurred, the inotrope was increased to 20 mcg/kg/min, with crossover to the other inotrope if treatment failed to maintain flow.
Results. Volume produced a more significant increase in SVC flow than dopamine (+43%). At the highest dose, dobutamine resulted in a significantly greater increase in SVC flow than dopamine (+9.9 vs –3.2 ml/kg/min, p = 0.02). Dopamine resulted in a significantly greater increase in blood pressure. Infants receiving dobutamine only at 24 hours had a greater right ventricular output than infants receiving dopamine (295 vs 167 ml/kg/min, p < 0.001). Forty percent of infants failed to increase or maintain SVC flow in response to either inotrope. No significant differences in mortality or morbidity were found.
Comment. This study used an echocardiographic measurement of SVC flow to investigate the relative effects of dopamine and dobutamine on cerebral blood flow. Low SVC flow has been previously shown to be associated with large patent ductus arteriosus, intraventricular hemorrhage and high systemic vascular resistance. We tend to use inotropes in preterm babies to treat hypotension, and judge the response to therapy in terms of blood pressure rise. While not easily measured, it may be more appropriate select inotropes that improve cardiac output and organ (especially brain) blood flow. This study suggests that dobutamine is superior to dopamine in this regard. For premature infants whose hypotension or hypoperfusion fail to improve with either of these medicines, remember to give hydrocortisone a try. See NeoNotes Vol. 2, Issue 6, 2001 (2-021) for a discussion of using hydrocortisone for hypotension in premature infants.
Date: 08 Apr 2002
Time: 14:35:13
We like to send many thanks to the study group for publishing this interesting article. We
use a dobutamine-strategy for circulatory support of ELWB-infants in our clinic since two
years. (dobutamine up to 20 µg/kg/min followed by dopamine and
hydrocortisone, if hypotension persists.). In more than 75% of all treated infants
dobutamine was the only drug to achieve normal blood pressure, and cardiac output >
250ml/kg/min. A simple, but important detail of this strategy is the possibility to
administer dobutamine using a peripheral venous access. The "time-factor" or
"stress-factor" of placing an x-ray documented central line should be regarded.
UserName: Dr.Christian Wieg
Institution: Neonatology, Klinikum Aschaffenburg
telephone: *496021323691
email: christian.wieg@klinikum-aschaffenburg.de
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