MANAGEMENT OF NEONATAL HYPOTENSION CLINICAL GUIDELINE 1. Aim/Purpose of this Guideline 1.1. To provide guidance on the assessment and management of infants with hypotension. All involved will benefit from the improvement in service and timing 2. The Guidance 2.1. Background. Very low birth weight (VLBW, wt <1500 gm) preterm babies are at higher risk of hypotension, especially in first 24 hrs. Hypotension in such babies is associated with a higher incidence of intraventricular haemorrhage and poor neuro-developmental outcome. Term infants with hypoic ischemic encephalopathy or sepsis are also at risk of hypotension. 2.2. When to treat? Monitoring of intra-arterial blood pressure through an umbilical or peripheral arterial catheter is widely accepted as the optimum method, oscillometric measurement at the lower levels in particular overestimates the blood pressure. Blood pressure is widely used as a surrogate marker of tissue perfusion. A mean arterial pressure (MAP) equivalent to the gestational age in weeks corresponds to 10 th centile of MAP for that particular gestation, and has generally been the threshold to consider starting treatment. There is growing evidence that blood pressure may not always be a true reflection of systemic tissue perfusion. Hence MAP as a guide to start treatment should be used in contet of other markers of tissue perfusion like metabolic acidosis, lactate, capillary refill time, urinary output, and peripheral temperature. If available, information from an echocardiogram may be a useful adjunct (for eample superior vena cava blood flow or right ventricular output). 2.3. Underlying Causes. If a baby is hypotensive look for underlying causes appropriately. Common causes include: Acute blood loss Pneumothora Heart failure. Drugs including opiates Adrenocortical insufficiency Sepsis High positive intrathoracic pressure in ventilated babies Page 1 of 7
Patent Arterial Duct Hypocalcaemia / hypomagnesaemia 2.4 Adopt step wise approach Step 1: Consider Hypovolaemia Hypovolaemia is an uncommon cause of hypotension in sick preterm newborn but moderate volume epansion has been a common first step before the institution of ionotropes. Saline has been shown to be equally effective as human albumin solution. Use of 4.5% Human Albumen Solution should be reserved for infants with protein losing condition for eample post gastrointestinal surgery. Hypovolaemia is difficult to diagnose and inotropes are less effective in a hypovolaemic infant. Volume Epansion Normal (0.9%) Saline: 10 ml/kg infused over 30 minutes, can be repeated once. If there is evidence of blood loss a blood transfusion should be given. Step 2: Inotropes There is limited evidence for selection of inotropes in hypotensive newborns. Dobutamine is suggested as preferred choice. Second and third line drugs are added as below: In VLBW Preterm babies <24 hrs of age (normal to low Mean Arterial Pressure with high vascular resistance) 1 st : Dobutamine 5-20micrograms/kg/min 2 nd : Dopamine 5-20 micrograms/kg/min 3 rd : Adrenaline (or Noradrenaline) 0.1 to 0.5micrograms/kg/min* (100 to 500 nanograms/kg/min) In Preterm babies >24 hrs and term babies (low Mean Arterial Pressure with vasodilatation) 1 st : Dopamine 5-20 micrograms/kg/min 2 nd : Dobutamine 5-20 micrograms/kg/min 3 rd : Adrenaline(or Noradrenaline) 0.1 to 1.0 microgram/kg/min* (100 nanograms/kg/min to 1 microgram/kg/min) *When using Adrenaline / Noradrenaline consider stopping dopamine Step 3: Steroids Antenatal steroids have been shown to have an independent effect on reducing the incidence of hypotension in preterm infants. The hypothesis is that infants with refractory hypotension may have relative adrenal insufficiency and cause them to be incapable of responding to sympathomimetic drugs. A suggested regime for Hydrocortisone: 2.5 mg/kg IV every 6 hours for 2 days 1.25 mg/kg IV every 6 hours for 2 days 0.625mg/kg IV every 6 hours for 2 days 2.5. Prescribing Information Dopamine (5ml vial containing 40mg/ml) 37.5 mg/kg in 25 ml of 5% detrose; run at 0.2 to 0.8 ml/hr (5-20 mcg/kg/min) Page 2 of 7
Dobutamine (20ml vial containing 12.5mg/ml) 37.5 mg/kg in 25 ml of 5% detrose; run at 0.2 to 0.8 ml/hr (5-20 mcg/kg/min) Adrenaline (1ml ampule of 1 in 1000 containing 1mg/ml.) or Noradrenaline (4ml ampule of 1 in 1000 containing 1mg/ml) 150 mcg/kg in 25 ml normal saline run at 0.1ml/hr for a dose of 0.01 mcg/kg/min 3. Monitoring compliance and effectiveness Element to be monitored Lead Tool Frequency Reporting arrangements Acting on recommendations and Lead(s) Change in practice and lessons to be shared Key changes in practice recommended by guidance Dr Paul Munyard, Consultant Paediatrician Audit Lead Audit To be included in neonatal clinical audit programme Findings reported to the directorate audit meeting / governance meeting As dictated by audit findings Child Health Directorate Audit and Clinical Guidelines meeting Dr Paul Munyard, Consultant Paediatrician Possible wording to use for this column. Required changes to practice will be identified and actioned within 3 months of audit. A lead member of the team will be identified to take each change forward where appropriate. Lessons will be shared with all the relevant stakeholders 4. Equality and Diversity 4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Diversity & Human Rights Policy' or the Equality and Diversity website. 4.2. Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendi 2. Page 3 of 7
Appendi 1. Governance Information Document Title Date Issued/Approved: November 2014 Management of Neonatal Hypotension Clinical Guideline Date Valid From: November 2014 Date Valid To: November 2017 Directorate / Department responsible (author/owner): Paul Munyard, consultant in Paediatrics and Neonatology Contact details: 01872 253293 Brief summary of contents This guideline is designed to ensure the implementation of a standardised approach to the diagnosis of hypotensive infants and their subsequent management Suggested Keywords: Target Audience Eecutive Director responsible for Policy: Neonate. Hypotension. RCHT PCH CFT KCCG Eecutive Director Date revised: November 2014 This document replaces (eact title of previous version): Approval route (names of committees)/consultation: Guideline for Management of Hypotension in Neonates Paediatric Consultants Child Health Audit and Guidelines Meeting Divisional Manager confirming approval processes Sheena Wallace Name and Post Title of additional signatories Signature of Eecutive Director giving approval Publication Location (refer to Policy on Policies Approvals and Ratification): Document Library Folder/Sub Folder Links to key eternal standards Related Documents: Page 4 of 7 Not Required {Original Copy Signed} Internet & Intranet Neonatal None Intranet Only 1. Dasgupta SJ, Gill AB. Hypotension in the very low birth weight infant: the old, the new and the uncertain. Arch Dis Child
Training Need Identified? Fetal Neonatal Ed. 2003; 88:F450-F454 2. Evans N. Which inotropes for which baby? Arch Dis Child Fetal Neonatal Ed 2006; 91: F213-F220 3. Subhedar NV, Shaw NJ. Dopamine versus dobutamine for hypotensive preterm infants. Cochrane database Syst Rev 2004:(2):CD 00205 No Version Control Table Date Versio n No Feb 2007 V1.0 Initial Issue Summary of Changes Nov 2014 V2.0 Review and Reformatted Changes Made by (Name and Job Title) Paul Munyard, consultant Paediatrician and Neonatologist Reviewer: Paul Munyard Consultant Paediatrician and Neonatologist Formatter: Kim Smith. Staff Nurse All or part of this document can be released under the Freedom of Information Act 2000 This document is to be retained for 10 years from the date of epiry. This document is only valid on the day of printing Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the epress permission of the author or their Line Manager. Page 5 of 7
Appendi 2. Initial Equality Impact Assessment Form Name of Strategy: Directorate and service area: Is this a new or eisting Policy? Child Health Directorate. Neonatal Eisting Guideline Name of individual completing Telephone: assessment: Paul Munyard 01872 3293 1. Policy Aim* To provide guidance on the assessment and management of Who is the strategy / neonates with hypotension. policy / proposal / This guideline is aimed at hospital based staff responsible for neonatal service function care aimed at? 2. Policy Objectives* As above 3. Policy intended Outcomes* 4. *How will you measure the outcome? 5. Who is intended to benefit from the policy? 6a) Is consultation required with the workforce, equality groups, local interest groups etc. around this policy? Evidence based and standardised practice Audit Neonatal Medical staff Neonatal Patients No. neonatal guidelines Group consultant approved guideline b) If yes, have these *groups been consulted? C). Please list any groups who have been consulted about this procedure. 7. The Impact Please complete the following table. Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Rationale for Assessment / Eisting Evidence Age Se (male, female, transgender / gender reassignment) Page 6 of 7
Race / Ethnic communities /groups Disability - learning disability, physical disability, sensory impairment and mental health problems Religion / other beliefs Marriage and civil partnership Pregnancy and maternity Seual Orientation, Biseual, Gay, heteroseual, Lesbian You will need to continue to a full Equality Impact Assessment if the following have been highlighted: You have ticked Yes in any column above and No consultation or evidence of there being consultation- this ecludes any policies which have been identified as not requiring consultation. or Major service redesign or development 8. Please indicate if a full equality analysis is recommended. No 9. If you are not recommending a Full Impact assessment please eplain why. No area indicated Signature of policy developer / lead manager / director Paul Munyard Date of completion and submission 12:11: 2014 Names and signatures of members carrying out the Screening Assessment Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead, c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD A summary of the results will be published on the Trust s web site. Signed: Kim Smith Date: 12:11:2014 Page 7 of 7