Hemodynamic Instability in Critically Ill Neonate

Alifah Anggraini
Outline
• Introduction
• How to diagnose circulatory failure?
• Fluid dynamics and blood pressure
• Characterizing the etiology of hemodynamic instability
• Summary
 Introduction
• Severe cardiovascular compromise in the neonatal period is
associated with increased morbidity and mortality.
• Recognition of shock in its early, compensated phase along with
identification of the underlying pathophysiology is of paramount
importance in reversing shock before its progression to
uncompensated cardiovascular failure when the obvious clinical
manifestations of shock become apparent.
• Many attempts to define neonatal hypotension and develop criteria
for initiating interventions using various approaches and vasoactive
medications, these and other related questions remain mostly
unanswered.
Seminars in Fetal & Neonatal Medicine 20 (2015) 246e254
 Introduction

• Hemodynamic management of critically ill neonates requires

knowledge of developmental physiology, hemodynamics, and
pharmacokinetics and pharmacodynamics of the cardiovascular
medications.
• The neonatal circulation functionally distinguishes itself from the
pediatric and adult circulation in many ways as the newborn
population is a rather heterogeneous group with a wide range in
gestational and postnatal ages, all with different levels of maturation
of the cardiovascular system.

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Front. Pediatr. 6:87.

doi: 10.3389/fped.2018.00087
DA
How to diagnose circulatory failure?
Serum
Urine
lactate?
output?
Blood gas
Capillary analysis?
refill time?

Blood
Pallor/ Pressure ?
acrocyanosis?

Mean
SpO2 ? arterial
pressure?

Heart
Rate ?

Early Human Development 86 (2010) 137–141

 How to diagnose circulatory failure?
*A survey questionnaire, sent to all directors of Dutch neonatal intensive care units.

Serum
Urine
lactate?
output?
Blood gas
Capillary analysis?
refill time?

Blood
Pallor/ Pressure ?
acrocyanosis?

Mean
SpO2 ? arterial
pressure?

Heart
Rate ? Cardiac output
measurement?
SemmSSmSmmmmmmmmmmmmmmmmmmmmmmmmmm
How to diagnose circulatory failure?

Traditional teaching
focuses on maintaining
mean blood pressure over
a set value, most
commonly the gestational
age (GA) in weeks, using
boluses of fluid and the
catecholamine receptor
agonists dopamine and
dobutamine.

SEMINARSINPERINATOLOGY40(2016)174–188
How to diagnose circulatory failure?

SEMINARSINPERINATOLOGY40(2016)174–188
How to diagnose circulatory failure?

The disappointing
predictive values
of individual
clinical markers
mean that only a
small portion of
newborns with
low systemic
blood flow will
be identified,
while a large
percentage will
falsely be
classified as low
cardiac output.

Early Human Development 86 (2010) 137–141

 Fluid dynamics and blood pressure
Ohm’s law of electricity and fluid dynamics

When applied to cardiovascular physiology:

Mean blood pressure – Right atrial pressure = Cardiac output (CO) x Systemic vascular resistance (SVR)

SemmSSmSmmmmmmmmmmmmmSmm major determinant of oxygen delivery

Pediatrics and Neonatology 62 (2021) S22eS29

Pediatrics and Neonatology 62 (2021) S22eS29
Front. Pediatr. 6:87.

doi: 10.3389/fped.2018.00087
Front. Pediatr. 6:87.

doi: 10.3389/fped.2018.00087
Characterizing the etiology of hemodynamic instability

• MAP is the most common parameter used to define hemodynamic

instability clinically.
• The individual components of systolic (SAP) and diastolic (DAP) arterial
pressure may provide valuable insight into underlying pathophysiology, but
are rarely considered in routine clinical practice.
• SAP is reflective of the contractile force and output of the left ventricle and
a low value reflects diminished stroke volume (SV). It is determined by 3
factors: left ventricular (LV) preload, contractility and afterload.
• DAP, in contrast, is reflective of the resting pressure of blood against the
vessel walls and is predominantly related to systemic vascular resistance
and volume status.

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Hemodynamic instability in the preterm infant

Hemodynamically
significant - Patent ductus arteriosus (hsPDA)

After ligation of a hemodynamically significant

PDA

Sepsis and necrotizing enterocolitis (NEC)

SEMINARSINPERINATOLOGY40(2016)174–188
SEMINARSINPERINATOLOGY40(2016)174–188
Hemodynamic instability in the term infant

SemmSSmSmmmmmmmmmmmmmSmmmmmmm

Persistent pulmonary
hypertension (PPHN)

Infants of diabetic mothers

SEMINARSINPERINATOLOGY40(2016)174–188
SEMINARSINPERINATOLOGY40(2016)174–188
SEMINARSINPERINATOLOGY40(2016)174–188
Summary
• The clinical assessment of cardiac output by the interpretation of indirect
parameters of systemic blood flow is inaccurate, irrespective of the level of
experience of the clinician.
• Since systemic blood pressure, one of the inaccurate markers of tissue
malperfusion, is generally used to guide cardiovascular therapy, many neonates
might be under- and overtreated at the risk of iatrogenic injury.
• Point-of-care echocardiography and other monitoring technologies such as near-
infrared spectroscopy can provide valuable information to guide the management
of cardiovascular insufficiency.
• Many of the medications used in adult and paediatric intensive care settings may
be used in the neonate; however, the unique characteristics of neonatal
physiology including differences in myocardial architecture, cellular receptors, the
presence of shunts and differences in disease pathology make direct
extrapolation inaccurate.
Thank you