From the Guidelines
Management of refractory neonatal shock requires a systematic approach starting with immediate fluid resuscitation using crystalloids (10-20 ml/kg boluses) while monitoring for fluid overload, as recommended by the American College of Critical Care Medicine 1.
Initial Resuscitation
The initial steps in managing refractory neonatal shock include maintaining airway and establishing access according to NRP guidelines, recognizing decreased perfusion, cyanosis, and RDS, and administering push boluses of 10 cc/kg isotonic saline or colloid up to 60 cc/kg until perfusion improves, unless hepatomegaly develops 1.
- Correcting hypoglycemia and hypocalcemia
- Beginning prostaglandin until ductal-dependent lesion is ruled out
- Initiating antibiotics
Vasopressor Therapy
If shock persists after adequate fluid resuscitation, vasopressors should be initiated, with dopamine being the first-line agent starting at 5 mcg/kg/min and titrating up to 20 mcg/kg/min as needed, as suggested by the clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock 1.
- For continued hypotension, epinephrine (0.05-1 mcg/kg/min) or norepinephrine (0.05-0.5 mcg/kg/min) should be added
- Hydrocortisone (1-2 mg/kg every 6 hours) is indicated for suspected adrenal insufficiency or catecholamine-resistant shock
Additional Therapies
Echocardiography is essential to assess cardiac function and guide therapy, and for cardiogenic shock, milrinone (0.25-0.75 mcg/kg/min) may improve cardiac output 1.
- Empiric antibiotics (ampicillin and gentamicin) should be administered if septic shock is suspected
- Maintaining adequate glucose levels (60-100 mg/dL), correcting electrolyte abnormalities, and ensuring appropriate ventilation and oxygenation are crucial supportive measures
- Extracorporeal membrane oxygenation (ECMO) may be considered in severe cases unresponsive to maximal medical therapy, as recommended by the American College of Critical Care Medicine 1.
Special Considerations
In very low birth weight (VLBW) newborns, pentoxifylline may be considered for its vasodilatory and anti-inflammatory effects, as suggested by a single-center randomized control trial 1.
- The persistence of the patent ductus arteriosus in VLBW infants should be addressed medically with indomethacin or surgically with ligation
- Rapid administration of fluid should be avoided to prevent pulmonary edema due to left-to-right shunting through the ductus.
From the Research
Management of Refractory Neonatal Shock
- The management of refractory neonatal shock is a complex clinical challenge, and there is limited evidence to guide treatment decisions 2.
- Traditionally, neonatal shock is equated to hypotension, and therapeutics are often initiated based on low blood pressure values alone, which may not address the underlying goal of optimizing tissue perfusion 2.
- The choice of vasoactive drugs in neonatal septic shock is empirical, and dopamine is the conventional first-line vasoactive drug, but epinephrine has been shown to be comparable in efficacy and safety 3.
- A study comparing dopamine and epinephrine in pediatric fluid-refractory hypotensive septic shock found that epinephrine was more effective in achieving resolution of shock within the first hour of resuscitation and improving organ functions 4.
- In neonates with refractory septic shock, noradrenaline has been shown to be effective in increasing systemic blood pressure and improving cardiac function and tissue perfusion 5.
Vasoactive Drugs
- Dopamine and dobutamine are the most common initial inotropes used in neonatal shock, but newer inodilators such as milrinone and levosimendan may be useful in selected settings 6.
- Epinephrine has been shown to be comparable to dopamine in the management of neonatal septic shock, and may be associated with better outcomes in neonates with lower gestational age 3.
Diagnostic Modalities
- Point-of-care cardiac ultrasound and near-infrared spectroscopy may be useful in the management of neonatal shock, but their use is not yet widely established and more research is needed to determine their effectiveness 6, 2.
- The use of these diagnostic modalities has not been proven to be associated with improved critical clinical outcomes such as mortality and major brain injury 2.