Diagnostic criteria and therapeutic interventions for the hypotensive very low birth weight infant

Introduction: The diagnosis and management of hypotension in the very low birth weight (VLBW) is a controversial area. Objective: To establish if there is any consensus in the diagnostic criteria and therapeutic interventions in the hypotensive VLBW among neonatologists in Canada. Methods: A postal questionnaire was sent to neonatologists in all level II and III neonatal intensive care units throughout Canada. Results: In total, 120 questionnaires were sent. Ninety-five completed questionnaires were returned. Seventy-six percent of respondents work in units where at least 50 VLBWs and 43% where at least 100 VLBWs are cared for annually. Fifty-seven percent of the respondents have at least 10 years experience as practicing neonatologists. 25.8% rely on blood pressure values alone when intervening, the most common being a blood pressure less than gestational age in weeks. Ninety-seven percent of respondents commence therapy with a fluid bolus. Normal saline is the predominant volume administered (95%). Dopamine remains the pressor of choice. Great variation exists in starting doses and total amount administered. Similar variation exists with epinephrine, with tenfold differences in starting doses (0.01-0.1 mcg/kg/min) and tenfold differences in maximum dose (0.4-4 mc/kg/min) administered. Steroid doses used ranged from 0.1 mg/kg/dose of hydrocortisone to 5 mg/kg/dose. Bicarbonate is rarely used. Three predominant therapeutic regimes exist. These include (i) volume followed by dopamine then a steroid (32%), (ii) volume, dopamine, dobutamine (29%), (iii) volume, dopamine, epinephrine (22%). Conclusion: This is the first large study of practices among neonatologists addressing hypotension in the VLBW infant. There is wide variation in practice, which is a reflection of the lack of good evidence currently available for this very common problem.