Thread by @EBNEO

Next up is Dr. Satyan Lakshminrusimha talking on systemic hypotension in PPHN. Satyan is a Professor and Pediatrician-in-Chief at UC Davis Children's Hospital, Department of Pediatrics.
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A brief talk on the definition of hypotension, cardiac output, pre and afterloads.
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"there's nothing like normal blood pressure"
We try to gather as much data as possible before deciding whether or not the infant has hypotension. Blood pressure is just one parameter of many.
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Plenty of studies talking about blood pressure variability in infants in the first hours of life.
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Maintaining systemic blood pressure seems to be vital in PPHN.
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Causes of systemic hypotension in babies with PPHN.
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Further illustration on the mechanism of systemic hypotension, this time mechanical ventilation involved (effect of mean airway pressure.)
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The vicious cycle of PPHN, systemic hypotension, and RV failure. "Keeping the heart happy is a real goal in the management of PPHN."
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Fluid management in PPHN. Dr. L prefers ringer's lactate over saline due to the chloride content of the latter.

Dopamine at high doses can impair end organ perfusion #HotTopicsNeo2019

A (real) case discussion.
Starting Dopamine?
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Dopamine was followed with a transient improvement.
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So why only transient improvement?
Unfortunately, Dopamine is not selective to systemic circulation.

Another explanation, the pop-off valve are now closed.
(Ductal dependent systemic circulation)
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How about Epinephrine and Norepinephrine?

The latter can cause pulmonary vasodilation due to stimulation of alpha-2 receptors. Response to norepi compared to dopamine is generally better in babies with PPHN.

Another case where use of dopamine led to negative effects (Mec aspiration, PPHN, hypertrophied septum). Vasopressin, iNO and fluid management on the other hand resulted in significant improvement.

There are no trials comparing norepinephrine with vasopressin. The effect of the latter on pulmonary circulation appears to be minimal.

High dose Hydrocortisone decreases PDE5 (Similar to Sildenafil's effect)

So how to choose the appropriate anti-hypotensive in the context of PPHN?
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