Neonatal Hypotension & Shock
Lange’s 5th Edition
Neonatology: Management,
Procedures, On-Call Problems,
Diseases, and Drugs 2004
Are shock and hypotension the
same thing? Why or Why not?
Are shock and hypotension the
same thing? Why or Why not?




Shock is decreased end organ
perfusion
Shock presents before
hypotension
Blood Pressure
Hypotension represents
uncompensated shock
Hypotension is >2SD below
normal for age


1000-1250g SBP49-61

1251-1500g SBP 46-61

1501-1750 SBP 46-58

1751-2000 SBP-48-61


For infants <30 weeks
gestation mean BP should
be at least the gestational
age
i.e. 29 week GA=MAP 29
Make sure cuff size
correct (2/3 of upper arm)

Cuff too small=BP

Cuff too large=BP
*But……. Do you have a BP cuff?

What are the signs of shock in
a neonate??

Tachycardia

Poor perfusion

Cold extremities with a
normal core temperature

Lethargy

Apnea & Bradycardia

Tachypnea

Metabolic acidosis

Weak pulses


Urine Output
What is normal?


Normal ~12cc/kg/hour
What can make
urine output
normal or even
high even when
an infant is in
shock???

Is there a history
of Birth Asphyxia?

Birth asphyxia
may be
associated with
hypotension
At delivery was there:
• Maternal bleeding
– Abrupto placenta
– Placenta previa
• Excessively delayed cord clamping
Name the Types of Shock in
Neonates
•
•
•
•
•
A
B
C
D
E
• F
• G
Types of Shock in a
Neonate
• A. Hypovolemic
• B. Septic Shock
• C. Cardiogenic
Shock
• D. Neurogenic
• E. Drug-induced
• F. Endocrine
• G. Extreme
prematurity
• 3 kg infant presents from outside with
extreme pallor, bleeding from umbilical
cord and is cold with a HR of 200
• What type of shock
• Work-up??
• Treatment??
Hypovolemic
• Antepartum blood loss (often associated
w/asphyxia)
–
–
–
–
Abruptio placentae
Placenta previa
Twin-twin transfusion
Fetomaternal hemorrhage
• Postpartum blood loss
–
–
–
–
Coagulation disorders
Vitamin K deficiency
Iatrogenic causes (loss of catheter
Birth trauma (liver injury, adrenal
hemorrhage, ICH, intraperitoneal hemorrhage
• 1 week old 4 kg infant born to a mother
with diabetes. Difficulty with IV
therefore UVC placed
• Doing better til this morning when noted
to have a systolic BP of 40, HR of 170,
temperature of 34°C
• Type of shock
• Work-up
• Treatment
Septic Shock
• Endotoxemia with release of vasodilator
substances
• Gram-negative often cause but can occur
with gram-positive
• Infant required bag-mask ventilation at
birth presents to nursery noted to be
cyanotic, in respiratory distress, cold,
clammy without breath sounds of the right
• Type of shock
• Work-up
• Treatment
Cardiogenic Shock
• 1. Birth asphyxia
• 2. Metabolic problems (eg hypoglycemia,
hyponatremia, hypocalcemia, acidemia) can
decrease cardiac output
• 3. Congenital heart disease (such as
hypoplastic left heart or aortic stenosis)
• 4. Arrythmias
• 5. Any obstruction of venous return
(tension pneumothorax)
• Term baby with Apgars of 3 at 3 minutes
and 5 at5 minutes noted to have poor
perfusion on arrival to nursery
• Type of shock
• Work-up
• Treatment
Neurogenic Shock
• Birth asphyxia
• Intracranial
hemorrhage
• 2.5 kg infant with status epilepticus and
has been loaded with 20mg/kg of
phentobarbital initially then given an
additional 5mg/kg q 5 minutes X5 for
persistent seizures because no other
drugs available to control seizures. After
5th dose noted to be very poorly perfused
• Type of shock
• Work-up
• Treatment
Drug-Induced
•
•
•
•
Sedatives
Magnesium
Digitalis
Barbituates especially if high dose
• Term infant with ambiguous genitalia
present at 3 weeks of age with
hypotension
• Type of shock
• Work-up (initial)
• Treatment
Endocrine Disorders
• Complete 21-hydroxylase deficiency
• Adrenal hemorrhage
• (What electrolyte abnormalities do
you expect in adrenogenital
syndrome??
– A. Low sodium, high potassium
– B. Hi sodium, high potassium
– C. Low sodium, low potassium
• 27 week infant noted to have a mean
arterial blood pressure of 24 on the new
automatic BP machine
• Type of shock
• Work-up
• Treatment
Extreme Prematurity
• Hypotension is very common
– 40% in 27-29 weeks
– 60-100% in 24-26 weeks
– Most likely due to adrenocortical
insufficiency, poor vascular tone, immature
catecholamine responses
– Hypotension in ELBW infants is associated
w/IVH and needs to be corrected
Work UP
• Look for signs of blood loss, sepsis and
clinical signs of shock
• Complete Blood Count
– Decreased hematocrit can occur with bleeding
however remember in acute blood loss maybe
normal
– Increased or decreased WBC or increase in
immature cells may point to sepsis
Work-up continued
• Coagulation studies (if disseminated
intravascular coagulation suspected)
• Serum glucose, electrolytes, and calcium
levels
• Cultures, CRP
• Kleihauer-Betke to rule out fetomaternal
transfusion is suspected
• Arterial blood gases to look for hypoxia and
acidosis
Other studies
• CXR
• Ultra-sound head
• ECG/EKG
Treatment-Determine cause if
possible to guide treatment
•
•
•
•
•
•
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1. Volume expansion
2. Blood replacement
3. Empiric antibiotics
4. Inotropes
5. Steroids
6. Blood
7. Chest aspiration
a.
b.
c.
d.
e.
f.
g.
Hypovolemic
Septic
Cardiogenic
Neurogenic
Drug-induced
Endocrine
ELBW
Match the treatments with the causes