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Increasing Mean Arterial Blood Pressure and Heart Rate With Catecholaminergic Drugs Does Not Improve the Microcirculation in Children With Congenital Diaphragmatic Hernia: A Prospective Cohort Study

Buijs, Erik A. B. MSc1; Reiss, Irwin K. M. MD, PhD2; Kraemer, Ulrike MD1; Andrinopoulou, Eleni-Rosalina MSc3; Zwiers, Alexandra J. M. MSc1; Ince, Can PhD4; Tibboel, Dick MD, PhD1

Pediatric Critical Care Medicine: May 2014 - Volume 15 - Issue 4 - p 343–354
doi: 10.1097/PCC.0000000000000105
Neonatal Intensive Care

Objective: To study whether dopamine, norepinephrine, and epinephrine improve not only mean arterial blood pressure and heart rate but also microcirculatory perfusion in children with congenital diaphragmatic hernia.

Design: Prospective observational cohort study from November 2009 to July 2012.

Setting: ICU of a level III university children’s hospital.

Patients: Twenty-eight consecutive congenital diaphragmatic hernia newborns of whom seven did not receive any catecholaminergic support and 21 received dopamine as the drug of first choice. Fourteen of the latter also received either norepinephrine or epinephrine in addition to dopamine. Twenty-eight healthy neonates, matched for gestational age, postnatal age, and gender, served as controls.

Interventions: None.

Measurements and Main Results: Data were obtained before and after dopamine start and before and after norepinephrine or epinephrine start in case it was given. For the congenital diaphragmatic hernia without catecholaminergic support, data were obtained at admission days 1 and 2 and for the controls on day 1 of life. The buccal microcirculation was studied using Sidestream Dark Field imaging. Also macrocirculatory, respiratory, and biochemical variables were collected. Mean arterial blood pressure had improved after dopamine start, whereas the microcirculation had not. After the start of either norepinephrine or epinephrine, both blood pressure and heart rate had increased. However, the microcirculation failed to improve again. The microcirculation in the healthy controls was better than that in the congenital diaphragmatic hernia patients with catecholaminergic support. After cutoff values for abnormal microcirculation had been defined, abnormal microcirculation after dopamine start predicted the need for additional catecholaminergic support (area under the curve, 0.74–0.88; sensitivity, 77–77%; specificity, 69–77%). Likewise, microcirculatory impairment was associated with the need for extracorporeal membrane oxygenation.

Conclusions: Catecholaminergic drug support with dopamine, norepinephrine, and/or epinephrine improved macrocirculatory function but did not improve the microcirculation in neonates with congenital diaphragmatic hernia. The microcirculation was not only impaired but it also predicted poor outcome.

1Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands.

2Division of Neonatology and Department of Pediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands.

3Department of Biostatistics, Erasmus MC, Rotterdam, The Netherlands.

4Intensive Care, Erasmus MC, Rotterdam, The Netherlands.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).

Dr. Kraemer received grant support from the Sophia Children's Hospital Foundation. Dr. Ince is the inventor of the Sidestream Dark Field imaging technology and holds shares in MicroVision Medical. He has served as a consultant for this company in the past but has ended all contact for more than 4 years. He has no other competing interests in this field beyond his commitment to promoting the importance of the microcirculation with regard to patient. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Address requests for reprints to: Erik A. B. Buijs, MSc, Intensive Care and Department of Pediatric Surgery, Erasmus MC, Sophia Children’s Hospital, University Medical Center, Room Sk-1324, Dr. Molewaterplein 60, PO Box 2060, 3000 CB, Rotterdam, The Netherlands. E-mail: e.a.b.buijs@erasmusmc.nl

©2014The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies