CabalunaDR Ppt 2006

8/4/2019 CabalunaDR Ppt 2006

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NEONATAL

HYPERTENSIONMARIFI DE JESUS U. CABALUNA, MD

PL-2

NOVEMBER 28, 2006


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QUESTIONS TO BE

ANSWERED What is the proper way of obtaining

BP in the neonate?

Does the device used in getting the

BP matters?

What is the primary determinant ofBP in both Term and Preterm infants?


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QUESTIONS TO BE

ANSWERED What are the common causes of

Hypertension among the neonates?

Does catheter tip placement play a

role in the incidence of Hypertension

among the neonates?

What are the RED FLAGS in historyand PE that points to neonatal

hypertension?


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QUESTIONS TO BE

ANSWERED What initial laboratory studies are

important?

Who should receive treatment ?

How do we choose a suitable agent?

Are there any medications to avoid?

Long term outcome and prognosis

depend on which factor?


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DEFINITION

Systolic and/or diastolic BP >/= 95%

(> 2 SD above the mean)

Stage 1 : BP at 95 to < 99 %

Stage 2 : BP >/= 99% + 5 mm Hg


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BLOOD PRESSURE

MEASUREMENTNwankwo et al

LBW and PT infants

BP is significantly lower in the prone

than supine position

First reading is significantly higher than

the third reading.


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BLOOD PRESSURE

MEASUREMENTSTANDARDIZED PROTOCOL

Check blood pressure 1.5 hours after

the last feeding or intervention

Apply appropriately sized cuff 2/3 the length of the limb segment

75% of the limb circumference


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BLOOD PRESSURE

MEASUREMENT

Wait 15 minutes or more of stillness

3 successive readings at 2-minute

interval.


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BLOOD PRESSURE

MEASUREMENTIntra-arterial catheters

most accurate technique

placed in aorta or radial artery continuous readings

Oscillometric devices

non-invasive ; continuous measure systolic and mean and calculate

diastolic pressure.


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BLOOD PRESSURE

MEASUREMENTINTRA-ARTERIAL CATHETERS VS.

OSCILLOMETRIC DEVICES

Low et al (study on 31 newborns) Average oscillometric pressures significantly

lower than intra-arterial pressures.

Systolic lower by 1 mm HG Mean pressure lower by 5.3 mm Hg

Diastolic pressure lower by 4.6 mm HG


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BLOOD PRESSURE

MEASUREMENT Leg pressures are higher than arm

pressures

Normal BP increases with gestational

age, post-conceptual age andbirthweight.


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BLOOD PRESSURE

MEASUREMENTZubrow et al (695 PT infant)

D1 Systolic and Diastolic correlate

strongly with BW and GA

First 5 days after birth

Systolic increase by 2.2-2.7 mm Hg/day

Diastolic increase by 1.6-2 mm Hg/

day regardless of BW and GA


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BLOOD PRESSURE

MEASUREMENTZubrow et al (695 PT infant)

After 5th Day more gradual

increments

Systolic 0.24-0.27 mm Hg/day

Diastolic 0 0.15 mm Hg/day


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BLOOD PRESSURE

MEASUREMENTZubrow et al (695 PT infant )

generated standard curves for mean

BP + upper and lower 95%confidence limits

regression lines developed based on

Birthweight Gestational age

Postconceptual age


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BLOOD PRESSURE

MEASUREMENT Postconceptual age/Postmenstrual

age (GA + postnatal age)primary

determinant of BP in this population

RECOMMENDATION BP consistently > 95% confidence

limit by ZUBROW CURVES.


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THE ZUBROW CURVE


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INCIDENCE

General NICU population

.08% (26/3,179)

NICU admissions

2% ( 20/988)

0.7 to 3 % in three studies


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INCIDENCE

More common in patients with certain

diagnoses :

BPD 6 %

PDA 3 %

IV hemorrhage 3 % Umbilical catheterization 9 %


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CAUSES OF NEONATAL

HYPERTENSION RENOVASCULAR

most common

thromboembolism umbilical artery catheters as theoretical sources of

thomboembolic events

studies established an association between local

thrombi and development of hypertension

renal artery stenosis

renal venous thrombosis

compression of renal artery


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CAUSES OF NEONATAL

HYPERTENSIONTHROMBOEMBOLISM

COCHRANE STUDY

analysis of 11 randomized clinical trials

one study using alternate assignments

To compare the incidence of

morbidity and mortality for HIGH Vs.

LOW catheter tip placement.


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CAUSES OF NEONATAL

HYPERTENSION HIGH in the descending aorta

above the diaphragm (T6 and T9) LOW above the bifurcation but below the renal

arteries (L3 and L5)

CONCLUSION

High catheter positions caused fewerischemic complications and possibly decreased thefrequency of aortic thrombosis

Hypertension appears with equal frequency


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CAUSES OF NEONATAL

HYPERTENSIONRENAL ARTERY STENOSIS

caused by fibromuscular dysplasia

if present there also may be mid-

aortic coarctation and cerebral

vascular stenosis may be due to congenital rubella


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CAUSES OF NEONATAL

HYPERTENSIONRENAL VEIN THROMBOSIS

Hypertension

gross hematuria

abdominal/flank mass

thrombocytopenia


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CAUSES OF NEONATAL

HYPERTENSIONCONGENITAL RENAL DISEASE

Polycystic kidney disease

autosomal dominant and recessive enlarged kidney and hypertension

multicystic-dysplastic kidney disease

non-functional ureteropelvic junction obstructionActivation of Renin-angiotensin system


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CAUSES OF NEONATAL

HYPERTENSIONACQUIRED RENAL DISEASE

ATN/Interstitial nephritis/cortical

necrosis

due to volume overload/hyperreninemia

HUS

Obstruction by a tumor


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CAUSES OF NEONATAL

HYPERTENSIONBRONCHOPULMONARY DYSPLASIA

13- 43% of infants develop systemic

hypertension cause unclear : chronic hypoxia

severity (greater need for diuretics) of BPD

related to likelihood of developingincreased BP.

sickest infant require the closest monitoring


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CAUSES OF NEONATAL

HYPERTENSIONCOARCTATION OF THE AORTA

early repair improves the long term

outcome

hypertension may persist even after

surgical repair


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CAUSES OF NEONATAL

HYPERTENSIONENDOCRINE

seizures and increased intracranial

pressure are common causes of

episodic hypertension

CAH

HYPERALDOSTERONISM

HYPERTHYROIDISM


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CAUSES OF NEONATAL

HYPERTENSIONIATROGENIC NICU meds Dexamethasone

Theophylline Caffeine Pancuronium Phenylephrine

Prolonged TPN lead to salt and water overload/hypercalcemia

Under treatment of pain


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CAUSES OF NEONATAL

HYPERTENSIONMATERNAL CAUSES

Cocaine use

harm the developing kidneys

Heroine use

with neonatal withdrawal


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CAUSES OF NEONATAL

HYPERTENSIONNEOPLASMS

from compression of renal vessels and

ureters production of vasoactive substances

Neuroblastoma

Wilms tumor Mesoblastic nephroma


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CAUSES OF NEONATAL

HYPERTENSIONMISCELLANEOUS CAUSES

closure of abdominal wall defect

adrenal hemorrhage

hypercalcemia

ECMO

birth asphyxia


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EVALUATION

Life-threatening presentation

CHF

Cardiogenic shock

Seizures

Presentation of less ill infants

feeding difficulties

unexplained tachypnea

lethargy, apnea, irritability

mottling of the skin


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EVALUATION

RED FLAGS IN THE HISTORY

prenatal exposures to heroin and

cocaine predisposing conditions BPD, CNS

disorders, PDA, hypervolemia (post

BT) Medications/ Umbilical artery

catheterizations


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EVALUATION

RED FLAGS IN THE PHYSICAL

EXAMINATION

BP in lower extremities/non-palpable

femoral pulses CoA

dysmorphic features CAH/Turner Sy

Flank mass UPJ obstruction

Epigastric bruit renal artery stenosis


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EVALUATION

RED FLAGS IN THE PHYSICAL

EXAMINATION

Abdominal distention obstructiveuropathy, PKD, tumors

Peripheral thrombi UAC related HTN

Tachycardia/flushing/LBWhyperthyroidism

Ambiguous genitalia - CAH


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LABORATORY

EXAMINATIONS Urinalysis

CBC

Electrolytes, BUN, Crea, Ca

Urine culture if UTI is suspected

Plasma renin level significantly

elevated level indicates renovascular

disease


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LABORATORY

EXAMINATIONSAdditional tests

Thyroid studies

VMA/Homovanillic acid

Aldosterone

Cortisol


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IMAGING STUDIES

CXRay/2D echo CHF

US of genitourinary tract

should be performed in all hypertensive infants to rule out UPJ obstruction, renal vein

thrombosis

Doppler flow studies

Abdominal/pelvic US

VCUG


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IMAGING STUDIES

Radionuclide imaging - Abnormal kidneydisplays:

decreased effective renal plasma flow decreased urine flow rate

increased isotope concentration

MRA gold standard for diagnosis of

reno vascular hypertension

must be 3 kg


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MANAGEMENT

optimal management uncertain

threshold for starting antihypertensive

has not been well defined

idiosyncratic responses to certain

drugs due to developmental

immaturity of liver and kidney

function.


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MANAGEMENT

RECOMMENDATION

Asymptomatic /Mild Hypertension

(Systolic 95th to < 99th %) observation

resolves in time

Moderate to Severe(Systolic >/= 99th %) antihypertensive therapy


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MANAGEMENT

Address correctible causes of

hypertension

treat pain

correct volume overload

wean inotropic infusion

Choose a suitable agent depends on specific clinical situation


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TREATMENT

ACUTELY ILL INFANTS

continuous IV infusion

intermittently administered agents causewide fluctuation in BP

PT are at increased risk for cerebral

ischemia and hemorrhage from rapidly

falling BPs.

allows titration for desired effect


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TREATMENT

ACUTELY ILL INFANTS

continuous IV infusion

Nicardipine - DOC Nitroprusside

Labetalol cathecholamine and CNS

mediated hypertension

- avoid in BPD

monitor BP Q 10-15 minutes


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TREATMENT

NICARDIPINE calcium channel blocker peripheral vasodilator short half life : 10-15 minutes IV infusion 0.5 mcg/kg/min if normal BP

not achieved in 15 minutes increase

infusion to max of 3 mcg/kg/min. If stillelevated, add Sodium nitroprussidethen stop Nicardipine.


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TREATMENT

NITROPRUSSIDE

potent vasodilator

rapid onset of action short duration of

effect

complications : hypotension and

thiocyanate toxicity.


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TREATMENT

LABETALOL

combined alpha-1 and beta-blocker

rapid onset of action

duration of action : 2-3 hours

do not cause tachycardia, cerebral

vasodilatation or changes in

intracranial pressure.


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TREATMENT(NeoReviews)

LESS SEVERE HYPERTENSION NOTREADY FOR ORAL

Intermittent IV agents Hydralazine

Labetalol

sometimes doses at lower end ofrecommended range cause significant

hypotension


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TREATMENT

HYDRALAZINE

peripheral vasodilator

relaxes vascular smooth muscle


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INFANT READY TO BE WEANED FROMIV / READY FOR ORAL

ORAL ANTIHYPERTENSIVE AGENTS Captopril

Diuretic - can be added if captopril is

ineffective B Blocker should be avoided (BPD)


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TREATMENT

CAPTOPRILDrug of choice

ACE inhibitor .017 mg/kg/dose PO BIDTID Extremely low doses (0.01

mg/kg/dose or 0.03 mg/kg/day)may be effective in newborns


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TREATMENT

CAPTOPRIL

more potent in newbornsthan older children because of

higher renal vascular resistance

longer duration of action


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TREATMENT

BETA BLOCKER

effective in newborns

side effects uncommon

avoided in infants with BPD

because of bronchoconstriction


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TREATMENT

DIURETICS

reduce extracellular and plasma

volume

use in newborns limited to mild

hypertension resulting from fluid

overload or as an adjunctive

medication.


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TREATMENT(UPTODATE)

IV Enalapril

IV administered ACE inhibitor

effective in renovascular hypertension

has been used successfully in

newborns

lowest dose should be tried first


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IV Enalapril

avoided because of its unpredictable

antihypertensive efficacy and

potential to cause oligoanuria via

blockade of the renin-angiotensin

axis.


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TREATMENT

Surgical correction CoA

UPJ obstruction

Medical management + surgery Renal artery stenosis

Nephrectomy

Polycystic kidney disease Chemotherapy + surgeryWilms tumor and Neuroblastoma


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PROGNOSIS

depends on the cause often resolves over time persistent polycystic kidney disease renal parenchymal disease renal vein thrombosis require

nephrectomy

recurrent restenosis of renal artery stenosis or CoA

after repair


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REFERENCES

Ettinger, Leigh et al : NeoreviewsVol 3No.8. 2002

Fanaroff, Jonathan, et al. Blood pressure disorders

in the Neonate : Hypotension and Hypertension.Seminars in Fetal and Neonatal Medicine Vol 11.No. 3, June 2006, 174-181.

Ettinger, Leigh et al : Neoreviews.Vol 3No. 8, 2002

Neonatal Hypertension : Uptodate.2006 Neonatal Hypertension : Emedicine. August

29, 2006 Sondheimer, Judith M. (editor) : Current

Pediatric Diagnosis and Treatment. 16th ed.McGraw-Hill Companies,2003


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THANK YOU

ANDGOOD MORNING

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CabalunaDR Ppt 2006