Management of Neonatal Respiratory and Cardiac Conditions

Initial Management Strategies

The American Heart Association recommends inhaled nitric oxide (iNO) at 20 ppm as the first-line treatment for persistent pulmonary hypertension of the newborn (PPHN), with extracorporeal membrane oxygenation (ECMO) reserved for refractory cases with oxygenation index >25 1
Optimize lung recruitment before or concurrent with iNO initiation, as lung recruitment strategies significantly improve iNO efficacy in PPHN with parenchymal lung disease like pneumonia 1
Metabolic alkalinization remains critical during initial resuscitation as PPHN can reverse when acidosis is corrected, according to the Society of Critical Care Medicine 2

ECMO is indicated when oxygenation index exceeds 25 despite iNO and optimized ventilation, as recommended by the American Heart Association 1
Consider sildenafil as adjunctive therapy for iNO-refractory PPHN with oxygenation index >25, according to the American Heart Association 1
Inhaled prostacyclin analogs may be added for refractory cases with oxygenation index >25, as suggested by the American Heart Association 1

Empiric antibiotics must be administered within 1 hour of sepsis identification, as recommended by the Society of Critical Care Medicine 3
Blood cultures should be obtained before antibiotics when possible, but never delay administration, according to the Society of Critical Care Medicine 3

Aggressive fluid resuscitation with 20 mL/kg boluses up to 60 mL/kg in the first hour, followed by early inotropic support if fluid-refractory, is essential for septic shock in preterm neonates, as recommended by the Society of Critical Care Medicine 3, 5
Administer empiric antibiotics within 1 hour, according to the Society of Critical Care Medicine 3
Push 20 mL/kg isotonic crystalloid or albumin boluses over 5-10 minutes, up to 60 mL/kg total, as suggested by the Society of Critical Care Medicine 3, 5

Start resuscitation with 21-30% oxygen, then titrate to target saturations, according to the American Academy of Pediatrics 7
Antenatal steroids reduce mortality, respiratory distress syndrome, and surfactant use, as reported by the American Academy of Pediatrics 4
Consider early surfactant for respiratory distress syndrome, as suggested by the American Academy of Pediatrics 4

Target normal mean arterial pressure-central venous pressure and central venous oxygen saturation >70%, according to the Society of Critical Care Medicine 5
For cold shock with normal blood pressure, titrate dopamine or epinephrine centrally, as recommended by the Society of Critical Care Medicine 5
For warm shock, titrate norepinephrine centrally, according to the Society of Critical Care Medicine 5

Any newborn with shock and hepatomegaly, cyanosis, cardiac murmur, or differential upper/lower extremity blood pressures must receive prostaglandin infusion immediately until complex congenital heart disease is excluded by echocardiography, as recommended by the American Heart Association 6
Start prostaglandin E1 infusion for ductal-dependent lesions, according to the American Heart Association 6
Evaluate for differential pulses and blood pressures, as suggested by the American Heart Association 6

Cardiac catheterization should include acute vasoreactivity testing unless contraindicated, according to the American Heart Association 1
Positive vasoreactivity test response: ≥20% decrease in pulmonary artery pressure and pulmonary vascular resistance/systemic vascular resistance without decreased cardiac output, as defined by the American Heart Association 1

Antibiotics within 1 hour, according to the Society of Critical Care Medicine 3
Fluid resuscitation with extreme caution - stop if hepatomegaly or rales develop, as recommended by the Society of Critical Care Medicine 3, 5
Early inotropic support for myocardial dysfunction, according to the Society of Critical Care Medicine 3, 5

Adherence to 1-hour antibiotic window for sepsis, as recommended by the Society of Critical Care Medicine 3
Appropriate use of lung recruitment with iNO, according to the American Heart Association 1
Timely recognition of fluid overload and initiation of diuretics/continuous venovenous hemofiltration, as suggested by the Society of Critical Care Medicine 3, 5
Proper ECMO candidacy assessment and timing, according to the American Heart Association and the Society of Critical Care Medicine 1, 2, 3