(29) First-line treatments in neonatal shock: Without a targeted approach, epinephrine is no better than dopamine

Background: Prior literature has demonstrated that targeted management is needed for neonatal shock. Dopamine was classically used in neonatal intensive care units (NICUs), but many units have now shifted to the use of epinephrine as a first-line agent.

Objectives: Our goals were to evaluate trends in the management of shock, including the use of echocardiography (echo), and to determine if outcomes differed between antihypotensive medications.

Design/Methods: We conducted a retrospective cohort study of patients with shock at a single Level IV NICU from January 2013 to September 2022. We used manual chart review to collect the clinical covariates and outcome variables defined in Table 1. Shock was classified by a neonatologist after review of discharge summaries and available autopsies. Developmental delay was defined using Bayley Scales of Infant and Toddler Development. We directly compared dopamine to epinephrine as other medications were ordered as a first-line agent too infrequently for analysis. Frequency tables, Chi-square tests, and Fisher’s exact tests were used to evaluate categorical variables. Descriptive statistics and the Mann-Whiney test were used to assess continuous variables. SPSS 28 and SAS 9.4 were used for all the analyses.

Results: Dopamine was the most used first-line antihypotensive medication from 2015-2018, while epinephrine was more common from 2019 onward (Figure 1). When comparing both medications (Table 1), dopamine was most likely to be chosen for transitional shock (p=0.0007) along with infants born at a younger gestational age (p < 0.0001) and smaller birth weight (p < 0.0001). However, there were no significant differences in any of our outcome measures. Overall, echo was used in 50% or fewer cases for seven out of the nine years studied (Figure 2). Combined, Figures 1 and 2 suggest much of the data represent somewhat standardized first-line medication use over targeted treatment choice.

Conclusion: From 2013-2022, we observed a transition from first-line dopamine to first-line epinephrine with a relatively low rate of echos to guide therapy. Epinephrine was not associated with better outcomes than dopamine when used indiscriminately for neonatal shock. This study adds to the existing literature advocating for targeted and individual hemodynamic management of neonatal shock. The authors declare no conflicting financial interests. Ryan Majinski was funded by the Medical Student Summer Quality Improvement Program (Pediatrics) CSG at the Medical College of Wisconsin.