BNF for Children 2011-2012

BNFC 2011–2012 2.7.1 Inotropic sympathomimetics 111vascular resistance is high (cold shock), adrenaline(epinephrine) (section 2.7.2) should be added. Additionally,in cold shock, a vasodilator such as milrinone(section 2.1.2), glyceryl trinitrate (section 2.6.1), orsodium nitroprusside (on specialist advice only) (section2.5.1.1) can be used to reduce vascular resistance.If the shock is resistant to volume expansion and catecholamines,and there is suspected or proven adrenalinsufficiency, low dose hydrocortisone (section 6.3.2)can be used. ACTH-stimulated plasma-cortisol concentrationshould be measured; however, hydrocortisonecan be started without such information.Alternatively, if the child is resistant to catecholamines,and vascular resistance is low, vasopressin (section6.5.2) can be added.Neonatal septic shock can be complicated by the transitionfrom fetal to neonatal circulation. Treatment toreverse right ventricular failure, by decreasing pulmonaryartery pressures, is commonly needed in neonateswith fluid-refractory shock and persistent pulmonaryhypertension of the newborn (section 2.5.1.2).Rapid administration of fluid in neonates with patentductus arteriosus may cause left-to-right shunting andcongestive heart failure induced by ventricular overload.In cardiogenic shock, the aim is to improve cardiacoutput and to reduce the afterload on the heart. Ifcentral venous pressure is low, cautious volume expansionwith a colloid or crystalloid can be used. Aninotrope such as adrenaline (epinephrine) (section2.7.2) or dopamine should be given to increase cardiacoutput. Dobutamine is a peripheral vasodilator and isan alternative if hypotension is not significant.Milrinone (section 2.1.2) has both inotropic and vasodilatoryeffects and can be used when vascular resistanceis high. Alternatively, glyceryl trinitrate (2.6.1) orsodium nitroprusside (on specialist advice only) (section2.5.1.1) can be used to reduce vasoconstriction.Hypovolaemic shock should be treated with a crystalloidor colloid solution (or whole or reconstituted bloodif source of hypovolaemia is haemorrhage) and furthersteps to improve cardiac output and decrease vascularresistance can be taken, as in cardiogenic shock.The use of sympathomimetic inotropes and vasoconstrictorsshould preferably be confined to the intensivecare setting and undertaken with invasive haemodynamicmonitoring.For advice on the management of anaphylactic shock,see section 3.4.3.DOBUTAMINECautions arrhythmias, acute myocardial infarction,acute heart failure, severe hypotension, markedobstruction of cardiac ejection (such as idiopathichypertrophic subaortic stenosis); correct hypovolaemiabefore starting treatment; tolerance maydevelop with continuous infusions longer than 72hours; hyperthyroidism; interactions: Appendix 1(sympathomimetics)Contra-indications phaeochromocytomaPregnancy no evidence of harm in animal studies—manufacturers advise use only if benefit outweighsriskBreast-feeding manufacturers advise avoid—noinformation availableSide-effects nausea; hypotension, hypertension(marked increase in systolic blood pressure indicatesoverdose), arrhythmias, palpitation, chest pain; dyspnoea,bronchospasm; headache; fever; increasedurinary urgency; eosinophilia; rash, phlebitis; veryrarely myocardial infarction, hypokalaemia; alsoreported coronary artery spasm and thrombocytopeniaLicensed use strong sterile solution not licensed foruse in childrenIndication and doseInotropic support in low cardiac output states,after cardiac surgery, cardiomyopathies, shock. By continuous intravenous infusionNeonate initially 5 micrograms/kg/minute,adjusted according to response to 2–15 micrograms/kg/minute;max. 20 micrograms/kg/minuteChild 1 month–18 years initially 5 micrograms/kg/minute adjusted according to response to 2–20 micrograms/kg/minuteAdministration for continuous intravenous infusion,using infusion pump, dilute to a concentration of 0.5–1 mg/mL (max. 5 mg/mL if fluid restricted) withGlucose 5% or Sodium Chloride 0.9%; infuse higherconcentration solutions through central venouscatheter only. Incompatible with bicarbonate andother strong alkaline solutions.Neonatal intensive care, dilute 30 mg/kg body-weightto a final volume of 50 mL with infusion fluid; anintravenous infusion rate of 0.5 mL/hour provides adose of 5 micrograms/kg/minuteDobutamine (Non-proprietary) AInjection, dobutamine (as hydrochloride) 5 mg/mL.To be diluted before use or given undiluted withsyringe pump. Net price 50-mL vial = £7.50Excipients may include sulphitesConcentrate for intravenous infusion, dobutamine(as hydrochloride) 12.5 mg/mL. To be diluted beforeuse. Net price 20-mL amp = £5.20Excipients may include sulphitesDOPAMINE HYDROCHLORIDECautions correct hypovolaemia; hyperthyroidism;interactions: Appendix 1 (sympathomimetics)Contra-indications tachyarrhythmia, phaeochromocytomaPregnancy manufacturer advises use only if potentialbenefit outweighs riskSide-effects nausea, vomiting, chest pain, palpitation,tachycardia, vasoconstriction, hypotension, dyspnoea,headache; less commonly bradycardia, hypertension,gangrene, mydriasis; rarely fatal ventriculararrhythmiasLicensed use not licensed for use in children under12 yearsIndication and doseTo correct the haemodynamic imbalance due toacute hypotension, shock, cardiac failure,adjunct following cardiac surgery. By continuous intravenous infusionNeonate initially 3 micrograms/kg/minute,adjusted according to response (max. 20 micrograms/kg/minute)2 Cardiovascular system