The Indian Journal of Pediatrics

, Volume 82, Issue 10, pp 923–929 | Cite as

Management of Shock in Neonates

  • B. Vishnu BhatEmail author
  • Nishad Plakkal
Review Article


Shock is characterized by inadequate oxygen delivery to the tissues, and is more frequent in very low birth weight infants, especially in the first few days of life. Shock is an independent predictor of mortality, and the survivors are at a higher risk of neurologic impairment. Understanding the pathophysiology helps to recognize and classify shock in the early compensated phase and initiate appropriate treatment. Hypovolemia is rarely the primary cause of shock in neonates. Myocardial dysfunction is especially common in extremely preterm infants, and in term infants with perinatal asphyxia. Blood pressure measurements are easy, but correlate poorly with cerebral and systemic blood flows. Point-of-care cardiac ultrasound can help in individualized assessment of problems, selecting appropriate therapy and monitoring response, but may not always be available, and long-term benefits need to be demonstrated. The use of near-infrared spectroscopy to guide treatment of neonatal shock is currently experimental. In the absence of hypovolemia, excessive administration of fluid boluses is inappropriate therapy. Dobutamine and dopamine are the most common initial inotropes used in neonatal shock. Dobutamine has been shown to improve systemic blood flow, especially in very low birth weight infants, but dopamine is better at improving blood pressure in hypotensive infants. Newer inodilators including milrinone and levosimendan may be useful in selected settings. Data on long-term survival and neurologic outcomes following different management strategies are scarce and future research efforts should focus on this.


Shock Neonate Hypotension Inotrope 



BVB and NP reviewed the literature and contributed to the manuscript. BVB will act as guarantor for this paper.

Conflict of Interest


Source of Funding



  1. 1.
    Zakariya BP, Bhat BV, Harish BN, Arun Babu T, Joseph NM. Risk factors and predictors of mortality in culture proven neonatal sepsis. Indian J Pediatr. 2012;79:358–61.CrossRefPubMedGoogle Scholar
  2. 2.
    Femitha P, Bhat BV. Early neonatal outcome in late preterms. Indian J Pediatr. 2012;79:1019–24.CrossRefPubMedGoogle Scholar
  3. 3.
    Al-Aweel I, Pursley DM, Rubin LP, Shah B, Weisberger S, Richardson DK. Variations in prevalence of hypotension, hypertension, and vasopressor use in NICUs. J Perinatol. 2001;21:272–8.CrossRefPubMedGoogle Scholar
  4. 4.
    Laughon M, Bose C, Allred E, et al; ELGAN Study Investigators. Factors associated with treatment for hypotension in extremely low gestational age newborns during the first postnatal week. Pediatrics. 2007;119:273–80.PubMedCentralCrossRefPubMedGoogle Scholar
  5. 5.
    Noori S, Friedlich PS, Seri I. Pathophysiology of shock in the fetus and neonate. In: Polin RA, Fox WW, Abman SH, editors. Fetal and neonatal physiology. 4th ed. Philadelphia: Elsevier Saunders; 2011. p. 853–63.CrossRefGoogle Scholar
  6. 6.
    Bauer K, Linderkamp O, Versmold HT. Systolic blood pressure and blood volume in preterm infants. Arch Dis Child. 1993;69:521–2.PubMedCentralCrossRefPubMedGoogle Scholar
  7. 7.
    Wright IM, Goodall SR. Blood pressure and blood volume in preterm infants. Arch Dis Child Fetal Neonatal Ed. 1994;70:F230–1.PubMedCentralCrossRefPubMedGoogle Scholar
  8. 8.
    Gill AB, Weindling AM. Echocardiographic assessment of cardiac function in shocked very low birthweight infants. Arch Dis Child. 1993;68:17–21.PubMedCentralCrossRefPubMedGoogle Scholar
  9. 9.
    Cabal LA, Devaskar U, Siassi B, Hodgman JE, Emmanouilides G. Cardiogenic shock associated with perinatal asphyxia in preterm infants. J Pediatr. 1980;96:705–10.CrossRefPubMedGoogle Scholar
  10. 10.
    Evans N. Which inotrope for which baby? Arch Dis Child Fetal Neonatal Ed. 2006;91:F213–20.PubMedCentralCrossRefPubMedGoogle Scholar
  11. 11.
    Egan JR, Festa M, Cole AD, Nunn GR, Gillis J, Winlaw DS. Clinical assessment of cardiac performance in infants and children following cardiac surgery. Intensive Care Med. 2005;31:568–73.CrossRefPubMedGoogle Scholar
  12. 12.
    Tibby S, Hatherill M, Marsh M, Murdoch I. Clinicians’ abilities to estimate cardiac index in ventilated children and infants. Arch Dis Child. 1997;77:516–8.PubMedCentralCrossRefPubMedGoogle Scholar
  13. 13.
    Bada HS, Korones SB, Perry EH, et al. Mean arterial blood pressure changes in premature infants and those at risk for intraventricular hemorrhage. J Pediatr. 1990;117:607–14.CrossRefPubMedGoogle Scholar
  14. 14.
    Cunningham S, Symon AG, Elton RA, Zhu C, McIntosh N. Intra-arterial blood pressure reference ranges, death and morbidity in very low birthweight infants during the first seven days of life. Early Hum Dev. 1999;56:151–65.CrossRefPubMedGoogle Scholar
  15. 15.
    Nuntnarumit P, Yang W, Bada-Ellzey HS. Blood pressure measurements in the newborn. Clin Perinatol. 1999;26:981–96, x.Google Scholar
  16. 16.
    Weindling AM. Blood pressure monitoring in the newborn. Arch Dis Child. 1989;64:444–7.PubMedCentralCrossRefPubMedGoogle Scholar
  17. 17.
    Dannevig I, Dale HC, Liestol K, Lindemann R. Blood pressure in the neonate: three non-invasive oscillometric pressure monitors compared with invasively measured blood pressure. Acta Paediatr. 2005;94:191–6.CrossRefPubMedGoogle Scholar
  18. 18.
    Troy R, Doron M, Laughon M, Tolleson-Rinehart S, Price W. Comparison of noninvasive and central arterial blood pressure measurements in ELBW infants. J Perinatol. 2009;29:744–9.CrossRefPubMedGoogle Scholar
  19. 19.
    Kluckow M, Evans N. Relationship between blood pressure and cardiac output in preterm infants requiring mechanical ventilation. J Pediatr. 1996;129:506–12.CrossRefPubMedGoogle Scholar
  20. 20.
    Lee J, Rajadurai V, Tan K. Blood pressure standards for very low birthweight infants during the first day of life. Arch Dis Child Fetal Neonatal Ed. 1999;81:F168–70.PubMedCentralCrossRefPubMedGoogle Scholar
  21. 21.
    Alderliesten T, Lemmers PM, van Haastert IC, et al. Hypotension in preterm neonates: low blood pressure alone does not affect neurodevelopmental outcome. J Pediatr. 2014;164:986–91.CrossRefPubMedGoogle Scholar
  22. 22.
    Kluckow M, Evans N. Superior vena cava flow in newborn infants: a novel marker of systemic blood flow. Arch Dis Child Fetal Neonatal Ed. 2000;82:F182–7.PubMedCentralCrossRefPubMedGoogle Scholar
  23. 23.
    Osborn DA, Evans N. Early volume expansion versus inotrope for prevention of morbidity and mortality in very preterm infants. Cochrane Database Syst Rev. 2001;2:CD002056.PubMedGoogle Scholar
  24. 24.
    Osborn DA, Evans N. Early volume expansion for prevention of morbidity and mortality in very preterm infants. Cochrane Database Syst Rev. 2004;2:CD002055.PubMedGoogle Scholar
  25. 25.
    Subhedar NV, Shaw NJ. Dopamine versus dobutamine for hypotensive preterm infants. Cochrane Database Syst Rev. 2003;3: CD001242.PubMedGoogle Scholar
  26. 26.
    Cheung PY, Barrington KJ, Pearson RJ, Bigam DL, Finer NN, Van Aerde JE. Systemic, pulmonary and mesenteric perfusion and oxygenation effects of dopamine and epinephrine. Am J Respir Crit Care Med. 1997;155:32–7.CrossRefPubMedGoogle Scholar
  27. 27.
    Crouchley JL, Smith PB, Cotten CM, et al. Effects of low-dose dopamine on urine output in normotensive very low birth weight neonates. J Perinatol. 2013;33:619–21.PubMedCentralCrossRefPubMedGoogle Scholar
  28. 28.
    Prins I, Plotz FB, Uiterwaal CS, van Vught HJ. Low-dose dopamine in neonatal and pediatric intensive care: a systematic review. Intensive Care Med. 2001;27:206–10.CrossRefPubMedGoogle Scholar
  29. 29.
    Seri I, Rudas G, Bors Z, Kanyicska B, Tulassay T. Effects of low-dose dopamine infusion on cardiovascular and renal functions, cerebral blood flow, and plasma catecholamine levels in sick preterm neonates. Pediatr Res. 1993;34:742–9.CrossRefPubMedGoogle Scholar
  30. 30.
    Barrington K, Brion LP. Dopamine versus no treatment to prevent renal dysfunction in indomethacin-treated preterm newborn infants. Cochrane Database Syst Rev. 2002;3:CD003213.PubMedGoogle Scholar
  31. 31.
    Friedrich JO, Adhikari N, Herridge MS, Beyene J. Meta-analysis: low-dose dopamine increases urine output but does not prevent renal dysfunction or death. Ann Intern Med. 2005;142:510–24.CrossRefPubMedGoogle Scholar
  32. 32.
    Van den Berghe G, de Zegher F, Lauwers P. Dopamine suppresses pituitary function in infants and children. Crit Care Med. 1994;22:1747–53.CrossRefPubMedGoogle Scholar
  33. 33.
    Osborn DA, Paradisis M, Evans N. The effect of inotropes on morbidity and mortality in preterm infants with low systemic or organ blood flow. Cochrane Database Syst Rev. 2007;1:CD005090.Google Scholar
  34. 34.
    Bourchier D, Weston PJ. Randomised trial of dopamine compared with hydrocortisone for the treatment of hypotensive very low birthweight infants. Arch Dis Child Fetal Neonatal Ed. 1997;76:F174–8.PubMedCentralCrossRefPubMedGoogle Scholar
  35. 35.
    Ng PC, Lee CH, Bnur FL, et al. A double-blind, randomized, controlled study of a “stress dose” of hydrocortisone for rescue treatment of refractory hypotension in preterm infants. Pediatrics. 2006;117:367–75.CrossRefPubMedGoogle Scholar
  36. 36.
    Peltoniemi O, Kari MA, Heinonen K, et al. Pretreatment cortisol values may predict responses to hydrocortisone administration for the prevention of bronchopulmonary dysplasia in high-risk infants. J Pediatr. 2005;146:632–7.CrossRefPubMedGoogle Scholar
  37. 37.
    Attridge JT, Clark R, Walker MW, Gordon PV. New insights into spontaneous intestinal perforation using a national data set: (1) SIP is associated with early indomethacin exposure. J Perinatol. 2006;26:93–9.CrossRefPubMedGoogle Scholar
  38. 38.
    Peltoniemi OM, Lano A, Puosi R, et al; Neonatal Hydrocortisone Working Group. Trial of early neonatal hydrocortisone: two-year follow-up. Neonatology. 2009;95:240–7.CrossRefPubMedGoogle Scholar
  39. 39.
    Brierley J, Carcillo JA, Choong K, et al. Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine. Crit Care Med. 2009;37:666–88.PubMedCentralCrossRefPubMedGoogle Scholar
  40. 40.
    Kluckow M. Use of ultrasound in the haemodynamic assessment of the sick neonate. Arch Dis Child Fetal Neonatal Ed. 2014;99:F332–7.CrossRefPubMedGoogle Scholar
  41. 41.
    Saugstad OD, Aune D. Optimal oxygenation of extremely low birth weight infants: a meta-analysis and systematic review of the oxygen saturation target studies. Neonatology. 2014;105:55–63.CrossRefPubMedGoogle Scholar
  42. 42.
    Jain A, Sahni M, El-Khuffash A, Khadawardi E, Sehgal A, McNamara PJ. Use of targeted neonatal echocardiography to prevent postoperative cardiorespiratory instability after patent ductus arteriosus ligation. J Pediatr. 2012;160:584–9.e1.CrossRefPubMedGoogle Scholar
  43. 43.
    Lechner E, Hofer A, Leitner-Peneder G, et al. Levosimendan versus milrinone in neonates and infants after corrective open-heart surgery: a pilot study. Pediatr Crit Care Med. 2012;13:542–8.CrossRefPubMedGoogle Scholar
  44. 44.
    Pellicer A, Riera J, Lopez-Ortego P, et al. Phase 1 study of two inodilators in neonates undergoing cardiovascular surgery. Pediatr Res. 2013;73:95–103.CrossRefPubMedGoogle Scholar
  45. 45.
    Dellinger RP, Levy MM, Rhodes A, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013;41:580–637.CrossRefPubMedGoogle Scholar
  46. 46.
    ProCESS Investigators, Yealy DM, Kellum JA, Huang DT, et al. A randomized trial of protocol-based care for early septic shock. N Engl J Med. 2014;370:1683–93.Google Scholar
  47. 47.
    Peake SL, Delaney A, Bailey M, et al. Goal-directed resuscitation for patients with early septic shock. N Engl J Med. 2014;371:1496–506.CrossRefPubMedGoogle Scholar

Copyright information

© Dr. K C Chaudhuri Foundation 2015

Authors and Affiliations

  1. 1.Department of NeonatologyJawaharlal Institute of Postgraduate Medical Education and ResearchPuducherryIndia

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