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American Academy of Pediatrics
Article

Milrinone Use in Persistent Pulmonary Hypertension of the Newborn

Amna Qasim and Sunil K. Jain
NeoReviews March 2020, 21 (3) e165-e178; DOI: https://doi.org/10.1542/neo.21-3-e165
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Amna Qasim
*Department of Pediatrics, Division of Pediatric Cardiology, Texas Children’s Hospital/Baylor College of Medicine, Houston, TX
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Sunil K. Jain
†Department of Pediatrics, Division of Neonatology, University of Texas Medical Branch, Galveston, TX
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  • Abbreviations:
    cAMP:
    cyclic adenosine monophosphate
    cGMP:
    cyclic guanosine monophosphate
    ECMO:
    extracorporeal membranous oxygenation
    eNOS:
    endothelial nitric oxide synthase
    iNO:
    inhaled nitric oxide
    LV:
    left ventricular
    NO:
    nitric oxide
    OI:
    oxygenation index
    PAP:
    pulmonary arterial pressure
    PBF:
    pulmonary blood flow
    PCWP:
    pulmonary capillary wedge pressure
    PDA:
    patent ductus arteriosus
    PDE:
    phosphodiesterase
    PFO:
    patent foramen ovale
    PPHN:
    persistent pulmonary hypertension of the newborn
    PVR:
    pulmonary vascular resistance
    RV:
    right ventricular
    SaO2:
    saturation of arterial oxygen
    SAP:
    systemic arterial pressure
    SVR:
    systemic vascular resistance
  • Abstract

    Failure of the normal transition from in utero to ex utero physiology leads to “persistent” pulmonary hypertension of the newborn (PPHN). PPHN is frequently associated with low systemic blood pressure and low cardiac output because of increased right ventricular afterload and myocardial dysfunction. The general management of newborns with PPHN is geared toward maintenance of normothermia, normal serum electrolytes, normal intravascular volume, correction of acidosis, adequate sedation/analgesia, adequate ventilation and oxygenation with optimal lung recruitment, and avoidance of hyperoxia. Inotropic and vasoactive agents are commonly initiated early to increase cardiac output, maintain adequate systemic blood pressure, and enhance oxygen delivery to the tissue. Unfortunately, there is not much evidence on the choice, timing of initiation, dosing, monitoring, and titrating of vasoactive agents in this patient population. In this review, we will discuss the pathophysiology of PPHN and review the use of inotropic, lusitropic, and vasoactive agents in the management of PPHN, with particular attention to milrinone.

    • Copyright © 2020 by the American Academy of Pediatrics

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    NeoReviews
    Vol. 21, Issue 3
    1 Mar 2020
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    Milrinone Use in Persistent Pulmonary Hypertension of the Newborn
    Amna Qasim, Sunil K. Jain
    NeoReviews Mar 2020, 21 (3) e165-e178; DOI: 10.1542/neo.21-3-e165

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    Milrinone Use in Persistent Pulmonary Hypertension of the Newborn
    Amna Qasim, Sunil K. Jain
    NeoReviews Mar 2020, 21 (3) e165-e178; DOI: 10.1542/neo.21-3-e165
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    • Article
      • Abstract
      • Practice Gaps
      • Objectives
      • Introduction
      • Fetal and Transitional Cardiopulmonary Circulation
      • Maladaptation of Cardiopulmonary Circulation at Birth
      • The Ideal Agent for the Management of PPHN
      • Myocardial Dysfunction in PPHN
      • The Paradox of Inotropes and Vasopressors in the Management of PPHN
      • Mechanisms of Action
      • The Role of PDE3 Inhibitors such as Milrinone in PPHN
      • PDE3 Inhibitor (Milrinone) Use in Special Populations
      • Safety Profile of Milrinone
      • Pharmacokinetics and Dosing of Milrinone in PPHN
      • Conclusion
      • Footnotes
      • References
    • Figures & Data
    • Info & Metrics
    • Comments
    • Quiz

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