Intervention Review

Early volume expansion versus inotrope for prevention of morbidity and mortality in very preterm infants

  1. David A Osborn1,*,
  2. Nicholas J Evans2

Editorial Group: Cochrane Neonatal Group

Published Online: 23 APR 2001

Assessed as up-to-date: 30 JUL 2008

DOI: 10.1002/14651858.CD002056

How to Cite

Osborn DA, Evans NJ. Early volume expansion versus inotrope for prevention of morbidity and mortality in very preterm infants. Cochrane Database of Systematic Reviews 2001, Issue 2. Art. No.: CD002056. DOI: 10.1002/14651858.CD002056.

Author Information

  1. 1

    Royal Prince Alfred Hospital, RPA Newborn Care, Camperdown, New South Wales, Australia

  2. 2

    Royal Prince Alfred Hospital, Neonatal Medicine, Camperdown, NSW, Australia

*David A Osborn, RPA Newborn Care, Royal Prince Alfred Hospital, Missenden Road, Camperdown, New South Wales, 2050, Australia. david.osborn@email.cs.nsw.gov.au.

Publication History

  1. Publication Status: New search for studies and content updated (no change to conclusions)
  2. Published Online: 23 APR 2001

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Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Background

Reduced perfusion of organs such as the brain, heart, kidneys and the gastrointestinal tract may lead to acute dysfunction and be associated with permanent injury. Various strategies have been used to provide cardiovascular support to preterm infants including inotropes, corticosteroids and volume expansion.

Objectives

To determine the effect of early volume expansion compared to inotrope in reducing morbidity and mortality in very preterm infants. Subgroup analysis was planned according to method of diagnosis of poor perfusion, postnatal age of treatment and type of volume expansion and inotrope used.

Search methods

Updated searches were performed of the Cochrane Central Register of Controlled Trials (Issue 3, 2008), MEDLINE (1996 - July 2008), EMBASE (1980 - July 2008), previous reviews including cross references, abstracts and conferences.

Selection criteria

All randomised trials that compared volume expansion to an inotrope in preterm infants born ≦ 32 weeks gestation or ≦ 1500 g in the first days after birth were included.

Data collection and analysis

Data were extracted independently by each author and analysed using the standard methods of the Cochrane Collaboration and its Neonatal Review Group using relative risk (RR), risk difference (RD) and weighted mean difference (WMD).

Main results

Two small studies comparing volume expansion (using albumin) with dopamine were included. Both studies were adequately randomised, unblinded studies of albumin vs. dopamine with no losses to follow-up and analysed by intention to treat. Data for clinical outcomes were available from one study in hypotensive preterm infants in the first day after birth. In this study, albumin had a higher failure rate for correcting hypotension dopamine (RR 5.23; 95% CI 1.33 to 20.55). As 49% of these infants had already been given volume, the question of which treatment should be given first was not answered. A second study compared albumin with dopamine in preterm infants with a normal mean blood pressure (BP) at a mean age of 32 hours. Dopamine produced a significant increase in mean BP when compared to infants who received albumin or no treatment, although the difference between the dopamine and albumin groups did not reach significance. Albumin and dopamine produced similar increases in left ventricular output but no significant change in cerebral blood flow. No difference was found in mortality (RR 1.45; 95% CI 0.53 to 3.95) or morbidity including any P/IVH, chronic lung disease or retinopathy. There was a higher rate of grade 2 - 4 P/IVH of borderline statistical significance in infants who received albumin in one study (RR 1.47; 95% CI 0.96 to 2.25: RD 0.27, 95% CI 0.00 to 0.54). No data were available for neurodevelopmental outcomes.

Authors' conclusions

Dopamine was more successful than albumin at correcting low BP in hypotensive preterm infants, many of whom had already received volume. Neither intervention has been shown to be superior at improving blood flow or in improving mortality and morbidity in preterm infants. The trials do not allow any firm conclusions to be made as to whether or when volume or dopamine should be used in preterm infants.

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Early volume expansion versus inotrope for prevention of morbidity and mortality in very preterm infants

Not enough evidence to show the effect of early volume expansion in very preterm babies. Low blood pressure and blood flow are common in preterm babies and can cause brain injury, organ damage and developmental problems. Increasing the amount of fluid in the blood stream (volume expansion) using albumin or salt solutions may increase the blood pressure and flow of blood. Inotrope drugs such as dopamine are used to increase the heart rate and blood pressure. The review of trials compared early volume expansion with inotropes. The review found dopamine is more effective than albumin at correcting low blood pressure in preterm babies but neither improves outcomes for babies. More research is needed.

 

摘要

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

背景

早期容積擴張與inotrope預防極早早產兒疾病與死亡的比較

器官,如大腦、心臟、腎臟和胃腸道血流灌注降低可導致急性功能不全,引起永久性損害。有多種不同的向早產兒提供心血管支持的方法,其中包括inotropices(心肌收縮藥)、皮質類固醇激素和容積擴張。

目標

為確定早期容積擴張與inotrope降低極早早產兒發病率和死亡率的效果比較。根據灌流不足診斷方法、治療時出生年齡和使用的容積擴張及inotrope類型,計劃亞組分析。

搜尋策略

使用Cochrane新生兒評價組的標準策略進行檢索。檢索的信息庫包括牛津圍生兒試驗數據庫,本評價對檢索進行了更新,其中包括檢索Cochrane對照試驗中心註冊資料庫(CENTRAL,Cochrane圖書館,2004年第1期)、MEDLINE (1996年 2004年1月)、含參考文獻的以往評價/綜述、摘要和會議(澳大利亞和新西蘭圍生兒學會,以及兒科學術學會和美國兒科學術學會1998年-2003年的會議)。

選擇標準

納入所有在早產兒出生後頭幾天對容積擴張與inotrope進行比較的隨機試驗。

資料收集與分析

每位評價員獨立提取數據並應用Cochrane協作組織及其新生兒評價組的標準方法,使用相對危險度(RR)、風險差(RD)和加權均數差(WMD)分析數據。

主要結論

納入兩項對用白蛋白補充容量與多巴胺進行比較的小規模試驗。這兩項研究均是充分隨機化,比較白蛋白與多巴胺的非盲法研究,無失訪,並且運用意向治療進行分析。一項研究提供了出生頭幾天低血壓早產兒的臨床結局數據。在該研究中,白蛋白糾正低血壓的失敗率高於多巴胺(RR 5.23;95% CI 1.33 - 20.55)。由於這些嬰兒的49%已經補充過血容量,所以無法回答應該首先應用哪種治療的問題。第二項研究在平均血壓正常,平均年齡32小時的早產兒中比較白蛋白與多巴胺。當與接受白蛋白或不治療的嬰兒進行比較時,多巴胺使平均血壓顯著升高,但多巴胺與白蛋白組間的差異未達到統計學顯著性。白蛋白與多巴胺使左心室輸出量的增加相似,但腦血流量無顯著增加。在死亡率(RR 1.45;95% CI 0.53 - 3.95)或包括任何P/IVH、慢性肺疾或視網膜病變在內的發病率上未發現差異。在一項研究中,接受白蛋白的嬰兒2-4級P/IVH的發生率較高,有臨界統計學意義(RR 1.47;95% CI 0.96 - 2.25; RD 0.27, 95% CI 0.00-0.54) 。沒有可利用的神經發育結局數據。

作者結論

多巴胺與白蛋白相比,糾正低血壓早產兒(其中許多早產兒已經接受過補充血容量)低血壓的成功率更高。沒有一種干預在改善早產兒血流,或改善死亡率和發病率上表現更優。以上試驗不可能就是否應該對早產兒使用容積擴張還是多巴胺,或何時使用得出任何明確的結論。

翻譯人

本摘要由臺中榮民總醫院薛榮華翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

沒有足夠的證據證明早期容積擴張治療極早早產嬰兒的效果。低血壓和低血流量常見於早產嬰兒,與腦損傷、其他器官傷害和發育問題有關。使用白蛋白和鹽溶液來增加血壓和血流量可增加血液中的液體量(容積擴張)。強心劑如多巴胺等藥物,可用於增加心率和血壓。在本試驗回顧比較了容積擴張與強心藥物。回顧發現,比起白蛋白,多巴胺是更有效來矯正早產嬰兒低血壓,但沒有改善嬰兒的後續結果。還需要更多的研究。