Hemodynamic instability is a common problem in neonates and has important implications for long-term outcomes. Inotropes and vasopressors are commonly used to treat low blood pressure or poor perfusion in neonatal intensive care, despite limited evidence to guide optimal management in specific clinical situations. Dopamine is the most commonly used agent in clinical practice, increasing blood pressure with limited adverse effects compared with epinephrine. Dobutamine is less commonly used but may be the optimal agent for premature neonates with poor perfusion due to immature myocardial contractility. New evidence is emerging to guide the treatment of hypotension in the setting of sepsis and persistent pulmonary hypertension. Norepinephrine and vasopressin may have utility in the setting of refractory hypotension due to sepsis. Increasing evidence supports use of norepinephrine, milrinone, and vasopressin in the setting of persistent pulmonary hypertension. Hydrocortisone should be reserved for vasopressor-resistant hypotension in preterm neonates; however, this agent may also prove useful in the treatment of persistent pulmonary hypertension in term neonates. Further clinical trials are necessary to determine the optimal treatment algorithm for neonates with hemodynamic instability. Future trials should include physiologically relevant end points and long-term follow-up. However, one approach may not be efficacious for all neonates even with a similar diagnosis. Therefore, bedside assessment techniques should continue to be explored to allow tailored therapy based on real-time assessment of underlying physiology.
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