Adenosina

Intravenous adenosine for refractory pulmonary hypertension in a low-weight premature newborn: A potential new drug for rescue therapy
Alessandro Motti, MD; Cécile Tissot, MD; Peter C. Rimensberger, MD; Aline Prina-Rousso, MD; Yacine Aggoun, MD; Michel Berner, MD; Maurice Beghetti, MD; Eduardo da Cruz, BSc, MD

Objectives: To use intravenous adenosine as a rescue therapy for neonatalrefractory pulmonary hypertension in a low-weight premature infant. Study Line: We report the successful use of a continuous intravenous adenosine infusion in a 1150-g premature baby with severe persistent pulmonary hypertension, refractory to classic management with high-frequency oscillatory ventilation, oxygen therapy and inhaled nitric oxide. Results: Adenosine infusion had a dramatic effect allowingfor a rapid weaning of oxygen, ventilatory variables, and nitric oxide. Conclusions: Although experience with continuous adenosine infusion is still at an early stage, it might be worth considering its administration as a rescue therapy or even as an alternative to extracorporeal membrane oxygenation. (Pediatr Crit Care Med 2006; 7:380 –382) KEY WORDS: premature infants; pulmonary hypertension;nitric oxide; high-frequency ventilation

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e report the dramatic effect of a continuous intravenous adenosine infusion in a 1150-g premature baby with severe persistent pulmonary hypertension, refractory to classic management. Although experience with continuous adenosine infusion is at an early stage, it might be worth considering it as an alternative to extracorporeal membrane oxygenation.CASE DESCRIPTION
A 1150-g premature baby with a gestational age of 30 wks 4 days was admitted to our intensive care unit with severe respiratory distress syndrome. He was born by urgent caesarean section for Doppler signs of fetal distress, with an Apgar score of 9 –9 –9. At 15 mins of life, he developed respiratory distress and became hypoxic with a significant pre- and

From the Service ofPediatric and Neonatal Intensive Care (AM, PCR, APR, M Berner, EdC) and the Pediatric Cardiology Unit (CT, YA, M Beghetti, EdC), Department of Pediatrics, Geneva Children’s University Hospital, Switzerland. Financial support used for the study: none. The authors have not disclosed any potential conflicts of interest. Copyright © 2006 by the Society of Critical Care Medicine and the WorldFederation of Pediatric Intensive and Critical Care Societies DOI: 10.1097/01.PCC.0000225000.78627.EB

postductal saturation differential (88% and 70%, respectively). A chest radiograph documented a grade III–IV hyaline membrane disease. Blood, urine, tracheal, and gastric cultures were undertaken and he was started and kept on intravenous ampicillin and gentamicin therapy until confirmation of theirnegativity. He was first treated with nasal continuous positive airway pressure but rapidly deteriorated, requiring nasotracheal intubation and instillation of surfactant therapy (Curosurf, 200 mg/kg). A first echocardiography performed at the second hour of life showed a structurally normal heart and pulmonary venous returns and an isosystemic pulmonary hypertension with high pulmonary vascularresistances. Following current conventional methods, he was treated by highfrequency oscillatory ventilation aiming to maintain a mildly alkalotic blood pH, and with inhaled nitric oxide at 10 ppm. With this approach he remained stable with FIO2 levels of 0.30 – 0.40 for the first 48 hrs. However, on day 3 his general conditions deteriorated and the echocardiographic appraisal documented a suprasystemicpulmonary hypertension, a dilated and poorly contractile right ventricle, and a massive right-to-left shunt through the foramen ovale and a large ductus arteriosus (Fig. 1). Although on very high oxygen requirements (FIO2 of

1.0), he remained very hypoxemic (PaO2 2.95 kPa), with preductal peripheral saturations around 65% and postductal saturations of 54%. A dopamine infusion at 5 g/kg/min was...