# Impact of Implementing a Standardized Neonatal Blood Pressure Chart and Neonatal Hypotension Management Guidelines in the Neonatal Intensive Care Unit: A Retrospective Cohort Study

## TL;DR

A standardized blood pressure chart and hypotension guidelines reduced inotrope use and improved outcomes in preterm infants.

## Contribution

Demonstrates the clinical benefits of standardized BP charts and hypotension guidelines in neonatal care.

## Key findings

- Inotrope use decreased significantly after implementing the guidelines.
- Periventricular leukomalacia rates fell, and early mortality in hypotensive infants was reduced.
- Norepinephrine and hydrocortisone use increased, while dopamine and fluid bolus use decreased.

## Abstract

This study aimed to evaluate the effect of a standardized blood pressure (BP) chart and neonatal hypotension management guidelines on inotrope use and clinical outcomes in preterm infants.

Retrospective cohort study of preterm infants (<32 weeks gestational age (GA)) at King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia. We compared data before (EPOCH1) and after (EPOCH2) implementing the BP chart and hypotension guidelines. Extracted variables included maternal/neonatal characteristics, inotrope use, morbidity, and mortality. Statistical significance was set at
p
 < 0.05.

Among 384 infants (192 per epoch), overall inotrope use declined significantly in EPOCH2 (33.9 vs. 17.7%,
p
 < 0.001). In the hypotension subgroup, EPOCH1 infants had higher GA, birth weight, and 5- and 10-minute APGAR scores. After implementation, dopamine (58.5 vs. 14.7%,
p
 < 0.001) and fluid bolus (80 vs. 41.2%,
p
 < 0.001) use decreased, whereas norepinephrine (26.2 vs. 70.6%,
p
 < 0.001) and hydrocortisone (46.2 vs. 82.4%,
p
 < 0.001) increased. Inotrope therapy was triggered at lower mean arterial pressure and systolic/diastolic thresholds; duration of inotrope use also dropped (4.2 vs. 2.6 days,
p
 < 0.034). Periventricular leukomalacia rates fell (15.1 vs. 6.5%,
p
 < 0.007), with no significant differences in overall mortality, intraventricular hemorrhage, bronchopulmonary dysplasia, retinopathy of prematurity, or necrotizing enterocolitis. However, early mortality (<72 hours) in hypotensive infants was reduced (64.3 vs. 26.7%,
p
 < 0.042).

The implementation of BP charts and hypotension management guidelines was associated with a significant reduction in the use of inotropes and fluid boluses, indicating a more standardized and objective approach to BP management in preterm infants. These changes reflect improved clinical decision-making based on defined BP thresholds, resulting in greater consistency in the timing and selection of interventions while potentially minimizing the risks linked to unnecessary cardiovascular support.

Blood pressure charts may improve treatment decisions for neonatal hypotension.

Hypotension often occurs in preterm infants and can significantly affect their morbidity and mortality.

Pathophysiology-based management of neonatal hypotension may reduce neonatal morbidity and mortality.