Role of Norepinephrine and Vasopressin in Persistent Pulmonary Hypertension of the Newborn with Shock: A Case Series from a Tertiary Care Centre in Northern India

Persistent Pulmonary Hypertension of the Newborn (PPHN) complicated by shock presents significant therapeutic challenges, particularly in resource-limited settings without access to inhaled Nitric Oxide (iNO) and Extracorporeal Membrane Oxygenation (ECMO). Conventional inotropic agents may worsen pulmonary pressures, making their use potentially detrimental. Norepinephrine and vasopressin, with their selective vasoconstrictive effects, may simultaneously improve systemic perfusion and pulmonary haemodynamics. This case series included five term and late-preterm neonates admitted to a tertiary Neonatal Intensive Care Unit (NICU) in North India between December 2023 and January 2025 with echocardiographically confirmed PPHN and systemic hypotension despite preserved cardiac function. All infants received intravenous sildenafil. Norepinephrine was initiated at 0.2 µg/kg/min and escalated up to 0.5 µg/kg/min as the first-line vasopressor. In cases with inadequate response, vasopressin was added, starting at 0.1 mU/kg/min and increased up to 0.2 mU/kg/min. All neonates developed hypotensive shock within the first 20–28 hours of life. Three infants showed clinical improvement in perfusion and oxygenation following norepinephrine alone while two required adjunctive vasopressin for persistent hypotension, with both demonstrating rapid stabilisation marked by improved mean arterial pressure, lactate clearance, and oxygenation indices. This dual-agent vasopressor strategy appears to be both feasible and beneficial in improving outcomes in such critical cases. However, larger prospective studies are warranted to validate these results and assess long-term safety and efficacy.