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Leslie A, Harrison C, Jackson A, Broster S, Clarke E, Davidson SL, Devon C, Forshaw B, Philpott A, Tinnion R, Whiston J, Fenton AC, Sharkey D. Tracking national neonatal transport activity and metrics using the UK Neonatal Transport Group dataset 2012-2021: a narrative review. Arch Dis Child Fetal Neonatal Ed 2024; 109:460-466. [PMID: 38272658 DOI: 10.1136/archdischild-2023-325532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 12/13/2023] [Indexed: 01/27/2024]
Abstract
There are no internationally agreed descriptors for categories of neonatal transports which facilitate comparisons between settings. To continually review and enhance neonatal transport care we need robust categories to develop benchmarks. This review aimed to report on the development and application of key measures across a national neonatal transport service. The UK Neonatal Transport Group (UK-NTG) developed a core dataset and benchmarks for transported infants and collected annual national data. Data were reported back to teams to allow benchmarking and improvements. From 2012 to 2021, the rate of UK neonatal transfers increased from 18 to 22/1000 live births despite a falling birth rate. Neonatal transfers on nitric oxide increased until 2016 before plateauing. The proportion of transport services able to provide high frequency oscillation and servo-controlled therapeutic hypothermia increased over the study period. High-flow nasal cannula oxygen use increased, becoming the most frequently used non-invasive respiratory support mode. For infants <27 weeks of gestational age, transfers for uplift of care in the first 3 days of life have fallen from 420 (2016) to 288 (2020/2021) and for lack of neonatal capacity from 24 (2016) to 2 (2020/2021). The rate of ventilated infants completing transfer with CO2 out of the benchmark range varied from 9% to 13% with marked variation between transport services' rates of hypocapnia (0-10%) and hypercapnia with acidosis (0-9%). The development of the UK-NTG dataset supports national tracking of activity and clinical trends allowing comparison of patient-focused benchmarks across teams.
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Affiliation(s)
- Andrew Leslie
- Centre for Perinatal Research, School of Medicine, University of Nottingham, Nottingham, UK
| | - Catherine Harrison
- Embrace, Sheffield Children's Hospital NHS Foundation Trust, Sheffield, UK
| | - Allan Jackson
- ScotSTAR Scottish Neonatal Transport Service, Glasgow, UK
| | - Susan Broster
- Paediatric and Neonatal Decision Support and Retrieval Service (PaNDR), Cambridge, UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Eileen Clarke
- Paediatric and Neonatal Decision Support and Retrieval Service (PaNDR), Cambridge, UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Sarah L Davidson
- Southampton Oxford Neonatal Transfer service (SONeT), Southampton University Hospitals NHS Trust, Southampton, UK
| | - Colin Devon
- ScotSTAR Scottish Neonatal Transport Service, Glasgow, UK
| | - Beverley Forshaw
- Northern Neonatal Transport Service (NNeTS), Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Alex Philpott
- Kids Intensive Care and Decision Support/Neonatal Transfer Service (KIDS-NTS), Birmingham, UK
| | - Robert Tinnion
- Northern Neonatal Transport Service (NNeTS), Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Jo Whiston
- Embrace, Sheffield Children's Hospital NHS Foundation Trust, Sheffield, UK
| | - Alan C Fenton
- Neonatology, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Don Sharkey
- Centre for Perinatal Research, School of Medicine, University of Nottingham, Nottingham, UK
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Ćaleta T, Ryll MJ, Bojanić K, Dessardo NS, Schroeder DR, Sprung J, Weingarten TN, Radoš M, Kostović I, Grizelj R. Regional cerebral oxygen saturation variability and brain injury in preterm infants. Front Pediatr 2024; 12:1426874. [PMID: 39105161 PMCID: PMC11298368 DOI: 10.3389/fped.2024.1426874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Accepted: 07/09/2024] [Indexed: 08/07/2024] Open
Abstract
Objective To examine whether variation of regional cerebral oxygen saturation (rScO2) within three days after delivery predicts development of brain injury (intraventricular/cerebellar hemorrhage or white matter injury) in preterm infants. Study design A prospective study of neonates <32 weeks gestational age with normal cranial ultrasound admitted between 2018 and 2022. All received rScO2 monitoring with near-infrared spectroscopy at admission up to 72 h of life. To assess brain injury a magnetic resonance imaging was performed at term-equivalent age. We assessed the association between rScO2 variability (short-term average real variability, rScO2ARV, and standard deviation, rScO2SD), mean rScO2 (rScO2MEAN), and percentage of time rScO2 spent below 60% (rScO2TIME<60%) during the first 72 h of life and brain injury. Results The median [IQR] time from birth to brain imaging was 68 [59-79] days. Of 81 neonates, 49 had some form of brain injury. Compared to neonates without injury, in those with injury rScO2ARV was higher during the first 24 h (P = 0.026); rScO2SD was higher at 24 and 72 h (P = 0.029 and P = 0.030, respectively), rScO2MEAN was lower at 48 h (P = 0.042), and rScO2TIME<60% was longer at 24, 48, and 72 h (P = 0.050, P = 0.041, and P = 0.009, respectively). Similar results were observed in multivariable logistic regression. Although not all results were statistically significant, increased rScO2 variability (rScO2ARV and rScO2SD) and lower mean values of rScO2 were associated with increased likelihood of brain injury. Conclusions In preterm infants increased aberration of rScO2 in early postdelivery period was associated with an increased likelihood of brain injury diagnosis at term-equivalent age.
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Affiliation(s)
- Tomislav Ćaleta
- Department of Pediatrics, School of Medicine University of Zagreb, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Martin J. Ryll
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, United States
| | - Katarina Bojanić
- Division of Neonatology, Department of Obstetrics and Gynecology, University Hospital Merkur, Zagreb, Croatia
| | - Nada Sindičić Dessardo
- Department of Pediatrics, School of Medicine University of Zagreb, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Darrell R. Schroeder
- Health Sciences Research, Division of Epidemiology, Mayo Clinic College of Medicine and Science, Rochester, MN, United States
| | - Juraj Sprung
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, United States
| | - Toby N. Weingarten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, United States
| | - Milan Radoš
- Croatian Institute for Brain Research, School of Medicine University of Zagreb, Zagreb, Croatia
| | - Ivica Kostović
- Croatian Institute for Brain Research, School of Medicine University of Zagreb, Zagreb, Croatia
| | - Ruža Grizelj
- Department of Pediatrics, School of Medicine University of Zagreb, University Hospital Centre Zagreb, Zagreb, Croatia
- Center for Research on Perinatal Etiopathogenesis of Neurological and Cognitive Diseases, School of Medicine University of Zagreb, Zagreb, Croatia
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Williams EE, Dassios T, Harris C, Greenough A. Capnography waveforms: basic interpretation in neonatal intensive care. Front Pediatr 2024; 12:1396846. [PMID: 38638588 PMCID: PMC11024230 DOI: 10.3389/fped.2024.1396846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 03/26/2024] [Indexed: 04/20/2024] Open
Abstract
End-tidal capnography can provide useful clinical information displayed on the ventilator screen or bedside monitor. It is important that clinicians can assess and utilise this information to assist in identifying underlying complications and pulmonary pathology. Sudden change or loss of the CO2 waveform can act as a safety measure in alerting clinicians of a dislodged or blocked endotracheal tube, considering the concurrent flow and volume waveforms. Visual pattern recognition by the clinicians of commonly seen waveform traces may act as an adjunct to other modes of ventilatory monitoring techniques. Waveforms traces can aid clinical management, help identify cases of ventilation asynchrony between the infant and the ventilator. We present some common clinical scenarios where tidal capnography can be useful in the timely identification of pulmonary complication and for practical troubleshooting at the cot-side.
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Affiliation(s)
- Emma E. Williams
- Department of Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
| | - Theodore Dassios
- Department of Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
- Neonatal Intensive Care Centre, King’s College Hospital NHS Foundation Trust, London, United Kingdom
| | - Christopher Harris
- Department of Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
- Neonatal Intensive Care Centre, King’s College Hospital NHS Foundation Trust, London, United Kingdom
| | - Anne Greenough
- Department of Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
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Molloy EJ, El-Dib M, Soul J, Juul S, Gunn AJ, Bender M, Gonzalez F, Bearer C, Wu Y, Robertson NJ, Cotton M, Branagan A, Hurley T, Tan S, Laptook A, Austin T, Mohammad K, Rogers E, Luyt K, Wintermark P, Bonifacio SL. Neuroprotective therapies in the NICU in preterm infants: present and future (Neonatal Neurocritical Care Series). Pediatr Res 2024; 95:1224-1236. [PMID: 38114609 PMCID: PMC11035150 DOI: 10.1038/s41390-023-02895-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 10/19/2023] [Accepted: 10/26/2023] [Indexed: 12/21/2023]
Abstract
The survival of preterm infants has steadily improved thanks to advances in perinatal and neonatal intensive clinical care. The focus is now on finding ways to improve morbidities, especially neurological outcomes. Although antenatal steroids and magnesium for preterm infants have become routine therapies, studies have mainly demonstrated short-term benefits for antenatal steroid therapy but limited evidence for impact on long-term neurodevelopmental outcomes. Further advances in neuroprotective and neurorestorative therapies, improved neuromonitoring modalities to optimize recruitment in trials, and improved biomarkers to assess the response to treatment are essential. Among the most promising agents, multipotential stem cells, immunomodulation, and anti-inflammatory therapies can improve neural outcomes in preclinical studies and are the subject of considerable ongoing research. In the meantime, bundles of care protecting and nurturing the brain in the neonatal intensive care unit and beyond should be widely implemented in an effort to limit injury and promote neuroplasticity. IMPACT: With improved survival of preterm infants due to improved antenatal and neonatal care, our focus must now be to improve long-term neurological and neurodevelopmental outcomes. This review details the multifactorial pathogenesis of preterm brain injury and neuroprotective strategies in use at present, including antenatal care, seizure management and non-pharmacological NICU care. We discuss treatment strategies that are being evaluated as potential interventions to improve the neurodevelopmental outcomes of infants born prematurely.
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Affiliation(s)
- Eleanor J Molloy
- Paediatrics, Trinity College Dublin, Trinity Research in Childhood Centre (TRICC), Dublin, Ireland.
- Children's Hospital Ireland (CHI) at Tallaght, Dublin, Ireland.
- Neonatology, CHI at Crumlin, Dublin, Ireland.
- Neonatology, Coombe Women's and Infants University Hospital, Dublin, Ireland.
| | - Mohamed El-Dib
- Department of Pediatrics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Janet Soul
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sandra Juul
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Alistair J Gunn
- Departments of Physiology and Paediatrics, School of Medical Sciences, University of Auckland, Private Bag 92019, Auckland, New Zealand
| | - Manon Bender
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Fernando Gonzalez
- Department of Neurology, Division of Child Neurology, University of California, San Francisco, California, USA
| | - Cynthia Bearer
- Division of Neonatology, Department of Pediatrics, Rainbow Babies & Children's Hospital, Cleveland, Ohio, USA
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Yvonne Wu
- Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Nicola J Robertson
- Institute for Women's Health, University College London, London, UK
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Mike Cotton
- Department of Pediatrics, Duke University, Durham, North Carolina, USA
| | - Aoife Branagan
- Paediatrics, Trinity College Dublin, Trinity Research in Childhood Centre (TRICC), Dublin, Ireland
- Neonatology, Coombe Women's and Infants University Hospital, Dublin, Ireland
| | - Tim Hurley
- Paediatrics, Trinity College Dublin, Trinity Research in Childhood Centre (TRICC), Dublin, Ireland
| | - Sidhartha Tan
- Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Abbot Laptook
- Department of Pediatrics, Women and Infants Hospital, Brown University, Providence, Rhode Island, USA
| | - Topun Austin
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Khorshid Mohammad
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Elizabeth Rogers
- Department of Pediatrics, University of California, San Francisco Benioff Children's Hospital, San Francisco, California, USA
| | - Karen Luyt
- Translational Health Sciences, University of Bristol, Bristol, UK
- Neonatology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Pia Wintermark
- Division of Neonatology, Montreal Children's Hospital, Montreal, Quebec, Canada
- McGill University Health Centre - Research Institute, Montreal, Quebec, Canada
| | - Sonia Lomeli Bonifacio
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
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5
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Dockery M, Harrison C. Understanding improved neonatal ventilation trends in a regional transport service. Acta Paediatr 2024; 113:709-715. [PMID: 38156363 DOI: 10.1111/apa.17065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 11/30/2023] [Accepted: 12/11/2023] [Indexed: 12/30/2023]
Abstract
AIM Review changes in neonatal ventilation practice within our regional transport service, Embrace, identifying interventions with greatest impact on improved rates of normocapnia during transfer. METHODS Using internal transport databases and UK Neonatal Transport Group data submissions, we tracked local and national rates of ventilation and normocapnia. We correlated this with internal changes in practice, including introduction of new equipment, staffing changes, educational interventions and quality improvement projects. RESULTS Data demonstrated improvement in normocapnia rates benchmarked against national figures, which was not explained by changes in ventilation methods or rates, or by changes in availability of post-transfer gases. Greatest improvement was identified following introduction of transcutaneous CO2 monitoring and ventilators enabling volume-guided ventilation strategies. Additionally, although less quantifiable, educational and quality improvement interventions, and case review mechanisms were felt to be influential. CONCLUSION Volume guided ventilation and transcutaneous CO2 monitoring have had a positive influence on the maintenance of normocapnia during transfer at Embrace Transport Service, although introduction of new equipment still presents challenges which must be overcome. Recognising the significant impact of these technologies allows for ongoing financial, time and educational investment to emphasise their importance and ensure appropriate awareness of limitations and troubleshooting options, maximising their positive impact.
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Affiliation(s)
- Morven Dockery
- Embrace Transport Service, Sheffield Childrens Hospital, Sheffield, UK
| | - Cath Harrison
- Embrace Transport Service, Sheffield Childrens Hospital, Sheffield, UK
- Leeds Teaching Hospital NHS Trust, Leeds, UK
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Fritz K, Sanidas G, Cardenas R, Ghaemmaghami J, Byrd C, Simonti G, Valenzuela A, Valencia I, Delivoria-Papadopoulos M, Gallo V, Koutroulis I, Dean T, Kratimenos P. Hypercapnia Causes Injury of the Cerebral Cortex and Cognitive Deficits in Newborn Piglets. eNeuro 2024; 11:ENEURO.0268-23.2023. [PMID: 38233145 PMCID: PMC10913040 DOI: 10.1523/eneuro.0268-23.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 10/30/2023] [Accepted: 11/20/2023] [Indexed: 01/19/2024] Open
Abstract
In critically ill newborns, exposure to hypercapnia (HC) is common and often accepted in neonatal intensive care units to prevent severe lung injury. However, as a "safe" range of arterial partial pressure of carbon dioxide levels in neonates has not been established, the potential impact of HC on the neurodevelopmental outcomes in these newborns remains a matter of concern. Here, in a newborn Yorkshire piglet model of either sex, we show that acute exposure to HC induced persistent cortical neuronal injury, associated cognitive and learning deficits, and long-term suppression of cortical electroencephalogram frequencies. HC induced a transient energy failure in cortical neurons, a persistent dysregulation of calcium-dependent proapoptotic signaling in the cerebral cortex, and activation of the apoptotic cascade, leading to nuclear deoxyribonucleic acid fragmentation. While neither 1 h of HC nor the rapid normalization of HC was associated with changes in cortical bioenergetics, rapid resuscitation resulted in a delayed onset of synaptosomal membrane lipid peroxidation, suggesting a dissociation between energy failure and the occurrence of synaptosomal lipid peroxidation. Even short durations of HC triggered biochemical responses at the subcellular level of the cortical neurons resulting in altered cortical activity and impaired neurobehavior. The deleterious effects of HC on the developing brain should be carefully considered as crucial elements of clinical decisions in the neonatal intensive care unit.
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Affiliation(s)
- Karen Fritz
- Drexel University College of Medicine, Philadelphia, Pennsylvania 19104
- Department of Pediatrics, St. Christopher's Hospital for Children, Philadelphia, Pennsylvania 19134
| | - Georgios Sanidas
- Center for Neuroscience Research, Children's National Research Institute, Washington, DC 20010
| | - Rodolfo Cardenas
- Center for Neuroscience Research, Children's National Research Institute, Washington, DC 20010
- Department of Pediatrics, Children's National Hospital, Washington, DC 20010
| | - Javid Ghaemmaghami
- Center for Neuroscience Research, Children's National Research Institute, Washington, DC 20010
| | - Chad Byrd
- Center for Neuroscience Research, Children's National Research Institute, Washington, DC 20010
| | - Gabriele Simonti
- Center for Neuroscience Research, Children's National Research Institute, Washington, DC 20010
| | - Adriana Valenzuela
- Center for Neuroscience Research, Children's National Research Institute, Washington, DC 20010
| | - Ignacio Valencia
- Drexel University College of Medicine, Philadelphia, Pennsylvania 19104
- Department of Pediatrics, St. Christopher's Hospital for Children, Philadelphia, Pennsylvania 19134
| | - Maria Delivoria-Papadopoulos
- Drexel University College of Medicine, Philadelphia, Pennsylvania 19104
- Department of Pediatrics, St. Christopher's Hospital for Children, Philadelphia, Pennsylvania 19134
| | - Vittorio Gallo
- Seattle Children's Research Institute, Seattle, Washington 98101
| | - Ioannis Koutroulis
- Center for Neuroscience Research, Children's National Research Institute, Washington, DC 20010
- Department of Pediatrics, Children's National Hospital, Washington, DC 20010
- The George Washington University School of Medicine and Health Sciences, Washington, DC 20052
| | - Terry Dean
- Center for Neuroscience Research, Children's National Research Institute, Washington, DC 20010
- Department of Pediatrics, Children's National Hospital, Washington, DC 20010
- The George Washington University School of Medicine and Health Sciences, Washington, DC 20052
| | - Panagiotis Kratimenos
- Center for Neuroscience Research, Children's National Research Institute, Washington, DC 20010
- Department of Pediatrics, Children's National Hospital, Washington, DC 20010
- The George Washington University School of Medicine and Health Sciences, Washington, DC 20052
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7
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Borenstein-Levin L, Avishay N, Soffer O, Arnon S, Riskin A, Dinur G, Lavie-Nevo K, Gover A, Kugelman A, Hochwald O. Transcutaneous CO 2 Monitoring in Extremely Low Birth Weight Premature Infants. J Clin Med 2023; 12:5757. [PMID: 37685823 PMCID: PMC10488371 DOI: 10.3390/jcm12175757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 08/29/2023] [Accepted: 08/30/2023] [Indexed: 09/10/2023] Open
Abstract
Extremely low birth weight (ELBW) premature infants are particularly susceptible to hypocarbia and hypercarbia, which are associated with brain and lung morbidities. Transcutaneous CO2 (TcCO2) monitoring allows for continuous non-invasive CO2 monitoring during invasive and non-invasive ventilation and is becoming more popular in the NICU. We aimed to evaluate the correlation and agreement between CO2 levels measured by a TcCO2 monitor and blood gas CO2 (bgCO2) among ELBW infants. This was a prospective observational multicenter study. All infants < 1000 g admitted to the participating NICUs during the study period were monitored by a TcCO2 monitor, if available. For each bgCO2 measured, a simultaneous TcCO2 measurement was documented. In total, 1828 pairs of TcCO2-bgCO2 values of 94 infants were collected, with a median (IQR) gestational age of 26.4 (26.0, 28.3) weeks and birth weight of 800 (702, 900) g. A moderate correlation (Pearson: r = 0.64) and good agreement (bias (95% limits of agreement)):(2.9 [-11.8, 17.6] mmHg) were found between the TcCO2 and bgCO2 values in the 25-70 mmHg TcCO2 range. The correlation between the TcCO2 and bgCO2 trends was moderate. CO2 measurements by TcCO2 are in good agreement (bias < 5 mmHg) with bgCO2 among premature infants < 1000 g during the first week of life, regardless of day of life, ventilation mode (invasive/non-invasive), and sampling method (arterial/capillary/venous). However, wide limits of agreement and moderate correlation dictate the use of TcCO2 as a complementary tool to blood gas sampling, to assess CO2 levels and trends in individual patients.
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Affiliation(s)
- Liron Borenstein-Levin
- Department of Neonatology, Rambam Health Care Campus, Haifa 3109601, Israel; (O.S.); (G.D.); (A.K.); (O.H.)
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 3200003, Israel; (N.A.); (A.R.); (K.L.-N.); (A.G.)
| | - Noa Avishay
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 3200003, Israel; (N.A.); (A.R.); (K.L.-N.); (A.G.)
| | - Orit Soffer
- Department of Neonatology, Rambam Health Care Campus, Haifa 3109601, Israel; (O.S.); (G.D.); (A.K.); (O.H.)
| | - Shmuel Arnon
- Department of Neonatology, Meir Medical Center, Kfar-Saba 4428164b, Israel;
- Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Arieh Riskin
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 3200003, Israel; (N.A.); (A.R.); (K.L.-N.); (A.G.)
- Department of Neonatology, Bnai Zion Medical Center, Haifa 32000, Israel
| | - Gil Dinur
- Department of Neonatology, Rambam Health Care Campus, Haifa 3109601, Israel; (O.S.); (G.D.); (A.K.); (O.H.)
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 3200003, Israel; (N.A.); (A.R.); (K.L.-N.); (A.G.)
| | - Karen Lavie-Nevo
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 3200003, Israel; (N.A.); (A.R.); (K.L.-N.); (A.G.)
- Department of Neonatology, Carmel Medical Center, Haifa 3436212, Israel
| | - Ayala Gover
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 3200003, Israel; (N.A.); (A.R.); (K.L.-N.); (A.G.)
- Department of Neonatology, Carmel Medical Center, Haifa 3436212, Israel
| | - Amir Kugelman
- Department of Neonatology, Rambam Health Care Campus, Haifa 3109601, Israel; (O.S.); (G.D.); (A.K.); (O.H.)
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 3200003, Israel; (N.A.); (A.R.); (K.L.-N.); (A.G.)
| | - Ori Hochwald
- Department of Neonatology, Rambam Health Care Campus, Haifa 3109601, Israel; (O.S.); (G.D.); (A.K.); (O.H.)
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 3200003, Israel; (N.A.); (A.R.); (K.L.-N.); (A.G.)
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8
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Travers CP, Carlo WA, Nakhmani A, Laney D, Chahine RA, Aban I, Ambalavanan N. Late permissive hypercapnia and respiratory stability among very preterm infants: a pilot randomised trial. Arch Dis Child Fetal Neonatal Ed 2023; 108:530-534. [PMID: 36914233 PMCID: PMC10578058 DOI: 10.1136/archdischild-2022-325166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 02/27/2023] [Indexed: 03/16/2023]
Abstract
OBJECTIVE Determine if targeting higher transcutaneous carbon dioxide improves respiratory stability among very preterm infants on ventilatory support. DESIGN Single-centre pilot randomised clinical trial. SETTING The University of Alabama at Birmingham. PATIENTS Very preterm infants on ventilatory support after postnatal day 7. INTERVENTIONS Infants were randomised to two different transcutaneous carbon dioxide levels targeting 5 mm Hg (0.67 kPa) changes with four sessions each lasting 24 hours for 96 hours: baseline-increase-baseline-increase or baseline-decrease-baseline-decrease. MAIN OUTCOME MEASURES We collected cardiorespiratory data evaluating episodes of intermittent hypoxaemia (oxygen saturations (SpO2)<85% for ≥10 s), bradycardia (<100 bpm for ≥10 s), and cerebral and abdominal hypoxaemia on near-infrared spectroscopy. RESULTS We enrolled 25 infants with a gestational age of 24 w 6 d±11 d (mean±SD) and birth weight 645±142 g on postnatal day 14±3. Continuous transcutaneous carbon dioxide values (56.8±6.9 in the higher group vs 54.5±7.8 in the lower group; p=0.36) did not differ significantly between groups during the intervention days. There were no differences in intermittent hypoxaemia (126±64 vs 105±61 per 24 hours; p=0.30) or bradycardia (11±16 vs 15±23 per hour; p=0.89) episodes between groups. The proportion of time with SpO2<85%, SpO2<80%, cerebral hypoxaemia or abdominal hypoxaemia did not differ (all p>0.05). There was moderate negative correlation between mean transcutaneous carbon dioxide and bradycardia episodes (r=-0.56; p<0.001). CONCLUSION Targeting 5 mm Hg (0.67 kPa) changes in transcutaneous carbon dioxide did not improve respiratory stability among very preterm infants on ventilatory support but the intended carbon dioxide separation was difficult to achieve and maintain. TRIAL REGISTRATION NUMBER NCT03333161.
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Affiliation(s)
- Colm P Travers
- Department of Pediatrics, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Waldemar A Carlo
- Department of Pediatrics, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Arie Nakhmani
- Department of Electrical and Computer Engineering, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Deborah Laney
- Department of Pediatrics, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Rouba A Chahine
- Department of Biostatistics, The University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Immaculada Aban
- Department of Biostatistics, The University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
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Gorbea M. Perioperative anesthetic management of premature neonates weighing less than 1500 grams undergoing transcatheter PDA (TC-PDA) closure: An institutional anesthetic experience. Heliyon 2023; 9:e17465. [PMID: 37456008 PMCID: PMC10344701 DOI: 10.1016/j.heliyon.2023.e17465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 06/16/2023] [Accepted: 06/19/2023] [Indexed: 07/18/2023] Open
Abstract
Objectives The aim of our study is to describe the various anesthetic techniques and intraoperative management used during transcatheter closure of hemodynamically significant PDAs in VLBW premature infants weighing less than 1.5 kg and their potential impact on postoperative outcomes using a retrospective chart review. Design A retrospective electronic medical chart review was performed in infants who underwent Transcatheter Patent Ductus Arteriosus (TC-PDA) closure at an academic institution between January 1, 2008 and October 4th 2019. Only premature patients with isolated PDA weighing less than 1500 g at the time of the procedure were included in the study. Setting Single Institutional Hospital. Participants Premature patients with isolated PDA weighing less than 1500 g at the time of the procedure. Interventions None. Measurements and main results Interprocedurally, there was no evidence of device embolization or clinically significant vascular obstruction on follow-up echocardiography, and inotropic or vasoactive infusions were not required. All patients survived and were discharged from the hospital after a mean of 86.4 ± 48.49 days (median 74, range 40-180) following initial admission to the NICU. At 7 post-operative days, freedom from ventilatory support reached 70% in all patients. Incidences of device embolization or clinically significant vascular obstruction were not noted on follow-up echocardiography. Conclusions Though our preliminary findings show promising outcomes following TC-PDA closure relative to traditional surgical approaches, further investigations with higher patient volume are needed to validate these promising observations.
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10
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Depala KS, Chintala S, Joshi S, Budhani S, Paidipelly N, Patel B, Rastogi A, Madas N, Vejju R, Mydam J. Clinical Variables Associated With Grade III and IV Intraventricular Hemorrhage (IVH) in Preterm Infants Weighing Less Than 750 Grams. Cureus 2023; 15:e40471. [PMID: 37456494 PMCID: PMC10349592 DOI: 10.7759/cureus.40471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND Despite innovative advances in neonatal medicine, intraventricular hemorrhage (IVH) continues to be a significant complication in neonatal intensive care units globally. OBJECTIVE The study aimed to discern the variables heightening the risk of severe IVH (Grade III and IV) in extremely premature infants weighing less than 750 grams. We postulated that a descending hematocrit (Hct) trend during the first week of life could serve as a predictive marker for the development of severe IVH in this vulnerable population. METHODS This retrospective case-control study encompassed infants weighing less than 750 grams at birth, diagnosed with Grade III and/or IV IVH, and born in a tertiary center from 2009 to 2014. A group of 17 infants with severe IVH was compared with 14 gestational age-matched controls. Acid-base status, glucose, fluid goal, urine output, and nutrient (caloric and protein) intake during the first four days of life were meticulously evaluated. Statistically significant variables from baseline data were further analyzed via univariable and multivariable logistic regression analyses, ensuring control for potential confounding variables. RESULTS The univariate logistic regression model delineated odds ratios (ORs) of 0.842 for day 2 average Hct (confidence interval [CI], 0.718-0.987) and 0.16 for urine output on day 3 (CI, 0.024-1.056), with the remaining six variables demonstrating no significant association. In the post-multivariable regression analysis, day 2 Hct was the only significant variable (OR, 0.731; 95% CI, 0.537-0.995; P=0.04). The receiver operating characteristic (ROC) curve analysis portrayed an area under the curve of 71% for the day 2 Hct variable. CONCLUSION The study revealed that a dip in Hct on day 2 of life augments the likelihood of Grade III and IV IVH among extremely premature infants with a birth weight of less than 750 grams. This insight amplifies our understanding of risk factors associated with severe IVH development in extremely preterm infants, potentially aiding in refining preventive strategies and optimizing clinical management and treatment of these affected infants.
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Affiliation(s)
- Kiran S Depala
- Department of Public Health and Social Justice, Saint Louis University, St. Louis, USA
| | - Soumini Chintala
- Department of Pediatrics, Phoenix Children's Hospital, Phoenix, USA
| | - Swosti Joshi
- Department of Neonatology, John H. Stroger, Jr. Hospital of Cook County, Chicago, USA
| | - Shaaista Budhani
- Department of Neonatology, John H. Stroger, Jr. Hospital of Cook County, Chicago, USA
| | - Nihal Paidipelly
- Department of Chemistry, Case Western Reserve University, Cleveland, USA
| | - Bansari Patel
- School of Medicine, American University of Barbados, Bridgetown, BRB
| | - Alok Rastogi
- Department of Neonatology, John H. Stroger, Jr. Hospital of Cook County, Chicago, USA
| | - Nimisha Madas
- Department of Internal Medicine, Northwestern Medicine McHenry Hospital, McHenry, USA
| | - Revanth Vejju
- Department of Biology, New Jersey Institute of Technology, Newark, USA
| | - Janardhan Mydam
- Department of Neonatology, John H. Stroger, Jr. Hospital of Cook County, Chicago, USA
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11
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Respiratory Management of the Preterm Infant: Supporting Evidence-Based Practice at the Bedside. CHILDREN 2023; 10:children10030535. [PMID: 36980093 PMCID: PMC10047523 DOI: 10.3390/children10030535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/10/2023] [Accepted: 03/08/2023] [Indexed: 03/14/2023]
Abstract
Extremely preterm infants frequently require some form of respiratory assistance to facilitate the cardiopulmonary transition that occurs in the first hours of life. Current resuscitation guidelines identify as a primary determinant of overall newborn survival the establishment, immediately after birth, of adequate lung inflation and ventilation to ensure an adequate functional residual capacity. Any respiratory support provided, however, is an important contributing factor to the development of bronchopulmonary dysplasia. The risks correlated to invasive ventilatory techniques increase inversely with gestational age. Preterm infants are born at an early stage of lung development and are more susceptible to lung injury deriving from mechanical ventilation. Any approach aiming to reduce the global burden of preterm lung disease must implement lung-protective ventilation strategies that begin from the newborn’s first breaths in the delivery room. Neonatologists today must be able to manage both invasive and noninvasive forms of respiratory assistance to treat a spectrum of lung diseases ranging from acute to chronic conditions. We searched PubMed for articles on preterm infant respiratory assistance. Our narrative review provides an evidence-based overview on the respiratory management of preterm infants, especially in the acute phase of neonatal respiratory distress syndrome, starting from the delivery room and continuing in the neonatal intensive care unit, including a section regarding exogenous surfactant therapy.
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12
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Benlamri A, Murthy P, Zein H, Thomas S, Scott JN, Abou Mehrem A, Esser MJ, Lodha A, Noort J, Tang S, Metcalfe C, Kowal D, Irvine L, Scotland J, Leijser LM, Mohammad K. Neuroprotection care bundle implementation is associated with improved long-term neurodevelopmental outcomes in extremely premature infants. J Perinatol 2022; 42:1380-1384. [PMID: 35831577 DOI: 10.1038/s41372-022-01443-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/08/2022] [Accepted: 06/15/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To study the impact of an evidence-based neuroprotection care (NPC) bundle on long-term neurodevelopmental impairment (NDI) in infants born extremely premature. STUDY DESIGN An NPC bundle targeting predefined risk factors for acute brain injury in extremely preterm infants was implemented. We compared the incidence of composite outcome of death or severe neurodevelopmental impairment (sNDI) at 21 months adjusted age pre and post bundle implementation. RESULTS Adjusting for confounding factors, NPC bundle implementation associated with a significant reduction in death or sNDI (aOR, 0.34; 95% CI 0.17-0.68; P = 0.002), mortality (aOR, 0.31; 95% CI (0.12-0.79); P = 0.015), sNDI (aOR, 0.37; 95% CI: 0.12-0.94; P = 0.039), any motor, language, or cognitive composite score <70 (aOR, 0.48; 95% CI: 0.26-0.90; P = 0.021). CONCLUSION Implementation of NPC bundle targeting predefined risk factors is associated with a reduction in mortality or sNDI in extremely preterm infants.
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Affiliation(s)
- Amina Benlamri
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, AB, Canada
| | - Prashanth Murthy
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, AB, Canada
| | - Hussein Zein
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, AB, Canada
| | - Sumesh Thomas
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, AB, Canada
| | - James N Scott
- Department of Diagnostic Imaging, Division of Neuroradiology, University of Calgary, Calgary, AB, Canada
| | - Ayman Abou Mehrem
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, AB, Canada
| | - Michael J Esser
- Department of Pediatrics, Section of Neurology, University of Calgary, Calgary, AB, Canada
| | - Abhay Lodha
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, AB, Canada
| | - Jennessa Noort
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, AB, Canada
| | - Selphee Tang
- Department of Obstetrics and Gynecology, Alberta Health Services, Calgary, AB, Canada
| | - Cathy Metcalfe
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, AB, Canada
| | - Derek Kowal
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, AB, Canada
| | - Leigh Irvine
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, AB, Canada
| | - Jillian Scotland
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, AB, Canada
| | - Lara M Leijser
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, AB, Canada
| | - Khorshid Mohammad
- Department of Pediatrics, Section of Neonatology, University of Calgary, Calgary, AB, Canada.
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13
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Kaufmann J, Wappler F. Kinderanästhesie – kompetente Versorgung im Fokus. Anasthesiol Intensivmed Notfallmed Schmerzther 2022; 57:520-522. [PMID: 36049736 DOI: 10.1055/a-1889-3369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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14
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Differential regional cerebrovascular reactivity to end-tidal gas combinations commonly seen during anaesthesia: A blood oxygenation level-dependent MRI observational study in awake adult subjects. Ugeskr Laeger 2022; 39:774-784. [PMID: 35852545 DOI: 10.1097/eja.0000000000001716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Regional cerebrovascular reactivity (rCVR) is highly variable in the human brain as measured by blood oxygenation level-dependent (BOLD) MRI to changes in both end-tidal CO 2 and O 2 . OBJECTIVES We examined awake participants under carefully controlled end-tidal gas concentrations to assess how regional CVR changes may present with end-tidal gas changes seen commonly with anaesthesia. DESIGN Observational study. SETTING Tertiary care centre, Winnipeg, Canada. The imaging for the study occurred in 2019. SUBJECTS Twelve healthy adult subjects. INTERVENTIONS Cerebral BOLD response was studied under two end-tidal gas paradigms. First end-tidal oxygen (ETO 2 ) maintained stable whereas ETCO 2 increased incrementally from hypocapnia to hypercapnia (CO 2 ramp); second ETCO 2 maintained stable whereas ETO 2 increased from normoxia to hyperoxia (O 2 ramp). BOLD images were modeled with end-tidal gas sequences split into two equal segments to examine regional CVR. MAIN OUTCOME MEASURES The voxel distribution comparing hypocapnia to mild hypercapnia and mild hyperoxia (mean F I O 2 = 0.3) to marked hyperoxia (mean F I O 2 = 0.7) were compared in a paired fashion ( P < 0.005 to reach threshold for voxel display). Additionally, type analysis was conducted on CO 2 ramp data. This stratifies the BOLD response to the CO 2 ramp into four categories of CVR slope based on segmentation (type A; +/+slope: normal response, type B +/-, type C -/-: intracranial steal, type D -/+.) Types B to D represent altered responses to the CO 2 stimulus. RESULTS Differential regional responsiveness was seen for both end-tidal gases. Hypocapnic regional CVR was more marked than hypercapnic CVR in 0.3% of voxels examined ( P < 0.005, paired comparison); the converse occurred in 2.3% of voxels. For O 2 , mild hyperoxia had more marked CVR in 0.2% of voxels compared with greater hyperoxia; the converse occurred in 0.5% of voxels. All subjects had altered regional CO 2 response based on Type Analysis ranging from 4 ± 2 to 7 ± 3% of voxels. CONCLUSION In awake subjects, regional differences and abnormalities in CVR were observed with changes in end-tidal gases common during the conduct of anaesthesia. On the basis of these findings, consideration could be given to minimising regional CVR fluctuations in patients-at-risk of neurological complications by tighter control of end-tidal gases near the individual's resting values.
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15
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Perlman JM. Periventricular- intraventricular hemorrhage in the premature infant- A historical perspective. Semin Perinatol 2022; 46:151591. [PMID: 35422351 DOI: 10.1016/j.semperi.2022.151591] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The objective of this chapter is to trace the evolution of intraventricular hemorrhage in the premature infant highlighting the importance of the germinal matrix, a critical role for cerebral blood flow changes in the genesis of hemorrhage, clinical factors that increase the bleeding risk, and potential preventative strategies. In 1976, neuropathological studies demonstrated capillary rupture within the germinal matrix as the precursor of hemorrhage. In 1980, introduction of cranial ultrasound facilitated diagnosis of intraventricular hemorrhage. In 1979, loss of cerebral autoregulation in sick newborn infants was demonstrated. In the 1980's, studies demonstrated the importance of intravascular factors in provoking hemorrhage. In 1983, the association of cerebral blood flow velocity fluctuations and subsequent hemorrhage was demonstrated. In 1994, antenatal steroids use to accelerate lung development was recommended. This was associated with an unanticipated reduction in hemorrhage. In the mid 1990's early indomethacin administration was associated with a reduction of severe hemorrhage.
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Affiliation(s)
- Jeffrey M Perlman
- Department of Pediatrics, Weill Cornell Medicine, Division Chief of Newborn Medicine, New York Presbyterian Hospital, 1283 York Avenue 15(th) Floor, New York, NY, 10065.
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16
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Abstract
Despite improvements in the mortality rates of preterm infants, rates of germinal matrix intraventricular hemorrhage (IVH) have remained static with an overall incidence of 25% in infants less than 32 weeks. The importance of the lesion relates primarily to the underlying injury to the developing brain and the associated long-term neurodevelopmental consequences. This clinical-orientated review focuses on the pathogenesis of IVH and discusses the evidence behind proposed prevention strategies.
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Affiliation(s)
- Aisling A Garvey
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Brian H Walsh
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA, USA; Department of Neonatology, Cork University Maternity Hospital, Cork, Ireland
| | - Terrie E Inder
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
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17
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Kasirer Y, David EB, Hammerman C, Shchors I, Nun AB. Hypercapnia: An Added Culprit in Gray Matter Injury in Preterm Neonates. Neuropediatrics 2022; 53:251-256. [PMID: 34983072 DOI: 10.1055/a-1730-7878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Over the last decade, there has been increased recognition of diverse forms of primary gray matter injury (GMI) in postpreterm neonates. In this study, we aimed to assess whether early neonatal hypercapnia in the preterm infant was associated with GMI on magnetic resonance imaging (MRI) at term equivalent age (TEA). All blood gases taken during the first 2 weeks of life were analyzed for hypercapnia. MRI was performed at TEA postpreterm infants using a unique neonatal MRI 1T scanner. The neonatal MRI scans were assessed using a standardized scoring system, the Kidokoro scoring system, a method used to assess abnormal brain metrics and the presence and severity of brain abnormalities. Subscores are assigned for different regions of the brain. Twenty-nine infants were studied, about half of whom had evidence of some gray matter abnormality. Fifteen of the infants were hypercapnic. The hypercapnic infants had significantly higher deep gray matter abnormality readings as compared with the nonhypercapnic infants (12 [11; 12] vs. 10 [8; 11], respectively; p = 0.0106). Correlations were observed between peak pCO2 over the first 2 weeks of life and the overall gray matter abnormality score (GMAS) at TEA, and between the percentage of hypercapnic blood gases during the first 2 weeks of life and the GMAS. All of the infants in our population who had severe GMI at TEA were hypercapnic in the first 2 weeks of life. In conclusion, our data show a correlation between early hypercapnia in preterm neonates and GMI at TEA.
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Affiliation(s)
- Yair Kasirer
- Department of Neonatology, Shaare Zedek Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Eliel Ben David
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Radiology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Cathy Hammerman
- Department of Neonatology, Shaare Zedek Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Irina Shchors
- Department of Neonatology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Alona Bin Nun
- Department of Neonatology, Shaare Zedek Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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18
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Buglowski M, Pfannschmidt V, Becker S, Braun O, Hutten M, Ophelders D, Oprea C, Pattai S, Schoberer M, Stollenwerk A. Closed-Loop Control of Arterial CO 2 in Mechanical Ventilation of Neonates. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2022; 2022:4991-4995. [PMID: 36083943 DOI: 10.1109/embc48229.2022.9871185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
During mechanical ventilation of the neonate the main goal is to stabilize respiratory function of the often premature lungs. Ventilating the patient without inflicting harm is then the subordinated next goal. Ideally the arterial partial pressure of CO2 lays within a normocapnic range and fluctuations are kept minimal. By closely monitoring CO2 and controlling ventilation parameters accordingly, CO2 levels in the blood can be managed. We present an approach consisting of a cascaded controller for arterial CO2 by approximating arterial partial pressure PaCO2 from end-tidal PetCO2. As a proof of concept, feasibility of the controller was first evaluated on a mathematical patient model and subsequently in-vivo in lamb experiments. The controller is able to regulate CO2 into a normocapnic range in both setups with satisfactory stationarity within the target range. Estimation of the arterial partial pressure of CO2 remains a critical aspect that needs to be further investigated. Clinical relevance-Closed-loop control of CO2 in mechanical ventilation aims to avoid PaC O2 extremes and to reduce fluctuations. Both are a relevant risk factors especially for neurological complications among preterm newborns.
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19
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Silvera F, Gagliardi T, Vollono P, Fernández C, García-Bayce A, Berardi A, Badía M, Beltrán B, Cabral T, Abella P, Farías L, Vaamonde L, Martell M, Blasina F. Study of the relationship between regional cerebral saturation and pCO2 changes during mechanical ventilation to evaluate modifications in cerebral perfusion in a newborn piglet model. Braz J Med Biol Res 2022; 55:e11543. [PMID: 35239775 PMCID: PMC8905677 DOI: 10.1590/1414-431x2022e11543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 01/04/2022] [Indexed: 11/22/2022] Open
Abstract
Near-infrared spectroscopy (NIRS) could be a useful continuous, non-invasive technique for monitoring the effect of partial pressure of carbon dioxide (PaCO2) fluctuations in the cerebral circulation during ventilation. The aim of this study was to examine the efficacy of NIRS to detect acute changes in cerebral blood flow following PaCO2 fluctuations after confirming the autoregulation physiology in piglets. Fourteen piglets (<72 h of life) were studied. Mean arterial blood pressure, oxygen saturation, pH, glycemia, hemoglobin, electrolytes, and temperature were monitored. Eight animals were used to evaluate brain autoregulation, assessing superior cava vein Doppler as a proxy of cerebral blood flow changing mean arterial blood pressure. Another 6 animals were used to assess hypercapnia generated by decreasing ventilatory settings and complementary CO2 through the ventilator circuit and hypocapnia due to increasing ventilatory settings. Cerebral blood flow was determined by jugular vein blood flow by Doppler and continuously monitored with NIRS. A decrease in PaCO2 was observed after hyperventilation (47.6±2.4 to 29.0±4.9 mmHg). An increase in PaCO2 was observed after hypoventilation (48.5±5.5 to 90.4±25.1 mmHg). A decrease in cerebral blood flow after hyperventilation (21.8±10.4 to 15.1±11.0 mL/min) and an increase after hypoventilation (23.4±8.4 to 38.3±10.5 mL/min) were detected by Doppler ultrasound. A significant correlation was found between cerebral oxygenation and Doppler-derived parameters of blood flow and PaCO2. Although cerebral NIRS monitoring is mainly used to detect changes in regional brain oxygenation, modifications in cerebral blood flow following experimental PaCO2 changes were detected in newborn piglets when no other important variables were modified.
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Affiliation(s)
- F Silvera
- Department of Neonatology, Centro Hospitalario Pereira Rossell, Administración de los Servicios de Salud del Estado, and Faculty of Medicine, Republic University, Montevideo, Uruguay
| | - T Gagliardi
- Department of Neonatology, Hospital de Clínicas Dr. Manuel Quintela, Faculty of Medicine, Republic University, Montevideo, Uruguay
| | - P Vollono
- Department of Neonatology, Hospital de Clínicas Dr. Manuel Quintela, Faculty of Medicine, Republic University, Montevideo, Uruguay
| | - C Fernández
- Department of Neonatology, Hospital de Clínicas Dr. Manuel Quintela, Faculty of Medicine, Republic University, Montevideo, Uruguay
| | - A García-Bayce
- Division of Pediatric Imagenology, Centro Hospitalario Pereira Rossell, Administración de los Servicios de Salud del Estado, and Faculty of Medicine, Republic University, Montevideo, Uruguay
| | - A Berardi
- Department of Neonatology, Centro Hospitalario Pereira Rossell, Administración de los Servicios de Salud del Estado, and Faculty of Medicine, Republic University, Montevideo, Uruguay
| | - M Badía
- Department of Neonatology, Hospital de Clínicas Dr. Manuel Quintela, Faculty of Medicine, Republic University, Montevideo, Uruguay
| | - B Beltrán
- Department of Neonatology, Hospital de Clínicas Dr. Manuel Quintela, Faculty of Medicine, Republic University, Montevideo, Uruguay
| | - T Cabral
- Department of Neonatology, Hospital de Clínicas Dr. Manuel Quintela, Faculty of Medicine, Republic University, Montevideo, Uruguay
| | - P Abella
- Department of Neonatology, Hospital de Clínicas Dr. Manuel Quintela, Faculty of Medicine, Republic University, Montevideo, Uruguay
| | - L Farías
- Department of Neonatology, Hospital de Clínicas Dr. Manuel Quintela, Faculty of Medicine, Republic University, Montevideo, Uruguay
| | - L Vaamonde
- Department of Neonatology, Hospital de Clínicas Dr. Manuel Quintela, Faculty of Medicine, Republic University, Montevideo, Uruguay
| | - M Martell
- Department of Neonatology, Hospital de Clínicas Dr. Manuel Quintela, Faculty of Medicine, Republic University, Montevideo, Uruguay
| | - F Blasina
- Department of Neonatology, Hospital de Clínicas Dr. Manuel Quintela, Faculty of Medicine, Republic University, Montevideo, Uruguay
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20
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Travers CP, Gentle S, Freeman AE, Nichols K, Shukla VV, Purvis D, Dolma K, Winter L, Ambalavanan N, Carlo WA, Lal CV. A Quality Improvement Bundle to Improve Outcomes in Extremely Preterm Infants in the First Week. Pediatrics 2022; 149:184566. [PMID: 35088085 PMCID: PMC9677934 DOI: 10.1542/peds.2020-037341] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/07/2021] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVES Our objective with this quality improvement initiative was to reduce rates of severe intracranial hemorrhage (ICH) or death in the first week after birth among extremely preterm infants. METHODS The quality improvement initiative was conducted from April 2014 to September 2020 at the University of Alabama at Birmingham's NICU. All actively treated inborn extremely preterm infants without congenital anomalies from 22 + 0/7 to 27 + 6/7 weeks' gestation with a birth weight ≥400 g were included. The primary outcome was severe ICH or death in the first 7 days after birth. Balancing measures included rates of acute kidney injury and spontaneous intestinal perforation. Outcome and process measure data were analyzed by using p-charts. RESULTS We studied 820 infants with a mean gestational age of 25 + 3/7 weeks and median birth weight of 744 g. The rate of severe ICH or death in the first week after birth decreased from the baseline rate of 27.4% to 15.0%. The rate of severe ICH decreased from a baseline rate of 16.4% to 10.0%. Special cause variation in the rate of severe ICH or death in the first week after birth was observed corresponding with improvement in carbon dioxide and pH targeting, compliance with delayed cord clamping, and expanded use of indomethacin prophylaxis. CONCLUSIONS Implementation of a bundle of evidence-based potentially better practices by using specific electronic order sets was associated with a lower rate of severe ICH or death in the first week among extremely preterm infants.
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Affiliation(s)
- Colm P. Travers
- Division of Neonatology, Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Samuel Gentle
- Division of Neonatology, Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Amelia E. Freeman
- Division of Neonatology, Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Kim Nichols
- University of Alabama at Birmingham Hospital, Birmingham, Alabama
| | - Vivek V. Shukla
- Division of Neonatology, Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Donna Purvis
- University of Alabama at Birmingham Hospital, Birmingham, Alabama
| | - Kalsang Dolma
- Division of Neonatology, Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama,Division of Neonatology, Department of Pediatrics, College of Medicine, University of South Alabama, Mobile, Alabama
| | - Lindy Winter
- Division of Neonatology, Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Namasivayam Ambalavanan
- Division of Neonatology, Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Waldemar A. Carlo
- Division of Neonatology, Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Charitharth V. Lal
- Division of Neonatology, Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama,Address correspondence to Charitharth V. Lal, MD, Division of Neonatology, Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, 1700 6th Ave South, Birmingham, AL 35249. E-mail:
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21
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Brooks Peterson M, Szolnoki J. Modes of ventilation for pediatric patients under anesthesia: A Pro/Con conversation. Paediatr Anaesth 2022; 32:295-301. [PMID: 34882920 DOI: 10.1111/pan.14368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/03/2021] [Accepted: 12/06/2021] [Indexed: 11/29/2022]
Abstract
The development of sophisticated modes of ventilation for pediatric patients undergoing anesthesia is ongoing; what remains a challenge for the pediatric anesthesiologist is thoughtful selection of the mode(s) of ventilation for a particular patient in the context of the surgical procedure and the goals of the anesthetic. This article provides some historical accounting of a variety of modes of ventilation, defines the terminology of modern ventilatory modes, and reviews in detail the benefits and pitfalls of the specific modes of ventilation and their applicability to the practice of pediatric anesthesiology. In an attempt to debate the Pros and Cons of different modes of ventilation, and to finally resolve the debate "spontaneous vs. controlled ventilation," we share with you a thoughtful conversation of the continuum of modes of ventilation and their applicability to our pediatric anesthesia population.
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Affiliation(s)
- Melissa Brooks Peterson
- Pediatric Anesthesiology, University of Colorado / Children's Hospital Colorado Department of Anesthesiology, Aurora, Colorado, USA
| | - Judit Szolnoki
- Pediatric Anesthesiology, University of Central Florida, Nemours Children's Hospital Department of Anesthesiology, Orlando, Florida, USA
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22
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Carbon dioxide levels in neonates: what are safe parameters? Pediatr Res 2022; 91:1049-1056. [PMID: 34230621 PMCID: PMC9122818 DOI: 10.1038/s41390-021-01473-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 03/01/2021] [Accepted: 03/02/2021] [Indexed: 02/01/2023]
Abstract
There is no consensus on the optimal pCO2 levels in the newborn. We reviewed the effects of hypercapnia and hypocapnia and existing carbon dioxide thresholds in neonates. A systematic review was conducted in accordance with the PRISMA statement and MOOSE guidelines. Two hundred and ninety-nine studies were screened and 37 studies included. Covidence online software was employed to streamline relevant articles. Hypocapnia was associated with predominantly neurological side effects while hypercapnia was linked with neurological, respiratory and gastrointestinal outcomes and Retinpathy of prematurity (ROP). Permissive hypercapnia did not decrease periventricular leukomalacia (PVL), ROP, hydrocephalus or air leaks. As safe pCO2 ranges were not explicitly concluded in the studies chosen, it was indirectly extrapolated with reference to pCO2 levels that were found to increase the risk of neonatal disease. Although PaCO2 ranges were reported from 2.6 to 8.7 kPa (19.5-64.3 mmHg) in both term and preterm infants, there are little data on the safety of these ranges. For permissive hypercapnia, parameters described for bronchopulmonary dysplasia (BPD; PaCO2 6.0-7.3 kPa: 45.0-54.8 mmHg) and congenital diaphragmatic hernia (CDH; PaCO2 ≤ 8.7 kPa: ≤65.3 mmHg) were identified. Contradictory findings on the effectiveness of permissive hypercapnia highlight the need for further data on appropriate CO2 parameters and correlation with outcomes. IMPACT: There is no consensus on the optimal pCO2 levels in the newborn. There is no consensus on the effectiveness of permissive hypercapnia in neonates. A safe range of pCO2 of 5-7 kPa was inferred following systematic review.
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Feasibility of portable capnometer for mechanically ventilated preterm infants in the delivery room. Eur J Pediatr 2022; 181:629-636. [PMID: 34494159 PMCID: PMC8423335 DOI: 10.1007/s00431-021-04246-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 08/12/2021] [Accepted: 08/27/2021] [Indexed: 11/05/2022]
Abstract
This study aimed to determine whether a specific portable capnometer (EMMA™) can facilitate the maintenance of an appropriate partial pressure of arterial carbon dioxide (PaCO2) in intubated preterm infants in the delivery room. This study included preterm infants with a gestational age of 26 + 0 to 31 + 6 weeks who required intubation in the delivery room. We prospectively identified 40 infants who underwent the EMMA™ monitoring intervention group and 43 infants who did not undergo monitoring (historical control group). PaCO2 was evaluated either at admission in the neonatal intensive care unit or at 2 h after birth. The proportion of infants with an appropriate PaCO2 (35-60 mmHg) was greater in the intervention group than in the control group (80% vs. 42%; p = 0.001). There were no significant differences in the rate of accidental extubation (5.0% vs. 7.0%, p = 1.00) or in the proportion of infants with an appropriate PaCO2 among infants whose birth weight was < 1000 g (54% vs. 40%, p = 0.49). However, among infants whose birth weight was ≥ 1000 g, the PaCO2 tended to be more appropriate in the intervention group than in the control group (93% vs. 44%; p < 0.001).Conclusion: The EMMA™ facilitated the maintenance of an appropriate PaCO2 for mechanically ventilated preterm infants, especially infants with birth weight ≥1000 g, in the delivery room. What is Known: • An inappropriate partial pressure of arterial carbon dioxide has been associated with intraventricular hemorrhage in preterm infants. • There is a need to appropriately control the partial pressure of arterial carbon dioxide in preterm infants. What is New: • This is the first report regarding the feasibility of a portable capnometer, the EMMA™, in the delivery room. • The EMMA™ may be considered a feasible monitoring device in the delivery room for intubated preterm infants, especially infants with birth weight ≥1000 g.
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Sankaran D, Zeinali L, Iqbal S, Chandrasekharan P, Lakshminrusimha S. Non-invasive carbon dioxide monitoring in neonates: methods, benefits, and pitfalls. J Perinatol 2021; 41:2580-2589. [PMID: 34148068 PMCID: PMC8214374 DOI: 10.1038/s41372-021-01134-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 05/25/2021] [Accepted: 06/09/2021] [Indexed: 01/21/2023]
Abstract
Wide fluctuations in partial pressure of carbon dioxide (PaCO2) can potentially be associated with neurological and lung injury in neonates. Blood gas measurement is the gold standard for assessing gas exchange but is intermittent, invasive, and contributes to iatrogenic blood loss. Non-invasive carbon dioxide (CO2) monitoring has become ubiquitous in anesthesia and critical care and is being increasingly used in neonates. Two common methods of non-invasive CO2 monitoring are end-tidal and transcutaneous. A colorimetric CO2 detector (a modified end-tidal CO2 detector) is recommended by the International Liaison Committee on Resuscitation (ILCOR) and the American Academy of Pediatrics to confirm endotracheal tube placement. Continuous CO2 monitoring is helpful in trending PaCO2 in critically ill neonates on respiratory support and can potentially lead to early detection and minimization of fluctuations in PaCO2. This review includes a description of the various types of CO2 monitoring and their applications, benefits, and limitations in neonates.
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Affiliation(s)
- Deepika Sankaran
- Division of Neonatology, Department of Pediatrics, University of California Davis, Sacramento, CA, USA.
| | - Lida Zeinali
- Division of Neonatology, Department of Pediatrics, University of California Davis, Sacramento, CA, USA
| | - Sameeia Iqbal
- Division of Neonatology, Children's Hospital of Orange County, Orange, CA, USA
| | | | - Satyan Lakshminrusimha
- Division of Neonatology, Department of Pediatrics, University of California Davis, Sacramento, CA, USA
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González Á, Estay A. VENTILACIÓN MECÁNICA EN EL RECIÉN NACIDO PREMATURO EXTREMO, ¿HACIA DÓNDE VAMOS? REVISTA MÉDICA CLÍNICA LAS CONDES 2021. [DOI: 10.1016/j.rmclc.2021.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Impact of a “Brain Protection Bundle” in Reducing Severe Intraventricular Hemorrhage in Preterm Infants <30 Weeks GA: A Retrospective Single Centre Study. CHILDREN 2021; 8:children8110983. [PMID: 34828696 PMCID: PMC8624779 DOI: 10.3390/children8110983] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 10/17/2021] [Accepted: 10/18/2021] [Indexed: 11/16/2022]
Abstract
Background: despite advances in perinatal care, periventricular/intraventricular hemorrhage (IVH) continues to remain high in neonatal intensive care units (NICUs) worldwide. Studies have demonstrated the benefits of implementing interventions during the antenatal period, stabilization after birth (golden hour management) and postnatally in the first 72 h to reduce the incidence of IVH. Objective: to compare the incidence of severe intraventricular hemorrhage (IVH ≥ Grade III) before and after implementation of a “brain protection bundle” in preterm infants <30 weeks GA. Study design: a pre- and post-implementation retrospective cohort study to compare the incidence of severe IVH following execution of a “brain protection bundle for the first 72 h from 2015 to 2018. Demographics, management practices at birth and in the NICU, cranial ultrasound results and short-term morbidities were compared. Results: a total of 189 and 215 infants were included in the pre- and post-implementation phase, respectively. No difference in the incidence of severe IVH (6.9% vs. 9.8%, p = 0.37) was observed on the first cranial scan performed after 72 h of age. Conclusion: the implementation of a “brain protection bundle” was not effective in reducing the incidence of severe IVH within the first 72 h of life in our centre.
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Williams E, Dassios T, Greenough A. Carbon dioxide monitoring in the newborn infant. Pediatr Pulmonol 2021; 56:3148-3156. [PMID: 34365738 DOI: 10.1002/ppul.25605] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 07/28/2021] [Accepted: 07/29/2021] [Indexed: 11/06/2022]
Abstract
Carbon dioxide (CO2 ) monitoring is vital during mechanical ventilation of newborn infants, as morbidity increases when CO2 levels are inappropriate. Our aim was to review the uses and limitations of such noninvasive monitoring methods. Colorimetry is primarily utilized during resuscitation to determine whether successful intubation has occurred. False negative and positive results can however lead to delays in detecting tracheal versus esophageal intubation. Transcutaneous carbon dioxide sensors have limited use during resuscitation, but can be utilized to provide continuous trend data during on-going ventilation. End-tidal capnography can provide clinicians with quantitative end-tidal CO2 (EtCO2 ) values and a continuous real-time capnogram waveform trace. These devices are becoming more widely accepted for use in the neonatal population as the new devices are lightweight with minimal additional dead space. Nevertheless, they have been reported to have variable accuracy when compared to arterial CO2 measurements, however, divergence of results may be related to disease severity rather than technological limitations. During resuscitation EtCO2 can be detected by capnography more rapidly than by colorimetry. Furthermore, capnography can be currently utilized in neonatal research settings to determine the physiological dead space and ventilation inhomogeneity, and thus has potential to be beneficial to clinical care. In conclusion, novel modes of noninvasive carbon dioxide monitoring can be safely and reliably utilized in newborn infants during mechanical ventilation. Future randomized trials should aim to address which device provides the most optimal form of monitoring in different clinical contexts.
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Affiliation(s)
- Emma Williams
- Department of Woman and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Theodore Dassios
- Department of Woman and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.,Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Anne Greenough
- Department of Woman and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.,Asthma UK Centre for Allergic Mechanisms in Asthma, King's College London, London, UK.,National Institute for Health Research (NIHR) Biomedical Research Centre based at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
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Li BH, Zhao CL, Cao SL, Geng HL, Li JJ, Zhu M, Niu SP. Effect of electrode temperature on measurements of transcutaneous carbon dioxide partial pressure and oxygen partial pressure in very low birth weight infants. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2021; 23:809-813. [PMID: 34511170 PMCID: PMC8428917 DOI: 10.7499/j.issn.1008-8830.2103143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 06/16/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To evaluate the accuracy and safety of measurements of transcutaneous carbon dioxide partial pressure (TcPCO2) and transcutaneous oxygen partial pressure (TcPO2) at electrode temperatures lower than the value used in clinical practice in very low birth weight infants. METHODS A total of 45 very low birth weight infants were enrolled. TcPCO2 and TcPO2 measurements were performed in these infants. Two transcutaneous monitors were placed simultaneously for each subject. One electrode was set and maintained at 42℃ used in clinical practice for neonates (control group), and the other was successively set at 38℃, 39℃, 40°C, and 41℃ (experimental group). The paired t-test was used to compare the measurement results between the groups. A Pearson correlation analysis was used to analyze the correlation between the measurement results of the experimental group and control group, and between the measurement results of experimental group and arterial blood gas parameters. RESULTS There was no significant difference in TcPCO2 between each experimental subgroup (38-41℃) and the control group. TcPCO2 in each experimental subgroup (38-41℃) was strongly positively correlated with TcPCO2 in the control group (r>0.9, P<0.05) and arterial carbon dioxide partial pressure (r>0.8, P<0.05). There were significant differences in TcPO2 between each experimental subgroup (38-41℃) and the control group (P<0.05), but TcPO2 in each experimental subgroup (38-41℃) was positively correlated with TcPO2 in the control group (r=0.493-0.574, P<0.05) and arterial oxygen partial pressure (r=0.324-0.399, P<0.05). No skin injury occurred during transcutaneous measurements at all electrode temperatures. CONCLUSIONS Lower electrode temperatures (38-41℃) can accurately measure blood carbon dioxide partial pressure in very low birth weight infants, and thus can be used to replace the electrode temperature of 42°C. Transcutaneous measurements at the lower electrode temperatures may be helpful for understanding the changing trend of blood oxygen partial pressure.
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Affiliation(s)
- Bing-Hui Li
- Department of Neonatology, Zibo Maternal and Child Health Hospital, Zibo, Shandong 255000, China
| | - Chang-Liang Zhao
- Department of Neonatology, Zibo Maternal and Child Health Hospital, Zibo, Shandong 255000, China
| | - Shun-Li Cao
- Department of Neonatology, Zibo Maternal and Child Health Hospital, Zibo, Shandong 255000, China
| | - Hong-Li Geng
- Department of Neonatology, Zibo Maternal and Child Health Hospital, Zibo, Shandong 255000, China
| | - Jing-Jing Li
- Department of Neonatology, Zibo Maternal and Child Health Hospital, Zibo, Shandong 255000, China
| | - Min Zhu
- Department of Neonatology, Zibo Maternal and Child Health Hospital, Zibo, Shandong 255000, China
| | - Shi-Ping Niu
- Department of Neonatology, Zibo Maternal and Child Health Hospital, Zibo, Shandong 255000, China
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Williams E, Dassios T, O'Reilly N, Walsh A, Greenough A. End-tidal capnography monitoring in infants ventilated on the neonatal intensive care unit. J Perinatol 2021; 41:1718-1724. [PMID: 33649438 PMCID: PMC7917950 DOI: 10.1038/s41372-021-00978-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 12/22/2020] [Accepted: 01/28/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To assess whether end-tidal capnography (EtCO2) monitoring reduced the magnitude of difference in carbon dioxide (CO2) levels and the number of blood gases in ventilated infants. STUDY DESIGN A case-control study of a prospective cohort (n = 36) with capnography monitoring and matched historical controls (n = 36). RESULT The infants had a median gestational age of 31.6 weeks. A reduction in the highest CO2 level on day 1 after birth was observed after the introduction of EtCO2 monitoring (p = 0.043). There was also a reduction in the magnitude of difference in CO2 levels on days 1 (p = 0.002) and 4 (p = 0.049) after birth. There was no significant difference in the number of blood gases. CONCLUSION Continuous end-tidal capnography monitoring in ventilated infants was associated with a reduction in the degree of the magnitude of difference in CO2 levels and highest level of CO2 on the first day after birth.
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Affiliation(s)
- Emma Williams
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- The Asthma UK Centre for Allergic Mechanisms in Asthma, King's College London, London, UK
| | - Theodore Dassios
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Neonatal Intensive Care Unit, King's College Hospital NHS Foundation Trust, London, UK
| | - Niamh O'Reilly
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Alison Walsh
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Anne Greenough
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.
- The Asthma UK Centre for Allergic Mechanisms in Asthma, King's College London, London, UK.
- NIHR Biomedical Research Centre based at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK.
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Travers CP, Carlo WA. Carbon dioxide and brain injury in preterm infants. J Perinatol 2021; 41:183-184. [PMID: 33033389 DOI: 10.1038/s41372-020-00842-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 08/24/2020] [Accepted: 09/18/2020] [Indexed: 11/09/2022]
Affiliation(s)
- Colm P Travers
- University of Alabama at Birmingham, Birmingham, AL, USA
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Sullivan KP, White HO, Grover LE, Negron JJ, Lee AF, Rhein LM. Transcutaneous carbon dioxide pattern and trend over time in preterm infants. Pediatr Res 2021; 90:840-846. [PMID: 33469188 PMCID: PMC7814526 DOI: 10.1038/s41390-020-01308-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 10/08/2020] [Accepted: 10/29/2020] [Indexed: 01/30/2023]
Abstract
BACKGROUND Chronic lung disease remains a burden for extremely preterm infants. The changes in ventilation over time and optimal ventilatory management remains unknown. Newer, non-invasive technologies provide insight into these patterns. METHODS This single-center prospective cohort study enrolled infants ≤32 0/7 weeks. We obtained epochs of transcutaneous carbon dioxide (TcCO2) measurements twice each week to describe the pattern of hypercarbia throughout their hospitalization. RESULTS Patterns of hypercarbia varied based on birth gestational age and post-menstrual age (PMA) (p = 0.03), regardless of respiratory support. Infants receiving the most respiratory support had values 16-21 mmHg higher than those on room air (p < 0.001). Infants born at the youngest gestational ages had the greatest total change but the rate of change was slower (p = 0.049) compared to infants born at later gestational ages. All infants had TcCO2 values stabilize by 31-33 weeks PMA, when values were not significantly different compared to discharge. No rebound was observed when infants weaned off invasive support. CONCLUSIONS Hypercarbia improves as infants approached 31-33 weeks PMA. Hypercarbia was the highest in the most immature infants and improved with age and growth despite weaning respiratory support. IMPACT This study describes the evolution of hypercarbia as very preterm infants grow and develop. The pattern of ventilation is significantly different depending on the gestational age at birth and post-menstrual age. Average transcutaneous carbon dioxide (TCO2) decreased over time as infants became more mature despite weaning respiratory support. This improvement was most significant in infants born at the lowest gestational ages.
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Affiliation(s)
- Katherine P. Sullivan
- grid.168645.80000 0001 0742 0364Department of Neonatology, University of Massachusetts Medical School, Worcester, MA USA
| | - Heather O. White
- grid.168645.80000 0001 0742 0364Department of Neonatology, University of Massachusetts Medical School, Worcester, MA USA
| | - Lindsay E. Grover
- grid.168645.80000 0001 0742 0364Department of Neonatology, University of Massachusetts Medical School, Worcester, MA USA
| | - Jordi J. Negron
- grid.168645.80000 0001 0742 0364Department of Neonatology, University of Massachusetts Medical School, Worcester, MA USA
| | - Austin F. Lee
- grid.168645.80000 0001 0742 0364Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA USA ,grid.32224.350000 0004 0386 9924Department of Surgery, Massachusetts General Hospital, Worcester, MA USA
| | - Lawrence M. Rhein
- grid.168645.80000 0001 0742 0364Department of Neonatology, University of Massachusetts Medical School, Worcester, MA USA ,grid.168645.80000 0001 0742 0364Department of Pediatric Pulmonary Medicine, University of Massachusetts Medical School, Worcester, MA USA
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Murthy P, Zein H, Thomas S, Scott JN, Abou Mehrem A, Esser MJ, Lodha A, Metcalfe C, Kowal D, Irvine L, Scotland J, Leijser L, Mohammad K. Neuroprotection Care Bundle Implementation to Decrease Acute Brain Injury in Preterm Infants. Pediatr Neurol 2020; 110:42-48. [PMID: 32473764 DOI: 10.1016/j.pediatrneurol.2020.04.016] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 04/21/2020] [Accepted: 04/22/2020] [Indexed: 01/20/2023]
Abstract
BACKGROUND We assessed the impact of an evidence-based neuroprotection care bundle on the risk of brain injury in extremely preterm infants. METHODS We implemented a neuroprotection care bundle consisting of a combination of neuroprotection interventions such as minimal handling, midline head position, deferred cord clamping, and protocolization of hemodynamic and respiratory managements. These interventions targeted risk factors for acute brain injury in extremely preterm infants (born at gestational age less than 29 weeks) during the first three days of birth. Implementation occurred in a stepwise manner, including care bundle development by a multidisciplinary care team based on previous evidence and experience, standardization of outcome assessment tools, and education. We compared the incidence of the composite outcome of acute preterm brain injury or death preimplementation and postimplementation. RESULTS Neuroprotection care bundle implementation associated with a significant reduction in acute brain injury risk factors such as the use of inotropes (24% before, 7% after, P value < 0.001) and fluid boluses (37% before, 19% after, P value < 0.001), pneumothorax (5% before, 2% after, P value = 0.002), and opioid use (19% before, 7% after, P value < 0.001). Adjusting for confounding factors, the neuroprotection care bundle significantly reduced death or severe brain injury (adjusted odds ratio, 0.34; 95% confidence interval, 0.20 to 0.59; P value < 0.001) and severe brain injury (adjusted odds ratio, 0.31; 95% confidence interval, 0.17 to 0.58; P < 0.001). CONCLUSIONS Implementation of neuroprotection care bundle targeting predefined risk factors is feasible and effective in reducing acute brain injury in extremely preterm infants.
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Affiliation(s)
- Prashanth Murthy
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Hussein Zein
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Sumesh Thomas
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - James N Scott
- Division of Neuroradiology, Department of Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
| | - Ayman Abou Mehrem
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Michael J Esser
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Abhay Lodha
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Cathy Metcalfe
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Derek Kowal
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Leigh Irvine
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Jillian Scotland
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Lara Leijser
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Khorshid Mohammad
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada.
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Soriano SG, McCann ME. Is Anesthesia Bad for the Brain? Current Knowledge on the Impact of Anesthetics on the Developing Brain. Anesthesiol Clin 2020; 38:477-492. [PMID: 32792178 DOI: 10.1016/j.anclin.2020.05.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
There are compelling preclinical data that common general anesthetics cause increased neuroapoptosis in juvenile animals. Retrospective studies demonstrate that young children exposed to anesthesia have school difficulties, which could be caused by anesthetic neurotoxicity, perioperative hemodynamic and homeostatic instability, underlying morbidity, or the neuroinflammatory effects of surgical trauma. Unnecessary procedures should be avoided. Baseline measures of blood pressure are important in determining perioperative blood pressure goals. Inadvertent hypocapnia or moderate hypercapnia and hyperoxia or hypoxia should be avoided. Pediatric patients should be maintained in a normothermic, euglycemic state with neutral positioning. Improving outcomes of infants and children requires the collaboration of anesthesiologists, surgeons, pediatricians and neonatologists.
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Affiliation(s)
- Sulpicio G Soriano
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Mary Ellen McCann
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.
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Williams E, Dassios T, Greenough A. Assessment of sidestream end-tidal capnography in ventilated infants on the neonatal unit. Pediatr Pulmonol 2020; 55:1468-1473. [PMID: 32187888 DOI: 10.1002/ppul.24738] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 03/11/2020] [Indexed: 01/13/2023]
Abstract
OBJECTIVES Continuous monitoring of carbon dioxide (CO2 ) levels can be achieved by capnography. Our aims were to compare the performance of a sidestream capnograph with a low dead space and sampling rate to a mainstream device and evaluate whether its results correlated with arterial/capillary CO2 levels in infants with different respiratory disease severities. WORKING HYPOTHESES End-tidal carbon dioxide (EtCO2 ) results by sidestream and mainstream capnography would correlate, but the divergence of EtCO2 and CO2 results would occur in more severe lung disease. STUDY DESIGN Prospective cohort study. PATIENT-SUBJECT SELECTION Fifty infants with a median (interquartile range) gestational age of 31.1 (27.1-37.4) weeks and birth weight of 1.37 (0.76-2.95) kg. METHODOLOGY Concurrent measurements of EtCO2 in ventilated infants were made using a new Microstream sidestream device and a mainstream capnograph (gold standard). Results from both devices were compared with arterial or capillary CO2 levels. The ratio of dead space to tidal volume (Vd/Vt) was calculated to assess respiratory disease severity. RESULTS The mean difference between the concurrent measurements of EtCO2 was -0.54 ± 0.67 kPa (95% agreement levels - 1.86 to 0.77 kPa), the correlation between the two was r = .85 (P < .001). Sidestream capnography results correlated better with partial pressure of CO2 (PCO2 ) levels in infants with less (Vd/Vt < 0.35; r2 = .66, P < .001) rather than more severe (Vd/Vt > 0.35; r2 = .33, P = .01) lung disease. CONCLUSIONS The sidestream capnography performed similarly to the mainstream capnography. The poorer correlation of EtCO2 to PCO2 levels in infants with severe respiratory disease should highlight to clinicians increased ventilation-perfusion mismatch.
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Affiliation(s)
- Emma Williams
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.,The Asthma UK Centre for Allergic Mechanisms in Asthma, King's College London, London, UK
| | - Theodore Dassios
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.,Neonatal Intensive Care Unit, King's College Hospital NHS Foundation Trust, London, UK
| | - Anne Greenough
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.,The Asthma UK Centre for Allergic Mechanisms in Asthma, King's College London, London, UK.,NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
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McCann ME, Lee JK, Inder T. Beyond Anesthesia Toxicity: Anesthetic Considerations to Lessen the Risk of Neonatal Neurological Injury. Anesth Analg 2020; 129:1354-1364. [PMID: 31517675 DOI: 10.1213/ane.0000000000004271] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Infants who undergo surgical procedures in the first few months of life are at a higher risk of death or subsequent neurodevelopmental abnormalities. Although the pathogenesis of these outcomes is multifactorial, an understanding of the nature and pathogenesis of brain injury in these infants may assist the anesthesiologist in consideration of their day-to-day practice to minimize such risks. This review will summarize the main types of brain injury in preterm and term infants and their key pathways. In addition, the review will address key potential pathogenic pathways that may be modifiable including intraoperative hypotension, hypocapnia, hyperoxia or hypoxia, hypoglycemia, and hyperthermia. Each of these conditions may increase the risk of perioperative neurological injury, but their long-term ramifications are unclear.
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Affiliation(s)
- Mary Ellen McCann
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jennifer K Lee
- Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology, Johns Hopkins University, Baltimore, Maryland
| | - Terrie Inder
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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Cimino C, Saporito MAN, Vitaliti G, Pavone P, Mauceri L, Gitto E, Corsello G, Lubrano R, Falsaperla R. N-BiPAP vs n-CPAP in term neonate with respiratory distress syndrome. Early Hum Dev 2020; 142:104965. [PMID: 32044607 DOI: 10.1016/j.earlhumdev.2020.104965] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 01/22/2020] [Accepted: 01/28/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND Non-invasive respiratory ventilation has greatly improved the evolution of respiratory distress in neonates, especially for preterm infants, but few studies have investigated the use of non-invasive ventilation (NIV) in term infants. It is useful for neonatologists and nurses to identify the optimal ventilation strategy in terms of effectiveness for this group of newborns. The aim of our study was to investigate what type of respiratory support between nasal Continuous Positive Airway Pressure (nCPAP) or nasal Biphasic Positive Airway Pressure (nBiPAP) is more effective in term neonates with RDS. METHODS Our study was a retrospective observational study of 78 full term neonates who were admitted to the NICU at S. Bambino Hospital from December 2015 to December 2016 for respiratory distress at birth. All patients underwent non-invasive ventilation by nCPAP or nBiPAP were included. Oxygen saturations and vital signs were monitored continuously. We evaluated blood gas analysis parameters before treatment and after 1 h of ventilation. RESULTS During the study period, there were 78 full term newborns admitted in our NICU for neonatal distress who were treated with nCPAP ore nBIPAP ventilation. In nBiPAP patients, we noticed a statistically significant reduction in PaCO2 levels and FiO2 requirement with respect to nCPAP patients, after 1 h of ventilation with a simultaneous significant increase of pH and PaO2 levels. There was no difference in the length of NIV and hospital stay. Among nCPAP patients, two were then intubated and one developed a pneumothorax. CONCLUSION The results of our study showed that an early BiPAP ventilation on RDS is the more efficient NIV because it improves CO2 removal and reduces FiO2 requirement in comparison to nCPAP. Future studies can clarify if early BiPAP ventilation on RDS is the more efficient of NIV.
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Affiliation(s)
- Carla Cimino
- Unit of Neonatology, University Hospital "Policlinico - Vittorio Emanuele", Via Carlo Azeglio Ciampi, 95121 Catania, Italy.
| | - Marco Andrea Nicola Saporito
- Unit of Neonatology, University Hospital "Policlinico - Vittorio Emanuele", Via Carlo Azeglio Ciampi, 95121 Catania, Italy
| | - Giovanna Vitaliti
- Unit of Pediatrics and Pediatric Emergency, University Hospital "Policlinico-Vittorio Emanuele", Via Plebiscito 628, 95124 Catania, Italy
| | - Piero Pavone
- Unit of Pediatrics, University Hospital "Policlinico - Vittorio Emanuele", via Santa Sofia 78, Catania, Italy.
| | - Laura Mauceri
- Unit of Neonatology, University Hospital "Policlinico - Vittorio Emanuele", Via Carlo Azeglio Ciampi, 95121 Catania, Italy
| | - Eloisa Gitto
- Unit of Neonatal Intensive Care, University Hospital "G. Martino", Via Consolare Valeria 1, Messina, Italy.
| | - Giovanni Corsello
- Department of Maternal and Child Health, University of Palermo, Palermo, Italy.
| | - Riccardo Lubrano
- Department of Maternal and Child Health, UOC of Latina, University of La Sapienza Roma, Roma, Italy.
| | - Raffaele Falsaperla
- Unit of Neonatology, University Hospital "Policlinico - Vittorio Emanuele", Via Carlo Azeglio Ciampi, 95121 Catania, Italy
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End-tidal carbon dioxide levels during resuscitation and carbon dioxide levels in the immediate neonatal period and intraventricular haemorrhage. Eur J Pediatr 2020; 179:555-559. [PMID: 31848749 PMCID: PMC7080666 DOI: 10.1007/s00431-019-03543-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 11/29/2019] [Accepted: 12/03/2019] [Indexed: 11/18/2022]
Abstract
Abnormal levels of end-tidal carbon dioxide (EtCO2) during resuscitation in the delivery suite are associated with intraventricular haemorrhage (IVH) development. Our aim was to determine whether carbon dioxide (CO2) levels in the first 3 days after birth reflected abnormal EtCO2 levels in the delivery suite, and hence, a prolonged rather than an early insult resulted in IVH. In addition, we determined if greater EtCO2level fluctuations during resuscitation occurred in infants who developed IVH. EtCO2 levels during delivery suite resuscitation and CO2 levels on the neonatal unit were evaluated in 58 infants (median gestational age 27.3 weeks). Delta EtCO2 was the difference between the highest and lowest level of EtCO2. Thirteen infants developed a grade 3-4 IVH (severe group). There were no significant differences in CO2 levels between those who did and did not develop an IVH (or severe IVH) on the NICU. The delta EtCO2 during resuscitation differed between infants with any IVH (6.2 (5.4-7.5) kPa) or no IVH (3.8 (2.7-4.3) kPA) (p < 0.001) after adjusting for differences in gestational age. Delta EtCO2 levels gave an area under the ROC curve of 0.940 for prediction of IVH.Conclusion: The results emphasize the importance of monitoring EtCO2 levels in the delivery suite.What is Known:• Abnormal levels of carbon dioxide (CO2) in the first few days after birth and abnormal end-tidal CO2levels (EtCO2) levels during resuscitation are associated in preterm infants with the risk of developing intraventricular haemorrhage (IVH).What is New:• There were no significant differences in NICU CO2levels between those who developed an IVH or no IVH.• There was a poor correlation between delivery suite ETCO2levels and NICU CO2levels.• Large fluctuations in EtCO2during resuscitation in the delivery suite were highly predictive of IVH development in preterm infants.
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Goswami IR, Abou Mehrem A, Scott J, Esser MJ, Mohammad K. Metabolic acidosis rather than hypo/hypercapnia in the first 72 hours of life associated with intraventricular hemorrhage in preterm neonates. J Matern Fetal Neonatal Med 2019; 34:3874-3882. [PMID: 31852289 DOI: 10.1080/14767058.2019.1701649] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Aim: Safe limits of arterial partial pressure of carbon dioxide (PaCO2) and acidosis in premature infants are not well defined. Both respiratory and systemic illness along with center-specific ventilation strategies contribute to PaCO2 fluctuations and acid-base imbalances during the critical time period of first 72 h of life. This study evaluated the association between early blood gas parameters and intraventricular hemorrhage (IVH) in preterm infants.Methods: This retrospective observational study included neonates with a gestational age (GA) of ≤29 wks, who had at least 7 blood gas analysis done within the first 72 h of life. By adjusting for known variables that predispose to IVH, multivariable logistic regression analysis was used to study the association of PaCO2 and acid-base measures with the risk of IVH.Results: Between 2013-2016, among 272 neonates who met inclusion criteria and were assessed for IVH on cranial ultrasound within first week of life, 101 neonates [mean GA of 25 ± 1.5 wks] had IVH and 171 neonates [mean GA of 25 ± 1.6 wks] had normal scans. After adjustment for confounding variables, higher values of maximum lactate (OR = 1.18, 95% CI = 1.1-1.3, p < .0001) and maximum base deficit (OR = 1.19, 95% CI = 1.1-1.2, p < .0001) within 72 h of life increased the likelihood of any grade of IVH. However, time-weighted average PaCO2, maximum and minimum PaCO2 had no statistically significant effect on the risk of IVH. The relationship remained unchanged even when moderate-severe IVH was considered as the primary outcome.Conclusion: Severe metabolic acidosis rather than hypo/hypercapnia during the first 72 h of life was associated with higher odds of IVH in infants born at ≤29 wks of gestation. Future studies determining levels of PaCO2 that is safe for premature brain would need to control for the metabolic component of acidosis.
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Affiliation(s)
- Ipsita R Goswami
- Section of Neonatology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Ayman Abou Mehrem
- Section of Neonatology, Department of Paediatrics, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - James Scott
- Departments of Diagnostic Imaging and Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Michael J Esser
- Section of Pediatric Neurology, Department of Pediatrics, Alberta Children's Hospital, University of Calgary, Calgary, Canada
| | - Khorshid Mohammad
- Section of Neonatology, Department of Paediatrics, Cumming School of Medicine, University of Calgary, Calgary, Canada
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Lohmann P, Wright C. Does permissive hypercapnia carry increased risk for neurodevelopmental sequelae? Acta Paediatr 2019; 108:1547. [PMID: 31222809 DOI: 10.1111/apa.14872] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
| | - Clyde Wright
- University of Colorado Denver School of Medicine; Aurora CO USA
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Cooney M, Habre W. "Neonatal ventilation; What we don't know, can't hurt… right?". Paediatr Anaesth 2019; 29:670-671. [PMID: 31373131 DOI: 10.1111/pan.13682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 06/03/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Meghan Cooney
- Monash Medical Centre, Melbourne, Victoria, Australia
| | - Walid Habre
- Department of Acute Medicine, University Hospitals of Geneva, Geneva, Switzerland.,University of Geneva, Geneva, Switzerland
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Hochwald O, Borenstein-Levin L, Dinur G, Jubran H, Ben-David S, Kugelman A. Continuous Noninvasive Carbon Dioxide Monitoring in Neonates: From Theory to Standard of Care. Pediatrics 2019; 144:peds.2018-3640. [PMID: 31248940 DOI: 10.1542/peds.2018-3640] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/25/2019] [Indexed: 11/24/2022] Open
Abstract
Ventilatory support may affect the short- and long-term neurologic and respiratory morbidities of preterm infants. Ongoing monitoring of oxygenation and ventilation and control of adequate levels of oxygen, pressures, and volumes can decrease the incidence of such adverse outcomes. Use of pulse oximetry became a standard of care for titrating oxygen delivery, but continuous noninvasive monitoring of carbon dioxide (CO2) is not routinely used in NICUs. Continuous monitoring of CO2 level may be crucial because hypocarbia and hypercarbia in extremely preterm infants are associated with lung and brain morbidities, specifically bronchopulmonary dysplasia, intraventricular hemorrhage, and cystic periventricular leukomalacia. It is shown that continuous monitoring of CO2 levels helps in maintaining stable CO2 values within an accepted target range. Continuous monitoring of CO2 levels can be used in the delivery room, during transport, and in infants receiving invasive or noninvasive respiratory support in the NICU. It is logical to hypothesize that this will result in better outcome for extremely preterm infants. In this article, we review the different noninvasive CO2 monitoring alternatives and devices, their advantages and disadvantages, and the available clinical data supporting or negating their use as a standard of care in NICUs.
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Affiliation(s)
- Ori Hochwald
- Department of Neonatology, Rambam Health Care Campus, Haifa, Israel; and .,The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Liron Borenstein-Levin
- Department of Neonatology, Rambam Health Care Campus, Haifa, Israel; and.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Gil Dinur
- Department of Neonatology, Rambam Health Care Campus, Haifa, Israel; and.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Huda Jubran
- Department of Neonatology, Rambam Health Care Campus, Haifa, Israel; and.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Shlomit Ben-David
- Department of Neonatology, Rambam Health Care Campus, Haifa, Israel; and.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Amir Kugelman
- Department of Neonatology, Rambam Health Care Campus, Haifa, Israel; and.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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Ryan M, Lacaze-Masmonteil T, Mohammad K. Neuroprotection from acute brain injury in preterm infants. Paediatr Child Health 2019; 24:276-290. [PMID: 31239818 PMCID: PMC6587421 DOI: 10.1093/pch/pxz056] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Infants born at ≤32+6 weeks gestation are at higher risk for intracranial ischemic and hemorrhagic injuries, which often occur in the first 72 hours postbirth. Antenatal strategies to reduce the incidence of acute brain injuries include administering maternal corticosteroids and prompt antibiotic treatment for chorioamnionitis. Perinatal strategies include delivery within a tertiary centre, delayed cord clamping, and preventing hypothermia. Postnatal strategies include empiric treatment with antibiotics when chorioamnionitis is suspected, the cautious use of inotropes, the avoidance of blood PCO2 fluctuation, and neutral head positioning. Clinicians should be aware of the policies and procedures that, especially when combined, can provide neuroprotection for preterm infants.
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Affiliation(s)
- Michelle Ryan
- Canadian Paediatric Society, Fetus and Newborn Committee, Ottawa, Ontario
| | | | - Khorshid Mohammad
- Canadian Paediatric Society, Fetus and Newborn Committee, Ottawa, Ontario
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Ryan M, Lacaze-Masmonteil T, Mohammad K. La neuroprotection contre les lésions cérébrales aiguës chez les nouveau-nés prématurés. Paediatr Child Health 2019. [DOI: 10.1093/pch/pxz057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Michelle Ryan
- Société canadienne de pédiatrie, comité d’étude du fœtus et du nouveau-né, Ottawa (Ontario)
| | | | - Khorshid Mohammad
- Société canadienne de pédiatrie, comité d’étude du fœtus et du nouveau-né, Ottawa (Ontario)
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Chollat C, Lecointre M, Leuillier M, Remy-Jouet I, Do Rego JC, Abily-Donval L, Ramdani Y, Richard V, Compagnon P, Dureuil B, Marret S, Gonzalez BJ, Jégou S, Tourrel F. Beneficial Effects of Remifentanil Against Excitotoxic Brain Damage in Newborn Mice. Front Neurol 2019; 10:407. [PMID: 31068895 PMCID: PMC6491788 DOI: 10.3389/fneur.2019.00407] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 04/04/2019] [Indexed: 01/15/2023] Open
Abstract
Background: Remifentanil, a synthetic opioid used for analgesia during cesarean sections, has been shown in ex vivo experiments to exert anti-apoptotic activity on immature mice brains. The present study aimed to characterize the impact of remifentanil on brain lesions using an in vivo model of excitotoxic neonatal brain injury. Methods: Postnatal day 2 (P2) mice received three intraperitoneal injections of remifentanil (500 ng/g over a 10-min period) or saline just before an intracortical injection of ibotenate (10 μg). Cerebral reactive oxygen species (ROS) production, cell death, in situ labeling of cortical caspase activity, astrogliosis, inflammation mediators, and lesion size were determined at various time points after ibotenate injection. Finally, behavioral tests were performed until P18. Results: In the injured neonatal brain, remifentanil significantly decreased ROS production, cortical caspase activity, DNA fragmentation, interleukin-1β levels, and reactive astrogliosis. At P7, the sizes of the ibotenate-induced lesions were significantly reduced by remifentanil treatment. Performance on negative geotaxis (P6-8) and grasping reflex (P10-12) tests was improved in the remifentanil group. At P18, a sex specificity was noticed; remifentanil-treated females spent more time in the open field center than did the controls, suggesting less anxiety in young female mice. Conclusions: In vivo exposure to remifentanil exerts a beneficial effect against excitotoxicity on the developing mouse brain, which is associated with a reduction in the size of ibotenate-induced brain lesion as well as prevention of some behavioral deficits in young mice. The long-term effect of neonatal exposure to remifentanil should be investigated.
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Affiliation(s)
- Clément Chollat
- INSERM U1245, Genetics and Pathophysiology of Neurodevelopment Disorders Team, Faculty of Medicine, Institute of Research and Innovation in Biomedicine, Normandy University, Rouen, France.,Neonatal Intensive Care Unit of Port-Royal, Paris Centre University Hospitals, APHP, Paris Descartes University, Paris, France
| | - Maryline Lecointre
- INSERM U1245, Genetics and Pathophysiology of Neurodevelopment Disorders Team, Faculty of Medicine, Institute of Research and Innovation in Biomedicine, Normandy University, Rouen, France
| | - Matthieu Leuillier
- INSERM U1245, Genetics and Pathophysiology of Neurodevelopment Disorders Team, Faculty of Medicine, Institute of Research and Innovation in Biomedicine, Normandy University, Rouen, France
| | - Isabelle Remy-Jouet
- INSERM U1096, Biology Oxidative Stress Systems Platform, Institute for Research and Innovation in Biomedicine, Normandy University, Rouen, France
| | | | - Lénaïg Abily-Donval
- INSERM U1245, Genetics and Pathophysiology of Neurodevelopment Disorders Team, Faculty of Medicine, Institute of Research and Innovation in Biomedicine, Normandy University, Rouen, France.,Department of Neonatal Pediatrics and Intensive Care, Rouen University Hospital, Rouen, France
| | - Yasmina Ramdani
- INSERM U1245, Genetics and Pathophysiology of Neurodevelopment Disorders Team, Faculty of Medicine, Institute of Research and Innovation in Biomedicine, Normandy University, Rouen, France
| | - Vincent Richard
- INSERM U1096, Biology Oxidative Stress Systems Platform, Institute for Research and Innovation in Biomedicine, Normandy University, Rouen, France
| | | | - Bertrand Dureuil
- Department Anesthetics and Intensive Care, Rouen University Hospital, Rouen, France
| | - Stéphane Marret
- INSERM U1245, Genetics and Pathophysiology of Neurodevelopment Disorders Team, Faculty of Medicine, Institute of Research and Innovation in Biomedicine, Normandy University, Rouen, France.,Department of Neonatal Pediatrics and Intensive Care, Rouen University Hospital, Rouen, France
| | - Bruno José Gonzalez
- INSERM U1245, Genetics and Pathophysiology of Neurodevelopment Disorders Team, Faculty of Medicine, Institute of Research and Innovation in Biomedicine, Normandy University, Rouen, France
| | - Sylvie Jégou
- INSERM U1245, Genetics and Pathophysiology of Neurodevelopment Disorders Team, Faculty of Medicine, Institute of Research and Innovation in Biomedicine, Normandy University, Rouen, France
| | - Fabien Tourrel
- INSERM U1245, Genetics and Pathophysiology of Neurodevelopment Disorders Team, Faculty of Medicine, Institute of Research and Innovation in Biomedicine, Normandy University, Rouen, France.,Department Anesthetics and Intensive Care, Rouen University Hospital, Rouen, France
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45
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Yap V, Perlman JM. Intraventricular Hemorrhage and White Matter Injury in the Preterm Infant. Neurology 2019. [DOI: 10.1016/b978-0-323-54392-7.00002-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Leijser LM, de Vries LS. Preterm brain injury: Germinal matrix-intraventricular hemorrhage and post-hemorrhagic ventricular dilatation. HANDBOOK OF CLINICAL NEUROLOGY 2019; 162:173-199. [PMID: 31324310 DOI: 10.1016/b978-0-444-64029-1.00008-4] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Germinal matrix hemorrhage and intraventricular hemorrhages (GMH-IVH) remain a common and clinically significant problem in preterm infants, particularly extremely preterm infants. A large GMH-IVH is often complicated by posthemorrhagic ventricular dilation (PHVD) or parenchymal hemorrhagic infarction and is associated with an increased risk of adverse neurologic sequelae. The widespread use of cranial ultrasonography since the early 1980s has shown a gradual decrease in the incidence of GMH-IVH and has helped with the identification of antenatal and perinatal risk factors and timing of the lesion. The increased use of magnetic resonance imaging (MRI) has contributed to more detailed visualization of the site and extent of the GMH-IVH. In addition, MRI has contributed to the awareness of associated white matter changes as well as associated cerebellar hemorrhages. Although GMH-IVH and PHVD still cannot be prevented, cerebrospinal fluid drainage initiated in the early stage of PHVD development seems to be associated with a better neurodevelopmental outcome. Further studies are underway to improve treatment strategies for PHVD and to potentially prevent and repair GMH-IVH and PHVD and associated brain injury. This chapter discusses the pathogenesis, incidence, risk factors, and management, including preventive measures, of GHM-IVH and PHVD.
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Affiliation(s)
- Lara M Leijser
- Department of Pediatrics, Section of Neonatology, University of Calgary, Cumming School of Medicine, Calgary, Canada
| | - Linda S de Vries
- Department of Neonatology, University Medical Center Utrecht, Utrecht, The Netherlands.
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Chiriboga N, Cortez J, Pena-Ariet A, Makker K, Smotherman C, Gautam S, Trikardos AB, Knight H, Yeoman M, Burnett E, Beier A, Cohen I, Hudak ML. Successful implementation of an intracranial hemorrhage (ICH) bundle in reducing severe ICH: a quality improvement project. J Perinatol 2019; 39:143-151. [PMID: 30348961 DOI: 10.1038/s41372-018-0257-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 09/28/2018] [Accepted: 10/04/2018] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Our specific, measurable, attainable, relevant, and time-limited (SMART) aim was to reduce the incidence of severe intracranial hemorrhage (ICH) among preterm infants born <30 weeks' gestation from a baseline of 24% (January 2012-December 2013) to a long-term average of 11% by December 2015. STUDY DESIGN We instituted an ICH bundle consisting of elements of the "golden hour" (delayed cord clamping, optimized cardiopulmonary resuscitation, improved thermoregulation) and provision of cluster care in the neonatal intensive care unit (NICU). We identified key drivers to achieve our SMART aims, and implemented quality improvement (QI) cycles: initiation of the ICH bundle, education of NICU staff, and emphasis on sustained adherence. We excluded infants born outside our facility and those with congenital anomalies. RESULTS Using statistical process control analysis (p-chart), the ICH bundle was associated with successful reduction in severe ICH (grade 3-4) in our NICU from a prebundle rate of 24% (January 2012-December 2013) to a sustained reduction over the next 4 years to an average rate of 9.7% by December 2017. Results during 2016-2017 showed a sustained improvement beyond the goal for 2014-2015. Over the same interval, there was improvement in admission temperatures [median 36.1 °C (interquartile range: 35.3-36.7 °C) vs. 37.1 °C (36.8-37.5 °C), p < 0.01] and a decrease in mortality rate [pre: 16/117 (14%) vs. post: 16/281 (6%), P < 0.01]. CONCLUSION Our multidisciplinary QI initiative decreased severe ICH in our institution from a baseline rate of 24% to a lower rate of 9.7% over the ensuing 4 years. Intensive focus on sustained implementation of an ICH bundle protocol consisting of improved delivery room management, thermoregulation, and clustered care in the NICU was temporally associated with a clinically significant reduction in severe ICH.
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Affiliation(s)
- Nicolas Chiriboga
- Division of Neonatology, Department of Pediatrics, University of Florida College of Medicine Jacksonville, Jacksonville, FL, USA
| | - Josef Cortez
- Division of Neonatology, Department of Pediatrics, University of Florida College of Medicine Jacksonville, Jacksonville, FL, USA.
| | - Adriana Pena-Ariet
- Division of Neonatology, Department of Pediatrics, University of Florida College of Medicine Jacksonville, Jacksonville, FL, USA
| | - Kartikeya Makker
- Division of Neonatology, Department of Pediatrics, University of Florida College of Medicine Jacksonville, Jacksonville, FL, USA
| | - Carmen Smotherman
- Center for Health Equity and Quality Research, University of Florida College of Medicine Jacksonville, Jacksonville, FL, USA
| | - Shiva Gautam
- Center for Health Equity and Quality Research, University of Florida College of Medicine Jacksonville, Jacksonville, FL, USA
| | - Allison Blair Trikardos
- Department of Women's and Children's Nursing Services, Neonatal Intensive Care Unit, University of Florida Health Jacksonville, Jacksonville, FL, USA
| | - Holly Knight
- Department of Rehabilitation Services, Neonatal Intensive Care Unit, University of Florida Health Jacksonville, Jacksonville, FL, USA
| | - Mark Yeoman
- Department of Women's and Children's Nursing Services, Neonatal Intensive Care Unit, University of Florida Health Jacksonville, Jacksonville, FL, USA
| | - Erin Burnett
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Florida College of Medicine Jacksonville, Jacksonville, FL, USA
| | - Alexandra Beier
- Department of Neurosurgery, University of Florida College of Medicine Jacksonville, Jacksonville, FL, USA
| | - Inbal Cohen
- Department of Radiology, University of Florida College of Medicine Jacksonville, Jacksonville, FL, USA
| | - Mark L Hudak
- Division of Neonatology, Department of Pediatrics, University of Florida College of Medicine Jacksonville, Jacksonville, FL, USA
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48
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Pahuja A, Hunt K, Murthy V, Bhat P, Bhat R, Milner AD, Greenough A. Relationship of resuscitation, respiratory function monitoring data and outcomes in preterm infants. Eur J Pediatr 2018; 177:1617-1624. [PMID: 30066181 DOI: 10.1007/s00431-018-3222-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 07/23/2018] [Accepted: 07/25/2018] [Indexed: 11/26/2022]
Abstract
Intraventricular haemorrhage (IVH) and bronchopulmonary dysplasia (BPD) are major complications of premature birth. We tested the hypotheses that prematurely born infants who developed an IVH or BPD would have high expiratory tidal volumes (VTE) (VTE > 6 ml/kg) and/or low-end tidal carbon dioxide (ETCO2) levels (ETCO2 levels < 4.5 kPa) as recorded by respiratory function monitoring or hyperoxia (oxygen saturation (SaO2) > 95%) during resuscitation in the delivery suite. Seventy infants, median gestational age 27 weeks (range 23-33), were assessed; 31 developed an IVH and 43 developed BPD. Analysis was undertaken of 31,548 inflations. The duration of resuscitation did not differ significantly between the groups. Those who developed an IVH compared to those who did not had a greater number of inflations with a high VTE and a low ETCO2, which remained significant after correcting for differences in gestational age and birth weight between groups (p = 0.019). Differences between infants who did and did not develop BPD were not significant after correcting for differences in gestational age and birth weight. There were no significant differences in the duration of hyperoxia between the groups.Conclusions: Avoidance of high tidal volumes and hypocarbia in the delivery suite might reduce IVH development. What is known • Hypocarbia on the neonatal unit is associated with the development of intraventricular haemorrhage (IVH) and bronchopulmonary dysplasia (BPD). What is new • Infants who developed an IVH compared to those who did not had significantly more inflations with high expiratory tidal volumes and low ETCO2s.
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Affiliation(s)
- Anoop Pahuja
- Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Katie Hunt
- MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, UK
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Vadivelam Murthy
- MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, UK
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Prashanth Bhat
- MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, UK
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Ravindra Bhat
- Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Anthony D Milner
- MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, UK
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Anne Greenough
- Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, UK.
- MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, UK.
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.
- NIHR Biomedical Centre at Guy's and St Thomas NHS Foundation Trust, King's College London, London, UK.
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49
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Abstract
Analog-to-digital data conversion has created massive amounts of historical and real-time health care data. Costs associated with neonatal health issues are high. Big data use in the neonatal intensive care unit has the potential to facilitate earlier detection of clinical deterioration, expedite application of efficient clinical decision-making algorithms based on real-time and historical data mining, and yield significant cost-savings.
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Affiliation(s)
- Lynn E Bayne
- Christiana Care Health System, 4755 Ogletown-Stanton Road, Newark, DE 19716, USA; Alfred I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE 19803, USA.
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50
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Synchronized Oscillations of Arterial Oxygen Saturation, Cerebral Tissue Oxygenation and Heart Rate in Preterm Neonates: Investigation of Long-Term Measurements with Multiple Einstein's Cross Wavelet Analysis. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018. [PMID: 30178339 DOI: 10.1007/978-3-319-91287-5_25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register]
Abstract
BACKGROUND In preterm neonates, the cardiovascular and cerebral vascular control is immature, making the brain vulnerable to an increased incidence of hypoxic and hyperoxic episodes. AIM The aim of the study was to apply the recently developed multiple Einstein's cross wavelet analysis (MECWA) to quantify the coupling of fluctuations of peripherally measured arterial oxygen saturation (SpO2), cerebral tissue oxygen saturation (StO2) and heart rate (HR). METHODS Two long-term measurements on preterm neonates with a gestational age at birth of 26.4 and 26.8 weeks and a postnatal age of 2.1 and 3.9 weeks were analyzed. MECWA was applied to SpO2, StO2 and HR. RESULTS MECWA showed that the fluctuations of SpO2, StO2 and HR were synchronized in the low-frequency range with periods of ~1 h and ~0.5 h. The amplitudes of the synchronization frequencies were dependent on the individual neonate. DISCUSSION MECWA is a useful novel tool to assess the coupling of physiological signals. The parameters determined by MECWA seem to be related to the chronobiological processes, as well as constant regulations of the cardiovascular and cerebral perfusion state. CONCLUSION MECWA was able to identify long-term synchronization of the cardiovascular and cerebral perfusion state in preterm neonates with periods of ~1 h and ~0.5 h.
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