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Turova V, Sidorenko I, Eckardt L, Rieger-Fackeldey E, Felderhoff-Müser U, Alves-Pinto A, Lampe R. Machine learning models for identifying preterm infants at risk of cerebral hemorrhage. PLoS One 2020; 15:e0227419. [PMID: 31940391 PMCID: PMC6961932 DOI: 10.1371/journal.pone.0227419] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 12/18/2019] [Indexed: 11/18/2022] Open
Abstract
Intracerebral hemorrhage in preterm infants is a major cause of brain damage and cerebral palsy. The pathogenesis of cerebral hemorrhage is multifactorial. Among the risk factors are impaired cerebral autoregulation, infections, and coagulation disorders. Machine learning methods allow the identification of combinations of clinical factors to best differentiate preterm infants with intra-cerebral bleeding and the development of models for patients at risk of cerebral hemorrhage. In the current study, a Random Forest approach is applied to develop such models for extremely and very preterm infants (23-30 weeks gestation) based on data collected from a cohort of 229 individuals. The constructed models exhibit good prediction accuracy and might be used in clinical practice to reduce the risk of cerebral bleeding in prematurity.
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Affiliation(s)
- Varvara Turova
- Research Unit for Pediatric Neuroorthopedics and Cerebral Palsy of the Buhl-Strohmaier Foundation, Orthopedic Department, Klinikum Rechts der Isar, Technical University of Munich, München, Germany
- * E-mail:
| | - Irina Sidorenko
- Chair of Mathematical Modelling, Mathematical Faculty, Technical University of Munich, Garching bei München, Germany
| | - Laura Eckardt
- Departments of Pediatrics and Neonatology, University Hospital Essen, University of Duisburg‐Essen, Essen, Germany
| | - Esther Rieger-Fackeldey
- Department of Pediatrics, Neonatology, Klinikum Rechts der Isar, Technical University of Munich, München, Germany
| | - Ursula Felderhoff-Müser
- Departments of Pediatrics and Neonatology, University Hospital Essen, University of Duisburg‐Essen, Essen, Germany
| | - Ana Alves-Pinto
- Research Unit for Pediatric Neuroorthopedics and Cerebral Palsy of the Buhl-Strohmaier Foundation, Orthopedic Department, Klinikum Rechts der Isar, Technical University of Munich, München, Germany
| | - Renée Lampe
- Research Unit for Pediatric Neuroorthopedics and Cerebral Palsy of the Buhl-Strohmaier Foundation, Orthopedic Department, Klinikum Rechts der Isar, Technical University of Munich, München, Germany
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Continuous vital sign analysis for predicting and preventing neonatal diseases in the twenty-first century: big data to the forefront. Pediatr Res 2020; 87:210-220. [PMID: 31377752 PMCID: PMC6962536 DOI: 10.1038/s41390-019-0527-0] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 07/20/2019] [Accepted: 07/25/2019] [Indexed: 01/03/2023]
Abstract
In the neonatal intensive care unit (NICU), heart rate, respiratory rate, and oxygen saturation are vital signs (VS) that are continuously monitored in infants, while blood pressure is often monitored continuously immediately after birth, or during critical illness. Although changes in VS can reflect infant physiology or circadian rhythms, persistent deviations in absolute values or complex changes in variability can indicate acute or chronic pathology. Recent studies demonstrate that analysis of continuous VS trends can predict sepsis, necrotizing enterocolitis, brain injury, bronchopulmonary dysplasia, cardiorespiratory decompensation, and mortality. Subtle changes in continuous VS patterns may not be discerned even by experienced clinicians reviewing spot VS data or VS trends captured in the monitor. In contrast, objective analysis of continuous VS data can improve neonatal outcomes by allowing heightened vigilance or preemptive interventions. In this review, we provide an overview of the studies that have used continuous analysis of single or multiple VS, their interactions, and combined VS and clinical analytic tools, to predict or detect neonatal pathophysiology. We make the case that big-data analytics are promising, and with continued improvements, can become a powerful tool to mitigate neonatal diseases in the twenty-first century.
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Castel A, Frank YS, Feltner J, Karp FB, Albright CM, Frasch MG. Monitoring Fetal Electroencephalogram Intrapartum: A Systematic Literature Review. Front Pediatr 2020; 8:584. [PMID: 33042922 PMCID: PMC7518218 DOI: 10.3389/fped.2020.00584] [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: 06/25/2020] [Accepted: 08/07/2020] [Indexed: 12/05/2022] Open
Abstract
Background: Studies about the feasibility of monitoring fetal electroencephalogram (fEEG) during labor began in the early 1940s. By the 1970s, clear diagnostic and prognostic benefits from intrapartum fEEG monitoring were reported, but until today, this monitoring technology has remained a curiosity. Objectives: Our goal was to review the studies reporting the use of fEEG including the insights from interpreting fEEG patterns in response to uterine contractions during labor. We also used the most relevant information gathered from clinical studies to provide recommendations for enrollment in the unique environment of a labor and delivery unit. Data Sources: PubMed. Eligibility Criteria: The search strategy was: ("fetus"[MeSH Terms] OR "fetus"[All Fields] OR "fetal"[All Fields]) AND ("electroencephalography"[MeSH Terms] OR "electroencephalography"[All Fields] OR "eeg"[All Fields]) AND (Clinical Trial[ptyp] AND "humans"[MeSH Terms]). Because the landscape of fEEG research has been international, we included studies in English, French, German, and Russian. Results: From 256 screened studies, 40 studies were ultimately included in the qualitative analysis. We summarize and report features of fEEG which clearly show its potential to act as a direct biomarker of fetal brain health during delivery, ancillary to fetal heart rate monitoring. However, clinical prospective studies are needed to further establish the utility of fEEG monitoring intrapartum. We identified clinical study designs likely to succeed in bringing this intrapartum monitoring modality to the bedside. Limitations: Despite 80 years of studies in clinical cohorts and animal models, the field of research on intrapartum fEEG is still nascent and shows great promise to augment the currently practiced electronic fetal monitoring. Prospero Number: CRD42020147474.
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Affiliation(s)
- Aude Castel
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Université de Montréal, Montreal, QC, Canada
| | - Yael S Frank
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, United States
| | - John Feltner
- Department of Pediatrics, University of Washington, Seattle, WA, United States
| | - Floyd B Karp
- School of Pharmacy, University of Washington, Seattle, WA, United States
| | - Catherine M Albright
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, United States
| | - Martin G Frasch
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, United States.,Center on Human Development and Disability, University of Washington, Seattle, WA, United States
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Blood pressure extremes and severe IVH in preterm infants. Pediatr Res 2020; 87:69-73. [PMID: 31578033 PMCID: PMC6962547 DOI: 10.1038/s41390-019-0585-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 08/04/2019] [Accepted: 08/08/2019] [Indexed: 12/05/2022]
Abstract
BACKGROUND The optimal upper and lower limits of blood pressure in preterm infants are not known. Exceeding these thresholds may contribute to intraventricular hemorrhage (IVH). METHODS Preterm infants born ≤30 weeks GA were identified. Infants had continuous measurement of mean arterial blood pressure (MABP) for 7 days and cranial ultrasound imaging. IVH was classified as severe IVH (grade 3/4), no severe IVH (no IVH; grade 1/2), or no IVH. Mean ± SEM MABP values from hours 1-168 were calculated and sorted into bins 2 mm Hg wide. The normalized proportion of each recording spent in each bin was then calculated. Candidate limits were identified by comparison of MABP distribution in those with severe IVH vs. those without severe IVH. RESULTS Eighty-five million measurements were made from 157 infants. Mean EGA was 25.2 weeks; mean BW was 749 g; 65/157 female; inotrope use in 59/157; grade 3/4 IVH in 29/157. Infants with severe IVH spent significantly more time with extreme MABP measurements (<23 mm Hg or >46 mm Hg) compared to those without severe IVH (12% vs. 8% of recording, p = 0.02). CONCLUSIONS Infants who developed severe IVH had substantially more unstable MABP and spent a significantly greater period of time with MABP outside of the optimal range.
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Cerebral venous volume changes and pressure autoregulation in critically ill infants. J Perinatol 2020; 40:806-811. [PMID: 32157219 PMCID: PMC7224055 DOI: 10.1038/s41372-020-0626-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 02/04/2020] [Accepted: 02/11/2020] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To determine whether ventilator-related fluctuations in cerebral blood volume (CBV) are associated with cerebral pressure passivity. STUDY DESIGN In a prospective study of newborns undergoing positive-pressure ventilation, we calculated coherence between continuous mean arterial pressure (MAP) and cerebral near-infrared spectroscopy hemoglobin difference (HbD). Significant HbD-MAP coherence indicated cerebral pressure passivity. CBV changes were measured as the spectral power of total hemoglobin (SHbT) at the ventilator frequency. A regression model tested whether SHbT predicts cerebral pressure passivity and/or death/brain injury, controlling for birth gestational age and other factors. RESULTS We studied 68 subjects with prematurity (n = 19), congenital heart disease (n = 11), and hypoxic-ischemic encephalopathy (n = 38). SHbT, sedative use, and pCO2 were positively associated, and circulating hemoglobin negatively associated, with cerebral pressure passivity (p < 0.001), which was positively associated with brain injury (p < 0.001). CONCLUSION In sick newborns, ventilator-related CBV fluctuations may predispose to cerebral pressure passivity, which may predispose to an adverse neonatal outcome.
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Solanki NS, Hoffman SB. Association between dopamine and cerebral autoregulation in preterm neonates. Pediatr Res 2020; 88:618-622. [PMID: 32005034 PMCID: PMC7223955 DOI: 10.1038/s41390-020-0790-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 01/21/2020] [Accepted: 01/24/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND To test the hypothesis that dopamine is associated with impaired cerebral autoregulation (ICA) in a dose-dependent fashion. METHODS Non a priori designed secondary analysis of a prospectively enrolled cohort study subjects <12 h of life between 240 and 296 weeks gestation. Cerebral saturations (rScO2) and mean arterial blood pressure (MAP) were continuously monitored every 30 s for 96 h. ICA was defined by a 10 min epoch rScO2-MAP correlation coefficient of >0.5. RESULTS Twenty-three of 61 subjects (38%) required dopamine. Time spent with ICA was 23% in dopamine-exposed subjects vs. 14% in those not exposed (p = 0.0001). On the epoch level, time spent with ICA was 15%, 29%, 34%, 37%, and 23% in epochs with dopamine titration of 0, 1-5, 6-10, 11-15, and 16-20 μg/kg/min, respectively. Using mixed-effect modeling, ICA for each dopamine titration was significantly higher than unexposed times when controlling for gestation, presence of a patent ductus arteriosus, day of life, MAP less than gestational age, and illness severity score (p < 0.02). CONCLUSIONS Dopamine exposure during the first 96 h was associated with ICA. Time periods with ICA increased with dopamine exposure in a dose-dependent fashion peaking at a concentration of 11-15 μg/kg/min.
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Affiliation(s)
- Nina S. Solanki
- grid.411024.20000 0001 2175 4264Department of Pediatrics, School of Medicine, University of Maryland Baltimore, Baltimore, MD USA
| | - Suma B. Hoffman
- grid.411024.20000 0001 2175 4264Department of Pediatrics, School of Medicine, University of Maryland Baltimore, Baltimore, MD USA
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Klebe D, McBride D, Krafft PR, Flores JJ, Tang J, Zhang JH. Posthemorrhagic hydrocephalus development after germinal matrix hemorrhage: Established mechanisms and proposed pathways. J Neurosci Res 2020; 98:105-120. [PMID: 30793349 PMCID: PMC6703985 DOI: 10.1002/jnr.24394] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 12/05/2018] [Accepted: 01/14/2019] [Indexed: 01/17/2023]
Abstract
In addition to being the leading cause of morbidity and mortality in premature infants, germinal matrix hemorrhage (GMH) is also the leading cause of acquired infantile hydrocephalus. The pathophysiology of posthemorrhagic hydrocephalus (PHH) development after GMH is complex and vaguely understood, although evidence suggests fibrosis and gliosis in the periventricular and subarachnoid spaces disrupts normal cerebrospinal fluid (CSF) dynamics. Theories explaining general hydrocephalus etiology have substantially evolved from the original bulk flow theory developed by Dr. Dandy over a century ago. Current clinical and experimental evidence supports a new hydrodynamic theory for hydrocephalus development involving redistribution of vascular pulsations and disruption of Starling forces in the brain microcirculation. In this review, we discuss CSF flow dynamics, history and development of theoretical hydrocephalus pathophysiology, and GMH epidemiology and etiology as it relates to PHH development. We highlight known mechanisms and propose new avenues that will further elucidate GMH pathophysiology, specifically related to hydrocephalus.
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Affiliation(s)
- Damon Klebe
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA 92350
| | - Devin McBride
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA 92350
| | - Paul R Krafft
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA 92350
- Department of Neurosurgery, Loma Linda University School of Medicine, Loma Linda, CA 92350
| | - Jerry J Flores
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA 92350
| | - Jiping Tang
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA 92350
| | - John H Zhang
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA 92350
- Department of Anesthesiology and Neurosurgery, Loma Linda University School of Medicine, Loma Linda, CA 92350
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Katheria A, Reister F, Essers J, Mendler M, Hummler H, Subramaniam A, Carlo W, Tita A, Truong G, Davis-Nelson S, Schmölzer G, Chari R, Kaempf J, Tomlinson M, Yanowitz T, Beck S, Simhan H, Dempsey E, O’Donoghue K, Bhat S, Hoffman M, Faksh A, Arnell K, Rich W, Finer N, Vaucher Y, Khanna P, Meyers M, Varner M, Allman P, Szychowski J, Cutter G. Association of Umbilical Cord Milking vs Delayed Umbilical Cord Clamping With Death or Severe Intraventricular Hemorrhage Among Preterm Infants. JAMA 2019; 322:1877-1886. [PMID: 31742630 PMCID: PMC6865839 DOI: 10.1001/jama.2019.16004] [Citation(s) in RCA: 153] [Impact Index Per Article: 30.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
IMPORTANCE Umbilical cord milking as an alternative to delayed umbilical cord clamping may provide equivalent benefits to preterm infants, but without delaying resuscitation. OBJECTIVE To determine whether the rates of death or severe intraventricular hemorrhage differ among preterm infants receiving placental transfusion with umbilical cord milking vs delayed umbilical cord clamping. DESIGN, SETTING, AND PARTICIPANTS Noninferiority randomized clinical trial of preterm infants (born at 23-31 weeks' gestation) from 9 university and private medical centers in 4 countries were recruited and enrolled between June 2017 and September 2018. Planned enrollment was 750 per group. However, a safety signal comprising an imbalance in the number of severe intraventricular hemorrhage events by study group was observed at the first interim analysis; enrollment was stopped based on recommendations from the data and safety monitoring board. The planned noninferiority analysis could not be conducted and a post hoc comparison was performed instead. Final date of follow-up was December 2018. INTERVENTIONS Participants were randomized to umbilical cord milking (n = 236) or delayed umbilical cord clamping (n = 238). MAIN OUTCOMES AND MEASURES The primary outcome was a composite of death or severe intraventricular hemorrhage to determine noninferiority of umbilical cord milking with a 1% noninferiority margin. RESULTS Among 540 infants randomized, 474 (88%) were enrolled and completed the trial (mean gestational age of 28 weeks; 46% female). Twelve percent (29/236) of the umbilical cord milking group died or developed severe intraventricular hemorrhage compared with 8% (20/238) of the delayed umbilical cord clamping group (risk difference, 4% [95% CI, -2% to 9%]; P = .16). Although there was no statistically significant difference in death, severe intraventricular hemorrhage was statistically significantly higher in the umbilical cord milking group than in the delayed umbilical cord clamping group (8% [20/236] vs 3% [8/238], respectively; risk difference, 5% [95% CI, 1% to 9%]; P = .02). The test for interaction between gestational age strata and treatment group was significant for severe intraventricular hemorrhage only (P = .003); among infants born at 23 to 27 weeks' gestation, severe intraventricular hemorrhage was statistically significantly higher with umbilical cord milking than with delayed umbilical cord clamping (22% [20/93] vs 6% [5/89], respectively; risk difference, 16% [95% CI, 6% to 26%]; P = .002). CONCLUSIONS AND RELEVANCE In this post hoc analysis of a prematurely terminated randomized clinical trial of umbilical cord milking vs delayed umbilical cord clamping among preterm infants born at less than 32 weeks' gestation, there was no statistically significant difference in the rate of a composite outcome of death or severe intraventricular hemorrhage, but there was a statistically significantly higher rate of severe intraventricular hemorrhage in the umbilical cord milking group. The early study termination and resulting post hoc nature of the analyses preclude definitive conclusions. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03019367.
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Affiliation(s)
- Anup Katheria
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, California
| | - Frank Reister
- Department of Obstetrics, University of Ulm, Ulm, Germany
| | - Jochen Essers
- Department of Pediatrics, University of Ulm, Ulm, Germany
| | - Marc Mendler
- Department of Pediatrics, University of Ulm, Ulm, Germany
| | - Helmut Hummler
- Division of Neonatology, Department of Pediatrics, Sidra Medicine, Doha, Qatar
| | | | - Waldemar Carlo
- Department of Pediatrics, University of Alabama at Birmingham
| | - Alan Tita
- Department of Obstetrics, University of Alabama at Birmingham
| | - Giang Truong
- Department of Pediatrics, Loma Linda University, Loma Linda, California
| | | | - Georg Schmölzer
- Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Radha Chari
- Department of Obstetrics, University of Alberta, Edmonton, Canada
| | - Joseph Kaempf
- Women and Children’s Services, Providence St Vincent Medical Center, Portland, Oregon
| | - Mark Tomlinson
- Women and Children’s Services, Providence St Vincent Medical Center, Portland, Oregon
| | - Toby Yanowitz
- Department of Pediatrics, Magee Women’s Hospital of UPMC, Pittsburgh, Pennsylvania
| | - Stacy Beck
- Department of Obstetrics, Magee Women’s Hospital of UPMC, Pittsburgh, Pennsylvania
| | - Hyagriv Simhan
- Department of Obstetrics, Magee Women’s Hospital of UPMC, Pittsburgh, Pennsylvania
| | - Eugene Dempsey
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
- INFANT Research Centre, University College Cork, Cork, Ireland
| | | | - Shazia Bhat
- Department of Pediatrics, Christiana Care Health System, Newark, Delaware
| | - Matthew Hoffman
- Department of Obstetrics, Christiana Care Health System, Newark, Delaware
| | - Arij Faksh
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, California
| | - Kathy Arnell
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, California
| | - Wade Rich
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, California
| | - Neil Finer
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, California
| | - Yvonne Vaucher
- Department of Radiology, Children’s Hospital Colorado, University of Colorado School of Medicine, Denver
| | - Paritosh Khanna
- Department of Radiology, Rady Children’s Hospital, San Diego, California
| | - Mariana Meyers
- Department of Radiology, Children’s Hospital Colorado, University of Colorado School of Medicine, Denver
| | - Michael Varner
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City
| | - Phillip Allman
- Department of Biostatistics, University of Alabama at Birmingham
| | - Jeff Szychowski
- Department of Biostatistics, University of Alabama at Birmingham
| | - Gary Cutter
- Department of Biostatistics, University of Alabama at Birmingham
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Romantsik O, Bruschettini M, Moreira A, Thébaud B, Ley D. Stem cell-based interventions for the prevention and treatment of germinal matrix-intraventricular haemorrhage in preterm infants. Cochrane Database Syst Rev 2019; 9:CD013201. [PMID: 31549743 PMCID: PMC6757514 DOI: 10.1002/14651858.cd013201.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Germinal matrix-intraventricular haemorrhage (GMH-IVH) remains a substantial issue in neonatal intensive care units worldwide. Current therapies to prevent or treat GMH-IVH are limited. Stem cell-based therapies offer a potential therapeutic approach to repair, restore, and/or regenerate injured brain tissue. These preclinical findings have now culminated in ongoing human neonatal studies. OBJECTIVES To determine the benefits and harms of stem cell-based interventions for prevention or treatment of germinal matrix-intraventricular haemorrhage (GM-IVH) in preterm infants. SEARCH METHODS We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 1), in the Cochrane Library; MEDLINE via PubMed (1966 to 7 January 2019); Embase (1980 to 7 January 2019); and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to 7 January 2019). We also searched clinical trials databases, conference proceedings, and reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. SELECTION CRITERIA We attempted to identify randomised controlled trials, quasi-randomised controlled trials, and cluster trials comparing (1) stem cell-based interventions versus control; (2) mesenchymal stromal cells (MSCs) of type or source versus MSCs of other type or source; (3) stem cell-based interventions other than MSCs of type or source versus stem cell-based interventions other than MSCs of other type or source; or (4) MSCs versus stem cell-based interventions other than MSCs. For prevention studies, we included extremely preterm infants (less than 28 weeks' gestation), 24 hours of age or less, without ultrasound diagnosis of GM-IVH; for treatment studies, we included preterm infants (less than 37 weeks' gestation), of any postnatal age, with ultrasound diagnosis of GM-IVH. DATA COLLECTION AND ANALYSIS For each of the included trials, two review authors independently planned to extract data (e.g. number of participants, birth weight, gestational age, type and source of MSCs, other stem cell-based interventions) and assess the risk of bias (e.g. adequacy of randomisation, blinding, completeness of follow-up). Primary outcomes considered in this review are all-cause neonatal mortality, major neurodevelopmental disability, GM-IVH, and extension of pre-existing non-severe GM-IVH. We planned to use the GRADE approach to assess the quality of evidence. MAIN RESULTS Our search strategy yielded 769 references. We did not find any completed studies for inclusion. One randomised controlled trial is currently registered and ongoing. Five phase 1 trials are described in the excluded studies. AUTHORS' CONCLUSIONS Currently no evidence is available to show the benefits or harms of stem cell-based interventions for treatment or prevention of GM-IVH in preterm infants.
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Affiliation(s)
- Olga Romantsik
- Lund University, Skåne University HospitalDepartment of Clinical Sciences Lund, PaediatricsLundSweden
| | - Matteo Bruschettini
- Lund University, Skåne University HospitalDepartment of Clinical Sciences Lund, PaediatricsLundSweden
- Skåne University HospitalCochrane SwedenWigerthuset, Remissgatan 4, first floorroom 11‐221LundSweden22185
| | - Alvaro Moreira
- University of Texas Health Science Center at San AntonioPediatrics, Division of NeonatologySan AntonioTexasUSA
| | - Bernard Thébaud
- Children's Hospital of Eastern OntarioDepartment of PediatricsOttawaONCanada
- Ottawa Hospital Research Institute, Sprott Centre for Stem Cell ResearchOttawaCanada
- University of OttawaDepartment of Cellular and Molecular MedicineOttawaCanada
| | - David Ley
- Lund University, Skane University HospitalDepartment of Clinical Sciences Lund, PaediatricsLundSweden
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Hoffman SB, Cheng YJ, Magder LS, Shet N, Viscardi RM. Cerebral autoregulation in premature infants during the first 96 hours of life and relationship to adverse outcomes. Arch Dis Child Fetal Neonatal Ed 2019; 104:F473-F479. [PMID: 30385514 DOI: 10.1136/archdischild-2018-315725] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 09/26/2018] [Accepted: 10/05/2018] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To test the hypothesis that impaired cerebral autoregulation (ICA) increases the susceptibility of premature infants to adverse outcomes, we determined the relationship of ICA and cerebral reactivity (CR) measured in the first 96 hours of life to the outcome of grade 3 or 4 intraventricular haemorrhage (IVH) and/or death within 1 month. SETTING Single-centre level IV neonatal intensive care unit. PATIENTS Neonates 24-29 weeks' gestation less than 12 hours old with invasive blood pressure monitoring. DESIGN Cerebral saturations and mean arterial blood pressure were recorded every 30 s for 96 hours. For each 10 min epoch, the correlation coefficient (r) was calculated for mean arterial blood pressure versus cerebral saturations. The epoch was considered to have ICA if r>0.5 and CR if r<0. RESULTS Sixty-one subjects were included. During the first 96 hours, ICA occurred 17.6% and CR occurred 41% of recorded time. In those without adverse outcomes, ICA decreased and CR increased by postnatal day (p<0.05). Adjusted for birth weight and gestational age, those with IVH and those who died spent more time with ICA and less time with CR (p<0.05) over the entire recording period. Those with IVH had 1.5-fold increase in time with ICA on day 2 (p=0.021), and decrease in time with CR on day 3 (p=0.036). Compared with survivors, non-survivors spent more time with ICA on days 3 and 4 (p<0.005), and less with CR on day 3 (p=0.032). CONCLUSION ICA and CR vary by postnatal day and these patterns are associated with adverse outcomes.
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Affiliation(s)
- Suma B Hoffman
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Yun-Ju Cheng
- Department of Mathematics and Statistics, University of Maryland Baltimore County, Baltimore, Maryland, USA
| | - Laurence S Magder
- Department of Epidemiology and Preventive Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Narendra Shet
- Department of Diagnostic Imaging and Radiology, Children's National Health System, Michigan Avenue NW, Washington, DC, USA
| | - Rose M Viscardi
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Cohen E, Baerts W, Caicedo Dorado A, Naulaers G, van Bel F, Lemmers PMA. Cerebrovascular autoregulation in preterm fetal growth restricted neonates. Arch Dis Child Fetal Neonatal Ed 2019; 104:F467-F472. [PMID: 30355781 DOI: 10.1136/archdischild-2017-313712] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 09/12/2018] [Accepted: 09/22/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To investigate the effect of fetal growth restriction (FGR) on cerebrovascular autoregulation in preterm neonates during the first 3 days of life. DESIGN Case-control study. SETTING Neonatal intensive care unit of the Wilhelmina Children's Hospital, The Netherlands. PATIENTS 57 FGR (birth weight <10th percentile) and 57 appropriate for gestational age (AGA) (birth weight 20th-80th percentiles) preterm neonates, matched for gender, gestational age, respiratory and blood pressure support. METHODS The correlation between continuously measured mean arterial blood pressure and regional cerebral oxygen saturation was calculated to generate the cerebral oximetry index (COx). Mean COx was calculated for each patient for each postnatal day. The percentage of time with impaired autoregulation (COx>0.5) was also calculated. RESULTS FGR neonates had higher mean COx values than their AGA peers on day 2 (0.15 (95% CI 0.11 to 0.18) vs 0.09 (95% CI 0.06 to 0.13), p=0.029) and day 3 (0.17 (95% CI 0.13 to 0.20) vs 0.09 (95% CI 0.06 to 0.12), p=0.003) of life. FGR neonates spent more time with impaired autoregulation (COx value >0.5) than controls on postnatal day 2 (19% (95% CI 16% to 22%) vs 14% (95% CI 12% to 17%), p=0.035) and day 3 (20% (95% CI 17% to 24%) vs 15% (95% CI 12% to 18%), p=0.016). CONCLUSION FGR preterm neonates more frequently display impaired cerebrovascular autoregulation compared with AGA peers on days 2 and 3 of life which may predispose them to brain injury. Further studies are required to investigate whether this impairment persists beyond the first few days of life and whether this impairment is linked to poor neurodevelopmental outcome.
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Affiliation(s)
- Emily Cohen
- Department of Neonatology, Wilhelmina Children's Hospital/University Medical Centre Utrecht, Utrecht, The Netherlands.,The Ritchie Centre, Hudson Institute of Medical Research and Department of Paediatrics, Monash University, Melbourne, Victoria, Australia
| | - Willem Baerts
- Department of Neonatology, Wilhelmina Children's Hospital/University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Alexander Caicedo Dorado
- Department of Applied Mathematics and Computer Science, Faculty of Natural Sciences and Mathematics, Universidad del Rosario, Bogota, Colombia
| | - Gunnar Naulaers
- Department of Neonatology, University Hospital Leuven, Leuven, Belgium
| | - Frank van Bel
- Department of Neonatology, Wilhelmina Children's Hospital/University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Petra M A Lemmers
- Department of Neonatology, Wilhelmina Children's Hospital/University Medical Centre Utrecht, Utrecht, The Netherlands
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Regional tissue oxygenation monitoring in the neonatal intensive care unit: evidence for clinical strategies and future directions. Pediatr Res 2019; 86:296-304. [PMID: 31247635 DOI: 10.1038/s41390-019-0466-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 05/24/2019] [Accepted: 06/08/2019] [Indexed: 12/19/2022]
Abstract
Near-infrared spectroscopy (NIRS)-based monitoring of regional tissue oxygenation (rSO2) is becoming more commonplace in the neonatal intensive care unit (NICU). While increasing evidence supports rSO2 monitoring, actual standards for applying this noninvasive bedside technique continue to evolve. This review highlights the current strengths and pitfalls surrounding practical NIRS-based monitoring in the neonatal population. The physiologic background of rSO2 monitoring is discussed, with attention to understanding oxygen delivery/consumption mismatch and its effects on tissue oxygen extraction. The bedside utility of both cerebral and peripheral rSO2 monitoring in the NICU is then explored from two perspectives: (1) disease/event-specific "responsive" monitoring and (2) "routine," continuous monitoring. Recent evidence incorporating both monitoring approaches is summarized with emphasis on practical applicability in the NICU. Finally, a future paradigm for a broad-based NIRS monitoring strategy is presented, with attention towards improving personalization of neonatal care and ultimately enhancing long-term outcomes.
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63
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Changes in hemodynamics, cerebral oxygenation and cerebrovascular reactivity during the early transitional circulation in preterm infants. Pediatr Res 2019; 86:247-253. [PMID: 31029059 DOI: 10.1038/s41390-019-0410-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Accepted: 04/16/2019] [Indexed: 11/08/2022]
Abstract
BACKGROUND Changes in systemic and cerebral hemodynamics in preterm infants during early transitional circulation are complex and may differ between infants with or without intraventricular hemorrhage (IVH). METHOD In total, 43 infants born at median (range) 25 + 5 (23 + 3-31) had continuous near-infrared spectroscopy (NIRS) monitoring of tissue oxygenation index (TOI) and cerebrovascular reactivity within the first 48 h of life. Measurements of left and right cardiac outputs (LVO, RVO) and patent ductus arteriosus (PDA) were collected at 6, 12, 24, and 48 h of life. RESULTS LVO increased within the first 48 h in the IVH (P = 0.007) and no-IVH (P < 0.001) groups. The pattern of change in LVO and RVO was not different between these two groups. TOI was lower in the IVH (P < 0.001) group. A positive correlation between TOI and LVO (P = 0.003) and a negative correlation between the tissue oxygen reactivity index (TOx) and LVO (P = 0.04) were observed at 24 h of life in the IVH group. PDA diameter was not different between IVH groups at any time interval. CONCLUSION Cerebral oxygenation was lower and cerebrovascular reactivity was passive to systemic blood flow at 24 h in infants who developed an IVH.
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Usuda H, Watanabe S, Saito M, Sato S, Musk GC, Fee ME, Carter S, Kumagai Y, Takahashi T, Kawamura MS, Hanita T, Kure S, Yaegashi N, Newnham JP, Kemp MW. Successful use of an artificial placenta to support extremely preterm ovine fetuses at the border of viability. Am J Obstet Gynecol 2019; 221:69.e1-69.e17. [PMID: 30853365 DOI: 10.1016/j.ajog.2019.03.001] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 02/26/2019] [Accepted: 03/04/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Ex vivo uterine environment therapy is an experimental life support platform designed to reduce the risk of morbidity and mortality for extremely preterm infants born at the border of viability (21-24 weeks' gestation). To spare the functionally immature lung, this platform performs gas exchange via a membranous oxygenator connected to the umbilical vessels, and the fetus is submerged in a protective bath of artificial amniotic fluid. We and others have demonstrated the feasibility of extended survival with ex vivo uterine environment therapy therapy in late preterm fetuses; however, there is presently no evidence to show that the use of such a platform can support extremely preterm fetuses, the eventual translational target for therapy of this nature. OBJECTIVE The objective of the study was to use our ex vivo uterine environment therapy platform to support the healthy maintenance of 600-700 g/95 days gestational age (equivalent to 24 weeks of human gestation) sheep fetuses. Primary outcome measures were as follows: (1) maintenance of key physiological variables; (2) absence of infection; (3) absence of brain injury; and (4) growth and cardiovascular function patterns matching that of noninstrumented, age-matched in utero controls. STUDY DESIGN Singleton fetuses from 8 ewes underwent surgical delivery at 95 days' gestation (term, 150 days). Fetuses were adapted to ex vivo uterine environment therapy and maintained for 120 hours with real-time monitoring of key physiological variables. Umbilical artery blood samples were regularly collected to assess blood gas data, differential counts, inflammation, and microbial load to exclude infection. Brain injury was evaluated by gross anatomical and histopathological approaches after euthanasia. Nine pregnant control animals were euthanized at 100 days' gestation to allow comparative postmortem analyses. Data were tested for mean differences with an analysis of variance. RESULTS Seven of 8 ex vivo uterine environment group fetuses (87.5%) completed 120 hours of therapy with key parameters maintained in a normal physiological range. There were no significant intergroup differences (P > .05) in final weight, crown-rump length, and body weight-normalized lung and brain weights at euthanasia compared with controls. There were no biologically significant differences in hematological parameters (total or differential leucocyte counts and plasma concentration of tumor necrosis factor-α and monocyte chemoattractant protein 1) (P > .05). Daily blood cultures were negative for aerobic and anaerobic growth in all ex vivo uterine environment animals. There was no difference in airspace consolidation between control and ex vivo uterine environment animals, and there was no increase in the number of lung cells staining positive for the T-cell marker CD3. There were no increases in interleukin-1, interleukin-6, interleukin-8, tumor necrosis factor-α, and monocyte chemoattractant protein 1 mRNA expression in lung tissues compared with the control group. No cases of intraventricular hemorrhage were observed, and white matter injury was identified in only 1 ex vivo uterine environment fetus. CONCLUSION For several decades, there has been little improvement in outcomes of extremely preterm infants born at the border of viability. In the present study, we report the use of artificial placenta technology to support, for the first time, extremely preterm ovine fetuses (equivalent to 24 weeks of human gestation) in a stable, growth-normal state for 120 hours. With additional refinement, the data generated by this study may inform a treatment option to improve outcomes for extremely preterm infants.
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65
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Valdez Sandoval P, Hernández Rosales P, Quiñones Hernández DG, Chavana Naranjo EA, García Navarro V. Intraventricular hemorrhage and posthemorrhagic hydrocephalus in preterm infants: diagnosis, classification, and treatment options. Childs Nerv Syst 2019; 35:917-927. [PMID: 30953157 DOI: 10.1007/s00381-019-04127-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 03/15/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE Intraventricular hemorrhage is the most important adverse neurologic event for preterm and very low weight birth infants in the neonatal period. This pathology can lead to various delays in motor, language, and cognition development. The aim of this article is to give an overview of the knowledge in diagnosis, classification, and treatment options of this pathology. METHOD A systematic review has been made. RESULTS The cranial ultrasound can be used to identify the hemorrhage and grade it according to the modified Papile grading system. There is no standardized protocol of intervention as there are controversial results on which of the temporizing neurosurgical procedures is best and about the appropriate parameters to consider a conversion to ventriculoperitoneal shunt. However, it has been established that the most important prognosis factor is the involvement and damage of the white matter. CONCLUSION More evidence is required to create a standardized protocol that can ensure the best possible outcome for these patients.
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Affiliation(s)
- Paola Valdez Sandoval
- Department of Clinical Sciences, Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Campus Guadalajara, Avenida General Ramón Corona 2514, Guadalajara, 45138, Mexico
| | - Paola Hernández Rosales
- Department of Clinical Sciences, Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Campus Guadalajara, Avenida General Ramón Corona 2514, Guadalajara, 45138, Mexico
| | - Deyanira Gabriela Quiñones Hernández
- Department of Clinical Sciences, Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Campus Guadalajara, Avenida General Ramón Corona 2514, Guadalajara, 45138, Mexico
| | | | - Victor García Navarro
- Department of Clinical Sciences, Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Campus Guadalajara, Avenida General Ramón Corona 2514, Guadalajara, 45138, Mexico. .,Neurosurgery Department, Nuevo Hospital Civil de Guadalajara, Juan I. Menchaca, Guadalajara, 44340, Mexico.
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Vesoulis ZA, Liao SM, Mathur AM. Delayed cord clamping is associated with improved dynamic cerebral autoregulation and decreased incidence of intraventricular hemorrhage in preterm infants. J Appl Physiol (1985) 2019; 127:103-110. [PMID: 31046516 DOI: 10.1152/japplphysiol.00049.2019] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Delayed cord clamping (DCC) improves neurologic outcomes in preterm infants through a reduction in intraventricular hemorrhage (IVH) incidence. The mechanism behind this neuroprotective effect is not known. Infants born <28 wk gestation were recruited for longitudinal monitoring. All infants underwent 72 h of synchronized near-infrared spectroscopy (NIRS) and mean arterial blood pressure (MABP) recording within 24 h of birth. Infants with DCC were compared with control infants with immediate cord clamping (ICC), controlling for severity of illness [clinical risk index for babies (CRIB-II) score], chorioamnionitis, antenatal steroids, sedation, inotropes, and delivery mode. Autoregulatory dampening was calculated as the transfer function gain coefficient between the MABP and NIRS signals. Forty-five infants were included (DCC; n = 15, paired 2:1 with ICC controls n = 30). ICC and DCC groups were similar including gestational age (25.5 vs. 25.2 wk, P = 0.48), birth weight (852.3 vs. 816.6 g, P = 0.73), percent female (40 vs. 40%, P = 0.75), and dopamine usage (27 vs. 23%, P = 1.00). There was a significant difference in IVH incidence between the DCC and ICC groups (20 vs. 50%, P = 0.04). Mean MABP was not different (35.9 vs. 35.1 mmHg, P = 0.44). Compared with the DCC group, the ICC group had diminished autoregulatory dampening capacity (-12.96 vs. -15.06 dB, P = 0.01), which remained significant when controlling for confounders. Dampening capacity was, in turn, strongly associated with decreased risk of IVH (odds ratio = 0.14, P < 0.01). The results of this pilot study demonstrate that DCC is associated with improved dynamic cerebral autoregulatory function and may be the mechanism behind the decreased incidence of IVH. NEW & NOTEWORTHY The neuroprotective mechanism of delayed cord clamping in premature infants is unclear. Delayed cord clamping was associated with improved cerebral autoregulatory function and a marked decrease in intraventricular hemorrhage (IVH). Improved dynamic cerebral autoregulation may decrease arterial baroreceptor sensitivity, thereby reducing the risk of IVH.
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Affiliation(s)
- Zachary A Vesoulis
- Division of Newborn Medicine, Edward Mallinckrodt Department of Pediatrics, Washington University School of Medicine , St. Louis, Missouri
| | - Steve M Liao
- Division of Newborn Medicine, Edward Mallinckrodt Department of Pediatrics, Washington University School of Medicine , St. Louis, Missouri
| | - Amit M Mathur
- Division of Newborn Medicine, Edward Mallinckrodt Department of Pediatrics, Washington University School of Medicine , St. Louis, Missouri
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67
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Govindan RB, Brady KM, Massaro AN, Perin J, Jennings JM, DuPlessis AJ, Koehler RC, Lee JK. Comparison of Frequency- and Time-Domain Autoregulation and Vasoreactivity Indices in a Piglet Model of Hypoxia-Ischemia and Hypothermia. Dev Neurosci 2019; 40:1-13. [PMID: 31048593 PMCID: PMC6824917 DOI: 10.1159/000499425] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 03/06/2019] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION The optimal method to detect impairments in cerebrovascular pressure autoregulation in neonates with hypoxic-ischemic encephalopathy (HIE) is unclear. Improving autoregulation monitoring methods would significantly advance neonatal neurocritical care. METHODS We tested several mathematical algorithms from the frequency and time domains in a piglet model of HIE, hypothermia, and hypotension. We used laser Doppler flowmetry and induced hypotension to delineate the gold standard lower limit of autoregulation (LLA). Receiver operating characteristics curve analyses were used to determine which indices could distinguish blood pressure above the LLA from that below the LLA in each piglet. RESULTS Phase calculation in the frequency band with maximum coherence, as well as the correlation between mean arterial pressure (MAP) and near-infrared spectroscopy relative total tissue hemoglobin (HbT) or regional oxygen saturation (rSO2), accurately discriminated functional from dysfunctional autoregulation. Neither hypoxia-ischemia nor hypothermia affected the accuracy of these indices. Coherence alone and gain had low diagnostic value relative to phase and correlation. CONCLUSION Our findings indicate that phase shift is the most accurate component of autoregulation monitoring in the developing brain, and it can be measured using correlation or by calculating phase when coherence is maximal. Phase and correlation autoregulation indices from MAP and rSO2 and vasoreactivity indices from MAP and HbT are accurate metrics that are suitable for clinical HIE studies.
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Affiliation(s)
- Rathinaswamy B Govindan
- Fetal Medicine Institute, Children's National Health System, Washington, District of Columbia, USA
- The George Washington University School of Medicine, Washington, District of Columbia, USA
| | - Ken M Brady
- Department of Anesthesiology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - An N Massaro
- Fetal Medicine Institute, Children's National Health System, Washington, District of Columbia, USA
- The George Washington University School of Medicine, Washington, District of Columbia, USA
- Neonatology, Children's National Health System, Washington, District of Columbia, USA
| | - Jamie Perin
- Center for Child and Community Health Research, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jacky M Jennings
- Center for Child and Community Health Research, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Adre J DuPlessis
- Fetal Medicine Institute, Children's National Health System, Washington, District of Columbia, USA
- The George Washington University School of Medicine, Washington, District of Columbia, USA
| | - Raymond C Koehler
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jennifer K Lee
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA,
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68
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Naimo PS, Konstantinov IE. Commentary: White matter injury and heart surgery-Will we get to the heart of the matter? J Thorac Cardiovasc Surg 2019; 158:878-879. [PMID: 31036357 DOI: 10.1016/j.jtcvs.2019.03.069] [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: 03/20/2019] [Accepted: 03/21/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Phillip S Naimo
- Department of Cardiothoracic Surgery, Royal Children's Hospital, Melbourne, Australia; Murdoch Children's Research Institute, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | - Igor E Konstantinov
- Department of Cardiothoracic Surgery, Royal Children's Hospital, Melbourne, Australia; Murdoch Children's Research Institute, Melbourne, Australia; University of Melbourne, Melbourne, Australia; Melbourne Children's Centre for Cardiovascular Genomics and Regenerative Medicine, Melbourne, Australia.
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Pereira SS, Sinha AK, Morris JK, Wertheim DF, Shah DK, Kempley ST. Blood pressure intervention levels in preterm infants: pilot randomised trial. Arch Dis Child Fetal Neonatal Ed 2019; 104:F298-F305. [PMID: 30049724 DOI: 10.1136/archdischild-2017-314159] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 06/06/2018] [Accepted: 06/18/2018] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To examine the feasibility of a trial allocating different blood pressure (BP) intervention levels for treatment in extremely preterm infants. DESIGN Three-arm open randomised controlled trial performed between February 2013 and April 2015. SETTING Single tertiary level neonatal intensive care unit. PATIENTS Infants born <29 weeks' gestation were eligible to participate, if parents consented and they did not have a major congenital malformation. INTERVENTIONS Infants were randomised to different levels of mean arterial BP at which they received cardiovascular support: active (<30 mm Hg), moderate (<gestational age mm Hg) or permissive (signs of poor perfusion or <19 mm Hg). Once this threshold was breached, all were managed using the same treatment guideline. BP profiles were downloaded continuously; cardiac output and carotid blood flow were measured at 1 day and 3 days, and amplitude integrated EEG was recorded during the first week. Cranial ultrasound scans were reviewed blind to study allocation. MAIN OUTCOME MEASURE Inotrope usage and achieved BP. RESULTS Of 134 cases screened, 60 were enrolled, with mean gestation 25.8 weeks (SD 1.5) and birth weight 817 g (SD 190). Invasively measured BP on the first day and inotrope usage were highest in the active and lowest in the permissive arms. There were no differences in haemodynamic or EEG variables or in clinical complications. Predefined cranial ultrasound findings did not differ significantly; no infants in the active arm had parenchymal brain lesions. CONCLUSION The BP threshold used to trigger treatment affects the achieved BP and inotrope usage, and it was possible to explore these effects using this study design. TRIAL REGISTRATION NUMBER ISRCTN83507686.
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Affiliation(s)
- Sujith Stanley Pereira
- Neonatal Unit, Royal London Hospital, Barts Health NHS Trust, London, UK.,Centre for Genomics and Child Health, Blizard Institute, Barts and the London School of Medicine and Dentistry, London, UK
| | - Ajay Kumar Sinha
- Neonatal Unit, Royal London Hospital, Barts Health NHS Trust, London, UK.,Centre for Genomics and Child Health, Blizard Institute, Barts and the London School of Medicine and Dentistry, London, UK
| | - Joan Katherine Morris
- Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - David F Wertheim
- Faculty of Science, Engineering and Computing, Kingston University, Kingston, UK
| | - Divyen K Shah
- Neonatal Unit, Royal London Hospital, Barts Health NHS Trust, London, UK.,Centre for Genomics and Child Health, Blizard Institute, Barts and the London School of Medicine and Dentistry, London, UK
| | - Stephen Terence Kempley
- Neonatal Unit, Royal London Hospital, Barts Health NHS Trust, London, UK.,Centre for Genomics and Child Health, Blizard Institute, Barts and the London School of Medicine and Dentistry, London, UK
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70
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Pregnolato S, Chakkarapani E, Isles AR, Luyt K. Glutamate Transport and Preterm Brain Injury. Front Physiol 2019; 10:417. [PMID: 31068830 PMCID: PMC6491644 DOI: 10.3389/fphys.2019.00417] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 03/27/2019] [Indexed: 12/19/2022] Open
Abstract
Preterm birth complications are the leading cause of child death worldwide and a top global health priority. Among the survivors, the risk of life-long disabilities is high, including cerebral palsy and impairment of movement, cognition, and behavior. Understanding the molecular mechanisms of preterm brain injuries is at the core of future healthcare improvements. Glutamate excitotoxicity is a key mechanism in preterm brain injury, whereby the accumulation of extracellular glutamate damages the delicate immature oligodendrocytes and neurons, leading to the typical patterns of injury seen in the periventricular white matter. Glutamate excitotoxicity is thought to be induced by an interaction between environmental triggers of injury in the perinatal period, particularly cerebral hypoxia-ischemia and infection/inflammation, and developmental and genetic vulnerabilities. To avoid extracellular build-up of glutamate, the brain relies on rapid uptake by sodium-dependent glutamate transporters. Astrocytic excitatory amino acid transporter 2 (EAAT2) is responsible for up to 95% of glutamate clearance, and several lines of evidence suggest that it is essential for brain functioning. While in the adult EAAT2 is predominantly expressed by astrocytes, EAAT2 is transiently upregulated in the immature oligodendrocytes and selected neuronal populations during mid-late gestation, at the peak time for preterm brain injury. This developmental upregulation may interact with perinatal hypoxia-ischemia and infection/inflammation and contribute to the selective vulnerability of the immature oligodendrocytes and neurons in the preterm brain. Disruption of EAAT2 may involve not only altered expression but also impaired function with reversal of transport direction. Importantly, elevated EAAT2 levels have been found in the reactive astrocytes and macrophages of human infant post-mortem brains with severe white matter injury (cystic periventricular leukomalacia), potentially suggesting an adaptive mechanism against excitotoxicity. Interestingly, EAAT2 is suppressed in animal models of acute hypoxic-ischemic brain injury at term, pointing to an important and complex role in newborn brain injuries. Enhancement of EAAT2 expression and transport function is gathering attention as a potential therapeutic approach for a variety of adult disorders and awaits exploration in the context of the preterm brain injuries.
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Affiliation(s)
- Silvia Pregnolato
- Department of Neonatal Neurology, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Elavazhagan Chakkarapani
- Department of Neonatal Neurology, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Anthony R Isles
- Behavioural Genetics Group, MRC Centre for Neuropsychiatric Genetics and Genomics, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Karen Luyt
- Department of Neonatal Neurology, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
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71
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Sola C, Hertz L, Bringuier S, De La Arena P, Macq C, Deziel-Malouin S, Raux O, Dadure C. Spinal anaesthesia in neonates and infants: what about the cerebral oxygen saturation? Br J Anaesth 2019; 119:964-971. [PMID: 28981572 DOI: 10.1093/bja/aex218] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2017] [Indexed: 01/26/2023] Open
Abstract
Background Spinal Anaesthesia (SA) has been firmly established as an efficient and safe technique, with minimal cardio-respiratory disturbance when administered in the neonatal period. Our objective was to assess the haemodynamic consequences of SA in infants, particularly its impact on cerebral perfusion using near-infrared spectroscopy (NIRS)-based cerebral oximetry (rSco2). Methods All infants up to 60 weeks' postmenstrual age, whether formerly preterm or not, and undergoing spinal anaesthesia, were enrolled. Haemodynamic data records, rSco2 and mean arterial blood pressure (MAP), were prospectively collected before SA (T0) and every five min for 30 min (T30) after the puncture. Compared with baseline measures, any changes of > 10% in rSco2 and of > 20% in MAP were considered clinically significant. Relative variations of data between T0 and T30 were analysed. Results Data of 103 infants were analysed. The mean relative changes in rSco2 were -2.25% (97.5% CI [-3.97; -0.5]) at T15, and 0.11% (97.5% CI [-1.67; 1.90]) at T30. No significant variation of rSco2 was recorded. The mean changes in MAP were respectively -13.94% (97.5% CI [-17.74; -10.14]) at T15 and -20.27% (97.5% CI [-24,25; -16.29]) at T30. MAP decrease was statistically and clinically significant 30 min after SA. No correlation between changes in MAP and rSco2 was found. The subgroup analysis did not reveal any effect of added intrathecal clonidine or preterm birth history on these results. Conclusions In neonate and infants, SA did not cause clinically significant variation in cerebral oxygen saturation. Despite a significant decrease in MAP, cerebral auto-regulation seems to remain effective in neonates and not altered by spinal anaesthesia.
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Affiliation(s)
- C Sola
- Department of Anaesthesia and Critical Care Medicine, Paediatric Anaesthesia Unit, Lapeyronie University Hospital, Montpellier, France
| | - L Hertz
- Department of Anaesthesia and Critical Care Medicine, Paediatric Anaesthesia Unit, Lapeyronie University Hospital, Montpellier, France
| | - S Bringuier
- Biostatistics and Clinical Research Consultant, Department of Anaesthesiology and Critical Care Medicine, Lapeyronie University Hospital, Montpellier, France
| | - P De La Arena
- Department of Anaesthesia and Critical Care Medicine, Paediatric Anaesthesia Unit, Lapeyronie University Hospital, Montpellier, France
| | - C Macq
- Department of Anaesthesia and Critical Care Medicine, Paediatric Anaesthesia Unit, Lapeyronie University Hospital, Montpellier, France
| | - S Deziel-Malouin
- Department of Anaesthesia and Critical Care Medicine, Paediatric Anaesthesia Unit, Lapeyronie University Hospital, Montpellier, France.,Department of Anesthesia, Sherbrooke University Hospital, Sherbrooke, Canada
| | - O Raux
- Department of Anaesthesia and Critical Care Medicine, Paediatric Anaesthesia Unit, Lapeyronie University Hospital, Montpellier, France
| | - C Dadure
- Department of Anaesthesia and Critical Care Medicine, Paediatric Anaesthesia Unit, Lapeyronie University Hospital, Montpellier, France
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Pham T, Tgavalekos K, Sassaroli A, Blaney G, Fantini S. Quantitative measurements of cerebral blood flow with near-infrared spectroscopy. BIOMEDICAL OPTICS EXPRESS 2019; 10:2117-2134. [PMID: 31061774 PMCID: PMC6484993 DOI: 10.1364/boe.10.002117] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 03/07/2019] [Accepted: 03/20/2019] [Indexed: 05/29/2023]
Abstract
We propose a new near-infrared spectroscopy (NIRS) method for quantitative measurements of cerebral blood flow (CBF). Because this method uses concepts of coherent hemodynamics spectroscopy (CHS), we identify this new method with the acronym NIRS-CHS. We tested this method on the prefrontal cortex of six healthy human subjects during mean arterial pressure (MAP) transients induced by the rapid deflation of pneumatic thigh cuffs. A comparison of CBF dynamics measured with NIRS-CHS and with diffuse correlation spectroscopy (DCS) showed a good agreement for characteristic times of the CBF transient. We also report absolute measurements of baseline CBF with NIRS-CHS (69 ± 6 ml/100g/min over the six subjects). NIRS-CHS can provide more accurate measurements of CBF with respect to previously reported NIRS surrogates of CBF.
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Affiliation(s)
- Thao Pham
- Department of Biomedical Engineering, Tufts University, 4 Colby Street, Medford, MA 02155, USA
| | - Kristen Tgavalekos
- Department of Biomedical Engineering, Tufts University, 4 Colby Street, Medford, MA 02155, USA
| | - Angelo Sassaroli
- Department of Biomedical Engineering, Tufts University, 4 Colby Street, Medford, MA 02155, USA
| | - Giles Blaney
- Department of Biomedical Engineering, Tufts University, 4 Colby Street, Medford, MA 02155, USA
| | - Sergio Fantini
- Department of Biomedical Engineering, Tufts University, 4 Colby Street, Medford, MA 02155, USA
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73
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Huvanandana J, Thamrin C, Hinder M, McEwan A, Tracy MB. The effect of caffeine loading on cerebral autoregulation in preterm infants. Acta Paediatr 2019; 108:436-442. [PMID: 30403427 DOI: 10.1111/apa.14636] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 10/26/2018] [Accepted: 11/01/2018] [Indexed: 11/30/2022]
Abstract
AIM To evaluate cerebral autoregulation changes in preterm infants receiving a loading dose of caffeine base. METHODS In a cohort of 30 preterm infants, we extracted measures of cerebral autoregulation using time and frequency domain techniques to determine the correlation between mean arterial pressure (MAP) and tissue oxygenation index (TOI) signals. These measures included the cerebral oximetry index (COx), cross-correlation and coherence measures, and were extracted prior to caffeine loading and in the 2 hours following administration of 10 mg/kg caffeine base. RESULTS We observed acute reductions in time domain correlation measures, including the cerebral oximetry index (linear mixed model coefficient -0.093, standard error 0.04; p = 0.028) and the detrended cross-correlation coefficient (ρ5 coefficient -0.13, standard error 0.055; p = 0.025). These reductions suggested an acute improvement in cerebral autoregulation. Features from detrended cross-correlation analysis also showed greater discriminative value than other methods in identifying changes prior to and following caffeine administration. CONCLUSION We observed a reduced correlation between MAP and TOI from near-infrared spectroscopy following caffeine administration. These findings suggest an acute enhanced capacity for cerebral autoregulation following a loading dose of caffeine in preterm infants, contributing to our understanding of the physiological impact of caffeine therapy.
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Affiliation(s)
- Jacqueline Huvanandana
- School of Electrical and Information Engineering University of Sydney Sydney NSW Australia
- Woolcock Institute of Medical Research University of Sydney Sydney NSW Australia
| | - Cindy Thamrin
- Woolcock Institute of Medical Research University of Sydney Sydney NSW Australia
| | - Murray Hinder
- School of Electrical and Information Engineering University of Sydney Sydney NSW Australia
- Westmead Hospital Sydney NSW Australia
| | - Alistair McEwan
- School of Electrical and Information Engineering University of Sydney Sydney NSW Australia
- Cerebral Palsy Alliance Sydney NSW Australia
| | - Mark B. Tracy
- Westmead Hospital Sydney NSW Australia
- School of Paediatrics and Child Health University of Sydney Sydney NSW Australia
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74
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Tgavalekos K, Pham T, Krishnamurthy N, Sassaroli A, Fantini S. Frequency-resolved analysis of coherent oscillations of local cerebral blood volume, measured with near-infrared spectroscopy, and systemic arterial pressure in healthy human subjects. PLoS One 2019; 14:e0211710. [PMID: 30753203 PMCID: PMC6372153 DOI: 10.1371/journal.pone.0211710] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 01/19/2019] [Indexed: 01/18/2023] Open
Abstract
We report a study on twenty-two healthy human subjects of the dynamic relationship between cerebral hemoglobin concentration ([HbT]), measured with near-infrared spectroscopy (NIRS) in the prefrontal cortex, and systemic arterial blood pressure (ABP), measured with finger plethysmography. [HbT] is a measure of local cerebral blood volume (CBV). We induced hemodynamic oscillations at discrete frequencies in the range 0.04-0.20 Hz with cyclic inflation and deflation of pneumatic cuffs wrapped around the subject's thighs. We modeled the transfer function of ABP and [HbT] in terms of effective arterial (K(a)) and venous (K(v)) compliances, and a cerebral autoregulation time constant (τ(AR)). The mean values (± standard errors) of these parameters across the twenty-two subjects were K(a) = 0.01 ± 0.01 μM/mmHg, K(v) = 0.09 ± 0.05 μM/mmHg, and τ(AR) = 2.2 ± 1.3 s. Spatially resolved measurements in a subset of eight subjects reveal a spatial variability of these parameters that may exceed the inter-subject variability at a set location. This study sheds some light onto the role that ABP and cerebral blood flow (CBF) play in the dynamics of [HbT] measured with NIRS, and paves the way for new non-invasive optical studies of cerebral blood flow and cerebral autoregulation.
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Affiliation(s)
- Kristen Tgavalekos
- Department of Biomedical Engineering, Tufts University, Medford, Massachusetts, United States of America
| | - Thao Pham
- Department of Biomedical Engineering, Tufts University, Medford, Massachusetts, United States of America
| | - Nishanth Krishnamurthy
- Department of Biomedical Engineering, Tufts University, Medford, Massachusetts, United States of America
| | - Angelo Sassaroli
- Department of Biomedical Engineering, Tufts University, Medford, Massachusetts, United States of America
| | - Sergio Fantini
- Department of Biomedical Engineering, Tufts University, Medford, Massachusetts, United States of America
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75
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Plomgaard AM, Alderliesten T, van Bel F, Benders M, Claris O, Cordeiro M, Dempsey E, Fumagalli M, Gluud C, Hyttel-Sorensen S, Lemmers P, Pellicer A, Pichler G, Greisen G. No neurodevelopmental benefit of cerebral oximetry in the first randomised trial (SafeBoosC II) in preterm infants during the first days of life. Acta Paediatr 2019; 108:275-281. [PMID: 29908039 PMCID: PMC6585779 DOI: 10.1111/apa.14463] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 04/20/2018] [Accepted: 06/13/2018] [Indexed: 11/30/2022]
Abstract
AIM Cerebral hypoxia has been associated with neurodevelopmental impairment. We studied whether reducing cerebral hypoxia in extremely preterm infants during the first 72 hours of life affected neurological outcomes at two years of corrected age. METHODS In 2012-2013, the phase II randomised Safeguarding the Brains of our smallest Children trial compared visible cerebral near-infrared spectroscopy (NIRS) monitoring in an intervention group and blinded NIRS monitoring in a control group. Cerebral hypoxia was significantly reduced in the intervention group. We followed up 115 survivors from eight European centres at two years of corrected age, by conducting a medical examination and assessing their neurodevelopment with the Bayley Scales of Infant and Toddler Development, Second or Third Edition, and the parental Ages and Stages Questionnaire (ASQ). RESULTS There were no differences between the intervention (n = 65) and control (n = 50) groups with regard to the mean mental developmental index (89.6 ± 19.5 versus 88.4 ± 14.7, p = 0.77), ASQ score (215 ± 58 versus 213 ± 58, p = 0.88) and the number of children with moderate-to-severe neurodevelopmental impairment (10 versus six, p = 0.58). CONCLUSION Cerebral NIRS monitoring was not associated with long-term benefits or harm with regard to neurodevelopmental outcome at two years of corrected age.
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Affiliation(s)
- Anne M. Plomgaard
- Department of Neonatology; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - Thomas Alderliesten
- Wilhelmina Children's Hospital; University Medical Center Utrecht; Utrecht The Netherlands
| | - Frank van Bel
- Wilhelmina Children's Hospital; University Medical Center Utrecht; Utrecht The Netherlands
| | - Manon Benders
- Wilhelmina Children's Hospital; University Medical Center Utrecht; Utrecht The Netherlands
| | - Olivier Claris
- Department of Neonatology; Hospices Civils de Lyon; Claude Bernard University; Lyon France
| | - Malaika Cordeiro
- Department of Neonatology; La Paz University Hospital; Madrid Spain
| | | | - Monica Fumagalli
- NICU; Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico; Università degli Studi di Milano; Milan Italy
| | - Christian Gluud
- Copenhagen Trial Unit; Centre for Clinical Intervention Research; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - Simon Hyttel-Sorensen
- Department of Neonatology; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - Petra Lemmers
- Wilhelmina Children's Hospital; University Medical Center Utrecht; Utrecht The Netherlands
| | - Adelina Pellicer
- Department of Neonatology; La Paz University Hospital; Madrid Spain
| | - Gerhard Pichler
- Department of Pediatrics; Research Unit for Neonatal Micro- and Macrocirculation; Medical University of Graz; Graz Austria
| | - Gorm Greisen
- Department of Neonatology; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
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76
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Abdul Aziz AN, Thomas S, Murthy P, Rabi Y, Soraisham A, Stritzke A, Kamaluddeen M, Al-Awad E, Mohammad K. Early inotropes use is associated with higher risk of death and/or severe brain injury in extremely premature infants. J Matern Fetal Neonatal Med 2019; 33:2751-2758. [PMID: 30563374 DOI: 10.1080/14767058.2018.1560408] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Introduction: Extremely premature infants are susceptible to fluctuations in cerebral blood flow due to immaturity of cerebral autoregulation. Inotropes may cause rapid changes to systemic blood pressure and consequently cerebral blood flow, especially within the first 72 hours of life. This period is recognized to carry the greatest risk for cerebral hemorrhage. This study evaluates the incidence of death and/or severe brain injury in extremely preterm infants treated with inotropes in the first 72 hours of life.Methods: Prospective cohort study of infants born ≤29+0 weeks gestational age (GA) between January 2013 and December 2016. Severe brain injury was defined based on head ultrasound as presence of: grade III or IV intraventricular hemorrhage (IVH), moderate to severe post-hemorrhagic ventricular dilatation (PHVD), or cystic periventricular leukomalacia (cPVL). The association between inotrope use and death and/or brain injury was explored via logistic regression controlling for predefined confounding risk factors.Results: Of 497 eligible infants, 97 (19.5%) received inotropes during the first 72 hours. GA at birth, birth weight (BW), and 5-minute Apgar scores were lower among infants who received early inotropes compared to those not treated with inotropes. A stepwise logistic regression of the predefined confounding factors showed GA, exposure for antenatal steroids, and admission hypothermia to be significant confounding factors. Adjusting for those factors, early use of inotropes was associated with increased risk of death and/or severe brain injury (AOR 4.5; 95%CI: 2.4-8.5), severe brain injury (AOR 4.2; 95% CI: 1.9-8.9), and IVH of any grade (AOR 2.9; 95%CI: 1.7-4.9).Conclusion: Early inotropes use was associated with higher risk of death and/or severe brain injury. Strict indications and strategies for minimizing inotrope use while preventing hypotension should be implemented in the early postnatal care of infants at risk for severe brain injury.
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Affiliation(s)
- Ahmad Nizar Abdul Aziz
- Section of Neonatology, Department of Pediatrics, University of Calgary, Alberta, Canada
| | - Sumesh Thomas
- Section of Neonatology, Department of Pediatrics, University of Calgary, Alberta, Canada
| | - Prashanth Murthy
- Section of Neonatology, Department of Pediatrics, University of Calgary, Alberta, Canada
| | - Yacov Rabi
- Section of Neonatology, Department of Pediatrics, University of Calgary, Alberta, Canada
| | - Amuchou Soraisham
- Section of Neonatology, Department of Pediatrics, University of Calgary, Alberta, Canada
| | - Amelie Stritzke
- Section of Neonatology, Department of Pediatrics, University of Calgary, Alberta, Canada
| | - Majeeda Kamaluddeen
- Section of Neonatology, Department of Pediatrics, University of Calgary, Alberta, Canada
| | - Essa Al-Awad
- Section of Neonatology, Department of Pediatrics, University of Calgary, Alberta, Canada
| | - Khorshid Mohammad
- Section of Neonatology, Department of Pediatrics, University of Calgary, Alberta, Canada
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77
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Vesoulis ZA, Bank RL, Lake D, Wallman-Stokes A, Sahni R, Moorman JR, Isler JR, Fairchild KD, Mathur AM. Early hypoxemia burden is strongly associated with severe intracranial hemorrhage in preterm infants. J Perinatol 2019; 39:48-53. [PMID: 30267001 PMCID: PMC6298838 DOI: 10.1038/s41372-018-0236-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 08/16/2018] [Accepted: 09/10/2018] [Indexed: 11/09/2022]
Abstract
OBJECTIVES The objective of this study was to define the association between the burden of severe hypoxemia (SpO2 ≤70%) in the first week of life and development of severe ICH (grade III/IV) in preterm infants. STUDY DESIGN Infants born at <32 weeks or weighing <1500 g underwent prospective SpO2 recording from birth through 7 days. Severe hypoxemia burden was calculated as the percentage of the error-corrected recording where SpO2 ≤70%. Binary logistic regression was used to model the relationship between hypoxemia burden and severe ICH. RESULTS A total of 163.3 million valid SpO2 data points were collected from 645 infants with mean EGA = 27.7 ± 2.6 weeks, BW = 1005 ± 291 g; 38/645 (6%) developed severe ICH. There was a greater mean hypoxemia burden for infants with severe ICH (3%) compared to those without (0.1%) and remained significant when controlling for multiple confounding factors. CONCLUSION The severe hypoxemia burden in the first week of life is strongly associated with severe ICH.
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Affiliation(s)
- Zachary A. Vesoulis
- Department of Pediatrics, Washington University School of Medicine, Division of Newborn Medicine, St. Louis, MO
| | - Rachel L. Bank
- Department of Pediatrics, Washington University School of Medicine, Division of Newborn Medicine, St. Louis, MO
| | - Doug Lake
- Department of Medicine, University of Virginia, Charlottesville, VA
| | | | - Rakesh Sahni
- Department of Pediatrics, Columbia University, New York, NY
| | | | | | | | - Amit M. Mathur
- Department of Pediatrics, Washington University School of Medicine, Division of Newborn Medicine, St. Louis, MO
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78
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Mitra S, Bale G, Highton D, Gunny R, Uria-Avellanal C, Bainbridge A, Sokolska M, Price D, Huertas-Ceballos A, Kendall GS, Meek J, Tachtsidis I, Robertson NJ. Pressure passivity of cerebral mitochondrial metabolism is associated with poor outcome following perinatal hypoxic ischemic brain injury. J Cereb Blood Flow Metab 2019; 39:118-130. [PMID: 28949271 PMCID: PMC6311664 DOI: 10.1177/0271678x17733639] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Hypoxic ischemic encephalopathy (HIE) leads to significant morbidity and mortality. Impaired autoregulation after hypoxia-ischaemia has been suggested to contribute further to injury. Thalamic lactate/N-Acetylasperate (Lac/NAA) peak area ratio of > 0.3 on proton (1H) magnetic resonance spectroscopy (MRS) is associated with poor neurodevelopment outcome following HIE. Cytochrome-c-oxidase (CCO) plays a central role in mitochondrial oxidative metabolism and ATP synthesis. Using a novel broadband NIRS system, we investigated the impact of pressure passivity of cerebral metabolism (CCO), oxygenation (haemoglobin difference (HbD)) and cerebral blood volume (total haemoglobin (HbT)) in 23 term infants following HIE during therapeutic hypothermia (HT). Sixty-minute epochs of data from each infant were studied using wavelet analysis at a mean age of 48 h. Wavelet semblance (a measure of phase difference) was calculated to compare reactivity between mean arterial blood pressure (MABP) with oxCCO, HbD and HbT. OxCCO-MABP semblance correlated with thalamic Lac/NAA ( r = 0.48, p = 0.02). OxCCO-MABP semblance also differed between groups of infants with mild to moderate and severe injury measured using brain MRI score ( p = 0.04), thalamic Lac/NAA ( p = 0.04) and neurodevelopmental outcome at one year ( p = 0.04). Pressure passive changes in cerebral metabolism were associated with injury severity indicated by thalamic Lac/NAA, MRI scores and neurodevelopmental assessment at one year of age.
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Affiliation(s)
- Subhabrata Mitra
- 1 Institute for Women's Health, University College London, London, UK
| | - Gemma Bale
- 2 Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - David Highton
- 3 Neurocritical Care, National Hospital for Neurology & Neurosurgery, University College London, London, UK
| | - Roxanna Gunny
- 4 Paediatric Neuroradiology, Great Ormond Street Hospital for Children, London, UK
| | | | - Alan Bainbridge
- 5 Department of Medical Physics and Biomedical Engineering, University College London Hospital, London, UK
| | - Magdalena Sokolska
- 5 Department of Medical Physics and Biomedical Engineering, University College London Hospital, London, UK
| | - David Price
- 5 Department of Medical Physics and Biomedical Engineering, University College London Hospital, London, UK
| | | | - Giles S Kendall
- 6 Neonatal Unit, University College London Hospital, London, UK
| | - Judith Meek
- 1 Institute for Women's Health, University College London, London, UK
| | - Ilias Tachtsidis
- 2 Department of Medical Physics and Biomedical Engineering, University College London, London, UK
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79
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Mian Q, Cheung PY, O'Reilly M, Barton SK, Polglase GR, Schmölzer GM. Impact of delivered tidal volume on the occurrence of intraventricular haemorrhage in preterm infants during positive pressure ventilation in the delivery room. Arch Dis Child Fetal Neonatal Ed 2019; 104:F57-F62. [PMID: 29353261 DOI: 10.1136/archdischild-2017-313864] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 12/21/2017] [Accepted: 12/22/2017] [Indexed: 11/04/2022]
Abstract
BACKGROUND AND OBJECTIVES Delivery of inadvertent high tidal volume (VT) during positive pressure ventilation (PPV) in the delivery room is common. High VT delivery during PPV has been associated with haemodynamic brain injury in animal models. We examined if VT delivery during PPV at birth is associated with brain injury in preterm infants <29 weeks' gestation. METHODS A flow-sensor was placed between the mask and the ventilation device. VT values were compared with recently described reference ranges for VT in spontaneously breathing preterm infants at birth. Infants were divided into two groups: VT<6 mL/kg or VT>6 mL/kg (normal and high VT, respectively). Brain injury (eg, intraventricular haemorrhage (IVH)) was assessed using routine ultrasound imaging within the first days after birth. RESULTS A total of 165 preterm infants were included, 124 (75%) had high VT and 41 (25%) normal VT. The mean (SD) gestational age and birth weight in high and normal VT group was similar, 26 (2) and 26 (1) weeks, 858 (251) g and 915 (250) g, respectively. IVH in the high VT group was diagnosed in 63 (51%) infants compared with 5 (13%) infants in the normal VT group (P=0.008).Severe IVH (grade III or IV) developed in 33/124 (27%) infants in the high VT group and 2/41 (6%) in the normal VT group (P=0.01). CONCLUSIONS High VT delivery during mask PPV at birth was associated with brain injury. Strategies to limit VT delivery during mask PPV should be used to prevent high VT delivery.
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Affiliation(s)
- Qaasim Mian
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, Alberta, Canada.,Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Po-Yin Cheung
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, Alberta, Canada.,Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Megan O'Reilly
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, Alberta, Canada.,Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Samantha K Barton
- The Ritchie Centre, Hudson Institute of Medical Research, and Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Graeme R Polglase
- The Ritchie Centre, Hudson Institute of Medical Research, and Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Georg M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, Alberta, Canada.,Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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80
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Abstract
Despite the advances in neonatal intensive care, the preterm brain remains vulnerable to white matter injury (WMI) and disruption of normal brain development (i.e., dysmaturation). Compared to severe cystic WMI encountered in the past decades, contemporary cohorts of preterm neonates experience milder WMIs. More than destructive lesions, disruption of the normal developmental trajectory of cellular elements of the white and the gray matter occurs. In the acute phase, in response to hypoxia-ischemia and/or infection and inflammation, multifocal areas of necrosis within the periventricular white matter involve all cellular elements. Later, chronic WMI is characterized by diffuse WMI with aberrant regeneration of oligodendrocytes, which fail to mature to myelinating oligodendrocytes, leading to myelination disturbances. Complete neuronal degeneration classically accompanies necrotic white matter lesions, while altered neurogenesis, represented by a reduction of the dendritic arbor and synapse formation, is observed in response to diffuse WMI. Neuroimaging studies now provide more insight in assessing both injury and dysmaturation of both gray and white matter. Preterm brain injury remains an important cause of neurodevelopmental disabilities, which are still observed in up to 50% of the preterm survivors and take the form of a complex combination of motor, cognitive, and behavioral concerns.
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Affiliation(s)
- Juliane Schneider
- Department of Woman-Mother-Child, Clinic of Neonatology, University Hospital Center and University of Lausanne, Lausanne, Switzerland
| | - Steven P Miller
- Division of Neurology and Centre for Brain and Mental Health, Hospital for Sick Children, Toronto, ON, Canada.
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81
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Stenning FJ, Hooper SB, Kluckow M, Crossley KJ, Gill AW, Wallace EM, Te Pas AB, LaRosa D, Polglase GR. Transfusion or Timing: The Role of Blood Volume in Delayed Cord Clamping During the Cardiovascular Transition at Birth. Front Pediatr 2019; 7:405. [PMID: 31649907 PMCID: PMC6794342 DOI: 10.3389/fped.2019.00405] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 09/19/2019] [Indexed: 01/08/2023] Open
Abstract
Placental transfusion has been thought to be the main benefit of delayed umbilical cord clamping (DCC) in preterm neonates. However, the importance of cardiovascular stability provided by allowing lung aeration prior to cord clamping has recently been highlighted. We aimed to determine the influence of blood volume changes on cardiovascular stability at birth. Preterm lambs (0.85 gestation) were instrumented for measurement of pulmonary, systemic and cerebral blood pressures and flows, systemic oxygen saturation and cerebral oxygenation. Left ventricular output (LVO) was assessed by Doppler Echocardiography. Lambs underwent immediate cord clamping followed by (1) 25 ml/kg infusion of whole blood over (90 s; or 2) withdrawal of 10 ml/kg blood over 90 s. Ventilation was initiated 30 s after volume change (2 min after cord clamping) and was maintained for 30 min. Blood infusion significantly increased pulmonary blood flow (PBF) which maintained systemic cardiac output during the infusion, and increased carotid arterial pressure, flow and heart rate, which remained elevated until after ventilation onset. Upon completion of transfusion PBF rapidly returned to control levels and LVO decreased. Conversely, blood withdrawal decreased PBF and LVO. The cardiovascular changes that accompanied ventilation onset were similar between groups. Providing a blood volume transfusion immediately after umbilical cord clamping maintains PBF and cardiac output during the transfusion, which does not persist beyond the period of the transfusion. Our study implies that an apneic newborn cannot maintain cardiac output through an increase blood volume alone. Importantly, delaying umbilical cord clamping until after breathing/aeration of the lung may be a way to maintain cardiac output throughout delivery at birth.
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Affiliation(s)
- Fiona J Stenning
- The Ritchie Centre, The Hudson Institute of Medical Research, Monash University, Clayton, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - Stuart B Hooper
- The Ritchie Centre, The Hudson Institute of Medical Research, Monash University, Clayton, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - Martin Kluckow
- Department of Neonatology, Royal North Shore Hospital and Sydney University, St Leonards, NSW, Australia
| | - Kelly J Crossley
- The Ritchie Centre, The Hudson Institute of Medical Research, Monash University, Clayton, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - Andrew W Gill
- Centre for Neonatal Education and Research, The University of Western Australia, Crawley, WA, Australia
| | - Euan M Wallace
- The Ritchie Centre, The Hudson Institute of Medical Research, Monash University, Clayton, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - Arjan B Te Pas
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Centre, Leiden, Netherlands
| | - Domenic LaRosa
- The Ritchie Centre, The Hudson Institute of Medical Research, Monash University, Clayton, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - Graeme R Polglase
- The Ritchie Centre, The Hudson Institute of Medical Research, Monash University, Clayton, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
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82
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Abstract
Most neonatal seizures in preterm newborns are of acute symptomatic origin with a prevalence higher than in full-term infants. To date, recommendations for management of seizures in preterm newborns are scarce and do not differ from those in full-term newborns. Mortality in preterm newborns with seizures has significantly declined over the last decades, from figures of 84%-94% in the 1970s and 1980s to 22%-45% in the last years. However, mortality is significantly higher in those with a birth weight<1000g and a gestational age<28 weeks. Seizures are a strong predictor of unfavorable outcomes, including not only cerebral palsy, epilepsy, and intellectual disability, but also vision, hearing impairment, and microcephaly. The majority of patients with developmental delay are severely affected and this is usually associated with cerebral palsy. Furthermore, the incidence of epilepsy after neonatal seizures seems to be lower in preterm than in full-term infants but the risk is approximately 40 times greater than in the general population. Clinical studies cannot disentangle the specific and independent contributions of seizure-induced functional changes and the role of etiology and brain damage severity in determining the long-term outcomes in these newborns.
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Affiliation(s)
- Francesco Pisani
- Child Neuropsychiatry Unit, Department of Medicine & Surgery, University of Parma, Parma, Italy.
| | - Carlotta Spagnoli
- Child Neurology Unit, Department of Pediatrics, Santa Maria Nuova Hospital, AUSL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
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83
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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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84
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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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85
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El-Dib M, Soul JS. Monitoring and management of brain hemodynamics and oxygenation. HANDBOOK OF CLINICAL NEUROLOGY 2019; 162:295-314. [PMID: 31324316 DOI: 10.1016/b978-0-444-64029-1.00014-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
While cardiorespiratory monitoring is standard for newborns in the NICU, monitoring of brain hemodynamics and oxygenation is usually sporadic and targeted to newborns with suspected or confirmed neurologic disorders. This is unfortunate, since critically ill newborns, both preterm and term-born, are at high risk of brain injury and would benefit from improved techniques for continuous monitoring of brain hemodynamics and oxygenation, in addition to monitoring of systemic hemodynamics and oxygenation. Near-infrared spectroscopy (NIRS) and, to a lesser extent, Doppler ultrasound are techniques that have been used in research and increasingly for clinical purposes to measure and monitor brain hemodynamics and oxygenation in newborns. NIRS monitoring can be useful for detection of diverse pathologic conditions that occur frequently in very preterm newborns and in selected populations of term newborns at risk for brain injury related to disturbances of systemic hemodynamics. This chapter reviews the current state of the art with regard to brain-monitoring techniques and the research directed at this important area, and it concludes with suggestions for the use of currently available tools to manage newborns at high risk of neurologic injury from disturbances in brain hemodynamics and oxygenation.
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Affiliation(s)
- Mohamed El-Dib
- Neonatal Neurocritical Care, Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA, United States
| | - Janet S Soul
- Fetal-Neonatal Neurology Program, Department of Neurology, Boston Children's Hospital, Boston, MA, United States; Department of Neurology, Harvard Medical School, Boston, MA, United States.
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A comparison of postoperative outcomes with PDA ligation in the OR versus the NICU: a retrospective cohort study on the risks of transport. BMC Anesthesiol 2018; 18:199. [PMID: 30579349 PMCID: PMC6303951 DOI: 10.1186/s12871-018-0658-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Accepted: 12/03/2018] [Indexed: 12/04/2022] Open
Abstract
Background Although patent ductus arteriosus (PDA) ligations in the Neonatal Intensive Care Unit (NICU) have been an accepted practice, many are still performed in the Operating Room (OR). Whether avoiding transport leads to improved perioperative outcomes is unclear. Here we aimed to determine whether PDA ligations in the NICU corresponded to higher risk of surgical site infection or mortality and if transport was associated with worsened perioperative outcomes. Methods We performed a retrospective cohort study of NICU patients, ≤37 weeks post-menstrual age, undergoing surgical PDA ligation in the NICU or OR. We excluded any infants undergoing device PDA closure. We measured the incidence of perioperative hypothermia, cardiac arrest, decreases in SpO2, hemodynamic instability and postoperative surgical site infection, sepsis and mortality. Results Data was collected on 189 infants (100 OR, 89 NICU). After controlling for number of preoperative comorbidities, weight at time of procedure, procedure location and hospital in the mixed-effect model, no significant difference in mortality or sepsis was found (odds ratio 0.31, 95%CI 0.07, 1.30; p = 0.107, and odds ratio 0.40; 95%CI 0.14, 1.09; p = 0.072, respectively). There was an increased incidence of hemodynamic instability on transport postoperatively in the OR group (12.4% vs 2%, odds ratio 6.93; 95% CI 1.48, 35.52; p = 0.014). Conclusion PDA ligations in the NICU were not associated with higher incidences of surgical site infection or mortality. There was an increased incidence of hemodynamic instability in the OR group on transport back to the NICU. Larger multicenter studies following long-term outcomes are needed to evaluate the safety of performing all PDA ligations in the NICU. Keywords Patent ductus arteriosus, Newborn infant, Neonatal intensive care unit, Surgical wound infection, Postoperative period, Hemodynamics
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87
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da Costa CS, Czosnyka M, Smielewski P, Austin T. Optimal Mean Arterial Blood Pressure in Extremely Preterm Infants within the First 24 Hours of Life. J Pediatr 2018; 203:242-248. [PMID: 30243537 DOI: 10.1016/j.jpeds.2018.07.096] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 07/17/2018] [Accepted: 07/27/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To define levels of mean arterial blood pressure (MABP) where cerebrovascular reactivity is strongest (MABPOPT) during the early transitional circulation in extremely preterm infants and to investigate the association between deviations above and below MABPOPT with intraventricular hemorrhage (IVH) and mortality. STUDY DESIGN A total of 44 infants born at a median gestational age 25 (23-27) weeks with indwelling arterial catheter were studied at a median 5.5 (3.1-12.6) hours within the first 24 hours of life. Cerebrovascular reactivity (tissue oxygenation heart rate reactivity index) was estimated by the moving correlation coefficient between heart rate and near-infrared spectroscopy tissue oxygenation index. MABPOPT was defined as the MABP where tissue oxygenation heart rate reactivity index reaches minimum value. Deviations below or above MABPOPT values were calculated along with MABPOPT values during retrospective data analysis. RESULTS MABPOPT was detected in all infants. The mean (SD) MABPOPT was 31.3 (±4.7) mm Hg. MABPOPT increased with increasing gestational age, R = 0.424; P = .004. Deviations below MABPOPT were greater in the IVH group (mean 2.7 mm Hg; 95% CI 2.0-3.5) compared with no-IVH (mean 1.7 mm Hg; 1.1-2.2), P = .006. In infants who died, the deviation below MABPOPT was greater (mean 3.3; 95% CI 1.9-4.8) compared with those who survived (mean 1.9 mm Hg; 95% CI 1.4-2.3), P = .015. CONCLUSIONS Defining optimal MABP based on the strength of cerebrovascular reactivity within the first 24 hours of life is feasible and can provide an individualized approach to the care of extremely preterm infants. Deviations below MABPOPT were significantly associated with IVH and death.
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Affiliation(s)
- Cristine Sortica da Costa
- Neonatal Unit, The Rosie Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom.
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom; Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Topun Austin
- Neonatal Unit, The Rosie Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
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88
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Walter LM, Ahmed B, Odoi A, Cooney H, Horne RSC, Wong FY. Bradycardias are associated with more severe effects on cerebral oxygenation in very preterm infants than in late preterm infants. Early Hum Dev 2018; 127:33-41. [PMID: 30245358 DOI: 10.1016/j.earlhumdev.2018.08.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 08/24/2018] [Accepted: 08/27/2018] [Indexed: 01/05/2023]
Abstract
BACKGROUND Commonly the magnitude and frequency of bradycardia is underestimated in the neonatal unit due to the long averaging time used in bedside oximeters. We aimed to assess the frequency and severity of bradycardia in preterm infants using the lowest averaging time (2 s) available on a clinical oximeter, compared with bradycardia detected using electrocardiogram (ECG), and whether bradycardia severity and postmenstrual age affected cerebral oxygenation. METHODS Preterm infants (10 M/9F) were studied longitudinally at 26-31 (very preterm) and 32-38 weeks (late preterm) postmenstrual age. Heart rate falls calculated from ECG were used to determine mild or moderate/severe (MS) bradycardias. Cerebral tissue oxygenation index (TOI, %) was recorded and fractional tissue oxygen extraction (FTOE) calculated. RESULTS Of the 615 bradycardias scored using ECG criteria, 10% were not detected by oximetry. TOI falls associated with bradycardias were greater for MS bradycardias compared with Mild for both groups (p < 0.001 for both). The FTOE associated with MS bradycardias was higher for the very preterm compared with the late preterm group (p < 0.001). In very preterm infants 61% of MS and 35% Mild bradycardias were associated with TOI nadirs below 55%. CONCLUSION Even the most sensitive oximeter setting underestimates bradycardias. The cerebral effect from bradycardias in very preterm infants is more severe than in late preterm infants. Even the mild bradycardias are associated with falls in cerebral oxygenation. Routine NIRS monitoring of cerebral oxygenation in NICUs may increase staff awareness for interventions to reduce the repetitive falls in cerebral oxygenation in preterm infants.
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Affiliation(s)
- Lisa M Walter
- The Ritchie Centre, Hudson Institute of Medical Research, Department of Paediatrics, Monash University, Melbourne, Australia
| | - Bushra Ahmed
- The Ritchie Centre, Hudson Institute of Medical Research, Department of Paediatrics, Monash University, Melbourne, Australia
| | - Alexsandria Odoi
- The Ritchie Centre, Hudson Institute of Medical Research, Department of Paediatrics, Monash University, Melbourne, Australia
| | - Hannah Cooney
- The Ritchie Centre, Hudson Institute of Medical Research, Department of Paediatrics, Monash University, Melbourne, Australia
| | - Rosemary S C Horne
- The Ritchie Centre, Hudson Institute of Medical Research, Department of Paediatrics, Monash University, Melbourne, Australia
| | - Flora Y Wong
- The Ritchie Centre, Hudson Institute of Medical Research, Department of Paediatrics, Monash University, Melbourne, Australia; Monash Newborn, Monash Children's Hospital, Melbourne, Australia.
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89
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Morrison JL, Berry MJ, Botting KJ, Darby JRT, Frasch MG, Gatford KL, Giussani DA, Gray CL, Harding R, Herrera EA, Kemp MW, Lock MC, McMillen IC, Moss TJ, Musk GC, Oliver MH, Regnault TRH, Roberts CT, Soo JY, Tellam RL. Improving pregnancy outcomes in humans through studies in sheep. Am J Physiol Regul Integr Comp Physiol 2018; 315:R1123-R1153. [PMID: 30325659 DOI: 10.1152/ajpregu.00391.2017] [Citation(s) in RCA: 101] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Experimental studies that are relevant to human pregnancy rely on the selection of appropriate animal models as an important element in experimental design. Consideration of the strengths and weaknesses of any animal model of human disease is fundamental to effective and meaningful translation of preclinical research. Studies in sheep have made significant contributions to our understanding of the normal and abnormal development of the fetus. As a model of human pregnancy, studies in sheep have enabled scientists and clinicians to answer questions about the etiology and treatment of poor maternal, placental, and fetal health and to provide an evidence base for translation of interventions to the clinic. The aim of this review is to highlight the advances in perinatal human medicine that have been achieved following translation of research using the pregnant sheep and fetus.
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Affiliation(s)
- Janna L Morrison
- Early Origins of Adult Health Research Group, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Mary J Berry
- Department of Paediatrics and Child Health, University of Otago , Wellington , New Zealand
| | - Kimberley J Botting
- Department of Physiology, Development, and Neuroscience, University of Cambridge , Cambridge , United Kingdom
| | - Jack R T Darby
- Early Origins of Adult Health Research Group, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Martin G Frasch
- Department of Obstetrics and Gynecology, University of Washington , Seattle, Washington
| | - Kathryn L Gatford
- Robinson Research Institute and Adelaide Medical School, University of Adelaide , Adelaide, South Australia , Australia
| | - Dino A Giussani
- Department of Physiology, Development, and Neuroscience, University of Cambridge , Cambridge , United Kingdom
| | - Clint L Gray
- Department of Paediatrics and Child Health, University of Otago , Wellington , New Zealand
| | - Richard Harding
- Department of Anatomy and Developmental Biology, Monash University , Clayton, Victoria , Australia
| | - Emilio A Herrera
- Pathophysiology Program, Biomedical Sciences Institute (ICBM), Faculty of Medicine, University of Chile , Santiago , Chile
| | - Matthew W Kemp
- Division of Obstetrics and Gynecology, University of Western Australia , Perth, Western Australia , Australia
| | - Mitchell C Lock
- Early Origins of Adult Health Research Group, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - I Caroline McMillen
- Early Origins of Adult Health Research Group, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Timothy J Moss
- The Ritchie Centre, Hudson Institute of Medical Research, Department of Obstetrics and Gynaecology, Monash University , Clayton, Victoria , Australia
| | - Gabrielle C Musk
- Animal Care Services, University of Western Australia , Perth, Western Australia , Australia
| | - Mark H Oliver
- Liggins Institute, University of Auckland , Auckland , New Zealand
| | - Timothy R H Regnault
- Department of Obstetrics and Gynecology and Department of Physiology and Pharmacology, Western University, and Children's Health Research Institute , London, Ontario , Canada
| | - Claire T Roberts
- Robinson Research Institute and Adelaide Medical School, University of Adelaide , Adelaide, South Australia , Australia
| | - Jia Yin Soo
- Early Origins of Adult Health Research Group, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Ross L Tellam
- Early Origins of Adult Health Research Group, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia
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90
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Romantsik O, Bruschettini M, Moreira A, Thébaud B, Ley D. Stem cell-based interventions for the prevention and treatment of germinal matrix-intraventricular haemorrhage in preterm infants. Hippokratia 2018. [DOI: 10.1002/14651858.cd013201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Olga Romantsik
- Lund University, Skåne University Hospital; Department of Paediatrics; Lund Sweden
| | - Matteo Bruschettini
- Lund University, Skåne University Hospital; Department of Paediatrics; Lund Sweden
- Skåne University Hospital; Cochrane Sweden; Wigerthuset, Remissgatan 4, first floor room 11-221 Lund Sweden 22185
| | - Alvaro Moreira
- University of Texas Health Science Center at San Antonio; Pediatrics, Division of Neonatology; San Antonio Texas USA
| | - Bernard Thébaud
- Children's Hospital of Eastern Ontario; Department of Pediatrics; Ottawa ON Canada
- Ottawa Hospital Research Institute, Sprott Center for Stem Cell Research; Ottawa Canada
- University of Ottawa; Department of Cellular and Molecular Medicine; Ottawa Canada
| | - David Ley
- Lund University, Skåne University Hospital; Department of Paediatrics; Lund Sweden
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91
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Rhee CJ, da Costa CS, Austin T, Brady KM, Czosnyka M, Lee JK. Neonatal cerebrovascular autoregulation. Pediatr Res 2018; 84:602-610. [PMID: 30196311 PMCID: PMC6422675 DOI: 10.1038/s41390-018-0141-6] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 06/04/2018] [Accepted: 07/27/2018] [Indexed: 12/12/2022]
Abstract
Cerebrovascular pressure autoregulation is the physiologic mechanism that holds cerebral blood flow (CBF) relatively constant across changes in cerebral perfusion pressure (CPP). Cerebral vasoreactivity refers to the vasoconstriction and vasodilation that occur during fluctuations in arterial blood pressure (ABP) to maintain autoregulation. These are vital protective mechanisms of the brain. Impairments in pressure autoregulation increase the risk of brain injury and persistent neurologic disability. Autoregulation may be impaired during various neonatal disease states including prematurity, hypoxic-ischemic encephalopathy (HIE), intraventricular hemorrhage, congenital cardiac disease, and infants requiring extracorporeal membrane oxygenation (ECMO). Because infants are exquisitely sensitive to changes in cerebral blood flow (CBF), both hypoperfusion and hyperperfusion can cause significant neurologic injury. We will review neonatal pressure autoregulation and autoregulation monitoring techniques with a focus on brain protection. Current clinical therapies have failed to fully prevent permanent brain injuries in neonates. Adjuvant treatments that support and optimize autoregulation may improve neurologic outcomes.
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Affiliation(s)
- Christopher J. Rhee
- Baylor College of Medicine, Texas Children’s Hospital, Department of Pediatrics, Section of Neonatology, Houston, TX, USA
| | | | - Topun Austin
- Neonatal Unit, Rosie Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Ken M. Brady
- Baylor College of Medicine, Texas Children’s Hospital, Department of Pediatrics, Critical Care Medicine and Anesthesiology, Houston, TX, USA
| | - Marek Czosnyka
- Department of Academic Neurosurgery, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - Jennifer K. Lee
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
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92
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Govindan RB, Massaro AN, du Plessis A. Ensuring signal quality of cerebral near infrared spectroscopy during continuous longterm monitoring. J Neurosci Methods 2018; 309:147-152. [PMID: 30189283 PMCID: PMC6323003 DOI: 10.1016/j.jneumeth.2018.09.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 08/18/2018] [Accepted: 09/02/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Near infrared spectroscopy (NIRS) derived hemoglobin difference (HbD: oxygenated [HbO2] - reduced hemoglobin [Hb]) and total hemoglobin (HbT: HbO2+Hb) have been used as surrogate measures of cerebral blood flow and volume, respectively. Statistically, a lack of HbD-blood pressure (BP) or negative HbT-BP association is regarded as a state of intact cerebral pressure autoregulation (CPA). In contrast, a co-variation of HbD/HbT and systemic blood pressure (BP) in the same direction is thought of as a failure of CPA. If the quality of one (NIRS/BP) or both signals is compromised, the reliability of the results may be adversely affected. In this work, we develop an analytic approach to assess the quality of the NIRS signals. NEW METHOD Given that cardiac pulses cause hemodynamic changes that are transmitted through the peripheral vasculature, cerebral NIRS signals should exhibit cyclical changes at the pulse frequency. Therefore, we propose that an association between HbD/HbT and electrocardiogram (EKG) signals would be an indicator of NIRS quality. We demonstrate the application of this approach with data collected from six newborns undergoing therapeutic hypothermia for neonatal encephalopathy. RESULTS We observed an intermittent lack of association between NIRS signals and EKG data over the course of several hours of continuous records, indicating a loss in the strength in NIRS signals. COMPARISON WITH EXISTING METHOD Existing CPA characterization suffers from Type-II error which the current preprocessing approach can mitigate. CONCLUSIONS The proposed approach will allow for real-time assessment of NIRS signal quality that is essential for accurate CPA monitoring.
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Affiliation(s)
- R B Govindan
- Division of Fetal and Transitional Medicine, Children's National Health System, 111 Michigan Ave, NW, Washington, DC', 20010, USA.
| | - A N Massaro
- Division of Fetal and Transitional Medicine, Children's National Health System, 111 Michigan Ave, NW, Washington, DC', 20010, USA; Division of Neonatology, Children's National Health System, 111 Michigan Ave, NW, Washington, DC, 20010, USA
| | - Adre du Plessis
- Division of Fetal and Transitional Medicine, Children's National Health System, 111 Michigan Ave, NW, Washington, DC', 20010, USA
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93
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Spagnoli C, Falsaperla R, Deolmi M, Corsello G, Pisani F. Symptomatic seizures in preterm newborns: a review on clinical features and prognosis. Ital J Pediatr 2018; 44:115. [PMID: 30382869 PMCID: PMC6211591 DOI: 10.1186/s13052-018-0573-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 10/16/2018] [Indexed: 01/23/2023] Open
Abstract
Neonatal seizures are the most common neurological event in newborns, showing higher prevalence in preterm than in full-term infants. In the majority of cases they represent acute symptomatic phenomena, the main etiologies being intraventricular haemorrhage, hypoxic-ischemic encephalopathy, central nervous system infections and transient metabolic derangements.Current definition of neonatal seizures requires detection of paroxysmal EEG-changes, and in preterm newborns the incidence of electrographic-only seizures seems to be particularly high, further stressing the crucial role of electroencephalogram monitoring in this population. Imaging work-up includes an integration of serial cranial ultrasound and brain magnetic resonance at term-equivalent age. Unfavourable outcomes following seizures in preterm infants include death, neurodevelopmental impairment, epilepsy, cerebral palsy, hearing and visual impairment. As experimental evidence suggests a detrimental role of seizures per se in determining subsequent outcome, they should be promptly treated with the aim to reduce seizure burden and long-term disabilities. However, neonatal seizures show low response to conventional anticonvulsant drugs, and this is even more evident in preterm newborns, due to intrinsic developmental factors. As a consequence, as literature does not provide any specific guidelines, due to the lack of robust evidence, off-label medications are often administered in clinical practice.
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Affiliation(s)
- Carlotta Spagnoli
- Child Neuropsychiatry Unit, Department of Pediatrics, Arcispedale Santa Maria Nuova, IRCSS, Reggio Emilia, Italy
| | - Raffaele Falsaperla
- Neonatal Intensive Care Unit, Santo Bambino Hospital, University Hospital "Policlinico-Vittorio Emanuele", Via Tindaro 2, 95124, Catania, Italy.
| | - Michela Deolmi
- Pediatrics Unit, Medicine & Surgery Department, University of Parma, Parma, Italy
| | - Giovanni Corsello
- Department of Maternal and Child Health, University of Palermo, Palermo, Italy
| | - Francesco Pisani
- Child Neuropsychiatry Unit, Medicine & Surgery Department, Neuroscience Division, University of Parma, Parma, Italy
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Sidorenko I, Turova V, Botkin N, Eckardt L, Alves-Pinto A, Felderhoff-Müser U, Rieger-Fackeldey E, Kovtanyuk A, Lampe R. Modeling Cerebral Blood Flow Dependence on Carbon Dioxide and Mean Arterial Blood Pressure in the Immature Brain With Accounting for the Germinal Matrix. Front Neurol 2018; 9:812. [PMID: 30356709 PMCID: PMC6189337 DOI: 10.3389/fneur.2018.00812] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 09/10/2018] [Indexed: 12/20/2022] Open
Abstract
Intraventricular hemorrhage (IVH) is one of the most critical complications in the development of preterm infants. The likelihood of IVH is strongly associated with disturbances in cerebral blood flow (CBF) and with microvascular fragility in the germinal matrix (GM). The CBF value and its reactivity to changes in arterial carbon dioxide pressure (pCO2) and mean arterial blood pressure (MABP) are relevant indicators in the clinical assessment of preterm infants. The objective of the present study is mathematical modeling of the influence of pCO2 and MABP on CBF in immature brain, based on clinical data collected from 265 preterm infants with 23–30 gestational weeks. The model was adapted to the peculiarities of immature brain by taking into account the morphological characteristics of the GM capillary network and vascular reactivity, according to gestational and postnatal age. An analysis of model based values of CBF and its reactivity to changes in MABP and pCO2 was performed separately for each gestational week and for the first two days of life both for preterm infants with and without IVH. The developed model for the estimation of CBF was validated against equivalent experimental measurements taken from the literature. A good agreement between the estimated values of CBF, as well as its reaction on changes in MABP and pCO2 and the equivalent values obtained in experimental studies was shown.
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Affiliation(s)
- Irina Sidorenko
- Mathematical Faculty, Technical University of Munich, Garching, Germany
| | - Varvara Turova
- Orthopedic Department, University Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Nikolai Botkin
- Mathematical Faculty, Technical University of Munich, Garching, Germany
| | - Laura Eckardt
- Pediatric Department I, Neonatology, Pediatric Intensive Care, Pediatric Neurology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Ana Alves-Pinto
- Orthopedic Department, University Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Ursula Felderhoff-Müser
- Pediatric Department I, Neonatology, Pediatric Intensive Care, Pediatric Neurology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Esther Rieger-Fackeldey
- Pediatric Department, University Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Andrey Kovtanyuk
- Orthopedic Department, University Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Renée Lampe
- Orthopedic Department, University Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
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95
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Hypobaric birth room may prevent intraventricular hemorrhage in extremely low birth weights infants. Med Hypotheses 2018; 119:11-13. [PMID: 30122480 DOI: 10.1016/j.mehy.2018.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 07/02/2018] [Accepted: 07/14/2018] [Indexed: 02/06/2023]
Abstract
In the early postnatal period, intraventricular hemorrhage may develop in infants with extremely low birth weights due to hemodynamic instability. One of the most significant factors in intraventricular hemorrhage development is fluctuations in the cerebral blood flow due to left-to-right shunting as a result of patent ductus arteriosus, and such cases most frequently develop intraventricular hemorrhage within the first 72 h. The frequency of intraventricular hemorrhage may be reduced through the prevention of fluctuations in the cerebral blood flow in this time frame. Based on our hypothesis, we recommend that extremely low birth weight infants should be delivered and monitored in hypobaric rooms for the first three days after birth, as this may reduce left-to-right shunting as a result of patent ductus arteriosus by preventing the rapid drops seen in pulmonary pressure after birth. A more stable hemodynamic status may be achieved by increasing the cerebral blood flow during an acute term in a hypobaric environment. Gradual transition to the normobaric status at the end of the third day may prevent the long-term negative effects of hypobaric conditions.
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Abstract
The transition from intrauterine to extrauterine life represents a critical phase of physiological adaptation which impacts many organ systems, most notably the heart and the lungs. The majority of term neonates complete this transition without complications; however, dysregulation of normal postnatal adaptation may lead to acute cardiopulmonary instability, necessitating advanced intensive care support. Although not as well appreciated as changes in vascular resistances, the shunt across the DA plays a crucial physiologic role in the adaptive processes related to normal transitional circulation. Further, we describe key differences in the behavior of the ductal shunt during transition in preterm neonates and we postulate mechanisms through which the DA may modulate major hemodynamic complications during this vulnerable period. Finally, we describe the conditions in which preservation of ductal patency is a desired clinical goal and we discuss clinical factors that may determine adequate balance between pulmonary and systemic circulation.
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97
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de Boode WP, van der Lee R, Horsberg Eriksen B, Nestaas E, Dempsey E, Singh Y, Austin T, El-Khuffash A. The role of Neonatologist Performed Echocardiography in the assessment and management of neonatal shock. Pediatr Res 2018; 84:57-67. [PMID: 30072807 PMCID: PMC6257224 DOI: 10.1038/s41390-018-0081-1] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
One of the major challenges of neonatal intensive care is the early detection and management of circulatory failure. Routine clinical assessment of the hemodynamic status of newborn infants is subjective and inaccurate, emphasizing the need for objective monitoring tools. An overview will be provided about the use of neonatologist-performed echocardiography (NPE) to assess cardiovascular compromise and guide hemodynamic management. Different techniques of central blood flow measurement, such as left and right ventricular output, superior vena cava flow, and descending aortic flow are reviewed focusing on methodology, validation, and available reference values. Recommendations are provided for individualized hemodynamic management guided by NPE.
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Affiliation(s)
- Willem P de Boode
- Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands.
| | - Robin van der Lee
- Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
| | | | - Eirik Nestaas
- Institute of Clinical Medicine, Faculty of Medicine, University of, Oslo, Norway
- Department of Cardiology and Center for Cardiological Innovation, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Department of Paediatrics, Vestfold Hospital Trust, Tønsberg, Norway
| | - Eugene Dempsey
- INFANT Centre, Cork University Maternity Hospital, University College, Cork, Ireland
| | - Yogen Singh
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Topun Austin
- Department of Neonatology, Rosie Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Afif El-Khuffash
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland
- Department of Pediatrics, The Royal College of Surgeons in Ireland, Dublin, Ireland
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98
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Utility of prenatal Doppler ultrasound to predict neonatal impaired cerebral autoregulation. J Perinatol 2018; 38:474-481. [PMID: 29410542 DOI: 10.1038/s41372-018-0050-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Revised: 12/06/2017] [Accepted: 01/02/2018] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Determine if abnormal prenatal Doppler ultrasound indices are predictive of postnatal impaired cerebral autoregulation. STUDY DESIGN Prospective cohort study of 46 subjects, 240-296 weeks' gestation. Utilizing near-infrared spectroscopy and receiver-operating characteristic analysis, impaired cerebral autoregulation was defined as >16.5% time spent in a dysregulated state within 96 h of life. Normal and abnormal Doppler indices were compared for perinatal outcomes. RESULTS Subjects with abnormal cerebroplacental ratio (n = 12) and abnormal umbilical artery pulsatility index (n = 13) were likely to develop postnatal impaired cerebral autoregulation (p ≤ 0.02). Abnormal cerebroplacental ratio was associated with impaired cerebral autoregulation between 24 and 48 h of life (p = 0.016). These subjects have increased risk for fetal growth restriction, lower birth weight, lower Apgar scores, acidosis, and severe intraventricular hemorrhage and/or death (p < 0.05). CONCLUSION Abnormal cerebroplacental ratio and umbilical artery pulsatility index are associated with postnatal impairment in cerebral autoregulation and adverse outcome.
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99
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Beausoleil TP, Janaillac M, Barrington KJ, Lapointe A, Dehaes M. Cerebral oxygen saturation and peripheral perfusion in the extremely premature infant with intraventricular and/or pulmonary haemorrhage early in life. Sci Rep 2018; 8:6511. [PMID: 29695729 PMCID: PMC5916916 DOI: 10.1038/s41598-018-24836-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 04/09/2018] [Indexed: 12/29/2022] Open
Abstract
Extremely preterm infants are at higher risk of pulmonary (PH) and intraventricular (IVH) haemorrhage during the transitioning physiology due to immature cardiovascular system. Monitoring of haemodynamics can detect early abnormal circulation that may lead to these complications. We described time-frequency relationships between near infrared spectroscopy (NIRS) cerebral regional haemoglobin oxygen saturation (CrSO2) and preductal peripheral perfusion index (PI), capillary oxygen saturation (SpO2) and heart rate (HR) in extremely preterm infants in the first 72 h of life. Patients were sub-grouped in infants with PH and/or IVH (N H = 8) and healthy controls (N C = 11). Data were decomposed in wavelets allowing the analysis of localized variations of power. This approach allowed to quantify the percentage of time of significant cross-correlation, semblance, gain (transfer function) and coherence between signals. Ultra-low frequencies (<0.28 mHz) were analyzed as slow and prolonged periods of impaired circulation are considered more detrimental than transient fluctuations. Cross-correlation between CrSO2 and oximetry (PI, SpO2 and HR) as well as in-phase semblance and gain between CrSO2 and HR were significantly lower while anti-phase semblance between CrSO2 and HR was significantly higher in PH-IVH infants compared to controls. These differences may reflect haemodynamic instability associated with cerebrovascular autoregulation and hemorrhagic complications observed during the transitioning physiology.
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Affiliation(s)
- Thierry P Beausoleil
- Institute of Biomedical Engineering, University of Montréal, Montréal, Canada.,Research Centre, CHU Sainte-Justine, Montréal, Canada
| | - Marie Janaillac
- Department of Pediatrics, Division of Neonatology, CHU Sainte-Justine and University of Montréal, Montréal, Canada
| | - Keith J Barrington
- Research Centre, CHU Sainte-Justine, Montréal, Canada.,Department of Pediatrics, Division of Neonatology, CHU Sainte-Justine and University of Montréal, Montréal, Canada
| | - Anie Lapointe
- Department of Pediatrics, Division of Neonatology, CHU Sainte-Justine and University of Montréal, Montréal, Canada
| | - Mathieu Dehaes
- Research Centre, CHU Sainte-Justine, Montréal, Canada. .,Department of Radiology, Radio-oncology and Nuclear Medicine, University of Montréal, Montréal, Canada.
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100
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Marin T, Moore JE. Mesenteric Oxygenation Changes Associated With Necrotizing Enterocolitis and Pneumoperitoneum After Multiple Blood Transfusions: A Case Report. Adv Neonatal Care 2018; 18:121-127. [PMID: 29300196 DOI: 10.1097/anc.0000000000000461] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND The multifactorial pathology and broad clinical presentation of necrotizing enterocolitis (NEC) development in premature infants make prediction of disease onset extremely challenging. Over the past decade, packed red blood cell (PRBC) transfusions have been temporally linked to the development of NEC in severely anemic preterm infants, although this issue is highly controversial. PURPOSE In this case study, we describe events of an extremely low birth-weight infant who developed NEC complicated by pneumoperitoneum after receiving multiple PRBC transfusions. Specifically, we describe mesenteric tissue oxygenation trend changes as measured by continuous near-infrared spectroscopy (NIRS) technology. METHODS As part of a larger prospective, observational investigation, this infant was monitored with NIRS (INVOS 5100C; Medtronic, Boulder, Colorado) before, during, and 48 hours following PRBC transfusions. RESULTS The infant demonstrated severe, prolonged, and persistent reductions in mesenteric tissue oxygenation following blood transfusions, yet routine physiologic monitoring did not indicate intestinal hypoperfusion or impending NEC onset. IMPLICATIONS FOR PRACTICE This report demonstrates the ability of NIRS to capture possible tissue ischemia during early stages of NEC that may help guide bedside therapeutic interventions. IMPLICATIONS FOR RESEARCH Larger cohort studies to evaluate the ability of NIRS to capture early tissue ischemia are essential to validate the feasibility of adding this technology as a routine clinical bedside tool.Video Abstract available at https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx.
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