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Thome UH, Dreyhaupt J, Genzel-Boroviczeny O, Bohnhorst B, Schmid M, Fuchs H, Rohde O, Avenarius S, Topf HG, Zimmermann A, Faas D, Timme K, Kleinlein B, Buxmann H, Schenk W, Segerer H, Teig N, Ackermann B, Hentschel R, Heckmann M, Schlösser R, Peters J, Rossi R, Rascher W, Böttger R, Seidenberg J, Hansen G, Bode H, Zernickel M, Muche R, Hummler HD. Influence of PCO2 Control on Clinical and Neurodevelopmental Outcomes of Extremely Low Birth Weight Infants. Neonatology 2018; 113:221-230. [PMID: 29298438 DOI: 10.1159/000485828] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Accepted: 11/28/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Levels or fluctuations in the partial pressure of CO2 (PCO2) may affect outcomes for extremely low birth weight infants. OBJECTIVES In an exploratory analysis of a randomized trial, we hypothesized that the PCO2 values achieved could be related to significant outcomes. METHODS On each treatment day, infants were divided into 4 groups: relative hypocapnia, normocapnia, hypercapnia, or fluctuating PCO2. Ultimate assignment to a group for the purpose of this analysis was made according to the group in which an infant spent the most days. Statistical analyses were performed with analysis of variance (ANOVA), the Kruskal-Wallis test, the χ2 test, and the Fisher exact test as well as by multiple logistic regression. RESULTS Of the 359 infants, 57 were classified as hypocapnic, 230 as normocapnic, 70 as hypercapnic, and 2 as fluctuating PCO2. Hypercapnic infants had a higher average product of mean airway pressure and fraction of inspired oxygen (MAP × FiO2). For this group, mortality was higher, as was the likelihood of having moderate/severe bronchopulmonary dysplasia (BPD), necrotizing enterocolitis (NEC), and poorer neurodevelopment. Multiple logistic regression analyses showed an increased risk for BPD or death associated with birth weight (p < 0.001) and MAP × FiO2 (p < 0.01). The incidence of adverse neurodevelopment was associated with birth weight (p < 0.001) and intraventricular hemorrhage (IVH; p < 0.01). CONCLUSIONS Birth weight and respiratory morbidity, as measured by MAP × FiO2, were the most predictive of death or BPD and NEC, whereas poor neurodevelopmental outcome was associated with low birth weight and IVH. Univariate models also identified PCO2. Thus, hypercapnia seems to reflect greater disease severity, a likely contributor to differences in outcomes.
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Affiliation(s)
- Ulrich H Thome
- Division of Neonatology, University Hospital for Children and Adolescents, University of Leipzig, Leipzig, Germany
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Puchwein-Schwepcke AF, Schottmayer K, Mormanová Z, Dreyhaupt J, Genzel-Boroviczeny O, Thome UH. Permissive Hypercapnia Results in Decreased Functional Vessel Density in the Skin of Extremely Low Birth Weight Infants. Front Pediatr 2018; 6:52. [PMID: 29662873 PMCID: PMC5890181 DOI: 10.3389/fped.2018.00052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Accepted: 02/23/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Ventilator-induced lung injury with subsequent bronchopulmonary dysplasia remains an important issue in the care of extremely low-birth-weight infants. Permissive hypercapnia has been proposed to reduce lung injury. Hypercapnia changes cerebral perfusion, but its influence on the peripheral microcirculation is unknown. METHODS Data were collected from 12 infants, who were randomized to a permissive high PCO2 target group (HTG) or a control group (CG). Inclusion criteria were birth weight between 400 and 1,000 g, gestational age from 23 to 28 6/7 weeks, intubation during the first 24 h of life, and no malformations. The PCO2 target range was increased stepwise in both groups for weaning and was always 15 mmHg higher in the HTG than in the CG. Skin microvascular parameters were assessed non-invasively with sidestream dark field imaging on the inner side of the right arm every 24 h during the first week of life and on the 14th day of life. RESULTS Infants in the HTG had significantly higher max. PCO2 exposure, which was associated with a significantly and progressively reduced functional vessel density (FVD, p < 0.01). Moreover, there were significant differences in the diameter distribution over time, with HTG subjects having fewer small vessels but more large vessels. CONCLUSION High PCO2 levels significantly impaired peripheral microcirculation in preterm infants, as shown by a decreased FVD, presumably secondary to peripheral vasoconstriction. ISRCTN 56143743.
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Affiliation(s)
| | - Kristina Schottmayer
- Divsion of Neonatology, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Zuzana Mormanová
- Divsion of Neonatology, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Jens Dreyhaupt
- Institute for Epidemiology and Medical Biometry, University of Ulm, Ulm, Germany
| | - Orsolya Genzel-Boroviczeny
- Divsion of Neonatology, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Ulrich H Thome
- Divsion of Neonatology, University Hospital of Leipzig, Leipzig, Germany
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53
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Lin HJ, Huang CT, Hsiao HF, Chiang MC, Jeng MJ. End-tidal carbon dioxide measurement in preterm infants with low birth weight. PLoS One 2017; 12:e0186408. [PMID: 29040312 PMCID: PMC5645127 DOI: 10.1371/journal.pone.0186408] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Accepted: 09/29/2017] [Indexed: 02/06/2023] Open
Abstract
Objective There are conflicting data regarding the use of end-tidal carbon dioxide (PetCO2) measurement in preterm infants. The aim of this study was to evaluate the effects of different dead space to tidal volume ratios (VD/VT) on the correlation between PetCO2 and arterial carbon dioxide pressure (PaCO2) in ventilated preterm infants with respiratory distress syndrome (RDS). Methods We enrolled ventilated preterm infants (with assist control mode or synchronous intermittent mandatory mode) with RDS who were treated with surfactant in this prospective study. Simultaneous PetCO2 and PaCO2 data pairs were obtained from ventilated neonates monitored using mainstream capnography. Data obtained before and after surfactant treatment were also analyzed. Results One-hundred and one PetCO2 and PaCO2 pairs from 34 neonates were analyzed. There was a moderate correlation between PetCO2 and PaCO2 values (r = 0.603, P < 0.01). The correlation was higher in the post-surfactant treatment group (r = 0.786, P < 0.01) than the pre-surfactant treatment group (r = 0.235). The values of PaCO2 and PetCO2 obtained based on the treatment stage of surfactant therapy were 42.4 ± 8.6 mmHg and 32.6 ± 7.2 mmHg, respectively, in pre-surfactant treatment group, and 37.8 ± 10.3 mmHg and 33.7 ± 9.3 mmHg, respectively, in the post-surfactant treatment group. Furthermore, we found a significant decrease in VD/VT in the post-surfactant treatment group when compared to the pre-surfactant treatment group (P = 0.003). Conclusions VD/VT decreased significantly after surfactant therapy and the correlation between PetCO2 and PaCO2 was higher after surfactant therapy in preterm infants with RDS.
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Affiliation(s)
- Hsin-Ju Lin
- Department of Respiratory Therapy, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Institute of Emergency and Critical Care Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Ching-Tzu Huang
- Department of Respiratory Therapy, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Institute of Emergency and Critical Care Medicine, National Yang-Ming University, Taipei, Taiwan
- Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Hsiu-Feng Hsiao
- Department of Respiratory Therapy, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Ming-Chou Chiang
- Department of Respiratory Therapy, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Chang Gung University College of Medicine, Taoyuan, Taiwan
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- * E-mail: (MCC); (MJJ)
| | - Mei-Jy Jeng
- Institute of Emergency and Critical Care Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Pediatrics, Children’s Medical Center, Taipei Veterans General Hospital, Taipei, Taiwan
- * E-mail: (MCC); (MJJ)
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54
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Dix LML, Weeke LC, de Vries LS, Groenendaal F, Baerts W, van Bel F, Lemmers PMA. Carbon Dioxide Fluctuations Are Associated with Changes in Cerebral Oxygenation and Electrical Activity in Infants Born Preterm. J Pediatr 2017; 187:66-72.e1. [PMID: 28578157 DOI: 10.1016/j.jpeds.2017.04.043] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 04/05/2017] [Accepted: 04/20/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate the effects of acute arterial carbon dioxide partial pressure changes on cerebral oxygenation and electrical activity in infants born preterm. STUDY DESIGN This retrospective observational study included ventilated infants born preterm with acute fluctuations of continuous end-tidal CO2 (etCO2) as a surrogate marker for arterial carbon dioxide partial pressure, during the first 72 hours of life. Regional cerebral oxygen saturation and fractional tissue oxygen extraction were monitored with near-infrared spectroscopy. Brain activity was monitored with 2-channel electroencephalography. Spontaneous activity transients (SATs) rate (SATs/minute) and interval between SATs (in seconds) were calculated. Ten-minute periods were selected for analysis: before, during, and after etCO2 fluctuations of ≥5 mm Hg. RESULTS Thirty-eight patients (mean ± SD gestational age of 29 ± 1.8 weeks) were included, with 60 episodes of etCO2 increase and 70 episodes of etCO2 decrease. During etCO2 increases, brain oxygenation increased (regional cerebral oxygen saturation increased, fractional tissue oxygen extraction decreased; P < .01) and electrical activity decreased (SATs/minute decreased, interval between SATs increased; P < .01). All measures recovered when etCO2 returned to baseline. During etCO2 decreases, brain oxygenation decreased (regional cerebral oxygen saturation decreased, fractional tissue oxygen extraction decreased; P < .01) and brain activity increased (SATs/minute increased, P < .05), also with recovery after return of etCO2 to baseline. CONCLUSION An acute increase in etCO2 is associated with increased cerebral oxygenation and decreased brain activity, whereas an acute decrease is associated with decreased cerebral oxygenation and slightly increased brain activity. Combining continuous CO2 monitoring with near-infrared spectroscopy may enable the detection of otherwise undetected fluctuations in arterial carbon dioxide partial pressure that may be harmful to the neonatal brain.
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Affiliation(s)
- Laura Marie Louise Dix
- Department of Neonatology, Wilhelmina Children's Hospital/University Medical Center Utrecht, The Netherlands
| | - Lauren Carleen Weeke
- Department of Neonatology, Wilhelmina Children's Hospital/University Medical Center Utrecht, The Netherlands
| | - Linda Simone de Vries
- Department of Neonatology, Wilhelmina Children's Hospital/University Medical Center Utrecht, The Netherlands
| | - Floris Groenendaal
- Department of Neonatology, Wilhelmina Children's Hospital/University Medical Center Utrecht, The Netherlands
| | - Willem Baerts
- Department of Neonatology, Wilhelmina Children's Hospital/University Medical Center Utrecht, The Netherlands
| | - Frank van Bel
- Department of Neonatology, Wilhelmina Children's Hospital/University Medical Center Utrecht, The Netherlands
| | - Petra Maria Anna Lemmers
- Department of Neonatology, Wilhelmina Children's Hospital/University Medical Center Utrecht, The Netherlands.
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Houck CS, Vinson AE. Anaesthetic considerations for surgery in newborns. Arch Dis Child Fetal Neonatal Ed 2017; 102:F359-F363. [PMID: 28283552 DOI: 10.1136/archdischild-2016-311800] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 02/09/2017] [Accepted: 02/15/2017] [Indexed: 12/31/2022]
Abstract
Almost 30 years ago, the American Academy of Pediatrics Committee on Fetus and Newborn coauthored a policy statement strongly advocating for the use of anaesthesia in all neonates stating 'local or systemic pharmacologic agents now available permit relatively safe administration of anesthesia or analgesia to neonates undergoing surgical procedures and that such administration is indicated according to the usual guidelines for the administration of anesthesia to high-risk, potentially unstable patients'. With current techniques and advanced monitoring, preterm and full-term infants routinely undergo surgical procedures under general anaesthesia to repair congenital defects that were lethal in years past. Recent research in immature animal models, however, has shown evidence of enhanced neuroapoptosis and other signs of neurotoxicity with all of the currently used anaesthetic agents. There is also increasing concern about the potential adverse effects of perioperative hypotension and hypocapnia on neurocognitive development in infants. This review outlines the most recent animal and human evidence regarding the effects of general anaesthesia and anaesthetic-related haemodynamic changes on the developing brain of newborns.
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Affiliation(s)
- Constance S Houck
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Amy E Vinson
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
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Abdel-Hady H, Shouman B. Permissive hypercapnia in extremely low-birthweight infants: how far should we go? Acta Paediatr 2017; 106:1011. [PMID: 28121055 DOI: 10.1111/apa.13727] [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: 12/02/2016] [Revised: 12/16/2016] [Accepted: 12/21/2016] [Indexed: 11/27/2022]
Affiliation(s)
- Hesham Abdel-Hady
- Pediatrics/Neonatology, Mansoura University Children's Hospital, Mansoura, Egypt
| | - Basma Shouman
- Pediatrics/Neonatology, Mansoura University Children's Hospital, Mansoura, Egypt
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Almenrader N, Colucci P, De Castro V, Valeri D, Palmery M, Trezza V, Campolongo P. Effects of sevoflurane and clonidine on acid base status and long-term emotional and cognitive outcomes in spontaneously breathing rat pups. PLoS One 2017; 12:e0173969. [PMID: 28319126 PMCID: PMC5358762 DOI: 10.1371/journal.pone.0173969] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Accepted: 03/01/2017] [Indexed: 12/20/2022] Open
Abstract
Background Numerous experiments in rodents suggest a causative link between exposure to general anaesthetics during brain growth spurt and poor long-lasting neurological outcomes. Many of these studies have been questioned with regard of their translational value, mainly because of extremely long anaesthesia exposure. Therefore, the aim of the present study was to assess the impact of a short sevoflurane anaesthesia, alone or combined with clonidine treatment, on respiratory function in spontaneously breathing rat pups and overall effects on long-lasting emotional and cognitive functions. Methods At postnatal day (PND) 7, male Sprague Dawley rat pups were randomized into four groups and exposed to sevoflurane for one hour, to a single dose of intraperitoneal clonidine or to a combination of both and compared to a control group. Blood gas analysis was performed at the end of sevoflurane anaesthesia and after 60 minutes from clonidine or saline injection. Emotional and cognitive outcomes were evaluated in different group of animals at infancy (PND12), adolescence (PND 30–40) and adulthood (PND 70–90). Results Rat pups exposed to either sevoflurane or to a combination of sevoflurane and clonidine developed severe hypercapnic acidosis, but maintained normal arterial oxygenation. Emotional and cognitive outcomes were not found altered in any of the behavioural task used either at infancy, adolescence or adulthood. Conclusions Sixty minutes of sevoflurane anaesthesia in newborn rats, either alone or combined with clonidine, caused severe hypercapnic acidosis in spontaneously breathing rat pups, but was devoid of long-term behavioural dysfunctions in the present setting.
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Affiliation(s)
- Nicole Almenrader
- Department of Physiology and Pharmacology, Sapienza University of Rome, Rome, Italy
- Department of Anaesthesia and Intensive Care, Policlinico Umberto I, Rome, Italy
| | - Paola Colucci
- Department of Physiology and Pharmacology, Sapienza University of Rome, Rome, Italy
| | - Valentina De Castro
- Department of Physiology and Pharmacology, Sapienza University of Rome, Rome, Italy
| | - Daniela Valeri
- Department of Physiology and Pharmacology, Sapienza University of Rome, Rome, Italy
| | - Maura Palmery
- Department of Physiology and Pharmacology, Sapienza University of Rome, Rome, Italy
| | - Viviana Trezza
- Department of Science, Section of Biomedical Sciences and Technologies, University “Roma Tre”, Rome, Italy
| | - Patrizia Campolongo
- Department of Physiology and Pharmacology, Sapienza University of Rome, Rome, Italy
- * E-mail:
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Omer M, Molloy EJ. QUESTION 2: Is permissive hypercapnia beneficial to preterm infants? Arch Dis Child 2017; 102:113-115. [PMID: 27881376 DOI: 10.1136/archdischild-2016-312050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 11/07/2016] [Indexed: 11/04/2022]
Affiliation(s)
- Murwan Omer
- Department of Paediatrics, Coombe Women and Infants University Hospital, Dublin, Ireland
| | - Eleanor J Molloy
- Department of Neonatology, Our lady's Children's Hospital, Trinity College, the University of Dublin, Dublin, Ireland
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Huang H, Cheung PY, O'Reilly M, van Os S, Solevåg AL, Aziz K, Schmölzer GM. Impact of Changing Clinical Practices on Early Blood Gas Analyses in Very Preterm Infants and Their Associated Inpatient Outcomes. Front Pediatr 2017; 5:11. [PMID: 28243581 PMCID: PMC5303872 DOI: 10.3389/fped.2017.00011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 01/16/2017] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Early studies suggest an association of abnormal carbon dioxide (PCO2) or oxygen (PO2) levels with adverse inpatient outcomes in very preterm babies. Recent resuscitation practice changes, such as targeted oxygen therapy, end-expiratory pressure, and rescue surfactant may influence these associations. OBJECTIVE The aim of this study is to assess the range of the initial partial pressures of PCO2 and PO2 in preterm neonates <33 weeks gestational age after birth and their correlation to inpatient neonatal outcomes. STUDY DESIGN This is a prospective observational cohort study of infants <33 weeks gestational age with arterial or venous blood gas analysis performed within the first hour after birth. RESULTS One hundred seventy infants (arterial n = 75, venous n = 95) with mean (SD) gestational age of 28 (3) weeks and birth weight of 1,111 (403) g were included. None of the infants with arterial blood gases had hypocarbia (<30 mmHg), 32 (43%) had normocarbia (30-55 mmHg), and 43 (57%) had hypercarbia (>55 mmHg). Seventeen of the infants with arterial blood gases (22%) had hypoxia (<50 mmHg), 50 (67%) normoxia, and 8 (11%) hyperoxia (>80 mmHg). In infants with venous blood samples, none had venous PCO2 < 40 mmHg, 41 (43%) had venous PCO2 40-60 mmHg, and 54 (57%) had venous PCO2 > 60 mmHg. Multivariable logistic regression analysis showed no association of low or high PCO2 or PO2 with death or major inpatient morbidities. CONCLUSION With current resuscitation and stabilization practices, hyperoxia and hypocarbia was uncommon, and hypercarbia occurred frequently. None of these findings correlate with adverse inpatient outcomes or death. Our findings are in direct contrast to published observations using historical practices.
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Affiliation(s)
- Hongmei Huang
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada; Department of Pediatrics, Hong Kong University-Shenzhen Hospital, Shenzhen, China
| | - Po-Yin Cheung
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada; Department of Pediatrics, Hong Kong University-Shenzhen Hospital, Shenzhen, China; Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Megan O'Reilly
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada; Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Sylvia van Os
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital , Edmonton, AB , Canada
| | - Anne Lee Solevåg
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital , Edmonton, AB , Canada
| | - Khalid Aziz
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada; Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Georg M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada; Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
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Dix LML, van Bel F, Lemmers PMA. Monitoring Cerebral Oxygenation in Neonates: An Update. Front Pediatr 2017; 5:46. [PMID: 28352624 PMCID: PMC5348638 DOI: 10.3389/fped.2017.00046] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 02/24/2017] [Indexed: 11/13/2022] Open
Abstract
Cerebral oxygenation is not always reflected by systemic arterial oxygenation. Therefore, regional cerebral oxygen saturation (rScO2) monitoring with near-infrared spectroscopy (NIRS) is of added value in neonatal intensive care. rScO2 represents oxygen supply to the brain, while cerebral fractional tissue oxygen extraction, which is the ratio between rScO2 and systemic arterial oxygen saturation, reflects cerebral oxygen utilization. The balance between oxygen supply and utilization provides insight in neonatal cerebral (patho-)physiology. This review highlights the potential and limitations of cerebral oxygenation monitoring with NIRS in the neonatal intensive care unit.
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Affiliation(s)
- Laura Marie Louise Dix
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands; Monash Newborn, Monash Medical Centre, Melbourne, VIC, Australia
| | - Frank van Bel
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht , Utrecht , Netherlands
| | - Petra Maria Anna Lemmers
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht , Utrecht , Netherlands
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García-Muñoz Rodrigo F, Urquía Martí L, Galán Henríquez G, Rivero Rodríguez S, Tejera Carreño P, Molo Amorós S, Cabrera Vega P, Rodríguez Ramón F. Perinatal risk factors for pneumothorax and morbidity and mortality in very low birth weight infants. J Matern Fetal Neonatal Med 2016; 30:2679-2685. [DOI: 10.1080/14767058.2016.1261281] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
| | - Lourdes Urquía Martí
- Hospital Materno-Infantil de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - Gloria Galán Henríquez
- Hospital Materno-Infantil de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - Sonia Rivero Rodríguez
- Hospital Materno-Infantil de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | | | - Silvia Molo Amorós
- Hospital Materno-Infantil de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - Pedro Cabrera Vega
- Hospital Materno-Infantil de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
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Bermick J, Dechert RE, Sarkar S. Does hyperglycemia in hypernatremic preterm infants increase the risk of intraventricular hemorrhage? J Perinatol 2016; 36:729-32. [PMID: 27195979 DOI: 10.1038/jp.2016.86] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 03/30/2016] [Accepted: 04/13/2016] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Hypernatremia and hyperglycemia are highly prevalent in preterm infants during the first week after birth, and both can lead to hyperosmolarity and osmotic shifts. The objective is to determine whether hyperglycemia increases the risk of intraventricular hemorrhage (IVH) in hypernatremic preterm infants. STUDY DESIGN Single-center retrospective medical record review of 216 infants <1000 g birth weight and <29 weeks gestational age (admitted over a 9-year period) who had serum sodium levels and blood glucose levels monitored at least every 24 h and more frequently if indicated during the first 10 days after birth. Hyperglycemia was defined as persistently high blood glucose (usually >200 mg dl(-1)) treated with an insulin infusion. Hypernatremia was defined as a serum sodium level of ⩾150 mmol l(-1) on repeated measurements. RESULTS Of the 216 infants studied, 76 (35%) developed hyperglycemia and 126 (58%) developed hypernatremia. IVH developed more frequently in infants with hyperglycemia (P=0.006, odds ratio (OR) 2.3, 95% confidence interval (CI) 1.3 to 4.1), in infants with hypernatremia (P=0.018, OR 2.0, 95% CI 1.2 to 3.5) and in infants with hypernatremia plus hyperglycemia (P=0.001, OR 3.2, 95% CI 1.6 to 6.4). Multivariate regression analysis confirmed the independent association of higher risk of IVH with the presence of hypernatremia plus hyperglycemia (P=0.015, OR 2.6, 95% CI 1.2 to 5.5) but not with hypernatremia or hyperglycemia alone. CONCLUSION Hyperglycemia increases the risk of IVH in hypernatremic preterm infants.
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Affiliation(s)
- J Bermick
- Division of Neonatal-Perinatal Medicine, C.S. Mott Children's Hospital, University of Michigan Health System, Ann Arbor, MI, USA
| | - R E Dechert
- Division of Neonatal-Perinatal Medicine, C.S. Mott Children's Hospital, University of Michigan Health System, Ann Arbor, MI, USA
| | - S Sarkar
- Division of Neonatal-Perinatal Medicine, C.S. Mott Children's Hospital, University of Michigan Health System, Ann Arbor, MI, USA
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Ma J, Ye H. Effects of permissive hypercapnia on pulmonary and neurodevelopmental sequelae in extremely low birth weight infants: a meta-analysis. SPRINGERPLUS 2016; 5:764. [PMID: 27386250 PMCID: PMC4912505 DOI: 10.1186/s40064-016-2437-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 05/27/2016] [Indexed: 11/17/2022]
Abstract
Objectives To perform a systematic review and meta-analysis of the efficacy and safety of permissive hypercapnia in extremely low birth weight infants. Methods A systematic search of MEDLINE, EMBASE, the Cochrane Database of randomized trials. Eligibility and quality of trials were assessed, and data on study design, patient characteristics, and relevant outcomes were extracted. Results Four studies that enrolled a total of 693 participants were selected. Meta-analysis revealed no effect of permissive hypercapnia on decreasing rates of bronchopulmonary dysplasia (BPD). Permissive hypercapnia also had no significant effect on mortality, intraventricular haemorrhage (IVH), IVH (grade 3–4), periventricular leukomalacia (PVL), necrotising enterocolitis (NEC), retinopathy of prematurity (ROP) or air leaks in extremely low birth weight infants. Neurodevelopmental outcomes were comparable at 18–22 months’ corrected age in two studies. permissive hypercapnia did not increase the risk of cerebral palsy, Mental Developmental Index <70, Psychomotor Developmental Index <70, visual deficit, or hearing deficit. Conclusions Permissive hypercapnia did not reduce the rate of BPD in extremely low birth weight infants. The rates of mortality, IVH, PVL, NEC, ROP and neurodevelopmental outcomes did not differ between these two groups. These results suggest that permissive hypercapnia does not bring extra benefits in extremely low birth weight infants.
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Affiliation(s)
- Jianglin Ma
- Department of Pediatrics, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, 310000 People's Republic of China
| | - Hui Ye
- Department of Pediatrics, Taizhou First People's Hospital, Taizhou, 318020 People's Republic of China
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Accuracy of Transcutaneous Carbon Dioxide Measurement in Premature Infants. Crit Care Res Pract 2016; 2016:8041967. [PMID: 27375901 PMCID: PMC4916268 DOI: 10.1155/2016/8041967] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Accepted: 05/17/2016] [Indexed: 12/05/2022] Open
Abstract
Background. In premature infants, maintaining blood partial pressure of carbon dioxide (pCO2) value within a narrow range is important to avoid cerebral lesions. The aim of this study was to assess the accuracy of a noninvasive transcutaneous method (TcpCO2), compared to blood partial pressure of carbon dioxide (pCO2). Methods. Retrospective observational study in a tertiary neonatal intensive care unit. We analyzed the correlation between blood pCO2 and transcutaneous values and the accuracy between the trends of blood pCO2 and TcpCO2 in all consecutive premature infants born at <33 weeks' gestational age. Results. 248 infants were included (median gestational age: 29 + 5 weeks and median birth weight: 1250 g), providing 1365 pairs of TcpCO2 and blood pCO2 values. Pearson's R correlation between these values was 0.58. The mean bias was −0.93 kPa with a 95% confidence limit of agreement of −4.05 to +2.16 kPa. Correlation between the trends of TcpCO2 and blood pCO2 values was good in only 39.6%. Conclusions. In premature infants, TcpCO2 was poorly correlated to blood pCO2, with a wide limit of agreement. Furthermore, concordance between trends was equally low. We warn about clinical decision-making on TcpCO2 alone when used as continuous monitoring.
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Bruschettini M, Romantsik O, Zappettini S, Ramenghi LA, Calevo MG. Transcutaneous carbon dioxide monitoring for the prevention of neonatal morbidity and mortality. Cochrane Database Syst Rev 2016; 2:CD011494. [PMID: 26874180 PMCID: PMC8720274 DOI: 10.1002/14651858.cd011494.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Carbon dioxide (CO2) measurement is a fundamental evaluation in a neonatal intensive care unit (NICU), as both low and high values of CO2 might have detrimental effects on neonatal morbidity and mortality. Though measurement of CO2 in the arterial blood gas is the most accurate way to assess the amount of CO2, it requires blood sampling and it does not provide a continuous monitoring of CO2. OBJECTIVES To assess whether the use of continuous transcutaneous CO2 (tcCO2) monitoring in newborn infants reduces mortality and improves short and long term respiratory and neurodevelopmental outcomes. SEARCH METHODS We used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 11), MEDLINE via PubMed (1966 to November 1, 2015), EMBASE (1980 to November 1, 2015), and CINAHL (1982 to November 1, 2015). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomized controlled trials and quasi-randomized trials. SELECTION CRITERIA Randomized, quasi-randomized and cluster randomized controlled trials comparing different strategies regarding tcCO2 monitoring in newborns. Three comparisons were considered, that is, continuous tcCO2 monitoring versus 1) any intermittent modalities to measure CO2; 2) other continuous CO2 monitoring; and 3) with or without intermittent CO2 monitoring. DATA COLLECTION AND ANALYSIS We used the standard methods of the Cochrane Neonatal Review Group. Two review authors independently assessed studies identified by the search strategy for inclusion. MAIN RESULTS Our search strategy yielded 106 references. Two review authors independently assessed all references for inclusion. We did not find any completed studies for inclusion, nor ongoing trials. AUTHORS' CONCLUSIONS There was no evidence to recommend or refute the use of transcutaneous CO2 monitoring in neonates. Well-designed, adequately powered randomized controlled studies are necessary to address efficacy and safety of transcutaneous CO2 monitoring in neonates.
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Affiliation(s)
- Matteo Bruschettini
- Institute for Clinical Sciences, Lund UniversityDepartment of PediatricsLundSweden21185
| | - Olga Romantsik
- Institute for Clinical Sciences, Lund UniversityDepartment of PediatricsLundSweden21185
| | | | | | - Maria Grazia Calevo
- Istituto Giannina GasliniEpidemiology, Biostatistics and Committees UnitGenoaItaly16147
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Stoops C, Sims B, Griffin R, Askenazi DJ. Neonatal Acute Kidney Injury and the Risk of Intraventricular Hemorrhage in the Very Low Birth Weight Infant. Neonatology 2016; 110:307-312. [PMID: 27490643 PMCID: PMC5821253 DOI: 10.1159/000445931] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 04/05/2016] [Indexed: 11/19/2022]
Abstract
Despite improvements in survival of premature infants, many have comorbid conditions. The role of the kidney in multiorgan dysfunction is unclear, particularly in regard to intraventricular hemorrhage (IVH). We hypothesized that infants diagnosed with acute kidney injury (AKI) have an increased risk of IVH independent of gestational age (GA) and other variables associated with both comorbidities. This prospective cohort study consisted of 125 infants with a birth weight ≤1,200 g and/or GA ≤31 weeks. A definition of AKI was used from KDIGO, not including urine output as nonoliguria is common in this population. IVH was based on serial head ultrasounds. Neonates with AKI had a higher trend towards having IVH compared to those without [14/35 (40%) vs. 22/83 (26.5%), p = 0.1]. Infants with AKI were more likely to have stage 2 IVH or higher than those without AKI [12/36 (33.3%) vs. 6/82 (7.3%); p < 0.01]. AKI was associated with a 3.6-fold increased risk of a grade 2 or higher IVH [hazard ratio (HR) 3.55, 95% confidence interval (CI) 1.39-9.07] and over 4-fold increase in risk of a grade 3 or higher IVH (HR 4.34, 95% CI 1.43-13.21). While there was no association between AKI and IVH overall, those with AKI had a higher hazard ratio to develop a grade 2 or higher IVH even when controlling for birth weight, antenatal steroid use, and 5-min Apgar score. Future studies are indicated to expand sample size and to control for other clinical variables that could be associated with both AKI and IVH.
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Affiliation(s)
- Christine Stoops
- Division of Neonatology, University of Alabama at Birmingham, Birmingham, Ala., USA
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Bang SR. Neonatal anesthesia: how we manage our most vulnerable patients. Korean J Anesthesiol 2015; 68:434-41. [PMID: 26495052 PMCID: PMC4610921 DOI: 10.4097/kjae.2015.68.5.434] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 07/31/2015] [Accepted: 08/18/2015] [Indexed: 12/12/2022] Open
Abstract
Neonates undergoing surgery are at higher risk than older children for anesthesia-related adverse events. During the perioperative period, the maintenance of optimal hemodynamics in these patients is challenging and requires a thorough understanding of neonatal physiology and pharmacology. Data from animals and human cohort studies have shown relation of the currently used anesthetics may associate with neurotoxic brain injury that lead to later neurodevelopmental impairment in the developing brain. In this review, the unique neonatal physiologic and pharmacologic features and anesthesia-related neurotoxicity will be discussed.
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Affiliation(s)
- Si Ra Bang
- Department of Anesthesiology and Pain Medicine, Seoul Paik Hospital, Inje University School of Medicine, Seoul, Korea
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Noori S, Seri I. Evidence-based versus pathophysiology-based approach to diagnosis and treatment of neonatal cardiovascular compromise. Semin Fetal Neonatal Med 2015; 20:238-45. [PMID: 25823937 DOI: 10.1016/j.siny.2015.03.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
With the advances in biomedical research and neonatal intensive care, our understanding of cardiovascular developmental physiology and pathophysiology has significantly improved during the last few decades. Despite this progress, the current management of circulatory compromise depends primarily on experts' opinions rather than high level of evidence. The lack of reliable, accurate, continuous and preferably non-invasive monitoring techniques has further limited our ability to collect the information needed for the design and execution of more sophisticated clinical trials with a better chance to provide the evidence we need. Given the lack of randomized, placebo-controlled trials investigating clinically relevant outcomes of novel treatments of neonatal cardiovascular compromise, we must now use the available lower level of evidence and our present understanding of developmental physiology and pathophysiology when providing cardiovascular supportive care to critically ill neonates. However, with recent advances in cardiovascular monitoring capabilities, direct and more objective assessment of the changes in cardiovascular function, organ blood flow, and tissue oxygenation have become possible. These advances have helped in our clinical assessment and enabled us to start designing more sophisticated interventional clinical trials using clinically relevant endpoints.
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Affiliation(s)
- Shahab Noori
- Division of Neonatology and the Center for Fetal and Neonatal Medicine, Department of Pediatrics, Children's Hospital Los Angeles and the LAC+USC Medical Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| | - Istvan Seri
- Sidra Medical and Research Center, Doha, Qatar
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69
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Hemodynamic antecedents of peri/intraventricular hemorrhage in very preterm neonates. Semin Fetal Neonatal Med 2015; 20:232-7. [PMID: 25818879 DOI: 10.1016/j.siny.2015.02.004] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Novel hemodynamic monitoring technologies have contributed to the understanding of developmental cardiovascular physiology and pathophysiology in general, and of developmental hemodynamics in particular. Hemodynamic disturbances play a significant role in the pathogenesis of peri/intraventricular hemorrhage (P/IVH) in preterm infants. Immaturity of the myocardium, delayed and incomplete cardiopulmonary transition, sustained patency of the ductus arteriosus, and unintended consequences of respiratory and cardiovascular supportive care are all likely to be involved in the presentation of low cardiac output syndrome and decreased organ blood flow in a large number of very preterm neonates (gestational age ≤28 weeks). Forebrain vessels in very preterm infants may not have achieved a "high-priority vasculature" status at the time of delivery; in these patients, forebrain perfusion is not protected during the compensated phase of shock. Reperfusion may be attenuated by the careful use of medications decreasing cerebrovascular reactivity, thus providing a potential target for the development of careful pharmacological support of transitional hemodynamics in selected patients at high risk for the development of P/IVH.
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70
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Thome UH, Genzel-Boroviczeny O, Bohnhorst B, Schmid M, Fuchs H, Rohde O, Avenarius S, Topf HG, Zimmermann A, Faas D, Timme K, Kleinlein B, Buxmann H, Schenk W, Segerer H, Teig N, Gebauer C, Hentschel R, Heckmann M, Schlösser R, Peters J, Rossi R, Rascher W, Böttger R, Seidenberg J, Hansen G, Zernickel M, Alzen G, Dreyhaupt J, Muche R, Hummler HD. Permissive hypercapnia in extremely low birthweight infants (PHELBI): a randomised controlled multicentre trial. THE LANCET RESPIRATORY MEDICINE 2015; 3:534-43. [PMID: 26088180 DOI: 10.1016/s2213-2600(15)00204-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Revised: 05/08/2015] [Accepted: 05/14/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND Tolerating higher partial pressure of carbon dioxide (pCO2) in mechanically ventilated, extremely low birthweight infants might reduce ventilator-induced lung injury and bronchopulmonary dysplasia. We aimed to test the hypothesis that higher target ranges for pCO2 decrease the rate of bronchopulmonary dysplasia or death. METHODS In this randomised multicentre trial, we recruited infants from 16 tertiary care perinatal centres in Germany with birthweight between 400 g and 1000 g and gestational age 23-28 weeks plus 6 days, who needed endotracheal intubation and mechanical ventilation within 24 h of birth. Infants were randomly assigned to either a high target or control group. The high target group aimed at pCO2 values of 55-65 mm Hg on postnatal days 1-3, 60-70 mm Hg on days 4-6, and 65-75 mm Hg on days 7-14, and the control target at pCO2 40-50 mmHg on days 1-3, 45-55 mm Hg on days 4-6, and 50-60 mm Hg on days 7-14. The primary outcome was death or moderate to severe bronchopulmonary dysplasia, defined as need for mechanical pressure support or supplemental oxygen at 36 weeks postmenstrual age. Cranial ultrasonograms were assessed centrally by a masked paediatric radiologist. This trial is registered with the ISRCTN registry, number ISRCTN56143743. RESULTS Between March 1, 2008, and July 31, 2012, we recruited 362 patients of whom three dropped out, leaving 179 patients in the high target and 180 in the control group. The trial was stopped after an interim analysis (n=359). The rate of bronchopulmonary dysplasia or death in the high target group (65/179 [36%]) did not differ significantly from the control group (54/180 [30%]; p=0·18). Mortality was 25 (14%) in the high target group and 19 (11%; p=0·32) in the control group, grade 3-4 intraventricular haemorrhage was 26 (15%) and 21 (12%; p=0·30), and the rate of severe retinopathy recorded was 20 (11%) and 26 (14%; p=0·36). INTERPRETATION Targeting a higher pCO2 did not decrease the rate of bronchopulmonary dysplasia or death in ventilated preterm infants. The rates of mortality, intraventricular haemorrhage, and retinopathy did not differ between groups. These results suggest that higher pCO2 targets than in the slightly hypercapnic control group do not confer increased benefits such as lung protection. FUNDING Deutsche Forschungsgemeinschaft.
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Affiliation(s)
- Ulrich H Thome
- Division of Neonatology, University Hospital for Children and Adolescents, University of Leipzig, Leipzig, Germany.
| | - Orsolya Genzel-Boroviczeny
- Division of Neonatology, Dr. von Hauner University Children's Hospital, Ludwig Maximilian University of Munich, Munich, Germany
| | - Bettina Bohnhorst
- Division of Pediatric Pneumology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany
| | - Manuel Schmid
- Division of Neonatology and Pediatric Critical Care, University Hospital for Children and Adolescents, University of Ulm, Ulm, Germany
| | - Hans Fuchs
- Division of Neonatology and Pediatric Critical Care, University Hospital for Children and Adolescents, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Oliver Rohde
- Division of Neonatology and Pediatric Critical Care, Elisabeth Children's Hospital, Klinikum Oldenburg, Medical Campus, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
| | - Stefan Avenarius
- Hospital for General Pediatrics and Neonatology, Otto von Guericke University Magdeburg, Magdeburg, Germany
| | - Hans-Georg Topf
- Division of Neonatology, University Hospital for Children and Adolescents, Friedrich-Alexander University Erlangen, Erlangen, Germany
| | - Andrea Zimmermann
- Mutter-Kind-Zentrum, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Dirk Faas
- University Hospital for General Pediatrics and Neonatology, Justus Liebig University Giessen, Giessen, Germany
| | - Katharina Timme
- Division of Neonatology, Hospital for Children and Adolescents, Vivantes-Hospital Neukölln, Berlin, Berlin, Germany
| | - Barbara Kleinlein
- Hospital for Children and Adolescents, Children's Hospital of the Third Order, Munich, Germany
| | - Horst Buxmann
- Division of Neonatology, University Hospital for Children and Adolescents of the J.W. Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Wilfried Schenk
- Hospital for Children and Adolescents, Central Hospital Augsburg, Augsburg, Germany
| | - Hugo Segerer
- St. Hedwig Hospital, University of Regensburg, Regensburg, Germany
| | - Norbert Teig
- Department of Neonatology and Pediatric Intensive Care, Katholisches Klinikum, Ruhr University Bochum, Bochum, Germany
| | - Corinna Gebauer
- Division of Neonatology, University Hospital for Children and Adolescents, University of Leipzig, Leipzig, Germany
| | - Roland Hentschel
- Division of Neonatology and Pediatric Critical Care, University Hospital for Children and Adolescents, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Matthias Heckmann
- Division of Neonatology and Pediatric Critical Care, University Hospital for Children and Adolescents, Ernst Moritz Arndt University Greifswald, Greifswald, Germany
| | - Rolf Schlösser
- Division of Neonatology, University Hospital for Children and Adolescents of the J.W. Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Jochen Peters
- Hospital for Children and Adolescents, Children's Hospital of the Third Order, Munich, Germany
| | - Rainer Rossi
- Division of Neonatology, Hospital for Children and Adolescents, Vivantes-Hospital Neukölln, Berlin, Berlin, Germany
| | - Wolfgang Rascher
- Division of Neonatology, University Hospital for Children and Adolescents, Friedrich-Alexander University Erlangen, Erlangen, Germany
| | - Ralf Böttger
- Hospital for General Pediatrics and Neonatology, Otto von Guericke University Magdeburg, Magdeburg, Germany
| | - Jürgen Seidenberg
- Division of Neonatology and Pediatric Critical Care, Elisabeth Children's Hospital, Klinikum Oldenburg, Medical Campus, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
| | - Gesine Hansen
- Division of Pediatric Pneumology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany
| | - Maria Zernickel
- Division of Neonatology and Pediatric Critical Care, University Hospital for Children and Adolescents, University of Ulm, Ulm, Germany
| | - Gerhard Alzen
- Division of Pediatric Radiology, University Hospital of the Justus Liebig University Giessen, Giessen, Germany
| | - Jens Dreyhaupt
- Institute of Epidemiology and Medical Biometry, University of Ulm, Ulm, Germany
| | - Rainer Muche
- Institute of Epidemiology and Medical Biometry, University of Ulm, Ulm, Germany
| | - Helmut D Hummler
- Division of Neonatology and Pediatric Critical Care, University Hospital for Children and Adolescents, University of Ulm, Ulm, Germany
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Hawkes GA, Kenosi M, Ryan CA, Dempsey EM. Quantitative or qualitative carbon dioxide monitoring for manual ventilation: a mannequin study. Acta Paediatr 2015; 104:e148-51. [PMID: 25495353 DOI: 10.1111/apa.12868] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Revised: 09/15/2014] [Accepted: 11/12/2014] [Indexed: 11/27/2022]
Abstract
AIM To compare the effectiveness of an in-line EtCO2 detector (DET) and a quantitative EtCO2 detector (CAP), both attached to a t-piece resuscitator, during PPV via a face mask. METHODS Paediatric trainees were randomly assigned to determine the method of PPV they commenced with (No device (ND), DET or CAP). Participants used each method for 2 min. Participants were video-recorded to determine the amount of effective ventilations delivered with each method. RESULTS Twenty-three paediatric trainees provided a total of 6035 ventilations, and 91.2% were deemed effective. The percentages of median effective ventilations with the ND, the DET and the CAP were 91.0%, 93.0% and 94.0%, respectively. Fourteen (61%) of the trainees indicated a preference for the DET method, 8 (35%) for the CAP method, and 1 (4%) of the trainees indicated a preference for the ND method. Capnography was the most effective method per patient. CONCLUSION There was no adverse effect with the addition of EtCO2 detectors. Trainees favoured methods of EtCO2 monitoring during ventilation. The NeoStat device was the preferred device by the majority. The greatest efficacy was achieved with the capnography device. Capnography may enhance face mask ventilation.
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Affiliation(s)
- GA Hawkes
- Department of Paediatrics and Child Health; University College Cork; Ireland
- Irish Centre for Fetal and Neonatal Translational Research (INFANT); Cork Ireland
| | - M Kenosi
- Department of Paediatrics and Child Health; University College Cork; Ireland
- Irish Centre for Fetal and Neonatal Translational Research (INFANT); Cork Ireland
| | - CA Ryan
- Department of Paediatrics and Child Health; University College Cork; Ireland
- Irish Centre for Fetal and Neonatal Translational Research (INFANT); Cork Ireland
| | - EM Dempsey
- Department of Paediatrics and Child Health; University College Cork; Ireland
- Irish Centre for Fetal and Neonatal Translational Research (INFANT); Cork Ireland
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Ambalavanan N, Carlo WA, Wrage LA, Das A, Laughon M, Cotten CM, Kennedy KA, Laptook AR, Shankaran S, Walsh MC, Higgins RD. PaCO2 in surfactant, positive pressure, and oxygenation randomised trial (SUPPORT). Arch Dis Child Fetal Neonatal Ed 2015; 100:F145-9. [PMID: 25425651 PMCID: PMC4336211 DOI: 10.1136/archdischild-2014-306802] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To determine the association of arterial partial pressure of carbon dioxide PaCO2 with severe intraventricular haemorrhage (sIVH), bronchopulmonary dysplasia (BPD), and neurodevelopmental impairment (NDI) at 18-22 months in premature infants. DESIGN Secondary exploratory data analysis of Surfactant, Positive Pressure, and Oxygenation Randomised Trial (SUPPORT). SETTING Multiple referral neonatal intensive care units. PATIENTS 1316 infants 24 0/7 to 27 6/7 weeks gestation randomised to different oxygenation (SpO2 target 85-89% vs 91-95%) and ventilation strategies. MAIN OUTCOME MEASURES Blood gases from postnatal day 0 to day14 were analysed. Five PaCO2 variables were defined: minimum (Min), maximum (Max), SD, average (time-weighted), and a four level categorical variable (hypercapnic (highest quartile of Max PaCO2), hypocapnic (lowest quartile of Min PaCO2), fluctuators (hypercapnia and hypocapnia), and normocapnic (middle two quartiles of Max and Min PaCO2)). PaCO2 variables were compared for infants with and without sIVH, BPD and NDI (±death). Multivariable logistic regression models were developed for adjusted results. RESULTS sIVH, BPD and NDI (±death) were associated with hypercapnic infants and fluctuators. Association of Max PaCO2 and outcomes persisted after adjustment (per 10 mm Hg increase: sIVH/death: OR 1.27 (1.13 to 1.41); BPD/death: OR 1.27 (1.12 to 1.44); NDI/death: OR 1.23 (1.10 to 1.38), death: OR 1.27 (1.12 to 1.44), all p<0.001). No interaction was found between PaCO2 category and SpO2 treatment group for sIVH/death, NDI/death or death. Max PaCO2 was positively correlated with maximum FiO2 (rs0.55, p<0.0001) and ventilator days (rs0.61, p<0.0001). CONCLUSIONS Higher PaCO2 was an independent predictor of sIVH/death, BPD/death and NDI/death. Further trials are needed to evaluate optimal PaCO2 targets for high-risk infants.
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Affiliation(s)
| | - Waldemar A. Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Lisa A. Wrage
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, NC
| | - Abhik Das
- Social, Statistical and Environmental Sciences Unit, RTI International, Rockville, MD
| | - Matthew Laughon
- Department of Pediatrics, University of North Carolina, Chapel Hill, NC
| | | | - Kathleen A. Kennedy
- Department of Pediatrics, University of Texas Medical School at Houston, Houston, TX
| | - Abbot R. Laptook
- Department of Pediatrics, Women and Infants Hospital, Providence, RI
| | | | - Michele C. Walsh
- Department of Pediatrics, Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, OH
| | - Rosemary D. Higgins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
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Hansen G, Al Shafouri N, Narvey M, Vallance JK, Srinivasan G. High blood carbon dioxide variability and adverse outcomes in neonatal hypoxic ischemic encephalopathy. J Matern Fetal Neonatal Med 2015; 29:680-3. [PMID: 25714478 DOI: 10.3109/14767058.2015.1015983] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Hypocarbia during the first 12 h of life is associated with mortality and disability in neonatal hypoxic ischemic encephalopathy (HIE). Notable variation in arterial carbon dioxide tension (PaCO2) during the first 4 d of life is related to severe intraventricular hemorrhages in preterm infants. We examined the association between PaCO2 during 72 h of whole-body therapeutic hypothermia for neonatal HIE and 2-year neurodevelopmental outcomes. METHODS A retrospective review of 23 term neonates treated with whole-body hypothermia documented clinical, demographic and arterial blood gas data. Comparisons were made across good and severe neurodevelopmental outcome groups at 2 years of age. RESULTS Severe neurodevelopmental outcomes were documented in 8 of 23 toddlers. There were no significant differences between outcome groups with regard to the number of patients with hypocarbic means or measurements. There were also no significant differences with mean PaCO2, PaO2, pH, time-weighted cumulative hypocarbia, and PaCO2 range. The severe neurodevelopmental outcomes group had a significantly higher mean PaCO2 standard deviation (p = 0.04; 95% CI, -5.46 to -0.39). CONCLUSION Severe neurodevelopmental outcomes were significantly associated with high PaCO2 variability over 72 h in whole-body-cooled HIE neonates. Mitigating these fluctuations may be a potential management strategy.
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Affiliation(s)
- Gregory Hansen
- a Section of Pediatric Intensive Care, Department of Pediatrics and Child Health and
| | - Nasser Al Shafouri
- b Section of Neonatology, Department of Pediatrics and Child Health , University of Manitoba, Children's Hospital , Winnipeg , Manitoba , Canada , and
| | - Michael Narvey
- b Section of Neonatology, Department of Pediatrics and Child Health , University of Manitoba, Children's Hospital , Winnipeg , Manitoba , Canada , and
| | - Jeff K Vallance
- c Faculty of Health Disciplines , Athabasca University , Athabasca , Alberta , Canada
| | - Ganesh Srinivasan
- b Section of Neonatology, Department of Pediatrics and Child Health , University of Manitoba, Children's Hospital , Winnipeg , Manitoba , Canada , and
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Setting the Ventilator in the NICU. PEDIATRIC AND NEONATAL MECHANICAL VENTILATION 2015. [PMCID: PMC7122498 DOI: 10.1007/978-3-642-01219-8_42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Success in providing respiratory support to the neonate requires a clear understanding of the context in which it is being applied. Perhaps more than for any other age group, the array of different situations in which ventilation is applied to the newborn infant is extremely broad, with in each case different pathophysiological disturbances and often the need to use a specific approach to apply ventilation optimally. Table 42.1 provides a list of the more common situations in which conventional ventilation is used in the neonate and includes some considerations regarding ventilator settings for each situation. For each situation, a suggested mode of ventilation is indicated, along with target ranges for positive end-expiratory pressure (PEEP) and tidal volume (VT). Further discussion of the physiological rationale and available evidence for ventilator settings is set out below.
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75
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Maheshwari R, Luig M. Review of respiratory management of extremely premature neonates during transport. Air Med J 2014; 33:286-291. [PMID: 25441522 DOI: 10.1016/j.amj.2014.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Revised: 08/01/2014] [Accepted: 08/19/2014] [Indexed: 06/04/2023]
Abstract
INTRODUCTION The objective was to evaluate the respiratory management of neonates of 23 to 26 weeks' gestation transported after birth outside a tertiary center. Another objective was to collect data regarding survival, intraventricular hemorrhage (IVH), and chronic lung disease. METHODS This was a retrospective study of transports from a statewide dedicated neonatal and pediatric transport service over a 3-year period. Data were collected from the local databases. Neonates with and without transcutaneous carbon dioxide (TcCO2) monitoring were compared. Outcomes were compared with the inborn group from the same period. RESULTS A total of 43 mechanically ventilated neonates were included. Significant hypocarbia and/or hypercarbia were seen in 49%. Hyperoxia was noted in 46.5%. Despite the moderate correlation between PCO2 and TcCO2 readings, no clinical benefit was seen with TcCO2 monitoring. Survival was 65.1%. Rates of IVH were 60% for any IVH and 27.5% for severe IVH. IVH was more common in the study cohort. CONCLUSIONS Neonates born at 23 to 26 weeks' gestation outside tertiary centers have high rates of mortality and morbidity. The avoidance of hypocarbia, hypercarbia, and hyperoxia is challenging in the transport environment. Transcutaneous monitoring is an imperfect tool for following PCO2 levels.
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Affiliation(s)
- Rajesh Maheshwari
- New South Wales Newborn and Paediatric Emergency Transport Service, Westmead, New South Wales, Australia.
| | - Melissa Luig
- New South Wales Newborn and Paediatric Emergency Transport Service, Westmead, New South Wales, Australia
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Abstract
Ongoing advances in the perioperative management of the newborn have undoubtedly decreased the incidence of morbidity and mortality of this vulnerable patient group. The introduction of new surgical techniques and more comprehensive understanding of the effects of varied anesthetic drugs and techniques on the surgical newborn present many challenges for pediatric surgeons and anesthesiologists. Thorough preoperative evaluation and open communication between members of the health care team are important. A basic understanding of age-dependent variables and the interaction of anesthetic and surgical procedures is essential in minimizing perioperative morbidity and mortality.
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Affiliation(s)
- Mary Ellen McCann
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children׳s Hospital, 300 Longwood Ave, Boston, MA 02115; Department of Anaesthesia, Harvard Medical School, Boston, MA.
| | - Sulpicio G Soriano
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children׳s Hospital, 300 Longwood Ave, Boston, MA 02115; Department of Anaesthesia, Harvard Medical School, Boston, MA
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Ou X, Glasier CM, Ramakrishnaiah RH, Angtuaco TL, Mulkey SB, Ding Z, Kaiser JR. Diffusion tensor imaging in extremely low birth weight infants managed with hypercapnic vs. normocapnic ventilation. Pediatr Radiol 2014; 44:980-6. [PMID: 24671721 PMCID: PMC4204475 DOI: 10.1007/s00247-014-2946-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Revised: 01/27/2014] [Accepted: 02/20/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Permissive hypercapnia is a ventilatory strategy used to prevent lung injury in ventilated extremely low birth weight (ELBW, birth weight ≤1,000 g) infants. However, there is retrospective evidence showing that high CO2 is associated with brain injury. OBJECTIVE The objective of this study was to compare brain white matter development at term-equivalent age in ELBW infants randomized to hypercapnic vs. normocapnic ventilation during the first week of life and in healthy non-ventilated term newborns. MATERIALS AND METHODS Twenty-two ELBW infants from a randomized controlled trial were included in this study; 11 received hypercapnic (transcutaneous PCO2 [tcPCO2] 50-60 mmHg) ventilation and 11 normocapnic (tcPCO2 35-45 mmHg) ventilation during the first week of life while still intubated. In addition, ten term healthy newborns served as controls. Magnetic resonance imaging (MRI) with diffusion tensor imaging (DTI) was performed at term-equivalent age for the ELBW infants and at approximately 2 weeks of age for the control infants. White matter injury on conventional MRI was graded in the ELBW and control infants using a scoring system adopted from literature. Tract-based spatial statistics (TBSS) was used to evaluate for differences in DTI measured fractional anisotropy (FA, spatially normalized to a customized template) among the ELBW and term control infants. RESULTS Conventional MRI white matter scores were not different (7.3 ± 1.7 vs. 6.9 ± 1.4, P = 0.65) between the hypercapnic and normocapnic ELBW infants. TBSS analysis did not show significant differences (P < 0.05, corrected) between the two ELBW infant groups, although before multiple comparisons correction, hypercapnic infants had many regions with lower FA and no regions with higher FA (P < 0.05, uncorrected) compared to normocapnic infants. When compared to the control infants, normocapnic ELBW infants had a few small regions with significantly lower FA, while hypercapnic ELBW infants had more widespread regions with significantly lower FA (P < 0.05, fully corrected for multiple comparisons). CONCLUSIONS Normocapnic ventilation vs. permissive hypercapnia may be associated with improved white matter development at term-equivalent age in ELBW infants. This effect, however, was small and was not apparent on conventional MRI. Further research is needed using larger sample sizes to assess if permissive hypercapnic ventilation in ELBW infants is associated with worse white matter development.
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Affiliation(s)
- Xiawei Ou
- Department of Radiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA,
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Noori S, Anderson M, Soleymani S, Seri I. Effect of carbon dioxide on cerebral blood flow velocity in preterm infants during postnatal transition. Acta Paediatr 2014; 103:e334-9. [PMID: 24673183 DOI: 10.1111/apa.12646] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Revised: 02/18/2014] [Accepted: 03/25/2014] [Indexed: 01/18/2023]
Abstract
AIM High arterial carbon dioxide (PaCO2 ) and cerebral reperfusion are associated with peri/intraventricular haemorrhage. Our aim was to study the relationship between PaCO2 and cerebral blood flow (CBF) in preterm infants during postnatal transition. METHODS We prospectively studied ≤30 weeks' gestation haemodynamically stable preterm infants during the first three postnatal days (n = 21; gestational age 25.8 ± 1.4 weeks). We measured middle cerebral artery mean flow velocity (MCA-MV) as a surrogate for CBF at the time of blood gas analysis. RESULTS We obtained 78 PaCO2 -MCA-MV data pairs. The expected positive linear relationship between PaCO2 and MCA-MV was absent on the first postnatal day, equivocal on the second and present on the third. Using piecewise bilinear regression models, we identified PaCO2 breakpoints at 52.7 and 51.0 mmHg for postnatal days two and three, respectively. CONCLUSION In haemodynamically stable preterm neonates, the expected positive linear relationship between PaCO2 and CBF may be absent on postnatal day one. On postnatal day three, and possibly day two, a PaCO2 threshold exists for this relationship, above which CBF becomes reactive to PaCO2 . We speculate that the enhanced CBF response to PaCO2 above the threshold contributes to the reperfusion injury and partly explains the association between hypercapnia and peri/intraventricular haemorrhage.
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Affiliation(s)
- Shahab Noori
- Division of Neonatology and the Center for Fetal and Neonatal Medicine; Department of Pediatrics; Children's Hospital Los Angeles and the LAC+USC Medical Center; Keck School of Medicine; University of Southern California; Los Angeles CA USA
| | - Michael Anderson
- Biostatistics and Epidemiology; University of Oklahoma Health Sciences Center; Oklahoma City OK USA
| | - Sadaf Soleymani
- Division of Neonatology and the Center for Fetal and Neonatal Medicine; Department of Pediatrics; Children's Hospital Los Angeles and the LAC+USC Medical Center; Keck School of Medicine; University of Southern California; Los Angeles CA USA
- Department of Biomedical Engineering; Viterbi School of Engineering; University of Southern California; Los Angeles CA USA
| | - Istvan Seri
- Division of Neonatology and the Center for Fetal and Neonatal Medicine; Department of Pediatrics; Children's Hospital Los Angeles and the LAC+USC Medical Center; Keck School of Medicine; University of Southern California; Los Angeles CA USA
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Hawkes GA, Kelleher J, Ryan CA, Dempsey EM. A review of carbon dioxide monitoring in preterm newborns in the delivery room. Resuscitation 2014; 85:1315-9. [PMID: 25086296 DOI: 10.1016/j.resuscitation.2014.07.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Revised: 07/14/2014] [Accepted: 07/18/2014] [Indexed: 01/24/2023]
Abstract
INTRODUCTION The physiologic adaptation to extra uterine life during the immediate neonatal period is unique. Many newborns require assistance in this adaptive process. Recent evidence now supports titrating oxygen to guide resuscitation but no guidance is provided on utilizing exhaled CO2 measurements. AIM To review the current evidence relating to the use of CO2 monitoring in preterm newborns in the delivery room. METHODS Search was performed using the Cochrane Central Register of Controlled Trials, MEDLINE (1966-2014) and PREMEDLINE, EMBASE (1980-2014), CINAHL (1982-2014), Web of Science (1975-2014) and the Oxford Database of Perinatal Trials. RESULTS The search revealed 21 articles relating to CO2 detection, either quantitative or qualitative, in the newborn infant. The majority of these were observational studies, eight relating to CO2 detection as a means of confirming correct endotracheal tube placement in the newborn infant. The other indication is for mask ventilation, and there is one randomized control trial and four observational studies of CO2 detection during mask ventilation. The overall recommendation for CO2 detection for both clinical uses in the delivery suite is level B. DISCUSSION CO2 detection may be of particular benefit for preterm infants in the delivery suite. However there is a need for further research into CO2 detection, in particular capnography, as a means of confirming effective PPV in neonatal resuscitation.
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Affiliation(s)
- G A Hawkes
- Department of Neonatology, Cork University Maternity Hospital, Ireland; Department of Paediatrics and Child Health, University College Cork, Ireland; Irish Centre for Fetal and Neonatal Translational Research (INFANT), Cork University Maternity Hospital, Wilton, Co. Cork, Ireland
| | - J Kelleher
- Department of Neonatology, University Maternity Hospital Limerick, Ireland
| | - C A Ryan
- Department of Neonatology, Cork University Maternity Hospital, Ireland; Department of Paediatrics and Child Health, University College Cork, Ireland
| | - E M Dempsey
- Department of Neonatology, Cork University Maternity Hospital, Ireland; Department of Paediatrics and Child Health, University College Cork, Ireland; Irish Centre for Fetal and Neonatal Translational Research (INFANT), Cork University Maternity Hospital, Wilton, Co. Cork, Ireland.
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Brew N, Walker D, Wong FY. Cerebral vascular regulation and brain injury in preterm infants. Am J Physiol Regul Integr Comp Physiol 2014; 306:R773-86. [PMID: 24647591 DOI: 10.1152/ajpregu.00487.2013] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Cerebrovascular lesions, mainly germinal matrix hemorrhage and ischemic injury to the periventricular white matter, are major causes of adverse neurodevelopmental outcome in preterm infants. Cerebrovascular lesions and neuromorbidity increase with decreasing gestational age, with the white matter predominantly affected. Developmental immaturity in the cerebral circulation, including ongoing angiogenesis and vasoregulatory immaturity, plays a major role in the severity and pattern of preterm brain injury. Prevention of this injury requires insight into pathogenesis. Cerebral blood flow (CBF) is low in the preterm white matter, which also has blunted vasoreactivity compared with other brain regions. Vasoreactivity in the preterm brain to cerebral perfusion pressure, oxygen, carbon dioxide, and neuronal metabolism is also immature. This could be related to immaturity of both the vasculature and vasoactive signaling. Other pathologies arising from preterm birth and the neonatal intensive care environment itself may contribute to impaired vasoreactivity and ineffective CBF regulation, resulting in the marked variations in cerebral hemodynamics reported both within and between infants depending on their clinical condition. Many gaps exist in our understanding of how neonatal treatment procedures and medications have an impact on cerebral hemodynamics and preterm brain injury. Future research directions for neuroprotective strategies include establishing cotside, real-time clinical reference values for cerebral hemodynamics and vasoregulatory capacity and to demonstrate that these thresholds improve long-term outcomes for the preterm infant. In addition, stimulation of vascular development and repair with growth factor and cell-based therapies also hold promise.
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Affiliation(s)
- Nadine Brew
- The Ritchie Centre, Monash Institute of Medical Research-Prince Henry's Institute, Melbourne, Clayton, Victoria, Australia; and
| | - David Walker
- The Ritchie Centre, Monash Institute of Medical Research-Prince Henry's Institute, Melbourne, Clayton, Victoria, Australia; and Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Flora Y Wong
- The Ritchie Centre, Monash Institute of Medical Research-Prince Henry's Institute, Melbourne, Clayton, Victoria, Australia; and Monash Newborn, Monash Medical Centre, Melbourne, Victoria, Australia; and Department of Pediatrics, Monash University, Melbourne, Victoria, Australia
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81
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Noori S, McCoy M, Anderson MP, Ramji F, Seri I. Changes in cardiac function and cerebral blood flow in relation to peri/intraventricular hemorrhage in extremely preterm infants. J Pediatr 2014; 164:264-70.e1-3. [PMID: 24183212 DOI: 10.1016/j.jpeds.2013.09.045] [Citation(s) in RCA: 130] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2013] [Revised: 09/04/2013] [Accepted: 09/19/2013] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To investigate whether changes in cardiac function and cerebral blood flow (CBF) precede the occurrence of peri/intraventricular hemorrhage (P/IVH) in extremely preterm infants. STUDY DESIGN In this prospective observational study, 22 preterm infants (gestational age 25.9 ± 1.2 weeks; range 23-27 weeks) were monitored between 4 and 76 hours after birth. Cardiac function and changes in CBF and P/IVH were assessed by ultrasound every 12 hours. Changes in CBF were also followed by continuous monitoring of cerebral regional oxygen saturation (rSO2) and by calculating cerebral fractional oxygen extraction. RESULTS Five patients developed P/IVH (1 patient grade II and 4 patients grade IV). Whereas measures of cardiac function and CBF remained unchanged in neonates without P/IVH, patients with P/IVH tended to have lower left ventricular output and had lower left ventricle stroke volume and cerebral rSO2 and higher cerebral fractional oxygen extraction during the first 12 hours of the study. By 28 hours, these variables were similar in the 2 groups and myocardial performance index was lower and middle cerebral artery mean flow velocity higher in the P/IVH group. P/IVH was detected after these changes occurred. CONCLUSIONS Cardiac function and CBF remain stable in very preterm neonates who do not develop P/IVH during the first 3 postnatal days. In very preterm neonates developing P/IVH during this period, lower systemic perfusion and CBF followed by an increase in these variables precede the development of P/IVH. Monitoring cardiac function and cerebral rSO2 may identify infants at higher risk for developing P/IVH before the bleeding occurs.
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Affiliation(s)
- Shahab Noori
- Division of Neonatology and the Center for Fetal and Neonatal Medicine, Department of Pediatrics, Children's Hospital Los Angeles and the LAC+USC Medical Center, Keck School of Medicine, University of Southern California, Los Angeles, CA.
| | - Michael McCoy
- Neonatal-Perinatal Medicine, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Michael P Anderson
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Faridali Ramji
- Department of Pediatric Imaging, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Istvan Seri
- Division of Neonatology and the Center for Fetal and Neonatal Medicine, Department of Pediatrics, Children's Hospital Los Angeles and the LAC+USC Medical Center, Keck School of Medicine, University of Southern California, Los Angeles, CA
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82
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McCann ME, Schouten ANJ. Beyond survival; influences of blood pressure, cerebral perfusion and anesthesia on neurodevelopment. Paediatr Anaesth 2014; 24:68-73. [PMID: 24267703 DOI: 10.1111/pan.12310] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/21/2013] [Indexed: 02/04/2023]
Abstract
Neonates have a higher perioperative mortality risk largely due to the degree of prior illness of the infants, the complexity of their surgeries, and infant physiology. It is important to consider contributing anesthetic factors during the perioperative period that may affect cerebral perfusion and neurocognitive outcome, such as alterations in hemodynamics and ventilation. Limitations of blood pressure as a marker for cerebral perfusion are discussed, as well as the effect of hypocapnia on the brain.
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Affiliation(s)
- Mary Ellen McCann
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
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83
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Neumann RP, von Ungern-Sternberg BS. The neonatal lung--physiology and ventilation. Paediatr Anaesth 2014; 24:10-21. [PMID: 24152199 DOI: 10.1111/pan.12280] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/18/2013] [Indexed: 12/22/2022]
Abstract
This review article focuses on neonatal respiratory physiology, mechanical ventilation of the neonate and changes induced by anesthesia and surgery. Optimal ventilation techniques for preterm and term neonates are discussed. In summary, neonates are at high risk for respiratory complications during anesthesia, which can be explained by their characteristic respiratory physiology. Especially the delicate balance between closing volume and functional residual capacity can be easily disturbed by anesthetic and surgical interventions resulting in respiratory deterioration. Ventilatory strategies should ideally include application of an 'open lung strategy' as well avoidance of inappropriately high VT and excessive oxygen administration. In critically ill and unstable neonates, for example, extremely low-birthweight infants surgery in the neonatal intensive care unit might be an appropriate alternative to the operating theater. Best respiratory management of neonates during anesthesia is a team effort that should involve a joint multidisciplinary approach of anesthetists, pediatric surgeons, cardiologists, and neonatologists to reduce complications and optimize outcomes in this vulnerable population.
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Affiliation(s)
- Roland P Neumann
- Department of Neonatal Intensive Care, Basel University Children's Hospital (UKBB), Basel, Switzerland
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84
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Hwang JH. Optimal Ventilatory Strategies in Preterm Infants: Permissive Hypercapnia. NEONATAL MEDICINE 2014. [DOI: 10.5385/nm.2014.21.2.114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Jong Hee Hwang
- Department of Pediatrics, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
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85
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Fischer HS, Bührer C. Avoiding endotracheal ventilation to prevent bronchopulmonary dysplasia: a meta-analysis. Pediatrics 2013; 132:e1351-60. [PMID: 24144716 DOI: 10.1542/peds.2013-1880] [Citation(s) in RCA: 195] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Mechanical ventilation via an endotracheal tube is a risk factor for bronchopulmonary dysplasia (BPD), one of the most common morbidities of very preterm infants. Our objective was to investigate the effect that strategies to avoid endotracheal mechanical ventilation (eMV) have on the incidence of BPD in preterm infants <30 weeks' gestational age (GA). METHODS In February 2013, we searched the databases Medline, Embase, and the Cochrane Central Register of Controlled Trials. Study selection criteria included randomized controlled trials published in peer-reviewed journals since the year 2000 that compared preterm infants <30 weeks' GA treated by using a strategy aimed at avoiding eMV with a control group in which mechanical ventilation via an endotracheal tube was performed at an earlier stage. Data were extracted and analyzed by using the standard methods of the Cochrane Neonatal Review Group. The authors independently assessed study eligibility and risk of bias, extracted data and calculated odds ratios and 95% confidence intervals, employing RevMan version 5.1.6. RESULTS We identified 7 trials that included a total of 3289 infants. The combined odds ratio (95% confidence interval) of death or BPD was 0.83 (0.71-0.96). The number needed to treat was 35. The study results were remarkably homogeneous. Avoiding eMV had no influence on the incidence of severe intraventricular hemorrhage. CONCLUSIONS Strategies aimed at avoiding eMV in infants <30 weeks' GA have a small but significant beneficial impact on preventing BPD.
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Affiliation(s)
- Hendrik S Fischer
- Klinik für Neonatologie, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany.
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86
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van Kaam AH, De Jaegere AP, Rimensberger PC. Incidence of hypo- and hyper-capnia in a cross-sectional European cohort of ventilated newborn infants. Arch Dis Child Fetal Neonatal Ed 2013; 98:F323-6. [PMID: 23241364 DOI: 10.1136/archdischild-2012-302649] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To determine the incidence of hypo- and hyper-capnia in a European cohort of ventilated newborn infants. DESIGN AND SETTING Two-point cross-sectional prospective study in 173 European neonatal intensive care units. PATIENTS AND METHODS Patient characteristics, ventilator settings and measurements, and blood gas analyses were collected for endotracheally ventilated newborn infants on two separate dates. RESULTS A total of 1569 blood gas analyses were performed in 508 included patients with a mean±SD Pco2 of 48±12 mm Hg or 6.4±1.6 kPa (range 17-104 mm Hg or 2.3-13.9 kPa). Hypocapnia (Pco2<30 mm Hg or 4 kPa) and hypercapnia (Pco2>52 mm Hg or 7 kPa) was present in, respectively, 69 (4%) and 492 (31%) of the blood gases. Hypocapnia was most common in the first 3 days of life (7.3%) and hypercapnia after the first week of life (42.6%). Pco2 was significantly higher in preterm infants (49 mm Hg or 6.5 kPa) than term infants (43 mm Hg or 5.7 kPa) and significantly lower during pressure-limited ventilation (47 mm Hg or 6.3±1.6 kPa) compared with volume-targeted ventilation (51 mm Hg or 6.8±1.7 kPa) and high-frequency ventilation (50 mm Hg or 6.7±1.7 kPa). CONCLUSIONS This study shows that hypocapnia is a relatively uncommon finding during neonatal ventilation. The higher incidence of hypercapnia may suggest that permissive hypercapnia has found its way into daily clinical practice.
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Affiliation(s)
- Anton H van Kaam
- Department of Neonatology, Emma Children's Hospital AMC, Amsterdam, The Netherlands.
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87
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Kong JY, Rich W, Finer NN, Leone TA. Quantitative end-tidal carbon dioxide monitoring in the delivery room: a randomized controlled trial. J Pediatr 2013; 163:104-8.e1. [PMID: 23333003 DOI: 10.1016/j.jpeds.2012.12.016] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Revised: 11/19/2012] [Accepted: 12/06/2012] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To investigate the utility of continuous quantitative end-tidal CO2 (Etco2) monitoring for managing assisted ventilation in the delivery room (DR). STUDY DESIGN This is a prospective randomized controlled trial. Infants who received positive pressure ventilation (PPV) were randomized to a control versus a monitored arm. In the monitored arm, the resuscitating team adjusted PPV based on Etco2 values. In the control arm, the team provided PPV based on clinical assessment. Etco2 levels after resuscitation and admission Pco2 levels were compared between groups. RESULTS Fifty infants were enrolled, and 48 subjects had primary outcome data. Of those, 7 infants were intubated in the DR, 41 infants received PPV via mask until respiratory support could be maintained on continuous positive airway pressure alone. The median Etco2 levels at the end of resuscitation were 44 mm Hg (16-66 mm Hg) in the control arm and 43 mm Hg (29-59 mm Hg) in the monitored arm. The proportion of Etco2 levels outside of the prespecified range was 52.6% (control) and 33.3% (monitored) (P = .236). The median admission Pco2 levels were 57 mm Hg (36-110 mm Hg) in the control arm and 55 mm Hg (40-93 mm Hg) in the monitored arm. The proportion of admission Pco2 levels outside of the prespecified range was 33.3% (control) versus 37.5% (monitored) (P = .763). CONCLUSIONS Etco2 monitoring in the DR did not reduce the proportion of admission Pco2 levels outside of the prespecified range in a population of infants supported mostly with noninvasive ventilation.
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Affiliation(s)
- Juin Yee Kong
- Division of Neonatology, Department of Pediatrics, University of California, San Diego, CA, USA
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88
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McCann ME, Soriano SG. Perioperative central nervous system injury in neonates. Br J Anaesth 2013; 109 Suppl 1:i60-i67. [PMID: 23242752 DOI: 10.1093/bja/aes424] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Anaesthetic-induced developmental neurotoxicity (AIDN) has been clearly established in laboratory animal models. The possibility of neurotoxicity during uneventful anaesthetic procedures in human neonates or infants has led to serious questions about the safety of paediatric anaesthesia. However, the applicability of animal data to clinical anaesthesia practice remains uncertain. The spectre of cerebral injury due to cerebral hypoperfusion, metabolic derangements, coexisting disease, and surgery itself further muddles the picture. Given the potential magnitude of the public health importance of this issue, the clinician should be cognisant of the literature and ongoing investigations on AIDN, and raise awareness of the risks of both surgery and anaesthesia.
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Affiliation(s)
- M E McCann
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA 02115, USA
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89
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Abstract
Experimental and clinical data indicate that ventilator strategies with permissive hypercapnia may reduce lung injury by a variety of mechanisms. Seven randomized controlled trials in preterm neonates suggest that permissive hypercapnia started early, before the initiation of mechanical ventilation (in conjunction with continuous positive airway pressure), followed by prolonged permissive hypercapnia if mechanical ventilation is needed is an alternative to early ventilation and surfactant. Permissive hypercapnia may improve pulmonary outcomes and survival.
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Affiliation(s)
- Julie Ryu
- Department of Pediatrics, Rady Children's Hospital, University of California San Diego, 9500 Gilman Drive, MC 0735, La Jolla, CA 92093, USA
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90
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Abstract
Near-infrared spectroscopy (NIRS) is a noninvasive technique that monitors regional tissue oxygenation reflecting perfusion status. Near-infrared spectroscopy has the ability to continuously and simultaneously monitor tissue perfusion in different organ systems at the bedside without interrupting routine care. Research has demonstrated its benefit in monitoring cerebral, intestinal, and renal perfusion to detect potential ischemic episodes. Near-infrared spectroscopy can augment current physiologic monitoring to increase awareness of abnormal perfusion status in the preterm population and potentially reduce risks associated with many diseases that may lead to ischemic injury. This article provides an overview describing NIRS technology and function, its current use in neonatology, and pertinent research findings illustrating its benefit in the neonatal population. Near-infrared spectroscopy may evolve into an important diagnostic and prognostic tool for neonatal treatment and outcome.
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Resnick S, Jacques A, Patole S, Simmer K. Does after-hours in-house senior physician cover improve standard of care and outcomes in high-risk preterm neonates? A retrospective cohort study. J Paediatr Child Health 2011; 47:795-801. [PMID: 21426436 DOI: 10.1111/j.1440-1754.2011.02028.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM To compare the standard of care and outcomes to discharge for inborn high-risk preterm (gestation <32 weeks) neonates admitted to the neonatal intensive care unit (NICU) before and after adopting an after-hours in-house senior physician cover roster (ISPCR). The ISPCR involved the presence of a consultant neonatologist or neonatal fellow in the NICU until 11 pm. METHODS This was a retrospective analysis of prospectively collected data for 12 months before (1 February 2002 to 31 January 2003, epoch 1) and after (1 April 2003 to 31 March 2004, epoch 2) adopting the ISPCR. Short-term neonatal outcomes, including mortality and morbidity such as intraventricular haemorrhage, retinopathy of prematurity, necrotising enterocolitis and chronic lung disease, were examined. The standard of acute care, including admission temperature, correct positioning of tubes and lines, and preventable ventilatory complications in the first 8 h following admission, was also compared. RESULTS The numbers (235 in epoch 1, 245 in epoch 2), demographic characteristics and severity of illness (CRIB score) of neonates admitted to the NICU was comparable between epochs. Overall neonatal outcomes did not show significant improvement after adopting an ISPCR, nor were they improved for after-hours admissions in the presence of senior in-house physicians. The standard of acute care was also not significantly different. Minor improvements, such as earlier administration of surfactant, were noted in epoch 2. CONCLUSIONS Adoption of an ISPCR was not associated with any significant change in the standard of acute care and short-term outcomes for inborn neonates <32 weeks' gestation.
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Affiliation(s)
- Steven Resnick
- Neonatology Clinical Care Unit, King Edward Memorial Hospital for Women, Perth, Western Australia, Australia.
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92
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Abstract
Infants of birth weight ≤2500 g are termed low birth weight (LBW). These children often have considerable morbidity from prematurity and intra-uterine growth restriction. Additionally, LBW infants have increased risk for cardiac and noncardiac congenital anomalies and may require surgery. Primary rather than palliative surgical repair of cardiac lesions has been preferred in recent years. However, LBW remains a risk factor for increased mortality and morbidity after open-heart surgery (OHS). There is a paucity of information about the anesthetic challenges presented by LBW infants undergoing OHS. This review summarizes the perioperative issues of relevance to anesthesiologists who manage these high-risk patients. Emphasis is placed on management concerns that are unique to LBW infants. Retrospective data from the authors' institution are provided for those aspects of anesthetic care that lack published studies. Successful outcome often requires substantial hospital resources and collaborative multi-disciplinary effort.
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Affiliation(s)
- Glyn D Williams
- Department of Anesthesiology, Stanford University, Lucile Packard Children’s Hospital, Stanford, CA, USA
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93
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Pappas A, Shankaran S, Laptook AR, Langer JC, Bara R, Ehrenkranz RA, Goldberg RN, Das A, Higgins RD, Tyson JE, Walsh MC. Hypocarbia and adverse outcome in neonatal hypoxic-ischemic encephalopathy. J Pediatr 2011; 158:752-758.e1. [PMID: 21146184 PMCID: PMC3229432 DOI: 10.1016/j.jpeds.2010.10.019] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2010] [Revised: 09/10/2010] [Accepted: 10/15/2010] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To evaluate the association between early hypocarbia and 18- to 22-month outcome among neonates with hypoxic-ischemic encephalopathy. STUDY DESIGN Data from the National Institute of Child Health and Human Development Neonatal Research Network randomized, controlled trial of whole-body hypothermia for neonatal hypoxic-ischemic encephalopathy were used for this secondary observational study. Infants (n = 204) had multiple blood gases recorded from birth to 12 hours of study intervention (hypothermia versus intensive care alone). The relationship between hypocarbia and outcome (death/disability at 18 to 22 months) was evaluated by unadjusted and adjusted analyses examining minimum PCO(2) and cumulative exposure to PCO(2) <35 mm Hg. The relationship between cumulative PCO(2) <35 mm Hg (calculated as the difference between 35 mm Hg and the sampled PCO(2) multiplied by the duration of time spent <35 mm Hg) and outcome was evaluated by level of exposure (none-high) using a multiple logistic regression analysis with adjustments for pH, level of encephalopathy, treatment group (± hypothermia), and time to spontaneous respiration and ventilator days; results were expressed as odds ratios and 95% confidence intervals. Alternative models of CO(2) concentration were explored to account for fluctuations in CO(2). RESULTS Both minimum PCO(2) and cumulative PCO(2) <35 mm Hg were associated with poor outcome (P < .05). Moreover, death/disability increased with greater cumulative exposure to PCO(2) <35 mm Hg. CONCLUSIONS Hypocarbia is associated with poor outcome after hypoxic-ischemic encephalopathy.
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Affiliation(s)
- Athina Pappas
- Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI 48201, USA.
| | - Seetha Shankaran
- Department of Pediatrics, Wayne State University School of Medicine, Detroit MI
| | - Abbot R. Laptook
- Department of Pediatrics, Women and Infants’ Hospital, Brown University, Providence RI
| | - John C. Langer
- Statistics and Epidemiology, RTI International, Research Triangle Park, NC
| | - Rebecca Bara
- Department of Pediatrics, Wayne State University School of Medicine, Detroit MI
| | | | | | - Abhik Das
- Statistics and Epidemiology, RTI International, Research Triangle Park, NC
| | - Rosemary D. Higgins
- Pregnancy and Perinatology Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health
| | - Jon E. Tyson
- Department of Pediatrics, University of Texas Medical School at Houston
| | - Michele C. Walsh
- Department of Pediatrics, Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland OH
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94
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Blount M, Ebling MR, Eklund JM, James AG, McGregor C, Percival N, Smith KP, Sow D. Real-time analysis for intensive care: development and deployment of the artemis analytic system. ACTA ACUST UNITED AC 2010; 29:110-8. [PMID: 20659848 DOI: 10.1109/memb.2010.936454] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The lives of many thousands of children born premature or ill at term around the world have been saved by those who work within neonatal intensive care units (NICUs). Modern-day neonatologists, together with nursing staff and other specialists within this domain, enjoy modern technologies for activities such as financial transactions, online purchasing, music, and video on demand. Yet, when they move into their workspace, in many cases, they are supported by nearly the same technology they used 20 years ago. Medical devices provide visual displays of vital signs through physiological streams such as electrocardiogram (ECG), heart rate, blood oxygen saturation (SpO(2)), and respiratory rate. Electronic health record initiatives around the world provide an environment for the electronic management of medical records, but they fail to support the high-frequency interpretation of streaming physiological data. We have taken a collaborative research approach to address this need to provide a flexible platform for the real-time online analysis of patients' data streams to detect medically significant conditions that precede the onset of medical complications. The platform supports automated or clinician-driven knowledge discovery to discover new relationships between physiological data stream events and latent medical conditions as well as to refine existing analytics. Patients benefit from the system because earlier detection of signs of the medical conditions may lead to earlier intervention that may potentially lead to improved patient outcomes and reduced length of stays. The clinician benefits from a decision support tool that provides insight into multiple streams of data that are too voluminous to assess with traditional methods. The remainder of this article summarizes the strengths of our research collaboration and the resulting environment known as Artemis, which is currently being piloted within the NICU of The Hospital for Sick Children (SickKids) in Toronto, Ontario, Canada. Although the discussion in this article focuses on a NICU, the technologies can be applied to any intensive care environment.
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Affiliation(s)
- Marion Blount
- IBM T.J. Watson Research Center, Hawthorne, NY 10532, USA.
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95
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Establishing gas exchange and improving oxygenation in the delivery room management of the lung. Adv Neonatal Care 2010; 10:256-60. [PMID: 20838076 DOI: 10.1097/anc.0b013e3181f0836d] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
One of the components of promoting good outcomes in high-risk neonates is supporting normal gas exchange while avoiding lung injury. Respiratory care in the first hour following birth plays an important role in stabilizing the infant with respiratory problems. The goal of this article is to review the causes of lung injury that can occur in the first hour and that could be prevented with careful respiratory support.
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96
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Honoré JC, Kooli A, Hou X, Hamel D, Rivera JC, Picard É, Hardy P, Tremblay S, Varma DR, Jankov RP, Mancini JA, Balazy M, Chemtob S. Sustained hypercapnia induces cerebral microvascular degeneration in the immature brain through induction of nitrative stress. Am J Physiol Regul Integr Comp Physiol 2010; 298:R1522-30. [DOI: 10.1152/ajpregu.00807.2009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Hypercapnia is regularly observed in chronic lung disease, such as bronchopulmonary dysplasia in preterm infants. Hypercapnia results in increased nitric oxide synthase activity and in vitro formation of nitrates. Neural vasculature of the immature subject is particularly sensitive to nitrative stress. We investigated whether exposure to clinically relevant sustained high CO2 causes microvascular degeneration in the newborn brain by inducing nitrative stress, and whether this microvascular degeneration has an impact on brain growth. Newborn rat pups were exposed to 10% CO2 as inspired gas (PaCO2 = 60–70 mmHg) starting within 24 h of birth until postnatal day 7 (P7). Brains were notably collected at different time points to measure vascular density, determine brain cortical nitrite/nitrate, and trans-arachidonic acids (TAAs; products of nitration) levels as effectors of vessel damage. Chronic exposure of rat pups to high CO2 (PaCO2 ≈ 65 mmHg) induced a 20% loss in cerebrovascular density at P3 and a 15% decrease in brain mass at P7; at P30, brain mass remained lower in CO2-exposed animals. Within 24 h of exposure to CO2, brain eNOS expression and production of nitrite/nitrate doubled, lipid nitration products (TAAs) increased, and protein nitration (3-nitrotyrosine immunoreactivity) was also coincidently augmented on brain microvessels (lectin positive). Intracerebroventricular injection of TAAs (10 μM) replicated cerebrovascular degeneration. Treatment of rat pups with NOS inhibitor (l-Nω-nitroarginine methyl ester) or a peroxynitrite decomposition catalyst (FeTPPS) prevented hypercapnia-induced microvascular degeneration and preserved brain mass. Cytotoxic effects of high CO2 were reproduced in vitro /ex vivo on cultured endothelial cells and sprouting microvessels. In summary, hypercapnia at values frequently observed in preterm infants with chronic lung disease results in increased nitrative stress, which leads to cerebral cortical microvascular degeneration and curtails brain growth.
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Affiliation(s)
- Jean-Claude Honoré
- Department of Pediatrics, Research Center-Centre Hospitalier Universitaire Ste-Justine, Montréal, Quebec, Canada
- Department of Pharmacology, Université de Montréal, Quebec, Canada
| | - Amna Kooli
- Department of Pediatrics, Research Center-Centre Hospitalier Universitaire Ste-Justine, Montréal, Quebec, Canada
- Department of Pharmacology and Therapeutics, McGill University, Montréal, Quebec, Canada
| | - Xin Hou
- Department of Pediatrics, Research Center-Centre Hospitalier Universitaire Ste-Justine, Montréal, Quebec, Canada
| | - David Hamel
- Department of Pediatrics, Research Center-Centre Hospitalier Universitaire Ste-Justine, Montréal, Quebec, Canada
- Department of Pharmacology, Université de Montréal, Quebec, Canada
| | - José Carlos Rivera
- Department of Pediatrics, Research Center-Centre Hospitalier Universitaire Ste-Justine, Montréal, Quebec, Canada
- Department of Pharmacology, Université de Montréal, Quebec, Canada
| | - Émilie Picard
- Department of Pediatrics, Research Center-Centre Hospitalier Universitaire Ste-Justine, Montréal, Quebec, Canada
- Department of Pharmacology, Université de Montréal, Quebec, Canada
| | - Pierre Hardy
- Department of Pediatrics, Research Center-Centre Hospitalier Universitaire Ste-Justine, Montréal, Quebec, Canada
- Department of Pharmacology, Université de Montréal, Quebec, Canada
| | - Sophie Tremblay
- Department of Pediatrics, Research Center-Centre Hospitalier Universitaire Ste-Justine, Montréal, Quebec, Canada
| | - Daya R. Varma
- Department of Pharmacology and Therapeutics, McGill University, Montréal, Quebec, Canada
| | - Robert P. Jankov
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; and
| | - Joseph A. Mancini
- Department of Pediatrics, Research Center-Centre Hospitalier Universitaire Ste-Justine, Montréal, Quebec, Canada
| | - Michael Balazy
- Department of Pathology, New York Medical College, New York, New York
| | - Sylvain Chemtob
- Department of Pediatrics, Research Center-Centre Hospitalier Universitaire Ste-Justine, Montréal, Quebec, Canada
- Department of Pharmacology, Université de Montréal, Quebec, Canada
- Department of Pharmacology and Therapeutics, McGill University, Montréal, Quebec, Canada
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97
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98
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Abstract
There is an increased interest in methods of objective cardiac output measurement in critically ill patients. Several techniques are available for measurement of cardiac output in children, although this remains very complex in newborns. Cardiac output monitoring could provide essential information to guide hemodynamic management. An overview is given of various methods of cardiac output monitoring with advantages and major limitations of each technology together with a short explanation of the basic principles.
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Affiliation(s)
- Willem-Pieter de Boode
- Radboud University Nijmegen Medical Centre, Department of Neonatology, Nijmegen, The Netherlands.
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99
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Pfister RH, Goldsmith JP. Quality improvement in respiratory care: decreasing bronchopulmonary dysplasia. Clin Perinatol 2010; 37:273-93. [PMID: 20363459 DOI: 10.1016/j.clp.2010.01.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Chronic lung disease (CLD) is one of the most common long-term complications in very preterm infants. Bronchopulmonary dysplasia (BPD) is the most common cause of CLD in infancy. Modern neonatal respiratory care has witnessed the emergence of a new BPD that exhibits decreased fibrosis and emphysema, but also decreased alveolar septation, and microvascular development. CLD encompasses the classic and the new BPD, and recognizes that lung injury can occur in term infants who need aggressive ventilatory support and who develop lung injury as a result, and that CLD is a multisystem disease. Controversy exists on whether quality improvement (QI) methods that implement multiple interventions will be effective in limiting pathology with multiple causes. Caution in generalization of QI findings is encouraged. QI methods toward improvement in CLD or any other outcome should be considered as a tool for implementing evidence and studying the effects of change in complex adaptive systems.
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Affiliation(s)
- Robert H Pfister
- Department of Pediatrics, The University of Vermont, Burlington, VT, USA
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100
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Liu JQ, Saugstad OD, Cheung PY. Using 100% oxygen for the resuscitation of term neonates until evidence of spontaneous circulation: More investigations needed. Resuscitation 2010; 81:145-7. [DOI: 10.1016/j.resuscitation.2009.11.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2009] [Accepted: 11/30/2009] [Indexed: 01/12/2023]
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