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Ramaswamy VV, Kumar G, Abdul Kareem P, Somasekhara Aradhya A, Suryawanshi P, Sahni M, Khurana S, Sharma D, More K. Comparative efficacy of volume expansion, inotropes and vasopressors in preterm neonates with probable transitional circulatory instability in the first week of life: a systematic review and network meta-analysis. BMJ Paediatr Open 2024; 8:e002500. [PMID: 38769048 PMCID: PMC11110579 DOI: 10.1136/bmjpo-2024-002500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 03/12/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND There exists limited agreement on the recommendations for the treatment of transitional circulatory instability (TCI) in preterm neonates OBJECTIVE: To compare the efficacy of various interventions used to treat TCI METHODS: Medline and Embase were searched from inception to 21st July 2023. Two authors extracted the data independently. A Bayesian random effects network meta-analysis was used. Recommendations were formulated using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework. INTERVENTIONS Dopamine, dobutamine, epinephrine, hydrocortisone, vasopressin, milrinone, volume and placebo. MAIN OUTCOME MEASURES Mortality, major brain injury (MBI) (intraventricular haemorrhage > grade 2 or cystic periventricular leukomalacia), necrotising enterocolitis (NEC) ≥stage 2 and treatment response (as defined by the author). RESULTS 15 Randomized Controlled Trials (RCTs) were included from the 1365 titles and abstracts screened. Clinical benefit or harm could not be ruled out for the critical outcome of mortality. For the outcome of MBI, epinephrine possibly decreased the risk when compared to dobutamine and milrinone (very low certainty). Epinephrine was possibly associated with a lesser risk of NEC when compared with dopamine, dobutamine, hydrocortisone and milrinone (very low certainty). Dopamine was possibly associated with a lesser risk of NEC when compared with dobutamine (very low certainty). Vasopressin possibly decreased the risk of NEC compared with dopamine, dobutamine, hydrocortisone and milrinone (very low certainty). Clinical benefit or harm could not be ruled out for the outcome response to treatment. CONCLUSIONS Epinephrine may be used as the first-line drug in preterm neonates with TCI, the evidence certainty being very low. We suggest future trials evaluating the management of TCI with an emphasis on objective criteria to define it.
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Affiliation(s)
| | - Gunjana Kumar
- Neonatology, National Institute of Medical Sciences and Research, Jaipur, Rajasthan, India
| | | | | | - Pradeep Suryawanshi
- Neonatology, Bharati Vidyapeeth University Medical College & Hospital, Pune, Maharashtra, India
| | - Mohit Sahni
- Neonatology, Surat Kids Hospital, Surat, Gujarat, India
| | | | - Deepak Sharma
- Neonatology, National Institute of Medical Sciences and Research, Jaipur, Rajasthan, India
| | - Kiran More
- Neonatology, MRR Children's Hospital, Thane, Maharashtra, India
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Alfarano A, Marzollo R, Bosio MI, Tomasi C, Codega A, Picciau L, Motta M, Risso FM. Inter-observer variability of right ventricular output measurement in newborn infants: an observational study. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2024; 40:1011-1017. [PMID: 38345663 DOI: 10.1007/s10554-024-03066-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 02/06/2024] [Indexed: 06/05/2024]
Abstract
Neonatologist Performed Echocardiography (NPE) is one of the emerging technologies used to evaluate Systemic Blood Flow (SBF) in term and preterm infants. Right Ventricular Output (RVO) can assess SBF correctly in the absence of significant interatrial or interventricular shunts, even in the presence of a large patent ductus arteriosus (PDA), but only few studies evaluated inter-observer variability in neonates. Furthermore, measuring pulmonary peak flow (PF) provides a simple screening tool for low SBF state, easier and faster to perform than RVO; no previous studies evaluated PF inter-observer variability. To describe inter-observer variability of RVO and PF measurement in neonates. We conducted a prospective observational study in term and preterm infants admitted to the Neonatal Intensive Care Unit (NICU). Echocardiographic examinations were performed by two expert neonatologists, blinded to each other. Recordings were analyzed off-line to assess RVO and PF variability between observers. We analyzed a cohort of 33 neonates, 17 of them born prematurely. Inter-observer mean difference for RVO was 22,1 mL/kg/min (p = 0.005); the biggest discrepancy was due to pulmonary valve diameter measurement (p = 0.0001). Inter-observer mean difference for PF measurement was not statistically significant. We found a statistically significant inter-observer variability for RVO measurement, consistent with previous reports; PF instead showed low inter-observer variability. For this reason, PF could be evaluated in future studies as a surrogate for RVO in both term and preterm infants, especially in emergency conditions or in presence of a poor echocardiographic window.
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Affiliation(s)
- Angela Alfarano
- Neonatal Intensive Care Unit, Children's Hospital, ASST Spedali Civili di Brescia, Brescia, Italy.
| | - Roberto Marzollo
- Neonatal Intensive Care Unit, Children's Hospital, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Maria Ilaria Bosio
- Neonatal Intensive Care Unit, Children's Hospital, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Cesare Tomasi
- Neonatal Intensive Care Unit, Children's Hospital, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Alessandra Codega
- Neonatal Intensive Care Unit, Children's Hospital, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Laura Picciau
- Neonatal Intensive Care Unit, Children's Hospital, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Mario Motta
- Neonatal Intensive Care Unit, Children's Hospital, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Francesco Maria Risso
- Neonatal Intensive Care Unit, Children's Hospital, ASST Spedali Civili di Brescia, Brescia, Italy
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Tanaka K, Matsumoto S, Minamitani Y, Imamura H, Yoshimatsu H, Nakamura T, Naramura T, Iwai M, Mitsubuchi H, Nakamura K. Changes in Internal Cerebral Vein Pulsation and Intraventricular Hemorrhage in Extremely Preterm Infants. Am J Perinatol 2024; 41:e37-e45. [PMID: 35381610 PMCID: PMC11166026 DOI: 10.1055/a-1817-6638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 03/28/2022] [Indexed: 11/01/2022]
Abstract
OBJECTIVES This study aimed to investigate the relationship between internal cerebral vein (ICV) pulsation and intraventricular hemorrhage (IVH) and to identify the cut-off values that predict IVH. We hypothesized that the severity of ICV flow pulsations was related to IVH severity. STUDY DESIGN In this prospective observational study, ICV flow was measured in 61 extremely preterm infants using ultrasonography at every 12 hours until 96 hours after birth and on days 7, 14, and 28. The ICV pulsation index (ICVPI = minimum/maximum ICV speed) was calculated and compared among the groups determined by Papile's IVH classification. The ICVPI cut-off values for IVH were determined by receiver operating characteristic curve analysis. RESULTS Compared with those in the no IVH (NIVH) group (n = 51), the ICVPI median values in the severe IVH (SIVH; grades 3 and 4) group (n = 5) were lower at 25 to 96 hours and on day 7, whereas those in the mild IVH (MIVH; grades 1 and 2) group (n = 5) were lower at 37 to 60 hours. All SIVH events were initially detected within 60 hours after birth. The ICVPI cut-off values for SIVH were 0.92 at 13 to 24 hours, 0.42 at 25 to 36 hours, 0.58 at 37 to 48 hours, and 0.55 at 49 to 60 hours. Infants whose ICVPI values were below the cut-off value ≥3 times between 13 and 60 hours had a significantly higher SIVH incidence than those whose ICVPI values were below the cut-off value ≤2 times (57.1 vs. 1.9%, p < 0.001). CONCLUSION Our results indicate that SIVH had sustained pronounced internal cerebral vein pulsations and that the ICVPI values may help predict SIVH. Further research on strategies to decrease venous pressure for IVH prevention is needed. KEY POINTS · IVH preterm infants had sustained ICV pulsations.. · ICV flow in SIVH pulsated stronger.. · ICVPI fluctuation implies postnatal adaptation.. · We newly defined ICVPI to predict SIVH..
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Affiliation(s)
- Kenichi Tanaka
- Division of Neonatology, Kumamoto University Hospital, Kumamoto, Japan
| | - Shirou Matsumoto
- Division of Neonatology, Kumamoto University Hospital, Kumamoto, Japan
| | - Youhei Minamitani
- Division of Neonatology, Kumamoto University Hospital, Kumamoto, Japan
| | - Hiroko Imamura
- Division of Neonatology, Kumamoto University Hospital, Kumamoto, Japan
| | | | - Tomomi Nakamura
- Division of Neonatology, Kumamoto University Hospital, Kumamoto, Japan
| | - Tetsuo Naramura
- Division of Neonatology, Kumamoto University Hospital, Kumamoto, Japan
| | - Masanori Iwai
- Division of Neonatology, Kumamoto University Hospital, Kumamoto, Japan
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Agakidou E, Chatziioannidis I, Kontou A, Stathopoulou T, Chotas W, Sarafidis K. An Update on Pharmacologic Management of Neonatal Hypotension: When, Why, and Which Medication. CHILDREN (BASEL, SWITZERLAND) 2024; 11:490. [PMID: 38671707 PMCID: PMC11049273 DOI: 10.3390/children11040490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 03/30/2024] [Accepted: 04/15/2024] [Indexed: 04/28/2024]
Abstract
Anti-hypotensive treatment, which includes dopamine, dobutamine, epinephrine, norepinephrine, milrinone, vasopressin, terlipressin, levosimendan, and glucocorticoids, is a long-established intervention in neonates with arterial hypotension (AH). However, there are still gaps in knowledge and issues that need clarification. The main questions and challenges that neonatologists face relate to the reference ranges of arterial blood pressure in presumably healthy neonates in relation to gestational and postnatal age; the arterial blood pressure level that potentially affects perfusion of critical organs; the incorporation of targeted echocardiography and near-infrared spectroscopy for assessing heart function and cerebral perfusion in clinical practice; the indication, timing, and choice of medication for each individual patient; the limited randomized clinical trials in neonates with sometimes conflicting results; and the sparse data regarding the potential effect of early hypotension or anti-hypotensive medications on long-term neurodevelopment. In this review, after a short review of AH definitions used in neonates and existing data on pathophysiology of AH, we discuss currently available data on pharmacokinetic and hemodynamic effects, as well as the effectiveness and safety of anti-hypotensive medications in neonates. In addition, data on the comparisons between anti-hypotensive medications and current suggestions for the main indications of each medication are discussed.
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Affiliation(s)
- Eleni Agakidou
- 1st Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Ippokrateion General Hospital, 54642 Thessaloniki, Greece; (I.C.); (A.K.); (T.S.); (K.S.)
| | - Ilias Chatziioannidis
- 1st Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Ippokrateion General Hospital, 54642 Thessaloniki, Greece; (I.C.); (A.K.); (T.S.); (K.S.)
| | - Angeliki Kontou
- 1st Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Ippokrateion General Hospital, 54642 Thessaloniki, Greece; (I.C.); (A.K.); (T.S.); (K.S.)
| | - Theodora Stathopoulou
- 1st Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Ippokrateion General Hospital, 54642 Thessaloniki, Greece; (I.C.); (A.K.); (T.S.); (K.S.)
| | - William Chotas
- Department of Neonatology, University of Vermont, Burlington, VT 05405, USA
| | - Kosmas Sarafidis
- 1st Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Ippokrateion General Hospital, 54642 Thessaloniki, Greece; (I.C.); (A.K.); (T.S.); (K.S.)
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Smolich JJ, Kenna KR, Mynard JP. Extended period of ventilation before delayed cord clamping augments left-to-right shunting and decreases systemic perfusion at birth in preterm lambs. J Physiol 2024; 602:1791-1813. [PMID: 38532618 DOI: 10.1113/jp285799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 02/26/2024] [Indexed: 03/28/2024] Open
Abstract
Previous studies have suggested that an extended period of ventilation before delayed cord clamping (DCC) augments birth-related rises in pulmonary arterial (PA) blood flow. However, it is unknown whether this greater rise in PA flow is accompanied by increases in left ventricular (LV) output and systemic arterial perfusion or whether it reflects enhanced left-to-right shunting across the ductus arteriosus and/or foramen ovale (FO), with decreased systemic arterial perfusion. Using an established preterm lamb birth transition model, this study compared the effect of a short (∼40 s, n = 11), moderate (∼2 min, n = 11) or extended (∼5 min, n = 12) period of initial mechanical lung ventilation before DCC on flow probe-derived perinatal changes in PA flow, LV output, total systemic arterial blood flow, ductal shunting and FO shunting. The LV output was relatively stable during initial ventilation but increased after DCC, with similar responses in all groups. Systemic arterial flow patterns displayed only minor differences during brief and moderate periods of initial ventilation and were similar after DCC. However, an increase in PA flow was augmented with an extended initial ventilation (P < 0.001), owing to an earlier onset of left-to-right ductal and FO shunting (P < 0.001), and was accompanied by a pronounced reduction in total systemic arterial flow (P = 0.005) that persisted for 4 min after DCC (P ≤ 0.039). These findings suggest that, owing to increased left-to-right shunting and a greater reduction in systemic arterial perfusion, an extended period of ventilation before DCC does not result in greater perinatal circulatory benefits than shorter periods of initial ventilation in the birth transition. KEY POINTS: Previous studies suggest that an extended period of initial ventilation before delayed cord clamping (DCC) augments birth-related rises in pulmonary arterial (PA) blood flow. It is unknown whether this greater rise in PA flow is accompanied by an increased left ventricular output and systemic arterial perfusion or whether it reflects enhanced left-to-right shunting across the ductus arteriosus and/or foramen ovale, with decreased systemic arterial perfusion. Anaesthetized preterm fetal lambs instrumented with central arterial flow probes underwent a brief (∼40 s), moderate (∼2 min) or extended (∼5 min) period of ventilation before DCC. Perinatal changes in left ventricular output were similar in all groups, but extended initial ventilation augmented both perinatal increases in PA flow, owing to earlier onset and greater left-to-right ductal and foramen ovale shunting, and perinatal reductions in total systemic arterial perfusion. Extended ventilation before DCC does not confer a greater perinatal circulatory benefit than shorter periods of initial ventilation.
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Affiliation(s)
- Joseph J Smolich
- Heart Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Kelly R Kenna
- Heart Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Jonathan P Mynard
- Heart Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
- Department of Biomedical Engineering, University of Melbourne, Parkville, Victoria, Australia
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Geisinger R, Rios DR, McNamara PJ, Levy PT. Asphyxia, Therapeutic Hypothermia, and Pulmonary Hypertension. Clin Perinatol 2024; 51:127-149. [PMID: 38325938 DOI: 10.1016/j.clp.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
Neonates with a perinatal hypoxic insult and subsequent neonatal encephalopathy are at risk of acute pulmonary hypertension (aPH) in the transitional period. The phenotypic contributors to aPH following perinatal asphyxia include a combination of hypoxic vasoconstriction of the pulmonary vascular bed, right heart dysfunction, and left heart dysfunction. Therapeutic hypothermia is the standard of care for neonates with moderate-to-severe hypoxic ischemic encephalopathy. This review summarizes the underlying risk factors, causes of aPH in neonates with perinatal asphyxia, discusses the unique phenotypical contributors to disease, and explores the impact of the initial insult and subsequent therapeutic hypothermia on aPH.
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Affiliation(s)
- Regan Geisinger
- Division of Neonatology, Department of Pediatrics, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA
| | - Danielle R Rios
- Division of Neonatology, Department of Pediatrics, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA
| | - Patrick J McNamara
- Division of Neonatology, Department of Pediatrics, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA
| | - Philip T Levy
- Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Hunnewell 436, Boston, MA 02115, USA.
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Mullaly R, El-Khuffash AF. Haemodynamic assessment and management of hypotension in the preterm. Arch Dis Child Fetal Neonatal Ed 2024; 109:120-127. [PMID: 37173119 DOI: 10.1136/archdischild-2022-324935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 05/02/2023] [Indexed: 05/15/2023]
Abstract
The management of low blood flow states in premature neonates is fraught with many challenges. We remain over-reliant on regimented stepwise protocols that use mean blood pressure as a threshold for intervention to guide treatment, without giving due consideration to the underlying pathophysiology. The current available evidence does not reflect the need to concentrate on the unique pathophysiology of the preterm infant and thus leads to widespread misuse of vasoactive agents that often do not provide the desired clinical effect. Therefore, understanding the underlying pathophysiological underpinnings of haemodynamic compromise may better guide choice of agent and assess physiological response to the selected intervention.
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Affiliation(s)
- Rachel Mullaly
- Department of Paediatrics, Royal College of Surgeons in Ireland, Dublin, Ireland
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8
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Surak A, Bischoff A. Should SVC flow be a routine measure when performing targeted neonatal echocardiography? A narrative review. Pediatr Neonatol 2024:S1875-9572(24)00009-3. [PMID: 38341334 DOI: 10.1016/j.pedneo.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 12/05/2023] [Accepted: 01/09/2024] [Indexed: 02/12/2024] Open
Abstract
Superior vena cava is commonly used in neonatal hemodynamics and is suggested to be the best available non-invasive marker for systemic circulation in preterm infants. Inter- and intra-observer variability remain to be an issue. Its association with neonatal outcomes is has not been established. This is a narrative review about this marker, its use, and its potential pitfalls. OBJECTIVE This is a narrative review about SVC flow in preterm infants, physiology, techniques of measurement and its potential association with outcomes. SOURCES Literature revie mainly PubMED. SUMMARY OF THE FINDINGS SVC flow measurement has some limitations and pitfalls. CONCLUSIONS SVC flow association with neonatal outcomes, still needs to be established in further research.
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Affiliation(s)
- Aimann Surak
- Philip C. Etches Neonatal Intensive Care Unit, DTC 5027, 10240 Kingsway NW, Edmonton, Alberta, Canada, T5H 3V9.
| | - Adrianne Bischoff
- University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA.
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Tanaka K, Matsumoto S, Minamitani Y, Yoshimatsu H, Nakamura T, Naramura T, Iwai M, Mitsubuchi H, Nakamura K. Change over time in internal cerebral vein pulsation in premature infants at risk of intraventricular hemorrhage. Early Hum Dev 2023; 179:105747. [PMID: 36898266 DOI: 10.1016/j.earlhumdev.2023.105747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 02/27/2023] [Accepted: 02/28/2023] [Indexed: 03/12/2023]
Abstract
BACKGROUND Prolonged continuation of augmented internal cerebral vein (ICV) pulsation may be related to the development of premature intraventricular hemorrhage (IVH). However, the characteristics of ICV flow patterns in premature infants are unclear. AIM To investigate the changes over time in ICV pulsation in premature infants at risk of IVH. STUDY DESIGN A 5-year retrospective observational study of a single-center trial. SUBJECTS In total, 112 very-low-birth-weight infants with gestational age of ≤32 weeks. OUTCOME MEASURES ICV flow was measured every 12 h until 96 h after birth and thereafter on days 7, 14, and 28. The ICV pulsation index (ICVPI), which is a ratio of the minimum/maximum speed of ICV flow, was calculated. We recorded longitudinal ICVPI change and compared ICVPI among three groups classified according to gestational age. RESULTS ICVPI started declining after day 1 and reached the minimum median value in 49-60 h after birth (1.0 during 0-36 h, 0.9 during 37-72 h, and 1.0 after 73-84 h). ICVPI was significantly lower during 25-96 h than during 0-24 h and on days 7, 14, and 28. ICVPI in the 23-25-week group was significantly lower between 13-24 h and day 14 than that in the 29-32-week group, and the same was observed for the 26-28-week group between 13-24 h and 49-60 h. CONCLUSIONS ICV pulsation was affected by time after birth and gestational age, and this ICVPI fluctuation may reflect a postnatal circulatory adaptation.
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Affiliation(s)
- Kenichi Tanaka
- Department of Pediatrics, Kumamoto University Hospital, Kumamoto, Japan.
| | - Shirou Matsumoto
- Department of Pediatrics, Kumamoto University Hospital, Kumamoto, Japan
| | - Youhei Minamitani
- Department of Pediatrics, Kumamoto University Hospital, Kumamoto, Japan
| | | | - Tomomi Nakamura
- Department of Pediatrics, Kumamoto University Hospital, Kumamoto, Japan
| | - Tetsuo Naramura
- Department of Pediatrics, Kumamoto University Hospital, Kumamoto, Japan
| | - Masanori Iwai
- Department of Pediatrics, Kumamoto University Hospital, Kumamoto, Japan
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Chakkarapani AA, Roehr CC, Hooper SB, Te Pas AB, Gupta S. Transitional circulation and hemodynamic monitoring in newborn infants. Pediatr Res 2023:10.1038/s41390-022-02427-8. [PMID: 36593283 DOI: 10.1038/s41390-022-02427-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 11/14/2022] [Accepted: 11/21/2022] [Indexed: 01/03/2023]
Abstract
Transitional circulation is normally transient after birth but can vary markedly between infants. It is actually in a state of transition between fetal (in utero) and neonatal (postnatal) circulation. In the absence of definitive clinical trials, information from applied physiological studies can be used to facilitate clinical decision making in the presence of hemodynamic compromise. This review summarizes the peculiar physiological features of the circulation as it transitions from one phenotype into another in term and preterm infants. The common causes of hemodynamic compromise during transition, intact umbilical cord resuscitation, and advanced hemodynamic monitoring are discussed. IMPACT: Transitional circulation can vary markedly between infants. There are alterations in preload, contractility, and afterload during the transition of circulation after birth in term and preterm infants. Hemodynamic monitoring tools and technology during neonatal transition and utilization of bedside echocardiography during the neonatal transition are increasingly recognized. Understanding the cardiovascular physiology of transition can help clinicians in making better decisions while managing infants with hemodynamic compromise. The objective assessment of cardio-respiratory transition and understanding of physiology in normal and disease states have the potential of improving short- and long-term health outcomes.
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Affiliation(s)
| | - Charles C Roehr
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, Medical Sciences Division, University of Oxford, Oxford, UK
- Newborn Services, Southmead Hospital, North Bristol Trust, Bristol, UK
- Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Stuart B Hooper
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
- The Ritchie Centre, Hudson Institute for Medical Research, Melbourne, VIC, Australia
| | - Arjan B Te Pas
- Neonatology, Willem Alexander Children's Hospital, Leiden University Medical Center Leiden, Leiden, The Netherlands
| | - Samir Gupta
- Division of Neonatology, Sidra Medicine, Doha, Qatar.
- Durham University, Durham, UK.
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Amelio GS, Provitera L, Raffaeli G, Amodeo I, Gulden S, Cortesi V, Manzoni F, Pesenti N, Tripodi M, Pravatà V, Lonati C, Cervellini G, Mosca F, Cavallaro G. Proinflammatory Endothelial Phenotype in Very Preterm Infants: A Pilot Study. Biomedicines 2022; 10:biomedicines10051185. [PMID: 35625922 PMCID: PMC9138391 DOI: 10.3390/biomedicines10051185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 05/17/2022] [Accepted: 05/18/2022] [Indexed: 02/04/2023] Open
Abstract
Very preterm infants are exposed to prenatal inflammatory processes and early postnatal hemodynamic and respiratory complications, but limited data are available about the endothelial effect of these conditions. The present pilot study investigates the perinatal endothelial phenotype in very preterm infants (VPIs) and explores its predictive value on neonatal mortality and hemodynamic and respiratory complications. Angiopoietin 1 (Ang-1), Ang-2, E-selectin, vascular adhesion molecule 1 (VCAM-1), tissue factor (TF), and endothelin 1 (ET-1) concentrations were tested in first (T1), 3rd (T2), and 7–10th (T3) day of life in 20 VPIs using Luminex technology and compared with 14 healthy full-term infants (FTIs). Compared to FTIs, VPIs had lower Ang-1 at T1 and T2; higher Ang-2 at T1, T2, and T3; higher Ang-2/Ang-1 ratio at T1, T2, and T3; lower E-selectin at T1, T2, and T3; higher VCAM-1 at T1; higher TF at T2. No differences in concentrations were found in neonatal deaths. VPIs with hemodynamic or respiratory complications had higher Ang-2 at T3. Perinatal low Ang-1 and high Ang-2 associated with high VCAM-1 and TF in VPIs suggest a proinflammatory endothelial phenotype, resulting from the synergy of a pathological prenatal inheritance and a premature extrauterine transition.
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Affiliation(s)
- Giacomo S. Amelio
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (G.S.A.); (L.P.); (G.R.); (I.A.); (S.G.); (V.C.); (F.M.); (N.P.); (M.T.); (V.P.); (G.C.); (F.M.)
| | - Livia Provitera
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (G.S.A.); (L.P.); (G.R.); (I.A.); (S.G.); (V.C.); (F.M.); (N.P.); (M.T.); (V.P.); (G.C.); (F.M.)
| | - Genny Raffaeli
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (G.S.A.); (L.P.); (G.R.); (I.A.); (S.G.); (V.C.); (F.M.); (N.P.); (M.T.); (V.P.); (G.C.); (F.M.)
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, 20122 Milan, Italy
| | - Ilaria Amodeo
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (G.S.A.); (L.P.); (G.R.); (I.A.); (S.G.); (V.C.); (F.M.); (N.P.); (M.T.); (V.P.); (G.C.); (F.M.)
| | - Silvia Gulden
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (G.S.A.); (L.P.); (G.R.); (I.A.); (S.G.); (V.C.); (F.M.); (N.P.); (M.T.); (V.P.); (G.C.); (F.M.)
| | - Valeria Cortesi
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (G.S.A.); (L.P.); (G.R.); (I.A.); (S.G.); (V.C.); (F.M.); (N.P.); (M.T.); (V.P.); (G.C.); (F.M.)
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, 20122 Milan, Italy
| | - Francesca Manzoni
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (G.S.A.); (L.P.); (G.R.); (I.A.); (S.G.); (V.C.); (F.M.); (N.P.); (M.T.); (V.P.); (G.C.); (F.M.)
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, 20122 Milan, Italy
| | - Nicola Pesenti
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (G.S.A.); (L.P.); (G.R.); (I.A.); (S.G.); (V.C.); (F.M.); (N.P.); (M.T.); (V.P.); (G.C.); (F.M.)
- Department of Statistics and Quantitative Methods, Division of Biostatistics, Epidemiology, and Public Health, University of Milano-Bicocca, 20126 Milan, Italy
| | - Matteo Tripodi
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (G.S.A.); (L.P.); (G.R.); (I.A.); (S.G.); (V.C.); (F.M.); (N.P.); (M.T.); (V.P.); (G.C.); (F.M.)
| | - Valentina Pravatà
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (G.S.A.); (L.P.); (G.R.); (I.A.); (S.G.); (V.C.); (F.M.); (N.P.); (M.T.); (V.P.); (G.C.); (F.M.)
| | - Caterina Lonati
- Center for Preclinical Investigation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Gaia Cervellini
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (G.S.A.); (L.P.); (G.R.); (I.A.); (S.G.); (V.C.); (F.M.); (N.P.); (M.T.); (V.P.); (G.C.); (F.M.)
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, 20122 Milan, Italy
| | - Fabio Mosca
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (G.S.A.); (L.P.); (G.R.); (I.A.); (S.G.); (V.C.); (F.M.); (N.P.); (M.T.); (V.P.); (G.C.); (F.M.)
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, 20122 Milan, Italy
| | - Giacomo Cavallaro
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (G.S.A.); (L.P.); (G.R.); (I.A.); (S.G.); (V.C.); (F.M.); (N.P.); (M.T.); (V.P.); (G.C.); (F.M.)
- Correspondence: ; Tel.: +39-(02)-55032234; Fax: +39-(02)-55032217
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12
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Goldsmith JP, Keels E. Recognition and Management of Cardiovascular Insufficiency in the Very Low Birth Weight Newborn. Pediatrics 2022; 149:184900. [PMID: 35224636 DOI: 10.1542/peds.2021-056051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The measurement of blood pressure in the very low birth weight newborn infant is not simple and may be erroneous because of numerous factors. Assessment of cardiovascular insufficiency in this population should be based on multiple parameters and not only on numeric blood pressure readings. The decision to treat cardiovascular insufficiency should be made after considering the potential complications of such treatment. There are numerous potential strategies to avoid or mitigate hypoperfusion states in the very low birth weight infant.
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Affiliation(s)
- Jay P Goldsmith
- Department of Pediatrics, Division of Newborn Medicine, Tulane University, New Orleans, Louisiana
| | - Erin Keels
- Neonatal Practitioner Program, Neonatal Services, Nationwide Children's Hospital, Columbus, Ohio
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13
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Bravo MC, López-Ortego P, Sánchez L, Díez J, Cabañas F, Pellicer A. Randomised trial of dobutamine versus placebo for low superior vena cava flow in preterm infants: Long-term neurodevelopmental outcome. J Paediatr Child Health 2021; 57:872-876. [PMID: 33464688 DOI: 10.1111/jpc.15344] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 12/30/2020] [Accepted: 12/31/2020] [Indexed: 11/29/2022]
Abstract
AIM Although circulatory impairment during the transitional circulation associates morbidity and mortality, its treatment remains controversial. In a pilot trial on circulatory impairment defined as low superior vena cava (SVC) flow, dobutamine (Db) versus placebo (PL) showed a trend towards improved short-term outcomes. The purpose of this study was to report on the long-term outcome of the infants who were observed for SVC flow patterns. METHODS Among the 126 infants <31 weeks of gestation prospectively scanned from birth, 28 presented low SVC flow within the first 24 h after birth and received Db (n = 16) or PL (n = 12). Follow-up of survivors included motor assessment and Bayley Scales II or III at 2 years, and the Reynolds Intellectual Assessment Scale at 6 years. Neurodevelopmental impairment (NDI) was defined as: cerebral palsy (Gross Motor Function Classification System ≥ level 2), or a cognitive function score < -2 standard deviations; or moderate or severe hearing or visual impairment. Db group, PL group and normal-flow group were compared. RESULTS Eighteen infants died (Db: 5; PL: 2; normal flow group: 11, P = 0.1). Follow-up in survivors was accomplished in 80% and 55% of the cohort at 2 years and 6 years, respectively. No significant difference in the combined outcome (mortality or NDI) was found between the groups (42% Db, 36% PL, 30% normal flow group). CONCLUSIONS This exploratory analysis did not show any differences in the long-term outcome of infants according to SVC flow patterns or its treatment early after birth.
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Affiliation(s)
| | | | - Laura Sánchez
- Department of Neonatology, Hospital Universitario La Paz, Madrid, Spain
| | - Jesús Díez
- Division of Statistics, Hospital Universitario La Paz, Madrid, Spain
| | - Fernando Cabañas
- Department of Pediatrics and Neonatology, Quironsalud Madrid University Hospital & Quironsalud San José Hospital, E-28223 Madrid, Spain
| | - Adelina Pellicer
- Department of Neonatology, Hospital Universitario La Paz, Madrid, Spain
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14
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Hansen ML, Hyttel-Sørensen S, Jakobsen JC, Gluud C, Kooi EMW, Mintzer J, de Boode WP, Fumagalli M, Alarcon A, Alderliesten T, Greisen G. The clinical effects of cerebral near-infrared spectroscopy monitoring (NIRS) versus no monitoring: a protocol for a systematic review with meta-analysis and trial sequential analysis. Syst Rev 2021; 10:111. [PMID: 33863369 PMCID: PMC8052775 DOI: 10.1186/s13643-021-01660-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 04/01/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Multiple clinical conditions are associated with cerebral hypoxia/ischaemia and thereby an increased risk of hypoxic-ischaemic brain injury. Cerebral near-infrared spectroscopy monitoring (NIRS) is a tool to monitor brain oxygenation and perfusion, and the clinical uptake of NIRS has expanded over recent years. Specifically, NIRS is used in the neonatal, paediatric, and adult perioperative and intensive care settings. However, the available literature suggests that clinical benefits and harms of cerebral NIRS monitoring are uncertain. As rates of clinically significant hypoxic-ischaemic brain injuries are typically low, it is difficult for randomised clinical trials to capture a sufficiently large number of events to evaluate the clinical effect of cerebral NIRS monitoring, when focusing on specific clinical settings. The aim of this systematic review will be to evaluate the benefits and harms of clinical care with access to cerebral NIRS monitoring versus clinical care without cerebral NIRS monitoring in children and adults across all clinical settings. METHODS We will conduct a systematic review with meta-analysis and trial sequential analysis. We will only include randomised clinical trials. The primary outcomes are all-cause mortality, moderate or severe persistent cognitive or neurological deficit, and proportion of participants with one or more serious adverse events. We will search CENTRAL, EMBASE, MEDLINE, and the Science Citation Index Expanded from their inception and onwards. Two reviewers will independently screen all citations, full-text articles, and extract data. The risk of bias will be appraised using the Cochrane risk of bias tool version 2.0. If feasible, we will conduct both random-effects meta-analysis and fixed-effect meta-analysis of outcome data. Additional analysis will be conducted to explore the potential sources of heterogeneity (e.g. risk of bias, clinical setting). DISCUSSION As we include trials across multiple clinical settings, there is an increased probability of reaching a sufficient information size. However, heterogeneity between the included trials may impair our ability to interpret results to specific clinical settings. In this situation, we may have to depend on subgroup analyses with inherent increased risks of type I and II errors. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42020202986 . This systematic review protocol has been submitted for registration in the International Prospective Register of Systematic Reviews (PROSPERO) (http://www.crd.york.ac.uk/prospero) on the 12th of October 2020 and published on the 12th of November 2020 (registration ID CRD42020202986 ).
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Affiliation(s)
- Mathias Lühr Hansen
- Department of Neonatology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark.
| | - Simon Hyttel-Sørensen
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, The Capital Region of Denmark, Denmark.,Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, The Capital Region of Denmark, Denmark.,Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Elisabeth M W Kooi
- Division of Neonatology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Jonathan Mintzer
- Department of Pediatrics, Division of Newborn Medicine, Mountainside Medical Center, Montclair, NJ, USA
| | - Willem P de Boode
- Division of Neonatology, Department of Pediatrics, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, Netherlands
| | - Monica Fumagalli
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan, Via Francesc Sforza 35, 20122, Milano, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Via Festa del Perdono 7, 20122, Milano, Italy
| | - Ana Alarcon
- Department of Neonatology, Hospital Sant Joan de Deu, Passeig de Sant Joan de Deu 2, 08950 Esplugues de Llobregat, Barcelona, Spain
| | - Thomas Alderliesten
- Department of Neonatology, University Medical Center Utrecht Brain Center, Utrecht University, Utrecht, Netherlands
| | - Gorm Greisen
- Department of Neonatology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
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15
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Pharmacokinetic study (phase I-II) of a new dobutamine formulation in preterm infants immediately after birth. Pediatr Res 2021; 89:981-986. [PMID: 32610341 DOI: 10.1038/s41390-020-1009-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 05/22/2020] [Accepted: 06/02/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND Dobutamine is particularly suited to treatment of haemodynamic insufficiency caused by increased peripheral vascular resistance and myocardial dysfunction in the preterm infant. Knowledge of the elimination half-life is essential to estimate the steady state when its efficacy/safety can be evaluated. METHODS Analysis of pharmacokinetic data in ten preterm newborns treated with a new neonatal formulation of dobutamine (IMP) after screening for haemodynamic insufficiency within the first 72 h from birth. Blood samples were withdrawn at the end of IMP infusion and at a random time after the end of infusion (5 min, 15 min, 45 min, 2 h and 6 h). IMP concentration in each sample was measured by ultra-high performance liquid chromatography with electrochemical detection. RESULTS Median duration of IMP infusion was 37.7 h (IQR 21.2). Calculated IMP half-life ranged between 3.06 and 36.1 min (median 10.6 min), leading to a time to reach the steady-state concentration between 15 min and >2 h. Adverse events were not related to IMP. CONCLUSIONS The wide variability in dobutamine metabolism in preterm infants requires awareness about the risk of under- or overtreatment. A delay of up to 3 h might be required before drawing blood samples to evaluate the effective dose. IMPACT Small trials suggest dobutamine as the optimal drug in the preterm infant with haemodynamic insufficiency after birth. Age-related differences in drug pharmacokinetics may result in suboptimal treatments. The lack of formal studies in preterms results in inadequate data on efficacy and safety. This study provides data on the variability of the elimination half-life of dobutamine in the very preterm infant during transitional circulation. There is a wide variation in the time to reach the plasma concentration corresponding to steady state, the moment when its efficacy/safety can be reliably evaluated. This information is crucial for planning future trials on cardiovascular support.
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16
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Sehgal A, Steenhorst JJ, Mclennan DI, Merkus D, Ivy D, McNamara PJ. The Left Heart, Systemic Circulation, and Bronchopulmonary Dysplasia: Relevance to Pathophysiology and Therapeutics. J Pediatr 2020; 225:13-22.e2. [PMID: 32553872 DOI: 10.1016/j.jpeds.2020.06.031] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 06/06/2020] [Accepted: 06/09/2020] [Indexed: 12/25/2022]
Affiliation(s)
- Arvind Sehgal
- Monash Children's Hospital, Monash University, Melbourne, Australia; Department of Pediatrics, Monash University, Melbourne, Australia.
| | - Jarno J Steenhorst
- Department of Cardiology, Erasmus MC, Rotterdam, the Netherlands; Department of Pediatrics, Erasmus MC, Rotterdam, the Netherlands
| | - Daniel I Mclennan
- Department of Pediatrics, University of Iowa Children's Hospital, Dr, Iowa City, IA; Internal Medicine, University of Iowa Children's Hospital, Dr, Iowa City, IA
| | - Daphne Merkus
- Department of Cardiology, Erasmus MC, Rotterdam, the Netherlands; Department of Pediatrics, Erasmus MC, Rotterdam, the Netherlands; Institut für Chirurgische Forschung, Klinikum Universität München, Ludwig Maximillian Universität München, München, Germany
| | - Dunbar Ivy
- Pediatric Cardiology, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO
| | - Patrick J McNamara
- Department of Pediatrics, University of Iowa Children's Hospital, Dr, Iowa City, IA; Internal Medicine, University of Iowa Children's Hospital, Dr, Iowa City, IA
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17
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Abstract
Primary function of cardiovascular system is to meet body's metabolic demands. The aim of inotrope therapy is to minimise adverse impact of cardiovascular compromise. Current use of inotropes is primarily guided by the pathophysiology of cardiovascular compromise and anticipated actions of inotropes. Lack of significant reduction in morbidity and mortality associated with cardiovascular compromise despite inotrope use, highlights major gaps in our understanding of circulatory targets, thresholds and choices of inotrope therapy. Thus far, prevention of cardiovascular compromise remains the most effective strategy to optimize outcomes. Studies of alternative design are needed for further advancement in cardiovascular therapy in neonates.
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Affiliation(s)
- Nilkant Phad
- Department of Neonatology, John Hunter Children's Hospital, Lookout Road, New Lambton Heights, New South Wales 2305, Australia; University of Newcastle, Newcastle, Australia.
| | - Koert de Waal
- Department of Neonatology, John Hunter Children's Hospital, Lookout Road, New Lambton Heights, New South Wales 2305, Australia; University of Newcastle, Newcastle, Australia
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18
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Dempsey E, El-Khuffash A. Clinical Trials in Hemodynamic Support: Past, Present, and Future. Clin Perinatol 2020; 47:641-652. [PMID: 32713455 DOI: 10.1016/j.clp.2020.05.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Managing low blood flow states in the preterm population remains a challenge in neonatal clinical care. The heterogeneity of the trials to date and the relatively low number of infants enrolled, in addition to a desire to oversimplify the underlying pathophysiology, have contributed to an inability to draw meaningful conclusions to direct clinical care. This article reviews the current literature on this topic in the preterm population and outlines the challenges that have been encountered in performing such trials. Alternative studies are proposed, based on the lessons learned over the past number of years.
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Affiliation(s)
- Eugene Dempsey
- Department of Paediatrics and Child Health, INFANT Centre, University College Cork, Wilton, Cork, Ireland.
| | - Afif El-Khuffash
- The Rotunda Hospital, Dublin and Royal College of Surgeons, Dublin, Ireland
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19
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Continuous vital sign analysis for predicting and preventing neonatal diseases in the twenty-first century: big data to the forefront. Pediatr Res 2020; 87:210-220. [PMID: 31377752 PMCID: PMC6962536 DOI: 10.1038/s41390-019-0527-0] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 07/20/2019] [Accepted: 07/25/2019] [Indexed: 01/03/2023]
Abstract
In the neonatal intensive care unit (NICU), heart rate, respiratory rate, and oxygen saturation are vital signs (VS) that are continuously monitored in infants, while blood pressure is often monitored continuously immediately after birth, or during critical illness. Although changes in VS can reflect infant physiology or circadian rhythms, persistent deviations in absolute values or complex changes in variability can indicate acute or chronic pathology. Recent studies demonstrate that analysis of continuous VS trends can predict sepsis, necrotizing enterocolitis, brain injury, bronchopulmonary dysplasia, cardiorespiratory decompensation, and mortality. Subtle changes in continuous VS patterns may not be discerned even by experienced clinicians reviewing spot VS data or VS trends captured in the monitor. In contrast, objective analysis of continuous VS data can improve neonatal outcomes by allowing heightened vigilance or preemptive interventions. In this review, we provide an overview of the studies that have used continuous analysis of single or multiple VS, their interactions, and combined VS and clinical analytic tools, to predict or detect neonatal pathophysiology. We make the case that big-data analytics are promising, and with continued improvements, can become a powerful tool to mitigate neonatal diseases in the twenty-first century.
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20
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Kim ES, Kaiser JR, Rios DR, Bornemeier RA, Rhee CJ. Cerebral Hemodynamics Are Not Affected by the Size of the Patent Ductus Arteriosus. Neonatology 2020; 117:182-188. [PMID: 32434188 PMCID: PMC7381380 DOI: 10.1159/000506835] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 02/26/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Although patent ductus arteriosus (PDA) has been implicated to play a role in the development of cerebral ischemia and intraventricular hemorrhage (IVH) through a cerebral steal phenomenon, there is conflicting data on the impact of PDA size on cerebral blood flow (CBF). Cerebral autoregulation is the brain's innate protective mechanism to maintain constant CBF despite changes in blood pressure, and it is unclear if it is influenced by PDA hemodynamics. OBJECTIVE To delineate the relationship between PDA size and CBF velocity (CBFv) in premature infants. METHODS 113 premature infants born at 23-29 weeks' gestation had echocardiograms performed during the first week after birth to evaluate for PDA. The infants were divided into 3 groups according to PDA size: none-to-small, moderate, or large. All infants had continuous recordings of umbilical artery blood pressure (ABP) and CBFv during the first week after birth. Critical closing pressure (CrCP) was calculated from ABP and CBFv tracings. Diastolic closing margin (DCM), defined as diastolic blood pressure minus CrCP, was calculated as a marker for the risk of developing IVH. RESULTS Infants with a large PDA (n = 16) had the lowest ABP across all phases of the cardiac cycle (systole [p = 0.003], mean [p = 0.005], and diastole [p = 0.012]) compared to infants with a moderate (n = 19) or none-to-small PDA (n = 78). Despite blood pressure being different, systolic, mean, and diastolic CBFv were not different across groups. Cerebral autoregulation, as measured during systole, was intact regardless of the PDA size. CrCP and DCM were also not different across groups. CONCLUSIONS In this cohort, CBFv and cerebral autoregulation during systole were not influenced by PDA size. Intact cerebral autoregulation may play a role in maintaining CBFv regardless of PDA size and differences in ABP.
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Affiliation(s)
- Eun Sun Kim
- Department of Pediatrics, Kangwon National University School of Medicine, Chuncheon, Republic of Korea,
| | - Jeffrey R Kaiser
- Division of Neonatal-Perinatal Medicine, Departments of Pediatrics and Obstetrics and Gynecology, Penn State Health Children's Hospital, Hershey, Pennsylvania, USA
| | - Danielle R Rios
- Section of Neonatology, Department of Pediatrics,Texas Children's Hospital/Baylor College of Medicine, Houston, Texas, USA
| | - Renee A Bornemeier
- Department of Pediatrics, Arkansas Children's Hospital/University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Christopher J Rhee
- Section of Neonatology, Department of Pediatrics,Texas Children's Hospital/Baylor College of Medicine, Houston, Texas, USA
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21
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Kappico JM, Siassi B, Ebrahimi M, Ramanathan R. Pulmonary Venous Congestion and Pulmonary Hemorrhage in an Extremely Premature Neonate With a Large Patent Ductus Arteriosus and Closed Patent Foramen Ovale: A Case Report. J Investig Med High Impact Case Rep 2020; 8:2324709620982430. [PMID: 33349039 PMCID: PMC7758650 DOI: 10.1177/2324709620982430] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We describe a case of an extremely low birthweight infant with a large patent ductus arteriosus and closed foramen ovale resulting in markedly increased pulmonary blood flow, pulmonary venous congestion, and pulmonary hemorrhage.
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Affiliation(s)
| | - Bijan Siassi
- LAC+USC Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Mahmood Ebrahimi
- LAC+USC Medical Center, University of Southern California, Los Angeles, CA, USA
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22
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Hansen ML, Pellicer A, Gluud C, Dempsey E, Mintzer J, Hyttel-Sørensen S, Heuchan AM, Hagmann C, Ergenekon E, Dimitriou G, Pichler G, Naulaers G, Cheng G, Guimarães H, Tkaczyk J, Kreutzer KB, Fumagalli M, Claris O, Lemmers P, Fredly S, Szczapa T, Austin T, Jakobsen JC, Greisen G. Cerebral near-infrared spectroscopy monitoring versus treatment as usual for extremely preterm infants: a protocol for the SafeBoosC randomised clinical phase III trial. Trials 2019; 20:811. [PMID: 31888764 PMCID: PMC6937938 DOI: 10.1186/s13063-019-3955-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 12/04/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cerebral oxygenation monitoring may reduce the risk of death and neurologic complications in extremely preterm infants, but no such effects have yet been demonstrated in preterm infants in sufficiently powered randomised clinical trials. The objective of the SafeBoosC III trial is to investigate the benefits and harms of treatment based on near-infrared spectroscopy (NIRS) monitoring compared with treatment as usual for extremely preterm infants. METHODS/DESIGN SafeBoosC III is an investigator-initiated, multinational, randomised, pragmatic phase III clinical trial. Inclusion criteria will be infants born below 28 weeks postmenstrual age and parental informed consent (unless the site is using 'opt-out' or deferred consent). Exclusion criteria will be no parental informed consent (or if 'opt-out' is used, lack of a record that clinical staff have explained the trial and the 'opt-out' consent process to parents and/or a record of the parents' decision to opt-out in the infant's clinical file); decision not to provide full life support; and no possibility to initiate cerebral NIRS oximetry within 6 h after birth. Participants will be randomised 1:1 into either the experimental or control group. Participants in the experimental group will be monitored during the first 72 h of life with a cerebral NIRS oximeter. Cerebral hypoxia will be treated according to an evidence-based treatment guideline. Participants in the control group will not undergo cerebral oxygenation monitoring and will receive treatment as usual. Each participant will be followed up at 36 weeks postmenstrual age. The primary outcome will be a composite of either death or severe brain injury detected on any of the serial cranial ultrasound scans that are routinely performed in these infants up to 36 weeks postmenstrual age. Severe brain injury will be assessed by a person blinded to group allocation. To detect a 22% relative risk difference between the experimental and control group, we intend to randomise a cohort of 1600 infants. DISCUSSION Treatment guided by cerebral NIRS oximetry has the potential to decrease the risk of death or survival with severe brain injury in preterm infants. There is an urgent need to assess the clinical effects of NIRS monitoring among preterm neonates. TRIAL REGISTRATION ClinicalTrial.gov, NCT03770741. Registered 10 December 2018.
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Affiliation(s)
- Mathias Lühr Hansen
- Department of Neonatology, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Adelina Pellicer
- Department of Neonatology, La Paz University Hospital, Paseo De La Castellana 261, 28046 Madrid, Spain
| | - Christian Gluud
- Copenhagen Trial Unit, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Eugene Dempsey
- Infant Centre and Department of Paediatrics and Child Health, University College Cork, College Road, Cork, Ireland
| | - Jonathan Mintzer
- Division of Newborn Medicine, Hackensack Meridian Health – Mountainside Medical Center, 1 Bay Ave, Montclair, NJ USA
| | - Simon Hyttel-Sørensen
- Department of Intensive Care, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Anne Marie Heuchan
- Department of Neonatology, Royal Hospital for Children, 1345 Govan Rd, Glasgow, G51 4TF UK
| | - Cornelia Hagmann
- Department of Neonatology, Children’s University Hospital of Zürich, Steinweisstrasse 75, 8037 Zurich, Switzerland
| | - Ebru Ergenekon
- Department of Neonatology, Gazi University Hospital, Emniyet Mahallesi, Gazeteci Yazar Muammer Yaşar Bostancı Sokak, 06560 Yenimahalle/Ankara, Turkey
| | - Gabriel Dimitriou
- NICU, Department of Pediatrics, University General Hospital of Patras, 265 04 Patras, Greece
| | - Gerhard Pichler
- Department of Pediatrics, Medical University of Graz, Auenbruggerplatz 30, Graz, Austria
| | - Gunnar Naulaers
- Department of Neonatology, University Hospital Leuven, Herestraat 49 Leuven, Belgium
| | - Guoqiang Cheng
- Department of Neonatology, Children’s Hospital of Fudan University, 399 Wanyuan Rd, Minhang Qu, Shanghai Shi, China
| | - Hercilia Guimarães
- Department of Neonatology, Centro hospitalar Universitário de São João, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Jakub Tkaczyk
- Department of Neonatology, University Hospital Motol, V Uvalu 84, 150 06 Prague 5, Czech Republic
| | - Karen B. Kreutzer
- Department of Neonatology, University Children’s Hospital Tuebingen, Hoppe-Seyler-Straße 1, 72076 Tuebingen, Germany
| | - Monica Fumagalli
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan, Via della Commenda 12, IT- 20122 Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Via Francesco Sforza 35, 20122 Milan, Italy
| | - Olivier Claris
- Department of Neonatology, Hospices Civil De Lyon, 3 Quai des Célestins, 69002 Lyon, France
| | - Petra Lemmers
- Department of Neonatology, Wilhelmina Children’s Hospital, Lundlaan 6, 3584 EA Utrecht, Netherlands
| | - Siv Fredly
- Department of Neonatology, Oslo University Hospital, Kirkeveien, 166 0450 Oslo, Norway
| | - Tomasz Szczapa
- Department of Neonatology, Poznan University of Medical Sciences, Polna 33, 60-535 Poznań, Poland
| | - Topun Austin
- Neonatal Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0SW UK
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
- Department of Cardiology, Holbæk Hospital, Smedelundsgade 60, 4300 Holbæk, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Gorm Greisen
- Department of Neonatology, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
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The Relationship between blood pressure parameters and left ventricular output in neonates. J Perinatol 2019; 39:619-625. [PMID: 30770881 DOI: 10.1038/s41372-019-0337-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 11/29/2018] [Accepted: 01/25/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To evaluate the relationship between systolic (SBP), diastolic (DBP), mean (MBP) blood pressures and pulse pressure (PP), and left ventricular output (LVO), a surrogate of systemic blood flow. STUDY DESIGN This retrospective study included neonates who underwent targeted neonatal echocardiography (TNE) in 3-tertiary NICUs over 2 years. Associations between LVO and BP components were investigated. Analysis was adjusted for relevant covariates. RESULT 1060 studies from 485 neonates were included, with a mean GA of 28.4 ± 4.6 weeks and birth weight of 1234 ± 840 grams. LVO was associated positively with SBP and PP, and negatively with GA. PP demonstrated the highest predictive value for identifying infants with LVO < 150 ml/kg/min (area under the curve 0.75 [95% CI 0.68, 0.82]). MBP and DBP demonstrated no correlation with LVO. CONCLUSION BP parameters correlate poorly with LVO, irrespective of GA and underlying etiology. Narrow PP may be more reflective of low LVO than low SBP.
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Bussmann N, El-Khuffash A. Future perspectives on the use of deformation analysis to identify the underlying pathophysiological basis for cardiovascular compromise in neonates. Pediatr Res 2019; 85:591-595. [PMID: 30666047 DOI: 10.1038/s41390-019-0293-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 12/28/2018] [Accepted: 01/02/2019] [Indexed: 12/28/2022]
Abstract
The assessment of the wellbeing of the cardiovascular status in premature infants has come to the forefront in recent years. There is an increasing realisation that myocardial performance, systemic blood flow and end-organ perfusion (particularly during the transitional period) play an important role in determining short and long-term outcomes in this population. The recent open access series on Neonatologist Performed Echocardiography (NPE) published in this journal outline the necessary techniques for image acquisition and analysis and provide a framework for the potential clinical applications of NPE in neonatal, and specifically preterm care. In this "Future Perspectives" review, we describe the important determinants of adequate cellular metabolism and myocardial performance (e.g. loading conditions, intrinsic contractility and morphological change), we discuss the maladaptive state of the preterm cardiovascular system, and highlight the emerging role that non-invasive echocardiography techniques, such as deformation analysis, serve in identifying the underlying physiological basis for cardiovascular instability.
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Affiliation(s)
- Neidin Bussmann
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland
| | - Afif El-Khuffash
- School of Medicine, Department of Pediatrics, Royal College of Surgeons in Ireland, Dublin, Ireland.
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25
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Lee ES, Sohn JA, Kim HS, Heo JS, Lee JA. Risk Factors for Brain Damage in Preterm Infants After Late-Onset Circulatory Collapse Events. NEONATAL MEDICINE 2019. [DOI: 10.5385/nm.2019.26.1.55] [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
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26
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Lobo L, Stevenson G, Alphonse J, Welsh A, Oei JL, Schindler T. Four-Dimensional Ultrasound for Evaluating Newborn Cardiac Output: A Pilot Study of Healthy Infants. Neonatology 2019; 116:115-122. [PMID: 31137032 DOI: 10.1159/000496452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Accepted: 12/21/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND There is currently no reliable non-invasive method of measuring cardiac output in neonatal intensive care. Spatiotemporal image correlation (STIC) is a novel four-dimensional (4D) ultrasound technique that was developed to assess the foetal heart, and it may be a useful way to assess neonatal haemodynamics. OBJECTIVE This study aimed to evaluate the feasibility and reproducibility of determining neonatal cardiac output using STIC ultrasound in newborn infants. DESIGN Infants were recruited opportunistically from a neonatal intensive care unit and then examined by 2 independent observers. STIC was used to obtain images of the heart. End-diastolic and end-systolic ventricular volumes were measured using virtual organ computer-aided analysis (VOCAL) and used to calculate cardiac output. Reproducibility was assessed with intraclass correlation coefficients (ICC) and agreement with Bland-Altman analysis. RESULTS Twenty-four clinically stable infants of 34-43 weeks corrected gestational age were assessed. Both observers successfully acquired 4D STIC volumes in all infants. Left ventricular output showed good reproducibility, with an intra-observer ICC of 0.86 (0.69-0.94) and inter-observer ICC of 0.87 (0.70-0.95). Right ventricular output also showed good reproducibility, with an intra-observer ICC of 0.88 (0.70-95) and inter-observer ICC of 0.84 (0.63-0.93). CONCLUSIONS Determining cardiac output using 4D STIC ultrasound is feasible and reproducible in well newborn infants. With further evaluation, this technique may provide valuable information about haemodynamic status in newborn infants requiring intensive care.
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Affiliation(s)
- Lisha Lobo
- School of Women's and Children's Health, University of New South Wales, Randwick, New South Wales, Australia
| | - Gordon Stevenson
- School of Women's and Children's Health, University of New South Wales, Randwick, New South Wales, Australia
| | - Jennifer Alphonse
- School of Women's and Children's Health, University of New South Wales, Randwick, New South Wales, Australia
| | - Alec Welsh
- School of Women's and Children's Health, University of New South Wales, Randwick, New South Wales, Australia.,Department of Maternal-Foetal Medicine, Royal Hospital for Women, Randwick, New South Wales, Australia
| | - Ju Lee Oei
- School of Women's and Children's Health, University of New South Wales, Randwick, New South Wales, Australia.,Department of Newborn Care, Royal Hospital for Women, Randwick, New South Wales, Australia
| | - Timothy Schindler
- School of Women's and Children's Health, University of New South Wales, Randwick, New South Wales, Australia, .,Department of Newborn Care, Royal Hospital for Women, Randwick, New South Wales, Australia,
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27
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da Costa CS, Czosnyka M, Smielewski P, Austin T. Optimal Mean Arterial Blood Pressure in Extremely Preterm Infants within the First 24 Hours of Life. J Pediatr 2018; 203:242-248. [PMID: 30243537 DOI: 10.1016/j.jpeds.2018.07.096] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 07/17/2018] [Accepted: 07/27/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To define levels of mean arterial blood pressure (MABP) where cerebrovascular reactivity is strongest (MABPOPT) during the early transitional circulation in extremely preterm infants and to investigate the association between deviations above and below MABPOPT with intraventricular hemorrhage (IVH) and mortality. STUDY DESIGN A total of 44 infants born at a median gestational age 25 (23-27) weeks with indwelling arterial catheter were studied at a median 5.5 (3.1-12.6) hours within the first 24 hours of life. Cerebrovascular reactivity (tissue oxygenation heart rate reactivity index) was estimated by the moving correlation coefficient between heart rate and near-infrared spectroscopy tissue oxygenation index. MABPOPT was defined as the MABP where tissue oxygenation heart rate reactivity index reaches minimum value. Deviations below or above MABPOPT values were calculated along with MABPOPT values during retrospective data analysis. RESULTS MABPOPT was detected in all infants. The mean (SD) MABPOPT was 31.3 (±4.7) mm Hg. MABPOPT increased with increasing gestational age, R = 0.424; P = .004. Deviations below MABPOPT were greater in the IVH group (mean 2.7 mm Hg; 95% CI 2.0-3.5) compared with no-IVH (mean 1.7 mm Hg; 1.1-2.2), P = .006. In infants who died, the deviation below MABPOPT was greater (mean 3.3; 95% CI 1.9-4.8) compared with those who survived (mean 1.9 mm Hg; 95% CI 1.4-2.3), P = .015. CONCLUSIONS Defining optimal MABP based on the strength of cerebrovascular reactivity within the first 24 hours of life is feasible and can provide an individualized approach to the care of extremely preterm infants. Deviations below MABPOPT were significantly associated with IVH and death.
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Affiliation(s)
- Cristine Sortica da Costa
- Neonatal Unit, The Rosie Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom.
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom; Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Topun Austin
- Neonatal Unit, The Rosie Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
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Chandrasekharan P, Rawat M, Gugino SF, Koenigsknecht C, Helman J, Nair J, Vali P, Lakshminrusimha S. Effect of various inspired oxygen concentrations on pulmonary and systemic hemodynamics and oxygenation during resuscitation in a transitioning preterm model. Pediatr Res 2018; 84:743-750. [PMID: 29967523 PMCID: PMC6275138 DOI: 10.1038/s41390-018-0085-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 05/23/2018] [Accepted: 05/25/2018] [Indexed: 01/23/2023]
Abstract
BACKGROUND The Neonatal Resuscitation Program recommends initial resuscitation of preterm infants with low oxygen (O2) followed by titration to target preductal saturations (SpO2). We studied the effect of resuscitation with titrated O2 on gas exchange, pulmonary, and systemic hemodynamics. METHODOLOGY Twenty-nine preterm lambs (127 d gestation) were randomized to resuscitation with 21% O2 (n = 7), 100% O2 (n = 6), or initiation at 21% and titrated to target SpO2 (n = 16). Seven healthy term control lambs were ventilated with 21% O2. RESULTS Preductal SpO2 achieved by titrating O2 was within the desired range similar to term lambs in 21% O2. Resuscitation of preterm lambs with 21% and 100% O2 resulted in SpO2 below and above the target, respectively. Ventilation of preterm lambs with 100% O2 and term lambs with 21% O2 effectively decreased pulmonary vascular resistance (PVR). In contrast, preterm lambs with 21% O2 and titrated O2 demonstrated significantly higher PVR than term lambs on 21% O2. CONCLUSION(S) Initial resuscitation with 21% O2 followed by titration of O2 led to suboptimal pulmonary vascular transition at birth in preterm lambs. Ventilation with 100% O2 in preterm lambs caused hyperoxia but reduced PVR similar to term lambs on 21% O2. Studies evaluating the initiation of resuscitation at a higher O2 concentration followed by titration based on SpO2 in preterm neonates are needed.
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Affiliation(s)
| | - Munmun Rawat
- Department of Pediatrics, University at Buffalo, Buffalo, NY
| | | | | | - Justin Helman
- Department of Pediatrics, University at Buffalo, Buffalo, NY
| | - Jayasree Nair
- Department of Pediatrics, University at Buffalo, Buffalo, NY
| | - Payam Vali
- Department of Pediatrics, UC Davis, Sacramento, CA
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29
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Phad N, de Waal K, Jones M. Agreement and reliability of the velocity time integral method and the method of disks to determine stroke volume in preterm infants. Early Hum Dev 2018; 125:31-34. [PMID: 30196166 DOI: 10.1016/j.earlhumdev.2018.08.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 08/08/2018] [Accepted: 08/27/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Nilkant Phad
- John Hunter Children's Hospital, Department of Neonatology, Newcastle, NSW, Australia; University of Newcastle, NSW, Australia.
| | - Koert de Waal
- John Hunter Children's Hospital, Department of Neonatology, Newcastle, NSW, Australia; University of Newcastle, NSW, Australia
| | - Mark Jones
- Hunter Medical Research Institute, Newcastle, Australia
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30
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Agnew EJ, Ivy JR, Stock SJ, Chapman KE. Glucocorticoids, antenatal corticosteroid therapy and fetal heart maturation. J Mol Endocrinol 2018; 61:R61-R73. [PMID: 29720513 PMCID: PMC5976079 DOI: 10.1530/jme-18-0077] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 05/02/2018] [Indexed: 01/08/2023]
Abstract
Glucocorticoids are essential in mammals to mature fetal organs and tissues in order to survive after birth. Hence, antenatal glucocorticoid treatment (termed antenatal corticosteroid therapy) can be life-saving in preterm babies and is commonly used in women at risk of preterm birth. While the effects of glucocorticoids on lung maturation have been well described, the effects on the fetal heart remain less clear. Experiments in mice have shown that endogenous glucocorticoid action is required to mature the fetal heart. However, whether the potent synthetic glucocorticoids used in antenatal corticosteroid therapy have similar maturational effects on the fetal heart is less clear. Moreover, antenatal corticosteroid therapy may increase the risk of cardiovascular disease in adulthood. Here, we present a narrative review of the evidence relating to the effects of antenatal glucocorticoid action on the fetal heart and discuss the implications for antenatal corticosteroid therapy.
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Affiliation(s)
- Emma J Agnew
- University/BHF Centre for Cardiovascular ScienceUniversity of Edinburgh, The Queen’s Medical Research Institute, Edinburgh, UK
| | - Jessica R Ivy
- University/BHF Centre for Cardiovascular ScienceUniversity of Edinburgh, The Queen’s Medical Research Institute, Edinburgh, UK
| | - Sarah J Stock
- MRC Centre for Reproductive HealthUniversity of Edinburgh, The Queen’s Medical Research Institute, Edinburgh, UK
| | - Karen E Chapman
- University/BHF Centre for Cardiovascular ScienceUniversity of Edinburgh, The Queen’s Medical Research Institute, Edinburgh, UK
- Correspondence should be addressed to K E Chapman:
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31
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Utility of prenatal Doppler ultrasound to predict neonatal impaired cerebral autoregulation. J Perinatol 2018; 38:474-481. [PMID: 29410542 DOI: 10.1038/s41372-018-0050-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Revised: 12/06/2017] [Accepted: 01/02/2018] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Determine if abnormal prenatal Doppler ultrasound indices are predictive of postnatal impaired cerebral autoregulation. STUDY DESIGN Prospective cohort study of 46 subjects, 240-296 weeks' gestation. Utilizing near-infrared spectroscopy and receiver-operating characteristic analysis, impaired cerebral autoregulation was defined as >16.5% time spent in a dysregulated state within 96 h of life. Normal and abnormal Doppler indices were compared for perinatal outcomes. RESULTS Subjects with abnormal cerebroplacental ratio (n = 12) and abnormal umbilical artery pulsatility index (n = 13) were likely to develop postnatal impaired cerebral autoregulation (p ≤ 0.02). Abnormal cerebroplacental ratio was associated with impaired cerebral autoregulation between 24 and 48 h of life (p = 0.016). These subjects have increased risk for fetal growth restriction, lower birth weight, lower Apgar scores, acidosis, and severe intraventricular hemorrhage and/or death (p < 0.05). CONCLUSION Abnormal cerebroplacental ratio and umbilical artery pulsatility index are associated with postnatal impairment in cerebral autoregulation and adverse outcome.
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32
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Beausoleil TP, Janaillac M, Barrington KJ, Lapointe A, Dehaes M. Cerebral oxygen saturation and peripheral perfusion in the extremely premature infant with intraventricular and/or pulmonary haemorrhage early in life. Sci Rep 2018; 8:6511. [PMID: 29695729 PMCID: PMC5916916 DOI: 10.1038/s41598-018-24836-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 04/09/2018] [Indexed: 12/29/2022] Open
Abstract
Extremely preterm infants are at higher risk of pulmonary (PH) and intraventricular (IVH) haemorrhage during the transitioning physiology due to immature cardiovascular system. Monitoring of haemodynamics can detect early abnormal circulation that may lead to these complications. We described time-frequency relationships between near infrared spectroscopy (NIRS) cerebral regional haemoglobin oxygen saturation (CrSO2) and preductal peripheral perfusion index (PI), capillary oxygen saturation (SpO2) and heart rate (HR) in extremely preterm infants in the first 72 h of life. Patients were sub-grouped in infants with PH and/or IVH (N H = 8) and healthy controls (N C = 11). Data were decomposed in wavelets allowing the analysis of localized variations of power. This approach allowed to quantify the percentage of time of significant cross-correlation, semblance, gain (transfer function) and coherence between signals. Ultra-low frequencies (<0.28 mHz) were analyzed as slow and prolonged periods of impaired circulation are considered more detrimental than transient fluctuations. Cross-correlation between CrSO2 and oximetry (PI, SpO2 and HR) as well as in-phase semblance and gain between CrSO2 and HR were significantly lower while anti-phase semblance between CrSO2 and HR was significantly higher in PH-IVH infants compared to controls. These differences may reflect haemodynamic instability associated with cerebrovascular autoregulation and hemorrhagic complications observed during the transitioning physiology.
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Affiliation(s)
- Thierry P Beausoleil
- Institute of Biomedical Engineering, University of Montréal, Montréal, Canada.,Research Centre, CHU Sainte-Justine, Montréal, Canada
| | - Marie Janaillac
- Department of Pediatrics, Division of Neonatology, CHU Sainte-Justine and University of Montréal, Montréal, Canada
| | - Keith J Barrington
- Research Centre, CHU Sainte-Justine, Montréal, Canada.,Department of Pediatrics, Division of Neonatology, CHU Sainte-Justine and University of Montréal, Montréal, Canada
| | - Anie Lapointe
- Department of Pediatrics, Division of Neonatology, CHU Sainte-Justine and University of Montréal, Montréal, Canada
| | - Mathieu Dehaes
- Research Centre, CHU Sainte-Justine, Montréal, Canada. .,Department of Radiology, Radio-oncology and Nuclear Medicine, University of Montréal, Montréal, Canada.
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33
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Correlations between near-infrared spectroscopy, perfusion index, and cardiac outputs in extremely preterm infants in the first 72 h of life. Eur J Pediatr 2018; 177:541-550. [PMID: 29374830 DOI: 10.1007/s00431-018-3096-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 12/14/2017] [Accepted: 01/17/2018] [Indexed: 10/18/2022]
Abstract
UNLABELLED Haemodynamic assessment during the transitional period in preterm infants is challenging. We aimed to describe the relationships between cerebral regional tissue oxygen saturation (CrSO2), perfusion index (PI), echocardiographic, and clinical parameters in extremely preterm infants in their first 72 h of life. Twenty newborns born at < 28 weeks of gestation were continuously monitored with CrSO2 and preductal PI. Cardiac output was measured at H6, H24, H48, and H72. The median gestational age and birth weight were 25.0 weeks (24-26) and 750 g (655-920), respectively. CrSO2 and preductal PI had r values < 0.35 with blood gases, lactates, haemoglobin, and mean blood pressure. Cardiac output significantly increased over the 72 h of the study period. Fifteen patients had at least one episode of low left and/or right ventricular output (RVO), during which there was a strong correlation between CrSO2 and superior vena cava (SVC) flow (at H6 (r = 0.74) and H24 (r = 0.86)) and between PI and RVO (at H6 (r = 0.68) and H24 (r = 0.92)). Five patients had low SVC flow (≤ 40 mL/kg/min) at H6, during which PI was strongly correlated with RVO (r = 0.98). CONCLUSION CrSO2 and preductal PI are strongly correlated with cardiac output during low cardiac output states. What is Known: • Perfusion index and near-infrared spectroscopy are non-invasive tools to evaluate haemodynamics in preterm infants. • Pre- and postductal perfusion indexes strongly correlate with left ventricular output in term infants, and near-infrared spectroscopy has been validated to assess cerebral oxygenation in term and preterm infants. What is New: • Cerebral regional tissue oxygen saturation and preductal perfusion index were strongly correlated with cardiac output during low cardiac output states. • The strength of the correlation between cerebral regional tissue oxygen saturation, preductal perfusion index, and cardiac output varied in the first 72 h of life, reflecting the complexity of the transitional physiology.
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Rios DR, Bhattacharya S, Levy PT, McNamara PJ. Circulatory Insufficiency and Hypotension Related to the Ductus Arteriosus in Neonates. Front Pediatr 2018; 6:62. [PMID: 29600242 PMCID: PMC5863525 DOI: 10.3389/fped.2018.00062] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Accepted: 03/02/2018] [Indexed: 12/12/2022] Open
Abstract
The biological role of the ductus arteriosus (DA) in neonates varies from an innocent bystander role during normal postnatal transition, to a supportive role when there is compromise to either systemic or pulmonary blood flow, to a pathological state in the presence of hemodynamically significant systemic to pulmonary shunts, as occurs in low birth weight infants. Among a wide array of clinical manifestations arising due to the ductal entity, systemic circulatory insufficiency and hypotension are of significant concern as they are particularly challenging to manage. An understanding of the physiologic interplay between the DA and the circulatory system is the key to developing appropriate targeted therapeutic strategies. In this review, we discuss the relationship of systemic hypotension to the DA, emphasizing the importance of critical thinking and a precise individual approach to intensive care support. We particularly focus on the variable states of hypotension arising directly due to a hemodynamically significant DA or seen in the period following successful surgical ligation. In addition, we explore the mechanistic contributions of the ductus to circulatory insufficiency that may manifest during the transitional period, states of maladapted transition (such as acute pulmonary hypertension of the newborn), and congenital heart disease (both ductal dependent and non-ductal dependent lesions). Understanding the dynamic modulator role of the ductus according to the ambient physiology enables a more precise approach to management. We review the pathophysiology, clinical manifestations, diagnosis, monitoring, and therapeutic intervention for the spectrum of DA-related circulatory compromise.
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Affiliation(s)
- Danielle R. Rios
- Section of Neonatology, Department of Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, United States
| | - Soume Bhattacharya
- Division of Neonatology, Department of Paediatrics, Western University, London, ON, Canada
| | - Philip T. Levy
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, Saint Louis, MI, United States
| | - Patrick J. McNamara
- Division of Neonatology, Department of Paediatrics and Physiology, University of Toronto, Toronto, ON, Canada
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35
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Kluckow M. The Pathophysiology of Low Systemic Blood Flow in the Preterm Infant. Front Pediatr 2018; 6:29. [PMID: 29503814 PMCID: PMC5820306 DOI: 10.3389/fped.2018.00029] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 01/31/2018] [Indexed: 11/13/2022] Open
Abstract
Assessment and treatment of the VLBW infant with cardiovascular impairment requires understanding of the underlying physiology of the infant in transition. The situation is dynamic with changes occurring in systemic blood pressure, pulmonary pressures, myocardial function, and ductal shunt in the first postnatal days. New insights into the role of umbilical cord clamping in the transitional circulation have been provided by large clinical trials of early versus later cord clamping and a series of basic science reports describing the physiology in an animal model. Ultrasound assessment is invaluable in assessment of the physiology of the transition and can provide information about the size and shunt direction of the ductus arteriosus, the function of the myocardium and its filling as well as measurements of the cardiac output and an estimate of the state of peripheral vascular resistance. This information not only allows more specific treatment but it will often reduce the need for treatment.
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Affiliation(s)
- Martin Kluckow
- Department of Neonatology, Royal North Shore Hospital, University of Sydney, Sydney, NSW, Australia
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36
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Abstract
Cardiac ultrasound techniques are increasingly used in the neonatal intensive care unit to guide cardiorespiratory care of the sick newborn. This is the first in a series of eight review articles discussing the current status of "neonatologist-performed echocardiography" (NPE). The aim of this introductory review is to discuss four key elements of NPE. Indications for scanning are summarized to give the neonatologist with echocardiography skills a clear scope of practice. The fundamental physics of ultrasound are explained to allow for image optimization and avoid erroneous conclusions from artifacts. To ensure patient safety during echocardiography recommendations are given to prevent cardiorespiratory instability, hypothermia, infection, and skin lesions. A structured approach to echocardiography, with the same standard views acquired in the same sequence at each scan, is suggested in order to ensure that the neonatologist confirms normal structural anatomy or acquires the necessary images for a pediatric cardiologist to do so when reviewing the scan.
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37
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Application of Neonatologist Performed Echocardiography in the Assessment and Management of Neonatal Heart Failure unrelated to Congenital Heart Disease. Pediatr Res 2018; 84:78-88. [PMID: 30072802 PMCID: PMC6257223 DOI: 10.1038/s41390-018-0075-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Neonatal heart failure (HF) is a progressive disease caused by cardiovascular and non-cardiovascular abnormalities. The most common cause of neonatal HF is structural congenital heart disease, while neonatal cardiomyopathy represents the most common cause of HF in infants with a structurally normal heart. Neonatal cardiomyopathy is a group of diseases manifesting with various morphological and functional phenotypes that affect the heart muscle and alter cardiac performance at, or soon after birth. The clinical presentation of neonates with cardiomyopathy is varied, as are the possible causes of the condition and the severity of disease presentation. Echocardiography is the selected method of choice for diagnostic evaluation, follow-up and analysis of treatment results for cardiomyopathies in neonates. Advances in neonatal echocardiography now permit a more comprehensive assessment of cardiac performance that could not be previously achieved with conventional imaging. In this review, we discuss the current and emerging echocardiographic techniques that aid in the correct diagnostic and pathophysiological assessment of some of the most common etiologies of HF that occur in neonates with a structurally normal heart and acquired cardiomyopathy and we provide recommendations for using these techniques to optimize the management of neonate with HF.
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American College of Critical Care Medicine Clinical Practice Parameters for Hemodynamic Support of Pediatric and Neonatal Septic Shock. Crit Care Med 2017; 45:1061-1093. [PMID: 28509730 DOI: 10.1097/ccm.0000000000002425] [Citation(s) in RCA: 381] [Impact Index Per Article: 54.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES The American College of Critical Care Medicine provided 2002 and 2007 guidelines for hemodynamic support of newborn and pediatric septic shock. Provide the 2014 update of the 2007 American College of Critical Care Medicine "Clinical Guidelines for Hemodynamic Support of Neonates and Children with Septic Shock." DESIGN Society of Critical Care Medicine members were identified from general solicitation at Society of Critical Care Medicine Educational and Scientific Symposia (2006-2014). The PubMed/Medline/Embase literature (2006-14) was searched by the Society of Critical Care Medicine librarian using the keywords: sepsis, septicemia, septic shock, endotoxemia, persistent pulmonary hypertension, nitric oxide, extracorporeal membrane oxygenation, and American College of Critical Care Medicine guidelines in the newborn and pediatric age groups. MEASUREMENTS AND MAIN RESULTS The 2002 and 2007 guidelines were widely disseminated, translated into Spanish and Portuguese, and incorporated into Society of Critical Care Medicine and American Heart Association/Pediatric Advanced Life Support sanctioned recommendations. The review of new literature highlights two tertiary pediatric centers that implemented quality improvement initiatives to improve early septic shock recognition and first-hour compliance to these guidelines. Improved compliance reduced hospital mortality from 4% to 2%. Analysis of Global Sepsis Initiative data in resource rich developed and developing nations further showed improved hospital mortality with compliance to first-hour and stabilization guideline recommendations. CONCLUSIONS The major new recommendation in the 2014 update is consideration of institution-specific use of 1) a "recognition bundle" containing a trigger tool for rapid identification of patients with septic shock, 2) a "resuscitation and stabilization bundle" to help adherence to best practice principles, and 3) a "performance bundle" to identify and overcome perceived barriers to the pursuit of best practice principles.
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Abstract
BACKGROUND The postnatal period in preterm infants involves multiple physiological changes occurring immediately after birth and continuing for days or weeks. To recognise and treat compromise, it is important to measure cardiovascular function. The aim of this study was to describe longitudinal left ventricular function using conventional and novel echocardiography techniques in preterm infants who did not experience significant antenatal or postnatal complications and treatments. METHODS We prospectively obtained cardiac ultrasound images at days 3, 7, 14, 21, and 28 in 25 uncomplicated, preterm infants <30 weeks of gestation. Speckle tracking analysis of the four chambers and short-axis images provided parameters of left ventricular volume, deformation, and basal myocardial velocities. The patent ductus arteriosus, cardiac dimensions, and atrial volume were also measured. RESULTS Stroke volume increased by 24% during the study period (1.05-1.30 ml/kg, p<0.05). Cardiac length, diameter, and systolic basal myocardial velocity increased with unchanged wall stress and deformation parameters. Diastolic function parameters resembled that of the fetus with predominance of atrial contraction compared with early diastolic velocities. Blood pressure and estimates of left ventricular filing pressure increased, suggesting that left ventricular compliance did not change in this period. CONCLUSION Stroke volume increased in the first 28 days after preterm birth. The preterm heart adapted by increasing its size, while maintaining systolic and atrial function, independent of early diastolic maturation. Longitudinal deformation of the left ventricle remained unchanged, suggesting relatively preserved function with maturation.
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Ishiguro A. Perfusion monitoring and intraventricular hemorrhage in preterm infants. Pediatr Int 2017; 59:759-763. [PMID: 28453903 DOI: 10.1111/ped.13317] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 03/30/2017] [Accepted: 04/26/2017] [Indexed: 01/01/2023]
Abstract
Cardiovascular instability in preterm infants during the early postnatal period correlates with the development of intraventricular hemorrhage (IVH). Due to the correlation between hypotension and fluctuation of blood pressure, treatment was targeted specifically at hypotension to prevent IVH, but this was not successful. Recently, several novel perfusion markers have been found to be correlated with the development of IVH, and they are of current interest in cardiovascular management. In this review, the correlation between IVH and conventional, as well as novel, perfusion markers is examined.
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Affiliation(s)
- Akio Ishiguro
- Division of Neonatal Medicine, Center for Maternal, Fetal and Neonatal Medicine, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
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Levy PT, El-Khuffash A, Patel MD, Breatnach CR, James AT, Sanchez AA, Abuchabe C, Rogal SR, Holland MR, McNamara PJ, Jain A, Franklin O, Mertens L, Hamvas A, Singh GK. Maturational Patterns of Systolic Ventricular Deformation Mechanics by Two-Dimensional Speckle-Tracking Echocardiography in Preterm Infants over the First Year of Age. J Am Soc Echocardiogr 2017; 30:685-698.e1. [PMID: 28433214 DOI: 10.1016/j.echo.2017.03.003] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Indexed: 01/29/2023]
Abstract
BACKGROUND The aim of this study was to determine the maturational changes in systolic ventricular strain mechanics by two-dimensional speckle-tracking echocardiography in extremely preterm neonates from birth to 1 year of age and discern the impact of common cardiopulmonary abnormalities on the deformation measures. METHODS In a prospective multicenter study of 239 extremely preterm infants (<29 weeks gestation at birth), left ventricular (LV) global longitudinal strain (GLS) and global longitudinal systolic strain rate (GLSRs), interventricular septal wall (IVS) GLS and GLSRs, right ventricular (RV) free wall longitudinal strain and strain rate, and segmental longitudinal strain in the RV free wall, LV free wall, and IVS were serially measured on days 1, 2, and 5 to 7, at 32 and 36 weeks postmenstrual age, and at 1 year corrected age (CA). Premature infants who developed bronchopulmonary dysplasia or had echocardiographic findings of pulmonary hypertension were analyzed separately. RESULTS In uncomplicated preterm infants (n = 103 [48%]), LV GLS and GLSRs remained unchanged from days 5 to 7 to 1 year CA (P = .60 and P = .59). RV free wall longitudinal strain, RV free wall longitudinal strain rate, and IVS GLS and GLSRs significantly increased over the same time period (P < .01 for all measures). A significant base-to-apex (highest to lowest) segmental longitudinal strain gradient (P < .01) was seen in the RV free wall and a reverse apex-to-base gradient (P < .01) in the LV free wall. In infants with bronchopulmonary dysplasia and/or pulmonary hypertension (n = 119 [51%]), RV free wall longitudinal strain and IVS GLS were significantly lower (P < .01), LV GLS and GLSRs were similar (P = .56), and IVS segmental longitudinal strain persisted as an RV-dominant base-to-apex gradient from 32 weeks postmenstrual age to 1 year CA. CONCLUSIONS This study tracks the maturational patterns of global and regional deformation by two-dimensional speckle-tracking echocardiography in extremely preterm infants from birth to 1 year CA. The maturational patterns are ventricular specific. Bronchopulmonary dysplasia and pulmonary hypertension leave a negative impact on RV and IVS strain, while LV strain remains stable.
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Affiliation(s)
- Philip T Levy
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri; Department of Pediatrics, Goryeb Children's Hospital, Morristown, New Jersey.
| | - Afif El-Khuffash
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland; School of Medicine, Department of Paediatrics, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Meghna D Patel
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Colm R Breatnach
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland
| | - Adam T James
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland
| | - Aura A Sanchez
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Cristina Abuchabe
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Sarah R Rogal
- Department of Pediatrics, Goryeb Children's Hospital, Morristown, New Jersey
| | - Mark R Holland
- Department of Radiology and Imaging Sciences, Indiana University Purdue University, Indianapolis, Indiana
| | - Patrick J McNamara
- Division of Neonatology and Department of Physiology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Amish Jain
- Department of Paediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Orla Franklin
- Department of Cardiology, Our Lady's Children's Hospital Crumlin, Dublin, Ireland
| | - Luc Mertens
- Division of Cardiology, The Labatt Family Heart Centre, The Hospital for Children, Toronto, Ontario, Canada
| | - Aaron Hamvas
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Gautam K Singh
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
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Abstract
Hypotension is common in low birth weight neonates and less common in term newborns and is associated with significant morbidity and mortality. Determining an adequate blood pressure in neonates remains challenging for the neonatal nurse because of the lack of agreed-upon norms. Values for determining norms for blood pressure at varying gestational and postnatal ages are based on empirical data. Understanding cardiovascular pathophysiology, potential causes of hypotension, and assessment of adequate perfusion in the neonatal population is important and can assist the neonatal nurse in the evaluation of effective blood pressure. This article reviews cardiovascular pathophysiology as it relates to blood pressure and discusses potential causes of hypotension in the term and preterm neonate. Variation in management of hypotension across centers is discussed. Underlying causes and pathophysiology of hypotension in the neonate are described.
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Ficial B, Bonafiglia E, Padovani EM, Prioli MA, Finnemore AE, Cox DJ, Broadhouse KM, Price AN, Durighel G, Groves AM. A modified echocardiographic approach improves reliability of superior vena caval flow quantification. Arch Dis Child Fetal Neonatal Ed 2017; 102:F7-F11. [PMID: 27231267 DOI: 10.1136/archdischild-2015-309523] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Revised: 03/17/2016] [Accepted: 05/08/2016] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To assess accuracy and repeatability of a modified echocardiographic approach to quantify superior vena cava (SVC) flow volume that uses a short-axis view to directly measure SVC area and a suprasternal view to measure flow velocity, both at the level of the right pulmonary artery. SETTING Three tertiary-level neonatal intensive care units. DESIGN This was a multicentre, prospective, observational study. Accuracy of the traditional and modified approach was first assessed by comparing echo measurements according to both techniques with Phase contrast MRI (PCMRI) assessments, in a cohort of 10 neonates. In a second cohort of 40 neonates, intraobserver scan-rescan repeatability and interobserver analysis-reanalysis repeatability were assessed by repeated SVC flow echo measurements, according to both techniques. RESULTS The traditional echocardiographic approach to assessment of SVC flow had a moderate agreement with PCMRI (r2 0.259), a scan-rescan intraobserver repeatability index (RI) of 37% (limits of agreement (LOA) -47/+51 mL/kg/min) and an interobserver analysis-reanalysis RI of 31% (LOA -38/+40 mL/kg/min). The modified approach showed a stronger agreement with PCMRI (r2 0.775), an improved intraobserver scan-rescan repeatability (RI 22%, LOA -24/+18 mL/kg/min) and improved interobserver analysis-reanalysis repeatability (RI 18%, LOA -18/+20 mL/kg/min). CONCLUSIONS Echocardiographic assessment of SVC flow volume by tracing area from a short-axis view and measuring velocity-time integral from a suprasternal view offered an improvement in accuracy and repeatability, building on the traditional approach previously described.
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Affiliation(s)
- Benjamim Ficial
- Neonatal Unit, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy.,Imperial College and MRC Clinical Sciences Centre, Queen Charlotte's and Chelsea Hospital, London, UK
| | - Elena Bonafiglia
- Neonatal Unit, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Ezio M Padovani
- Neonatal Unit, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Maria A Prioli
- Department of Cardiology, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Anna E Finnemore
- Imperial College and MRC Clinical Sciences Centre, Queen Charlotte's and Chelsea Hospital, London, UK.,Division of Imaging Sciences and Biomedical Engineering, The Centre for the Developing Brain, St Thomas' Hospital, King's College London, London, UK
| | - David J Cox
- Imperial College and MRC Clinical Sciences Centre, Queen Charlotte's and Chelsea Hospital, London, UK.,Division of Imaging Sciences and Biomedical Engineering, The Centre for the Developing Brain, St Thomas' Hospital, King's College London, London, UK
| | - Kathryn M Broadhouse
- Division of Imaging Sciences and Biomedical Engineering, The Centre for the Developing Brain, St Thomas' Hospital, King's College London, London, UK
| | - Anthony N Price
- Division of Imaging Sciences and Biomedical Engineering, The Centre for the Developing Brain, St Thomas' Hospital, King's College London, London, UK
| | - Giuliana Durighel
- Imperial College and MRC Clinical Sciences Centre, Queen Charlotte's and Chelsea Hospital, London, UK
| | - Alan M Groves
- Division of Newborn Medicine, Weill Cornell Medical College, New York, New York, USA
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Wu TW, Azhibekov T, Seri I. Transitional Hemodynamics in Preterm Neonates: Clinical Relevance. Pediatr Neonatol 2016; 57:7-18. [PMID: 26482579 DOI: 10.1016/j.pedneo.2015.07.002] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 07/03/2015] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Each newborn enters this world facing tremendous respiratory, hemodynamic and neuroendocrine challenges while going through drastic physiological changes during the process of adaption from fetal to postnatal life. Even though the vast majority of term infants transition smoothly without apparent consequences, this task becomes increasingly arduous for the extremely preterm infant. METHODS & RESULTS This article reviews the physiology and pathophysiology of cardiovascular adaptation of the very preterm neonate. In particular it describes the physiology of fetal circulation, summarizes the hemodynamic changes occurring during preterm births and discusses the impact of the most frequently seen clinical scenarios that place additional burden on the premature infant during immediate transition. Finally an emphasis is placed on discussing common clinical dilemmas and practical aspects of developmental hemodynamics such as neonatal hypotension and patent ductus arteriosus; clinical presentations the neonatologist encounters on a daily basis. CONCLUSION The review provides a physiology-based view on the hemodynamics of the immediate postnatal transitional period.
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Affiliation(s)
- Tai-Wei Wu
- Division of Neonatology, Department of Pediatrics, Chang Gung Children's Hospital and Chang Gung Memorial Hospital, Chang Gung College of Medicine, Taoyuan, Taiwan
| | - Timur Azhibekov
- Division of Neonatology, Department of Pediatrics, Children's Hospital Los Angeles, CA, USA; Center for Fetal and Neonatal Medicine LAC+USC Medical Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Istvan Seri
- Center of Excellence in Neonatology, Department of Pediatrics, Sidra Medical and Research Center and Weill Cornell Medical College, Doha, Qatar.
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Mahoney L, Shah G, Crook D, Rojas-Anaya H, Rabe H. A Literature Review of the Pharmacokinetics and Pharmacodynamics of Dobutamine in Neonates. Pediatr Cardiol 2016; 37:14-23. [PMID: 26346024 DOI: 10.1007/s00246-015-1263-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 08/27/2015] [Indexed: 01/09/2023]
Abstract
Since its discovery in 1975 dobutamine has been used off-label for treating hemodynamic insufficiency in newborns and children. We present a structured literature review of pharmacokinetic and pharmacodynamic data for dobutamine in the pediatric population. Structured searches were conducted to identify relevant articles according to pre-defined inclusion criteria. Where possible, results for the pharmacodynamic and pharmacokinetic effect of dobutamine were reported as pooled data. Forty-six papers met the inclusion criteria. With regard to pharmacodynamic data a number of studies reported significant increases in a number of clinical parameters such as heart rate, blood pressure, cardiac output across a wide range of pediatric populations. With regard to pharmacokinetic data studies reported that the infusion rate was positively correlated to plasma dobutamine concentration. There was great variability with regard to dobutamine clearance between individuals and as to whether it followed first- or zero-order elimination kinetics. While the pharmacodynamic effects of dobutamine appear to reflect the pharmacological profile of the drug, the pharmacokinetic data are difficult to interpret due to inhomogeneity between study populations ages, comorbidities, dobutamine dosages and methodologies. High-quality prospective pharmacokinetic and pharmacodynamic data especially in newborns are urgently required prior to a large randomized study.
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Affiliation(s)
- Liam Mahoney
- Academic Department of Paediatrics, Brighton and Sussex Medical School, Royal Alexandra Children's Hospital, Level 6, Room 663, Eastern Road, Brighton, BN2 5BE, UK.
| | - Geetika Shah
- Academic Department of Paediatrics, Brighton and Sussex Medical School, Royal Alexandra Children's Hospital, Level 6, Room 663, Eastern Road, Brighton, BN2 5BE, UK
| | - David Crook
- Clinical Investigation and Research Unit, Royal Sussex County Hospital, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Hector Rojas-Anaya
- Academic Department of Paediatrics, Brighton and Sussex Medical School, Royal Alexandra Children's Hospital, Level 6, Room 663, Eastern Road, Brighton, BN2 5BE, UK
| | - Heike Rabe
- Academic Department of Paediatrics, Brighton and Sussex Medical School, Royal Alexandra Children's Hospital, Level 6, Room 663, Eastern Road, Brighton, BN2 5BE, UK
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Cardiovascular Transition of the Extremely Premature Infant and Challenges to Maintain Hemodynamic Stability. J Perinat Neonatal Nurs 2016; 30:68-72. [PMID: 26813394 DOI: 10.1097/jpn.0000000000000156] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The intricate fetal circulatory blood flow undergoes abrupt changes and restructuring at birth, allowing transition to extrauterine life and survival. In the extremely low-birth-weight newborn infant (birth weight <1000 g), these changes are affected by the immaturity of the fetal cardiovascular and pulmonary systems. The immature physiology associated with the inability to transition properly can lead to a poor prognosis and create problematic issues for the clinical management of these infants. Potentially problematic issues and complications include immature myocardium, adrenal insufficiency, patent ductus arteriosus, hypotension, and anemia. Understanding the unique transition to extrauterine life for these infants, problems that arise from immaturity and incomplete transition, and current approaches to management will help nurses and physicians caring for ELBW infants to improve the care they give and minimize mortality and morbidity in this vulnerable population. This article will review transitional physiology for term and preterm newborns, potential problems and complications, and current management approaches.
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Randomized, Placebo-Controlled Trial of Dobutamine for Low Superior Vena Cava Flow in Infants. J Pediatr 2015; 167:572-8.e1-2. [PMID: 26116470 DOI: 10.1016/j.jpeds.2015.05.037] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Revised: 04/16/2015] [Accepted: 05/20/2015] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To gather information for a future confirmatory trial of dobutamine (DB) for circulatory impairment (ie, low superior vena cava [SVC] flow). STUDY DESIGN A total of 127 infants born at < 31 weeks gestational age were serially scanned from birth to 96 hours after birth. The infants were randomly assigned to 2 groups and were treated with DB (stepwise dose increase, 5-10-15-20 μg/kg/min) or placebo if they had an SVC flow < 41 mL/kg/min within the first 24 hours after birth. The primary outcome measures were the achievement and maintenance of an SVC flow ≥ 41 mL/kg/min. Secondary outcome measures were the short-term evolution of clinical and biochemical variables, near-infrared spectroscopy, cranial Doppler ultrasound, and clinical outcomes. RESULTS SVC flow increased throughout the first 96 hours for the entire cohort. All of the randomized infants (n = 28) except 2 achieved and maintained an SVC flow ≥ 41 mL/kg/min after intervention; however, the infants treated with DB (n = 16) showed a higher heart rate and improved base excess compared with those treated with placebo (n = 12). Low SVC flow was associated with low gestational age (P = .02) and poor condition at birth (P = .02). Low SVC flow significantly increased the risk of severe ischemic events (OR, 13; 95% CI, 2.4-69.2; P < .01). CONCLUSION This exploratory trial demonstrates a tendency toward improved short-term clinical and biochemical perfusion variable outcomes in infants with low SVC flow treated with DB. TRIAL REGISTRATION ClinicalTrials.gov (NCT01605279) and the European Clinical Trials Database (EurodraCT 2009-010901-35).
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Abstract
Immediate clamping and cutting of the umbilical cord at birth has been the accepted standard of care for decades. The physiologic rationale relating umbilical cord clamping (UCC) to the events of the circulatory transition is not considered in arbitrarily recommended cord clamping times. Systematic review of early versus deferred UCC shows significant hemodynamic benefits to the deferred group. Mechanisms for this protective effect are considered in this review. The original concept of a placental transfusion with a volume load and prevention of low cardiac output relies on the physiological end point of the amount of blood transfused. The newer concept of an ordered physiological transition is increasingly supported. This model places aeration of the lungs and an increase in pulmonary blood flow back at the centre of the circulatory transition with timing of UCC being related to establishment of respiration. The need for "physiologically based" UCC is discussed.
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Affiliation(s)
- Martin Kluckow
- University of Sydney and Royal North Shore Hospital, Sydney, Australia.
| | - Stuart B Hooper
- The Ritchie Centre, MIMR-PHI Institute for Medical Research, Monash University, Melbourne, Australia
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da Costa CS, Czosnyka M, Smielewski P, Mitra S, Stevenson GN, Austin T. Monitoring of Cerebrovascular Reactivity for Determination of Optimal Blood Pressure in Preterm Infants. J Pediatr 2015; 167:86-91. [PMID: 25891381 DOI: 10.1016/j.jpeds.2015.03.041] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2014] [Revised: 01/27/2015] [Accepted: 03/18/2015] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To define levels of mean arterial blood pressure (MABP) where cerebrovascular reactivity is strongest in preterm infants (ie, optimal MABP, or MABPOPT) and correlate deviations from MABPOPT with mortality and intraventricular hemorrhage (IVH). STUDY DESIGN A total of 60 preterm infants born at median gestational age 26 ± 2 weeks (23 ± 2 to 32 ± 1) with indwelling arterial catheter were studied at a median 34 hours (range 5-228) of age. Tissue oxygenation heart rate (HR) reactivity index, which estimates cerebrovascular reactivity, was calculated as the moving correlation coefficient between slow waves of tissue oxygenation index, measured with near-infrared spectroscopy, and HR. MABPOPT was defined by dividing MABP into 2-mm Hg bins and averaging the tissue oxygenation HR reactivity index within those bins. A measurement of divergence from MABPOPT was calculated as the absolute difference between mean MABP and mean MABPOPT. RESULTS Individual MABPOPT was defined in 81% of the patients. A measurement of divergence from MABPOPT was greater in those patients who died (mean 4.2 mm Hg; 95% CI 3.33-4.96) compared with those who survived (mean 2.1 mm Hg; 95% CI 1.64-2.56), P = .013. Patients who had MABP lower than MABPOPT by 4 mm Hg or more had a greater rate of mortality (40%) than those with MABP close to or above MABPOPT (13%), P = .049. Patients with MABP greater than MABPOPT by 4 mm Hg had greater IVH scores, P = .042. CONCLUSIONS Continuous monitoring of cerebrovascular reactivity allows the determination of MABPOPT in preterm neonates. Significant deviation below MABPOPT was observed in infants who died. Deviation of MABP above optimal level was observed in infants who developed more severe IVH.
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Affiliation(s)
- Cristine Sortica da Costa
- Neonatal Unit, Rosie Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom.
| | - Marek Czosnyka
- Department of Clinical Neurosciences, Academic Neurosurgical Unit, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom; Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
| | - Peter Smielewski
- Department of Clinical Neurosciences, Academic Neurosurgical Unit, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Subhabrata Mitra
- Neonatal Unit, Elizabeth Garret Anderson Wing, University College London Hospital, London, United Kingdom
| | - Gordon N Stevenson
- Neonatal Unit, Rosie Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Topun Austin
- Neonatal Unit, Rosie Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
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