1
|
Bischoff AR, Backes CH, Rivera B, Jasani B, Patel F, Cheung E, Sathanandam S, Philip R, McNamara PJ. Cardiorespiratory Instability after Percutaneous Patent Ductus Arteriosus Closure: A Multicenter Cohort Study. J Pediatr 2024; 271:114052. [PMID: 38615941 DOI: 10.1016/j.jpeds.2024.114052] [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: 02/22/2024] [Revised: 04/01/2024] [Accepted: 04/08/2024] [Indexed: 04/16/2024]
Abstract
OBJECTIVE To evaluate postprocedural clinical characteristics of preterm infants undergoing transcatheter patent ductus arteriosus (PDA) closure, including oxygenation/ventilation failure and cardiovascular compromise. STUDY DESIGN Multicenter retrospective cohort study of preterm infants who were ≤2 kg at the time of percutaneous PDA closure between August 2018 and July 2021. Indices of cardiorespiratory stability were collected pre-closure, immediately post-closure, and subsequently averaged every 4 hours for the first 24 hours post-procedure. The primary outcome was incidence of post-transcatheter cardiorespiratory syndrome: composite of hemodynamic instability (defined by systemic hypotension, systemic hypertension, or use of new inotropes/vasopressors in the first 24 hours after catheterization) and at least one of the following: (i) ventilation failure or (ii) oxygenation failure. RESULTS A total of 197 patients were included with a median [IQR] age and weight at catheterization of 34 [25, 43] days and 1090 [900, 1367] grams, respectively. The primary composite outcome of post-transcatheter cardiorespiratory syndrome was reported in 46 (23.3%). CONCLUSION Post-transcatheter cardiorespiratory syndrome is characterized primarily by systemic hypertension and oxygenation failure, with a very low incidence of hypotension and need for inotropes.
Collapse
Affiliation(s)
- Adrianne R Bischoff
- Division of Neonatology, Department of Pediatrics, University of Iowa, Iowa City, IA
| | - Carl H Backes
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - Brian Rivera
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - Bonny Jasani
- Department of Pediatrics, The Hospital for Sick Children, Toronto, ON
| | - Foram Patel
- Department of Pediatrics, The Hospital for Sick Children, Toronto, ON
| | - Erica Cheung
- Department of Pediatrics, The Hospital for Sick Children, Toronto, ON
| | - Shyam Sathanandam
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN
| | - Ranjit Philip
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN
| | - Patrick J McNamara
- Division of Neonatology, Department of Pediatrics, University of Iowa, Iowa City, IA; Department of Internal Medicine, University of Iowa, Iowa City, IA.
| |
Collapse
|
2
|
Termerova J, Kubena AA, Liska K, Tomek V, Plavka R. Association between patent ductus arteriosus flow and home oxygen therapy in extremely preterm infants. Pediatr Res 2024; 96:208-215. [PMID: 38454005 PMCID: PMC11257949 DOI: 10.1038/s41390-024-03120-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 02/09/2024] [Accepted: 02/15/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Central blood flow measurements include the estimation of right and left ventricular output (RVO, LVO), superior vena cava (SVC) flow, and calculated patent ductus arteriosus (PDA) flow. We aimed to provide an overview of the maturation patterns of these values and the relationship between PDA flow and the need for home oxygen therapy. METHODS This prospective single-center study was conducted in infants born at <26 weeks of gestation. We performed echocardiographic measurements five times during their life (from the 4th post-natal day to the 36th postmenstrual week). RESULTS Sixty patients with a mean birth weight of 680 (590, 760) g were included. Postnatal development of LVO and PDA flow peaked at the end of the second postnatal week (427 and 66 mL/kg/min, respectively). The RVO increased between days 4 and 7-8. The SVCF was most stable. The development curves of PDA flow differed between the groups with (n = 28; 47%) and without home oxygen therapy. CONCLUSION We present the central blood flow values and their postnatal development in infants <26 weeks of gestation. This study demonstrates the association between PDA flow and the future need for home oxygen therapy. IMPACT This study enriches our knowledge of the long-term development of central blood flow parameters and derived patent ductus arteriosus (PDA) flow in extremely preterm infants (<26 weeks). While pulmonary resistance decreased, PDA flow continued to increase from day 4 to the end of the second week of life. Similarly, left ventricular output increased as a marker of preload. The superior vena cava flow remained stable. The observed association between PDA flow and an unfavorable respiratory outcome is important for future studies focusing on the prevention of chronic lung disease.
Collapse
Affiliation(s)
- Jana Termerova
- Department of Gynecology, Obstetrics and Neonatology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic.
| | - Ales A Kubena
- Institute of Medical Biochemistry and Laboratory Diagnostics, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Karel Liska
- Department of Gynecology, Obstetrics and Neonatology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Viktor Tomek
- Children's Heart Center, Second Faculty of Medicine, Charles University and Motol University Hospital in Prague, Prague, Czech Republic
| | - Richard Plavka
- Department of Gynecology, Obstetrics and Neonatology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| |
Collapse
|
3
|
Banerjee J, Khatib N, Mansfield RC, Sathiyamurthy S, Kariholu U, Lees C. Continuous non-invasive measurement of cardiac output in neonatal intensive care using regional impedance cardiography: a prospective observational study. Arch Dis Child Fetal Neonatal Ed 2024; 109:450-455. [PMID: 38123965 DOI: 10.1136/archdischild-2023-325941] [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: 06/10/2023] [Accepted: 12/02/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVES To compare agreement between echocardiography and regional impedance cardiography (RIC)-derived cardiac output (CO), and to construct indicative normative ranges of CO for gestational age groups. DESIGN, SETTING AND PARTICIPANTS Prospective cohort observational study performed in a tertiary centre in London, UK, including neonates born between 25 and 42 weeks' gestational age. EXPOSURES Neonates on the postnatal ward had 2 hours of RIC monitoring; neonates in intensive care had RIC monitoring for the first 72 hours, then weekly for 2 hours, with concomitant echocardiography measures. MAIN OUTCOMES AND MEASURES RIC was used to measure CO continuously. Statistical analyses were performed using R (V.4.2.2; R Core Team 2022). RIC-derived CO and echocardiography-derived CO were compared using Pearson's correlations and Bland-Altman analyses. Differences in RIC-derived CO between infants born extremely, very and late preterm were assessed using analyses of variance and mixed-effects modelling. RESULTS 127 neonates (22 extremely, 46 very, 29 late preterm and 30 term) were included. RIC and echocardiography-measured weight-adjusted CO were correlated (r=0.62, p<0.001) with a Bland-Altman bias of -31 mL/min/kg (limits of agreement -322 to 261 mL/min/kg). The RIC-derived CO fell over 12 hours, then increased until 72 hours after birth. The 72-hour weight-adjusted mean CO was higher in extremely preterm (424±158 mL/min/kg) compared with very (325±131 mL/min/kg, p<0.001) and late preterm (237±81 mL/min/kg, p<0.001) neonates; this difference disappeared by 2-3 weeks of age. CONCLUSIONS RIC is valid for continuous, non-invasive CO measurement in neonates. Indicative normative CO ranges could help clinicians to make more informed haemodynamic management decisions, which should be explored in future studies. TRIAL REGISTRATION NUMBER NCT04064177.
Collapse
Affiliation(s)
- Jayanta Banerjee
- Neonatology, Imperial College Healthcare NHS Trust, London, UK
- Institute of Reproductive and Developmental Biology, Imperial College London Institute of Clinical Sciences, London, UK
- Biomedical Research Centre, Imperial College Healthcare NHS Trust, London, UK
- Origins of Child Health and Disease, Centre for Paediatrics and Child Health, Imperial College London, London, UK
| | - Nidal Khatib
- Institute of Reproductive and Developmental Biology, Imperial College London Institute of Clinical Sciences, London, UK
- Biomedical Research Centre, Imperial College Healthcare NHS Trust, London, UK
| | - Roshni C Mansfield
- Neonatology, Imperial College Healthcare NHS Trust, London, UK
- Institute of Reproductive and Developmental Biology, Imperial College London Institute of Clinical Sciences, London, UK
- Biomedical Research Centre, Imperial College Healthcare NHS Trust, London, UK
| | | | - Ujwal Kariholu
- Neonatology, Imperial College Healthcare NHS Trust, London, UK
| | - Christoph Lees
- Institute of Reproductive and Developmental Biology, Imperial College London Institute of Clinical Sciences, London, UK
- Biomedical Research Centre, Imperial College Healthcare NHS Trust, London, UK
- Fetal Medicine, Queen Charlotte's and Chelsea Hospital, London, UK
| |
Collapse
|
4
|
Petoello E, Flore AI, Nogara S, Bonafiglia E, Lenzi MB, Arnone OC, Benfari G, Ciarcià M, Corsini I, De Waal K, Gottin L, Ficial B. Global longitudinal strain is an informative index of left ventricular performance in neonates receiving intensive care. Sci Rep 2024; 14:8881. [PMID: 38632330 PMCID: PMC11024117 DOI: 10.1038/s41598-024-59441-5] [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] [Received: 01/22/2024] [Accepted: 04/10/2024] [Indexed: 04/19/2024] Open
Abstract
Echocardiographic assessment of left ventricular function is crucial in NICU. The study aimed to compare the accuracy and agreement of global longitudinal strain (GLS) with conventional measurements. Real-life echocardiograms of neonates receiving intensive care were retrospectively reviewed. Shortening fraction (SF), ejection fraction (EF) and S' measurements were retrieved from health records. GLS was calculated offline from stored images. The association with stroke volume indexed for body weight (iSV) was evaluated by regression analysis. The diagnostic ability to identify uncompensated shock was assessed by ROC curve analysis. Cohen's κ was run to assess agreement. 334 echocardiograms of 155 neonates were evaluated. Mean ± SD gestational age and birth weight were 34.5 ± 4.1 weeks and 2264 ± 914 g, respectively. SF, EF, S' and GLS were associated with iSV with R2 of 0.133, 0.332, 0.252 and 0.633, (all p < .001). Including all variables in a regression model, iSV prediction showed an adjusted R2 of 0.667, (p < .001). GLS explained 73% of the model variance. GLS showed a better ability to diagnose uncompensated shock (AUC 0.956) compared to EF, S' and SF (AUC 0.757, 0.737 and 0.606, respectively). GLS showed a moderate agreement with EF (κ = .500, p < .001) and a limited agreement with S' and SF (κ = .260, p < .001, κ = .242, p < .001). GLS was a more informative index of left ventricular performance, providing the rationale for a more extensive use of GLS at the cotside.
Collapse
Affiliation(s)
- Enrico Petoello
- Neonatal Intensive Care Unit, University and Hospital Trust of Verona, P.le A. Stefani 1, 37126, Verona, Italy
| | - Alice Iride Flore
- Neonatal Intensive Care Unit, University and Hospital Trust of Verona, P.le A. Stefani 1, 37126, Verona, Italy
| | - Silvia Nogara
- Neonatal Intensive Care Unit, University and Hospital Trust of Verona, P.le A. Stefani 1, 37126, Verona, Italy
| | - Elena Bonafiglia
- Neonatal Intensive Care Unit, University and Hospital Trust of Verona, P.le A. Stefani 1, 37126, Verona, Italy
| | - Maria Beatrice Lenzi
- Neonatal Intensive Care Unit, University and Hospital Trust of Verona, P.le A. Stefani 1, 37126, Verona, Italy
| | - Olivia C Arnone
- Neonatal Intensive Care Unit, University and Hospital Trust of Verona, P.le A. Stefani 1, 37126, Verona, Italy
| | - Giovanni Benfari
- Section of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Martina Ciarcià
- Neonatal Intensive Care Unit, University and Hospital Trust of Verona, P.le A. Stefani 1, 37126, Verona, Italy
| | - Iuri Corsini
- Division of Neonatology, Careggi University Hospital of Florence, Florence, Italy
| | - Koert De Waal
- Department of Neonatology, John Hunter Children's Hospital, Newcastle, NSW, Australia
- University of Newcastle, Newcastle, NSW, Australia
| | - Leonardo Gottin
- Intensive Care Unit, Department of Surgery, Dentistry, Maternity and Infant, University and Hospital Trust of Verona, Verona, Italy
| | - Benjamim Ficial
- Neonatal Intensive Care Unit, University and Hospital Trust of Verona, P.le A. Stefani 1, 37126, Verona, Italy.
| |
Collapse
|
5
|
Petoello E, Kerkow E, Phad N, Ficial B, de Waal K. Which left atrial volume measurement should we use in the neonatal intensive care? Early Hum Dev 2024; 191:105985. [PMID: 38513546 DOI: 10.1016/j.earlhumdev.2024.105985] [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: 01/24/2024] [Revised: 03/01/2024] [Accepted: 03/03/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND Increased left atrial volume (LAV) is a marker of cardiovascular risk. Echocardiography standards to assess LAV in adults and children are the biplane area-length method (AL) and method of disks (MOD). LAV in neonatology is usually derived as M-mode ratio between the LA and the Aorta (LAAo). The aim of this study is to determine feasibility and reliability of these methods in neonatal clinical practice. METHODS Clinically indicated echocardiograms in neonatal intensive care patients were retrospectively analyzed. Feasibility was determined with an image quality score describing insonation angle, foreshortening and wall clarity. Reliability was determined with Bland-Altman and correlation coefficient analysis of intra- and inter-observer measurements. RESULTS 104 infants ranging from 23 to 39 weeks gestation were included. The feasibility of LAAo, AL and MOD was comparable (median image score 4 out of 6 points). Linear regression between AL and MOD was excellent (R2 0.99). LAAo best-fit with MOD was reached with curve-linear regression (R2 0.28) whereby a LAAo of 1.60 correlated with 1.24 ml/kg, but with a wide 95 % CI. The correlation coefficient within and between observers for LAAo, biplane AL, biplane MOD and monoplane MOD was 0.93 (0.87-0.96), 0.98 (0.96-0.99), 0.98 (0.96-0.99), 0.99 (0.97-0.99) and 0.58 (0.11-0.81), 0.75 (0.44-0.89), 0.92 (0.88-0.98), 0.96 (0.88-0.98) respectively. CONCLUSION All methods were equally feasible and reliable when repeated by the same observer, but LAAo reliability was poor when repeated by a different observer. Biplane MOD was the most reliable and thus recommended in neonatal practice. Monoplane MOD performed well and could be considered as alternative but might be less accurate.
Collapse
Affiliation(s)
- Enrico Petoello
- John Hunter Children's Hospital, Department of Neonatology, Newcastle, NSW, Australia; Neonatal Intensive Care Unit, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy.
| | - Emma Kerkow
- John Hunter Children's Hospital, Department of Neonatology, Newcastle, NSW, Australia
| | - Nilkant Phad
- John Hunter Children's Hospital, Department of Neonatology, Newcastle, NSW, Australia; University of Newcastle, Newcastle, NSW, Australia
| | - Benjamim Ficial
- Neonatal Intensive Care Unit, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Koert de Waal
- John Hunter Children's Hospital, Department of Neonatology, Newcastle, NSW, Australia; University of Newcastle, Newcastle, NSW, Australia
| |
Collapse
|
6
|
McNamara PJ, Jain A, El-Khuffash A, Giesinger R, Weisz D, Freud L, Levy PT, Bhombal S, de Boode W, Leone T, Richards B, Singh Y, Acevedo JM, Simpson J, Noori S, Lai WW. Guidelines and Recommendations for Targeted Neonatal Echocardiography and Cardiac Point-of-Care Ultrasound in the Neonatal Intensive Care Unit: An Update from the American Society of Echocardiography. J Am Soc Echocardiogr 2024; 37:171-215. [PMID: 38309835 DOI: 10.1016/j.echo.2023.11.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2024]
Abstract
Targeted neonatal echocardiography (TNE) involves the use of comprehensive echocardiography to appraise cardiovascular physiology and neonatal hemodynamics to enhance diagnostic and therapeutic precision in the neonatal intensive care unit. Since the last publication of guidelines for TNE in 2011, the field has matured through the development of formalized neonatal hemodynamics fellowships, clinical programs, and the expansion of scientific knowledge to further enhance clinical care. The most common indications for TNE include adjudication of hemodynamic significance of a patent ductus arteriosus, evaluation of acute and chronic pulmonary hypertension, evaluation of right and left ventricular systolic and/or diastolic function, and screening for pericardial effusions and/or malpositioned central catheters. Neonatal cardiac point-of-care ultrasound (cPOCUS) is a limited cardiovascular evaluation which may include line tip evaluation, identification of pericardial effusion and differentiation of hypovolemia from severe impairment in myocardial contractility in the hemodynamically unstable neonate. This document is the product of an American Society of Echocardiography task force composed of representatives from neonatology-hemodynamics, pediatric cardiology, pediatric cardiac sonography, and neonatology-cPOCUS. This document provides (1) guidance on the purpose and rationale for both TNE and cPOCUS, (2) an overview of the components of a standard TNE and cPOCUS evaluation, (3) disease and/or clinical scenario-based indications for TNE, (4) training and competency-based evaluative requirements for both TNE and cPOCUS, and (5) components of quality assurance. The writing group would like to acknowledge the contributions of Dr. Regan Giesinger who sadly passed during the final revisions phase of these guidelines. Her contributions to the field of neonatal hemodynamics were immense.
Collapse
Affiliation(s)
| | - Amish Jain
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Afif El-Khuffash
- Department of Paediatrics, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Regan Giesinger
- Department of Pediatrics, University of Iowa, Iowa City, Iowa
| | - Dany Weisz
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Lindsey Freud
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Philip T Levy
- Division of Newborn Medicine, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Shazia Bhombal
- Department of Pediatrics, Division of Neonatology, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Willem de Boode
- Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, the Netherlands
| | - Tina Leone
- Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | | | - Yogen Singh
- Loma Linda University School of Medicine, Loma Linda, California
| | - Jennifer M Acevedo
- Department of Pediatrics-Cardiology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - John Simpson
- Department of Pediatrics, Evelina London Children's Hospital, London, United Kingdom
| | - Shahab Noori
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Wyman W Lai
- CHOC Children's Hospital, Orange, California; University of California, Irvine, Orange, California
| |
Collapse
|
7
|
Cave DG, Bautista MJ, Mustafa K, Bentham JR. Cardiac output monitoring in children: a review. Arch Dis Child 2023; 108:949-955. [PMID: 36927620 DOI: 10.1136/archdischild-2022-325030] [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: 11/04/2022] [Accepted: 03/02/2023] [Indexed: 03/18/2023]
Abstract
Cardiac output monitoring enables physiology-directed management of critically ill children and aids in the early detection of clinical deterioration. Multiple invasive techniques have been developed and have demonstrated ability to improve clinical outcomes. However, all require invasive arterial or venous catheters, with associated risks of infection, thrombosis and vascular injury. Non-invasive monitoring of cardiac output and fluid responsiveness in infants and children is an active area of interest and several proven techniques are available. Novel non-invasive cardiac output monitors offer a promising alternative to echocardiography and have proven their ability to influence clinical practice. Assessment of perfusion remains a challenge; however, technologies such as near-infrared spectroscopy and photoplethysmography may prove valuable clinical adjuncts in the future.
Collapse
Affiliation(s)
- Daniel Gw Cave
- Leeds Congenital Heart Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Leeds Institute for Data Analytics, University of Leeds, Leeds, West Yorkshire, UK
| | - Melissa J Bautista
- General Surgery, St James's University Hospital, Leeds, West Yorkshire, UK
- General Surgery, University of Leeds, Leeds, West Yorkshire, UK
| | - Khurram Mustafa
- Paediatric Intensive Care, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - James R Bentham
- Leeds Congenital Heart Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| |
Collapse
|
8
|
Dinh J, Johnson TN, Grimstein M, Lewis T. Physiologically Based Pharmacokinetics Modeling in the Neonatal Population-Current Advances, Challenges, and Opportunities. Pharmaceutics 2023; 15:2579. [PMID: 38004559 PMCID: PMC10675397 DOI: 10.3390/pharmaceutics15112579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 10/24/2023] [Accepted: 10/29/2023] [Indexed: 11/26/2023] Open
Abstract
Physiologically based pharmacokinetic (PBPK) modeling is an approach to predicting drug pharmacokinetics, using knowledge of the human physiology involved and drug physiochemical properties. This approach is useful when predicting drug pharmacokinetics in under-studied populations, such as pediatrics. PBPK modeling is a particularly important tool for dose optimization for the neonatal population, given that clinical trials rarely include this patient population. However, important knowledge gaps exist for neonates, resulting in uncertainty with the model predictions. This review aims to outline the sources of variability that should be considered with developing a neonatal PBPK model, the data that are currently available for the neonatal ontogeny, and lastly to highlight the data gaps where further research would be needed.
Collapse
Affiliation(s)
- Jean Dinh
- Certara UK Limited, Sheffield S1 2BJ, UK; (J.D.); (T.N.J.)
| | | | - Manuela Grimstein
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD 20903, USA
| | - Tamorah Lewis
- Pediatric Clinical Pharmacology & Toxicology, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
| |
Collapse
|
9
|
Huang J, Singh Y, Adie M, Noori S, Ebrahimi M, Durand M, Cayabyab R, Ramanathan R. Effect of assessing velocity time integral at different locations across ventricular outflow tracts when calculating cardiac output in neonates. Eur J Pediatr 2023; 182:4433-4441. [PMID: 37490109 PMCID: PMC10593614 DOI: 10.1007/s00431-023-05121-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/29/2023] [Accepted: 07/15/2023] [Indexed: 07/26/2023]
Abstract
This study aims to evaluate the effect of assessing velocity time integral at different locations across ventricular outflow tracts for calculating cardiac output (CO) in neonates. Velocity time integral (VTI) and CO were measured at 3 different locations across right and left ventricular outflow tracts using transthoracic echocardiography in healthy term neonates without any major congenital heart disease. ANOVA with Bonferroni correction was used to determine the differences between the VTI and CO sampled at these three locations. Forty-one neonates met inclusion criteria with mean gestational age of 38.6 ± 1 weeks and mean birth weight of 3155 ± 463 g. The median hours after birth when echocardiography was obtained was 23 h (range 11-68 h after birth). Left CO were 121 ± 30 mL/kg/min, 155 ± 38 mL/kg/min, and 176 ± 36 mL/kg/min measured below the valve, hinges of the valve, and tip of the valve, respectively. Right CO were 197 ± 73 mL/kg/min, 270 ± 83 mL/kg/min, and 329 ± 104 mL/kg/min measured below the valve, hinges of the valve, and tip of the valve, respectively. A statistically significant difference (P < 0.001) was found in the VTI and CO measured at the 3 different locations across both left and right ventricular outflow tracts. Conclusions: There is a significant difference in measurements of VTI and CO depending on the location of Doppler gate sampling across the ventricular outflow tracts. Consistency and precision in Doppler gate location are essential for measuring VTI and calculating CO while assessing changes in hemodynamic status in critically ill infants. What is Known: • Targeted Neonatal Echocardiography is increasingly applied to measure cardiac output in critically ill neonates and serial assessments are performed to assess the trend in changes in cardiac output. • Noninvasive measurement using velocity time integral to calculate cardiac output is commonly performed. However, location of Doppler sample gate to measure ventricular outflow tract velocity time integral is not consistent. What is New: • Statistically significant changes in measured velocity time integral and cardiac output are noted based on the location of Doppler gate sampling. • To monitor the cardiac output for trending, it is important to be consistent with regards to the location of the Doppler sample gate to assess changes in cardiac output in critically ill newborns.
Collapse
Affiliation(s)
- Jane Huang
- Division of Neonatology, Department of Pediatrics, LAC+USC Medical Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| | - Yogen Singh
- Division of Neonatology, Department of Pediatrics, LAC+USC Medical Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Division of Neonatology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Mohammad Adie
- Division of Neonatology, Department of Pediatrics, LAC+USC Medical Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Shahab Noori
- Fetal and Neonatal Institute, Division of Neonatology, Department of Pediatrics, Keck School of Medicine, Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA, USA
| | - Mahmood Ebrahimi
- Division of Neonatology, Department of Pediatrics, LAC+USC Medical Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Manuel Durand
- Division of Neonatology, Department of Pediatrics, LAC+USC Medical Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Rowena Cayabyab
- Division of Neonatology, Department of Pediatrics, LAC+USC Medical Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Rangasamy Ramanathan
- Division of Neonatology, Department of Pediatrics, LAC+USC Medical Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| |
Collapse
|
10
|
Shin JA, Lee JY, Yum SK. Echocardiographic assessment of brain sparing in small-for-gestational age infants and association with neonatal outcomes. Sci Rep 2023; 13:10248. [PMID: 37353588 PMCID: PMC10290080 DOI: 10.1038/s41598-023-37376-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 06/20/2023] [Indexed: 06/25/2023] Open
Abstract
Brain sparing is an adaptive phenomenon (redistribution of blood flow to the brain) observed in fetuses exposed to chronic hypoxia, who are at risk of intrauterine growth restriction. Here, we assessed the blood flow distribution during the early neonatal period (< 7 days of life) using echocardiography, and evaluated the impact of brain-sparing on postnatal course and neurodevelopmental outcomes. This retrospective study included 42 small-for-gestational age (SGA) infants [further classified into asymmetric SGA (a-SGA, n = 21) and symmetric SGA (s-SGA, n = 21) groups according to their birth head circumference percentiles], and 1: 2 matched appropriate-for-gestational age (AGA) infants (n = 84) admitted to the neonatal intensive care unit. Left ventricular (LV) stroke volume, LV cardiac output (LVCO), upper body blood flow (UBBF), and UBBF/LVCO ratio (%) were significantly higher in both a-SGA and s-SGA infants than in AGA infants. Both a-SGA and s-SGA groups consisted predominantly of infants with higher UBBF/LVCO (%). A UBBF/LVCO ≥ 58.2% (3rd interquartile range) was associated with a later need for rehabilitative therapy after discharge. In summary, brain-sparing effect may continue during the early postnatal life in SGA infants, and may be a promising marker to detect future adverse neurodevelopmental outcomes.
Collapse
Affiliation(s)
- Ju Ae Shin
- Department of Pediatrics, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-Daero, Seocho-Gu, Seoul, 06591, Republic of Korea
| | - Jae Young Lee
- Department of Pediatrics, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-Daero, Seocho-Gu, Seoul, 06591, Republic of Korea
| | - Sook Kyung Yum
- Department of Pediatrics, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-Daero, Seocho-Gu, Seoul, 06591, Republic of Korea.
| |
Collapse
|
11
|
A novel echocardiography method to assess upper body systemic blood flow in preterm infants and comparison with superior vena cava flow measurement. Eur J Pediatr 2023; 182:1839-1845. [PMID: 36795189 PMCID: PMC10167188 DOI: 10.1007/s00431-023-04866-9] [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: 09/18/2022] [Revised: 01/31/2023] [Accepted: 02/04/2023] [Indexed: 02/17/2023]
Abstract
UNLABELLED To evaluate feasibility, reproducibility, and prognostic value of a new echocardiographic method to assess systemic arterial blood flow directed to the upper part of the body (UBAF, upper body arterial flow) alternative to superior vena cava flow (SVCF) measurement. We performed echocardiographic evaluations in 106 infants in the first 2 days of life to obtain SVCF, left ventricle output (LVO), UBAF, and standard parameters of patent ductus arteriosus (PDA) significance. UBAF was calculated by subtracting from LVO the aortic arch blood flow measured immediately distally to the origin of the left subclavian artery. Main outcome measures: UBAF and SVCF agreement was assessed by Bland-Altman analysis in terms of bias, limits of agreement and repeatability index. The Intraclass Correlation Coefficient was used to measure the strength of inter-rater agreement. The agreement between UBAF and SVCF was high. The Concordance Correlation Coefficient (CCC) was 0.7434. (CCC 0.7434, 95% C.I. [0.656, 0.8111]). There was a good absolute agreement between the two raters ICC = 0.747; p value < 0.0001; 95%CI [0.601; 0.845]. Adjusting for confounding factors (BW, GA, PDA) included in the model, there was a statistically significant relationship between UBAF and SVCF. CONCLUSION UBAF showed a strong agreement with the SCVF with a better reproducibility. Our data support UBAF as a potentially useful marker of cerebral perfusion in the evaluation of preterm infants. WHAT IS KNOWN • Low SVC (superior vena cava) flow in the neonatal period has been associated with periventricular haemorrhage and unfavourable long-term neurodevelopmental outcome. • Ultrasound measurement of flow in SVC shows relatively high inter-operator variability. WHAT IS NEW • Our study highlights how much overlap there is between upper-body arterial flow (UBAF) measurement and SCV flow measurement. UBAF is easier to perform and has a strong correlation with better reproducibility. • UBAF may replace measurement of cava flow as a method for haemodynamic monitoring of unstable preterm and asphyxiated infants.
Collapse
|
12
|
Riccardi R, Barone G, Iannotta R, Prontera G, D'Andrea V, Vento G. Normal values for superior vena cava flow in preterm neonates using a new echocardiographic approach. Echocardiography 2023; 40:45-50. [PMID: 36478465 DOI: 10.1111/echo.15507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 10/17/2022] [Accepted: 11/27/2022] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE Recently, a novel approach to imaging Superior Vena Cava (SVC) flow has been presented, showing better repeatability and better agreement with MRI-derived SVC flow measures. The objective was to establish normal values of SVC flow with the novel approach in the first 48 h of life. STUDY DESIGN This was a prospective, observational study. All infants with gestational age (GA) less than 31 weeks were eligible. Echocardiographic evaluation was performed at 5, 12, 24, 48 h of postnatal life. A subgroup of uncomplicated infants was studied to define a normal range for SVC flow. RESULTS Forty-five infants were enrolled. We estimated normative values in a subgroup of 31 uncomplicated infants. The median SVC flow significantly increases from 83 ml/kg/min at 5 h of life to 153 ml/kg/min at 48 h (p < .001). CONCLUSION Using the novel approach we derived normal values of SVC flow in a cohort of uncomplicated preterm population at high risk for developing IVH.
Collapse
Affiliation(s)
- Riccardo Riccardi
- Neonatal Intensive Care Unit, "San Giovanni Calibita Fatebenefratelli" Hospital, Isola Tiberina, Rome, Italy
| | - Giovanni Barone
- Neonatal Intensive Care Unit, Infermi Hospital, Rimini, Italy
| | - Rossella Iannotta
- Neonatal Intensive Care Unit, 'Sacro Cuore di Gesù' Fatebenefratelli Hospital, Benevento, Italy
| | - Giorgia Prontera
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Vito D'Andrea
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Giovanni Vento
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| |
Collapse
|
13
|
Echocardiographic Quantification of Superior Vena Cava (SVC) Flow in Neonates: Pilot Study of Modified Technique. Diagnostics (Basel) 2022; 12:diagnostics12092083. [PMID: 36140485 PMCID: PMC9498289 DOI: 10.3390/diagnostics12092083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 08/10/2022] [Accepted: 08/25/2022] [Indexed: 11/23/2022] Open
Abstract
Ultrasound Superior Vena Cava (SVC) flow assessment is a common measure of systemic and cerebral perfusion, although accuracy is limited. The aim of this study was to evaluate whether any improvements in accuracy could be achieved by measuring stroke distance from the instantaneous mean velocity, rather than from peak velocity, and by directly tracing area from images obtained with a high frequency linear probe. Paired phase contrast magnetic resonance imaging (PCMRI) and ultrasound assessments of SVC flow were performed in a pilot cohort of 7 infants. Median postnatal age, corrected gestation and weight at scan were 7 (2–74) days, 34.8 (31.7–37.2) weeks 1870 (970–2660) g. Median interval between PCMRI and ultrasound scans was 0.3 (0.2–0.5) h. The methodology trialed here showed a better agreement with PCMRI (mean bias −8 mL/kg/min, LOA −25–+8 mL/kg/min), compared to both the original method reported by Kluckow et al. (mean bias + 42 mL/kg/min, LOA −53–+137 mL/kg/min), and our own prior adaptation (mean bias + 23 mL/kg/min, LOA −25–+71 mL/kg/min). Ultrasound assessment of SVC flow volume using the modifications described led to enhanced accuracy and decreased variability compared to prior techniques in a small cohort of premature infants.
Collapse
|
14
|
Ficial B, Bonafiglia E, Gangemi A, Clemente M, Cappelleri A, Corsini I, Biban P. Impact of Aortic Diameter Measurements at Three Anatomical Landmarks on Left Ventricular Output Calculation in Neonates. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2022; 41:1187-1194. [PMID: 34423855 DOI: 10.1002/jum.15808] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 07/04/2021] [Accepted: 07/24/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES To assess reproducibility and accuracy of left ventricular output (LVO) quantifications in neonates, when left ventricular outflow tract diameter (LVOTD) was measured at the hinges of the aortic valve (AV), at the aortic sinus (AS), and at the sinotubular junction (STJ). METHODS This was an observational study. In the first cohort of very preterm neonates, we assessed intraobserver and interobserver repeatability of LVOTD measured at the AV, AS, and STJ and of the corresponding LVO. In the second cohort of older neonates, we compared paired LVO measurements by echo and magnetic resonance imaging (MRI). RESULTS In the first cohort of 48 neonates, mean (standard deviation) weight and age at scan were 1046 (302) g and 28.1 (2.7) weeks. Interobserver bias (95% limits of agreement [LOA]) for LVOTD at the AV, AS, and STJ was 0 (-0.3 to 0.3) mm, 0 (-0.7 to 0.7) mm, and 0 (-0.8 to 0.7) mm, respectively. Interobserver bias (95% LOA) for the corresponding LVO was -1.3 (-31 to 33) ml/kg/min, -0.5 (-88 to 87) ml/kg/min, and -7.2 (-83 to 69) ml/kg/min, respectively. In the second cohort of 10 neonates, median (range) weight and age at scan were 1942 (970-3640) g and 37.2 (31.7-39.8) weeks. LVO measured at the AV showed stronger agreement with MRI: bias (LOA) -10.6 (-74 to 52) ml/kg/min, compared to LVO measured at AS and STJ: 194 (-0.5 to 388) ml/kg/min and 43 (-72 to 159) ml/kg/min respectively. CONCLUSIONS Reproducibility and accuracy of LVO quantification by echo were better when aortic diameter was measured at AV.
Collapse
Affiliation(s)
- Benjamim Ficial
- Neonatal Intensive Care Unit, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Elena Bonafiglia
- Neonatal Intensive Care Unit, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Antonella Gangemi
- Department of Health Promotion Sciences Maternal and Infantile Care, Internal Medicine and Medical Specialties "G. D'Alessandro", University of Palermo, Palermo, Italy
| | - Maria Clemente
- Neonatal Intensive Care Unit, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Alessia Cappelleri
- Neonatal Intensive Care Unit, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Iuri Corsini
- Division of Neonatology, Careggi University Hospital of Florence, Florence, Italy
| | - Paolo Biban
- Neonatal Intensive Care Unit, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| |
Collapse
|
15
|
Abstract
In evaluating vitamin E (VE) nutritional status of preterm infants, it is essential that any data should be compared with those of healthy term infants, and never with those of adults. Moreover, it should be evaluated in terms of gestational age (GA), not birth weight (BW), because placental transfer of most nutrients from mother to fetus is dependent on GA, not BW. Judging from the limited data during the last 75 years, there was no significant correlation between GA and VE concentrations in circulation or in the red blood cells (RBCs), leukocytes, and buccal mucosal cells. In addition, the oxidizability of polyunsaturated fatty acids (PUFAs) in plasma or RBCs, as targets for protection by VE chain-breaking ability, was lower in preterm infants. However, because of the minimal information available about hepatic VE levels, which is considered a key determinant of whole body VE status, the decision on whether VE status of preterm infants is comparable with that of term infants should be postponed. Clinical trials of VE supplementation in preterm infants were repeatedly undertaken to investigate whether VE reduces severity or inhibits development of several diseases specific to preterm infants, namely retinopathy of prematurity (ROP), bronchopulmonary dysplasia (BPD), and germinal matrix hemorrhage - intraventricular hemorrhage (GMH-IVH). Most of these trials resulted in a misfire, with a few exceptions for IVH prevention. However, almost all these studies were performed from 1980s to early 1990s, in the pre-surfactant era, and the study populations were composed of mid-preterm infants with GAs of approximately 30 weeks (wks). There is considerable difference in 'preterm infants' between the pre- and post-surfactant eras; modern neonatal medicine mainly treats preterm infants of 28 wks GA or less. Therefore, these results are difficult to apply in modern neonatal care. Before considering new trials of VE supplementation, we should fully understand modern neonatal medicine, especially the recent method of oxygen supplementation. Additionally, a deeper understanding of recent progress in pathophysiology and therapies for possible target diseases is necessary to decide whether VE administration is still worth re-challenging in modern neonatal intensive care units (NICUs). In this review, we present recent concepts and therapeutic trends in ROP, BPD, and GMH-IVH for those unfamiliar with neonatal medicine. Numerous studies have reported the possible involvement of reactive oxygen species (ROS)-induced damage in relation to supplemental oxygen use, inflammation, and immature antioxidant defense in the development of both BPD and ROP. Various antioxidants effectively prevented the exacerbation of BPD and ROP in animal models. In the future, VE should be re-attempted as a complementary factor in combination with various therapies for BPD, ROP, and GMH-IVH. Because VE is a natural and safe supplement, we are certain that it will attract attention again in preterm medicine.
Collapse
Affiliation(s)
- Tohru Ogihara
- Division of Neonatology, Department of Pediatrics, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan.
| | - Makoto Mino
- Division of Neonatology, Department of Pediatrics, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| |
Collapse
|
16
|
Feasibility, Reproducibility and Reference Ranges of Left Atrial Strain in Preterm and Term Neonates in the First 48 h of Life. Diagnostics (Basel) 2022; 12:diagnostics12020350. [PMID: 35204441 PMCID: PMC8871374 DOI: 10.3390/diagnostics12020350] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 01/22/2022] [Accepted: 01/27/2022] [Indexed: 11/17/2022] Open
Abstract
Left atrial strain (LAS) is the most promising technique for assessment of diastolic dysfunction but few data are available in neonates. Our aim was to assess feasibility and reproducibility, and to provide reference ranges of LAS in healthy neonates in the first 48 h of life. We performed one echocardiography in 30 neonates to assess feasibility and develop a standard protocol for image acquisition and analysis. LAS reservoir (LASr), conduit (LAScd) and contraction (LASct) were measured. We performed echocardiography at 24 and 48 h of life in an unrelated cohort of 90 neonates. Median (range) gestational age and weight of the first cohort were 34.4 (26.4–40.2) weeks and 2075 (660–3680) g. LAS feasibility was 96.7%. Mean (SD) gestational age and weight of the second cohort were 34.2 (3.8) weeks and 2162 (833) g. Mean (SD) LASr significantly increased from 24 to 48 h: 32.9 (3.2) to 36.8 (4.6). Mean (SD) LAScd and LASct were stable: −20.6 (8.0) and −20.8 (9.9), −11.6 (4.9) and −13.5 (6.4). Intra and interobserver intraclass correlation coefficient for LASr, LAScd and LASct were 0.992, 0.993, 0.986 and 0.936, 0.938 and 0.871, respectively. We showed high feasibility and reproducibility of LAS in neonates and provided reference ranges.
Collapse
|
17
|
Characterization of the Ejector Pump Performance for the Assisted Bidirectional Glenn Procedure. FLUIDS 2022. [DOI: 10.3390/fluids7010031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
This study introduces an algebraic model informed by computational fluid dynamics (CFD) simulations to investigate the performance of the assisted bidirectional Glenn (ABG) operation on a broad range of conditions. The performance of this operation, as measured by the superior vena cava (SVC) pressure, depends on the nozzle area in its ejector pump and the patient’s pulmonary vascular resistance (PVR). Using the developed algebraic model to explore this two-dimensional parameter space shows that the ejector pump can create a pressure difference between the pulmonary artery and the SVC as high as 5 mmHg. The lowest SVC pressure is produced at a nozzle area that decreases linearly with the PVR such that, at PVR =4.2 (Wood units-m2), there is no added benefit in utilizing the ejector pump effect (optimal nozzle area is zero, corresponding to the bidirectional Glenn circulation). At PVR =2 (Wood units-m2), the SVC pressure can be lowered to less than 4 mmHg by using an optimal nozzle area of ≈2.5 mm2. Regardless of the PVR, adding a 2 mm2 nozzle to the baseline bidirectional Glenn boosts the oxygen saturation and delivery by at least 15%. The SVC pressure for that 2 mm2 nozzle remains below 14 mmHg for all PVRs less than 7 Wood units-m2. The mechanical efficiency of the optimal designs consistently remains below 30%, indicating the potential for improvement in the future. A good agreement is observed between the algebraic model and high-fidelity CFD simulations.
Collapse
|
18
|
Nestaas E. Neonatologist Performed Echocardiography for Evaluating the Newborn Infant. Front Pediatr 2022; 10:853205. [PMID: 35402362 PMCID: PMC8987714 DOI: 10.3389/fped.2022.853205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 02/03/2022] [Indexed: 11/13/2022] Open
Abstract
The interest in the use of cardiac ultrasound for hemodynamic evaluation in neonates has increased in the last decades. Several overlapping terms exists, and a non-comprehensive list includes point-of-care ultrasound, clinician-performed ultrasound, focused cardiac ultrasound, targeted neonatal echocardiography, and neonatologist performed echocardiography. This review will use the term neonatologist performed echocardiography. Neonatologist performed echocardiography is primarily echocardiography to obtain snapshots of hemodynamics and heart function, usually as repeated exams during intensive care. It provides the neonatologist with in-depth information on the hemodynamics not available by blood pressure, pulse oximetry, capillary refill time, and various blood tests. The review provides a brief overview of some relevant methods for assessment of hemodynamics and heart function. It does not discuss training, implementation, accreditation, and certification nor in-depth technical aspects and detailed use of neonatologist performed echocardiography. If the information obtainable by neonatologist performed echocardiography had been accessible easily (e.g., via a sensor put on the neonate similarly to a pulse oximeter), neonatologist performed echocardiography would have been more widely used. Acquiring skills for neonatologist performed echocardiography take time and resources. Future developments probably include a stronger focus on education, training, and certification. It is likely that echocardiographic methods will evolve further, probably involving establishing new indexes and methods and implementing artificial intelligence in the analyses procedure to improve accuracy and workflow. It is important to acknowledge that neonatologist performed echocardiography is not a therapeutic intervention; it is a diagnostic tool providing additional information.
Collapse
Affiliation(s)
- Eirik Nestaas
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Clinic of Pediatrics and Adolesence, Akershus University Hospital, Nordbyhagen, Norway
| |
Collapse
|
19
|
Pereira SS. Comparison of Left Ventricular Outflow Tract Diameter Measurements Using Echocardiography in Newborn Infants. Am J Perinatol 2021; 38:1480-1482. [PMID: 32604447 DOI: 10.1055/s-0040-1713653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE This study aimed to compare left ventricular outflow tract (LVOT) diameter measurements using two-dimensional (2D) echocardiography at the sino-tubular junction (STJ) and at the aortic valve (AV) hinges in newborn infants. STUDY DESIGN This is a retrospective study in a tertiary neonatal unit where infants underwent echocardiography for evaluation of murmur or as part of cardiovascular assessment. Three consecutive cardiac cycles were chosen to measure the LVOT diameter in end systole at the STJ and at the AV hinges. Bias and levels of agreement were examined using Bland-Altman plot. Intraobserver variability was examined using intraclass correlation. RESULTS A total of 366 measurements were obtained from 61 infants with a mean (standard deviation) gestation and birth weight of 33.4 (6.9) weeks and 2,181 (1369) g, respectively. There was good correlation between the LVOT diameter measurements using the STJ and AV hinges (r = 0.958, p < 0.001). The mean (standard deviation and 95% confidence interval) bias between LVOT diameter measurements using STJ and AV hinges were 0.93 (0.45 and 0.06-1.81) mm. There was good intraobserver variability between the measurements using both methods. CONCLUSION Using 2D echocardiography, LVOT measurements using the STJ tend to be higher when compared with LVOT measurements using the AV hinges. KEY POINTS · Echocardiographic assessment of left ventricular output is undertaken frequently.. · Left ventricular outflow tract can be measured at the aortic valve hinges, sinus of valsalva, or sino-tubular junction.. · Left ventricular outflow tract measured at the sino-tubular junction tends to higher when compared with aortic valve.
Collapse
Affiliation(s)
- Sujith S Pereira
- Neonatal Unit, Homerton University Hospital NHS Foundation Trust, London, United Kingdom.,Centre for Genomics and Child Health, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| |
Collapse
|
20
|
Singh Y, Bhombal S, Katheria A, Tissot C, Fraga MV. The evolution of cardiac point of care ultrasound for the neonatologist. Eur J Pediatr 2021; 180:3565-3575. [PMID: 34125292 DOI: 10.1007/s00431-021-04153-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 06/06/2021] [Accepted: 06/09/2021] [Indexed: 01/22/2023]
Abstract
Cardiac point of care ultrasound (POCUS) is increasingly being utilized in neonatal intensive care units to provide information in real time to aid clinical decision making. While training programs and scope of practice have been well defined for other specialties, such as adult critical care and emergency medicine, there is a lack of structure for neonatal cardiac POCUS. A more comprehensive and advanced hemodynamic evaluation by a neonatologist has previously published its own clinical guidelines and specific rigorous training programs have been established to achieve competency in neonatal hemodynamics. However, it is becoming increasingly evident that access and training for basic cardiac assessment by ultrasound enhances bedside clinical care for specific indications. Recently, expert consensus POCUS guidelines for use in neonatal and pediatric intensive care endorsed by the European Society of Pediatric and Neonatal Intensive Care (ESPNIC) have been published to guide the clinicians in using POCUS for specific indications, though the line between cardiac POCUS and advanced hemodynamic evaluation remains somewhat fluid.Conclusion: This article is focused on neonatal cardiac POCUS and its evolution, value, and limitations in the modern neonatal clinical practice. Cardiac POCUS can provide physiological and hemodynamic information in making clinical decisions while dealing with neonatal emergencies. However, it should be applied only for the specific indications and should be performed by a clinician trained in cardiac POCUS. There is an urgent need of developing cardiac POCUS curriculum and certification to support a widespread and safe use in neonates. What is Known: • International training guidelines and curriculum have been published for neonatologist-performed echocardiography (NPE) or targeted neonatal echocardiography (TNE). • International evidence-based guidelines for use of point of care ultrasound (POCUS) in neonates and children have been recently published. What is New: • Cardiac POCUS is increasingly being incorporated in neonatal practice for emergency situations. However, one must be aware of its specific indications and limitations, especially for the neonatal clinical practice. • Cardiac POCUS and NPE/TNE are continuum of cardiac imaging with different indications and training requirements.
Collapse
Affiliation(s)
- Yogen Singh
- Department of Pediatrics - Neonatology and Pediatric Cardiology, Addenbrooke's Hospital, Cambridge University Hospitals, Box 402, NICU, Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK. .,Departmet of Pediatrics, Division of Neonatology, Loma Linda University School of Medicine, Loma Linda, CA, USA.
| | - Shazia Bhombal
- Department of Pediatrics, Division of Neonatal and Behavioral Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Anup Katheria
- Department of Neonatology, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, USA
| | - Cecile Tissot
- Centre de Pediatrie, Clinique des Grangettes, 7 ch des Grangettes, 1224 Chêne-Bougeries, Geneva, Switzerland
| | - María V Fraga
- Department of Pediatrics, Division of Neonatology, Children's Hospital of Philadelphia and Perelman School of Medicine, Philadelphia, USA
| |
Collapse
|
21
|
Bischoff AR, Stanford AH, McNamara PJ. Short-term ventriculo-arterial coupling and myocardial work efficiency in preterm infants undergoing percutaneous patent ductus arteriosus closure. Physiol Rep 2021; 9:e15108. [PMID: 34806325 PMCID: PMC8606853 DOI: 10.14814/phy2.15108] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 10/13/2021] [Accepted: 10/21/2021] [Indexed: 01/21/2023] Open
Abstract
Definitive closure of a patent ductus arteriosus (PDA) causes significant changes in loading conditions of the left ventricle (LV) which can lead to cardiorespiratory instability including hypotension, low cardiac output, oxygenation, and ventilation impairment. Physiological insights of the adaptation of the LV can be gained by looking at ventriculo-arterial coupling (VAC) and myocardial work-energetics. We conducted a retrospective cohort study of preterm infants with echocardiographic assessment of VAC parameters, including end-systolic and arterial elastance (EES , EA ), and myocardial work indices derived from longitudinal strain analysis before and 1-h after percutaneous PDA closure. A total of 35 patients were included with mean [±SD] age at intervention of 30.8 ± 9.9 days and median [IQR] weight of 1130 [995, 1318] grams. There was a reduction in preload and stroke volume, an increase in EA (38.6 ± 11.4 vs. 60 ± 15.1 mmHg/ml/kg, p < 0.001) and in EES (72 [61.5, 109.8] vs. 91.6 [72.2, 125.2] mmHg/ml/kg, p = 0.003) post-closure. Myocardial work indices reduced after PDA closure, including global work efficiency (93.9 ± 2.3 vs. 91.1 ± 3.6%, p < 0.001). A total of 17 (48.6%) patients developed post-closure instability which was associated with younger age, lower preload, and higher EA and EES . Percutaneous PDA closure is associated with major short-term changes in VAC and myocardium energetics, which may provide novel insights on the physiology of PDA closure and on the differential vulnerability to changes in loading conditions.
Collapse
Affiliation(s)
- Adrianne R. Bischoff
- Division of NeonatologyDepartment of PediatricsUniversity of IowaIowa CityIowaUSA
| | - Amy H. Stanford
- Division of NeonatologyDepartment of PediatricsUniversity of IowaIowa CityIowaUSA
| | - Patrick J. McNamara
- Division of NeonatologyDepartment of PediatricsUniversity of IowaIowa CityIowaUSA
- Department of Internal MedicineUniversity of IowaIowa CityIowaUSA
| |
Collapse
|
22
|
Stanford AH, Reyes M, Rios DR, Giesinger RE, Jetton JG, Bischoff AR, McNamara PJ. Safety, Feasibility, and Impact of Enalapril on Cardiorespiratory Physiology and Health in Preterm Infants with Systemic Hypertension and Left Ventricular Diastolic Dysfunction. J Clin Med 2021; 10:jcm10194519. [PMID: 34640535 PMCID: PMC8509219 DOI: 10.3390/jcm10194519] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 09/23/2021] [Accepted: 09/25/2021] [Indexed: 11/16/2022] Open
Abstract
Neonatal hypertension has been increasingly recognized in premature infants with bronchopulmonary dysplasia (BPD); of note, a sub-population of these infants may have impaired left ventricular (LV) diastolic function, warranting timely treatment to minimize long term repercussions. In this case series, enalapril, an angiotensin-converting enzyme (ACE) inhibitor, was started in neonates with systemic hypertension and echocardiography signs of LV diastolic dysfunction. A total of 11 patients were included with birth weight of 785 ± 239 grams and gestational age of 25.3 (24, 26.1) weeks. Blood pressure improvement was noticed within 2 weeks of treatment. Improvement in LV diastolic function indices were observed with a reduction in Isovolumic Relaxation Time (IVRT) from 63.1 ± 7.2 to 50.9 ± 7.4 msec and improvement in the left atrium size indexed to aorta (LA:Ao) from1.73 (1.43, 1.88) to 1.23 (1.07, 1.29). Neonatal systemic hypertension is often underappreciated in ex-preterm infants and may be associated with important maladaptive cardiac changes with long term implications. It is biologically plausible that identifying and treating LV diastolic dysfunction in neonates with systemic hypertension may have a positive modulator effect on cardiovascular health in childhood and beyond.
Collapse
Affiliation(s)
- Amy H. Stanford
- Division of Neonatology, Department of Pediatrics, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA; (A.H.S.); (M.R.); (D.R.R.); (R.E.G.); (A.R.B.)
| | - Melanie Reyes
- Division of Neonatology, Department of Pediatrics, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA; (A.H.S.); (M.R.); (D.R.R.); (R.E.G.); (A.R.B.)
| | - Danielle R. Rios
- Division of Neonatology, Department of Pediatrics, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA; (A.H.S.); (M.R.); (D.R.R.); (R.E.G.); (A.R.B.)
| | - Regan E. Giesinger
- Division of Neonatology, Department of Pediatrics, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA; (A.H.S.); (M.R.); (D.R.R.); (R.E.G.); (A.R.B.)
| | - Jennifer G. Jetton
- Division of Pediatric Nephrology, Department of Pediatrics, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA;
| | - Adrianne R. Bischoff
- Division of Neonatology, Department of Pediatrics, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA; (A.H.S.); (M.R.); (D.R.R.); (R.E.G.); (A.R.B.)
| | - Patrick J. McNamara
- Division of Neonatology, Department of Pediatrics, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA; (A.H.S.); (M.R.); (D.R.R.); (R.E.G.); (A.R.B.)
- Department of Internal Medicine, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA
- Correspondence: ; Tel.: +1-319-467-7435
| |
Collapse
|
23
|
Dal Col AK, Bhombal S, Tacy TA, Hintz SR, Feinstein J, Altit G. Comprehensive Echocardiographic Assessment of Ventricular Function and Pulmonary Pressure in the Neonatal Omphalocele Population. Am J Perinatol 2021; 38:e109-e115. [PMID: 32198744 DOI: 10.1055/s-0040-1708048] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Pulmonary hypertension (PH) has been described in the neonatal omphalocele population. This study was aimed to describe cardiac function and PH severity using echocardiography in newborns with giant omphalocele (GO) and with non-GO and determine if right ventricular (RV) dysfunction is associated with mortality. STUDY DESIGN Retrospective, single-center analysis of first echocardiography among neonatal omphalocele patients born between 2004 and 2017 was conducted. Multivariate logistic and univariate Cox's regression was constructed to measure hazard ratio (HR) for death outcome. RESULTS There were 32 newborns, of whom 18 were GO and 7 died. GO had increased systolic pulmonary arterial to systolic systemic blood pressure ratio (97% [isosystemic] vs. 73% [three-fourths systemic] p = 0.03). RV performance parameters (tricuspid annular plane excursion, HR = 0.40; fractional area change, HR = 0.90; and RV peak global longitudinal strain, HR = 1.39) were associated with mortality. These RV performance parameters remained associated in a multiple logistic regression accounting for gestational age and GO status. The overall population had abnormal eccentricity index and pulmonary artery acceleration time to RV ejection time ratio, two markers of PH. CONCLUSION Patients with omphalocele have increased pulmonary pressure, with GO being worse than non-GO. RV dysfunction at initial echocardiography was significantly associated with mortality.
Collapse
Affiliation(s)
- Alexis K Dal Col
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Lucile Packard Children's Hospital, Stanford, California
| | - Shazia Bhombal
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Lucile Packard Children's Hospital, Stanford, California
| | - Theresa A Tacy
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Lucile Packard Children's Hospital, Stanford, California
| | - Susan R Hintz
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Lucile Packard Children's Hospital, Stanford, California
| | - Jeffrey Feinstein
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Lucile Packard Children's Hospital, Stanford, California
| | - Gabriel Altit
- Department of Neonatology, McGill University Health Centre, Montreal Children's Hospital, Montreal, Quebec, Canada.,Department of Pediatrics, McGill University, Montreal, Quebec, Canada
| |
Collapse
|
24
|
Bischoff AR, Giesinger RE, Stanford AH, Ashwath R, McNamara PJ. Assessment of superior vena cava flow and cardiac output in different patterns of patent ductus arteriosus shunt. Echocardiography 2021; 38:1524-1533. [PMID: 34309068 DOI: 10.1111/echo.15163] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 06/07/2021] [Accepted: 07/09/2021] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Despite the widespread use of superior vena cava (SVC) flow as a marker of systemic blood flow from the upper body, no previous studies have systematically evaluated the correlation between SVC flow and other echocardiography measures of systemic blood flow in the context of different patterns of patent ductus arteriosus (PDA) shunt direction METHODS: A retrospective cohort study of preterm infants (< 30 weeks, < 21 days of life) who underwent comprehensive targeted neonatal echocardiography (TnECHO) was performed. Patients were categorized as follows: (i) Hemodynamically significant left-to-right shunt; (ii): Bidirectional shunt; (iii) No PDA or insignificant shunt. SVC flow, as measured by two distinct methods, was compared to left and right ventricular outputs (LVO and RVO). Intra- and inter-observer reliability testing was performed RESULTS: In total, 45 patients were included (15 in each group) with a median [IQR] weight of 720 [539, 917] grams at the time of assessment. SVC dimensions and flow measurements were not different between the groups, although patients with left-to-right shunt had higher LVO/RVO ratio. SVC flow, as estimated using the modified method, had a strong correlation with LVO (r = .63, p = 0.012) and RVO (r = .635, p = 0.011) in patients with no PDA. Inter- and intra-observer reliability were both stronger for LVO and RVO when compared to SVC flow measurements CONCLUSION: SVC flow was comparable across all three groups irrespective of higher LVO and LVO/RVO ratio in patients with left-to-right shunts. This may reflect poor measurement reliability or compensation for left-to-right ductal shunt by increased LVO to maintain systemic perfusion.
Collapse
Affiliation(s)
| | - Regan E Giesinger
- Division of Neonatology, Department of Pediatrics, University of Iowa, Iowa City, Iowa, USA
| | - Amy H Stanford
- Division of Neonatology, Department of Pediatrics, University of Iowa, Iowa City, Iowa, USA
| | - Ravi Ashwath
- Division of Pediatric Cardiology, Department of Pediatrics, University of Iowa, Iowa City, Iowa, USA
| | - Patrick J McNamara
- Division of Neonatology, Department of Pediatrics, University of Iowa, Iowa City, Iowa, USA.,Department of Internal Medicine, University of Iowa, Iowa City, Iowa, USA
| |
Collapse
|
25
|
Altit G, Bhombal S, Chock VY. End-organ saturations correlate with aortic blood flow estimates by echocardiography in the extremely premature newborn - an observational cohort study. BMC Pediatr 2021; 21:312. [PMID: 34253175 PMCID: PMC8274006 DOI: 10.1186/s12887-021-02790-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 06/10/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Near-infrared spectroscopy (NIRS) measures of cerebral saturation (Csat) and renal saturation (Rsat) in extreme premature newborns may be affected by systemic blood flow fluctuations. Despite increasing clinical use of NIRS to monitor tissue saturation in the premature infant, validation of NIRS measures as a correlate of blood flow is still needed. We compared echocardiography (ECHO) derived markers of ascending aorta (AscAo) and descending aorta (DesAo) blood flow with NIRS measurements obtained during the ECHO. METHODS Newborns < 29 weeks' gestation (2013-2017) underwent routine NIRS monitoring. Csat, Rsat and systemic saturation at the time of ECHO were retrospectively analyzed and compared with Doppler markers of aortic flow. Renal and cerebral fractional tissue oxygen extraction (rFTOE and cFTOE, respectively) were calculated. Mixed effects models evaluated the association between NIRS and Doppler markers. RESULTS Forty-nine neonates with 75 Csat-ECHO and 62 Rsat-ECHO observations were studied. Mean post-menstrual age was 28.3 ± 3.8 weeks during the ECHO. Preductal measures including AscAo velocity time integral (VTI) and AscAo output were correlated with Csat or cFTOE, while postductal measures including DesAo VTI, DesAo peak systolic velocity, and estimated DesAo output were more closely correlated with Rsat or rFTOE. CONCLUSIONS NIRS measures are associated with aortic blood flow measurements by ECHO in the extremely premature population. NIRS is a tool to consider when following end organ perfusion in the preterm infant.
Collapse
Affiliation(s)
- Gabriel Altit
- Department of Pediatrics, Division of Neonatology, Montreal Children's Hospital, McGill University Health Center, Montreal, Canada.
| | - Shazia Bhombal
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital Stanford, Palo Alto, USA
| | - Valerie Y Chock
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital Stanford, Palo Alto, USA
| |
Collapse
|
26
|
Jia D, Peroni M, Khalapyan T, Esmaily M. An Efficient Assisted Bidirectional Glenn Design With Lowered Superior Vena Cava Pressure for Stage-One Single Ventricle Patients. J Biomech Eng 2021; 143:071008. [PMID: 33590839 DOI: 10.1115/1.4050170] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Indexed: 11/08/2022]
Abstract
Recently, the assisted bidirectional Glenn (ABG) procedure has been proposed as an alternative to the modified Blalock-Taussig shunt (mBTS) operation for neonates with single-ventricle physiology. Despite success in reducing heart workload and maintaining sufficient pulmonary flow, the ABG also raised the superior vena cava (SVC) pressure to a level that may not be tolerated by infants. To lower the SVC pressure, we propose a modified version of the ABG (mABG), in which a shunt with a slit-shaped nozzle exit is inserted at the junction of the right and left brachiocephalic veins. The proposed operation is compared against the ABG, the mBTS, and the bidirectional Glenn (BDG) operations using closed-loop multiscale simulations. Both normal (2.3 Wood units-m2) and high (7 Wood units-m2) pulmonary vascular resistance (PVR) values are simulated. The mABG provides the highest oxygen saturation, oxygen delivery, and pulmonary flow rate in comparison to the BDG and the ABG. At normal PVR, the SVC pressure is significantly reduced below that of the ABG and the BDG (mABG: 4; ABG: 8; BDG: 6; mBTS: 3 mmHg). However, the SVC pressure remains high at high PVR (mABG: 15; ABG: 16; BDG: 12; mBTS: 3 mmHg), motivating an optimization study to improve the ABG hemodynamics efficiency for a broader range of conditions in the future. Overall, the mABG preserves all advantages of the original ABG procedure while reducing the SVC pressure at normal PVR.
Collapse
Affiliation(s)
- Dongjie Jia
- Sibley School of Mechanical and Aerospace Engineering, Cornell University, Ithaca, NY 14850
| | - Matthew Peroni
- Sibley School of Mechanical and Aerospace Engineering, Cornell University, Ithaca, NY 14850
| | | | - Mahdi Esmaily
- Sibley School of Mechanical and Aerospace Engineering, Cornell University, Ithaca, NY 14850
| |
Collapse
|
27
|
Abduljalil K, Pan X, Pansari A, Jamei M, Johnson TN. A Preterm Physiologically Based Pharmacokinetic Model. Part I: Physiological Parameters and Model Building. Clin Pharmacokinet 2021; 59:485-500. [PMID: 31583613 DOI: 10.1007/s40262-019-00825-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Developmental physiology can alter pharmacotherapy in preterm populations. Because of ethical and clinical constraints in studying this vulnerable age group, physiologically based pharmacokinetic models offer a viable alternative approach to predicting drug pharmacokinetics and pharmacodynamics in this population. However, such models require comprehensive information on the changes of anatomical, physiological and biochemical variables, where such data are not available in a single source. OBJECTIVE The objective of this study was to integrate the relevant physiological parameters required to build a physiologically based pharmacokinetic model for the preterm population. METHODS Published information on developmental preterm physiology and some drug-metabolising enzymes were collated and analysed. Equations were generated to describe the changes in parameter values during growth. RESULTS Data on organ size show different growth patterns that were quantified as functions of bodyweight to retain physiological variability and correlation. Protein binding data were quantified as functions of age as the body weight was not reported in the original articles. Ontogeny functions were derived for cytochrome P450 1A2, 3A4 and 2C9. Tissue composition values and how they change with age are limited. CONCLUSIONS Despite the limitations identified in the availability of some tissue composition values, the data presented in this article provide an integrated resource of system parameters needed for building a preterm physiologically based pharmacokinetic model.
Collapse
Affiliation(s)
- Khaled Abduljalil
- Simcyp Division Level 2-Acero, Certara UK Limited, 1 Concourse Way, Sheffield, S1 2BJ, UK.
| | - Xian Pan
- Simcyp Division Level 2-Acero, Certara UK Limited, 1 Concourse Way, Sheffield, S1 2BJ, UK
| | - Amita Pansari
- Simcyp Division Level 2-Acero, Certara UK Limited, 1 Concourse Way, Sheffield, S1 2BJ, UK
| | - Masoud Jamei
- Simcyp Division Level 2-Acero, Certara UK Limited, 1 Concourse Way, Sheffield, S1 2BJ, UK
| | - Trevor N Johnson
- Simcyp Division Level 2-Acero, Certara UK Limited, 1 Concourse Way, Sheffield, S1 2BJ, UK
| |
Collapse
|
28
|
Authors' Response to a Letter to the Editor. Pediatr Cardiol 2021; 42:983-984. [PMID: 33835231 DOI: 10.1007/s00246-021-02605-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 04/01/2021] [Indexed: 10/21/2022]
|
29
|
Pereira SS, Sinha AK, Shah DK, Kempley ST. Common carotid artery blood flow volume in extremely preterm infants. Acta Paediatr 2021; 110:1157-1165. [PMID: 33145798 DOI: 10.1111/apa.15655] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 10/14/2020] [Accepted: 11/02/2020] [Indexed: 11/28/2022]
Abstract
AIM The aim of this study was to determine carotid blood flow volume, a surrogate for cerebral blood flow, using Doppler ultrasound in extremely preterm infants. METHODS In infants <29 weeks, right common carotid artery flow volume (RCCAF) was calculated from vessel diameter and intensity-weighted mean velocity measured using Doppler ultrasound on days 1 and 3. In addition, left ventricular output (LVO), ductus arteriosus characteristics and invasive mean arterial blood pressure (MABP) were obtained. RESULTS Sixty infants with mean gestation of 25.8 weeks were studied. The median RCCAF increased from 12 (IQR 9-15) mL/kg/min on day 1, to 14 (IQR 12-18) mL/kg/min on day 3 (p = 0.007). RCCAF was positively correlated with invasive MABP on days 1 and 3. RCCAF significantly correlated with LVO in infants with closing or closed ductus arteriosus on day 1. Using multiple regression analysis, RCCAF was significantly associated with invasive MABP on day 1 and to inotropic treatment on day 3. CONCLUSION Doppler ultrasound can be used to measure RCCAF in extremely preterm infants receiving intensive care. RCCAF increased during the first three days and was positively related to invasive MABP on day 1. Values were lower than previously described in more mature infants. CLINICAL TRIAL REGISTRATION ISRCTN 83507686.
Collapse
Affiliation(s)
- Sujith S. Pereira
- Centre for Genomics and Child Health Blizard Institute Barts and the London School of Medicine Queen Mary University of London London UK
- Neonatal Unit Homerton University Hospital Foundation NHS Trust London UK
| | - Ajay K. Sinha
- Centre for Genomics and Child Health Blizard Institute Barts and the London School of Medicine Queen Mary University of London London UK
- Neonatal Unit Royal London Hospital, Barts Health NHS Trust London UK
| | - Divyen K. Shah
- Neonatal Unit Royal London Hospital, Barts Health NHS Trust London UK
- Centre for Neuroscience and Trauma Blizard Institute Barts and the London School of Medicine and Dentistry Queen Mary University of London London UK
| | - Stephen T. Kempley
- Centre for Genomics and Child Health Blizard Institute Barts and the London School of Medicine Queen Mary University of London London UK
| |
Collapse
|
30
|
Miletin J, Stranak Z, Ó Catháin N, Janota J, Semberova J. Comparison of Two Techniques of Superior Vena Cava Flow Measurement in Preterm Infants With Birth Weight <1,250 g in the Transitional Period-Prospective Observational Cohort Study. Front Pediatr 2021; 9:661698. [PMID: 33898366 PMCID: PMC8058217 DOI: 10.3389/fped.2021.661698] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 03/09/2021] [Indexed: 11/26/2022] Open
Abstract
Objectives: Superior Vena Cava (SVC) flow in neonates measured by the standard approach has been validated by different groups around the world. The modified SVC flow measurement technique was recently suggested. The aim of our study was to evaluate standard and modified technique of echocardiography SVC flow measurement in a cohort of extremely preterm neonates in the immediate postnatal period. Methods: Prospective, observational cohort study in a level III neonatal center. Infants with birth weight <1,250 g were eligible for enrolment. SVC flow was measured by echocardiography using standard and modified methods at 6, 18 and 36 h of age. Our primary outcome was equivalency (using raw bounds of -20 to +20 mL/kg/min difference between the paired measurements), agreement and correlation between standard and modified methods of the SVC flow measurements. Results: Thirty-nine infants were enrolled. The mean gestational age of the cohort was 27.4 (SD 2.1) weeks of postmenstrual age, the mean birth weight was 0.95 kg (SD 0.2). The measurements at 6 and 36 h of age were equivalent as defined in the design of the study (p = 0.003 and p = 0.004 respectively; raw bounds -20 to +20 mL/kg/min). At 6 h of age the mean difference (bias) between the measurements was -0.8 mL/kg/min with 95% limits of agreement -65.0 to 63.4 mL/kg/min. At 18 h of age, the mean difference (bias) between the measurements was +9.5 mL/kg/min, with 95% limits of agreement -79.6 to 98.7 mL/kg/min. At 36 h of age the mean difference (bias) between the measurements was -2.2 mL/kg/min with 95% limits of agreement -73.4 to 69.1 mL/kg/min. There was a weak, but statistically significant correlation between the standard and modified method at 6 h of age (r = 0.39, p = 0.04). Conclusion: Both SVC flow echocardiography measurement techniques yielded clinically equivalent results, however due to wide limits of agreement and poor correlation they do not seem to be interchangeable.
Collapse
Affiliation(s)
- Jan Miletin
- Coombe Women and Infants University Hospital, Dublin, Ireland.,Institute for the Care of Mother and Child, Prague, Czechia.,UCD School of Medicine, University College Dublin, Dublin, Ireland.,3rd Faculty of Medicine, Charles University, Prague, Czechia
| | - Zbynek Stranak
- Institute for the Care of Mother and Child, Prague, Czechia.,3rd Faculty of Medicine, Charles University, Prague, Czechia
| | - Niamh Ó Catháin
- Coombe Women and Infants University Hospital, Dublin, Ireland.,UCD School of Medicine, University College Dublin, Dublin, Ireland
| | - Jan Janota
- 1st and 2nd Faculty of Medicine, Charles University, Prague, Czechia.,Motol University Hospital, Prague, Czechia
| | - Jana Semberova
- Coombe Women and Infants University Hospital, Dublin, Ireland.,Institute for the Care of Mother and Child, Prague, Czechia.,UCD School of Medicine, University College Dublin, Dublin, Ireland
| |
Collapse
|
31
|
de Waal K, Kluckow M. Superior vena cava flow: Role, assessment and controversies in the management of perinatal perfusion. Semin Fetal Neonatal Med 2020; 25:101122. [PMID: 32467039 DOI: 10.1016/j.siny.2020.101122] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The superior vena cava (SVC) is a large vein responsible for the venous return of blood from structures located superior to the diaphragm. The flow in the SVC can be assessed with Doppler ultrasound and can be used as a proxy for cerebral perfusion. Early clinical research studies showed that low SVC flow, particularly if for a prolonged period, was associated with short term morbidity such as intraventricular hemorrhage, mortality, and poorer neurodevelopmental outcomes. However, these findings have not been consistently reported in more recent studies, and the role of SVC flow in early management and as a predictor of poor long-term neurodevelopment has been questioned. This paper provides an overview of SVC assessment, the expected range of findings, and reviews the role of SVC flow as a diagnostic and monitoring tool for the assessment of perinatal perfusion.
Collapse
Affiliation(s)
- Koert de Waal
- John Hunter Children's Hospital Department of Neonatology and University of Newcastle, Newcastle, NSW, Australia.
| | - Martin Kluckow
- Royal North Shore Hospital Department of Neonatology and University of Sydney, Sydney, NSW, Australia
| |
Collapse
|
32
|
Zamith MM, Figueira SDAN, Oliveira ACD, Metolina C, Castro JSD, Santos CND, Capo ALDOAD, Moisés VA. Functional echocardiography training in the neonatal intensive care unit: comparing measurements and results with the pediatric cardiologist. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2020. [DOI: 10.1016/j.jpedp.2019.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
|
33
|
Zamith MM, Figueira SDAN, Oliveira ACD, Metolina C, Castro JSD, Santos CND, Capo ALDOAD, Moisés VA. Functional echocardiography training in the neonatal intensive care unit: comparing measurements and results with the pediatric cardiologist. J Pediatr (Rio J) 2020; 96:614-620. [PMID: 31176690 PMCID: PMC9432006 DOI: 10.1016/j.jped.2019.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 04/25/2019] [Accepted: 04/26/2019] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES Functional echocardiography is a valuable tool in the neonatal intensive care unit, but training programs are not standardized. The aim was to report an functional echocardiography training program for neonatologists and to describe the agreement of their measurements with the pediatric cardiologist. METHODS Functional echocardiography training lasted 32h. After training program, the neonatologists performed functional echocardiography in the neonatal intensive care unit and were required to measure left cardiac chambers dimensions, left ventricle systolic function, right and left ventricular output, ductus arteriosus diameter, and flow pattern. Images were recorded by the equipment and reviewed offline by the pediatric cardiologist. The Bland-Altman test was used for quantitative variables and the kappa test, for qualitative variables. RESULTS Twenty-two trained neonatologists performed 100 functional echocardiography exams. Ductus arteriosus identification and flow pattern had substantial agreement (kappa=0.91 and 0.88, respectively), as well as its diameter (mean difference=0.04mm). The mean difference for the aortic root was -1.2mm; left atrium, 0.60mm; left ventricle diastolic diameter, -0.90mm; left ventricle systolic diameter, -0.30mm. Shortening fraction and ejection fraction correlated well with broad limits of agreement, -2.96% (14.88; -20.82%) and --3.43% (15.54; -22.40%), respectively. Right and left ventricular output had broad limits of agreement, 16.69mL/kg/min (222.76; -189.37) and 23.57mL/kg/min (157.88; -110), respectively. There was good agreement between interpretations of normal or low cardiac output (76.7% for right ventricular output; 75.7% for left ventricular output). CONCLUSION This functional echocardiography training program enabled neonatologists to obtain adequate skills in performing the images, obtaining good agreement with the cardiologist in simple hemodynamic measurements and ductus arteriosus evaluation.
Collapse
Affiliation(s)
- Marina Maccagnano Zamith
- Universidade Federal de São Paulo (Unifesp), Departamento de Medicina, Divisão de Cardiologia, São Paulo, SP, Brazil.
| | | | - Allan Chiaratti de Oliveira
- Universidade Federal de São Paulo (Unifesp), Departamento de Pediatria, Divisão de Neonatologia, São Paulo, SP, Brazil
| | - Cristiane Metolina
- Universidade Federal de São Paulo (Unifesp), Departamento de Pediatria, Divisão de Neonatologia, São Paulo, SP, Brazil
| | - Junia Sampel de Castro
- Universidade Federal de São Paulo (Unifesp), Departamento de Pediatria, Divisão de Neonatologia, São Paulo, SP, Brazil
| | - Cristina Nunes Dos Santos
- Universidade Federal de São Paulo (Unifesp), Departamento de Pediatria, Divisão de Neonatologia, São Paulo, SP, Brazil
| | | | - Valdir Ambrósio Moisés
- Universidade Federal de São Paulo (Unifesp), Departamento de Medicina, Divisão de Cardiologia, São Paulo, SP, Brazil
| |
Collapse
|
34
|
Abstract
Clinical assessment of cardiac output by interpretation of indirect parameters has proven to be inaccurate, irrespective of the level of experience of the clinician. Objective cardiac output monitoring is feasible in newborn infants in intensive care. The most promising methods include transthoracic echocardiography, transcutaneous Doppler, electrical biosensing technologies, transpulmonary ultrasound dilution, and arterial pulse contour analysis. Simultaneous assessment of blood pressure and cardiac output enables the identification of the earliest stage of shock. Comprehensive hemodynamic monitoring is pivotal for an individualized pathophysiology-based hemodynamic management.
Collapse
Affiliation(s)
- Willem-Pieter de Boode
- Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, PO Box 9101, Nijmegen 6500 HB, The Netherlands.
| |
Collapse
|
35
|
Defining information needs in neonatal resuscitation with work domain analysis. J Clin Monit Comput 2020; 35:689-710. [PMID: 32458169 DOI: 10.1007/s10877-020-00526-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Accepted: 05/07/2020] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To gain a deeper understanding of the information requirements of clinicians conducting neonatal resuscitation in the first 10 min after birth. BACKGROUND During the resuscitation of a newborn infant in the first minutes after birth, clinicians must monitor crucial physiological adjustments that are relatively unobservable, unpredictable, and highly variable. Clinicians' access to information regarding the physiological status of the infant is also crucial to determining which interventions are most appropriate. To design displays to support clinicians during newborn resuscitation, we must first carefully consider the information requirements. METHODS We conducted a work domain analysis (WDA) for the neonatal transition in the first 10 min after birth. We split the work domain into two 'subdomains'; the physiology of the neonatal transition, and the clinical resources supporting the neonatal transition. A WDA can reveal information requirements that are not yet supported by resources. RESULTS The physiological WDA acted as a conceptual tool to model the exact processes and functions that clinicians must monitor and potentially support during the neonatal transition. Importantly, the clinical resources WDA revealed several capabilities and limitations of the physical objects in the work domain-ultimately revealing which physiological functions currently have no existing sensor to provide clinicians with information regarding their status. CONCLUSION We propose two potential approaches to improving the clinician's information environment: (1) developing new sensors for the information we lack, and (2) employing principles of ecological interface design to present currently available information to the clinician in a more effective way.
Collapse
|
36
|
Camfferman FA, de Goederen R, Govaert P, Dudink J, van Bel F, Pellicer A, Cools F. Diagnostic and predictive value of Doppler ultrasound for evaluation of the brain circulation in preterm infants: a systematic review. Pediatr Res 2020; 87:50-58. [PMID: 32218536 PMCID: PMC7098887 DOI: 10.1038/s41390-020-0777-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Very and extremely preterm infants frequently have brain injury-related long-term neurodevelopmental problems. Altered perfusion, for example, seen in the context of a hemodynamically significant patent ductus arteriosus (PDA), has been linked to injury of the immature brain. However, a direct relation with outcome has not been reviewed systematically. METHODS A systematic review was conducted to provide an overview of the value of different cerebral arterial blood flow parameters assessed by Doppler ultrasound, in relation to brain injury, to predict long-term neurodevelopmental outcome in preterm infants. RESULTS In total, 23 studies were included. Because of heterogeneity of studies, a meta-analysis of results was not possible. All included studies on resistance index (RI) showed significantly higher values in subjects with a hemodynamically significant PDA. However, absolute differences in RI values were small. Studies using Doppler parameters to predict brain injury and long-term neurodevelopmental outcome were inconsistent. DISCUSSION There is no clear evidence to support the routine determination of RI or other Doppler parameters in the cerebral arteries to predict brain injury and long-term neurodevelopmental outcome in the preterm infant. However, there is evidence that elevated RI can point to the presence of a hemodynamically significant PDA.
Collapse
Affiliation(s)
- Fleur A Camfferman
- Department of Neonatology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium.
| | - Robbin de Goederen
- Dutch Craniofacial Centre Rotterdam, Department of Plastic and Reconstructive Surgery, Erasmus Medical Center University, Rotterdam, The Netherlands
| | - Paul Govaert
- Department of Neonatology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
- Department of Neonatology, Erasmus Medical Center University, Sophia Children's Hospital, Rotterdam, The Netherlands
- Department of Neonatology, ZNA Middelheim, Antwerp, Belgium
- Department of Rehabilitation and Physical Therapy, Gent University Hospital, Gent, Belgium
| | - Jeroen Dudink
- Department of Neonatology, Erasmus Medical Center University, Sophia Children's Hospital, Rotterdam, The Netherlands
- Department of Neonatology, University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Frank van Bel
- Department of Neonatology, University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Adelina Pellicer
- Department of Neonatology, La Paz University Hospital, Madrid, Spain
| | - Filip Cools
- Department of Neonatology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| |
Collapse
|
37
|
Singh Y, Tissot C, Fraga MV, Yousef N, Cortes RG, Lopez J, Sanchez-de-Toledo J, Brierley J, Colunga JM, Raffaj D, Da Cruz E, Durand P, Kenderessy P, Lang HJ, Nishisaki A, Kneyber MC, Tissieres P, Conlon TW, De Luca D. International evidence-based guidelines on Point of Care Ultrasound (POCUS) for critically ill neonates and children issued by the POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC). Crit Care 2020; 24:65. [PMID: 32093763 PMCID: PMC7041196 DOI: 10.1186/s13054-020-2787-9] [Citation(s) in RCA: 291] [Impact Index Per Article: 72.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 02/14/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Point-of-care ultrasound (POCUS) is nowadays an essential tool in critical care. Its role seems more important in neonates and children where other monitoring techniques may be unavailable. POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) aimed to provide evidence-based clinical guidelines for the use of POCUS in critically ill neonates and children. METHODS Creation of an international Euro-American panel of paediatric and neonatal intensivists expert in POCUS and systematic review of relevant literature. A literature search was performed, and the level of evidence was assessed according to a GRADE method. Recommendations were developed through discussions managed following a Quaker-based consensus technique and evaluating appropriateness using a modified blind RAND/UCLA voting method. AGREE statement was followed to prepare this document. RESULTS Panellists agreed on 39 out of 41 recommendations for the use of cardiac, lung, vascular, cerebral and abdominal POCUS in critically ill neonates and children. Recommendations were mostly (28 out of 39) based on moderate quality of evidence (B and C). CONCLUSIONS Evidence-based guidelines for the use of POCUS in critically ill neonates and children are now available. They will be useful to optimise the use of POCUS, training programs and further research, which are urgently needed given the weak quality of evidence available.
Collapse
Affiliation(s)
- Yogen Singh
- Department of Paediatrics - Neonatology and Paediatric Cardiology, Cambridge University Hospitals and University of Cambridge School of Clinical Medicine, Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK.
- Addenbrooke's Hospital, Box 402, Cambridge, UK.
| | - Cecile Tissot
- Paediatric Cardiology, Centre de Pédiatrie, Clinique des Grangettes, Geneva, Switzerland
| | - María V Fraga
- Department of Paediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, Philadelphia, USA
| | - Nadya Yousef
- Division of Paediatrics and Neonatal Critical Care, APHP - Paris Saclay University Hospitals, "A. Béclère" Medical centre, Paris, France
| | - Rafael Gonzalez Cortes
- Department of Paediatric Intensive Care, Gregorio Marañón General University Hospital, Madrid, Spain
| | - Jorge Lopez
- Department of Paediatric Intensive Care, Gregorio Marañón General University Hospital, Madrid, Spain
| | | | - Joe Brierley
- Department of Paediatric Intensive Care, Great Ormond Street Hospital, London, UK
| | - Juan Mayordomo Colunga
- Department of Paediatric Intensive Care, Hospital Universitario Central de Asturias, Oviedo. CIBER-Enfermedades Respiratorias. Instituto de Salud Carlos III, Madrid. Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
| | - Dusan Raffaj
- Department of Paediatric Intensive Care, Nottingham University Hospitals, Nottingham, UK
| | - Eduardo Da Cruz
- Department of Paediatric and Cardiac Intensive Care, Children's Hospital Colorado, Aurora, USA
| | - Philippe Durand
- Division of Paediatric Critical Care, APHP - Paris Saclay University Hospitals, "Kremlin Bicetre" Medical Centre, Paris, France
| | - Peter Kenderessy
- Department of Paediatric Anaesthesia and Intensive Care, Children's Hospital Banska Bystrica, Banska Bystrica, Slovakia
| | - Hans-Joerg Lang
- Department of Paediatrics, Medicins Sans Frontieres (Suisse), Geneva, Switzerland
| | - Akira Nishisaki
- Department of Anaesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine, Philadelphia, USA
| | - Martin C Kneyber
- Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Pierre Tissieres
- Division of Paediatric Critical Care, APHP - Paris Saclay University Hospitals, "Kremlin Bicetre" Medical Centre, Paris, France
| | - Thomas W Conlon
- Department of Anaesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine, Philadelphia, USA
| | - Daniele De Luca
- Division of Paediatrics and Neonatal Critical Care, APHP - Paris Saclay University Hospitals, "A. Béclère" Medical centre, Paris, France
- Physiopathology and Therapeutic Innovation Unit-INSERM Unit U999, South Paris Medical School, Paris Saclay University, Paris, France
| |
Collapse
|
38
|
O'Neill R, Dempsey EM, Garvey AA, Schwarz CE. Non-invasive Cardiac Output Monitoring in Neonates. Front Pediatr 2020; 8:614585. [PMID: 33585366 PMCID: PMC7880199 DOI: 10.3389/fped.2020.614585] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 12/15/2020] [Indexed: 12/19/2022] Open
Abstract
Circulatory monitoring is currently limited to heart rate and blood pressure assessment in the majority of neonatal units globally. Non-invasive cardiac output monitoring (NiCO) in term and preterm neonates is increasing, where it has the potential to enhance our understanding and management of overall circulatory status. In this narrative review, we summarized 33 studies including almost 2,000 term and preterm neonates. The majority of studies evaluated interchangeability with echocardiography. Studies were performed in various clinical settings including the delivery room, patent ductus arteriosus assessment, patient positioning, red blood cell transfusion, and therapeutic hypothermia for hypoxic ischemic encephalopathy. This review presents an overview of NiCO in neonatal care, focusing on technical and practical aspects as well as current available evidence. We discuss potential goals for future research.
Collapse
Affiliation(s)
- Roisin O'Neill
- Department of Neonatology, Cork University Maternity Hospital, Cork, Ireland.,Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Eugene M Dempsey
- Department of Neonatology, Cork University Maternity Hospital, Cork, Ireland.,Department of Paediatrics and Child Health, University College Cork, Cork, Ireland.,Irish Centre for Maternal and Child Health Research (INFANT) Research Centre, University College Cork, Cork, Ireland
| | - Aisling A Garvey
- Department of Neonatology, Cork University Maternity Hospital, Cork, Ireland.,Department of Paediatrics and Child Health, University College Cork, Cork, Ireland.,Irish Centre for Maternal and Child Health Research (INFANT) Research Centre, University College Cork, Cork, Ireland
| | - Christoph E Schwarz
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland.,Irish Centre for Maternal and Child Health Research (INFANT) Research Centre, University College Cork, Cork, Ireland.,Department of Neonatology, University Children's Hospital, Tübingen, Germany
| |
Collapse
|
39
|
Altit G, Bhombal S, Feinstein J, Hopper RK, Tacy TA. Diminished right ventricular function at diagnosis of pulmonary hypertension is associated with mortality in bronchopulmonary dysplasia. Pulm Circ 2019; 9:2045894019878598. [PMID: 31662848 PMCID: PMC6792284 DOI: 10.1177/2045894019878598] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 09/05/2019] [Indexed: 11/16/2022] Open
Abstract
Pulmonary vascular disease and resultant pulmonary hypertension (PH) have been increasingly recognized in the preterm population, particularly among patients with bronchopulmonary dysplasia (BPD). Limited data exist on the impact of PH severity and right ventricular (RV) dysfunction at PH diagnosis on outcome. The purpose of this study was to evaluate if echocardiography measures of cardiac dysfunction and PH severity in BPD-PH were associated with mortality. The study is a retrospective analysis of the echocardiography at three months or less from time of PH diagnosis. Survival analysis using a univariate Cox proportional hazard model is presented and expressed using hazard ratios (HR). We included 52 patients with BPD and PH of which 16 (31%) died at follow-up. Average gestational age at birth was 26.3 ± 2.3 weeks. Echocardiography was performed at a median of 43.3 weeks (IQR: 39.0–54.7). The median time between PH diagnosis and death was 117 days (range: 49–262 days). Multiple measures of PH severity and RV performance were associated with mortality (sPAP/sBP: HR 1.02, eccentricity index: HR 2.02, tricuspid annular plane systolic excursion Z-score: HR 0.65, fractional area change: HR 0.88, peak longitudinal strain: HR 1.22). Hence, PH severity and underlying RV dysfunction at PH diagnosis were associated with mortality in BPD-PH patients. While absolute estimation of pulmonary pressures is not feasible in every screening echocardiography, thorough evaluation of RV function and other markers of PH may allow to discriminate the most at-risk population and should be considered as standard add-ons to the current screening at 36 weeks.
Collapse
Affiliation(s)
- Gabriel Altit
- Neonatology, McGill University Health Centre, Montreal Children's Hospital, Montreal, Canada.,Department of Pediatrics, McGill University, Montreal, Canada
| | - Shazia Bhombal
- Neonatal and Developmental Medicine, Stanford University School of Medicine, Lucile Packard Children's Hospital, Palo Alto, CA, USA
| | - Jeffrey Feinstein
- Pediatric Cardiology, Stanford University School of Medicine, Lucile Packard Children's Hospital, Palo Alto, CA, USA
| | - Rachel K Hopper
- Pediatric Cardiology, Stanford University School of Medicine, Lucile Packard Children's Hospital, Palo Alto, CA, USA
| | - Theresa A Tacy
- Pediatric Cardiology, Stanford University School of Medicine, Lucile Packard Children's Hospital, Palo Alto, CA, USA
| |
Collapse
|
40
|
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.
Collapse
|
41
|
Pereira SS, Sinha AK, Morris JK, Wertheim DF, Shah DK, Kempley ST. Blood pressure intervention levels in preterm infants: pilot randomised trial. Arch Dis Child Fetal Neonatal Ed 2019; 104:F298-F305. [PMID: 30049724 DOI: 10.1136/archdischild-2017-314159] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 06/06/2018] [Accepted: 06/18/2018] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To examine the feasibility of a trial allocating different blood pressure (BP) intervention levels for treatment in extremely preterm infants. DESIGN Three-arm open randomised controlled trial performed between February 2013 and April 2015. SETTING Single tertiary level neonatal intensive care unit. PATIENTS Infants born <29 weeks' gestation were eligible to participate, if parents consented and they did not have a major congenital malformation. INTERVENTIONS Infants were randomised to different levels of mean arterial BP at which they received cardiovascular support: active (<30 mm Hg), moderate (<gestational age mm Hg) or permissive (signs of poor perfusion or <19 mm Hg). Once this threshold was breached, all were managed using the same treatment guideline. BP profiles were downloaded continuously; cardiac output and carotid blood flow were measured at 1 day and 3 days, and amplitude integrated EEG was recorded during the first week. Cranial ultrasound scans were reviewed blind to study allocation. MAIN OUTCOME MEASURE Inotrope usage and achieved BP. RESULTS Of 134 cases screened, 60 were enrolled, with mean gestation 25.8 weeks (SD 1.5) and birth weight 817 g (SD 190). Invasively measured BP on the first day and inotrope usage were highest in the active and lowest in the permissive arms. There were no differences in haemodynamic or EEG variables or in clinical complications. Predefined cranial ultrasound findings did not differ significantly; no infants in the active arm had parenchymal brain lesions. CONCLUSION The BP threshold used to trigger treatment affects the achieved BP and inotrope usage, and it was possible to explore these effects using this study design. TRIAL REGISTRATION NUMBER ISRCTN83507686.
Collapse
Affiliation(s)
- Sujith Stanley Pereira
- Neonatal Unit, Royal London Hospital, Barts Health NHS Trust, London, UK.,Centre for Genomics and Child Health, Blizard Institute, Barts and the London School of Medicine and Dentistry, London, UK
| | - Ajay Kumar Sinha
- Neonatal Unit, Royal London Hospital, Barts Health NHS Trust, London, UK.,Centre for Genomics and Child Health, Blizard Institute, Barts and the London School of Medicine and Dentistry, London, UK
| | - Joan Katherine Morris
- Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - David F Wertheim
- Faculty of Science, Engineering and Computing, Kingston University, Kingston, UK
| | - Divyen K Shah
- Neonatal Unit, Royal London Hospital, Barts Health NHS Trust, London, UK.,Centre for Genomics and Child Health, Blizard Institute, Barts and the London School of Medicine and Dentistry, London, UK
| | - Stephen Terence Kempley
- Neonatal Unit, Royal London Hospital, Barts Health NHS Trust, London, UK.,Centre for Genomics and Child Health, Blizard Institute, Barts and the London School of Medicine and Dentistry, London, UK
| |
Collapse
|
42
|
El-Saiedi S, AbdelMassih AF, Sedky Y, Malash A, Hussain N, Alfons M, Essam R. Development of tissue Doppler-derived predictors of hemodynamically significant patent ductus arteriosus and the ability to incorporate it in targeted neonatal echocardiography protocol. J Saudi Heart Assoc 2019; 31:69-74. [PMID: 30618483 PMCID: PMC6313813 DOI: 10.1016/j.jsha.2018.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Revised: 10/21/2018] [Accepted: 11/12/2018] [Indexed: 11/30/2022] Open
Abstract
Background Hemodynamically significant (HS) patent ductus arteriosus (PDA) is a significant cause of mortality in preterm neonates. Early detection of HS PDA and pre-symptomatic closure may help in avoiding complications. For this to happen, easily performed predictors must be available; the aim of this paper is to test the reliability and repeatability of tissue Doppler-derived parameters for prediction of HS PDA. Methods Preterm neonates <32 weeks were screened with echocardiography at Day 3 of life; 80 neonates with PDA were classified into HS group and hemodynamically insignificant (HIS) group based on benchmark parameter namely left ventricular outflow to superior vena caval flow ratio (LVO/SVC), and a ratio ≥4 was considered predictive of HS PDA. Tissue Doppler-derived left ventricular myocardial systolic and diastolic velocities were also performed. Results In total, 105 neonates (55 among HS and 60 among HIS groups) were included in the study. Septal systolic velocity (S′) proved of high sensitivity (100%) in the prediction of HS PDA; nevertheless, it proved to be more repeatable than the initially discriminating parameter (LVO/SVC) with a Kappa of 0.92. Conclusion This study concludes that septal S′ can be reliably used even by neonatologists for pre-symptomatic detection of HS PDA. This may also indicate the need of adding tissue Doppler parameters to the standard protocol of targeted neonatal echocardiography.
Collapse
Affiliation(s)
- Sonia El-Saiedi
- Pediatric Cardiology Unit, Department of Pediatrics, Kasr AlAiny Faculty of Medicine, Cairo University, Cairo, EgyptEgypt
| | - Antoine Fakhry AbdelMassih
- Pediatric Cardiology Unit, Department of Pediatrics, Kasr AlAiny Faculty of Medicine, Cairo University, Cairo, EgyptEgypt.,Consultant of Pediatric Cardiology, Children Cancer Hospital of Egypt (57357 Hospital), Cairo, Egypt
| | - Yasser Sedky
- Pediatric Cardiology Unit, Department of Pediatrics, Kasr AlAiny Faculty of Medicine, Cairo University, Cairo, EgyptEgypt
| | - Amr Malash
- Neonatology Unit, Department of Pediatrics, Kasr AlAiny Faculty of Medicine, Cairo University, Cairo, EgyptEgypt
| | - Nouran Hussain
- Neonatology Unit, Department of Pediatrics, Kasr AlAiny Faculty of Medicine, Cairo University, Cairo, EgyptEgypt
| | - Monica Alfons
- Neonatology Unit, Department of Pediatrics, Kasr AlAiny Faculty of Medicine, Cairo University, Cairo, EgyptEgypt
| | - Rana Essam
- Neonatology Unit, Department of Pediatrics, Kasr AlAiny Faculty of Medicine, Cairo University, Cairo, EgyptEgypt
| |
Collapse
|
43
|
Oulego Erroz I, Alonso Quintela P, Jiménez Gonzalez A, Terroba Seara S, Rodríguez Blanco S, Rosón Varas M, Castañón López L. Impact of screening and treatment of low systemic blood flow in the prevention of severe intraventricular haemorrhage and/or death in pre-term infants. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2018. [DOI: 10.1016/j.anpede.2018.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
|
44
|
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
| |
Collapse
|
45
|
Mahoney L, Fernandez-Alvarez JR, Rojas-Anaya H, Aiton N, Wertheim D, Seddon P, Rabe H. Intra- and Inter-rater Agreement of Superior Vena Cava Flow and Right Ventricular Outflow Measurements in Late Preterm and Term Neonates. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2018; 37:2181-2190. [PMID: 29476553 DOI: 10.1002/jum.14568] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 12/18/2017] [Accepted: 12/22/2017] [Indexed: 06/08/2023]
Abstract
OBJECTIVES To explore the intra- and inter-rater agreement of superior vena cava (SVC) flow and right ventricular (RV) outflow in healthy and unwell late preterm neonates (33-37 weeks' gestational age), term neonates (≥37 weeks' gestational age), and neonates receiving total-body cooling. METHODS The intra- and inter-rater agreement (n = 25 and 41 neonates, respectively) rates for SVC flow and RV outflow were determined by echocardiography in healthy and unwell late preterm and term neonates with the use of Bland-Altman plots, the repeatability coefficient, the repeatability index, and intraclass correlation coefficients. RESULTS The intra-rater repeatability index values were 41% for SVC flow and 31% for RV outflow, with intraclass correlation coefficients indicating good agreement for both measures. The inter-rater repeatability index values for SVC flow and RV outflow were 63% and 51%, respectively, with intraclass correlation coefficients indicating moderate agreement for both measures. CONCLUSIONS If SVC flow or RV outflow is used in the hemodynamic treatment of neonates, sequential measurements should ideally be performed by the same clinician to reduce potential variability.
Collapse
Affiliation(s)
- Liam Mahoney
- Department of Neonatology, Brighton and Sussex University Hospitals National Health Service Trust, Brighton, England
- Department of Academic Pediatrics, Brighton and Sussex Medical School, Brighton, England
| | - Jose R Fernandez-Alvarez
- Department of Neonatology, Brighton and Sussex University Hospitals National Health Service Trust, Brighton, England
- Department of Academic Pediatrics, Brighton and Sussex Medical School, Brighton, England
| | - Hector Rojas-Anaya
- Department of Neonatology, Brighton and Sussex University Hospitals National Health Service Trust, Brighton, England
| | - Neil Aiton
- Department of Neonatology, Brighton and Sussex University Hospitals National Health Service Trust, Brighton, England
| | - David Wertheim
- Faculty of Science, Engineering, and Computing, Kingston University, Kingston, England
| | - Paul Seddon
- Department of Neonatology, Brighton and Sussex University Hospitals National Health Service Trust, Brighton, England
| | - Heike Rabe
- Department of Neonatology, Brighton and Sussex University Hospitals National Health Service Trust, Brighton, England
- Department of Academic Pediatrics, Brighton and Sussex Medical School, Brighton, England
| |
Collapse
|
46
|
Marr K, Jakimovski D, Mancini M, Carl E, Zivadinov R. Jugular Venous Flow Quantification Using Doppler Sonography. ULTRASOUND IN MEDICINE & BIOLOGY 2018; 44:1762-1769. [PMID: 29784437 PMCID: PMC6026550 DOI: 10.1016/j.ultrasmedbio.2018.04.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 03/30/2018] [Accepted: 04/15/2018] [Indexed: 06/08/2023]
Abstract
A consensus on venous flow quantification using echo spectral Doppler sonography is lacking. Doppler sonography data from 83 healthy individuals were examined using manually traced transverse cross-sectional area and diameter-derived cross-sectional area obtained in longitudinal view measurements of the internal jugular vein. Time-averaged velocity over a 4-s interval was obtained in the longitudinal plane using manual tracing of the waveform. Manual and computer-generated blood flow volume calculations were also obtained for the common carotid artery, for accuracy purposes. No differences were detected between semi-automated and manual blood flow volume calculations for the common carotid artery. The manual calculation method resulted in almost twofold larger venous internal jugular vein flow measurements compared with the semi-automated method. Doppler sonography equipment does not provide accurate automated calculation of venous size and blood flow. Until further technological development occurs, manual calculation of venous blood flow is warranted.
Collapse
Affiliation(s)
- Karen Marr
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Dejan Jakimovski
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Marcello Mancini
- Institute of Biostructure and Bioimaging, National Research Council of Italy, Rome, Italy
| | - Ellen Carl
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Robert Zivadinov
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA; Center for Biomedical Imaging at Clinical Translational Science Institute, University at Buffalo, State University of New York, Buffalo, New York, USA.
| |
Collapse
|
47
|
|
48
|
de Boode WP, van der Lee R, Horsberg Eriksen B, Nestaas E, Dempsey E, Singh Y, Austin T, El-Khuffash A. The role of Neonatologist Performed Echocardiography in the assessment and management of neonatal shock. Pediatr Res 2018; 84:57-67. [PMID: 30072807 PMCID: PMC6257224 DOI: 10.1038/s41390-018-0081-1] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
One of the major challenges of neonatal intensive care is the early detection and management of circulatory failure. Routine clinical assessment of the hemodynamic status of newborn infants is subjective and inaccurate, emphasizing the need for objective monitoring tools. An overview will be provided about the use of neonatologist-performed echocardiography (NPE) to assess cardiovascular compromise and guide hemodynamic management. Different techniques of central blood flow measurement, such as left and right ventricular output, superior vena cava flow, and descending aortic flow are reviewed focusing on methodology, validation, and available reference values. Recommendations are provided for individualized hemodynamic management guided by NPE.
Collapse
Affiliation(s)
- Willem P de Boode
- Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands.
| | - Robin van der Lee
- Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
| | | | - Eirik Nestaas
- Institute of Clinical Medicine, Faculty of Medicine, University of, Oslo, Norway
- Department of Cardiology and Center for Cardiological Innovation, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Department of Paediatrics, Vestfold Hospital Trust, Tønsberg, Norway
| | - Eugene Dempsey
- INFANT Centre, Cork University Maternity Hospital, University College, Cork, Ireland
| | - Yogen Singh
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Topun Austin
- Department of Neonatology, Rosie Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Afif El-Khuffash
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland
- Department of Pediatrics, The Royal College of Surgeons in Ireland, Dublin, Ireland
| |
Collapse
|
49
|
Abstract
INTRODUCTION Newborns with congenital diaphragmatic hernia (CDH) have varying degrees of pulmonary hypoplasia and pulmonary hypertension (PH), and there is limited evidence that cardiac dysfunction is present. We sought to study early neonatal biventricular function and performance in these patients by reviewing early post-natal echocardiography (ECHO) measurements and comparing them to normal term newborns. METHODS Retrospective case-control study reviewing clinical and ECHO data on term newborns with CDH and normal controls born between 2009 and 2016. Patients were excluded if major anomalies, genetic syndromes, or no ECHO available. PH was assessed by ductal shunting and tricuspid regurgitant jet velocity. Speckle-tracking echocardiography was used to assess myocardial deformation using velocity vector imaging. RESULTS Forty-four patients with CDH and 18 age-matched controls were analyzed. Pulmonary pressures were significantly higher in the CDH cohort (systolic pulmonary arterial pressure to systolic blood pressure of 103 ± 13 vs. 78 ± 29%, p = 0.0001). CDH patients had decreased RV fractional area change (FAC - 28.6 ± 11.1 vs. 36.2 ± 9.6%, p = 0.02), tricuspid annular plane of systolic excursion (TAPSE-5.6 ± 1.6 vs. 8.6 ± 1.6 mm, p = 0.0001), and RV outflow tract stroke distance (8.6 ± 2.7 vs. 14.0 ± 4.5 cm, p = 0.0001) compared with controls. The left ventricular (LV) ejection fraction was similar in both groups, but CDH patients had a decreased LV end-diastolic volume by Simpson's rule (2.7 ± 1.0 vs. 5.0 ± 1.8 mL, p = 0.0001) and LVOT stroke distance (9.7 ± 3.4 vs. 12.6 ± 3.6 cm, p = 0.004). Biventricular global longitudinal strain (GLS) was markedly decreased in the CDH population compared to controls (RV-GLS: - 9.0 ± 5.3 vs. - 19.5 ± 1.4%, p = 0.0001; LV GLS: - 13.2 ± 5.8 vs. - 20.8 ± 3.5%, p = 0.0001). CONCLUSION CDH newborns have evidence of biventricular dysfunction and decreased cardiac output. Abnormal function may be a factor in the non-response to pulmonary arterial vasodilators in CDH patients. A two-pronged management strategy aimed at improving cardiac function, as well as reducing pulmonary artery pressure in CDH newborns, may be warranted.
Collapse
|
50
|
Oulego Erroz I, Alonso Quintela P, Jiménez Gonzalez A, Terroba Seara S, Rodríguez Blanco S, Rosón Varas M, Castañón López L. [Impact of screening and treatment of low systemic blood flow in the prevention of severe intraventricular haemorrhage and/or death in pre-term infants]. An Pediatr (Barc) 2018; 89:369-377. [PMID: 29622414 DOI: 10.1016/j.anpedi.2018.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 02/08/2018] [Accepted: 02/14/2018] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To assess the effect of a protocolised intervention for low systemic blood flow (SBF) in the occurrence of severe intraventricular haemorrhage (IVH) or death in pre-term infants. METHODS A study with a quasi-experimental design with retrospective controls was conducted on pre-term infants of less than 30weeks of gestational age, born between January 2016 and July 2017, who were consecutively included in the intervention period. The control cohort included pre-term infants (born between January 2013 and December 2015) matched by gestational age, birth weight, and gender (two controls for each case). The cases of low SBF diagnosed according to functional echocardiography during the study period received dobutamine (5-10μg/kg/min) for 48hours. RESULTS The study included 29 cases (intervention period) and 54 controls (pre-intervention period). Ten out of 29 (34.5%) infants received dobutamine for low SBF during the intervention period, with 3/29 (10.3%) cases of severe IVH and/or death compared to 17/54 (31.5%) in the control cohort (p=.032). There was an independent association between the intervention and a decreased occurrence of severe IVH/death after adjusting for confounding factors both in the logistic regression model [OR 0.11 (95%CI: 0.01-0.65), p=.015], as well as in the sensitivity analysis using inverse probability of treatment weighting [OR 0.23 (95%CI: 0.09-0.56); p=.001]. CONCLUSIONS In this study with retrospective controls, a protocolised screening, and treatment for low SBF was associated with a decreased occurrence of severe IVH or death in preterm infants. Large, adequately powered trials, are needed in order to determine whether postnatal interventions directed at low SBF can improve neurological outcomes.
Collapse
Affiliation(s)
- Ignacio Oulego Erroz
- Unidad de Neonatología, Servicio de Pediatría, Complejo Asistencial Universitario de León, León, España.
| | - Paula Alonso Quintela
- Unidad de Neonatología, Servicio de Pediatría, Complejo Asistencial Universitario de León, León, España
| | - Aquilina Jiménez Gonzalez
- Unidad de Neonatología, Servicio de Pediatría, Complejo Asistencial Universitario de León, León, España
| | - Sandra Terroba Seara
- Unidad de Neonatología, Servicio de Pediatría, Complejo Asistencial Universitario de León, León, España
| | - Silvia Rodríguez Blanco
- Unidad de Neonatología, Servicio de Pediatría, Complejo Asistencial Universitario de León, León, España
| | - María Rosón Varas
- Unidad de Neonatología, Servicio de Pediatría, Complejo Asistencial Universitario de León, León, España
| | - Leticia Castañón López
- Unidad de Neonatología, Servicio de Pediatría, Complejo Asistencial Universitario de León, León, España
| |
Collapse
|