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Fedriga M, Martini S, Iodice FG, Sortica da Costa C, Pezzato S, Moscatelli A, Beqiri E, Czosnyka M, Smielewski P, Agrawal S. Cerebral autoregulation in paediatric and neonatal intensive care: A scoping review. J Cereb Blood Flow Metab 2024:271678X241261944. [PMID: 38867574 DOI: 10.1177/0271678x241261944] [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] [Indexed: 06/14/2024]
Abstract
Deranged cerebral autoregulation (CA) is associated with worse outcome in adult brain injury. Strategies for monitoring CA and maintaining the brain at its 'best CA status' have been implemented, however, this approach has not yet developed for the paediatric population. This scoping review aims to find up-to-date evidence on CA assessment in children and neonates with a view to identify patient categories in which CA has been measured so far, CA monitoring methods and its relationship with clinical outcome if any. A literature search was conducted for studies published within 31st December 2022 in 3 bibliographic databases. Out of 494 papers screened, this review includes 135 studies. Our literature search reveals evidence for CA measurement in the paediatric population across different diagnostic categories and age groups. The techniques adopted, indices and thresholds used to assess and define CA are heterogeneous. We discuss the relevance of available evidence for CA assessment in the paediatric population. However, due to small number of studies and heterogeneity of methods used, there is no conclusive evidence to support universal adoption of CA monitoring, technique, and methodology. This calls for further work to understand the clinical impact of CA monitoring in paediatric and neonatal intensive care.
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Affiliation(s)
- Marta Fedriga
- Neonatal and Paediatric Intensive Care Unit, IRCCS Giannina Gaslini Institute, Genoa, Italy
| | - Silvia Martini
- Neonatal Intensive Care Unit, IRCCS AOUBO, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Francesca G Iodice
- Paediatric Cardiac Anaesthesia and Intensive Care Unit, IRCCS, Bambino Gesu' Hospital, Rome, Italy
| | | | - Stefano Pezzato
- Neonatal and Paediatric Intensive Care Unit, IRCCS Giannina Gaslini Institute, Genoa, Italy
| | - Andrea Moscatelli
- Neonatal and Paediatric Intensive Care Unit, IRCCS Giannina Gaslini Institute, Genoa, Italy
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
| | - Shruti Agrawal
- Department of Paediatric Intensive Care, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
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Jiang L, Yu Q, Wang F, Wu M, Liu F, Fu M, Gao J, Feng X, Zhang L, Xu Z. The role of blood pressure variability indicators combined with cerebral blood flow parameters in predicting intraventricular hemorrhage in very low birth weight preterm infants. Front Pediatr 2023; 11:1241809. [PMID: 37876522 PMCID: PMC10590921 DOI: 10.3389/fped.2023.1241809] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 09/22/2023] [Indexed: 10/26/2023] Open
Abstract
Background Hemodynamic instability is the main factor responsible for the development of intraventricular hemorrhage (IVH) in premature newborns. Herein, we evaluated the predictive ability of blood pressure variability (BPV) and anterior cerebral artery (ACA) blood flow parameters in IVH in premature infants with gestational age (GA) ≤32 weeks and birth weight (BW) ≤ 1,500 g. Methods Preterm infants with GA ≤32 weeks and BW ≤ 1,500 g admitted to the neonatal intensive care unit (NICU) of the hospital affiliated to Yangzhou University from January 2020 to January 2023 were selected as the research subjects. All preterm infants were admitted within 1 h after birth, and systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial blood pressure (MABP) were monitored at 1-h intervals. The difference between maximum and minimum values (max-min), standard deviation (SD), coefficient of variation (CV), and successive variation (SV) were used as BPV indicators. On the 1st, 3rd, and 7th day after birth, transcranial ultrasound examination was performed to screen for the occurrence of IVH. On the 24 ± 1 h after birth, systolic velocity (Vs), diastolic velocity (Vd), and resistance index (RI) of the ACA were measured simultaneously. Preterm infants were divided into the IVH group and non-IVH group based on the results of transcranial ultrasound examination, and the correlation between BPV indicators, ACA blood flow parameters, and development of IVH was analyzed. Results A total of 92 premature infants were enrolled, including 49 in the IVH group and 43 in the non-IVH group. There was no statistically significant difference in baseline characteristics such as BW, GA, sex, and perinatal medical history between the two groups of preterm infants (P > 0.05). The SBP SD (OR: 1.480, 95%CI: 1.020-2.147) and ACA-RI (OR: 3.027, 95%CI: 2.769-3.591) were independent risk factors for IVH in premature newborns. The sensitivity and specificity of combined detection of SBP SD and ACA-RI in predicting IVH were 61.2% and 79.1%, respectively. Conclusion High BPV and ACA-RI are related to IVH in premature infants with GA ≤32 w and BW ≤1,500 g. Combined detection of SBP SD and ACA-RI has a certain predictive effect on early identification of IVH.
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Affiliation(s)
- Lijun Jiang
- Department of Neonatology, Affiliated Hospital of Yangzhou University, Yangzhou, China
| | - Qian Yu
- Department of Neonatology, Affiliated Hospital of Yangzhou University, Yangzhou, China
| | - Fudong Wang
- Department of Neonatology, Affiliated Hospital of Yangzhou University, Yangzhou, China
| | - Mingfu Wu
- Department of Neonatology, Affiliated Hospital of Yangzhou University, Yangzhou, China
| | - Feng Liu
- Department of Neonatology, Affiliated Hospital of Yangzhou University, Yangzhou, China
| | - Mingfeng Fu
- Department of Neonatology, Affiliated Hospital of Yangzhou University, Yangzhou, China
| | - Junyan Gao
- Department of Neonatology, Affiliated Hospital of Yangzhou University, Yangzhou, China
| | - Xing Feng
- Department of Neonatology, Affiliated Children's Hospital of Soochow University, Suzhou, China
| | - Longfeng Zhang
- Department of Clinical Laboratory, Affiliated Hospital of Jiangsu University, Zhenjiang, China
| | - Zhenxing Xu
- Department of Neonatology, Affiliated Hospital of Yangzhou University, Yangzhou, China
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Chao H, Acosta S, Rusin C, Rhee C. Comparison of Near-Infrared Spectroscopy-Based Cerebral Autoregulatory Indices in Extremely Low Birth Weight Infants. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1361. [PMID: 37628360 PMCID: PMC10453436 DOI: 10.3390/children10081361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 07/20/2023] [Accepted: 08/08/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND Premature infants are born with immature cerebral autoregulation function and are vulnerable to pressure passive cerebral circulation and subsequent brain injury. Measurements derived from near-infrared spectroscopy (NIRS) have enabled continuous assessment of cerebral vasoreactivity. Although NIRS has enabled a growing field of research, the lack of clear standardization in the field remains problematic. A major limitation of current literature is the absence of a comparative analysis of the different methodologies. OBJECTIVES To determine the relationship between NIRS-derived continuous indices of cerebral autoregulation in a cohort of extremely low birth weight (ELBW) infants. METHODS Premature infants of birth weight 401-1000 g were studied during the first 72 h of life. The cerebral oximetry index (COx), hemoglobin volume index (HVx), and tissue oxygenation heart rate reactivity index (TOHRx) were simultaneously calculated. The relationship between each of the indices was assessed with Pearson correlation. RESULTS Fifty-eight infants with a median gestational age of 25.8 weeks and a median birth weight of 738 g were included. Intraventricular hemorrhage (IVH) was detected in 33% of individuals. COx and HVx demonstrated the highest degree of correlation, although the relationship was moderate at best (r = 0.543, p < 0.001). No correlation was found either between COx and TOHRx (r = 0.318, p < 0.015) or between HVx and TOHRx (r = 0.287, p < 0.029). No significant differences in these relationships were found with respect to IVH and no IVH in subgroup analysis. CONCLUSIONS COx, HVx, and TOHRx are not numerically equivalent. Caution must be applied when interpreting or comparing results based on different methodologies for measuring cerebral autoregulation. Uniformity regarding data acquisition and analytical methodology are needed to firmly establish a gold standard for neonatal cerebral autoregulation monitoring.
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Affiliation(s)
- Howard Chao
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX 77030, USA
| | - Sebastian Acosta
- Department of Pediatrics, Division of Cardiology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX 77030, USA
| | - Craig Rusin
- Department of Pediatrics, Division of Cardiology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX 77030, USA
| | - Christopher Rhee
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX 77030, USA
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Martini S, Thewissen L, Austin T, da Costa CS, de Boode WP, Dempsey E, Kooi E, Pellicer A, Rhee CJ, Riera J, Wolf M, Wong F. Near-infrared spectroscopy monitoring of neonatal cerebrovascular reactivity: where are we now? Pediatr Res 2023:10.1038/s41390-023-02574-6. [PMID: 36997690 DOI: 10.1038/s41390-023-02574-6] [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] [Received: 10/27/2022] [Revised: 02/09/2023] [Accepted: 02/17/2023] [Indexed: 06/19/2023]
Abstract
Cerebrovascular reactivity defines the ability of the cerebral vasculature to regulate its resistance in response to both local and systemic factors to ensure an adequate cerebral blood flow to meet the metabolic demands of the brain. The increasing adoption of near-infrared spectroscopy (NIRS) for non-invasive monitoring of cerebral oxygenation and perfusion allowed investigation of the mechanisms underlying cerebrovascular reactivity in the neonatal population, confirming important associations with pathological conditions including the development of brain injury and adverse neurodevelopmental outcomes. However, the current literature on neonatal cerebrovascular reactivity is mainly still based on small, observational studies and is characterised by methodological heterogeneity; this has hindered the routine application of NIRS-based monitoring of cerebrovascular reactivity to identify infants most at risk of brain injury. This review aims (1) to provide an updated review on neonatal cerebrovascular reactivity, assessed using NIRS; (2) to identify critical points that need to be addressed with targeted research; and (3) to propose feasibility trials in order to fill the current knowledge gaps and to possibly develop a preventive or curative approach for preterm brain injury. IMPACT: NIRS monitoring has been largely applied in neonatal research to assess cerebrovascular reactivity in response to blood pressure, PaCO2 and other biochemical or metabolic factors, providing novel insights into the pathophysiological mechanisms underlying cerebral blood flow regulation. Despite these insights, the current literature shows important pitfalls that would benefit to be addressed in a series of targeted trials, proposed in the present review, in order to translate the assessment of cerebrovascular reactivity into routine monitoring in neonatal clinical practice.
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Affiliation(s)
- Silvia Martini
- Neonatal Intensive Care Unit, IRCCS AOU S. Orsola, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
| | | | - Topun Austin
- Neonatal Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Willem P de Boode
- Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Eugene Dempsey
- Department of Paediatrics and Child Health, INFANT Centre, University College Cork, Cork, Ireland
| | - Elisabeth Kooi
- Division of Neonatology, Beatrix Children's Hospital, University Medical Center, University of Groningen, Groningen, The Netherlands
| | - Adelina Pellicer
- Department of Neonatology, La Paz University Hospital, Madrid, Spain
| | - Christopher J Rhee
- Section of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Joan Riera
- Department of Neonatology, La Paz University Hospital, Madrid, Spain
- Center for Biomedical Technology, Technical University, Madrid, Spain
| | - Martin Wolf
- Biomedical Optics Research Laboratory, Department of Neonatology, University Hospital Zurich, Zurich, Switzerland
| | - Flora Wong
- Monash Newborn, Monash Children's Hospital, Hudson Institute of Medical Research, Department of Paediatrics, Monash University, Melbourne, VIC, Australia
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5
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Early Cerebrovascular Autoregulation in Neonates with Congenital Heart Disease. CHILDREN 2022; 9:children9111686. [DOI: 10.3390/children9111686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 10/28/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022]
Abstract
Neonates with congenital heart disease (CHD) display delayed brain development, predisposing them to impaired cerebrovascular autoregulation (CAR) and ischemic brain injury. For this paper, we analyzed the percentage of time with impaired CAR (%time impaired CAR) during the first 72 h after birth, the relation with clinical factors, and survival in 57 neonates with CHD. The primary outcome was a correlation coefficient of cerebral oxygenation (rcSO2) and mean arterial blood pressure (MABP, mmHg) for two hours on a daily basis. The %time impaired CAR ranged from 9.3% of the studied time on day one to 4.6% on day three. Variables associated with more %time impaired CAR were the use of inotropes (day 1, B = 19.5, 95%CI = 10.6–28.3; day 3, B = 11.5, 95%CI = 7.1–16), lower MABP (day 1, B = −0.6, 95%CI = −1.2–0.0), and dextro-transposition of the great arteries (dTGA) (16.2%) compared with other CHD types (2.0–5.0%; day 1, p = 0.022). Survival was not an associated variable. To summarize, impaired CAR was found in CHD neonates in up to 9.3% of the studied time. More evidence is necessary to evaluate an association with inotropes, dTGA, %time impaired CAR, and long-term outcome, further in larger cohorts.
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Hoffman SB, Magder LS, Viscardi RM. Renal versus cerebral saturation trajectories: the perinatal transition in preterm neonates. Pediatr Res 2022; 92:1437-1442. [PMID: 35177816 DOI: 10.1038/s41390-022-01984-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 01/04/2022] [Accepted: 01/26/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND The aim of this study was to develop reference renal saturation (rSrO2) curves in premature infants, depict how they differ from cerebral saturation (rScO2) curves, and evaluate the effect of blood pressure on these values using near-infrared spectroscopy (NIRS). METHODS This is a prospective cohort study of 57 inborn infants <12 h and <30 weeks gestation. rScO2, rSrO2, fractional tissue oxygen extraction (FTOE), and mean arterial blood pressure (MAP) were continuously monitored every 30 s for 96 h. Quantile regression was used to establish nomograms, and mean saturation values were evaluated for different MAP ranges. RESULTS Median rSrO2 at the start of monitoring was ~10% higher than rScO2. rSrO2 showed a significant decline over time while rScO2 peaked at 26 h. FTOE demonstrated a similar but inverse trend to their saturation counterparts. rScO2 declined as MAP increased, while rSrO2 showed a peak and decline as MAP increased. CONCLUSIONS We provide rSrO2 reference curves for the first 4 days of life, which differ in their trajectory from rScO2 and from what has previously been reported for rSrO2 in the full-term population. In addition, we observed a peak and decline in renal saturation with increasing MAP, suggesting a renovascular response to blood pressure changes. IMPACT This article depicts reference renal saturation curves during the perinatal transition in preterm infants. We show how renal saturation compares to cerebral saturation trends over time. We describe a peak and decline in renal saturation with increasing MAP, suggesting a renovascular response to blood pressure changes.
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Affiliation(s)
- Suma B Hoffman
- Department of Pediatrics, University of Maryland Baltimore School of Medicine, Baltimore, MD, USA. .,Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Children's National Health System - Neonatology, Washington, DC, USA.
| | - Laurence S Magder
- Department of Epidemiology and Public Health, University of Maryland Baltimore School of Medicine, Baltimore, MD, USA
| | - Rose M Viscardi
- Department of Pediatrics, University of Maryland Baltimore School of Medicine, Baltimore, MD, USA
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7
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Martini S, Czosnyka M, Smielewski P, Iommi M, Galletti S, Vitali F, Paoletti V, Camela F, Austin T, Corvaglia L. Clinical determinants of cerebrovascular reactivity in very preterm infants during the transitional period. Pediatr Res 2022; 92:135-141. [PMID: 35513715 DOI: 10.1038/s41390-022-02090-z] [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] [Received: 02/25/2022] [Revised: 03/29/2022] [Accepted: 04/10/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Preterm infants are at enhanced risk of brain injury due to altered cerebral haemodynamics during postnatal transition. This observational study aimed to assess the clinical determinants of transitional cerebrovascular reactivity and its association with intraventricular haemorrhage (IVH). METHODS Preterm infants <32 weeks underwent continuous monitoring of cerebral oxygenation and heart rate over the first 72 h after birth. Serial cranial and cardiac ultrasound assessments were performed to evaluate the ductal status and to diagnose IVH onset. The moving correlation coefficient between cerebral oxygenation and heart rate (TOHRx) was calculated. Linear mixed-effect models were used to analyse the impact of relevant clinical variables on TOHRx. The association between TOHRx and IVH development was also assessed. RESULTS Seventy-seven infants were included. A haemodynamically significant patent ductus arteriosus (hsPDA) (β = 0.044, 95% CI: 0.007-0.081) and ongoing dopamine treatment (β = 0.096, 95% CI: 0.032-0.159) were associated with increasing TOHRx, indicating impaired cerebrovascular reactivity. A significant association between TOHRx, mean arterial blood pressure (β = -0.004, 95% CI: -0.007, -0.001) and CRIB-II score (β = 0.007, 95% CI: 0.001-0.015) was also observed. TOHRx was significantly higher in infants developing high-grade IVH compared to those without IVH. CONCLUSIONS Dopamine treatment, low blood pressure, hsPDA and high CRIB-II are associated with impaired cerebrovascular reactivity during postnatal transition, with potential implications on IVH development. IMPACT The correlation coefficient between cerebral oxygenation and heart rate (TOHRx) provides a non-invasive estimation of cerebrovascular reactivity, whose failure has a potential pathogenic role in the development of IVH in preterm infants. This study shows that cerebrovascular reactivity during the transitional period improves over time and is affected by specific clinical and therapeutic factors, whose knowledge could support the development of individualized neuroprotective strategies in at-risk preterm infants. The evidence of increased TOHRx in infants developing high-grade compared to low-grade or no IVH during the transitional period further supports the role of impaired cerebrovascular reactivity in IVH pathophysiology.
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Affiliation(s)
- Silvia Martini
- Neonatal Intensive Care Unit, IRCCS S. Orsola-Malpighi Hospital, Bologna, Italy. .,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrookes Hospital, Cambridge, UK
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrookes Hospital, Cambridge, UK
| | - Marica Iommi
- Department of Biomedical and Neuromotor Sciences, Division of Hygiene and Biostatistics, University of Bologna, Bologna, Italy
| | - Silvia Galletti
- Neonatal Intensive Care Unit, IRCCS S. Orsola-Malpighi Hospital, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Francesca Vitali
- Neonatal Intensive Care Unit, IRCCS S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Vittoria Paoletti
- Neonatal Intensive Care Unit, IRCCS S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Federica Camela
- Neonatal Intensive Care Unit, IRCCS S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Topun Austin
- Neonatal Intensive Care Unit, The Rosie Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Luigi Corvaglia
- Neonatal Intensive Care Unit, IRCCS S. Orsola-Malpighi Hospital, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
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Abstract
Cerebrovascular autoregulation is the ability to maintain stable cerebral blood flow within a range of cerebral perfusion pressures. When cerebral perfusion pressure is outside the limits of effective autoregulation, the brain is subjected to hypoperfusion or hyperperfusion, which may cause vascular injury, hemorrhage, and/or hypoxic white matter injury. Infants born preterm, after fetal growth restriction, with congenital heart disease, or with hypoxic-ischemic encephalopathy are susceptible to a failure of cerebral autoregulation. Bedside assessment of cerebrovascular autoregulation would offer the opportunity to prevent brain injury. Clinicians need to know which patient populations and circumstances are associated with impaired/absent cerebral autoregulation.
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Affiliation(s)
- Elisabeth M W Kooi
- Division of Neonatology, University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Hanzeplein 1, PO Box 30001, Groningen 9700 RB, The Netherlands.
| | - Anne E Richter
- Division of Neonatology, University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Hanzeplein 1, PO Box 30001, Groningen 9700 RB, The Netherlands
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9
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Pérez-Iranzo A, Jarque A, Toledo JD, Tosca R. Less invasive surfactant administration reduces incidence of severe intraventricular haemorrage in preterms with respiratory distress syndrome: a cohort study. J Perinatol 2020; 40:1185-1192. [PMID: 32546828 DOI: 10.1038/s41372-020-0702-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 04/25/2020] [Accepted: 05/22/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Less invasive surfactant administration (LISA) has proved to safely improve morbidity in extreme preterms with respiratory distress syndrome (RDS). Its effect regarding intraventricular hemorrhage (IVH) remains controversial between most recent systematic reviews. We aimed to evaluate its effect over incidence of severe IVH in this population. STUDY DESIGN We compared the incidence of IVH in a prospective cohort of consecutively born preterm infants <34 weeks' gestation receiving LISA (n = 108) with a historical cohort receiving surfactant delivery via tracheal tube and managed with mechanical ventilation (n = 100). RESULTS No significant differences regarding perinatal characteristics were observed between both groups. There was a significant reduction in the incidence of severe IVH in LISA group as compared with the historical group [OR = 0.054 (95% CI 0.01-0.2) p = 0.000. NNT 5]. In addition, a significant trend towards decreased mortality was also observed in the study group [OR = 0.2 (95% CI 0.04-0.9) p = 0.027, NNT 9]. Intervention group infants also showed lower oxygenation requirements during the first 72 h post surfactant administration and a reduced incidence of pneumothorax. They were less frequently intubated [31 infants (28.4%) vs. 100 [100%]; P < 0.001] and required fewer days of mechanical ventilation. However, no significant difference in bronchopulmonary dysplasia incidence was observed between both groups. CONCLUSIONS LISA approach effectively reduces severe IVH in very low and low birth weight (BW) preterms with RDS. In addition we observe a significant trend towards reduction in both need and duration of MV support, air leak, and overall mortality in the intervention group.
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Affiliation(s)
- A Pérez-Iranzo
- Division of Neonatology, General and University Hospital, Castellon, Spain.
| | - A Jarque
- Division of Neonatology, General and University Hospital, Castellon, Spain
| | - J D Toledo
- Division of Neonatology, General and University Hospital, Castellon, Spain
| | - R Tosca
- Division of Neonatology, General and University Hospital, Castellon, Spain
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10
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Ng IHX, da Costa CS, Zeiler FA, Wong FY, Smielewski P, Czosnyka M, Austin T. Burden of hypoxia and intraventricular haemorrhage in extremely preterm infants. Arch Dis Child Fetal Neonatal Ed 2020; 105:242-247. [PMID: 31256012 DOI: 10.1136/archdischild-2019-316883] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 06/07/2019] [Accepted: 06/12/2019] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Thresholds of cerebral hypoxia through monitoring of near-infrared spectroscopy tissue oxygenation index (TOI) were used to investigate the relationship between intraventricular haemorrhage (IVH) and indices of hypoxia. DESIGN Prospective observational study. SETTING A single-centre neonatal intensive care unit. PATIENTS Infants <28 weeks' gestation with an umbilical artery catheter. METHODS Thresholds of hypoxia were determined from mean values of TOI using sequential Χ2 tests and used alongside thresholds from existing literature to calculate percentage of time in hypoxia and burden of hypoxia below each threshold. These indices were then compared between IVH groups. RESULTS 44 infants were studied for a median of 18.5 (range 6-21) hours in the first 24 hours of life. Sequential Χ2 analysis yielded a TOI threshold of 71% to differentiate between IVH (16 infants) and no IVH (28 infants). Percentage of time in hypoxia was significantly higher in infants with IVH than those without, using thresholds of 60%-67%. Burden of hypoxia was significantly higher in infants with IVH than without, using thresholds of 62%-80%. With the threshold of 71%, percentage of time in hypoxia was lower by 12.2% with a 95% CI of (-25.7 to 1.2) (p=0.073), and the burden of hypoxia was lower by 29.2% hour (%h) (95% CI -55.2 to -3.1)%h (p=0.012) in infants without IVH than those with IVH. CONCLUSIONS Using defined TOI thresholds, infants with IVH spent higher percentage of time in hypoxia with higher burden of cerebral hypoxia than those without, in the first 24 hours of life.
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Affiliation(s)
- Isabel Hui Xuan Ng
- Neonatal Unit, Rosie Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Fred A Zeiler
- Department of Medicine, Addenbrooke's Hospital Department of Anaesthesia, Cambridge, UK.,Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Flora Y Wong
- The Ritchie Centre, Monash University, Monash Institute of Medical Research, Clayton, Victoria, Australia
| | - Peter Smielewski
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Marek Czosnyka
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Topun Austin
- Neonatal Unit, Rosie Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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11
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Korček P, Širc J, Straňák Z. Cerebral oxygenation reflects fetal development in preterm monochorionic and dichorionic twins. Early Hum Dev 2020; 144:105025. [PMID: 32298945 DOI: 10.1016/j.earlhumdev.2020.105025] [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: 02/16/2020] [Revised: 03/21/2020] [Accepted: 03/23/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Cerebral oxygenation (crSO2) monitoring is increasingly used in high-risk infants. Monochorionic twins suffer from specific fetal pathologies that can affect cerebral hemodynamics. Limited data are available on crSO2 and blood flow patterns in this population after birth. OBJECTIVE To evaluate crSO2 changes in preterm monochorionic and dichorionic twins during the first 72 h of life. METHODS Near-infrared spectroscopy was used to measure crSO2 in 62 infants from 31 twin pregnancies <32 weeks of gestation. The study group was divided into 4 subgroups: donor (1) and recipient (2) monochorionic twins (with twin-twin transfusion syndrome), fetal growth restriction (FGR) infants (3) and twins without fetal compromise (4). RESULTS There was significant difference in birth weight (p < 0.001) among 4 subgroups. We observed significant variation in crSO2 among the subgroups using mixed model analysis (p < 0.001). The recipient twins exhibited the lowest crSO2 (mean ± SE) throughout the study period (76 ± 0.3%), whereas the FGR and donor twins presented with the highest values (86 ± 0.3% and 83 ± 0.4% respectively). We found no statistically significant differences in neonatal mortality and morbidity among subgroups. CONCLUSION Our study revealed significant correlation between crSO2 values postnatally and underlying fetal pathology in monochorionic and dichorionic preterm twins.
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Affiliation(s)
- Peter Korček
- Institute for the Care of Mother and Child - Neonatology, Podolské nábřeží 157/36, Prague 14700, Czech Republic; 3rd Faculty of Medicine - Charles University, Ruská 2411/87, Prague 10000, Czech Republic.
| | - Jan Širc
- Institute for the Care of Mother and Child - Neonatology, Podolské nábřeží 157/36, Prague 14700, Czech Republic; 3rd Faculty of Medicine - Charles University, Ruská 2411/87, Prague 10000, Czech Republic
| | - Zbyněk Straňák
- Institute for the Care of Mother and Child - Neonatology, Podolské nábřeží 157/36, Prague 14700, Czech Republic; 3rd Faculty of Medicine - Charles University, Ruská 2411/87, Prague 10000, Czech Republic
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12
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Comparison of wavelet and correlation indices of cerebral autoregulation in a pediatric swine model of cardiac arrest. Sci Rep 2020; 10:5926. [PMID: 32245979 PMCID: PMC7125097 DOI: 10.1038/s41598-020-62435-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 03/13/2020] [Indexed: 02/07/2023] Open
Abstract
Existing cerebrovascular blood pressure autoregulation metrics have not been translated to clinical care for pediatric cardiac arrest, in part because signal noise causes high index time-variability. We tested whether a wavelet method that uses near-infrared spectroscopy (NIRS) or intracranial pressure (ICP) decreases index variability compared to that of commonly used correlation indices. We also compared whether the methods identify the optimal arterial blood pressure (ABPopt) and lower limit of autoregulation (LLA). 68 piglets were randomized to cardiac arrest or sham procedure with continuous monitoring of cerebral blood flow using laser Doppler, NIRS and ICP. The arterial blood pressure (ABP) was gradually reduced until it dropped to below the LLA. Several autoregulation indices were calculated using correlation and wavelet methods, including the pressure reactivity index (PRx and wPRx), cerebral oximetry index (COx and wCOx), and hemoglobin volume index (HVx and wHVx). Wavelet methodology had less index variability with smaller standard deviations. Both wavelet and correlation methods distinguished functional autoregulation (ABP above LLA) from dysfunctional autoregulation (ABP below the LLA). Both wavelet and correlation methods also identified ABPopt with high agreement. Thus, wavelet methodology using NIRS may offer an accurate vasoreactivity monitoring method with reduced signal noise after pediatric cardiac arrest.
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13
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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.
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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
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14
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Cimatti AG, Martini S, Galletti S, Vitali F, Aceti A, Frabboni G, Faldella G, Corvaglia L. Cerebral Oxygenation and Autoregulation in Very Preterm Infants Developing IVH During the Transitional Period: A Pilot Study. Front Pediatr 2020; 8:381. [PMID: 32760685 PMCID: PMC7373744 DOI: 10.3389/fped.2020.00381] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 06/04/2020] [Indexed: 12/22/2022] Open
Abstract
Background: The transitional period, defined as the first 72 h after preterm birth, is often characterized by a significant hemodynamic instability, which represents an important risk factor for such neurological complications of prematurity as intraventricular hemorrhage (IVH). The impairment of cerebral autoregulation plays a key role in the pathogenesis of IVH, whose incidence is highest during the transitional period. This pilot study aimed to evaluate whether patterns of cerebral autoregulation and oxygenation differ in relation to IVH development in very preterm infants during the transitional period. Methods: Infants <32 weeks' gestation were enrolled within 12 h from birth. A simultaneous monitoring of cerebral oxygenation (CrSO2) by near-infrared spectroscopy and of heart rate and peripheral oxygen saturation by pulse oximetry was performed over the first 72 h. Cerebral fractional oxygen extraction (cFTOE) and tissue oxygenation-heart rate reactivity index (TOHRx), which represents a marker of cerebrovascular reactivity, were calculated. Daily cranial and cardiac ultrasound scans were performed, in order to assess the hemodynamic status and to detect a possible IVH onset. CrSO2 and cFTOE, clustered on 6-hour epochs, were compared between infants who developed IVH during the study period and those who did not. A between-group comparison of TOHRx before and after IVH detection was also performed. Results: Twenty preterm infants with a median gestational age of 27 weeks (interquartile range, IQR: 25-30 weeks) and median birth weight of 895 g (IQR: 822-1208 g) were enrolled. Of these, 8 developed IVH. The median age at IVH detection was 40 h (IQR: 30-48 h). Pre-IVH TOHRx was significantly higher compared to matched control periods (p <0.001). CrSO2 was significantly lower from 12 to 30 h and from 42 h onwards in cases compared to controls; however, a temporary CrSO2 rise preceded IVH detection. Similarly, cFTOE was significantly higher in IVH infants from 12 to 30 h and from 48 to 72 h, with a transient decrease between the two periods. Conclusions: In preterm infants during the transitional period, the development of IVH is preceded by transient changes in cerebral oxygenation and oxygen extraction which, in turn, may underlie an early impairment of cerebral autoregulation. Larger studies are needed to confirm these preliminary findings.
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Affiliation(s)
- Anna Giulia Cimatti
- Neonatal Intensive Care Unit, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Silvia Martini
- Neonatal Intensive Care Unit, S. Orsola-Malpighi University Hospital, Bologna, Italy.,Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Silvia Galletti
- Neonatal Intensive Care Unit, S. Orsola-Malpighi University Hospital, Bologna, Italy.,Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Francesca Vitali
- Neonatal Intensive Care Unit, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Arianna Aceti
- Neonatal Intensive Care Unit, S. Orsola-Malpighi University Hospital, Bologna, Italy.,Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Giulia Frabboni
- Neonatal Intensive Care Unit, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Giacomo Faldella
- Neonatal Intensive Care Unit, S. Orsola-Malpighi University Hospital, Bologna, Italy.,Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Luigi Corvaglia
- Neonatal Intensive Care Unit, S. Orsola-Malpighi University Hospital, Bologna, Italy.,Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
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15
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Hoffman SB, Cheng YJ, Magder LS, Shet N, Viscardi RM. Cerebral autoregulation in premature infants during the first 96 hours of life and relationship to adverse outcomes. Arch Dis Child Fetal Neonatal Ed 2019; 104:F473-F479. [PMID: 30385514 DOI: 10.1136/archdischild-2018-315725] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 09/26/2018] [Accepted: 10/05/2018] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To test the hypothesis that impaired cerebral autoregulation (ICA) increases the susceptibility of premature infants to adverse outcomes, we determined the relationship of ICA and cerebral reactivity (CR) measured in the first 96 hours of life to the outcome of grade 3 or 4 intraventricular haemorrhage (IVH) and/or death within 1 month. SETTING Single-centre level IV neonatal intensive care unit. PATIENTS Neonates 24-29 weeks' gestation less than 12 hours old with invasive blood pressure monitoring. DESIGN Cerebral saturations and mean arterial blood pressure were recorded every 30 s for 96 hours. For each 10 min epoch, the correlation coefficient (r) was calculated for mean arterial blood pressure versus cerebral saturations. The epoch was considered to have ICA if r>0.5 and CR if r<0. RESULTS Sixty-one subjects were included. During the first 96 hours, ICA occurred 17.6% and CR occurred 41% of recorded time. In those without adverse outcomes, ICA decreased and CR increased by postnatal day (p<0.05). Adjusted for birth weight and gestational age, those with IVH and those who died spent more time with ICA and less time with CR (p<0.05) over the entire recording period. Those with IVH had 1.5-fold increase in time with ICA on day 2 (p=0.021), and decrease in time with CR on day 3 (p=0.036). Compared with survivors, non-survivors spent more time with ICA on days 3 and 4 (p<0.005), and less with CR on day 3 (p=0.032). CONCLUSION ICA and CR vary by postnatal day and these patterns are associated with adverse outcomes.
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Affiliation(s)
- Suma B Hoffman
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Yun-Ju Cheng
- Department of Mathematics and Statistics, University of Maryland Baltimore County, Baltimore, Maryland, USA
| | - Laurence S Magder
- Department of Epidemiology and Preventive Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Narendra Shet
- Department of Diagnostic Imaging and Radiology, Children's National Health System, Michigan Avenue NW, Washington, DC, USA
| | - Rose M Viscardi
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland, USA
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16
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Changes in hemodynamics, cerebral oxygenation and cerebrovascular reactivity during the early transitional circulation in preterm infants. Pediatr Res 2019; 86:247-253. [PMID: 31029059 DOI: 10.1038/s41390-019-0410-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Accepted: 04/16/2019] [Indexed: 11/08/2022]
Abstract
BACKGROUND Changes in systemic and cerebral hemodynamics in preterm infants during early transitional circulation are complex and may differ between infants with or without intraventricular hemorrhage (IVH). METHOD In total, 43 infants born at median (range) 25 + 5 (23 + 3-31) had continuous near-infrared spectroscopy (NIRS) monitoring of tissue oxygenation index (TOI) and cerebrovascular reactivity within the first 48 h of life. Measurements of left and right cardiac outputs (LVO, RVO) and patent ductus arteriosus (PDA) were collected at 6, 12, 24, and 48 h of life. RESULTS LVO increased within the first 48 h in the IVH (P = 0.007) and no-IVH (P < 0.001) groups. The pattern of change in LVO and RVO was not different between these two groups. TOI was lower in the IVH (P < 0.001) group. A positive correlation between TOI and LVO (P = 0.003) and a negative correlation between the tissue oxygen reactivity index (TOx) and LVO (P = 0.04) were observed at 24 h of life in the IVH group. PDA diameter was not different between IVH groups at any time interval. CONCLUSION Cerebral oxygenation was lower and cerebrovascular reactivity was passive to systemic blood flow at 24 h in infants who developed an IVH.
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17
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Zhang Z, Pu Y, Mi D, Liu L. Cerebral Hemodynamic Evaluation After Cerebral Recanalization Therapy for Acute Ischemic Stroke. Front Neurol 2019; 10:719. [PMID: 31333570 PMCID: PMC6618680 DOI: 10.3389/fneur.2019.00719] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 06/18/2019] [Indexed: 12/14/2022] Open
Abstract
Cerebral recanalization therapy, either intravenous thrombolysis or mechanical thrombectomy, improves the outcomes in patients with acute ischemic stroke (AIS) by restoring the cerebral perfusion of the ischemic penumbra. Cerebral hemodynamic evaluation after recanalization therapy, can help identify patients with high risks of reperfusion-associated complications. Among the various hemodynamic modalities, magnetic resonance imaging (MRI), computed tomography perfusion, and transcranial Doppler sonography (TCD) are the most commonly used. Poststroke hypoperfusion is associated with infarct expansion, while hyperperfusion, which once was considered the hallmark of successful recanalization, is associated with hemorrhagic transformation. Either the hypo- or the hyperperfusion may result in poor clinical outcomes. Individual blood pressure target based on cerebral hemodynamic evaluation was crucial to improve the prognosis. This review summarizes literature on cerebral hemodynamic evaluation and management after recanalization therapy to guide clinical decision making.
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Affiliation(s)
- Zhe Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuehua Pu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Donghua Mi
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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18
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Liu X, Xiao R, Gadhoumi K, Tran N, Smielewski P, Czosnykan M, Hetts SW, Ko N, Hu X. Continuous monitoring of cerebrovascular reactivity through pulse transit time and intracranial pressure. Physiol Meas 2019; 40:01LT01. [PMID: 30577032 PMCID: PMC7197410 DOI: 10.1088/1361-6579/aafab1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Cerebrovascular reactivity (CR) is a mechanism that maintains stable blood flow supply to the brain. Pressure reactivity index (PRx), the correlation coefficient between slow waves of invasive arterial blood pressure (ABP) and intracranial pressure (ICP) has been validated for CR assessment. However, in clinical ward, not every subarachnoid hemorrhage (SAH) patient has invasive ABP monitoring. Pulse transit time (PTT), the propagation time of a pulse wave travelling from the heart to peripheral arteries, has been suggested as a surrogate measure of ABP. In this study, we proposed to use PTT instead of invasive ABP to monitor CR. APPROACH Forty-five SAH patients with simultaneous recordings of invasive ABP, ICP, oxygen saturation level (SpO2) and electrocardiograph (ECG) were included. PTT was calculated as the time from the ECG R-wave peak to the onset of SpO2. PTT based pressure reactivity index (tPRx) was calculated as the correlation coefficient between slow waves of PTT and ICP. Wavelet tPRx (wtRx) was calculated as the cosine of wavelet phase shift between PTT and ICP. Meanwhile, PRx and wPRx were also calculated using invasive ABP and ICP as input. MAIN RESULTS The result showed a negative relationship between PTT and ABP (r = -0.58, p < 0.001). tPRx negatively correlated with PRx (r = -0.51, p = 0.003). Wavelet method correlated well with correlation method demonstrated through positive relationship between wPRx and PRx (r = 0.82, p < 0.001) as well as wtPRx and tPRx (r = 0.84, p < 0.001). SIGNIFICANCE PTT demonstrates great potential as a useful tool for CR assessment when invasive ABP is unavailable. Key points • Pulse transit time (PTT), defined as the propagation time of a pulse wave travelling from the heart to the peripheral arteries, has been proposed as a surrogate measure of ABP. The relationship between PTT and ABP in SAH patients remains unknown. • Cerebrovascular reactivity (CR) assessment through PTT has advantages over invasive ABP, as it avoids bleeding and infection risk, and can be used outside of the ICU. • We introduced a new method to assess CR using PTT and ICP through correlation based method and wavelet based method. • We found that beat-to-beat PTT was negatively related with invasive ABP in SAH patients. A significant linear relationship exists between PTT-based CR parameter and a well validated method, PRx. PTT demonstrates great potential as a useful tool for CR assessment when invasive ABP is unavailable in SAH patients.
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Affiliation(s)
- Xiuyun Liu
- Department of Physiological Nursing, University of California, San Francisco, USA
| | - Ran Xiao
- Department of Physiological Nursing, University of California, San Francisco, USA
| | - Kais Gadhoumi
- Department of Physiological Nursing, University of California, San Francisco, USA
| | - Nate Tran
- Department of Physiological Nursing, University of California, San Francisco, USA
| | - Peter Smielewski
- Brain Physics Laboratory, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - Marek Czosnykan
- Brain Physics Laboratory, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - Steve W. Hetts
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, USA
| | - Nerissa Ko
- Department of Neurology, University of California, San Francisco, USA
| | - Xiao Hu
- Department of Physiological Nursing, University of California, San Francisco, USA
- Department of Neurosurgery, School of Medicine, University of California, Los Angeles, USA
- Department of Neurological Surgery, University of California, San Francisco, USA
- Institute of Computational Health Sciences, University of California, San Francisco, USA
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19
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da Costa CS, Czosnyka M, Smielewski P, Austin T. Optimal Mean Arterial Blood Pressure in Extremely Preterm Infants within the First 24 Hours of Life. J Pediatr 2018; 203:242-248. [PMID: 30243537 DOI: 10.1016/j.jpeds.2018.07.096] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 07/17/2018] [Accepted: 07/27/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To define levels of mean arterial blood pressure (MABP) where cerebrovascular reactivity is strongest (MABPOPT) during the early transitional circulation in extremely preterm infants and to investigate the association between deviations above and below MABPOPT with intraventricular hemorrhage (IVH) and mortality. STUDY DESIGN A total of 44 infants born at a median gestational age 25 (23-27) weeks with indwelling arterial catheter were studied at a median 5.5 (3.1-12.6) hours within the first 24 hours of life. Cerebrovascular reactivity (tissue oxygenation heart rate reactivity index) was estimated by the moving correlation coefficient between heart rate and near-infrared spectroscopy tissue oxygenation index. MABPOPT was defined as the MABP where tissue oxygenation heart rate reactivity index reaches minimum value. Deviations below or above MABPOPT values were calculated along with MABPOPT values during retrospective data analysis. RESULTS MABPOPT was detected in all infants. The mean (SD) MABPOPT was 31.3 (±4.7) mm Hg. MABPOPT increased with increasing gestational age, R = 0.424; P = .004. Deviations below MABPOPT were greater in the IVH group (mean 2.7 mm Hg; 95% CI 2.0-3.5) compared with no-IVH (mean 1.7 mm Hg; 1.1-2.2), P = .006. In infants who died, the deviation below MABPOPT was greater (mean 3.3; 95% CI 1.9-4.8) compared with those who survived (mean 1.9 mm Hg; 95% CI 1.4-2.3), P = .015. CONCLUSIONS Defining optimal MABP based on the strength of cerebrovascular reactivity within the first 24 hours of life is feasible and can provide an individualized approach to the care of extremely preterm infants. Deviations below MABPOPT were significantly associated with IVH and death.
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Affiliation(s)
- Cristine Sortica da Costa
- Neonatal Unit, The Rosie Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom.
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom; Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Topun Austin
- Neonatal Unit, The Rosie Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
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20
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Rhee CJ, da Costa CS, Austin T, Brady KM, Czosnyka M, Lee JK. Neonatal cerebrovascular autoregulation. Pediatr Res 2018; 84:602-610. [PMID: 30196311 PMCID: PMC6422675 DOI: 10.1038/s41390-018-0141-6] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 06/04/2018] [Accepted: 07/27/2018] [Indexed: 12/12/2022]
Abstract
Cerebrovascular pressure autoregulation is the physiologic mechanism that holds cerebral blood flow (CBF) relatively constant across changes in cerebral perfusion pressure (CPP). Cerebral vasoreactivity refers to the vasoconstriction and vasodilation that occur during fluctuations in arterial blood pressure (ABP) to maintain autoregulation. These are vital protective mechanisms of the brain. Impairments in pressure autoregulation increase the risk of brain injury and persistent neurologic disability. Autoregulation may be impaired during various neonatal disease states including prematurity, hypoxic-ischemic encephalopathy (HIE), intraventricular hemorrhage, congenital cardiac disease, and infants requiring extracorporeal membrane oxygenation (ECMO). Because infants are exquisitely sensitive to changes in cerebral blood flow (CBF), both hypoperfusion and hyperperfusion can cause significant neurologic injury. We will review neonatal pressure autoregulation and autoregulation monitoring techniques with a focus on brain protection. Current clinical therapies have failed to fully prevent permanent brain injuries in neonates. Adjuvant treatments that support and optimize autoregulation may improve neurologic outcomes.
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Affiliation(s)
- Christopher J. Rhee
- Baylor College of Medicine, Texas Children’s Hospital, Department of Pediatrics, Section of Neonatology, Houston, TX, USA
| | | | - Topun Austin
- Neonatal Unit, Rosie Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Ken M. Brady
- Baylor College of Medicine, Texas Children’s Hospital, Department of Pediatrics, Critical Care Medicine and Anesthesiology, Houston, TX, USA
| | - Marek Czosnyka
- Department of Academic Neurosurgery, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - Jennifer K. Lee
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
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21
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Sidorenko I, Turova V, Botkin N, Eckardt L, Alves-Pinto A, Felderhoff-Müser U, Rieger-Fackeldey E, Kovtanyuk A, Lampe R. Modeling Cerebral Blood Flow Dependence on Carbon Dioxide and Mean Arterial Blood Pressure in the Immature Brain With Accounting for the Germinal Matrix. Front Neurol 2018; 9:812. [PMID: 30356709 PMCID: PMC6189337 DOI: 10.3389/fneur.2018.00812] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 09/10/2018] [Indexed: 12/20/2022] Open
Abstract
Intraventricular hemorrhage (IVH) is one of the most critical complications in the development of preterm infants. The likelihood of IVH is strongly associated with disturbances in cerebral blood flow (CBF) and with microvascular fragility in the germinal matrix (GM). The CBF value and its reactivity to changes in arterial carbon dioxide pressure (pCO2) and mean arterial blood pressure (MABP) are relevant indicators in the clinical assessment of preterm infants. The objective of the present study is mathematical modeling of the influence of pCO2 and MABP on CBF in immature brain, based on clinical data collected from 265 preterm infants with 23–30 gestational weeks. The model was adapted to the peculiarities of immature brain by taking into account the morphological characteristics of the GM capillary network and vascular reactivity, according to gestational and postnatal age. An analysis of model based values of CBF and its reactivity to changes in MABP and pCO2 was performed separately for each gestational week and for the first two days of life both for preterm infants with and without IVH. The developed model for the estimation of CBF was validated against equivalent experimental measurements taken from the literature. A good agreement between the estimated values of CBF, as well as its reaction on changes in MABP and pCO2 and the equivalent values obtained in experimental studies was shown.
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Affiliation(s)
- Irina Sidorenko
- Mathematical Faculty, Technical University of Munich, Garching, Germany
| | - Varvara Turova
- Orthopedic Department, University Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Nikolai Botkin
- Mathematical Faculty, Technical University of Munich, Garching, Germany
| | - Laura Eckardt
- Pediatric Department I, Neonatology, Pediatric Intensive Care, Pediatric Neurology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Ana Alves-Pinto
- Orthopedic Department, University Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Ursula Felderhoff-Müser
- Pediatric Department I, Neonatology, Pediatric Intensive Care, Pediatric Neurology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Esther Rieger-Fackeldey
- Pediatric Department, University Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Andrey Kovtanyuk
- Orthopedic Department, University Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Renée Lampe
- Orthopedic Department, University Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
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22
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de Boode WP, van der Lee R, Horsberg Eriksen B, Nestaas E, Dempsey E, Singh Y, Austin T, El-Khuffash A. The role of Neonatologist Performed Echocardiography in the assessment and management of neonatal shock. Pediatr Res 2018; 84:57-67. [PMID: 30072807 PMCID: PMC6257224 DOI: 10.1038/s41390-018-0081-1] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
One of the major challenges of neonatal intensive care is the early detection and management of circulatory failure. Routine clinical assessment of the hemodynamic status of newborn infants is subjective and inaccurate, emphasizing the need for objective monitoring tools. An overview will be provided about the use of neonatologist-performed echocardiography (NPE) to assess cardiovascular compromise and guide hemodynamic management. Different techniques of central blood flow measurement, such as left and right ventricular output, superior vena cava flow, and descending aortic flow are reviewed focusing on methodology, validation, and available reference values. Recommendations are provided for individualized hemodynamic management guided by NPE.
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Affiliation(s)
- Willem P de Boode
- Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands.
| | - Robin van der Lee
- Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
| | | | - Eirik Nestaas
- Institute of Clinical Medicine, Faculty of Medicine, University of, Oslo, Norway
- Department of Cardiology and Center for Cardiological Innovation, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Department of Paediatrics, Vestfold Hospital Trust, Tønsberg, Norway
| | - Eugene Dempsey
- INFANT Centre, Cork University Maternity Hospital, University College, Cork, Ireland
| | - Yogen Singh
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Topun Austin
- Department of Neonatology, Rosie Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Afif El-Khuffash
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland
- Department of Pediatrics, The Royal College of Surgeons in Ireland, Dublin, Ireland
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23
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Cardim D, Griesdale DE. Near-infrared spectroscopy: unfulfilled promises. Br J Anaesth 2018; 121:523-526. [PMID: 30115246 DOI: 10.1016/j.bja.2018.05.058] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 05/28/2018] [Indexed: 11/30/2022] Open
Affiliation(s)
- D Cardim
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver BC, Canada
| | - D E Griesdale
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver BC, Canada; Department of Medicine, Divisions of Critical Care Medicine and Neurology, University of British Columbia, Vancouver BC, Canada.
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24
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Carrasco M, Perin J, Jennings JM, Parkinson C, Gilmore MM, Chavez-Valdez R, Massaro AN, Koehler RC, Northington FJ, Tekes A, Lee JK. Cerebral Autoregulation and Conventional and Diffusion Tensor Imaging Magnetic Resonance Imaging in Neonatal Hypoxic-Ischemic Encephalopathy. Pediatr Neurol 2018; 82:36-43. [PMID: 29622488 PMCID: PMC5960435 DOI: 10.1016/j.pediatrneurol.2018.02.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 02/16/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Deviation of mean arterial blood pressure (MAP) from the range that optimizes cerebral autoregulatory vasoreactivity (optimal MAP) could increase neurological injury from hypoxic-ischemic encephalopathy (HIE). We tested whether a global magnetic resonance imaging (MRI) brain injury score and regional diffusion tensor imaging (DTI) are associated with optimal MAP in neonates with HIE. METHODS Twenty-five neonates cooled for HIE were monitored with the hemoglobin volume index. In this observational study, we identified optimal MAP and measured brain injury by qualitative and quantitative MRIs with the Neonatal Research Network (NRN) score and DTI mean diffusivity scalars. Optimal MAP and blood pressure were compared with brain injury. RESULTS Neonates with blood pressure measurements within optimal MAP during rewarming had less brain injury by NRN score (P = 0.040). Longer duration of MAP within optimal MAP during hypothermia correlated with higher mean diffusivity in the anterior centrum semiovale (P = 0.008) and pons (P = 0.002). Blood pressure deviation below optimal MAP was associated with lower mean diffusivity in cerebellar white matter (P = 0.033). Higher optimal MAP values related to lower mean diffusivity in the basal ganglia (P = 0.021), the thalamus (P = 0.006), the posterior limb of the internal capsule (P = 0.018), the posterior centrum semiovale (P = 0.035), and the cerebellar white matter (P = 0.008). Optimal MAP values were not associated with the NRN score. CONCLUSIONS The NRN score and the regional mean diffusivity scalars detected injury with mean arterial blood pressure deviations from the optimal MAP. Higher optimal MAP and lower mean diffusivity may be related because of cytotoxic edema and limited vasodilatory reserve at low MAP in injured brain. DTI detected injury with elevated optimal MAP better than the NRN score.
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Affiliation(s)
- Melisa Carrasco
- Department of Neurology, Division of Pediatric Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Jamie Perin
- Center for Child and Community Health Research (CCHR), Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Jacky M. Jennings
- Center for Child and Community Health Research (CCHR), Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Charlamaine Parkinson
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, Maryland,Division of Neonatology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Maureen M. Gilmore
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, Maryland,Division of Neonatology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Raul Chavez-Valdez
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, Maryland,Division of Neonatology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - An N. Massaro
- Department of Pediatrics, Children’s National Medical Center, George Washington University School of Medicine, Washington, District of Columbia
| | - Raymond C. Koehler
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Frances J. Northington
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, Maryland,Division of Neonatology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Aylin Tekes
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, Maryland,Department of Radiology, Division of Pediatric Radiology and Pediatric Neuroradiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jennifer K. Lee
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, Maryland,Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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25
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Abstract
PURPOSE OF REVIEW There has been a significant increase in the utilization of NIRS in neonatal care over the last few years, with some centers now routinely utilizing this monitoring technique for direct intervention at the bedside. In this review, we provide a summary of the most up-to-date evidence on near infrared spectroscopy utilization, with particular emphasis on measurement of cerebral oxygenation in preterm infants. RECENT FINDINGS There have been significant advances in the technology, leading to an increase in the number of available devices and in the use of this monitoring tool to reduce cerebral injury in preterm infants. The role of NIRS in assessing cerebral autoregulation in preterm and term infants, in evaluating somatic oxygenation, and in the management of newborns with hypoxic ischaemic encephalopathy is discussed. SUMMARY Two recent pilot randomized controlled trials highlight the potential of cerebral oxygenation monitoring to direct management in the delivery room and the neonatal intensive care unit. However, we urge caution against routine use and await the results of further studies in this area before considering this type of monitoring as standard of care.
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26
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Kuik SJ, van der Laan ME, Brouwer-Bergsma MT, Hulscher JBF, Absalom AR, Bos AF, Kooi EMW. Preterm infants undergoing laparotomy for necrotizing enterocolitis or spontaneous intestinal perforation display evidence of impaired cerebrovascular autoregulation. Early Hum Dev 2018; 118:25-31. [PMID: 29454185 DOI: 10.1016/j.earlhumdev.2018.01.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 01/24/2018] [Accepted: 01/30/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND Preterm infants requiring surgery are at risk of impaired neurocognitive development caused, possibly, by cerebral ischemia associated with impaired cerebrovascular autoregulation (CAR). We evaluated CAR before, during, and after laparotomy. STUDY DESIGN This was a hypothesis generating prospective observational cohort study. SUBJECTS We included preterm infants requiring surgery for necrotizing enterocolitis (NEC) or spontaneous intestinal perforation (SIP). Before, during, and after surgery we measured cerebral oxygen saturation using NIRS and calculated cerebral fractional tissue oxygen extraction (cFTOE). OUTCOME MEASURES Impaired CAR was defined if correlation coefficients (rho) between mean cFTOE and mean arterial blood pressure values were ≤-0.30 with P < .05. We used logistic regression analyses to determine factors associated with impaired CAR. RESULTS Nineteen infants with median (IQR) GA 27.6 weeks (26.6-31.0), birth weight 1090 g (924-1430), and postnatal age 9 days (7-12) were included. CAR was impaired more often during surgery than before (12 versus 3, P = .02) or after (12 versus 0, P < .01). A higher PCO2 level was associated with impaired CAR during surgery (OR 3.04, 95% CI, 1.11-8.12 for every 1 kPa increase). CONCLUSIONS More than half of preterm infants with NEC or SIP displayed evidence of impaired CAR during laparotomy. Further research should focus on mechanisms contributing to impaired CAR in preterm infants during surgery.
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Affiliation(s)
- Sara J Kuik
- University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Division of Neonatology, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Michelle E van der Laan
- University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Division of Neonatology, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Margot T Brouwer-Bergsma
- University of Groningen, University Medical Center Groningen, Department of Anesthesiology, Division of Pediatric Anesthesiology, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Jan B F Hulscher
- University of Groningen, University Medical Center Groningen, Department of Surgery, Division of Pediatric Surgery, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Anthony R Absalom
- University of Groningen, University Medical Center Groningen, Department of Anesthesiology, Division of Pediatric Anesthesiology, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Arend F Bos
- University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Division of Neonatology, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Elisabeth M W Kooi
- University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Division of Neonatology, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.
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27
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Thewissen L, Caicedo A, Lemmers P, Van Bel F, Van Huffel S, Naulaers G. Measuring Near-Infrared Spectroscopy Derived Cerebral Autoregulation in Neonates: From Research Tool Toward Bedside Multimodal Monitoring. Front Pediatr 2018; 6:117. [PMID: 29868521 PMCID: PMC5960703 DOI: 10.3389/fped.2018.00117] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 04/11/2018] [Indexed: 12/30/2022] Open
Abstract
Introduction: Cerebral autoregulation (CAR), the ability of the human body to maintain cerebral blood flow (CBF) in a wide range of perfusion pressures, can be calculated by describing the relation between arterial blood pressure (ABP) and cerebral oxygen saturation measured by near-infrared spectroscopy (NIRS). In literature, disturbed CAR is described in different patient groups, using multiple measurement techniques and mathematical models. Furthermore, it is unclear to what extent cerebral pathology and outcome can be explained by impaired CAR. Aim and methods: In order to summarize CAR studies using NIRS in neonates, a systematic review was performed in the PUBMED and EMBASE database. To provide a general overview of the clinical framework used to study CAR, the different preprocessing methods and mathematical models are described and explained. Furthermore, patient characteristics, definition of impaired CAR and the outcome according to this definition is described organized for the different patient groups. Results: Forty-six articles were included in this review. Four patient groups were established: preterm infants during the transitional period, neonates receiving specific medication/treatment, neonates with congenital heart disease and neonates with hypoxic-ischemic encephalopathy (HIE) treated with therapeutic hypothermia. Correlation, coherence and transfer function (TF) gain are the mathematical models most frequently used to describe CAR. The definition of impaired CAR is depending on the mathematical model used. The incidence of intraventricular hemorrhage in preterm infants is the outcome variable most frequently correlated with impaired CAR. Hypotension, disease severity, dopamine treatment, injury on magnetic resonance imaging (MRI) and long term outcome are associated with impaired CAR. Prospective interventional studies are lacking in all research areas. Discussion and conclusion: NIRS derived CAR measurement is an important research tool to improve knowledge about central hemodynamic fluctuations during the transitional period, cerebral pharmacodynamics of frequently used medication (sedatives-inotropes) and cerebral effects of specific therapies in neonatology. Uniformity regarding measurement techniques and mathematical models is needed. Multimodal monitoring databases of neonatal intensive care patients of multiple centers, together with identical outcome parameters are needed to compare different techniques and make progress in this field. Real-time bedside monitoring of CAR, together with conventional monitoring, seems a promising technique to improve individual patient care.
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Affiliation(s)
- Liesbeth Thewissen
- Department of Neonatology, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Alexander Caicedo
- Department of Electrical Engineering, ESAT-Stadius, KU Leuven, Leuven, Belgium.,Interuniversity Microelectronics Centre, Leuven, Belgium
| | - Petra Lemmers
- Department of Neonatology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Frank Van Bel
- Department of Neonatology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Sabine Van Huffel
- Department of Electrical Engineering, ESAT-Stadius, KU Leuven, Leuven, Belgium.,Interuniversity Microelectronics Centre, Leuven, Belgium
| | - Gunnar Naulaers
- Department of Neonatology, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
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28
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Van Laere D, Voeten M, O' Toole JM, Dempsey E. Monitoring Circulation During Transition in Extreme Low Gestational Age Newborns: What's on the Horizon? Front Pediatr 2018; 6:74. [PMID: 29632852 PMCID: PMC5879103 DOI: 10.3389/fped.2018.00074] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 03/12/2018] [Indexed: 11/20/2022] Open
Abstract
Echocardiography and near-infrared spectroscopy have significantly changed our view on hemodynamic transition of the extreme preterm infant. Instead of focusing on maintaining an arbitrary target value of blood pressure, we aim for circulatory well-being by a comprehensive holistic assessment of markers of cardiovascular instability. Most of these clinical and biochemical indices are influenced by transition itself and remain poor discriminators to identify patients with a potential need for therapeutic intervention. At the same time, the evolution in data capturing and storage has led to a change in our approach to monitor vital parameters. Continuous trend monitoring has become more and more relevant. By using signal extraction methods, changes in trends over time can be quantified. In this review, we will discuss the impact of these innovations on the current monitoring practices and explore some of the potential benefits these techniques may have in improving real-time detection of extreme low birth weight infants at risk for morbidity related to impaired hemodynamic transition.
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Affiliation(s)
- David Van Laere
- Department of Neonatal Intensive Care, Antwerp University Hospital, Antwerp, Belgium.,Laboratory of Experimental Medicine and Pediatrics, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Michiel Voeten
- Department of Neonatal Intensive Care, Antwerp University Hospital, Antwerp, Belgium.,Laboratory of Experimental Medicine and Pediatrics, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - John M O' Toole
- Irish Centre for Fetal and Neonatal Translational Research, University College Cork, Cork, Ireland
| | - Eugene Dempsey
- Irish Centre for Fetal and Neonatal Translational Research, University College Cork, Cork, Ireland
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29
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Pressure reactivity index: journey through the past 20 years. Acta Neurochir (Wien) 2017; 159:2063-2065. [PMID: 28849287 DOI: 10.1007/s00701-017-3310-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 08/17/2017] [Indexed: 10/19/2022]
Abstract
Autoregulation after traumatic brain injury can be monitored continuously using simple signal processing of intracranial pressure and arterial blood pressure. The pressure reactivity index (PRx) showed several benefits when it was applied to continuous brain monitoring. Among them, a positive and strong correlation with the outcome and possibility of calculation of 'optimal cerebral perfusion pressure' have been listed. For this methodology, prospective clinical trials are missing-few of them are planned in the near future.
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30
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Korček P, Straňák Z, Širc J, Naulaers G. The role of near-infrared spectroscopy monitoring in preterm infants. J Perinatol 2017; 37:1070-1077. [PMID: 28471443 DOI: 10.1038/jp.2017.60] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Revised: 02/23/2017] [Accepted: 04/03/2017] [Indexed: 02/07/2023]
Abstract
Neurological morbidities such as peri/intraventricular hemorrhage and periventricular leukomalacia largely determine the neurodevelopmental outcome of vulnerable preterm infants and our aim should be to minimize their occurrence or severity. Bed-side neuromonitoring could provide valuable pieces of information about possible hemodynamic disturbances that are significantly associated with neurological morbidities and increased mortality. Near-infrared spectroscopy offers evaluation of regional cerebral oxygenation, which in conjunction with other non-invasive methods may give us a more complete picture about end-organ perfusion. This monitoring tool could help us fully understand the pathophysiology of severe neurological morbidities and guide our management in order to reduce their incidence.
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Affiliation(s)
- P Korček
- Institute for the Care of Mother and Child, Fetal Medicine Center, Prague, Czech Republic.,Third Faculty of Medicine, Prague, Czech Republic
| | - Z Straňák
- Institute for the Care of Mother and Child, Fetal Medicine Center, Prague, Czech Republic.,Third Faculty of Medicine, Prague, Czech Republic
| | - J Širc
- Institute for the Care of Mother and Child, Fetal Medicine Center, Prague, Czech Republic.,Third Faculty of Medicine, Prague, Czech Republic
| | - G Naulaers
- Department of Development and Regeneration, Katholieke Universiteit Leuven, Leuven, Belgium
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31
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Sortica da Costa C, Placek MM, Czosnyka M, Cabella B, Kasprowicz M, Austin T, Smielewski P. Complexity of brain signals is associated with outcome in preterm infants. J Cereb Blood Flow Metab 2017; 37:3368-3379. [PMID: 28075691 PMCID: PMC5624386 DOI: 10.1177/0271678x16687314] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A characteristic feature of complex healthy biological systems is the ability to react and adapt to minute changes in the environment. This 'complexity' manifests itself in highly irregular patterns of various physiological measurements. Here, we apply Multiscale Entropy (MSE) analysis to assess the complexity of systemic and cerebral near-infrared spectroscopy (NIRS) signals in a cohort of 61 critically ill preterm infants born at median (range) gestational age of 26 (23-31) weeks, before 24 h of life. We further correlate the complexity of these parameters with brain injury and mortality. Lower complexity index (CoI) of oxygenated haemoglobin (HbO2), deoxygenated haemoglobin (Hb) and tissue oxygenation index (TOI) were observed in those infants who developed intraventricular haemorrhage (IVH) compared to those who did not (P = 0.002, P = 0.010 and P = 0.038, respectively). Mean CoI of HbO2, Hb and total haemoglobin index (THI) were lower in those infants who died compared to those who survived (P = 0.012, P = 0.004 and P = 0.003, respectively). CoI-HbO2 was an independent predictor of IVH (P = 0.010). Decreased complexity of brain signals was associated with mortality and brain injury. Measurement of brain signal complexity in preterm infants is feasible and could represent a significant advance in the brain-oriented care.
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Affiliation(s)
| | - Michal M Placek
- 2 Department of Biomedical Engineering, Wroclaw University of Science and Technology, Wroclaw, Poland
| | - Marek Czosnyka
- 3 Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Brenno Cabella
- 3 Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Magdalena Kasprowicz
- 2 Department of Biomedical Engineering, Wroclaw University of Science and Technology, Wroclaw, Poland
| | - Topun Austin
- 1 The Rosie Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Peter Smielewski
- 3 Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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32
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Huvanandana J, Thamrin C, Tracy MB, Hinder M, Nguyen CD, McEwan AL. Advanced analyses of physiological signals in the neonatal intensive care unit. Physiol Meas 2017; 38:R253-R279. [DOI: 10.1088/1361-6579/aa8a13] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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33
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Kooi EMW, Verhagen EA, Elting JWJ, Czosnyka M, Austin T, Wong FY, Aries MJ. Measuring cerebrovascular autoregulation in preterm infants using near-infrared spectroscopy: an overview of the literature. Expert Rev Neurother 2017. [DOI: 10.1080/14737175.2017.1346472] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Elisabeth M. W. Kooi
- Beatrix Children’s Hospital, Division of Neonatology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Elise A. Verhagen
- Sophia Children’s Hospital, University of Rotterdam, Erasmus University Hospital, Rotterdam, The Netherlands
| | - Jan Willem J. Elting
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Marek Czosnyka
- Department of Academic Neurosurgery, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - Topun Austin
- Cambridge University Hospitals NHS Foundation Trust, Rosie Hospital, Cambridge, UK
| | - Flora Y. Wong
- Monash Newborn, Monash Medical Centre; Department of Paediatrics, Monash University; The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Australia
| | - Marcel J.H. Aries
- Department of Intensive Care, University of Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
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34
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Prediction of intraventricular haemorrhage in preterm infants using time series analysis of blood pressure and respiratory signals. Sci Rep 2017; 7:46538. [PMID: 28436467 PMCID: PMC5402275 DOI: 10.1038/srep46538] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 03/22/2017] [Indexed: 11/08/2022] Open
Abstract
Despite the decline in mortality rates of extremely preterm infants, intraventricular haemorrhage (IVH) remains common in survivors. The need for resuscitation and cardiorespiratory management, particularly within the first 24 hours of life, are important factors in the incidence and timing of IVH. Variability analyses of heart rate and blood pressure data has demonstrated potential approaches to predictive monitoring. In this study, we investigated the early identification of infants at a high risk of developing IVH, using time series analysis of blood pressure and respiratory data. We also explore approaches to improving model performance, such as the inclusion of multiple variables and signal pre-processing to enhance the results from detrended fluctuation analysis. Of the models we evaluated, the highest area under receiver-operator characteristic curve (5th, 95th percentile) achieved was 0.921 (0.82, 1.00) by mean diastolic blood pressure and the long-term scaling exponent of pulse interval (PI α2), exhibiting a sensitivity of >90% at a specificity of 75%. Following evaluation in a larger population, our approach may be useful in predictive monitoring to identify infants at high risk of developing IVH, offering caregivers more time to adjust intensive care treatment.
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35
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Czosnyka M, Pickard J, Steiner L. Principles of intracranial pressure monitoring and treatment. HANDBOOK OF CLINICAL NEUROLOGY 2017; 140:67-89. [DOI: 10.1016/b978-0-444-63600-3.00005-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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36
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Rhee CJ, Kaiser JR, Rios DR, Kibler KK, Easley RB, Andropoulos DB, Czosnyka M, Smielewski P, Varsos GV, Rusin CG, Gauss CH, Williams DK, Brady KM. Elevated Diastolic Closing Margin Is Associated with Intraventricular Hemorrhage in Premature Infants. J Pediatr 2016; 174:52-6. [PMID: 27112042 PMCID: PMC4925245 DOI: 10.1016/j.jpeds.2016.03.066] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 03/11/2016] [Accepted: 03/24/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To determine whether the diastolic closing margin (DCM), defined as diastolic blood pressure minus critical closing pressure, is associated with the development of early severe intraventricular hemorrhage (IVH). STUDY DESIGN A reanalysis of prospectively collected data was conducted. Premature infants (gestational age 23-31 weeks) receiving mechanical ventilation (n = 185) had ∼1-hour continuous recordings of umbilical arterial blood pressure, middle cerebral artery cerebral blood flow velocity, and PaCO2 during the first week of life. Models using multivariate generalized linear regression and purposeful selection were used to determine associations with severe IVH. RESULTS Severe IVH (grades 3-4) was observed in 14.6% of the infants. Irrespective of the model used, Apgar score at 5 minutes and DCM were significantly associated with severe IVH. A clinically relevant 5-mm Hg increase in DCM was associated with a 1.83- to 1.89-fold increased odds of developing severe IVH. CONCLUSION Elevated DCM was associated with severe IVH, consistent with previous animal data showing that IVH is associated with hyperperfusion. Measurement of DCM may be more useful than blood pressure in defining cerebral perfusion in premature infants.
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Affiliation(s)
- Christopher J Rhee
- Section of Neonatology, Department of Pediatrics, Texas Children's Hospital/Baylor College of Medicine, Houston, TX.
| | - Jeffrey R Kaiser
- Section of Neonatology, Department of Pediatrics, Texas Children's Hospital/Baylor College of Medicine, Houston, TX; Department of Obstetrics and Gynecology, Texas Children's Hospital/Baylor College of Medicine, Houston, TX
| | - Danielle R Rios
- Section of Neonatology, Department of Pediatrics, Texas Children's Hospital/Baylor College of Medicine, Houston, TX
| | - Kathleen K Kibler
- Department of Anesthesiology, Texas Children's Hospital/Baylor College of Medicine, Houston, TX; Department of Critical Care Medicine, Texas Children's Hospital/Baylor College of Medicine, Houston, TX; Department of Pediatrics, Texas Children's Hospital/Baylor College of Medicine, Houston, TX
| | - R Blaine Easley
- Department of Anesthesiology, Texas Children's Hospital/Baylor College of Medicine, Houston, TX; Department of Critical Care Medicine, Texas Children's Hospital/Baylor College of Medicine, Houston, TX; Department of Pediatrics, Texas Children's Hospital/Baylor College of Medicine, Houston, TX
| | - Dean B Andropoulos
- Department of Anesthesiology, Texas Children's Hospital/Baylor College of Medicine, Houston, TX; Department of Critical Care Medicine, Texas Children's Hospital/Baylor College of Medicine, Houston, TX; Department of Pediatrics, Texas Children's Hospital/Baylor College of Medicine, Houston, TX
| | - Marek Czosnyka
- Department of Academic Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Peter Smielewski
- Department of Academic Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Georgios V Varsos
- Department of Academic Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Craig G Rusin
- Section of Cardiology, Department of Pediatrics, Texas Children's Hospital/Baylor College of Medicine, Houston, TX
| | - C Heath Gauss
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR
| | - D Keith Williams
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Ken M Brady
- Department of Anesthesiology, Texas Children's Hospital/Baylor College of Medicine, Houston, TX; Department of Critical Care Medicine, Texas Children's Hospital/Baylor College of Medicine, Houston, TX; Department of Pediatrics, Texas Children's Hospital/Baylor College of Medicine, Houston, TX
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Govindan RB, Al-Shargabi T, Massaro AN, Metzler M, Andescavage NN, Joshi R, Dave R, du Plessis A. Baroreflex dysfunction in sick newborns makes heart rate an unreliable surrogate for blood pressure changes. Pediatr Res 2016; 79:929-33. [PMID: 26859365 PMCID: PMC4899139 DOI: 10.1038/pr.2016.17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 11/21/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Cerebral pressure passivity (CPP) in sick newborns can be detected by evaluating coupling between mean arterial pressure (MAP) and cerebral blood flow measured by near infra-red spectroscopy hemoglobin difference (HbD). However, continuous MAP monitoring requires invasive catheterization with its inherent risks. We tested whether heart rate (HR) could serve as a reliable surrogate for MAP in the detection of CPP in sick newborns. METHODS Continuous measurements of MAP, HR, and HbD were made and partitioned into 10-min epochs. Spectral coherence (COH) was computed between MAP and HbD (COHMAP-HbD) to detect CPP, between HR and HbD (COHHR-HbD) for comparison, and between MAP and HR (COHMAP-HR) to quantify baroreflex function (BRF). The agreement between COHMAP-HbD and COHHR-HbD was assessed using ROC analysis. RESULTS We found poor agreement between COHMAP-HbD and COHHR-HbD in left hemisphere (area under the ROC curve (AUC) 0.68) and right hemisphere (AUC 0.71). Baroreflex failure (COHMAP-HR not significant) was present in 79% of epochs. Confining comparison to epochs with intact BRF showed an AUC of 0.85 for both hemispheres. CONCLUSIONS In these sick newborns, HR was an unreliable surrogate for MAP required for the detection of CPP. This is likely due to the prevalence of BRF failure in these infants.
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Affiliation(s)
| | - Tareq Al-Shargabi
- Divison of Fetal and Transitional Medicine,
Children’s National Health System, Washington, DC
| | - An N Massaro
- Division of Neonatology, Children's National Health
System, Washington, DC
- Department of Pediatrics, The George Washington University
School of Medicine and Health Sciences, Washington, DC
| | - Marina Metzler
- Divison of Fetal and Transitional Medicine,
Children’s National Health System, Washington, DC
| | - Nickie N. Andescavage
- Division of Neonatology, Children's National Health
System, Washington, DC
- Department of Pediatrics, The George Washington University
School of Medicine and Health Sciences, Washington, DC
| | - Radhika Joshi
- Divison of Fetal and Transitional Medicine,
Children’s National Health System, Washington, DC
| | - Rhiya Dave
- Divison of Fetal and Transitional Medicine,
Children’s National Health System, Washington, DC
| | - Adre du Plessis
- Divison of Fetal and Transitional Medicine,
Children’s National Health System, Washington, DC
- Department of Pediatrics, The George Washington University
School of Medicine and Health Sciences, Washington, DC
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38
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Donnelly J, Budohoski KP, Smielewski P, Czosnyka M. Regulation of the cerebral circulation: bedside assessment and clinical implications. Crit Care 2016; 20:129. [PMID: 27145751 PMCID: PMC4857376 DOI: 10.1186/s13054-016-1293-6] [Citation(s) in RCA: 122] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Regulation of the cerebral circulation relies on the complex interplay between cardiovascular, respiratory, and neural physiology. In health, these physiologic systems act to maintain an adequate cerebral blood flow (CBF) through modulation of hydrodynamic parameters; the resistance of cerebral vessels, and the arterial, intracranial, and venous pressures. In critical illness, however, one or more of these parameters can be compromised, raising the possibility of disturbed CBF regulation and its pathophysiologic sequelae. Rigorous assessment of the cerebral circulation requires not only measuring CBF and its hydrodynamic determinants but also assessing the stability of CBF in response to changes in arterial pressure (cerebral autoregulation), the reactivity of CBF to a vasodilator (carbon dioxide reactivity, for example), and the dynamic regulation of arterial pressure (baroreceptor sensitivity). Ideally, cerebral circulation monitors in critical care should be continuous, physically robust, allow for both regional and global CBF assessment, and be conducive to application at the bedside. Regulation of the cerebral circulation is impaired not only in primary neurologic conditions that affect the vasculature such as subarachnoid haemorrhage and stroke, but also in conditions that affect the regulation of intracranial pressure (such as traumatic brain injury and hydrocephalus) or arterial blood pressure (sepsis or cardiac dysfunction). Importantly, this impairment is often associated with poor patient outcome. At present, assessment of the cerebral circulation is primarily used as a research tool to elucidate pathophysiology or prognosis. However, when combined with other physiologic signals and online analytical techniques, cerebral circulation monitoring has the appealing potential to not only prognosticate patients, but also direct critical care management.
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Affiliation(s)
- Joseph Donnelly
- />Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, University of Cambridge, Hills Road, Cambridge, CB2 0QQ UK
| | - Karol P. Budohoski
- />Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, University of Cambridge, Hills Road, Cambridge, CB2 0QQ UK
| | - Peter Smielewski
- />Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, University of Cambridge, Hills Road, Cambridge, CB2 0QQ UK
| | - Marek Czosnyka
- />Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, University of Cambridge, Hills Road, Cambridge, CB2 0QQ UK
- />Institute of Electronic Systems, Warsaw University of Technology, ul. Nowowiejska 15/19, 00-665 Warsaw, Poland
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