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Chock VY, Vesoulis ZA, El-Dib M, Austin T, van Bel F. The Future of Neonatal Cerebral Oxygenation Monitoring: Directions After the SafeBoosC-III Trial. J Pediatr 2024; 270:114016. [PMID: 38492916 DOI: 10.1016/j.jpeds.2024.114016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 02/18/2024] [Accepted: 03/12/2024] [Indexed: 03/18/2024]
Affiliation(s)
- Valerie Y Chock
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, CA.
| | | | - Mohamed El-Dib
- Division of Newborn Medicine, Department of Pediatrics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Topun Austin
- Neonatal Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Frank van Bel
- Department of Neonatology, University Medical Center Utrecht, Utrecht, The Netherlands
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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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Zanelli SA, Abubakar M, Andris R, Patwardhan K, Fairchild KD, Vesoulis ZA. Early Vital Sign Differences in Very Low Birth Weight Infants with Severe Intraventricular Hemorrhage. Am J Perinatol 2023; 40:1193-1201. [PMID: 34450675 PMCID: PMC9188354 DOI: 10.1055/s-0041-1733955] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Severe intraventricular hemorrhage (sIVH, grades 3 and 4) is a serious complication for very low birth weight (VLBW) infants and is often clinically silent requiring screening cranial ultrasound (cUS) for detection. Abnormal vital sign (VS) patterns might serve as biomarkers to identify risk or occurrence of sIVH. STUDY DESIGN This retrospective study was conducted in VLBW infants admitted to two level-IV neonatal intensive care units (NICUs) between January 2009 and December 2018. Inclusion criteria were: birth weight <1.5 kg and gestational age (GA) <32 weeks, at least 12 hours of systemic oxygen saturation from pulse oximetry (SpO2) data over the first 24 hours and cUS imaging. Infants were categorized as early sIVH (sIVH identified in the first 48 hours), late sIVH (sIVH identified after 48 hours and normal imaging in the first 48 hours), and no IVH. Infants with grades 1 and 2 or unknown timing IVH were excluded. Mean heart rate (HR), SpO2, mean arterial blood pressure (MABP), number of episodes of bradycardia (HR < 100 bpm), and desaturation (SpO2 < 80%) were compared. RESULTS A total of 639 infants (mean: 27 weeks' gestation) were included (567 no IVH, 34 early sIVH, and 37 late sIVH). In the first 48 hours, those with sIVH had significantly higher HR compared with those with no IVH. Infants with sIVH also had lower mean SpO2 and MABP and more desaturations <80%. No significant differences in VS patterns were identified in early versus late sIVH. Logistic regression identified higher HR and greater number of desaturations <80% as independently associated with sIVH. CONCLUSION VLBW infants who develop sIVH demonstrate VS differences with significantly lower SpO2 and higher mean HR over the first 48 hours after birth compared with VLBW infants with no IVH. Abnormalities in early VS patterns may be a useful biomarker for sIVH. Whether VS abnormalities predict or simply reflect sIVH remains to be determined. KEY POINTS · A higher HR in the first 48 hours is seen in infants with severe IVH.. · Infants with sIVH have lower blood pressure in the first 48 hours.. · Infants with sIVH have more oxygen desaturations in the first 48 hours..
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Affiliation(s)
- Santina A. Zanelli
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Maryam Abubakar
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Robert Andris
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Kavita Patwardhan
- Department of Pediatrics, Division of Newborn Medicine, Washington University, St. Louis, Missouri
| | - Karen D. Fairchild
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Zachary A. Vesoulis
- Department of Pediatrics, Division of Newborn Medicine, Washington University, St. Louis, Missouri
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Pfurtscheller D, Baik-Schneditz N, Schwaberger B, Urlesberger B, Pichler G. Insights into Neonatal Cerebral Autoregulation by Blood Pressure Monitoring and Cerebral Tissue Oxygenation: A Qualitative Systematic Review. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1304. [PMID: 37628303 PMCID: PMC10453558 DOI: 10.3390/children10081304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 07/20/2023] [Accepted: 07/26/2023] [Indexed: 08/27/2023]
Abstract
OBJECTIVE The aim of this qualitative systematic review was to identify publications on blood pressure monitoring in combination with cerebral tissue oxygenation monitoring during the first week after birth focusing on cerebral autoregulation. METHODS A systematic search was performed on PubMed. The following search terms were used: infants/newborn/neonates, blood pressure/systolic/diastolic/mean/MAP/SAP/DAP, near-infrared spectroscopy, oxygenation/saturation/oxygen, and brain/cerebral. Additional studies were identified by a manual search of references in the retrieved studies and reviews. Only human studies were included. RESULTS Thirty-one studies focused on preterm neonates, while five included preterm and term neonates. In stable term neonates, intact cerebral autoregulation was shown by combining cerebral tissue oxygenation and blood pressure during immediate transition, while impaired autoregulation was observed in preterm neonates with respiratory support. Within the first 24 h, stable preterm neonates had reduced cerebral tissue oxygenation with intact cerebral autoregulation, while sick neonates showed a higher prevalence of impaired autoregulation. Further cardio-circulatory treatment had a limited effect on cerebral autoregulation. Impaired autoregulation, with dependency on blood pressure and cerebral tissue oxygenation, increased the risk of intraventricular hemorrhage and abnormal neurodevelopmental outcomes. CONCLUSIONS Integrating blood pressure monitoring with cerebral tissue oxygenation measurements has the potential to improve treatment decisions and optimizes neurodevelopmental outcomes in high-risk neonates.
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Affiliation(s)
- Daniel Pfurtscheller
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria; (D.P.); (N.B.-S.); (B.S.); (B.U.)
- Research Unit for Neonatal Micro- and Macrocirculation, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria
- Research Unit for Cerebral Development and Oximetry, Division of Neonatology, Medical University of Graz, 8036 Graz, Austria
| | - Nariae Baik-Schneditz
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria; (D.P.); (N.B.-S.); (B.S.); (B.U.)
- Research Unit for Neonatal Micro- and Macrocirculation, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria
- Research Unit for Cerebral Development and Oximetry, Division of Neonatology, Medical University of Graz, 8036 Graz, Austria
| | - Bernhard Schwaberger
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria; (D.P.); (N.B.-S.); (B.S.); (B.U.)
- Research Unit for Neonatal Micro- and Macrocirculation, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria
- Research Unit for Cerebral Development and Oximetry, Division of Neonatology, Medical University of Graz, 8036 Graz, Austria
| | - Berndt Urlesberger
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria; (D.P.); (N.B.-S.); (B.S.); (B.U.)
- Research Unit for Neonatal Micro- and Macrocirculation, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria
- Research Unit for Cerebral Development and Oximetry, Division of Neonatology, Medical University of Graz, 8036 Graz, Austria
| | - Gerhard Pichler
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria; (D.P.); (N.B.-S.); (B.S.); (B.U.)
- Research Unit for Neonatal Micro- and Macrocirculation, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria
- Research Unit for Cerebral Development and Oximetry, Division of Neonatology, Medical University of Graz, 8036 Graz, Austria
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Aladangady N, Sinha A, Banerjee J, Asamoah F, Mathew A, Chisholm P, Kempley S, Morris J. Comparison of clinical outcomes between active and permissive blood pressure management in extremely preterm infants. NIHR OPEN RESEARCH 2023; 3:7. [PMID: 37881469 PMCID: PMC10593335 DOI: 10.3310/nihropenres.13357.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/02/2023] [Indexed: 10/27/2023]
Abstract
Background There remains uncertainty about the definition of normal blood pressure (BP), and when to initiate treatment for hypotension for extremely preterm infants. To determine the short-term outcomes of extremely preterm infants managed by active compared with permissive BP support regimens during the first 72 hours of life. Method This is a retrospective medical records review of 23 +0-28 +6 weeks' gestational age (GA) infants admitted to neonatal units (NNU) with active BP support (aimed to maintain mean arterial BP (MABP) >30 mmHg irrespective of the GA) and permissive BP support (used medication only when babies developed signs of hypotension) regimens. Babies admitted after 12 hours of age, or whose BP data were not available were excluded. Results There were 764 infants admitted to the participating hospitals; 671 (88%) were included in the analysis (263 active BP support and 408 permissive BP support). The mean gestational age, birth weight, admission temperature, clinical risk index for babies (CRIB) score and first haemoglobin of infants were comparable between the groups. Active BP support group infants had consistently higher MABP and systolic BP throughout the first 72 hours of life (p<0.01). In the active group compared to the permissive group 56 (21.3%) vs 104 (25.5%) babies died, and 21 (8%) vs 51 (12.5%) developed >grade 2 intra ventricular haemorrhage (IVH). Death before discharge (adjusted OR 1.38 (0.88 - 2.16)) or IVH (1.38 (0.96 - 1.98)) was similar between the two groups. Necrotising enterocolitis (NEC) ≥stage 2 was significantly higher in permissive BP support group infants (1.65 (1.07 - 2.50)). Conclusions There was no difference in mortality or IVH between the two BP management approaches. Active BP support may reduce NEC. This should be investigated prospectively in large multicentre randomised studies.
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Affiliation(s)
- Narendra Aladangady
- Department of Neonatology, Homerton University Hospital, Homerton Healthcare NHS Foundation Trust, London, E9 6SR, UK
- Centre for Paediatrics, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Ajay Sinha
- Centre for Paediatrics, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Department of Neonatology, The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Jayanta Banerjee
- Department of Neonatology, Imperial College Healthcare NHS Trust, London, UK
- Institute of Reproductive and Developmental Biology, Imperial College London, London, UK
| | - Felix Asamoah
- Department of Statistics, NHS England and Improvement, London, UK
| | - Asha Mathew
- Department of Neonatology, Homerton University Hospital, Homerton Healthcare NHS Foundation Trust, London, E9 6SR, UK
| | - Phillippa Chisholm
- Department of Neonatology, Homerton University Hospital, Homerton Healthcare NHS Foundation Trust, London, E9 6SR, UK
| | - Steven Kempley
- Centre for Paediatrics, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Department of Neonatology, The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Joan Morris
- Environment, Prevention & Health Care, Population Health Research Institute, St George’s University of London, London, UK
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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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Bereda G. Hypertensive Urgency and Anterior Epistaxis Caused by Antihypertensive Medication Noncompliance: A Case Report. Open Access Emerg Med 2023; 15:47-51. [PMID: 36760918 PMCID: PMC9904137 DOI: 10.2147/oaem.s400167] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 01/27/2023] [Indexed: 02/05/2023] Open
Abstract
Background and Aims A sudden increase in blood pressure without serious, life-threatening symptoms or indications of immediate target organ damage is referred to as "hypertensive urgency." This case study revealed the rare direct cause of epistaxis and the direct cause of hypertensive urgency in an elderly man due to antihypertensive medication noncompliance. Case Presentation A black male farmer, age 63, was brought to the emergency room on June 1st, 2022, with chief complaints of breathing difficulties, epistaxis, and disorientation. The patient was hospitalized after exhibiting symptoms of breathlessness, malaise, nausea, and vomiting. Magnetic resonance imaging, an echocardiogram, and a computed tomography scan of the brain are all clear. For the treatment of epistaxis, he received 1g of tranexamic acid intravenously three times a day for two days. He received intravenous labetalol, which was effective in treating his hypertensive urgency and rebound hypertension, utilizing repeated dosages of 5-20 mg. The patient's intravenous labetalol and previous enalapril were switched to captopril 25 mg orally three times a day for one month after starting drugs per os. Discussion The patient's hypertensive urgency is directly caused by forgetting to take his blood pressure medication and by not adhering to his previous antihypertensive drugs as prescribed. In this study, the patient's hypertension had been uncontrolled for the previous six months despite his treatment plan. Unaware that he had missed two doses of his antihypertensive medication, he was admitted to the emergency room with progressive anterior nose bleeding that persisted for four hours. The patient's elevated arterial blood pressure is what's causing the patient's nose to bleed.
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Affiliation(s)
- Gudisa Bereda
- Pharmacy Department, Alert Comprehensive Specialized Hospital, Addis Ababa, Ethiopia,Correspondence: Gudisa Bereda, Pharmacy Department, Alert Comprehensive Specialized Hospital, Addis Ababa, 1000, Ethiopia, Tel +251913118492; +251910790650, Email
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Neuromonitoring in neonatal critical care part II: extremely premature infants and critically ill neonates. Pediatr Res 2022:10.1038/s41390-022-02392-2. [PMID: 36434203 DOI: 10.1038/s41390-022-02392-2] [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: 05/05/2022] [Revised: 11/02/2022] [Accepted: 11/02/2022] [Indexed: 11/27/2022]
Abstract
Neonatal intensive care has expanded from cardiorespiratory care to a holistic approach emphasizing brain health. To best understand and monitor brain function and physiology in the neonatal intensive care unit (NICU), the most commonly used tools are amplitude-integrated EEG, full multichannel continuous EEG, and near-infrared spectroscopy. Each of these modalities has unique characteristics and functions. While some of these tools have been the subject of expert consensus statements or guidelines, there is no overarching agreement on the optimal approach to neuromonitoring in the NICU. This work reviews current evidence to assist decision making for the best utilization of these neuromonitoring tools to promote neuroprotective care in extremely premature infants and in critically ill neonates. Neuromonitoring approaches in neonatal encephalopathy and neonates with possible seizures are discussed separately in the companion paper. IMPACT: For extremely premature infants, NIRS monitoring has a potential role in individualized brain-oriented care, and selective use of aEEG and cEEG can assist in seizure detection and prognostication. For critically ill neonates, NIRS can monitor cerebral perfusion, oxygen delivery, and extraction associated with disease processes as well as respiratory and hypodynamic management. Selective use of aEEG and cEEG is important in those with a high risk of seizures and brain injury. Continuous multimodal monitoring as well as monitoring of sleep, sleep-wake cycling, and autonomic nervous system have a promising role in neonatal neurocritical care.
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Czosnyka M, Santarius T, Donnelly J, van den Dool REC, Sperna Weiland NH. Pro-Con Debate: The Clinical (Ir)relevance of the Lower Limit of Cerebral Autoregulation for Anesthesiologists. Anesth Analg 2022; 135:734-743. [DOI: 10.1213/ane.0000000000006123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Comparison of different metrics of cerebral autoregulation in association with major morbidity and mortality after cardiac surgery. Br J Anaesth 2022; 129:22-32. [PMID: 35597624 PMCID: PMC9428920 DOI: 10.1016/j.bja.2022.03.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 01/25/2022] [Accepted: 03/10/2022] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Cardiac surgery studies have established the clinical relevance of personalised arterial blood pressure management based on cerebral autoregulation. However, variabilities exist in autoregulation evaluation. We compared the association of several cerebral autoregulation metrics, calculated using different methods, with outcomes after cardiac surgery. METHODS Autoregulation was measured during cardiac surgery in 240 patients. Mean flow index and cerebral oximetry index were calculated as Pearson's correlations between mean arterial pressure (MAP) and transcranial Doppler blood flow velocity or near-infrared spectroscopy signals. The lower limit of autoregulation and optimal mean arterial pressure were identified using mean flow index and cerebral oximetry index. Regression models were used to examine associations of area under curve and duration of mean arterial pressure below thresholds with stroke, acute kidney injury (AKI), and major morbidity and mortality. RESULTS Both mean flow index and cerebral oximetry index identified the cerebral lower limit of autoregulation below which MAP was associated with a higher incidence of AKI and major morbidity and mortality. Based on magnitude and significance of the estimates in adjusted models, the area under curve of MAP < lower limit of autoregulation had the strongest association with AKI and major morbidity and mortality. The odds ratio for area under the curve of MAP < lower limit of autoregulation was 1.05 (95% confidence interval, 1.01-1.09), meaning every 1 mm Hg h increase of area under the curve was associated with an average increase in the odds of AKI by 5%. CONCLUSIONS For cardiac surgery patients, area under curve of MAP < lower limit of autoregulation using mean flow index or cerebral oximetry index had the strongest association with AKI and major morbidity and mortality. Trials are necessary to evaluate this target for MAP management.
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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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14
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Späth C, Stoltz Sjöström E, Ågren J, Ahlsson F, Domellöf M. Sodium supply from administered blood products was associated with severe intraventricular haemorrhage in extremely preterm infants. Acta Paediatr 2022; 111:1701-1708. [PMID: 35615868 PMCID: PMC9543447 DOI: 10.1111/apa.16423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 05/03/2022] [Accepted: 05/24/2022] [Indexed: 11/29/2022]
Abstract
Aim The aim of this study was to investigate the associations between sodium supply, fluid volume, sodium imbalances and severe intraventricular haemorrhage (IVH) in extremely preterm (EPT) infants. Methods We used data from the EXtremely PREterm infants in Sweden Study (EXPRESS) cohort consisting of all infants born at 22 to 26 gestational weeks from 2004 to 2007 and conducted a nested case–control study. For every infant with severe IVH (grade 3 or peri‐ventricular haemorrhagic infarction), one IVH‐free control infant with the birthday closest to the case infant and matched for hospital, sex, gestational age and birth weight was selected (n = 70 case–control pairs). Results Total sodium supply and fluid volume were higher in infants with severe IVH compared with controls [daily total sodium supply until postnatal Day 2: mean ± SD (mmol/kg/day): 5.49 ± 2.53 vs. 3.95 ± 1.91, p = 0.009]. These differences were accounted for by sodium and fluid from transfused blood products. High plasma sodium concentrations or large sodium fluctuations were not associated with severe IVH. Conclusion Our results suggest a relationship between sodium‐rich transfusions of blood products and severe IVH in EPT infants. It is unclear whether this is an effect of sodium load, volume load or some other transfusion‐related factor.
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Affiliation(s)
- Cornelia Späth
- Department of Clinical Sciences, Pediatrics Umeå University Umeå Sweden
| | | | - Johan Ågren
- Department of Women's and Children's Health Uppsala University Uppsala Sweden
| | - Fredrik Ahlsson
- Department of Women's and Children's Health Uppsala University Uppsala Sweden
| | - Magnus Domellöf
- Department of Clinical Sciences, Pediatrics Umeå University Umeå Sweden
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Liu X, Tekes A, Perin J, Chen MW, Soares BP, Massaro AN, Govindan RB, Parkinson C, Chavez-Valdez R, Northington FJ, Brady KM, Lee JK. Wavelet Autoregulation Monitoring Identifies Blood Pressures Associated With Brain Injury in Neonatal Hypoxic-Ischemic Encephalopathy. Front Neurol 2021; 12:662839. [PMID: 33995258 PMCID: PMC8113412 DOI: 10.3389/fneur.2021.662839] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 03/22/2021] [Indexed: 11/15/2022] Open
Abstract
Dysfunctional cerebrovascular autoregulation may contribute to neurologic injury in neonatal hypoxic-ischemic encephalopathy (HIE). Identifying the optimal mean arterial blood pressure (MAPopt) that best supports autoregulation could help identify hemodynamic goals that support neurologic recovery. In neonates who received therapeutic hypothermia for HIE, we hypothesized that the wavelet hemoglobin volume index (wHVx) would identify MAPopt and that blood pressures closer to MAPopt would be associated with less brain injury on MRI. We also tested a correlation-derived hemoglobin volume index (HVx) and single- and multi-window data processing methodology. Autoregulation was monitored in consecutive 3-h periods using near infrared spectroscopy in an observational study. The neonates had a mean MAP of 54 mmHg (standard deviation: 9) during hypothermia. Greater blood pressure above the MAPopt from single-window wHVx was associated with less injury in the paracentral gyri (p = 0.044; n = 63), basal ganglia (p = 0.015), thalamus (p = 0.013), and brainstem (p = 0.041) after adjustments for sex, vasopressor use, seizures, arterial carbon dioxide level, and a perinatal insult score. Blood pressure exceeding MAPopt from the multi-window, correlation HVx was associated with less injury in the brainstem (p = 0.021) but not in other brain regions. We conclude that applying wavelet methodology to short autoregulation monitoring periods may improve the identification of MAPopt values that are associated with brain injury. Having blood pressure above MAPopt with an upper MAP of ~50–60 mmHg may reduce the risk of brain injury during therapeutic hypothermia. Though a cause-and-effect relationship cannot be inferred, the data support the need for randomized studies of autoregulation and brain injury in neonates with HIE.
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Affiliation(s)
- Xiuyun Liu
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Aylin Tekes
- Department of Radiology, Johns Hopkins University, Baltimore, MD, United States
| | - Jamie Perin
- Department of Pediatrics, Center for Child and Community Health Research, Johns Hopkins University, Baltimore, MD, United States
| | - May W Chen
- Division of Neonatology, Johns Hopkins University, Baltimore, MD, United States
| | - Bruno P Soares
- Department of Radiology, University of Vermont, Burlington, VT, United States
| | - An N Massaro
- Fetal Medicine Institute, Children's National Health System, Washington, DC, United States.,The George Washington University School of Medicine, Washington, DC, United States.,Division of Neonatology, Children's National Health System, Washington, DC, United States
| | - Rathinaswamy B Govindan
- Fetal Medicine Institute, Children's National Health System, Washington, DC, United States.,The George Washington University School of Medicine, Washington, DC, United States
| | | | - Raul Chavez-Valdez
- Division of Neonatology, Johns Hopkins University, Baltimore, MD, United States
| | | | - Ken M Brady
- Department of Anesthesiology, Lurie Children's Hospital, Chicago, IL, United States
| | - Jennifer K Lee
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, United States
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Later cooling within 6 h and temperatures outside 33-34 °C are not associated with dysfunctional autoregulation during hypothermia for neonatal encephalopathy. Pediatr Res 2021; 89:223-230. [PMID: 32268341 PMCID: PMC7541414 DOI: 10.1038/s41390-020-0876-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 01/10/2020] [Accepted: 03/07/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Cooling delays, temperature outside 33-34 °C, and blood pressure below the mean arterial blood pressure with optimal cerebral autoregulation (MAPOPT) might diminish neuroprotection from therapeutic hypothermia in neonates with hypoxic-ischemic encephalopathy (HIE). We hypothesized that longer time to reach temperature <34 °C and having temperature outside 33-34 °C would be associated with worse autoregulation and greater brain injury. METHODS Neonates with HIE had rectal temperature and near-infrared spectroscopy autoregulation monitoring during hypothermia (n = 63) and rewarming (n = 58). All underwent brain MRI, and a subset received diffusion tensor imaging MRI before day 10 (n = 41). RESULTS Most neonates reached <34 °C at 3-6 h of life. MAPOPT was identified in 54/63 (86%) during hypothermia and in 53/58 (91%) during rewarming. Cooling time was not related to blood pressure deviation from MAPOPT. Later cooling was associated with lower ADC scalar in unilateral posterior centrum semiovale but not in other regions. Temperatures >34 °C were associated with blood pressure above MAPOPT but not with brain injury. CONCLUSIONS In neonates who were predominantly cooled after 3 h, cooling time was not associated with autoregulation or overall brain injury. Blood pressure deviation above MAPOPT was associated with temperature >34 °C. Additional studies are needed in a more heterogeneous population. IMPACT Cooling time to reach target hypothermia temperature within 6 h of birth did not affect cerebral autoregulation measured by NIRS in neonates with hypoxic-ischemic encephalopathy (HIE). Temperature fluctuations >33-34 °C were associated with blood pressures that exceeded the range of optimal autoregulatory vasoreactivity. Cooling time within 6 h of birth and temperatures >33-34 °C were not associated with qualitative brain injury on MRI. Regional apparent diffusion coefficient scalars on diffusion tensor imaging MRI were not appreciably affected by cooling time or temperature >33-34 °C. Additional research in a larger and more heterogeneous population is needed to determine how delayed cooling and temperatures beyond the target hypothermia range affect autoregulation and brain injury.
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Van Laere D, Meeus M, Beirnaert C, Sonck V, Laukens K, Mahieu L, Mulder A. Machine Learning to Support Hemodynamic Intervention in the Neonatal Intensive Care Unit. Clin Perinatol 2020; 47:435-448. [PMID: 32713443 DOI: 10.1016/j.clp.2020.05.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Hemodynamic support in neonatal intensive care is directed at maintaining cardiovascular wellbeing. At present, monitoring of vital signs plays an essential role in augmenting care in a reactive manner. By applying machine learning techniques, a model can be trained to learn patterns in time series data, allowing the detection of adverse outcomes before they become clinically apparent. In this review we provide an overview of the different machine learning techniques that have been used to develop models in hemodynamic care for newborn infants. We focus on their potential benefits, research pitfalls, and challenges related to their implementation in clinical care.
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Affiliation(s)
- David Van Laere
- Department of Neonatal Intensive Care, University Hospital Antwerp, Wilrijkstraat 10, Edegem BE-2650, Belgium; Laboratory of Pediatrics, Department of Life Sciences, University of Antwerp, Prinsstraat 13, Antwerpen 2000, Belgium.
| | - Marisse Meeus
- Department of Neonatal Intensive Care, University Hospital Antwerp, Wilrijkstraat 10, Edegem BE-2650, Belgium; Laboratory of Pediatrics, Department of Life Sciences, University of Antwerp, Prinsstraat 13, Antwerpen 2000, Belgium
| | - Charlie Beirnaert
- Adrem Data Lab, Department of Mathematics and Computer Science, University of Antwerp, Middelheimlaan 1, Antwerpen 2020, Belgium
| | - Victor Sonck
- ML6, Esplanade Oscar Van De Voorde 1, Ghent 9000, Belgium
| | - Kris Laukens
- Adrem Data Lab, Department of Mathematics and Computer Science, University of Antwerp, Middelheimlaan 1, Antwerpen 2020, Belgium
| | - Ludo Mahieu
- Department of Neonatal Intensive Care, University Hospital Antwerp, Wilrijkstraat 10, Edegem BE-2650, Belgium; Laboratory of Pediatrics, Department of Life Sciences, University of Antwerp, Prinsstraat 13, Antwerpen 2000, Belgium
| | - Antonius Mulder
- Department of Neonatal Intensive Care, University Hospital Antwerp, Wilrijkstraat 10, Edegem BE-2650, Belgium; Laboratory of Pediatrics, Department of Life Sciences, University of Antwerp, Prinsstraat 13, Antwerpen 2000, Belgium
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18
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Lampe R, Rieger-Fackeldey E, Sidorenko I, Turova V, Botkin N, Eckardt L, Alves-Pinto A, Kovtanyuk A, Schündeln M, Felderhoff-Müser U. Assessing key clinical parameters before and after intraventricular hemorrhage in very preterm infants. Eur J Pediatr 2020; 179:929-937. [PMID: 31993776 PMCID: PMC7220978 DOI: 10.1007/s00431-020-03585-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 01/15/2020] [Accepted: 01/16/2020] [Indexed: 11/17/2022]
Abstract
Intraventricular cerebral hemorrhage (IVH) is one of the most severe complications of premature birth, potentially leading to lifelong disability. The purpose of this paper is the assessment of the evolution of three of the most relevant parameters, before and after IVH: mean arterial pressure (MAP), arterial carbon dioxide pressure (pCO2), and cerebral blood flow (CBF). Clinical records of 254 preterm infants with a gestational age of 23-30 weeks, with and without a diagnosis of IVH, were reviewed for MAP and arterial pCO2 in the period up to 7 days before and 3 days after IVH or during the first 10 days of life in cases without IVH.Conclusion: A statistically significant increase in pCO2 and decrease in MAP in patients with IVH compared with those without were detected. Both the mean values and the mean absolute deviations of CBF were computed in this study, and the latter was significantly higher than in control group. High deviations of CBF, as well as hypercapnia and hypotension, are likely to contribute to the rupture of cerebral blood vessels in preterm infants, and consequently, to the development of IVH.What is Known:• The origin of IVH is multifactorial, but mean arterial pressure, carbon dioxide partial pressure, and cerebral blood flow are recognized as the most important parameters.• In premature infants, the autoregulation mechanisms are still underdeveloped and cannot compensate for cerebral blood flow fluctuations.What is New:• The numerical simulation of CBF is shown to be a promising approach that may be useful in the care of preterm infants.• The mean values of CBF before and after IVH in the affected group were similar to those in the control group, but the mean absolute deviations of CBF in the affected group before and after IVH were significantly higher than that in the control group.
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Affiliation(s)
- Renée Lampe
- School of Medicine, Klinikum rechts der Isar, Orthopedic Department, Research Unit for Pediatric Neuroorthopedics and Cerebral Palsy of the Buhl-Strohmaier Foundation, Technical University of Munich, Ismaningerstr 22, 81675 Munich, Germany
| | - Esther Rieger-Fackeldey
- School of Medicine, Klinikum rechts der Isar, Department of Pediatrics, Technical University of Munich, Ismaningerstr 22, 81675 Munich, Germany
| | - Irina Sidorenko
- Mathematical Faculty, Chair of Mathematical Modelling, Technical University of Munich, Boltzmannstr. 3, 85748 Garching, Germany
| | - Varvara Turova
- School of Medicine, Klinikum rechts der Isar, Orthopedic Department, Research Unit for Pediatric Neuroorthopedics and Cerebral Palsy of the Buhl-Strohmaier Foundation, Technical University of Munich, Ismaningerstr 22, 81675 Munich, Germany
| | - Nikolai Botkin
- Mathematical Faculty, Chair of Mathematical Modelling, Technical University of Munich, Boltzmannstr. 3, 85748 Garching, Germany
| | - Laura Eckardt
- University Hospital Essen, Department of Pediatrics I, Neonatology, Pediatric Intensive Care, Pediatric Neurology, Department of Pediatrics III, Pediatric Oncology, University Duisburg-Essen, Hufelandstraße 55, 45147 Essen, Germany
| | - Ana Alves-Pinto
- School of Medicine, Klinikum rechts der Isar, Orthopedic Department, Research Unit for Pediatric Neuroorthopedics and Cerebral Palsy of the Buhl-Strohmaier Foundation, Technical University of Munich, Ismaningerstr 22, 81675 Munich, Germany
| | - Andrey Kovtanyuk
- School of Medicine, Klinikum rechts der Isar, Orthopedic Department, Research Unit for Pediatric Neuroorthopedics and Cerebral Palsy of the Buhl-Strohmaier Foundation, Technical University of Munich, Ismaningerstr 22, 81675 Munich, Germany
| | - Michael Schündeln
- University Hospital Essen, Department of Pediatrics I, Neonatology, Pediatric Intensive Care, Pediatric Neurology, Department of Pediatrics III, Pediatric Oncology, University Duisburg-Essen, Hufelandstraße 55, 45147 Essen, Germany
| | - Ursula Felderhoff-Müser
- University Hospital Essen, Department of Pediatrics I, Neonatology, Pediatric Intensive Care, Pediatric Neurology, Department of Pediatrics III, Pediatric Oncology, University Duisburg-Essen, Hufelandstraße 55, 45147 Essen, Germany
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20
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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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Continuous vital sign analysis for predicting and preventing neonatal diseases in the twenty-first century: big data to the forefront. Pediatr Res 2020; 87:210-220. [PMID: 31377752 PMCID: PMC6962536 DOI: 10.1038/s41390-019-0527-0] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 07/20/2019] [Accepted: 07/25/2019] [Indexed: 01/03/2023]
Abstract
In the neonatal intensive care unit (NICU), heart rate, respiratory rate, and oxygen saturation are vital signs (VS) that are continuously monitored in infants, while blood pressure is often monitored continuously immediately after birth, or during critical illness. Although changes in VS can reflect infant physiology or circadian rhythms, persistent deviations in absolute values or complex changes in variability can indicate acute or chronic pathology. Recent studies demonstrate that analysis of continuous VS trends can predict sepsis, necrotizing enterocolitis, brain injury, bronchopulmonary dysplasia, cardiorespiratory decompensation, and mortality. Subtle changes in continuous VS patterns may not be discerned even by experienced clinicians reviewing spot VS data or VS trends captured in the monitor. In contrast, objective analysis of continuous VS data can improve neonatal outcomes by allowing heightened vigilance or preemptive interventions. In this review, we provide an overview of the studies that have used continuous analysis of single or multiple VS, their interactions, and combined VS and clinical analytic tools, to predict or detect neonatal pathophysiology. We make the case that big-data analytics are promising, and with continued improvements, can become a powerful tool to mitigate neonatal diseases in the twenty-first century.
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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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Abstract
PURPOSE OF REVIEW With the advent of therapeutic hypothermia for treatment of hypoxic ischemic encephalopathy, and improvements in neuroimaging and bedside neuromonitoring, a new era of neonatal brain-focused care has emerged in recent years. We describe the development of the first neurointensive care nursery (NICN) as a model for comanagement of neonates with identified neurologic risk factors by a multidisciplinary team constituted of neurologists, neonatologists, specialized nurses, and others with the goal of optimizing management, preventing secondary injury and maximizing long-term outcomes. RECENT FINDINGS Optimizing brain metabolic environment and perfusion and preventing secondary brain injury are key to neurocritical care. This includes close management of temperature, blood pressure, oxygenation, carbon dioxide, and glucose levels. Early developmental interventions and involvement of physical and occupational therapy provide additional assessment information. Finally, long-term follow-up is essential for any neurocritical care program. SUMMARY The NICN model aims to optimize evidence-based care of infants at risk for neurologic injury. Results from ongoing hypothermia and neuroprotective trials are likely to yield additional treatments. New technologies, such as functional MRI, continuous neurophysiological assessment, and whole genomic approaches to rapid diagnosis may further enhance clinical protocols and neonatal precision medicine. Importantly, advances in neurocritical care improve our ability to provide comprehensive information when counseling families. Long-term follow-up data will determine if the NICN/Neuro-NICU provides enduring benefit to infants at risk for neurologic injury.
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