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Leopold SM, Brown DH, Zhang X, Nguyen XT, Al-Subu AM, Olson KR. Early Impressions and Adoption of the AtriAmp for Managing Arrhythmias Following Congenital Heart Surgery. Pediatr Cardiol 2024:10.1007/s00246-024-03573-y. [PMID: 38970655 DOI: 10.1007/s00246-024-03573-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 06/30/2024] [Indexed: 07/08/2024]
Abstract
AtriAmp is a new medical device that displays a continuous real-time atrial electrogram on telemetry using temporary atrial pacing leads. Our objective was to evaluate early adoption of this device into patient care within our pediatric intensive care unit (PICU). This is a qualitative study using inductive analysis of semi-structured interviews to identify dominant themes. The study was conducted in a single-center, tertiary, academic 21-bed mixed PICU. The subjects were PICU multidisciplinary team members (Pediatric Cardiac Intensivists, PICU Nurse Practitioners, PICU nurses and Pediatric Cardiologists) who were early adopters of the AtriAmp (n = 14). Three prominent themes emerged: (1) Accelerated time from arrhythmia event to diagnosis and treatment; (2) Increased confidence in the accuracy of providers' arrhythmia diagnosis; and (3) Improvement in the ability to educate providers about post-operative arrhythmias. Providers also noted some learning curves, but none compromised medical care or clinical workflow. Insights from early adopters of AtriAmp signal the need for simplicity and fidelity in new PICU technologies. Our research suggests that such technologies can be pivotal to the support and growth of multi-disciplinary teams, even among those who do not participate in early implementation. Further research is needed to understand when and why novel technology adoption becomes widespread in high-stakes settings.
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Affiliation(s)
- Scott M Leopold
- Division of Critical Care, Department of Pediatrics, American Family Children's Hospital, 600 Highland Ave, Mailcode 4108, Madison, WI, 53742, USA.
| | - Diane H Brown
- Division of Critical Care, Department of Pediatrics, Presbyterian Hospital, Albuquerque, NM, USA
| | - Xiao Zhang
- Division of Pediatric Cardiology, Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Xuan T Nguyen
- Department of Sociology, University of Wisconsin-Madison, Madison, WI, USA
| | - Awni M Al-Subu
- Division of Critical Care, Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Krisjon R Olson
- Division of Pediatric Cardiology, Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
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Thomas AR, Levy PT, Sperotto F, Braudis N, Valencia E, DiNardo JA, Friedman K, Kheir JN. Arch watch: current approaches and opportunities for improvement. J Perinatol 2024; 44:325-332. [PMID: 38129600 DOI: 10.1038/s41372-023-01854-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 12/03/2023] [Accepted: 12/08/2023] [Indexed: 12/23/2023]
Abstract
Coarctation of the aorta (CoA) is a ductus arteriosus (DA)-dependent form of congenital heart disease (CHD) characterized by narrowing in the region of the aortic isthmus. CoA is a challenging diagnosis to make prenatally and is the critical cardiac lesion most likely to go undetected on the pulse oximetry-based newborn critical CHD screen. When undetected CoA causes obstruction to blood flow, life-threatening cardiovascular collapse may result, with a high burden of morbidity and mortality. Hemodynamic monitoring practices during DA closure (known as an "arch watch") vary across institutions and existing tools are often insensitive to developing arch obstruction. Novel measures of tissue oxygenation and oxygen deprivation may improve sensitivity and specificity for identifying evolving hemodynamic compromise in the newborn with CoA. We explore the benefits and limitations of existing and new tools to monitor the physiological changes of the aorta as the DA closes in infants at risk of CoA.
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Affiliation(s)
- Alyssa R Thomas
- Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA.
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Philip T Levy
- Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Francesca Sperotto
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Nancy Braudis
- Department of Nursing, Boston Children's Hospital, Boston, MA, USA
| | - Eleonore Valencia
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - James A DiNardo
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
- Department of Anaesthesia, Harvard Medical School, Boston, MA, USA
| | - Kevin Friedman
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - John N Kheir
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
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3
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Tabet M, Custer C, Khan IR, Sanford E, Sharma J, Choe R, Singh S, Sirsi D, Olson DM, Morriss MC, Raman L, Busch DR. Neuromonitoring of Pediatric and Adult Extracorporeal Membrane Oxygenation Patients: The Importance of Continuous Bedside Tools in Driving Neuroprotective Clinical Care. ASAIO J 2024; 70:167-176. [PMID: 38051987 DOI: 10.1097/mat.0000000000002107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a form of temporary cardiopulmonary bypass for patients with acute respiratory or cardiac failure refractory to conventional therapy. Its usage has become increasingly widespread and while reported survival after ECMO has increased in the past 25 years, the incidence of neurological injury has not declined, leading to the pressing question of how to improve time-to-detection and diagnosis of neurological injury. The neurological status of patients on ECMO is clinically difficult to evaluate due to multiple factors including illness, sedation, and pharmacological paralysis. Thus, increasing attention has been focused on developing tools and techniques to measure and monitor the brain of ECMO patients to identify dynamic risk factors and monitor patients' neurophysiological state as a function in time. Such tools may guide neuroprotective interventions and thus prevent or mitigate brain injury. Current means to continuously monitor and prevent neurological injury in ECMO patients are rather limited; most techniques provide indirect or postinsult recognition of irreversible brain injury. This review will explore the indications, advantages, and disadvantages of standard-of-care, emerging, and investigational technologies for neurological monitoring on ECMO, focusing on bedside techniques that provide continuous assessment of neurological health.
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Affiliation(s)
- Margherita Tabet
- From the Department of Anesthesiology and Pain Management, The University of Texas Southwestern medical center/Children's Medical Center, Dallas, Texas
| | - Chasity Custer
- Division of Pediatric Critical Care Medicine, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - Imad R Khan
- Department of Neurology, University of Rochester Medical Center, Rochester, New York
| | - Ethan Sanford
- From the Department of Anesthesiology and Pain Management, The University of Texas Southwestern medical center/Children's Medical Center, Dallas, Texas
- Division of Pediatric Critical Care Medicine, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - Jayesh Sharma
- From the Department of Anesthesiology and Pain Management, The University of Texas Southwestern medical center/Children's Medical Center, Dallas, Texas
| | - Regine Choe
- Department of Biomedical Engineering, University of Rochester, Rochester, New York
- Department of Electrical and Computer Engineering, University of Rochester, Rochester, New York
| | - Sumit Singh
- Department of Radiology, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - Deepa Sirsi
- Division of Pediatric Neurology, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - DaiWai M Olson
- Department of Neurology, UT Southwestern Medical Center, Dallas, Texas
- Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - Michael Craig Morriss
- Department of Radiology, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - Lakshmi Raman
- Department of Pediatrics, The University of Texas Southwestern medical center
| | - David R Busch
- From the Department of Anesthesiology and Pain Management, The University of Texas Southwestern medical center/Children's Medical Center, Dallas, Texas
- Department of Neurology, UT Southwestern Medical Center, Dallas, Texas
- Department of Biomedical Engineering, UT Southwestern Medical Center, Dallas, Texas
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Lovett ME, MacDonald JM, Mir M, Ghosh S, O'Brien NF, LaRovere KL. Noninvasive Neuromonitoring Modalities in Children Part I: Pupillometry, Near-Infrared Spectroscopy, and Transcranial Doppler Ultrasonography. Neurocrit Care 2024; 40:130-146. [PMID: 37160846 DOI: 10.1007/s12028-023-01730-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 04/03/2023] [Indexed: 05/11/2023]
Abstract
BACKGROUND Noninvasive neuromonitoring in critically ill children includes multiple modalities that all intend to improve our understanding of acute and ongoing brain injury. METHODS In this article, we review basic methods and devices, applications in clinical care and research, and explore potential future directions for three noninvasive neuromonitoring modalities in the pediatric intensive care unit: automated pupillometry, near-infrared spectroscopy, and transcranial Doppler ultrasonography. RESULTS All three technologies are noninvasive, portable, and easily repeatable to allow for serial measurements and trending of data over time. However, a paucity of high-quality data supporting the clinical utility of any of these technologies in critically ill children is currently a major limitation to their widespread application in the pediatric intensive care unit. CONCLUSIONS Future prospective multicenter work addressing major knowledge gaps is necessary to advance the field of pediatric noninvasive neuromonitoring.
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Affiliation(s)
- Marlina E Lovett
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University, Columbus, OH, USA
| | - Jennifer M MacDonald
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University, Columbus, OH, USA
| | - Marina Mir
- Division of Pediatric Critical Care, Montreal Children's Hospital and McGill University, Montreal, Canada
| | - Suman Ghosh
- Department of Neurology, State University of New York Downstate College of Medicine, Brooklyn, NY, USA
| | - Nicole F O'Brien
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University, Columbus, OH, USA
| | - Kerri L LaRovere
- Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.
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Sanford EL, Akorede R, Miller I, Morriss MC, Nandy K, Raman L, Busch DR. Association Between Disrupted Cerebral Autoregulation and Radiographic Neurologic Injury for Children on Extracorporeal Membrane Oxygenation: A Prospective Pilot Study. ASAIO J 2023; 69:e315-e321. [PMID: 37172001 DOI: 10.1097/mat.0000000000001970] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023] Open
Abstract
Validation of a real-time monitoring device to evaluate the risk or occurrence of neurologic injury while on extracorporeal membrane oxygenation (ECMO) may aid clinicians in prevention and treatment. Therefore, we performed a pilot prospective cohort study of children under 18 years old on ECMO to analyze the association between cerebral blood pressure autoregulation as measured by diffuse correlation spectroscopy (DCS) and radiographic neurologic injury. DCS measurements of regional cerebral blood flow were collected on enrolled patients and correlated with mean arterial blood pressure to determine the cerebral autoregulation metric termed DCSx. The primary outcome of interest was radiographic neurologic injury on eligible computed tomography (CT) or magnetic resonance imaging (MRI) scored by a blinded pediatric neuroradiologist utilizing a previously validated scale. Higher DCSx scores, which indicate disruption of cerebral autoregulation, were associated with higher radiographic neurologic injury score (slope, 11.0; 95% confidence interval [CI], 0.29-22). Patients with clinically significant neurologic injury scores of 10 or more had higher median DCSx measures than patients with lower neurologic injury scores (0.48 vs . 0.13; p = 0.01). Our study indicates that obtaining noninvasive DCS measures for children on ECMO is feasible and disruption of cerebral autoregulation determined from DCS is associated with higher radiographic neurologic injury score.
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Affiliation(s)
- Ethan L Sanford
- From the Department of Anesthesiology and Pain Management, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
- Division of Pediatric Critical Care Medicine, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - Rufai Akorede
- From the Department of Anesthesiology and Pain Management, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - Isabel Miller
- UT Southwestern Medical Center Medical School, Dallas, Texas
| | - Michael Craig Morriss
- Department of Radiology, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - Karabi Nandy
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Lakshmi Raman
- Division of Pediatric Critical Care Medicine, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - David R Busch
- From the Department of Anesthesiology and Pain Management, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
- Department of Neurology, UT Southwestern Medical Center, Dallas, Texas
- Department of Biomedical Engineering, UT Southwestern Medical Center, Dallas, Texas
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McDevitt WM, Farley M, Martin-Lamb D, Jones TJ, Morris KP, Seri S, Scholefield BR. Feasibility of non-invasive neuro-monitoring during extracorporeal membrane oxygenation in children. Perfusion 2023; 38:547-556. [PMID: 35212252 DOI: 10.1177/02676591211066804] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Detection of neurological complications during extracorporeal membrane oxygenation (ECMO) may be enhanced with non-invasive neuro-monitoring. We investigated the feasibility of non-invasive neuro-monitoring in a paediatric intensive care (PIC) setting. METHODS In a single centre, prospective cohort study we assessed feasibility of recruitment, and neuro-monitoring via somatosensory evoked potentials (SSEP), electroencephalography (EEG) and near infrared spectroscopy (NIRS) during venoarterial (VA) ECMO in paediatric patients (0-15 years). Measures were obtained within 24h of cannulation, during an intermediate period, and finally at decannulation or echo stress testing. SSEP/EEG/NIRS measures were correlated with neuro-radiology findings, and clinical outcome assessed via the Pediatric cerebral performance category (PCPC) scale 30 days post ECMO cannulation. RESULTS We recruited 14/20 (70%) eligible patients (median age: 9 months; IQR:4-54, 57% male) over an 18-month period, resulting in a total of 42 possible SSEP/EEG/NIRS measurements. Of these, 32/42 (76%) were completed. Missed recordings were due to lack of access/consent within 24 h of cannulation (5/42, 12%) or PIC death/discharge (5/42, 12%). In each patient, the majority of SSEP (8/14, 57%), EEG (8/14, 57%) and NIRS (11/14, 79%) test results were within normal limits. All patients with abnormal neuroradiology (4/10, 40%), and 6/7 (86%) with poor outcome (PCPC ≥4) developed indirect SSEP, EEG or NIRS measures of neurological complications prior to decannulation. No study-related adverse events or neuro-monitoring data interpreting issues were experienced. CONCLUSION Non-invasive neuro-monitoring (SSEP/EEG/NIRS) during ECMO is feasible and may provide early indication of neurological complications in this high-risk population.
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Affiliation(s)
- William M McDevitt
- Department of Neurophysiology, 156630Birmingham Children's Hospital Birmingham, UK
| | - Margaret Farley
- Paediatric Intensive Care Unit, 156630Birmingham Children's Hospital, Birmingham, UK
| | - Darren Martin-Lamb
- Department of Neurophysiology, 156630Birmingham Children's Hospital Birmingham, UK
| | - Timothy J Jones
- Department of Cardiac Surgery, 156630Birmingham Children's Hospital, Birmingham, UK.,Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Kevin P Morris
- Paediatric Intensive Care Unit, 156630Birmingham Children's Hospital, Birmingham, UK.,Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Stefano Seri
- Department of Neurophysiology, 156630Birmingham Children's Hospital Birmingham, UK.,Aston Brain Centre, School of Life and Health Sciences, Aston University, Birmingham, UK
| | - Barnaby R Scholefield
- Paediatric Intensive Care Unit, 156630Birmingham Children's Hospital, Birmingham, UK.,Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
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Searching High and Low: The Association of Superior and Inferior Vena Cava Saturations With Outcomes in Neonates After Cardiac Surgery. Pediatr Crit Care Med 2022; 23:573-575. [PMID: 35797576 DOI: 10.1097/pcc.0000000000002978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Arya B, Maskatia SA. Coarctation of the aorta: Prenatal assessment, postnatal management and neonatal outcomes. Semin Perinatol 2022; 46:151584. [PMID: 35422354 DOI: 10.1016/j.semperi.2022.151584] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Coarctation of the aorta (Coa) is a potentially life threatening diagnosis. It occurs in 0.3 per 1000 live births and accounts for 6-8% of all infants with congenital heart defects. Neonates with severe Coa may be completely asymptomatic at birth, as the ductus arteriosus can provide flow to the lower body. Those who are not diagnosed prenatally may be diagnosed only after constriction of the ductus arteriosus, when they present in cardiogenic shock. This group has a higher risk for mortality and morbidity relative to those diagnosed prenatally. Despite the increasing practice of universal pulse oximetry screening, many cases with significant coarctation of the aorta still go undiagnosed in the newborn period. In this article, we present the pathophysiology, diagnosis, presentation, treatment and outcomes of Coa.
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Affiliation(s)
- Bhawna Arya
- University of Washington School of Medicine, Seattle Children's Hospital, Seattle, WA, United States.
| | - Shiraz A Maskatia
- Stanford University School of Medicine, Lucile Packard Children's Hospital, Stanford, CA, United States
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9
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Doctor P, Aggarwal S, Garcia R. Is there an association of near-infrared spectroscopy with low cardiac output and adverse outcomes in single-ventricle patients after stage 1 palliation? Ann Pediatr Cardiol 2022; 15:249-256. [PMID: 36589644 PMCID: PMC9802614 DOI: 10.4103/apc.apc_234_21] [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: 12/12/2021] [Revised: 02/22/2022] [Accepted: 06/08/2022] [Indexed: 11/17/2022] Open
Abstract
Objective Our primary objective study was to evaluate the association between near-infrared spectroscopy (NIRS) and low cardiac output (LCO) in patients with single-ventricle physiology after stage 1 palliation. Methods In this retrospective study, infants ≤6 months of age with single-ventricle physiology who underwent stage 1 palliation were included. Cerebral and renal NIRS values at various time intervals after surgery were compared between patients with low and normal cardiac output. LCO within the first 48 after surgery was defined as per the pediatric cardiac critical care consortium database. NIRS values were also compared with other adverse outcomes such as cardiac arrest, need for extracorporeal membrane oxygenation and mortality. The receiver operative characteristic curve was generated to determine an optimal cut-off NIRS value for detecting LCO. Results Ninety-one patients with median (Interquartile range) age of 10 days (6-26) and weight of 3.3 kg (3-3.5) were included in the study. Cerebral NIRS at 1 h (41.2 vs. 49.5; P = 0.002), 6 h (44 vs. 52.2; P = 0.001), and 12 h (51.8 vs. 56; P = 0.025) was significantly lower in the grouP with LCO compared to no LCO. Cerebral NIRS at 6 h was independently associated with LCO (P = 0.018), and cerebral NIRS at 6 h ≤57% had 91% sensitivity and 72% specificity to detect LCO. Conclusions Cerebral NIRS ≤57% at 6 h after surgery detected LCO after stage 1 palliation in single-ventricle patients. Cerebral or renal NIRS was not associated with adverse outcomes and therefore, may not be useful in predicting adverse outcomes in this population.
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Affiliation(s)
- Pezad Doctor
- Department of Pediatrics, Division of Cardiology, Children's Medical Center, University of Texas Southwestern Medical Center, Medical District, Dallas, Texas, USA
| | - Sanjeev Aggarwal
- Department of Pediatrics, Division of Cardiology, Children's Hospital of Michigan, Central Michigan University College of Medicine, Beaubien Blvd, Detroit, MI, USA
| | - Richard Garcia
- Department of Pediatrics, Division of Critical Care Medicine, Children's Hospital of Michigan, Central Michigan University College of Medicine, Beaubien Blvd, Detroit, MI, USA
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Hansen ML, Hyttel-Sørensen S, Jakobsen JC, Gluud C, Kooi EMW, Mintzer J, de Boode WP, Fumagalli M, Alarcon A, Alderliesten T, Greisen G. Cerebral near-infrared spectroscopy monitoring (NIRS) in children and adults: a systematic review with meta-analysis. Pediatr Res 2022:10.1038/s41390-022-01995-z. [PMID: 35194162 DOI: 10.1038/s41390-022-01995-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 01/24/2022] [Accepted: 01/31/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Cerebral oxygenation monitoring utilising near-infrared spectroscopy (NIRS) is increasingly used to guide interventions in clinical care. The objective of this systematic review with meta-analysis and Trial Sequential Analysis is to evaluate the effects of clinical care with access to cerebral NIRS monitoring in children and adults versus care without. METHODS This review conforms to PRISMA guidelines and was registered in PROSPERO (CRD42020202986). Methods are outlined in our protocol (doi: 10.1186/s13643-021-01660-2). RESULTS Twenty-five randomised clinical trials were included (2606 participants). All trials were at a high risk of bias. Two trials assessed the effects of NIRS during neonatal intensive care, 13 during cardiac surgery, 9 during non-cardiac surgery and 1 during neurocritical care. Meta-analyses showed no significant difference for all-cause mortality (RR 0.75, 95% CI 0.51-1.10; 1489 participants; I2 = 0; 11 trials; very low certainty of evidence); moderate or severe, persistent cognitive or neurological deficit (RR 0.74, 95% CI 0.42-1.32; 1135 participants; I2 = 39.6; 9 trials; very low certainty of evidence); and serious adverse events (RR 0.82; 95% CI 0.67-1.01; 2132 participants; I2 = 68.4; 17 trials; very low certainty of evidence). CONCLUSION The evidence on the effects of clinical care with access to cerebral NIRS monitoring is very uncertain. IMPACT The evidence of the effects of cerebral NIRS versus no NIRS monitoring are very uncertain for mortality, neuroprotection, and serious adverse events. Additional trials to obtain sufficient information size, focusing on lowering bias risk, are required. The first attempt to systematically review randomised clinical trials with meta-analysis to evaluate the effects of cerebral NIRS monitoring by pooling data across various clinical settings. Despite pooling data across clinical settings, study interpretation was not substantially impacted by heterogeneity. We have insufficient evidence to support or reject the clinical use of cerebral NIRS monitoring.
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Affiliation(s)
- Mathias Lühr Hansen
- Department of Neonatology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
| | - Simon Hyttel-Sørensen
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Elisabeth M W Kooi
- Division of Neonatology, University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Groningen, the Netherlands
| | - Jonathan Mintzer
- Department of Pediatrics, Division of Newborn Medicine, Mountainside Medical Center, Montclair, NJ, USA
| | - Willem P de Boode
- Division of Neonatology, Department of Pediatrics, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, the Netherlands
| | - Monica Fumagalli
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan, Via Francesco Sforza 35, 20122, Milano, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Via Festa del Perdono 7, 20122, Milano, Italy
| | - Ana Alarcon
- Department of Neonatology, Hospital Sant Joan de Deu, Passeig de Sant Joan de Deu 2, 08950, Esplugues de Llobregat, Barcelona, Spain
| | - Thomas Alderliesten
- Department of Neonatology, University Medical Center Utrecht Brain Center, Utrecht University, Utrecht, the Netherlands
| | - Gorm Greisen
- Department of Neonatology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
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Baranger J, Villemain O, Wagner M, Vargas-Gutierrez M, Seed M, Baud O, Ertl-Wagner B, Aguet J. Brain perfusion imaging in neonates. NEUROIMAGE-CLINICAL 2021; 31:102756. [PMID: 34298475 PMCID: PMC8319803 DOI: 10.1016/j.nicl.2021.102756] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 06/21/2021] [Accepted: 07/03/2021] [Indexed: 02/07/2023]
Abstract
MRI is the modality of choice to image and quantify cerebral perfusion. Imaging of neonatal brain perfusion is possible using MRI and ultrasound. Novel ultrafast ultrasound imaging allows for excellent spatiotemporal resolution. Understanding cerebral hemodynamic changes of neonatal adaptation is key.
Abnormal variations of the neonatal brain perfusion can result in long-term neurodevelopmental consequences and cerebral perfusion imaging can play an important role in diagnostic and therapeutic decision-making. To identify at-risk situations, perfusion imaging of the neonatal brain must accurately evaluate both regional and global perfusion. To date, neonatal cerebral perfusion assessment remains challenging. The available modalities such as magnetic resonance imaging (MRI), ultrasound imaging, computed tomography (CT), near-infrared spectroscopy or nuclear imaging have multiple compromises and limitations. Several promising methods are being developed to achieve better diagnostic accuracy and higher robustness, in particular using advanced MRI and ultrasound techniques. The objective of this state-of-the-art review is to analyze the methodology and challenges of neonatal brain perfusion imaging, to describe the currently available modalities, and to outline future perspectives.
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Affiliation(s)
- Jérôme Baranger
- Department of Pediatrics, Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Translation Medicine Department, SickKids Research Institute, Toronto, Ontario, Canada
| | - Olivier Villemain
- Department of Pediatrics, Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Translation Medicine Department, SickKids Research Institute, Toronto, Ontario, Canada; Department of Medical Biophysics, University of Toronto, Toronto, Canada
| | - Matthias Wagner
- Department of Diagnostic Imaging, Division of Neuroradiology, The Hospital for Sick Children, Toronto, Canada
| | | | - Mike Seed
- Department of Pediatrics, Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Translation Medicine Department, SickKids Research Institute, Toronto, Ontario, Canada; Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Canada
| | - Olivier Baud
- Division of Neonatology and Pediatric Intensive Care, Children's University Hospital of Geneva and University of Geneva, Geneva, Switzerland
| | - Birgit Ertl-Wagner
- Department of Diagnostic Imaging, Division of Neuroradiology, The Hospital for Sick Children, Toronto, Canada
| | - Julien Aguet
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Canada.
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Grasso C, Marchesini V, Disma N. Applications and Limitations of Neuro-Monitoring in Paediatric Anaesthesia and Intravenous Anaesthesia: A Narrative Review. J Clin Med 2021; 10:jcm10122639. [PMID: 34203942 PMCID: PMC8232784 DOI: 10.3390/jcm10122639] [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: 05/17/2021] [Revised: 06/05/2021] [Accepted: 06/11/2021] [Indexed: 12/26/2022] Open
Abstract
Safe management of anaesthesia in children has been one of the top areas of research over the last decade. After the large volume of articles which focused on the putative neurotoxic effect of anaesthetic agents on the developing brain, the attention and research efforts shifted toward prevention and treatment of critical events and the importance of peri-anaesthetic haemodynamic stability to prevent negative neurological outcomes. Safetots.org is an international initiative aiming at raising the attention on the relevance of a high-quality anaesthesia in children undergoing surgical and non-surgical procedures to guarantee a favourable outcome. Children might experience hemodynamic instability for many reasons, and how the range of normality within brain autoregulation is maintained is still unknown. Neuro-monitoring can guide anaesthesia providers in delivering optimal anaesthetic drugs dosages and also correcting underling conditions that can negatively affect the neurological outcome. In particular, it is referred to EEG-based monitoring and monitoring for brain oxygenation.
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Affiliation(s)
- Chiara Grasso
- Unit for Research & Innovation, Department of Paediatric Anaesthesia, IRCCS Istituto Giannina Gaslini, 16147 Genova, Italy;
| | - Vanessa Marchesini
- Paediatric Intensive Care Unit, Royal Melbourne Children’s Hospital, Parkville 3052, Australia;
| | - Nicola Disma
- Unit for Research & Innovation, Department of Paediatric Anaesthesia, IRCCS Istituto Giannina Gaslini, 16147 Genova, Italy;
- Correspondence:
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13
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Cibulskis CC, Maheshwari A, Rao R, Mathur AM. Anemia of prematurity: how low is too low? J Perinatol 2021; 41:1244-1257. [PMID: 33664467 DOI: 10.1038/s41372-021-00992-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 01/20/2021] [Accepted: 02/04/2021] [Indexed: 12/11/2022]
Abstract
Anemia of prematurity (AOP) is a common condition with a well-described chronology, nadir hemoglobin levels, and timeline of recovery. However, the underlying pathophysiology and impact of prolonged exposure of the developing infant to low levels of hemoglobin remains unclear. Phlebotomy losses exacerbate the gradual decline of hemoglobin levels which is insidious in presentation, often without any clinical signs. Progressive anemia in preterm infants is associated with poor weight gain, inability to take oral feeds, tachycardia and exacerbation of apneic, and bradycardic events. There remains a lack of consensus on treatment thresholds for RBC transfusion which vary considerably. This review elaborates on the current state of the problem, its implication for the premature infant including association with subphysiologic cerebral tissue oxygenation, necrotizing enterocolitis, and retinopathy of prematurity. It outlines the impact of prophylaxis and treatment of anemia of prematurity and offers suggestions on improving monitoring and management of the condition.
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Affiliation(s)
- Catherine C Cibulskis
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Akhil Maheshwari
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rakesh Rao
- Department of Pediatrics, Division of Newborn Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Amit M Mathur
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Saint Louis University School of Medicine, St. Louis, MO, USA.
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Abstract
BACKGROUND The altered neurodevelopment of children operated on during the neonatal period might be due to peri-operative changes in the homeostasis of brain perfusion. Monitoring of vital signs is a standard of care, but it does not usually include monitoring of the brain. OBJECTIVES To evaluate methods of monitoring the brain that might be of value. We also wanted to clarify if there are specific risk factors that result in peri-operative changes and how this might be evaluated. DESIGN Systematic review. DATA SOURCES A structured literature search was performed in MEDLINE in Ovid, Embase, Cochrane CENTRAL, Web of Science and Google Scholar. ELIGIBILITY CRITERIA Studies in neonates who received peri-operative neuromonitoring were eligible for inclusion; studies on neurosurgical procedures or cardiac surgery with cardiopulmonary bypass and/or deep hypothermia cardiac arrest were excluded. RESULTS Nineteen of the 24 included studies, totalling 374 infants, reported the use of near-infrared spectroscopy. Baseline values of cerebral oxygenation greatly varied (mean 53 to 91%) and consequently, no coherent results were found. Two studies found a correlation between cerebral oxygenation and mean arterial blood pressure. Five studies, with in total 388 infants, used (amplitude-integrated) electro-encephalography to study peri-operative brain activity. Overall, the brain activity decreased during anaesthesia and epileptic activity was more frequent in the peri-operative phase. The association between intra-operative cerebral saturation or activity and neuro-imaging abnormalities and/or neurodevelopmental outcome was investigated in six studies, but no association was found. CONCLUSION Neuromonitoring with the techniques currently used will neither help our understanding of the altered neonatal pathophysiology, nor enable early detection of deviation from the norm. The modalities lack specificity and are not related to clinical (long-term) outcome or prognosis. Accordingly, we were unable to draw up a monitoring guideline.
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15
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Rao A, Gourkanti B, Van Helmond N. Near-Infrared Spectroscopy Monitoring in Pediatric Anesthesiology: A Pro-Con Discussion. Cureus 2021; 13:e13875. [PMID: 33868839 PMCID: PMC8043135 DOI: 10.7759/cureus.13875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Near-infrared spectroscopy (NIRS) has been increasingly used as a non-invasive measurement of cerebral tissue oxygen saturation. The aim of this short review is to discuss the benefits and drawbacks of its use in the pediatric anesthesia population. In the context of cardiac surgery, lower intraoperative NIRS values have shown a modest association with neurodevelopmental outcomes while lower neonatal intensive care unit NIRS values have been correlated with reduced neurodevelopment in children. However, it is still unclear if management aimed at increasing cerebral tissue oxygenation would have any benefit on these outcomes. Without prospective research looking into the effects of intervention given proper thresholds, the true benefit of NIRS use is still up for debate. Even with current research gaps, its use in the clinical setting continues.
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Affiliation(s)
- Anusha Rao
- Anesthesiology, West Virginia University, Morgantown, USA
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16
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Chen S, Fang F, Liu W, Liu C, Xu F. Cerebral Tissue Regional Oxygen Saturation as a Valuable Monitoring Parameter in Pediatric Patients Undergoing Extracorporeal Membrane Oxygenation. Front Pediatr 2021; 9:669683. [PMID: 34178887 PMCID: PMC8220806 DOI: 10.3389/fped.2021.669683] [Citation(s) in RCA: 2] [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: 02/19/2021] [Accepted: 05/04/2021] [Indexed: 12/16/2022] Open
Abstract
Objective: Brain function monitoring technology for extracorporeal membrane oxygenation (ECMO) support has been developing quite slowly. Our objective was to explore the data distribution, variation trend, and variability of cerebral tissue regional oxygen saturation (CrSO2) in pediatric patients undergoing ECMO. Methods: Eight patients who received venoarterial ECMO (V-A ECMO) were included in our study. All of them accepted continuous CrSO2 monitoring by near-infrared spectroscopy (NIRS) within 12 h of ECMO initiation until ECMO wean. Differences in the CrSO2 distribution characteristic, the variation trend of daily CrSO2, and the variability of CrSO2 for the first 5 days following ECMO initiation were compared between survivors and non-survivors according to pediatric intensive care unit (PICU) mortality. Results: The percentage of time of CrSO2 <60% against the whole monitoring time was significantly lower in survivors in both hemispheres {right: 4.34% [interquartile range (IQR) = 0.39-8.55%] vs. 47.45% [IQR = 36.03-64.52%], p = 0.036; left: 0.40% [IQR = 0.01-1.15%] vs. 30.9% [IQR = 26.92-49.62%], p = 0.036}. Survivors had significantly higher CrSO2 on the first 4 days. Root mean of successive squared differences (RMSSD), the variability variable of CrSO2, was significantly lower in survivors (right: 3.29 ± 0.79 vs. 6.16 ± 0.67, p = 0.002; left: 3.56 ± 1.20 vs. 6.04 ± 1.44, p = 0.039). Conclusion: Lower CrSO2, CrSO2 <60% over a longer period of time, and higher fluctuation of CrSO2 are likely associated with PICU mortality in pediatric patients undergoing V-A ECMO. Clinical Trial Registry: URL: http://www.chictr.org.cn/showproj.aspx?proj=46639, trial registry number: ChiCTR1900028021.
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Affiliation(s)
- Song Chen
- Department of Critical Care Medicine, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Fang Fang
- Department of Critical Care Medicine, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Wenjun Liu
- Department of Critical Care Medicine, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Chengjun Liu
- Department of Critical Care Medicine, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Feng Xu
- Department of Critical Care Medicine, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
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17
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Finucane E, Jooste E, Machovec KA. Neuromonitoring Modalities in Pediatric Cardiac Anesthesia: A Review of the Literature. J Cardiothorac Vasc Anesth 2020; 34:3420-3428. [DOI: 10.1053/j.jvca.2020.02.054] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 02/22/2020] [Accepted: 02/28/2020] [Indexed: 12/13/2022]
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18
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Song K, Xu Q, Koenig HM, Kong M, Slaughter MS, Huang Y, Clifford SP, Huang J. Validation of a Novel NeurOs Cerebral Oximetry Monitor Against the INVOS Monitor During Cardiac Surgery. J Cardiothorac Vasc Anesth 2020; 35:2009-2018. [PMID: 33218956 DOI: 10.1053/j.jvca.2020.10.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 10/23/2020] [Accepted: 10/24/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To compare the performance of a novel NeurOs cerebral oximetry monitor against the INVOS monitor during the entire intraoperative phase of cardiac surgery, including periods of known fluctuation in brain oxygenation, such as preoxygenation, induction, cannulation, and cardiopulmonary bypass. DESIGN This study was a prospective, nonrandomized, healthcare-provider and outcome-assessor blinded study. SETTING Tertiary care university hospital; single institutional study. PARTICIPANTS Twenty-three patients who underwent cardiac surgery with cardiopulmonary bypass. INTERVENTIONS Both self-adhesive INVOS sensors and the assembled NeurOs sensors were placed accordingly when the patient arrived in the operating room. MEASUREMENTS AND MAIN RESULTS Ten out of 13 cases under the normal mode and eight out of the 10 cases under the high- sensitivity mode showed significant correlations between the NeurOs and INVOS groups (p < 0.05, r value from 0.24-0.88). When all cases were combined, NeurOs demonstrated significant correlation with INVOS (r = 0.5, 95% confidence interval [CI] 0.44-0.56, p < 0.01 for normal mode; r = 0.69, 95% CI 0.64 to 0.74, p < 0.01 for high-sensitivity mode) in both modes. To evaluate the data diversity, the authors performed a cluster analysis and found much less variation existed in the NeurOs normal mode when compared with INVOS (standard deviation [SD] 16.6% in INVOS, 4% in NeurOs normal mode) but similar patterns in the high-sensitivity mode (SD 17.6% in INVOS, 15.2% in NeurOs high-sensitivity mode). Bland-Altman plot analysis showed that most of the data fell between ± 1.96 SD lines, which demonstrated good consistency between these two methods under both modes of NeurOs (-28.8 to 30.8 in the normal mode; -36.6 to 32.7 in high-sensitivity mode). In the normal mode of NeurOs monitoring, receiver operating characteristic analysis suggested a 2% cutoff point was most optimal from the baseline for detecting hyperoxia (sensitivity 73%; specificity 66%) and minus 1% (sensitivity 66%; specificity 67%) for detecting hypoxia. Whereas in the high-sensitivity mode, the optimal cutoff point was 3% from baseline for detecting hyperoxia (sensitivity 75%; specificity 68%), and minus 3% for detecting hypoxia (sensitivity 90%; specificity 45%). CONCLUSIONS In conclusion, the novel NeurOs system was found to correlate with INVOS cerebral oximetry measurements during cardiac surgery.
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Affiliation(s)
- Kaicheng Song
- Department of Anesthesiology & Perioperative Medicine, University of Louisville, Louisville, KY; Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, PR China
| | - Qian Xu
- Department of Bioinformatics and Biostatistics, SPHIS, University of Louisville, Louisville, KY
| | - Heidi M Koenig
- Department of Anesthesiology & Perioperative Medicine, University of Louisville, Louisville, KY
| | - Maiying Kong
- Department of Bioinformatics and Biostatistics, SPHIS, University of Louisville, Louisville, KY
| | - Mark S Slaughter
- Department of Cardiovascular & Thoracic Surgery, University of Louisville, Louisville, KY
| | - Yuguang Huang
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, PR China
| | - Sean P Clifford
- Department of Anesthesiology & Perioperative Medicine, University of Louisville, Louisville, KY
| | - Jiapeng Huang
- Department of Anesthesiology & Perioperative Medicine, University of Louisville, Louisville, KY; Department of Cardiovascular & Thoracic Surgery, University of Louisville, Louisville, KY.
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19
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Mavroudis CD, Ko TS, Morgan RW, Volk LE, Landis WP, Smood B, Xiao R, Hefti M, Boorady TW, Marquez A, Karlsson M, Licht DJ, Nadkarni VM, Berg RA, Sutton RM, Kilbaugh TJ. Epinephrine's effects on cerebrovascular and systemic hemodynamics during cardiopulmonary resuscitation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:583. [PMID: 32993753 PMCID: PMC7522922 DOI: 10.1186/s13054-020-03297-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 09/17/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Despite controversies, epinephrine remains a mainstay of cardiopulmonary resuscitation (CPR). Recent animal studies have suggested that epinephrine may decrease cerebral blood flow (CBF) and cerebral oxygenation, possibly potentiating neurological injury during CPR. We investigated the cerebrovascular effects of intravenous epinephrine in a swine model of pediatric in-hospital cardiac arrest. The primary objectives of this study were to determine if (1) epinephrine doses have a significant acute effect on CBF and cerebral tissue oxygenation during CPR and (2) if the effect of each subsequent dose of epinephrine differs significantly from that of the first. METHODS One-month-old piglets (n = 20) underwent asphyxia for 7 min, ventricular fibrillation, and CPR for 10-20 min. Epinephrine (20 mcg/kg) was administered at 2, 6, 10, 14, and 18 min of CPR. Invasive (laser Doppler, brain tissue oxygen tension [PbtO2]) and noninvasive (diffuse correlation spectroscopy and diffuse optical spectroscopy) measurements of CBF and cerebral tissue oxygenation were simultaneously recorded. Effects of subsequent epinephrine doses were compared to the first. RESULTS With the first epinephrine dose during CPR, CBF and cerebral tissue oxygenation increased by > 10%, as measured by each of the invasive and noninvasive measures (p < 0.001). The effects of epinephrine on CBF and cerebral tissue oxygenation decreased with subsequent doses. By the fifth dose of epinephrine, there were no demonstrable increases in CBF of cerebral tissue oxygenation. Invasive and noninvasive CBF measurements were highly correlated during asphyxia (slope effect 1.3, p < 0.001) and CPR (slope effect 0.20, p < 0.001). CONCLUSIONS This model suggests that epinephrine increases CBF and cerebral tissue oxygenation, but that effects wane following the third dose. Noninvasive measurements of neurological health parameters hold promise for developing and directing resuscitation strategies.
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Affiliation(s)
- Constantine D Mavroudis
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA. .,Division of Cardiovascular Surgery, The University of Pennsylvania, Philadelphia, PA, USA.
| | - Tiffany S Ko
- Department of Neurology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Lindsay E Volk
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - William P Landis
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Benjamin Smood
- Division of Cardiovascular Surgery, The University of Pennsylvania, Philadelphia, PA, USA
| | - Rui Xiao
- Department of Pediatrics, Division of Biostatistics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Marco Hefti
- Department of Pathology, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Timothy W Boorady
- Department of Neurology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alexandra Marquez
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Daniel J Licht
- Department of Neurology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Todd J Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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20
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Öztürk NY, Aygün B, Uyar E, Girgin Fİ. Comparison of Bilateral Cerebro-Renal Tissue Oxygenations in Healthy Children. Indian J Pediatr 2020; 87:99-104. [PMID: 31879839 DOI: 10.1007/s12098-019-03093-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 09/30/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To investigate right and left cerebral tissue (ctSO2) and renal tissue oxygenations (rtSO2) in otherwise healthy children. METHODS In this observational cross-sectional study, one hundred children seen as outpatients for well child care or common non-critical complaints, were included. Bilateral ctSO2 and rtSO2 were recorded simultaneously with INVOS™ 5100 device. RESULTS The median age was 6.7 y (IQR 3-10.4) and median weight was 21 kg (IQR 13-33). Right and left sided ctSO2 and rtSO2 values were 78.7% ± 6.0% and 79.1% ± 5.7%; 81.5% ± 9.4% and 81.4% ± 9.5% respectively. There were no differences in right and left cerebral and renal near infrared spectroscopy (NIRS) values, and no age centered lateralization effect. Renal measurements were higher than cerebral counterparts in 63% of the children. Interaction between age and regional oxygenation was significant. For both sides, renal oxygenation was higher than that of cerebrum in older children, whereas the opposite held true with younger age. CONCLUSIONS There are no right and left side differences in ctSO2 and rtSO2 values in otherwise healthy children. On the other hand, there seem to be differences between cerebral and renal regions with a significant age effect. Acknowledging its limitations, this study sheds light on laterality and cranial and renal NIRS measurements in otherwise healthy children, and may contribute to the interpretation of NIRS data in critically ill patients.
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Affiliation(s)
- Nilüfer Yalındağ Öztürk
- Division of Pediatric Critical Care, Department of Pediatrics, Marmara University School of Medicine, Marmara University Pendik Training and Research Hospital, Fevzi Cakmak Mah, Mimar Sinan Cad, No 41 Ust Kaynarca Pendik, 34889, Pendik, İstanbul, Turkey.
| | - Burcu Aygün
- Division of Pediatric Critical Care, Department of Pediatrics, Marmara University School of Medicine, Marmara University Pendik Training and Research Hospital, Fevzi Cakmak Mah, Mimar Sinan Cad, No 41 Ust Kaynarca Pendik, 34889, Pendik, İstanbul, Turkey
| | - Emel Uyar
- Division of Pediatric Critical Care, Department of Pediatrics, Marmara University School of Medicine, Marmara University Pendik Training and Research Hospital, Fevzi Cakmak Mah, Mimar Sinan Cad, No 41 Ust Kaynarca Pendik, 34889, Pendik, İstanbul, Turkey
| | - Feyza İnceköy Girgin
- Division of Pediatric Critical Care, Department of Pediatrics, Marmara University School of Medicine, Marmara University Pendik Training and Research Hospital, Fevzi Cakmak Mah, Mimar Sinan Cad, No 41 Ust Kaynarca Pendik, 34889, Pendik, İstanbul, Turkey
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Jildenstål P, Sandin J, WarrènStomberg M, Pålsson J, Ricksten SE, Snygg J. Agreement between frontal and occipital regional cerebral oxygen saturation in infants during surgery and general anesthesia an observational study. Paediatr Anaesth 2019; 29:1122-1127. [PMID: 31536668 DOI: 10.1111/pan.13743] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 08/26/2019] [Accepted: 09/14/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Advances in perioperative pediatric care have resulted in an increased number of procedures requiring anesthesia. During anesthesia and surgery, the patient is subjected to factors that affect the circulatory homeostasis, which can influence oxygenation of the brain. Near-infrared spectroscopy (NIRS) is an easy applicable noninvasive method for monitoring of regional tissue oxygenation (rScO₂%). Alternate placements for NIRS have been investigated; however, no alternative cranial placements have been explored. AIM To evaluate the agreement between frontal and occipital recordings of rScO₂% in infants using INVOSTM during surgery and general anesthesia. METHOD A standard frontal monitoring of rScO₂% with NIRS was compared with occipital rScO₂% measurements in fifteen children at an age <1 year, ASA 1-2, undergoing cleft lip and/or palate surgery during general anesthesia with sevoflurane. An agreement analysis was performed according to Bland and Altman. RESULTS Mean values of frontal and occipital rScO₂% at baseline were largely similar (70.7 ± 4.77% and 69.40 ± 5.04%, respectively). In the majority of the patients, the frontal and occipital recordings of rScO2 changed in parallel. There was a moderate positive correlation between frontal and occipital rScO₂% INVOS™ readings (rho[ρ]: 0.513, P < .01). The difference between frontal and occipital rScO₂ ranged from -31 to 28 with a mean difference (bias) of -0.15%. The 95% limit of agreement was -18.04%-17.74%. The error between frontal and occipital rScO₂ recordings was 23%. CONCLUSION The agreement between frontal and occipital recordings of brain rScO₂% in infants using INVOSTM during surgery and general anesthesia was acceptable. In surgical procedures where the frontal region of the head is not available for monitoring, occipital recordings of rScO₂% could be an option for monitoring.
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Affiliation(s)
- Pether Jildenstål
- Institute of Health and Care Sciences, Sahlgrenska academy, University of Gothenburg, Gothenburg, Sweden.,Department of Anesthesia and Intensive Care, Institute for Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Anesthesiology, Surgery and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Johan Sandin
- Department of children´s surgery division, Queen Silvia´s children´s hospital, Gothenburg, Sweden
| | - Margareta WarrènStomberg
- Institute of Health and Care Sciences, Sahlgrenska academy, University of Gothenburg, Gothenburg, Sweden
| | - Jan Pålsson
- Department of Anesthesia and Intensive Care, Institute for Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Anesthesiology, Surgery and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sven-Erik Ricksten
- Department of Anesthesia and Intensive Care, Institute for Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Anesthesiology, Surgery and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Johan Snygg
- Department of Anesthesia and Intensive Care, Institute for Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Anesthesiology, Surgery and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
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Denault A, Shaaban Ali M, Couture EJ, Beaubien-Souligny W, Bouabdallaoui N, Brassard P, Mailhot T, Jacquet-Lagrèze M, Lamarche Y, Deschamps A. A Practical Approach to Cerebro-Somatic Near-Infrared Spectroscopy and Whole-Body Ultrasound. J Cardiothorac Vasc Anesth 2019; 33 Suppl 1:S11-S37. [DOI: 10.1053/j.jvca.2019.03.039] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Frogel J, Kogan A, Augoustides JG, Berkenstadt H, Feduska E, Steyn J, Dwarakanath S, Nir EA, Stohl S. The Value of Cerebral Oximetry Monitoring in Cardiac Surgery: Challenges and Solutions in Adult and Pediatric Practice. J Cardiothorac Vasc Anesth 2019; 33:1778-1784. [DOI: 10.1053/j.jvca.2018.08.206] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Indexed: 02/04/2023]
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24
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Skowno JJ. Hemodynamic monitoring in children with heart disease: Overview of newer technologies. Paediatr Anaesth 2019; 29:467-474. [PMID: 30667124 DOI: 10.1111/pan.13590] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 12/26/2018] [Accepted: 01/14/2019] [Indexed: 12/21/2022]
Affiliation(s)
- Justin J Skowno
- Department of Anaesthesia, The Children's Hospital at Westmead, Sydney, NSW, Australia.,Discipline of Child and Adolescent Health, Faculty of Medicine and Health, The University of Sydney, NSW, Australia
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25
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Incremental value of noncerebral somatic tissue oxygenation monitoring for patients undergoing surgery. Curr Opin Anaesthesiol 2019; 32:50-56. [DOI: 10.1097/aco.0000000000000672] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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El-Dib M, Soul JS. Monitoring and management of brain hemodynamics and oxygenation. HANDBOOK OF CLINICAL NEUROLOGY 2019; 162:295-314. [PMID: 31324316 DOI: 10.1016/b978-0-444-64029-1.00014-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
While cardiorespiratory monitoring is standard for newborns in the NICU, monitoring of brain hemodynamics and oxygenation is usually sporadic and targeted to newborns with suspected or confirmed neurologic disorders. This is unfortunate, since critically ill newborns, both preterm and term-born, are at high risk of brain injury and would benefit from improved techniques for continuous monitoring of brain hemodynamics and oxygenation, in addition to monitoring of systemic hemodynamics and oxygenation. Near-infrared spectroscopy (NIRS) and, to a lesser extent, Doppler ultrasound are techniques that have been used in research and increasingly for clinical purposes to measure and monitor brain hemodynamics and oxygenation in newborns. NIRS monitoring can be useful for detection of diverse pathologic conditions that occur frequently in very preterm newborns and in selected populations of term newborns at risk for brain injury related to disturbances of systemic hemodynamics. This chapter reviews the current state of the art with regard to brain-monitoring techniques and the research directed at this important area, and it concludes with suggestions for the use of currently available tools to manage newborns at high risk of neurologic injury from disturbances in brain hemodynamics and oxygenation.
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Affiliation(s)
- Mohamed El-Dib
- Neonatal Neurocritical Care, Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA, United States
| | - Janet S Soul
- Fetal-Neonatal Neurology Program, Department of Neurology, Boston Children's Hospital, Boston, MA, United States; Department of Neurology, Harvard Medical School, Boston, MA, United States.
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Fister P, Robek D, Paro-Panjan D, Mazić U, Lenasi H. Decreased tissue oxygenation in newborns with congenital heart defects: a case-control study. Croat Med J 2018; 59:71-78. [PMID: 29740991 PMCID: PMC5941290 DOI: 10.3325/cmj.2018.59.71] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Aim To compare regional tissue oxygenation (rSO2) in the brain, intestine, and kidney between newborns with and without congenital heart defects (CHD). Methods This observational case-control study was conducted at the Neonatal Deparetment of Children's Hospital Ljubljana between December 2012 and April 2014. It included 35 newborns with CHD and 30 healthy age- and sex-matched controls. CHD were assessed echocardiographically and divided into acyanotic and cyanotic group. RSO2 in the brain, intestine, and kidney was measured using near-infrared spectroscopy (NIRS). Simultaneously, heart rate (HR), breathing frequency (BF), mean arterial blood pressure (MAP), and arterial oxygen saturation (Sao2) were recorded. Results Newborns with CHD had significantly lower rSO2 in the left brain hemisphere (67 ± 11% vs 76 ± 8%, P = 0.004), right brain hemisphere (68 ± 11% vs 77 ± 8%, P < 0.001), and the kidney (68 ± 13% vs 77 ± 10%, P = 0.015). RSO2 in the intestine did not significantly differ between the groups. HR, MAP, and Sao2 also did not differ between the groups, whereas BF was significantly higher in the CHD group (57 ± 12 vs 39 ± 10 breaths/min, P < 0.001). Between cyanotic and acyanotic group, we found no significant differences in rSO2 of any tissue. Conclusions Monitoring tissue oxygenation by NIRS could enable a timely detection of hemodynamically important CHD.
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Affiliation(s)
| | | | | | | | - Helena Lenasi
- Helena Lenasi, Institute of Physiology, Medical Faculty, University of Ljubljana, Zaloška 4, 1000 Ljubljana, Slovenia,
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Yu Y, Zhang K, Zhang L, Zong H, Meng L, Han R. Cerebral near-infrared spectroscopy (NIRS) for perioperative monitoring of brain oxygenation in children and adults. Cochrane Database Syst Rev 2018; 1:CD010947. [PMID: 29341066 PMCID: PMC6491319 DOI: 10.1002/14651858.cd010947.pub2] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Various techniques have been employed for the early detection of perioperative cerebral ischaemia and hypoxia. Cerebral near-infrared spectroscopy (NIRS) is increasingly used in this clinical scenario to monitor brain oxygenation. However, it is unknown whether perioperative cerebral NIRS monitoring and the subsequent treatment strategies are of benefit to patients. OBJECTIVES To assess the effects of perioperative cerebral NIRS monitoring and corresponding treatment strategies in adults and children, compared with blinded or no cerebral oxygenation monitoring, or cerebral oxygenation monitoring based on non-NIRS technologies, on the detection of cerebral oxygen desaturation events (CDEs), neurological outcomes, non-neurological outcomes and socioeconomic impact (including cost of hospitalization and length of hospital stay). SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 12), Embase (1974 to 20 December 2016) and MEDLINE (PubMed) (1975 to 20 December 2016). We also searched the World Health Organization (WHO) International Clinical Trials Registry Platform for ongoing studies on 20 December 2016. We updated this search in November 2017, but these results have not yet been incorporated in the review. We imposed no language restriction. SELECTION CRITERIA We included all relevant randomized controlled trials (RCTs) dealing with the use of cerebral NIRS in the perioperative setting (during the operation and within 72 hours after the operation), including the operating room, the postanaesthesia care unit and the intensive care unit. DATA COLLECTION AND ANALYSIS Two authors independently selected studies, assessed risk of bias and extracted data. For binary outcomes, we calculated the risk ratio (RR) and its 95% confidence interval (CI). For continuous data, we estimated the mean difference (MD) between groups and its 95% CI. As we expected clinical and methodological heterogeneity between studies, we employed a random-effects model for analyses and we examined the data for heterogeneity (I2 statistic). We created a 'Summary of findings' table using GRADEpro. MAIN RESULTS We included 15 studies in the review, comprising a total of 1822 adult participants. There are 12 studies awaiting classification, and eight ongoing studies.None of the 15 included studies considered the paediatric population. Four studies were conducted in the abdominal and orthopaedic surgery setting (lumbar spine, or knee and hip replacement), one study in the carotid endarterectomy setting, and the remaining 10 studies in the aortic or cardiac surgery setting. The main sources of bias in the included studies related to potential conflict of interest from industry sponsorship, unclear blinding status or missing participant data.Two studies with 312 participants considered postoperative neurological injury, however no pooled effect estimate could be calculated due to discordant direction of effect between studies (low-quality evidence). One study (N = 126) in participants undergoing major abdominal surgery reported that 4/66 participants experienced neurological injury with blinded monitoring versus 0/56 in the active monitoring group. A second study (N = 195) in participants having coronary artery bypass surgery reported that 1/96 participants experienced neurological injury in the blinded monitoring group compared with 4/94 participants in the active monitoring group.We are uncertain whether active cerebral NIRS monitoring has an important effect on the risk of postoperative stroke because of the low number of events and wide confidence interval (RR 0.25, 95% CI 0.03 to 2.20; 2 studies, 240 participants; low-quality evidence).We are uncertain whether active cerebral NIRS monitoring has an important effect on postoperative delirium because of the wide confidence interval (RR 0.63, 95% CI 0.27 to 1.45; 1 study, 190 participants; low-quality evidence).Two studies with 126 participants showed that active cerebral NIRS monitoring may reduce the incidence of mild postoperative cognitive dysfunction (POCD) as defined by the original studies at one week after surgery (RR 0.53, 95% CI 0.30 to 0.95, I2 = 49%, low-quality evidence).Based on six studies with 962 participants, there was moderate-quality evidence that active cerebral oxygenation monitoring probably does not decrease the occurrence of POCD (decline in cognitive function) at one week after surgery (RR 0.62, 95% CI 0.37 to 1.04, I2 = 80%). The different type of monitoring equipment in one study could potentially be the cause of the heterogeneity.We are uncertain whether active cerebral NIRS monitoring has an important effect on intraoperative mortality or postoperative mortality because of the low number of events and wide confidence interval (RR 0.63, 95% CI 0.08 to 5.03, I2= 0%; 3 studies, 390 participants; low-quality evidence). There was no evidence to determine whether routine use of NIRS-based cerebral oxygenation monitoring causes adverse effects. AUTHORS' CONCLUSIONS The effects of perioperative active cerebral NIRS monitoring of brain oxygenation in adults for reducing the occurrence of short-term, mild POCD are uncertain due to the low quality of the evidence. There is uncertainty as to whether active cerebral NIRS monitoring has an important effect on postoperative stroke, delirium or death because of the low number of events and wide confidence intervals. The conclusions of this review may change when the eight ongoing studies are published and the 12 studies awaiting assessment are classified. More RCTs performed in the paediatric population and high-risk patients undergoing non-cardiac surgery (e.g. neurosurgery, carotid endarterectomy and other surgery) are needed.
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Affiliation(s)
- Yun Yu
- Beijing Tiantan Hospital, Capital Medical UniversityDepartment of AnesthesiologyNo.6 Tiantan XiliBeijingChina100050
| | - Kaiying Zhang
- Beijing Tiantan Hospital, Capital Medical UniversityDepartment of AnesthesiologyNo.6 Tiantan XiliBeijingChina100050
| | - Ling Zhang
- School of Public Health, Capital Medical UniversityDepartment of Epidemiology and Health StatisticsNo. 129 Mail Box, No. 10 Xitoutiao, YouanmenwaiBeijingChina100069
| | - Huantao Zong
- Beijing Tiantan Hospital, Capital Medical UniversityDepartment of UrologyNo.6 Tiantan XiliBeijingChina100050
| | - Lingzhong Meng
- Yale University School of MedicineDepartment of AnesthesiologyNew HavenConnecticutUSA
| | - Ruquan Han
- Beijing Tiantan Hospital, Capital Medical UniversityDepartment of AnesthesiologyNo.6 Tiantan XiliBeijingChina100050
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Hyttel‐Sorensen S, Greisen G, Als‐Nielsen B, Gluud C. Cerebral near-infrared spectroscopy monitoring for prevention of brain injury in very preterm infants. Cochrane Database Syst Rev 2017; 9:CD011506. [PMID: 28869278 PMCID: PMC6483788 DOI: 10.1002/14651858.cd011506.pub2] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Cerebral injury and long-term neurodevelopmental impairment is common in extremely preterm infants. Cerebral near-infrared spectroscopy (NIRS) enables continuous estimation of cerebral oxygenation. This diagnostic method coupled with appropriate interventions if NIRS is out of normal range (that is cerebral oxygenation within the 55% to 85% range) may offer benefits without causing more harms. Therefore, NIRS coupled with appropriate responses to abnormal findings on NIRS needs assessment in a systematic review of randomised clinical trials and quasi-randomised studies. OBJECTIVES To evaluate the benefits and harms of interventions that attempt to alter cerebral oxygenation guided by cerebral NIRS monitoring in order to prevent cerebral injury, improve neurological outcome, and increase survival in preterm infants born more than 8 weeks preterm. SEARCH METHODS We used the standard search strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 8), MEDLINE via PubMed (1966 to 10 September 2016), Embase (1980 to 10 September 2016), and CINAHL (1982 to 10 September 2016). We also searched clinical trial databases, conference proceedings, and the reference lists of retrieved articles for randomised clinical trials and quasi-randomised studies. SELECTION CRITERIA Randomised clinical trials and quasi-randomised clinical studies comparing continuous cerebral NIRS monitoring for at least 24 hours versus blinded NIRS or versus no NIRS monitoring. DATA COLLECTION AND ANALYSIS Two review authors independently selected, assessed the quality of, and extracted data from the included trials and studies. If necessary, we contacted authors for further information. We conducted assessments of risks of bias; risks of design errors; and controlled the risks of random errors with Trial Sequential Analysis. We assessed the quality of the evidence with GRADE. MAIN RESULTS One randomised clinical trial met inclusion criteria, including infants born more than 12 weeks preterm. The trial employed adequate methodologies and was assessed at low risk of bias. One hundred and sixty-six infants were randomised to start continuous cerebral NIRS monitoring less than 3 hours after birth until 72 hours after birth plus appropriate interventions if NIRS was out of normal range according to a guideline versus conventional monitoring with blinded NIRS. There was no effect of NIRS plus guideline of mortality until term-equivalent age (RR 0.50, 95% CI 0.29 to 1.00; one trial; 166 participants). There were no effects of NIRS plus guideline on intraventricular haemorrhages: all grades (RR 0.93, 95% CI 0.65 to 1.34; one trial; 166 participants); grade III/IV (RR 0.57, 95% CI 0.25 to 1.31; one trial; 166 participants); and cystic periventricular leukomalacia (which did not occur in either group). Likewise, there was no effect of NIRS plus guideline on the occurrence of a patent ductus arteriosus (RR 1.96, 95% CI 0.94 to 4.08; one trial; 166 participants); chronic lung disease (RR 1.27, 95% CI 0.94 to 1.50; one trial; 166 participants); necrotising enterocolitis (RR 0.83, 95% CI 0.33 to 1.94; one trial; 166 participants); and retinopathy of prematurity (RR 1.64, 95% CI 0.75 to 3.00; one trial; 166 participants). There were no serious adverse events in any of the intervention groups. NIRS plus guideline caused more skin marks from the NIRS sensor in the control group than in the experimental group (unadjusted RR 0.31, 95% CI 0.10 to 0.92; one trial; 166 participants). There are no data regarding neurodevelopmental outcome, renal impairment or air leaks.The quality of evidence for all comparisons discussed above was assessed as very low apart from all-cause mortality and adverse events: these were assessed as low and moderate, respectively. The validity of all comparisons is hampered by a small sample of randomised infants, risk of bias due to lack of blinding, and indirectness of outcomes. AUTHORS' CONCLUSIONS The only eligible randomised clinical trial did not demonstrate any consistent effects of NIRS plus a guideline on the assessed clinical outcomes. The trial was, however, only powered to detect difference in cerebral oxygenation, not morbidities or mortality. Our systematic review did not reach sufficient power to prove or disprove effects on clinical outcomes. Further randomised clinical trials with low risks of bias and low risks of random errors are needed.
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Affiliation(s)
- Simon Hyttel‐Sorensen
- Rigshospitalet, Copenhagen University HospitalDepartment of NeonatologyBlegdamsvej 9CopenhagenRegion HovedstadenDenmarkDK‐2100
| | - Gorm Greisen
- Rigshospitalet, Copenhagen University HospitalDepartment of NeonatologyBlegdamsvej 9CopenhagenRegion HovedstadenDenmarkDK‐2100
| | - Bodil Als‐Nielsen
- The Child and Youth ClinicDepartment of Paediatric Haematology/Oncology (5054)RigshospitaletUniversity Hospital of CopenhagenCopenhagenDenmark2200
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalThe Cochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
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So near, yet so far: Is isolated cerebral near-infrared spectroscopy in neonates nearly as useful as it is noninvasive? J Thorac Cardiovasc Surg 2017; 154:1054-1055. [DOI: 10.1016/j.jtcvs.2017.04.061] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 04/21/2017] [Indexed: 11/20/2022]
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Changes of Cerebral Oxygenation in Sequential Glenn and Fontan Procedures in the Same Children. Pediatr Cardiol 2017; 38:1215-1219. [PMID: 28589407 DOI: 10.1007/s00246-017-1647-0] [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] [Received: 04/12/2017] [Accepted: 05/30/2017] [Indexed: 01/24/2023]
Abstract
Recently, it is common to perform the Fontan procedure after the Glenn procedure as surgical repair for the univentricular heart. How the brain oxygen saturation (rSO2) values change with the cardiac restoration and the process of growth during these procedures in individual children remains unknown. In this study, we retrospectively studied rSO2 data as well as the perioperative clinical records of 30 children who underwent both Glenn and Fontan procedures by the same surgeon in the same institute. The rSO2 was measured at the beginning and end of each procedure with an INVOS 5100C. Cerebral perfusion pressure was calculated by subtracting central venous pressure from mean arterial pressure. Arterial oxygen saturation (SaO2) and the hemoglobin concentration were obtained as candidates affecting rSO2 changes at the start and the end of both procedures. The rSO2 increased during the Glenn procedure, but this increase was slight and insignificant. On the other hand, the rSO2 significantly increased during the Fontan procedure. Significant increases in SaO2 were observed only between the beginning and end of the Fontan procedure. Correlation coefficients determined by linear regression analysis were more than 0.5 between rSO2 and SaO2 in both procedures. Multiple linear regression analysis showed that SaO2 was the key determinant of the rSO2. The rSO2 increases step by step from the Glenn to the Fontan procedure in the same patient. Within each procedure, SaO2 is the key determinant of the rSO2. The significance of rSO2 monitoring in these procedures should be further evaluated.
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Use of renal near-infrared spectroscopy measurements in congenital diaphragmatic hernia patients on ECMO. J Pediatr Surg 2017; 52:689-692. [PMID: 28190559 DOI: 10.1016/j.jpedsurg.2017.01.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 01/23/2017] [Indexed: 11/20/2022]
Abstract
INTRODUCTION This study tests the hypothesis that renal tissue oxygen saturation as measured by Near Infrared Spectroscopy (NIRS) would correlate with urine output in neonates with congenital diaphragmatic hernia (CDH) on extracorporeal membrane oxygenation (ECMO). METHODS Between 2012 and 2015, neonates with CDH were enrolled as part of a comprehensive study that provided renal/cerebral/abdominal NIRS monitoring for the duration of ECMO support. Continuous NIRS measurements, mean arterial pressure, and urine output were recorded. Periods of anuria (NU), adequate urine output >1ml/kg/h (AU), and low urine output <1ml/kg/h (LU) were noted and analyzed. RESULTS Over 1500h of continuous renal NIRS were obtained from six neonates. NIRS values were significantly different during periods of AU, LU, and anuria (84±6%, 76±3%, and 67±6%, p<0.01). ROC curves identified NIRS >76% as highly predictive of adequate urine output (AUC=0.96). MAP was significantly lower only in anuric patients, 36.42±10.26, compared to patients with AU and LU - 42.99±5.25 and 42.85±7.4, respectively (p<0.001). CONCLUSION Renal NIRS measurements correlate with urine production. Lower values are noted as urine output declines and precedes a decline in MAP. Renal NIRS may have promise as a non-invasive means of determining adequacy of renal perfusion and urine output in neonates with complex fluid shifts. LEVEL OF EVIDENCE IIb.
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Schlomer BJ, Keays MA, Grimsby GM, Granberg CF, DaJusta DG, Menon VS, Ostrov L, Sheth KR, Hill M, Sanchez EJ, Harrison CB, Jacobs MA, Huang R, Burgu B, Hennes H, Baker LA. Transscrotal Near Infrared Spectroscopy as a Diagnostic Test for Testis Torsion in Pediatric Acute Scrotum: A Prospective Comparison to Gold Standard Diagnostic Test Study. J Urol 2017; 198:694-701. [PMID: 28392394 DOI: 10.1016/j.juro.2017.03.134] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE A rapid test for testicular torsion in children may obviate the delay for testicular ultrasound. In this study we assessed testicular tissue percent oxygen saturation (%StO2) measured by transscrotal near infrared spectroscopy as a diagnostic test for pediatric testicular torsion. MATERIALS AND METHODS This was a prospective comparison to a gold standard diagnostic test study that evaluated near infrared spectroscopy %StO2 readings to diagnose testicular torsion. The gold standard for torsion diagnosis was standard clinical care. From 2013 to 2015 males with acute scrotum for more than 1 month and who were less than 18 years old were recruited. Near infrared spectroscopy %StO2 readings were obtained for affected and unaffected testes. Near infrared spectroscopy Δ%StO2 was calculated as unaffected minus affected reading. The utility of near infrared spectroscopy Δ%StO2 to diagnose testis torsion was described with ROC curves. RESULTS Of 154 eligible patients 121 had near infrared spectroscopy readings. Median near infrared spectroscopy Δ%StO2 in the 36 patients with torsion was 2.0 (IQR -4.2 to 9.8) vs -1.7 (IQR -8.7 to 2.0) in the 85 without torsion (p=0.004). AUC for near infrared spectroscopy as a diagnostic test was 0.66 (95% CI 0.55-0.78). Near infrared spectroscopy Δ%StO2 of 20 or greater had a positive predictive value of 100% and a sensitivity of 22.2%. Tanner stage 3-5 cases without scrotal edema or with pain for 12 hours or less had an AUC of 0.91 (95% CI 0.86-1.0) and 0.80 (95% CI 0.62-0.99), respectively. CONCLUSIONS In all children near infrared spectroscopy readings had limited utility in diagnosing torsion. However, in Tanner 3-5 cases without scrotal edema or with pain 12 hours or less, near infrared spectroscopy discriminated well between torsion and nontorsion.
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Affiliation(s)
- Bruce J Schlomer
- University of Texas Southwestern Medical Center, Dallas, Texas; Children's Health, Dallas, Texas.
| | | | | | | | | | - Vani S Menon
- University of Texas Southwestern Medical Center, Dallas, Texas; Children's Health, Dallas, Texas
| | | | - Kunj R Sheth
- University of Texas Southwestern Medical Center, Dallas, Texas
| | | | | | - Clanton B Harrison
- University of Texas Southwestern Medical Center, Dallas, Texas; Children's Health, Dallas, Texas
| | - Micah A Jacobs
- University of Texas Southwestern Medical Center, Dallas, Texas; Children's Health, Dallas, Texas
| | | | - Berk Burgu
- Ankara Üniversitesi Tıp Fakültesi, Ankara, Turkey
| | - Halim Hennes
- University of Texas Southwestern Medical Center, Dallas, Texas; Children's Health, Dallas, Texas
| | - Linda A Baker
- University of Texas Southwestern Medical Center, Dallas, Texas; Children's Health, Dallas, Texas
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Clair MP, Rambaud J, Flahault A, Guedj R, Guilbert J, Guellec I, Durandy A, Demoulin M, Jean S, Mitanchez D, Chalard F, Sileo C, Carbajal R, Renolleau S, Léger PL. Prognostic value of cerebral tissue oxygen saturation during neonatal extracorporeal membrane oxygenation. PLoS One 2017; 12:e0172991. [PMID: 28278259 PMCID: PMC5344369 DOI: 10.1371/journal.pone.0172991] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 01/31/2017] [Indexed: 12/02/2022] Open
Abstract
Objectives Extracorporeal membrane oxygenation support is indicated in severe and refractory respiratory or circulatory failures. Neurological complications are typically represented by acute ischemic or hemorrhagic lesions, which induce higher morbidity and mortality. The primary goal of this study was to assess the prognostic value of cerebral tissue oxygen saturation (StcO2) on mortality in neonates and young infants treated with ECMO. A secondary objective was to evaluate the association between StcO2 and the occurrence of cerebral lesions. Study design This was a prospective study in infants < 3 months of age admitted to a pediatric intensive care unit and requiring ECMO support. Measurements The assessment of cerebral perfusion was made by continuous StcO2 monitoring using near-infrared spectroscopy (NIRS) sensors placed on the two temporo-parietal regions. Neurological lesions were identified by MRI or transfontanellar echography. Results Thirty-four infants <3 months of age were included in the study over a period of 18 months. The ECMO duration was 10±7 days. The survival rate was 50% (17/34 patients), and the proportion of brain injuries was 20% (7/34 patients). The mean StcO2 during ECMO in the non-survivors was reduced in both hemispheres (p = 0.0008 right, p = 0.03 left) compared to the survivors. StcO2 was also reduced in deceased or brain-injured patients compared to the survivors without brain injury (p = 0.002). Conclusion StcO2 appears to be a strong prognostic factor of survival and of the presence of cerebral lesions in young infants during ECMO.
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Affiliation(s)
- Marie-Philippine Clair
- Department of Neonatal and Pediatric intensive care unit, Trousseau Hospital, AP-HP, Paris, France
| | - Jérôme Rambaud
- Department of Neonatal and Pediatric intensive care unit, Trousseau Hospital, AP-HP, Paris, France
| | - Adrien Flahault
- Laboratory of Central Neuropeptides in the Regulation of Body Fluid Homeostasis and Cardiovascular Functions, Center for Interdisciplinary Research in Biology (CIRB), INSERM, U1050, Paris, France
- CNRS, UMR 7241, Paris, France
| | - Romain Guedj
- Department of Emergency medicine, Trousseau Hospital, AP-HP, Paris, France
| | - Julia Guilbert
- Department of Neonatal and Pediatric intensive care unit, Trousseau Hospital, AP-HP, Paris, France
| | - Isabelle Guellec
- Department of Neonatal and Pediatric intensive care unit, Trousseau Hospital, AP-HP, Paris, France
| | - Amélie Durandy
- Department of Neonatal and Pediatric intensive care unit, Trousseau Hospital, AP-HP, Paris, France
| | - Maryne Demoulin
- Department of Neonatal and Pediatric intensive care unit, Trousseau Hospital, AP-HP, Paris, France
| | - Sandrine Jean
- Department of Neonatal and Pediatric intensive care unit, Trousseau Hospital, AP-HP, Paris, France
| | | | - François Chalard
- Department of Pediatric Radiology, Trousseau Hospital, AP-HP, Paris, France
| | - Chiara Sileo
- Department of Pediatric Radiology, Trousseau Hospital, AP-HP, Paris, France
| | - Ricardo Carbajal
- Department of Neonatal and Pediatric intensive care unit, Trousseau Hospital, AP-HP, Paris, France
- Department of Emergency medicine, Trousseau Hospital, AP-HP, Paris, France
- UPMC Pierre et Marie Curie University, Paris VI, France
| | - Sylvain Renolleau
- Department of Pediatric intensive care unit, Necker Hospital, AP-HP, Paris, France
| | - Pierre-Louis Léger
- Department of Neonatal and Pediatric intensive care unit, Trousseau Hospital, AP-HP, Paris, France
- * E-mail:
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Ferradal SL, Yuki K, Vyas R, Ha CG, Yi F, Stopp C, Wypij D, Cheng HH, Newburger JW, Kaza AK, Franceschini MA, Kussman BD, Grant PE. Non-invasive Assessment of Cerebral Blood Flow and Oxygen Metabolism in Neonates during Hypothermic Cardiopulmonary Bypass: Feasibility and Clinical Implications. Sci Rep 2017; 7:44117. [PMID: 28276534 PMCID: PMC5343476 DOI: 10.1038/srep44117] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 02/02/2017] [Indexed: 02/01/2023] Open
Abstract
The neonatal brain is extremely vulnerable to injury during periods of hypoxia and/or ischemia. Risk of brain injury is increased during neonatal cardiac surgery, where pre-existing hemodynamic instability and metabolic abnormalities are combined with long periods of low cerebral blood flow and/or circulatory arrest. Our understanding of events associated with cerebral hypoxia-ischemia during cardiopulmonary bypass (CPB) remains limited, largely due to inadequate tools to quantify cerebral oxygen delivery and consumption non-invasively and in real-time. This pilot study aims to evaluate cerebral blood flow (CBF) and oxygen metabolism (CMRO2) intraoperatively in neonates by combining two novel non-invasive optical techniques: frequency-domain near-infrared spectroscopy (FD-NIRS) and diffuse correlation spectroscopy (DCS). CBF and CMRO2 were quantified before, during and after deep hypothermic cardiopulmonary bypass (CPB) in nine neonates. Our results show significantly decreased CBF and CMRO2 during hypothermic CPB. More interestingly, a change of coupling between both variables is observed during deep hypothermic CPB in all subjects. Our results are consistent with previous studies using invasive techniques, supporting the concept of FD-NIRS/DCS as a promising technology to monitor cerebral physiology in neonates providing the potential for individual optimization of surgical management.
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Affiliation(s)
- Silvina L Ferradal
- Fetal-Neonatal Neuroimaging &Developmental Science Center, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Koichi Yuki
- Department of Anesthesiology, Perioperative &Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Rutvi Vyas
- Fetal-Neonatal Neuroimaging &Developmental Science Center, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher G Ha
- Fetal-Neonatal Neuroimaging &Developmental Science Center, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Francesca Yi
- Fetal-Neonatal Neuroimaging &Developmental Science Center, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christian Stopp
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David Wypij
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Henry H Cheng
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Aditya K Kaza
- Department of Cardiovascular Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Maria A Franceschini
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Charlestown, Massachusetts, USA
| | - Barry D Kussman
- Department of Anesthesiology, Perioperative &Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - P Ellen Grant
- Fetal-Neonatal Neuroimaging &Developmental Science Center, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Neurological injury in paediatric cardiac surgery. Indian J Thorac Cardiovasc Surg 2017. [DOI: 10.1007/s12055-016-0481-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Humblet K, Docquier MA, Rubay J, Momeni M. Multimodal Brain Monitoring in Congenital Cardiac Surgery: The Importance of Processed Electroencephalogram Monitor, NeuroSENSE, in Addition to Cerebral Near-Infrared Spectroscopy. J Cardiothorac Vasc Anesth 2017; 31:254-258. [DOI: 10.1053/j.jvca.2016.01.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Indexed: 11/11/2022]
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Nissen M, Cernaianu G, Thränhardt R, Vahdad MR, Barenberg K, Tröbs RB. Does metabolic alkalosis influence cerebral oxygenation in infantile hypertrophic pyloric stenosis? J Surg Res 2017; 212:229-237. [PMID: 28550912 DOI: 10.1016/j.jss.2017.01.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Revised: 12/30/2016] [Accepted: 01/19/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND This pilot study focuses on regional tissue oxygenation (rSO2) in patients with infantile hypertrophic pyloric stenosis in a perioperative setting. To investigate the influence of enhanced metabolic alkalosis (MA) on cerebral (c-rSO2) and renal (r-rSO2) tissue oxygenation, two-site near-infrared spectroscopy (NIRS) technology was applied. MATERIALS AND METHODS Perioperative c-rSO2, r-rSO2, capillary blood gases, and electrolytes from 12 infants were retrospectively compared before and after correction of MA at admission (T1), before surgery (T2), and after surgery (T3). RESULTS Correction of MA was associated with an alteration of cerebral oxygenation without affecting renal oxygenation. When compared to T1, 5-min mean (± standard deviation) c-rSO2 increased after correction of MA at T2 (72.74 ± 4.60% versus 77.89 ± 5.84%; P = 0.058), reaching significance at T3 (80.79 ± 5.29%; P = 0.003). Furthermore, relative 30-min c-rSO2 values at first 3 h of metabolic compensation were significantly lowered compared with postsurgical states at 16 and 24 h. Cerebral oxygenation was positively correlated with levels of sodium (r = 0.37; P = 0.03) and inversely correlated with levels of bicarbonate (r = -0.34; P = 0.05) and base excess (r = -0.36; P = 0.04). Analysis of preoperative and postoperative cerebral and renal hypoxic burden yielded no differences. However, a negative correlation (r = -0.40; P = 0.03) regarding hematocrite and mean r-rSO2, indirectly indicative of an increased renal blood flow under hemodilution, was obtained. CONCLUSIONS NIRS seems suitable for the detection of a transiently impaired cerebral oxygenation under state of pronounced MA in infants with infantile hypertrophic pyloric stenosis. Correction of MA led to normalization of c-rSO2. NIRS technology constitutes a promising tool for optimizing perioperative management, especially in the context of a possible diminished neurodevelopmental outcome after pyloromyotomy.
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Affiliation(s)
- Matthias Nissen
- Department of Pediatric Surgery, St. Mary's Hospital, St. Elisabeth Group, Ruhr-University of Bochum, Herne, Germany.
| | - Grigore Cernaianu
- Department of Pediatrics and Adolescent Medicine, Pediatric Surgery, University of Cologne, Cologne, Germany
| | - Rene Thränhardt
- Department of Pediatric Surgery, St. Mary's Hospital, St. Elisabeth Group, Ruhr-University of Bochum, Herne, Germany
| | - Mohammad R Vahdad
- Department of Pediatric Surgery, University Hospital Giessen/Marburg, Marburg, Germany
| | - Karin Barenberg
- Department of Pediatric Surgery, St. Mary's Hospital, St. Elisabeth Group, Ruhr-University of Bochum, Herne, Germany
| | - Ralf-Bodo Tröbs
- Department of Pediatric Surgery, St. Mary's Hospital, St. Elisabeth Group, Ruhr-University of Bochum, Herne, Germany
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Anderson CA, Lazard DS, Hartley DEH. Plasticity in bilateral superior temporal cortex: Effects of deafness and cochlear implantation on auditory and visual speech processing. Hear Res 2017; 343:138-149. [PMID: 27473501 DOI: 10.1016/j.heares.2016.07.013] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 07/20/2016] [Accepted: 07/25/2016] [Indexed: 12/01/2022]
Abstract
While many individuals can benefit substantially from cochlear implantation, the ability to perceive and understand auditory speech with a cochlear implant (CI) remains highly variable amongst adult recipients. Importantly, auditory performance with a CI cannot be reliably predicted based solely on routinely obtained information regarding clinical characteristics of the CI candidate. This review argues that central factors, notably cortical function and plasticity, should also be considered as important contributors to the observed individual variability in CI outcome. Superior temporal cortex (STC), including auditory association areas, plays a crucial role in the processing of auditory and visual speech information. The current review considers evidence of cortical plasticity within bilateral STC, and how these effects may explain variability in CI outcome. Furthermore, evidence of audio-visual interactions in temporal and occipital cortices is examined, and relation to CI outcome is discussed. To date, longitudinal examination of changes in cortical function and plasticity over the period of rehabilitation with a CI has been restricted by methodological challenges. The application of functional near-infrared spectroscopy (fNIRS) in studying cortical function in CI users is becoming increasingly recognised as a potential solution to these problems. Here we suggest that fNIRS offers a powerful neuroimaging tool to elucidate the relationship between audio-visual interactions, cortical plasticity during deafness and following cochlear implantation, and individual variability in auditory performance with a CI.
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Affiliation(s)
- Carly A Anderson
- National Institute for Health Research (NIHR) Nottingham Hearing Biomedical Research Unit, Ropewalk House, 113 The Ropewalk, Nottingham, NG1 5DU, United Kingdom; Otology and Hearing Group, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, NG7 2UH, United Kingdom.
| | - Diane S Lazard
- Institut Arthur Vernes, ENT Surgery, Paris, 75006, France; Nottingham University Hospitals NHS Trust, Derby Road, Nottingham, NG7 2UH, United Kingdom.
| | - Douglas E H Hartley
- National Institute for Health Research (NIHR) Nottingham Hearing Biomedical Research Unit, Ropewalk House, 113 The Ropewalk, Nottingham, NG1 5DU, United Kingdom; Otology and Hearing Group, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, NG7 2UH, United Kingdom; Nottingham University Hospitals NHS Trust, Derby Road, Nottingham, NG7 2UH, United Kingdom; Medical Research Council (MRC) Institute of Hearing Research, The University of Nottingham, University Park, Nottingham, NG7 2RD, United Kingdom.
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Aly SA, Zurakowski D, Glass P, Skurow-Todd K, Jonas RA, Donofrio MT. Cerebral tissue oxygenation index and lactate at 24 hours postoperative predict survival and neurodevelopmental outcome after neonatal cardiac surgery. CONGENIT HEART DIS 2016; 12:188-195. [DOI: 10.1111/chd.12426] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 08/31/2016] [Accepted: 10/16/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Safwat A. Aly
- Department of Pediatrics; Children's National Medical Center; Washington District of Columbia, USA
| | - David Zurakowski
- Departments of Anesthesia and Surgery; Boston Children's Hospital, Harvard Medical School; Boston Massachusetts USA
| | - Penny Glass
- Department of Psychiatry and Behavioral Science; Children's National Medical Center; Washington District of Columbia USA
| | - Kami Skurow-Todd
- Division of Cardiology; Children's National Medical Center; Washington District of Columbia USA
| | - Richard A. Jonas
- Division of Cardiothoracic Surgery; Children's National Medical Center; Washington District of Columbia USA
| | - Mary T. Donofrio
- Division of Cardiology; Children's National Medical Center; Washington District of Columbia USA
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Abstract
A mismatch between cerebral oxygen supply and demand can lead to cerebral hypoxia/ischemia and deleterious outcomes. Cerebral oxygenation monitoring is an important aspect of multimodality neuromonitoring. It is increasingly deployed whenever intracranial pressure monitoring is indicated. Although there is a large body of evidence demonstrating an association between cerebral hypoxia/ischemia and poor outcomes, it remains to be determined whether restoring cerebral oxygenation leads to improved outcomes. Randomized prospective studies are required to address uncertainties about cerebral oxygenation monitoring and management. This article describes the different methods of monitoring cerebral oxygenation, their indications, evidence base, limitations, and future perspectives.
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Affiliation(s)
- Matthew A Kirkman
- Neurocritical Care Unit, The National Hospital for Neurology and Neurosurgery, University College London Hospitals, Queen Square, London WC1N 3BG, UK
| | - Martin Smith
- Neurocritical Care Unit, The National Hospital for Neurology and Neurosurgery, University College London Hospitals, Queen Square, London WC1N 3BG, UK.
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Neurodevelopmental outcome in hypoplastic left heart syndrome: Impact of perioperative cerebral tissue oxygenation of the Norwood procedure. J Thorac Cardiovasc Surg 2016; 151:1358-66. [DOI: 10.1016/j.jtcvs.2016.02.035] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 01/08/2016] [Accepted: 02/07/2016] [Indexed: 11/21/2022]
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Conforti A, Giliberti P, Landolfo F, Valfrè L, Columbo C, Mondi V, Capolupo I, Dotta A, Bagolan P. Effects of ventilation modalities on near-infrared spectroscopy in surgically corrected CDH infants. J Pediatr Surg 2016; 51:349-53. [PMID: 26342630 DOI: 10.1016/j.jpedsurg.2015.07.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 07/25/2015] [Accepted: 07/31/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Near-infrared spectroscopy (NIRS) is a noninvasive technique for monitoring tissue oxygenation and perfusion. The aim of this study was to evaluate cerebral and splanchnic NIRS changes in CDH operated infants enrolled into the VICI trial and therefore randomized for ventilatory modalities. MATERIALS AND METHODS CDH newborns enrolled into the VICI trial (Netherlands Trial Register, NTR 1310) were randomized at birth for high-frequency oscillatory ventilation (HFOV) or conventional mechanical ventilation (CMV) according to the trial. Cerebral oxygenation (rSO2C) and splanchnic oxygenation (rSO2S) were obtained by NIRS (INVOS 5100; Somanetics, Troy, MI) before and after surgery. Variations in rSO2C and rSO2S were evaluated. Mann-Whitney test and one-way ANOVA were used as appropriate. p<0.05 was considered significant. RESULTS Thirteen VICI trial patients underwent surgical repair between March 2011 and December 2012, and were enrolled in the study. Seven patients were assigned to HFOV and six to CMV group respectively. During surgery, a significant reduction in rSO2C (p=0.0001) and rSO2S (p=0.005) were observed. HFOV patients experienced prolonged reduction in rSO2C value (p=0.003) while rSO2S did not vary between HFOV and CMV (p=0.94). CONCLUSIONS Surgical CDH repair was associated with decrease of cerebral and splanchnic oxygenation, regardless of ventilation. Patients ventilated by HFOV need a longer time interval to recovery normal rSO2C values, than those ventilated by CMV. This may be owing to a different impact of HFOV on patients' hemodynamic status with a higher impairment on total venous return and its negative consequences on cardiac output.
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Affiliation(s)
- Andrea Conforti
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, Rome, Italy.
| | - Paola Giliberti
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, Rome, Italy
| | - Francesca Landolfo
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, Rome, Italy
| | - Laura Valfrè
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, Rome, Italy
| | - Claudia Columbo
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, Rome, Italy
| | - Vito Mondi
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, Rome, Italy
| | - Irma Capolupo
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, Rome, Italy
| | - Andrea Dotta
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, Rome, Italy
| | - Pietro Bagolan
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, Rome, Italy
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Cruz SM, Akinkuotu AC, Rusin CG, Cass DL, Lee TC, Welty SE, Olutoye OO. A novel multimodal computational system using near-infrared spectroscopy to monitor cerebral oxygenation during assisted ventilation in CDH patients. J Pediatr Surg 2016; 51:38-43. [PMID: 26585879 DOI: 10.1016/j.jpedsurg.2015.10.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 10/06/2015] [Indexed: 11/15/2022]
Abstract
BACKGROUND/PURPOSE The aim of this study was to create a computational simulator to serve as an early alert system for cerebral hypoxemia prior to the onset of clinical symptoms. METHODS Neonates with congenital diaphragmatic hernia (Jan 2010-Dec 2014) were recruited to collect continuous measurements of cerebral tissue oxygen saturation (cStO2) using a near-infrared spectroscopy (NIRS) device (FORE-SIGHT®, CASMED). Clinicians were blinded to NIRS data and treated infants based on pre-established clinical protocols. Charts were reviewed retrospectively to identify clinical events of hypoxemia (spontaneous, sustained decrease in preductal SpO2<85% leading to ventilator changes). We developed a computational algorithm that determined baseline values, variability and event data for each patient. RESULTS Twenty-three of 36 patients enrolled met data criteria. The algorithm anticipated an event at least 15 minutes prior to the event in 77% of cases, with an average pre-event detection of 47 minutes (range 16-122 minutes). Post-event StO2 (SpO2<85%) was determined to be 63.7% ± 11.7. In this computational model, the sensitivity to distinguish low states of cerebral perfusion was 94% with a specificity of 96%. CONCLUSION We have developed a computational algorithm with an early warning system that has the potential of being translated into a real-time clinical interface that may improve management of neonates.
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Affiliation(s)
- Stephanie M Cruz
- Texas Children's Fetal Center and the Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Adesola C Akinkuotu
- Texas Children's Fetal Center and the Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Craig G Rusin
- Department of Pediatrics-Cardiology Division, Baylor College of Medicine, Houston, TX, United States
| | - Darrell L Cass
- Texas Children's Fetal Center and the Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States; Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, United States
| | - Timothy C Lee
- Texas Children's Fetal Center and the Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Stephen E Welty
- Department of Pediatrics-Newborn Section, Baylor College of Medicine, Houston, TX, United States
| | - Oluyinka O Olutoye
- Texas Children's Fetal Center and the Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States; Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, United States.
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CXCR4-targeted near-infrared imaging allows detection of orthotopic and metastatic human osteosarcoma in a mouse model. Sci Rep 2015; 5:15244. [PMID: 26472699 PMCID: PMC4607947 DOI: 10.1038/srep15244] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 09/17/2015] [Indexed: 11/27/2022] Open
Abstract
CXCR4 is expressed at primary and metastatic sites of osteosarcoma. We developed a novel CXCR4-targeted near-infrared (NIR) fluorescent imaging agent (referred to as CXCR4-IR-783). The binding to representative osteosarcoma cells (F5M2 and F4 for high- and low- CXCR4 expression) was examined. CXCR4-IR-783 fluorescence was also examined in a mouse xenograft model of human osteosarcoma using NIR fluorescence microscopy and a Kodak in-vivo multispectral system. Pulmonary metastases in mice bearing osteosarcoma xenografts were detected by micro CT, 18F-PET scan and NIR imaging scan. Briefly, the binding of CXCR4-IR-783 was significantly higher in F5M2 than in F4 cells. Intense NIR fluorescence signals were detected in osteosarcoma xenografts, with signal/background ratio at 4.87 in mice bearing the F5M2 cell. At 4 weeks after F5M2 cell inoculation, metastatic lesions in the lungs were detectable using CXCR4-IR-783 and micro-CT scan, but not with 18F-FDG PET scan. In conclusion, CXCR4-IR-783 is a promising tool for detection of high CXCR4-expressing osteosarcoma, and particularly for its metastatic lesions.
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Gil-Anton J, Redondo S, Garcia Urabayen D, Nieto Faza M, Sanz I, Pilar J. Combined Cerebral and Renal Near-Infrared Spectroscopy After Congenital Heart Surgery. Pediatr Cardiol 2015; 36:1173-8. [PMID: 25764508 DOI: 10.1007/s00246-015-1139-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 03/04/2015] [Indexed: 12/27/2022]
Abstract
The maintenance of an adequate oxygen supply to tissues after congenital heart surgery is essential for good outcomes. The objective of this study was to assess the usefulness of near-infrared spectroscopy (NIRS) for estimating central venous oxygen saturation (ScvO2) using both cerebral and renal measurements, explore its relation with cardiac output measurements and check its ability to detect low cardiac output. A prospective observational pilot study was conducted in patients weighing <10 kg undergoing cardiopulmonary bypass surgery. Spectroscopy probes were placed on the forehead and renal area, and serial cardiac output measurements were obtained by femoral transpulmonary thermodilution over the first 24 h after surgery. In the 15 patients studied, ScvO2 was correlated with cerebral (r = 0.58), renal (r = 0.60) and combined (r = 0.71) measurements. Likewise, the systolic index was correlated with the NIRS signals: cerebral (r = 0.60), renal (r = 0.50) and combined (r = 0.66). Statistically significant differences were found in the NIRS measures registered in the 29 low cardiac output events detected by thermodilution: cerebral: 62 % (59-65) versus 69 % (63-76); renal: 83 % (70-89) versus 89 % (83-95); and combined 64 % (60-69) versus 72 % (67-76). In our series, combined cerebral and renal monitoring was correlated with central venous oxygen saturation and cardiac output; low cardiac output detection associated a different spectroscopy pattern.
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Affiliation(s)
- Javier Gil-Anton
- Pediatric Intensive Care Unit, Cruces University Hospital, Bizkaia, Spain,
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Abstract
Near-infrared spectroscopy (NIRS) offers non-invasive, in-vivo, real-time monitoring of tissue oxygenation. Changes in regional tissue oxygenation as detected by NIRS may reflect the delicate balance between oxygen delivery and consumption. Originally used predominantly to assess cerebral oxygenation and perfusion perioperatively during cardiac and neurosurgery, and following head trauma, NIRS has gained widespread popularity in many clinical settings in all age groups including neonates. However, more studies are required to establish the ability of NIRS monitoring to improve patient outcomes, especially in neonates. This review provides a comprehensive description of the use of NIRS in neonates.
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Abstract
OBJECTIVE To establish whether the use of near-infrared spectroscopy is potentially beneficial in high-risk cardiac infants in United Kingdom paediatric intensive care units. DESIGN A prospective observational pilot study. SETTING An intensive care unit in North West England. PATIENTS A total of 10 infants after congenital heart surgery, five with biventricular repairs and five with single-ventricle physiology undergoing palliation. INTERVENTIONS Cerebral and somatic near-infrared spectroscopy monitoring for 24 hours post-operatively in the intensive care unit. MEASUREMENT AND MAIN RESULTS Overall, there was no strong correlation between cerebral near-infrared spectroscopy and mixed venous oxygen saturation (r=0.48). At individual time points, the correlation was only strong (r=0.74) 1 hour after admission. The correlation was stronger for the biventricular patients (r=0.68) than single-ventricle infants (r=0.31). A strong inverse correlation was demonstrated between cerebral near-infrared spectroscopy and serum lactate at 3 of the 5 post-operative time points (1, 4, and 12 hours: r=-0.76, -0.72, and -0.69). The correlation was stronger when the cerebral near-infrared spectroscopy was <60%. For cerebral near-infrared spectroscopy <60%, the inverse correlation with lactate was r=-0.82 compared with those cerebral near-infrared spectroscopy >60%, which was r=-0.50. No correlations could be demonstrated between (average) somatic near-infrared spectroscopy and serum lactate (r=-0.13, n=110) or mixed venous oxygen saturation and serum lactate. There was one infant who suffered a cardiopulmonary arrest, and the cerebral near-infrared spectroscopy showed a consistent 43 minute decline before the event. CONCLUSIONS We found that cerebral near-infrared spectroscopy is potentially beneficial as a non-invasive, continuously displayed value and is feasible to use on cost-constrained (National Health Service) cardiac intensive care units in children following heart surgery.
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Neonatal limb ischemia: caudal blockade and NIRS monitoring. Eur J Pediatr 2014; 173:1599-601. [PMID: 24005341 DOI: 10.1007/s00431-013-2152-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Accepted: 08/13/2013] [Indexed: 10/26/2022]
Abstract
The treatment of neonatal limb ischemia (LI) is challenging for neonatologists. Peripheral nerve blockade (PNB), alone or in association with other therapies, represents a valid therapy in case of vascular spasm or thromboembolic events responsible for LI. In the present case report, we describe the clinical history of a preterm neonate with catheter-related thrombosis of the left leg. PNB was not performed according to the traditional technique but rather by a peridural catheter left in situ for 9 days with a continuous infusion of ropivacaine. In conclusion, the effectiveness of this approach was confirmed by the contemporary near-infrared spectroscopy monitoring, documenting gradual improvement of leg perfusion.
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Sheward VE, Murdoch IA, Durward A, Tibby SM. Neonatal decompensation before surgery in hypoplastic left heart syndrome: a case control study. Arch Dis Child Fetal Neonatal Ed 2014; 99:F468-74. [PMID: 25005313 DOI: 10.1136/archdischild-2013-305182] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Prior to Norwood 1 surgery, neonates with hypoplastic left heart syndrome (HLHS) are at risk of decompensation from systemic underperfusion secondary to pulmonary overcirculation. We examined whether preoperative temporal profiles of physiological and laboratory variables differed between neonates who did and did not decompensate preoperatively. DESIGN Case control study. SETTING Paediatric Intensive Care Unit, 2002-2013. PATIENTS Eighty-five neonates with HLHS, matched by birth weight and admission date. MEASUREMENTS Decompensation was defined as the need for emergency intubation and ventilation due to clinically diagnosed impaired systemic oxygen delivery. The end point was time of decompensation (cases, n=33) or discharge for surgery (controls, n=52). Variable trajectories were modelled non-linearly using generalised estimating equations. RESULTS Decompensation occurred on median (IQR) day 3 (2-4) of life in cases, with surgery occurring on day 4 (3-7) in controls. Oxygen saturation and blood pressure trajectories were identical between groups (p>0.2). Heart and respiratory rates increased with time overall, but significantly faster in cases than controls; by an average of 4.0 bpm/day versus 1.4 bpm/day (p=0.002) and 5.3 respirations/minute/day versus 1.5 respirations/minute/day, respectively, (p=0.003). Although metabolic blood gas components began to decline subtly 24 h before clinical decompensation, they remained in the normal range for much of this period. CONCLUSIONS Heart and respiratory rates, and metabolic acid base trajectories show subtle differences prior to decompensation in neonates with HLHS. These findings highlight the importance of evaluating rates of change rather than absolute values of physiological and laboratory variables.
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