Recognition and management of neonatal hemodynamic compromise

A recommendation for the use of electrical biosensing technology in neonatology

Non-invasive cardiac output monitoring, via electrical biosensing technology (EBT), provides continuous, multi-parameter hemodynamic variable monitoring which may allow for timely identification of hemodynamic instability in some neonates, providing an opportunity for early intervention that may improve neonatal outcomes. EBT encompasses thoracic (TEBT) and whole body (WBEBT) methods. Despite the lack of relative accuracy of these technologies, as compared to transthoracic echocardiography, the use of these technologies in neonatology, both in the research and clinical arena, have increased dramatically over the last 30 years. The European Society of Pediatric Research Special Interest Group in Non-Invasive Cardiac Output Monitoring, a group of experienced neonatologists in the field of EBT, deemed it appropriate to provide recommendations for the use of TEBT and WBEBT in the field of neonatology. Although TEBT is not an accurate determinant of cardiac output or stroke volume, it may be useful for monitoring longitudinal changes of hemodynamic parameters. Few recommendations can be made for the use of TEBT in common neonatal clinical conditions. It is recommended not to use WBEBT to monitor cardiac output. The differences in technologies, study methodologies and data reporting should be addressed in ongoing research prior to introducing EBT into routine practice. IMPACT STATEMENT: TEBT is not recommended as an accurate determinant of cardiac output (CO) (or stroke volume (SV)). TEBT may be useful for monitoring longitudinal changes from baseline of hemodynamic parameters on an individual patient basis. TEBT-derived thoracic fluid content (TFC) longitudinal changes from baseline may be useful in monitoring progress in respiratory disorders and circulatory conditions affecting intrathoracic fluid volume. Currently there is insufficient evidence to make any recommendations regarding the use of WBEBT for CO monitoring in neonates. Further research is required in all areas prior to the implementation of these monitors into routine clinical practice.

Hemodynamic assessment by neonatologist using echocardiography: Primary provider versus consultation model

Hemodynamic instability is very common in sick neonates and the currently used traditional hemodynamic monitoring tools lack sensitivity and specificity. Hemodynamic evaluation on echocardiography can provide direct information regarding the pathophysiology causing the hemodynamic instability and help the bedside clinician in making a personalized treatment approach based upon the deranged pathophysiology. Assessment of cardiac function and hemodynamics is essential in the management of neonates with cardiorespiratory failure, and hence neonatologist-performed echocardiography is becoming an essential tool in modern neonatal care. Depending on the level and size of the NICU, there is a daily need for echocardiography, and for a subset of sick infants, serial echocardiographic assessments are warranted. Comprehensive guidelines for neonatologists performing echocardiography and targeted neonatal echocardiography have been published providing a framework for training and quality assurance. There has been a significant interest among the providers to learn echocardiography skills. This manuscript explores the various needs of neonatal care providers around echocardiography, the current challenges neonatologists face in learning echocardiography, and how they, especially neonatal fellows, can learn these important skills during their training.

A Nomogram for Predicting Surgical Risk in Neonates with Necrotizing Enterocolitis: A Retrospective Cohort Study

OBJECTIVES

To construct a nomogram that predicts the risk of surgery in patients with necrotizing enterocolitis (NEC).

METHODS

This retrospective cohort study recruited patients diagnosed with NEC at the Children's Hospital of Soochow University from 2013 to 2023. The neonates were divided into conservative and surgical-treatment groups. Univariate and multivariate logistic regressions were performed to identify factors influencing surgical risk, and a predictive model was constructed.

RESULTS

This study comprised 154 cases of NEC, 103 cases (66.9%) in the conservative group and 51 cases (33.1%) in the surgical group. Multivariate logistic regression analysis revealed that increased bloody stools [odds ratio (OR) 5.066; 95% confidence interval (CI) 1.7396-14.7532; p = 0.0029), oxygen inhalation (OR 1.8278; 95% CI 1.2113-2.7581; p = 0.0041), use of vasoconstrictors (OR 4.4446; 95% CI 1.7157-11.5137; p = 0.0021), portal venous gas (OR 4.5569; 95% CI 1.6324-12.7209; p = 0.0038), and blood sodium (OR 0.8339; 95% CI 0.7477-0.9301; p = 0.0011) were independent factors of surgical risk. The area under the nomogram's receiver operating characteristic (ROC) curve was 0.886. Decision curve analysis (DCA) and calibration curves demonstrated good predictive performance for the nomogram.

CONCLUSIONS

The nomogram effectively assessed the risk of surgical intervention in NEC patients, providing new insights and references for diagnosing and treating NEC.

[Risk factors and prognosis of hypotension within 72 hours after birth in extremely preterm infants]

OBJECTIVES

To investigate the risk factors and prognosis of hypotension within 72 hours after birth in extremely preterm infants.

METHODS

A retrospective analysis was conducted on clinical data of extremely preterm infants admitted to the Children's Hospital of Zhejiang University School of Medicine from January 2019 to April 2022. Based on the presence of hypotension within 72 hours after birth, the eligible infants were divided into a hypotension group (41 cases) and a normotension group (82 cases). The clinical characteristics, echocardiographic parameters within 72 hours after birth, and early complications were compared between the two groups. Multivariate logistic regression analysis was used to explore the risk factors for hypotension within 72 hours after birth, and receiver operating characteristic curve analysis was performed to evaluate the predictive value of relevant indicators for the occurrence of hypotension within 72 hours after birth in the preterm infants.

RESULTS

The proportion of infants who required medication or surgical closure of patent ductus arteriosus (PDA), the proportions of infants with intraventricular hemorrhage ≥ grade III and severe pulmonary hemorrhage, and the mortality rate within 7 days in the hypotension group were significantly higher than those in the normotension group (P<0.05). Multivariate logistic regression analysis showed that lower birth weight, larger PDA diameter, and hemodynamically significant PDA were risk factors for the occurrence of hypotension within 72 hours after birth in extremely preterm infants (P<0.05). The receiver operating characteristic curve analysis showed that the combination of birth weight, PDA diameter, and hemodynamically significant PDA had an area under the curve of 0.873 (95%CI: 0.802-0.944, P<0.05) for predicting hypotension within 72 hours after birth, with a sensitivity of 73.2% and specificity of 91.5%.

CONCLUSIONS

Hypotension within 72 hours after birth is closely related to birth weight and PDA, and increases the risk of early severe complications and mortality in extremely preterm infants.

Effect of assessing velocity time integral at different locations across ventricular outflow tracts when calculating cardiac output in neonates

This study aims to evaluate the effect of assessing velocity time integral at different locations across ventricular outflow tracts for calculating cardiac output (CO) in neonates. Velocity time integral (VTI) and CO were measured at 3 different locations across right and left ventricular outflow tracts using transthoracic echocardiography in healthy term neonates without any major congenital heart disease. ANOVA with Bonferroni correction was used to determine the differences between the VTI and CO sampled at these three locations. Forty-one neonates met inclusion criteria with mean gestational age of 38.6 ± 1 weeks and mean birth weight of 3155 ± 463 g. The median hours after birth when echocardiography was obtained was 23 h (range 11-68 h after birth). Left CO were 121 ± 30 mL/kg/min, 155 ± 38 mL/kg/min, and 176 ± 36 mL/kg/min measured below the valve, hinges of the valve, and tip of the valve, respectively. Right CO were 197 ± 73 mL/kg/min, 270 ± 83 mL/kg/min, and 329 ± 104 mL/kg/min measured below the valve, hinges of the valve, and tip of the valve, respectively. A statistically significant difference (P < 0.001) was found in the VTI and CO measured at the 3 different locations across both left and right ventricular outflow tracts.     Conclusions: There is a significant difference in measurements of VTI and CO depending on the location of Doppler gate sampling across the ventricular outflow tracts. Consistency and precision in Doppler gate location are essential for measuring VTI and calculating CO while assessing changes in hemodynamic status in critically ill infants. What is Known: • Targeted Neonatal Echocardiography is increasingly applied to measure cardiac output in critically ill neonates and serial assessments are performed to assess the trend in changes in cardiac output. • Noninvasive measurement using velocity time integral to calculate cardiac output is commonly performed. However, location of Doppler sample gate to measure ventricular outflow tract velocity time integral is not consistent. What is New: • Statistically significant changes in measured velocity time integral and cardiac output are noted based on the location of Doppler gate sampling. • To monitor the cardiac output for trending, it is important to be consistent with regards to the location of the Doppler sample gate to assess changes in cardiac output in critically ill newborns.

Relationship between cerebral oxygenation, cardiac output, and blood pressure during transitional period in extremely low gestational age neonates

Objective

To describe the relationship between cerebral oxygenation, cardiac output, arterial blood pressure (BP), and cerebral blood flow velocity in extremely low gestational age neonates (ELGANs) during transition.

Methods

This study comprises secondary analyses from a prospective observational study conducted at a tertiary Neonatal Intensive Care Unit. Recruited ELGANs underwent cerebral saturation (CrSO2) monitoring and serial echocardiography during 72 h from birth. Correlative analyses of CrSO2 and cerebral fractional tissue oxygen extraction (CFTOE) with left (LVO) and right ventricular output (RVO), superior vena cava (SVC) flow, middle cerebral artery blood flow mean velocity (MCA.MV), systolic (SBP), diastolic (DBP), and mean (MBP) BP were conducted.

Results

Fifty ELGANs with median (range) gestational age of 25.9 (23.1-27.9) weeks were recruited. Echocardiography was performed sequentially at a median (range) age 5.0 (3.8-6.6), 17.3 (15.4-19.4), 31.0 (27.0-34.1), and 53.7 (49.3-58.3) hours. RVO, LVO, CrSO2, and SBP increased over time but no changes in MBP, DBP, CFTOE, MCA.MV or SVC flow were noted. A weak correlation was identified between CrSO2 and SBP (r2 = 0.11, p = 0.047) and MBP (r2 = 0.12, p = 0.04) at 17.3 (15.4-19.4) hours. No correlation of either CrSO2 or CFTOE with any measures of blood flow was identified.

Conclusion

There is a weak correlation between measures of cardiac output, BP, and MCA.MV with both CrSO2 and CFTOE in ELGANs during transition. Whether this finding suggests intact cerebral autoregulation requires prospective evaluation in a cohort of sick ELGANs.

Efficacy and Safety of Vasopressin and Terlipressin in Preterm Neonates: A Systematic Review

INTRODUCTION

The use of arginine vasopressin (AVP) and terlipressin to treat hypotension in preterm neonates is increasing. Our aim was to review the available evidence on the efficacy and safety of AVP and terlipressin for use in preterm neonates.

METHODS

MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, Web of Science, and Google Scholar from inception to September 2021 were searched for studies of AVP and terlipressin in the treatment of hypotension of any cause in preterm neonates. Primary outcomes were improvement in end-organ perfusion and mortality. The risk of bias assessment and certainty of the evidence were performed using appropriate tools.

RESULTS

Fifteen studies describing the use of AVP (n = 12) or terlipressin (n = 3) among 148 preterm neonates were included. Certainly, the available evidence for the primary outcome of end-organ perfusion rated as very low. AVP or terlipressin were used to treat 144 and 4 neonates, respectively. Improvement in markers of end-organ perfusion was reported in 143 (99%) neonates treated with AVP and 3 (75%) treated with terlipressin. The mortality rate was 41% (n = 59) and 50% (n = 2) for neonates who received AVP and terlipressin, respectively. Hyponatremia was the most frequently reported adverse event (n = 37, 25%).

CONCLUSION

AVP and terlipressin may improve measured blood pressure values and possibly end-organ perfusion among neonates with refractory hypotension. However, the efficacy-safety balance of these drugs should be assessed on an individual basis and as per the underlying cause. Studies on the optimal dosing, efficacy, and safety of AVP and terlipressin in preterm neonates with variable underlying conditions are critically needed.

Engineering nano-drug biointerface to overcome biological barriers toward precision drug delivery

The rapid advancement of nanomedicine and nanoparticle (NP) materials presents novel solutions potentially capable of revolutionizing health care by improving efficacy, bioavailability, drug targeting, and safety. NPs are intriguing when considering medical applications because of their essential and unique qualities, including a significantly higher surface to mass ratio, quantum properties, and the potential to adsorb and transport drugs and other compounds. However, NPs must overcome or navigate several biological barriers of the human body to successfully deliver drugs at precise locations. Engineering the drug carrier biointerface can help overcome the main biological barriers and optimize the drug delivery in a more personalized manner. This review discusses the significant heterogeneous biological delivery barriers and how biointerface engineering can promote drug carriers to prevail over hurdles and navigate in a more personalized manner, thus ushering in the era of Precision Medicine. We also summarize the nanomedicines' current advantages and disadvantages in drug administration, from natural/synthetic sources to clinical applications. Additionally, we explore the innovative NP designs used in both non-personalized and customized applications as well as how they can attain a precise therapeutic strategy.