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Chinawa JM, Chinawa AT, Ujunwa FA, Odimegwu CL, Onyia JT, Chukwu K, Chukwu BF, Aronu AE, Ikefuna A. Normalization of Cardiac Structural dimension and Function to Body Surface Area in South East Nigeria Children. Niger J Clin Pract 2024; 27:109-116. [PMID: 38317043 DOI: 10.4103/njcp.njcp_547_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 12/18/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND Standardizing cardiac valve structures and function to body surface area will help the clinician and surgeons in decision-making. AIM To evaluate the z-scores of the sizes of cardiac structures and function and to present them in Gaussian curves and reference values. MATERIALS AND METHODS This was a cross-sectional study that involved 300 apparently healthy children. This study was performed among healthy children from birth to 18 years. Children with a normal echocardiogram, those with no chronic illness, no congenital heart defect, and no acquired heart defect were included in the study. RESULT The majority fell within the normal limits, as shown in the Gaussian curves. For instance, 40 (13.3%) of atrioventricular (AV) valve diameters were +1 Z-score above the normal, and only 5 (1.7%) were +2 Z-score above the normal. About 9.3% (28/300) had below -2 Z-score below normal, while only 5% had -1 Z-score below normal. Similarly, the left ventricular function z-scores were also derived at -3 Z-scores to +3 Z-scores. The standard reference values were compared with the results obtained from our Z score values. There was no significant difference noted in the Z-scores. P values ranged from 0.07 to 0.84 for all the cardiac structures except for gender, where Z-scores of the mitral valve and left pulmonary artery varied significantly (P = 0.02). CONCLUSION Reference values of cardiac structure and function were presented using Z scores, and we noted no significant difference when compared with the Western standard values except for the mitral valve and left pulmonary artery.
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Affiliation(s)
- J M Chinawa
- Department of Paediatrics, College of Medicine, University of Nigeria Ituku/Ozalla and University of Nigeria Teaching Hospital Ituku/Ozalla Enugu State, Nigeria
| | - A T Chinawa
- Department of Community Medicine, ESUCOM, Parklane Enugu, Nigeria
| | - F A Ujunwa
- Department of Paediatrics, College of Medicine, University of Nigeria Ituku/Ozalla and University of Nigeria Teaching Hospital Ituku/Ozalla Enugu State, Nigeria
| | - C L Odimegwu
- Department of Paediatrics, College of Medicine, University of Nigeria Ituku/Ozalla and University of Nigeria Teaching Hospital Ituku/Ozalla Enugu State, Nigeria
| | - J T Onyia
- Department of Paediatrics, College of Medicine, University of Nigeria Ituku/Ozalla and University of Nigeria Teaching Hospital Ituku/Ozalla Enugu State, Nigeria
| | - K Chukwu
- Department of Paediatrics, College of Medicine, ESUCOM Parklane Enugu, Nigeria
| | - B F Chukwu
- Department of Paediatrics, College of Medicine, University of Nigeria Ituku/Ozalla and University of Nigeria Teaching Hospital Ituku/Ozalla Enugu State, Nigeria
| | - A E Aronu
- Department of Paediatrics, College of Medicine, University of Nigeria Ituku/Ozalla and University of Nigeria Teaching Hospital Ituku/Ozalla Enugu State, Nigeria
| | - A Ikefuna
- Department of Paediatrics, College of Medicine, University of Nigeria Ituku/Ozalla and University of Nigeria Teaching Hospital Ituku/Ozalla Enugu State, Nigeria
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Barone G, D'Andrea V, Ancora G, Cresi F, Maggio L, Capasso A, Mastroianni R, Pozzi N, Rodriguez-Perez C, Romitti MG, Tota F, Spagnuolo F, Raimondi F, Pittiruti M. The neonatal DAV-expert algorithm: a GAVeCeLT/GAVePed consensus for the choice of the most appropriate venous access in newborns. Eur J Pediatr 2023; 182:3385-3395. [PMID: 37195350 DOI: 10.1007/s00431-023-04984-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 04/11/2023] [Accepted: 04/15/2023] [Indexed: 05/18/2023]
Abstract
In most NICUs, the choice of the venous access device currently relies upon the operator's experience and preferences. However, considering the high failure rate of vascular devices in the neonatal population, such clinical choice has a critical relevance and should preferably be based on the best available evidence. Though some algorithms have been published over the last 5 years, none of them seems in line with the current scientific evidence. Thus, the GAVePed-which is the pediatric interest group of the most important Italian group on venous access, GAVeCeLT-has developed a national consensus about the choice of the venous access device in the neonatal population. After a systematic review of the available evidence, the panel of the consensus (which included Italian neonatologists specifically experts in this area) has provided structured recommendations answering four sets of questions regarding (1) umbilical venous catheters, (2) peripheral cannulas, (3) epicutaneo-cava catheters, and (4) ultrasound-guided centrally and femorally inserted central catheters. Only statements reaching a complete agreement were included in the final recommendations. All recommendations were also structured as a simple visual algorithm, so as to be easily translated into clinical practice. Conclusion: The goal of the present consensus is to offer a systematic set of recommendations on the choice of the most appropriate vascular access device in Neonatal Intensive Care Unit.
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Affiliation(s)
- Giovanni Barone
- Neonatal Intensive Care Unit, Infermi Hospital, AUSL Della Romagna, Viale Settembrini 2, Rimini, Italy.
| | - Vito D'Andrea
- Neonatal Intensive Care Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Gina Ancora
- Neonatal Intensive Care Unit, Infermi Hospital, AUSL Della Romagna, Viale Settembrini 2, Rimini, Italy
| | - Francesco Cresi
- Neonatology and Neonatal Intensive Care Unit, Sant'Anna Hospital, University of Turin, Città Della Salute E Della Scienza, Turin, Italy
| | - Luca Maggio
- Neonatology and Neonatal Intensive Care Unit, AO San Camillo Forlanini, Rome, Italy
| | - Antonella Capasso
- Neonatology and Neonatal Intensive Care Unit, A.O.U. Federico 2, Naples, Italy
| | | | - Nicola Pozzi
- Neonatal Intensive Care Unit, San Pio Hospital, Benevento, Italy
| | - Carmen Rodriguez-Perez
- Neonatology and Neonatal Intensive Care Unit, ASST Spedali Civili, Ospedale Dei Bambini, Brescia, Italy
| | | | - Francesca Tota
- Neonatal Intensive Care Unit, Ospedale S. Chiara, APSS, Trento, Italy
| | - Ferdinando Spagnuolo
- Neonatal Intensive Care Unit, AOU Università Degli Studi Della Campania "Luigi Vanvitelli", Naples, Italy
| | - Francesco Raimondi
- Neonatology and Neonatal Intensive Care Unit, A.O.U. Federico 2, Naples, Italy
| | - Mauro Pittiruti
- Department of Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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Evaluation of the Hypotensive Preterm Infant: Evidence-Based Practice at the Bedside? CHILDREN 2023; 10:children10030519. [PMID: 36980077 PMCID: PMC10047557 DOI: 10.3390/children10030519] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 02/28/2023] [Accepted: 02/28/2023] [Indexed: 03/09/2023]
Abstract
Choosing the appropriate management approach for the preterm infant with low blood pressure during the transition period generally involved intervening when the blood pressure drifted below a certain threshold. It is now clear that this approach is too simplistic and does not address the underlying physiology. In this chapter, we explore the many monitoring tools available for evaluation of the hypotensive preterm and assess the evidence base supporting or refuting their use. The key challenge relates to incorporating these outputs with the clinical status of the patient and choosing the appropriate management strategy.
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Noori S, Seri I. Hypotension and significant patent ductus arteriosus in infants born extremely preterm during the postnatal transitional period: normal adaptation? J Pediatr 2022; 240:314-315. [PMID: 34555378 DOI: 10.1016/j.jpeds.2021.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 09/15/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Shahab Noori
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Istvan Seri
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California; First Department of Pediatrics, Semmelweis University, Faculty of Medicine, Budapest, Hungary
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Advances in Neonatal Critical Care: Pushing at the Boundaries and Connecting to Long-Term Outcomes. Crit Care Med 2021; 49:2003-2016. [PMID: 34380942 DOI: 10.1097/ccm.0000000000005251] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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de Waal K, Kluckow M. Superior vena cava flow: Role, assessment and controversies in the management of perinatal perfusion. Semin Fetal Neonatal Med 2020; 25:101122. [PMID: 32467039 DOI: 10.1016/j.siny.2020.101122] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The superior vena cava (SVC) is a large vein responsible for the venous return of blood from structures located superior to the diaphragm. The flow in the SVC can be assessed with Doppler ultrasound and can be used as a proxy for cerebral perfusion. Early clinical research studies showed that low SVC flow, particularly if for a prolonged period, was associated with short term morbidity such as intraventricular hemorrhage, mortality, and poorer neurodevelopmental outcomes. However, these findings have not been consistently reported in more recent studies, and the role of SVC flow in early management and as a predictor of poor long-term neurodevelopment has been questioned. This paper provides an overview of SVC assessment, the expected range of findings, and reviews the role of SVC flow as a diagnostic and monitoring tool for the assessment of perinatal perfusion.
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Affiliation(s)
- Koert de Waal
- John Hunter Children's Hospital Department of Neonatology and University of Newcastle, Newcastle, NSW, Australia.
| | - Martin Kluckow
- Royal North Shore Hospital Department of Neonatology and University of Sydney, Sydney, NSW, Australia
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Hummler H. Near-Infrared spectroscopy for perfusion assessment and neonatal management. Semin Fetal Neonatal Med 2020; 25:101145. [PMID: 32830077 DOI: 10.1016/j.siny.2020.101145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Term and preterm infants often present with adverse conditions after birth resulting in abnormal vital functions and severe organ failure, which are associated or sometimes caused by low oxygen and/or blood supply. Brain injury may lead to substantial mortality and morbidity often affecting long-term outcome. Standard monitoring techniques in the NICU focus on arterial oxygen supply and hemodynamics and include respiratory rate, heart rate, blood pressure and arterial oxygen saturation as measured by pulse oximetry but provide only limited information on end organ oxygen delivery. Near-Infrared Spectroscopy can bridge this gap by displaying continuous measurements of tissue oxygen saturation, providing information on the balance of oxygen delivery and consumption in organs of interest. Future techniques using multi-wavelength devices may provide additional information on oxidative metabolism in real time adding important information.
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Affiliation(s)
- Helmut Hummler
- Chief Division of Neonatology, Department of Pediatrics, Sidra Medicine, Al Gharrafa Street, Ar-Rayyan, PO Box 26999, Doha, Qatar; Professor of Pediatrics, Weill Cornell Medicine Qatar, Professor of Pediatrics adj. Ulm University, Germany.
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8
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Cerebral Circulation and Hypotension in the Premature Infant. Neurology 2019. [DOI: 10.1016/b978-0-323-54392-7.00001-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Abstract
Hemodynamic instability is frequent in high-risk infants admitted to neonatal intensive care units. However, monitoring and treatment strategies of those conditions might show variations among the units. Different factors can compromise hemodynamic status in preterm/ term infants. Treatment options mostly include volume replacement, inotropes and/or vasopressors (dopamine, dobutamine, epinephrine and milrinone) and hydrocortisone. In general, these treatments are driven by predetermined protocols, which are not patient-based. According to the current knowledge, a physiology-driven approach that takes the individual characteristics of the newborn into consideration is accepted to be more suitable. In neonatal hemodynamics, important determinants are cardiac output, systemic vascular resistance, blood pressure, regional tissue perfusion and oxygenation. The novel technological methods, "targeted neonatal echocardiography" and "near-infrared spectroscopy" can help to delineate the underlying pathophysiology better, when added to the clinical assessment. In this review, strategies for the assessment of neonatal hemodynamics, as well as etiology, monitoring, and treatment of hemodynamic instability in preterm and term infants are presented.
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Affiliation(s)
- Dilek Dilli
- Department of Neonatology, University of Health Sciences, Dr. Sami Ulus Maternity and Children's Training and Research Hospital, Ankara, Turkey
| | - Hanifi Soylu
- Division of Neonatology, Department of Pediatrics, Selçuk University, Faculty of Medicine, Konya, Turkey
| | - Neslihan Tekin
- Division of Neonatology, Department of Pediatrics, Eskişehir Osmangazi University, Faculty of Medicine, Eskişehir, Turkey
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Left ventricular pumping during the transition-adaptation sequence in preterm infants: impact of the patent ductus arteriosus. Pediatr Res 2018. [PMID: 29538367 DOI: 10.1038/pr.2018.22] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BackgroundPostnatally, the immature left ventricle (LV) is subjected to high systemic afterload. Hypothesizing that LV pumping would change during transition-adaptation, we analyzed the LV in preterm infants (GA≤32+6), clinically stable or with a hemodynamically significant patent ductus arteriosus (hPDA) by applying a pump model.MethodsPumping was characterized by EA (effective arterial elastance, reflecting afterload), EES (end-systolic LV elastance, reflecting contractility), EA/EES coupling ratios, descriptive EA:EES relations, and EA/EES graphs. Data calculated from echocardiography and blood pressure were analyzed by diagnosis (S group: clinically stable, no hPDA, n=122; hPDA group, n=53) and by periods (early transition: days of life 1-3; late transition: 4-7; and adaptation: 8-30).ResultsS group: LV pumping was characterized by an increased EA/EES coupling ratio of 0.65 secondary to low EES in early transition, a tandem rise of both EA and EES in late transition, and an EA/EES coupling ratio of 0.45 secondary to high EES in adaptation; hPDA group: time-trend analyses showed significantly lower EA (P<0.0001) and EES (P=0.006). Therefore, LV pumping was characterized by a lower EA/EES coupling ratio (P=0.088) throughout transition-adaptation.ConclusionsIn stable infants, facing high afterload, the immature LV, enhanced by the physiological PDA, increases its contractility. In hPDA, facing low afterload, the overloaded immature LV exhibits a consistently lower contractility.
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Rios DR, Bhattacharya S, Levy PT, McNamara PJ. Circulatory Insufficiency and Hypotension Related to the Ductus Arteriosus in Neonates. Front Pediatr 2018; 6:62. [PMID: 29600242 PMCID: PMC5863525 DOI: 10.3389/fped.2018.00062] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Accepted: 03/02/2018] [Indexed: 12/12/2022] Open
Abstract
The biological role of the ductus arteriosus (DA) in neonates varies from an innocent bystander role during normal postnatal transition, to a supportive role when there is compromise to either systemic or pulmonary blood flow, to a pathological state in the presence of hemodynamically significant systemic to pulmonary shunts, as occurs in low birth weight infants. Among a wide array of clinical manifestations arising due to the ductal entity, systemic circulatory insufficiency and hypotension are of significant concern as they are particularly challenging to manage. An understanding of the physiologic interplay between the DA and the circulatory system is the key to developing appropriate targeted therapeutic strategies. In this review, we discuss the relationship of systemic hypotension to the DA, emphasizing the importance of critical thinking and a precise individual approach to intensive care support. We particularly focus on the variable states of hypotension arising directly due to a hemodynamically significant DA or seen in the period following successful surgical ligation. In addition, we explore the mechanistic contributions of the ductus to circulatory insufficiency that may manifest during the transitional period, states of maladapted transition (such as acute pulmonary hypertension of the newborn), and congenital heart disease (both ductal dependent and non-ductal dependent lesions). Understanding the dynamic modulator role of the ductus according to the ambient physiology enables a more precise approach to management. We review the pathophysiology, clinical manifestations, diagnosis, monitoring, and therapeutic intervention for the spectrum of DA-related circulatory compromise.
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Affiliation(s)
- Danielle R. Rios
- Section of Neonatology, Department of Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, United States
| | - Soume Bhattacharya
- Division of Neonatology, Department of Paediatrics, Western University, London, ON, Canada
| | - Philip T. Levy
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, Saint Louis, MI, United States
| | - Patrick J. McNamara
- Division of Neonatology, Department of Paediatrics and Physiology, University of Toronto, Toronto, ON, Canada
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Tissot C, Singh Y, Sekarski N. Echocardiographic Evaluation of Ventricular Function-For the Neonatologist and Pediatric Intensivist. Front Pediatr 2018; 6:79. [PMID: 29670871 PMCID: PMC5893826 DOI: 10.3389/fped.2018.00079] [Citation(s) in RCA: 88] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 03/14/2018] [Indexed: 12/27/2022] Open
Abstract
In the neonatal and pediatric intensive care setting, bedside cardiac ultrasound is often used to assess ventricular dimensions and function. Depending upon the underlying disease process, it is necessary to be able to evaluate the systolic and diastolic function of left and or right ventricles. The systolic function of left ventricle is mostly assessed qualitatively on visual inspection "eye-balling" and quantitatively by measuring circumferential fraction shortening or calculating the ejection fraction by Simpson's planimetry. The assessment of left ventricular diastolic function relies essentially on the mitral valve and pulmonary venous Doppler tracings or tissue Doppler evaluation. The right ventricular particular shape and anatomical position does not permit to use the same parameters for measuring systolic function as is used for the LV. Tricuspid annular plane systolic excursion (TAPSE) and S' velocity on tissue Doppler imaging are more often used for quantitative assessment of right ventricle systolic function. Several parameters proposed to assess right ventricle systolic function such as fractional area change, 3D echocardiography, speckle tracking, and strain rate are being researched and normal values for children are being established. Diastolic function of right ventricle is evaluated by tricuspid valve and hepatic venous Doppler tracings or on tissue Doppler evaluation. The normal values for children are pretty similar to adults while normal values for the neonates, especially preterm infants, may differ significantly from adult population. The normal values for most of the parameters used to assess cardiac function in term neonates and children have now been established.
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Affiliation(s)
- Cécile Tissot
- Centre de Pediatrie, Clinique des Grangettes, Geneva, Switzerland
| | - Yogen Singh
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Nicole Sekarski
- Pediatric Cardiology Unit, Department of Pediatrics, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
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Abstract
Maintaining optimal circulatory status is a key component of preterm neonatal care. Low-cardiac output (CO) in the preterm neonate leads to inadequate perfusion of vital organs and has been linked to a variety of adverse outcomes with heightened acute morbidity and mortality and adverse neurodevelopmental outcomes. Having technology available to monitor CO allows us to detect low-output states and potentially intervene to mitigate the unwanted effects of reduced organ perfusion. There are many technologies available for the monitoring of CO in the preterm neonatal population and while many act as useful adjuncts to aid clinical decision-making no technique is perfect. In this review, we discuss the relative merits and limitations of various common methodologies available for monitoring CO in the preterm neonatal population. We will discuss the ongoing challenges in monitoring CO in the preterm neonate along with current gaps in our knowledge. We conclude by discussing emerging technologies and areas that warrant further study.
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Affiliation(s)
- Matthew McGovern
- Neonatology Department, Coombe Women and Infant University Hospital, Dublin, Ireland.,Department of Paediatrics, Trinity College Dublin, National Children's Hospital Tallaght, Dublin, Ireland
| | - Jan Miletin
- Neonatology Department, Coombe Women and Infant University Hospital, Dublin, Ireland.,Institute for the Care of Mother and Child, Prague, Czechia.,3rd School of Medicine, Charles University, Prague, Czechia.,UCD School of Medicine and Medical Sciences, Dublin, Ireland
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14
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Peeples ES, Mehic E, Mourad PD, Juul SE. Fast Doppler as a novel bedside measure of cerebral perfusion in preterm infants. Pediatr Res 2016; 79:333-8. [PMID: 26539662 DOI: 10.1038/pr.2015.227] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Accepted: 08/12/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND Altered cerebral perfusion from impaired autoregulation may contribute to the morbidity and mortality associated with premature birth. We hypothesized that fast Doppler imaging could provide a reproducible bedside estimation of cerebral perfusion and autoregulation in preterm infants. METHODS This is a prospective pilot study using fast Doppler ultrasound to assess blood flow velocity in the basal ganglia of 19 subjects born at 26-32 wk gestation. Intraclass correlation provided a measure of test-retest reliability, and linear regression of cerebral blood flow velocity and heart rate or blood pressure allowed for estimations of autoregulatory ability. RESULTS The intraclass correlation when imaging in the first 48 h of life was 0.634. We found significant and independent correlations between the systolic blood flow velocity and both systolic blood pressure and heart rate (P = 0.015 and 0.012 respectively) only in the 26-28 wk gestational age infants in the first 48 h of life. CONCLUSION Our results suggest that fast Doppler provides reliable bedside measurements of cerebral blood flow velocity at the tissue level in premature infants, acting as a proxy for cerebral tissue perfusion. Additionally, autoregulation appears to be impaired in the extremely preterm infants, even within a normal range of blood pressures.
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Affiliation(s)
- Eric S Peeples
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - Edin Mehic
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Pierre D Mourad
- Department of Neurological Surgery, University of Washington, Seattle, Washington.,Division of Engineering and Mathematics, University of Washington, Seattle, Washington
| | - Sandra E Juul
- Department of Pediatrics, University of Washington, Seattle, Washington
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