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Chesi E, Rossi K, Ancora G, Baraldi C, Corradi M, Di Dio F, Di Fazzio G, Galletti S, Mescoli G, Papa I, Solinas A, Braglia L, Di Caprio A, Cuoghi Costantini R, Miselli F, Berardi A, Gargano G. Patent ductus arteriosus (also non-hemodynamically significant) correlates with poor outcomes in very low birth weight infants. A multicenter cohort study. PLoS One 2024; 19:e0306769. [PMID: 38980835 PMCID: PMC11233010 DOI: 10.1371/journal.pone.0306769] [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: 09/18/2023] [Accepted: 06/24/2024] [Indexed: 07/11/2024] Open
Abstract
OBJECTIVES To standardize the diagnosis of patent ductus arteriosus (PDA) and report its association with adverse neonatal outcomes in very low birth weight infants (VLBW, birth weight < 1500 g). STUDY DESIGN A multicenter prospective observational study was conducted in Emilia Romagna from March 2018 to October 2019. The association between ultrasound grading of PDA and adverse neonatal outcomes was evaluated after correction for gestational age. A diagnosis of hemodynamically significant PDA (hsPDA) was established when the PDA diameter was ≥ 1.6 mm at the pulmonary end with growing or pulsatile flow pattern, and at least 2 of 3 indexes of pulmonary overcirculation and/or systemic hypoperfusion were present. RESULTS 218 VLBW infants were included. Among infants treated for PDA closure in the first postnatal week, up to 40% did not have hsPDA on ultrasound, but experienced clinical worsening. The risk of death was 15 times higher among neonates with non-hemodynamically significant PDA (non-hsPDA) compared to neonates with no PDA. In contrast, the risk of death was similar between neonates with hsPDA and neonates with no PDA. The occurrence of BPD was 6-fold higher among neonates with hsPDA, with no apparent beneficial role of early treatment for PDA closure. The risk of IVH (grade ≥ 3) and ROP (grade ≥ 3) increased by 8.7-fold and 18-fold, respectively, when both systemic hypoperfusion and pulmonary overcirculation were present in hsPDA. CONCLUSIONS The increased risk of mortality in neonates with non-hsPDA underscores the potential inadequacy of criteria for defining hsPDA within the first 3 postnatal days (as they may be adversely affected by other clinically severe factors, i.e. persistent pulmonary hypertension and mechanical ventilation). Parameters such as length, diameter, and morphology may serve as more suitable ultrasound indicators during this period, to be combined with clinical data for individualized management. Additionally, BPD, IVH (grade ≥ 3) and ROP (grade ≥ 3) are associated with hsPDA. The existence of an optimal timeframe for closing PDA to minimize these adverse neonatal outcomes remains uncertain.
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Affiliation(s)
- Elena Chesi
- Neonatal Intensive Care Unit, Department of Obstetrics and Pediatrics, IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Katia Rossi
- Neonatal Intensive Care Unit, Women's and Children's Health Department, University Hospital of Modena, Modena, Italy
| | - Gina Ancora
- Neonatal Intensive Care Unit, Infermi Hospital, Rimini, Italy
| | - Cecilia Baraldi
- Neonatal Intensive Care Unit, Women's and Children's Health Department, University Hospital of Modena, Modena, Italy
| | - Mara Corradi
- Neonatal Intensive Care Unit, Women's and Children's Health Department, AOUP, University of Parma, Parma, Italy
| | - Francesco Di Dio
- Neonatal Intensive Care Unit, Department of Obstetrics and Pediatrics, IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Giorgia Di Fazzio
- Neonatal Intensive Care Unit, ARNAS Garibaldi Hospital, Catania, Italy
| | - Silvia Galletti
- Neonatal Intensive Care Unit, Women's and Children's Health Department, University Hospital Sant'Orsola-Malpighi, Bologna, Italy
| | - Giovanna Mescoli
- Neonatal Intensive Care Unit, Women's and Children's Health Department, Maggiore University Hospital, Bologna, Italy
| | - Irene Papa
- Neonatal Intensive Care Unit, Infermi Hospital, Rimini, Italy
| | - Agostina Solinas
- Neonatal Intensive Care Unit, University Hospital S.Anna, Ferrara, Italy
| | | | - Antonella Di Caprio
- School of Pediatrics Residency, University of Modena and Reggio Emilia, Modena, Italy
| | - Riccardo Cuoghi Costantini
- Department of Medical and Surgical Sciences for Mother, Child and Adult, University of Modena and Reggio Emilia, Modena, Italy
| | - Francesca Miselli
- Neonatal Intensive Care Unit, Women's and Children's Health Department, University Hospital of Modena, Modena, Italy
- PhD Program in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Alberto Berardi
- Neonatal Intensive Care Unit, Women's and Children's Health Department, University Hospital of Modena, Modena, Italy
| | - Giancarlo Gargano
- Neonatal Intensive Care Unit, Department of Obstetrics and Pediatrics, IRCCS di Reggio Emilia, Reggio Emilia, Italy
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2
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Smolich JJ, Kenna KR, Mynard JP. Extended period of ventilation before delayed cord clamping augments left-to-right shunting and decreases systemic perfusion at birth in preterm lambs. J Physiol 2024; 602:1791-1813. [PMID: 38532618 DOI: 10.1113/jp285799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 02/26/2024] [Indexed: 03/28/2024] Open
Abstract
Previous studies have suggested that an extended period of ventilation before delayed cord clamping (DCC) augments birth-related rises in pulmonary arterial (PA) blood flow. However, it is unknown whether this greater rise in PA flow is accompanied by increases in left ventricular (LV) output and systemic arterial perfusion or whether it reflects enhanced left-to-right shunting across the ductus arteriosus and/or foramen ovale (FO), with decreased systemic arterial perfusion. Using an established preterm lamb birth transition model, this study compared the effect of a short (∼40 s, n = 11), moderate (∼2 min, n = 11) or extended (∼5 min, n = 12) period of initial mechanical lung ventilation before DCC on flow probe-derived perinatal changes in PA flow, LV output, total systemic arterial blood flow, ductal shunting and FO shunting. The LV output was relatively stable during initial ventilation but increased after DCC, with similar responses in all groups. Systemic arterial flow patterns displayed only minor differences during brief and moderate periods of initial ventilation and were similar after DCC. However, an increase in PA flow was augmented with an extended initial ventilation (P < 0.001), owing to an earlier onset of left-to-right ductal and FO shunting (P < 0.001), and was accompanied by a pronounced reduction in total systemic arterial flow (P = 0.005) that persisted for 4 min after DCC (P ≤ 0.039). These findings suggest that, owing to increased left-to-right shunting and a greater reduction in systemic arterial perfusion, an extended period of ventilation before DCC does not result in greater perinatal circulatory benefits than shorter periods of initial ventilation in the birth transition. KEY POINTS: Previous studies suggest that an extended period of initial ventilation before delayed cord clamping (DCC) augments birth-related rises in pulmonary arterial (PA) blood flow. It is unknown whether this greater rise in PA flow is accompanied by an increased left ventricular output and systemic arterial perfusion or whether it reflects enhanced left-to-right shunting across the ductus arteriosus and/or foramen ovale, with decreased systemic arterial perfusion. Anaesthetized preterm fetal lambs instrumented with central arterial flow probes underwent a brief (∼40 s), moderate (∼2 min) or extended (∼5 min) period of ventilation before DCC. Perinatal changes in left ventricular output were similar in all groups, but extended initial ventilation augmented both perinatal increases in PA flow, owing to earlier onset and greater left-to-right ductal and foramen ovale shunting, and perinatal reductions in total systemic arterial perfusion. Extended ventilation before DCC does not confer a greater perinatal circulatory benefit than shorter periods of initial ventilation.
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Affiliation(s)
- Joseph J Smolich
- Heart Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Kelly R Kenna
- Heart Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Jonathan P Mynard
- Heart Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
- Department of Biomedical Engineering, University of Melbourne, Parkville, Victoria, Australia
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3
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Surak A, Lalitha R, Bitar E, Hyderi A, Hicks M, Cheung PY, Kumaran K. Multimodal Assessment of Systemic Blood Flow in Infants. Neoreviews 2022; 23:e486-e496. [PMID: 35773505 DOI: 10.1542/neo.23-7-e486] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The assessment of systemic blood flow is a complex and comprehensive process with clinical, laboratory, and technological components. Despite recent advancements in technology, there is no perfect bedside tool to quantify systemic blood flow in infants that can be used for clinical decision making. Each option has its own merits and limitations, and evidence on the reliability of these physiology-based assessment processes is evolving. This article provides an extensive review of the interpretation and limitations of methods to assess systemic blood flow in infants, highlighting the importance of a comprehensive and multimodal approach in this population.
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Affiliation(s)
- Aimann Surak
- Division of Neonatology, Stollery Children's Hospital, Edmonton, AB, Canada
| | - Renjini Lalitha
- Division of Neonatology, London Health Sciences Centre, London, ON, Canada
| | - Eyad Bitar
- Division of Neonatology, Stollery Children's Hospital, Edmonton, AB, Canada
| | - Abbas Hyderi
- Division of Neonatology, Stollery Children's Hospital, Edmonton, AB, Canada
| | - Matt Hicks
- Division of Neonatology, Stollery Children's Hospital, Edmonton, AB, Canada
| | - Po Yin Cheung
- Division of Neonatology, Stollery Children's Hospital, Edmonton, AB, Canada.,Department of Pharmacology and Surgery, University of Alberta, Edmonton, AB, Canada.,Centre for the Studies of Asphyxia and Resuscitation, Edmonton, AB, Canada
| | - Kumar Kumaran
- Division of Neonatology, Stollery Children's Hospital, Edmonton, AB, Canada
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Aldana-Aguirre JC, Deshpande P, Jain A, Weisz DE. Physiology of Low Blood Pressure During the First Day After Birth Among Extremely Preterm Neonates. J Pediatr 2021; 236:40-46.e3. [PMID: 34019882 DOI: 10.1016/j.jpeds.2021.05.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 04/09/2021] [Accepted: 05/11/2021] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To investigate the circulatory physiology of hypotension during the first day after birth among stable extremely preterm neonates. STUDY DESIGN Case-control study of neonates born at ≤276/7 weeks gestational age with hypotension, defined as mean blood pressure in mmHg less than gestational age in weeks for at least 1 hour during the first 24 hours after birth, who underwent comprehensive echocardiography assessment before commencement of cardiovascular drugs. Neonates with hypotension (n = 14) were matched by gestational age and intensity of respiratory support with normotensive neonates (n = 27) who underwent serial echocardiography during the first day after birth, and relatively contemporaneous echocardiography assessments were used for comparison. RESULTS Neonates with hypotension had a higher frequency of patent ductus arteriosus ≥1.5 mm (71% vs 15%; P < .001) and ductal size (median diameter, 1.6 mm [IQR, 1.4-2.1] vs 1.0 mm [IQR, 0-1.3]; P = .002), higher echocardiography indices of left ventricular systolic function (mean shortening fraction, 34 ± 7% vs 26 ± 4%; P < .001; mean longitudinal strain, -16 ± 5% vs -14 ± 3%; P = .04; and mean velocity of circumferential fiber shortening, 1.24 ± 0.35 circ/s vs 1.01 ± 0.28 circ/s; P = .03), lower estimates of left ventricular afterload (mean end-systolic wall stress, 20 ± 7 g/cm2 vs 30 ± 9 g/cm2; P < .001 and mean arterial elastance, 43 ± 19 mmHg/mL vs 60 ± 22 mmHg/mL; P = .01), without significant difference in stress-velocity index z-score (-0.42 ± 1.60 vs -0.88 ± 1.30; P = .33). Neonates with hypotension had higher rates of any degree of intraventricular hemorrhage (71% vs 22%; P = .006). CONCLUSIONS Low blood pressure in otherwise well extremely low gestational age neonates was associated with low systemic afterload and larger patent ductus arteriosus, but not left ventricular dysfunction.
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Affiliation(s)
| | - Poorva Deshpande
- Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Amish Jain
- Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Dany E Weisz
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Department of Newborn and Developmental Pediatrics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
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5
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Martins FDF, Bassani DG, Rios DI, Resende MHF, Weisz D, Jain A, Lopes JMDA, McNamara PJ. Relationship of Patent Ductus Arteriosus Echocardiographic Markers With Descending Aorta Diastolic Flow. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2021; 40:1505-1514. [PMID: 33044780 DOI: 10.1002/jum.15528] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 08/10/2020] [Accepted: 09/16/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES To characterize the relationship of echocardiographic markers of left heart overload and flow in peripheral major end-organ vessels (eg, celiac artery) with the presence of reversed holodiastolic flow in the descending aorta, considered a surrogate marker of an increased transductal shunt volume, in preterm patients with a patent ductus arteriosus (PDA). METHODS This work was a retrospective study of data from echocardiography performed to investigate the hemodynamic significance of a PDA in preterm patients. We studied differences in echocardiographic markers of the PDA shunt volume according to patterns of flow in the postductal descending aorta (no PDA, PDA with antegrade diastolic flow, and PDA with reversed diastolic flow). The strength of the association between each echocardiographic marker and the presence of aortic holodiastolic flow reversal was investigated. RESULTS We studied 137 patients with a median (interquartile range) birth weight of 850 (694-1030) g and a median gestational age of 25 (24-27) weeks. Among patients with a PDA (113), those with diastolic flow reversal in the descending aorta (44) presented had increased echocardiographic markers representative of the shunt volume (increased left ventricular output, left atrial-to-aortic ratio, pulmonary vein D wave, and shorter isovolumic relaxation time) compared to those with aortic antegrade diastolic flow. A positive, albeit weak, correlation between diastolic flow reversal and shunt volume echocardiographic markers was found. Abnormal diastolic flow in the celiac artery had the strongest correlation (R2 = 0.24). CONCLUSIONS In preterm patients with a PDA, echocardiographic markers of the shunt volume were more abnormal in patients with reversed diastolic flow in the descending aorta. These data support the assumption that variance in these markers are related to the shunt volume, which needs consideration when adjudicating hemodynamic significance.
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Affiliation(s)
| | - Diego G Bassani
- Department of Pediatrics, Center for Global Child Health, Hospital for Sick Children, and Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Daniel Ibarra Rios
- Department of Neonatology, Hospital Infantil de México Federico Gómez, Ciudad de Mexico, Mexico
| | - Maura Helena F Resende
- Division of Neonatology and Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Dany Weisz
- Department of Newborn and Developmental Pediatrics, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Amish Jain
- Department of Neonatology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | | | - Patrick J McNamara
- Department of Neonatology, Fernandes Figueira Institute, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
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6
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Rios DR, Martins FDF, El-Khuffash A, Weisz DE, Giesinger RE, McNamara PJ. Early Role of the Atrial-Level Communication in Premature Infants with Patent Ductus Arteriosus. J Am Soc Echocardiogr 2021; 34:423-432.e1. [PMID: 33227390 PMCID: PMC8026594 DOI: 10.1016/j.echo.2020.11.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 11/11/2020] [Accepted: 11/14/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND High-volume systemic-to-pulmonary ductus arteriosus shunts in premature infants are associated with adverse neonatal outcomes. The role of an atrial communication (AC) in modulating the effects of a presumed hemodynamically significant patent ductus arteriosus (PDA) is poorly studied. The objective of this study was to characterize the relationship between early AC and echocardiographic indices of PDA shunt volume and clinical neonatal outcomes. METHODS A retrospective review of preterm infants (born at <32 weeks' gestation) who underwent echocardiography in the first postnatal week was performed. The cohort was divided into four groups on the basis of presence of a presumed hemodynamically significant PDA (≥1.5 vs <1.5 mm) and AC size (≤1 vs >1 mm), and echocardiographic measures of PDA shunt volume were then compared. Clinical outcomes, including chronic lung disease and intraventricular hemorrhage, were also compared among all four groups. RESULTS A total of 199 preterm infants (mean birth weight, 928 ± 632 g; mean gestational age, 26.6 ± 1.5 weeks) were identified; 159 infants had PDAs ≥ 1.5 mm, of whom 52 had ACs ≤ 1 mm and 107 had ACs > 1 mm. The remaining 40 infants had PDAs < 1.5 mm, of whom 23 had ACs ≤ 1 mm and 17 had ACs > 1 mm. Infants with PDAs ≥ 1.5 mm and ACs > 1 mm had higher pulmonary vein D-wave velocities (P < .05), higher left ventricular output (P < .005), higher PDA scores (P < .001), and increased rates of reversed diastolic flow in the descending aorta (P < .001), celiac artery (P < .001), and middle cerebral artery (P < .001) than infants with either PDAs < 1.5 mm or PDAs ≥ 1.5 mm and ACs ≤ 1 mm. There was no difference in the incidence of intraventricular hemorrhage, but infants with PDAs ≥ 1.5 mm and ACs > 1 mm had a higher risk for a composite outcome of chronic lung disease or death before hospital discharge (P < .05). CONCLUSIONS Echocardiographic evidence of ACs > 1 mm in patients with PDAs ≥ 1.5 mm during the first postnatal week may be a marker of a more pathologic hemodynamically significant PDA in premature infants. Future investigations should evaluate if early identification and treatment of patients with both high-volume PDAs and larger atrial-level communications may help mitigate adverse outcomes, such as chronic lung disease or death, in this high-risk patient population.
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Affiliation(s)
- Danielle R Rios
- Division of Neonatology and Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.
| | | | - Afif El-Khuffash
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland; Department of Paediatrics, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Dany E Weisz
- Department of Newborn and Developmental Pediatrics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Regan E Giesinger
- Division of Neonatology and Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Patrick J McNamara
- Division of Neonatology and Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
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7
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Miletin J, Stranak Z, Ó Catháin N, Janota J, Semberova J. Comparison of Two Techniques of Superior Vena Cava Flow Measurement in Preterm Infants With Birth Weight <1,250 g in the Transitional Period-Prospective Observational Cohort Study. Front Pediatr 2021; 9:661698. [PMID: 33898366 PMCID: PMC8058217 DOI: 10.3389/fped.2021.661698] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 03/09/2021] [Indexed: 11/26/2022] Open
Abstract
Objectives: Superior Vena Cava (SVC) flow in neonates measured by the standard approach has been validated by different groups around the world. The modified SVC flow measurement technique was recently suggested. The aim of our study was to evaluate standard and modified technique of echocardiography SVC flow measurement in a cohort of extremely preterm neonates in the immediate postnatal period. Methods: Prospective, observational cohort study in a level III neonatal center. Infants with birth weight <1,250 g were eligible for enrolment. SVC flow was measured by echocardiography using standard and modified methods at 6, 18 and 36 h of age. Our primary outcome was equivalency (using raw bounds of -20 to +20 mL/kg/min difference between the paired measurements), agreement and correlation between standard and modified methods of the SVC flow measurements. Results: Thirty-nine infants were enrolled. The mean gestational age of the cohort was 27.4 (SD 2.1) weeks of postmenstrual age, the mean birth weight was 0.95 kg (SD 0.2). The measurements at 6 and 36 h of age were equivalent as defined in the design of the study (p = 0.003 and p = 0.004 respectively; raw bounds -20 to +20 mL/kg/min). At 6 h of age the mean difference (bias) between the measurements was -0.8 mL/kg/min with 95% limits of agreement -65.0 to 63.4 mL/kg/min. At 18 h of age, the mean difference (bias) between the measurements was +9.5 mL/kg/min, with 95% limits of agreement -79.6 to 98.7 mL/kg/min. At 36 h of age the mean difference (bias) between the measurements was -2.2 mL/kg/min with 95% limits of agreement -73.4 to 69.1 mL/kg/min. There was a weak, but statistically significant correlation between the standard and modified method at 6 h of age (r = 0.39, p = 0.04). Conclusion: Both SVC flow echocardiography measurement techniques yielded clinically equivalent results, however due to wide limits of agreement and poor correlation they do not seem to be interchangeable.
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Affiliation(s)
- Jan Miletin
- Coombe Women and Infants University Hospital, Dublin, Ireland.,Institute for the Care of Mother and Child, Prague, Czechia.,UCD School of Medicine, University College Dublin, Dublin, Ireland.,3rd Faculty of Medicine, Charles University, Prague, Czechia
| | - Zbynek Stranak
- Institute for the Care of Mother and Child, Prague, Czechia.,3rd Faculty of Medicine, Charles University, Prague, Czechia
| | - Niamh Ó Catháin
- Coombe Women and Infants University Hospital, Dublin, Ireland.,UCD School of Medicine, University College Dublin, Dublin, Ireland
| | - Jan Janota
- 1st and 2nd Faculty of Medicine, Charles University, Prague, Czechia.,Motol University Hospital, Prague, Czechia
| | - Jana Semberova
- Coombe Women and Infants University Hospital, Dublin, Ireland.,Institute for the Care of Mother and Child, Prague, Czechia.,UCD School of Medicine, University College Dublin, Dublin, Ireland
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8
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de Boode WP, van der Lee R, Horsberg Eriksen B, Nestaas E, Dempsey E, Singh Y, Austin T, El-Khuffash A. The role of Neonatologist Performed Echocardiography in the assessment and management of neonatal shock. Pediatr Res 2018; 84:57-67. [PMID: 30072807 PMCID: PMC6257224 DOI: 10.1038/s41390-018-0081-1] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
One of the major challenges of neonatal intensive care is the early detection and management of circulatory failure. Routine clinical assessment of the hemodynamic status of newborn infants is subjective and inaccurate, emphasizing the need for objective monitoring tools. An overview will be provided about the use of neonatologist-performed echocardiography (NPE) to assess cardiovascular compromise and guide hemodynamic management. Different techniques of central blood flow measurement, such as left and right ventricular output, superior vena cava flow, and descending aortic flow are reviewed focusing on methodology, validation, and available reference values. Recommendations are provided for individualized hemodynamic management guided by NPE.
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Affiliation(s)
- Willem P de Boode
- Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands.
| | - Robin van der Lee
- Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
| | | | - Eirik Nestaas
- Institute of Clinical Medicine, Faculty of Medicine, University of, Oslo, Norway
- Department of Cardiology and Center for Cardiological Innovation, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Department of Paediatrics, Vestfold Hospital Trust, Tønsberg, Norway
| | - Eugene Dempsey
- INFANT Centre, Cork University Maternity Hospital, University College, Cork, Ireland
| | - Yogen Singh
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Topun Austin
- Department of Neonatology, Rosie Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Afif El-Khuffash
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland
- Department of Pediatrics, The Royal College of Surgeons in Ireland, Dublin, Ireland
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9
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Singh Y, Katheria AC, Vora F. Advances in Diagnosis and Management of Hemodynamic Instability in Neonatal Shock. Front Pediatr 2018; 6:2. [PMID: 29404312 PMCID: PMC5780410 DOI: 10.3389/fped.2018.00002] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Accepted: 01/05/2018] [Indexed: 01/20/2023] Open
Abstract
Shock in newborn infants has unique etiopathologic origins that require careful assessment to direct specific interventions. Early diagnosis is key to successful management. Unlike adults and pediatric patients, shock in newborn infants is often recognized in the uncompensated phase by the presence of hypotension, which may be too late. The routine methods of evaluation used in the adult and pediatric population are often invasive and less feasible. We aim to discuss the pathophysiology in shock in newborn infants, including the transitional changes at birth and unique features that contribute to the challenges in early identification. Special emphasis has been placed on bedside focused echocardiography/focused cardiac ultrasound, which can be used as an additional tool for early, neonatologist driven, ongoing evaluation and management. An approach to goal oriented management of shock has been described and how bed side functional echocardiography can help in making a logical choice of intervention (fluid therapy, inotropic therapy or vasopressor therapy) in infants with shock.
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Affiliation(s)
- Yogen Singh
- Department of Pediatric Cardiology and Neonatal Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- University of Cambridge Clinical School of Medicine, Cambridge, United Kingdom
| | - Anup C. Katheria
- Department of Neonatology, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, United States
- Department of Neonatology, Loma Linda University School of Medicine, Loma Linda, CA, United States
| | - Farha Vora
- Department of Neonatology, Loma Linda University School of Medicine, Loma Linda, CA, United States
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10
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Abstract
In many preterm infants, the ductus arteriosus remains patent beyond the first few days of life. This prolonged patency is associated with numerous adverse outcomes, but the extent to which these adverse outcomes are attributable to the hemodynamic consequences of ductal patency, if at all, has not been established. Different treatment strategies have failed to improve short-term outcomes, with a paucity of data on the correct diagnostic and pathophysiological assessment of the patent ductus arteriosus (PDA) in association with long-term outcomes. Echocardiography is the selected method of choice for detecting a PDA, assessing the impact on the preterm circulation and monitoring treatment response. PDA in a preterm infant can result in pulmonary overcirculation and systemic hypoperfusion, Therefore, echocardiographic assessment should include evaluation of PDA characteristics, indices of pulmonary overcirculation with left heart loading conditions, and indices of systemic hypoperfusion. In this review, we provide an evidence-based overview of the current and emerging ultrasound measurements available to identify and monitor a PDA in the preterm infant. We offer indications and limitations for using Neonatologist Performed Echocardiography to optimize the management of a neonate with a PDA.
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11
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Browning Carmo K, Lutz T, Greenhalgh M, Berry A, Kluckow M, Evans N. Feasibility and utility of portable ultrasound during retrieval of sick preterm infants. Acta Paediatr 2017; 106:1296-1301. [PMID: 28419552 DOI: 10.1111/apa.13881] [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: 01/09/2017] [Revised: 03/24/2017] [Accepted: 04/11/2017] [Indexed: 11/29/2022]
Abstract
AIM Document the incidence of haemodynamic pathology in critically ill preterm newborns requiring transport. METHOD A transport neonatologist performed cardiac and cerebral ultrasound before and after transportation of infants born ≤30 weeks gestation. RESULTS Forty-four newborns were studied in 2008-2015; of them, 21 were transported by road, 19, by helicopter and four, by fixed wing: median birthweight, 1130 g (680-1960 g) and median gestation, 27 weeks (23-30); 30 of 44 were male babies. Antenatal steroid course was complete in two babies. Ultrasound in the referring hospital was at a mean of two hours: 47 minutes (00:15-7:00) of age. Low systemic blood flow was common: 50% had right ventricular output <150mL/kg/min and 23%, a superior vena cava flow <50mL/kg/min. at stabilisation. Cranial US: 10 Grade I IVH, 2 Grade II IVH, 1 Grade IV IVH and 32 normal scans pretransport. After transport, three further Grade I IVH were reported. Mortality was higher in the babies with low systemic blood flow: 4 of 12 (33%) died vs 1 of 31 (6%) in the normal flow group (OR = 7.2, 95% CI: 1.1 to 47, p = 0.022). CONCLUSION Point-of-care ultrasound during the retrieval of preterm infants confirms a high incidence of haemodynamic pathology. The use of ultrasound during transport may provide an opportunity for earlier targeted circulatory support.
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Affiliation(s)
- Kathryn Browning Carmo
- Neonatal and Paediatric Emergency Transport Service (NETS); Sydney NSW Australia
- Grace Centre for Newborn Intensive Care; CHW; Sydney NSW Australia
- University of Sydney; Sydney NSW Australia
| | - Tracey Lutz
- Neonatal and Paediatric Emergency Transport Service (NETS); Sydney NSW Australia
- University of Sydney; Sydney NSW Australia
- Royal Prince Alfred Department of Newborn Care; Sydney NSW Australia
| | - Mark Greenhalgh
- Neonatal and Paediatric Emergency Transport Service (NETS); Sydney NSW Australia
- University of Sydney; Sydney NSW Australia
- Department of Neonatology; Royal North Shore Hospital; Sydney NSW Australia
| | - Andrew Berry
- Neonatal and Paediatric Emergency Transport Service (NETS); Sydney NSW Australia
| | - Martin Kluckow
- University of Sydney; Sydney NSW Australia
- Department of Neonatology; Royal North Shore Hospital; Sydney NSW Australia
| | - Nick Evans
- University of Sydney; Sydney NSW Australia
- Royal Prince Alfred Department of Newborn Care; Sydney NSW Australia
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12
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Yoon JH, Lee EJ, Yum SK, Moon CJ, Youn YA, Kwun YJ, Lee JY, Sung IK. Impacts of therapeutic hypothermia on cardiovascular hemodynamics in newborns with hypoxic-ischemic encephalopathy: a case control study using echocardiography. J Matern Fetal Neonatal Med 2017; 31:2175-2182. [DOI: 10.1080/14767058.2017.1338256] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Ji Hong Yoon
- Department of Pediatrics, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Eun-jung Lee
- Department of Pediatrics, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Sook Kyung Yum
- Department of Pediatrics, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Cheong-jun Moon
- Department of Pediatrics, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Young-Ah Youn
- Department of Pediatrics, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Yoo Jin Kwun
- Department of Pediatrics, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Jae Young Lee
- Department of Pediatrics, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - In Kyung Sung
- Department of Pediatrics, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
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13
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Urinary Neutrophil Gelatinase-associated Lipocalin in the evaluation of Patent Ductus Arteriosus and AKI in Very Preterm Neonates: a cohort study. BMC Pediatr 2017; 17:7. [PMID: 28068947 PMCID: PMC5223413 DOI: 10.1186/s12887-016-0761-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Accepted: 12/15/2016] [Indexed: 11/24/2022] Open
Abstract
Background A patent ductus arteriosus (PDA) is frequently found in very preterm neonates and is associated with increased risk of morbidity and mortality. A shunt across a PDA can result in an unfavorable distribution of the cardiac output and may in turn result in poor renal perfusion. Urinary Neutrophil Gelatinase-associated Lipocalin (U-NGAL) is a marker of renal ischemia and may add to the evaluation of PDA. Our primary aim was to investigate if U-NGAL is associated with PDA in very preterm neonates. Secondary, to investigate whether U-NGAL and PDA are associated with AKI and renal dysfunction evaluated by fractional excretion of sodium (FENa) and urine albumin in a cohort of very preterm neonates. Methods A cohort of 146 neonates born at a gestational age less than 32 weeks were consecutively examined with echocardiography for PDA and serum sodium, and urine albumin and sodium were measured on postnatal day 3 and U-NGAL and serum creatinine day 3 and 6. AKI was defined according to modified neonatal Acute Kidney Injury Network (AKIN) criteria. The association between U-NGAL and PDA was investigated. And secondly we investigated if PDA and U-NGAL was associated with AKI and renal dysfunction. Results U-NGAL was not associated with a PDA day 3 when adjusted for gestational age and gender. A PDA day 3 was not associated with AKI when adjusted for gestational age and gender; however, it was associated with urine albumin. U-NGAL was not associated with AKI, but was found to be associated with urine albumin and FENa. Conclusions Based on our study U-NGAL is not considered useful as a diagnostic marker to identify very preterm neonates with a PDA causing hemodynamic changes resulting in early renal morbidity. The interpretation of NGAL in preterm neonates remains to be fully elucidated.
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14
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McGovern M, Miletin J. A review of superior vena cava flow measurement in the neonate by functional echocardiography. Acta Paediatr 2017; 106:22-29. [PMID: 27611695 DOI: 10.1111/apa.13584] [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: 06/27/2016] [Revised: 08/29/2016] [Accepted: 09/07/2016] [Indexed: 11/27/2022]
Abstract
Neonatologists have begun using superior vena cava flow as assessed by functional echocardiography to facilitate real-time decision-making on cardiovascular care. This review aims to describe the basis of the technique, summarise the evidence for its use and compare the technique to existing clinical, biochemical and radiological techniques for assessing neonatal circulatory status. CONCLUSION Although echocardiographic measurements of superior vena cava flow, like other measures of perfusion, are not perfect, their noninvasive nature and ability to facilitate real-time decision-making means that at present, they remain the best available methodology of monitoring central perfusion in the neonatal population.
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Affiliation(s)
- Matthew McGovern
- Neonatology Department; Coombe Women and Infant University Hospital; Dublin Ireland
| | - Jan Miletin
- Neonatology Department; Coombe Women and Infant University Hospital; Dublin Ireland
- Institute for the Care of Mother and Child; Prague Czech Republic
- 3rd School of Medicine; Charles University; Prague Czech Republic
- UCD School of Medicine and Medical Sciences; Dublin Ireland
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15
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Browning Carmo K, Lutz T, Berry A, Kluckow M, Evans N. Feasibility and utility of portable ultrasound during retrieval of sick term and late preterm infants. Acta Paediatr 2016; 105:e549-e554. [PMID: 27628296 DOI: 10.1111/apa.13589] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 08/21/2016] [Accepted: 09/12/2016] [Indexed: 12/01/2022]
Abstract
AIM To determine the role of clinician performed ultrasound (CPU) during the retrieval and transport of critically ill term and near term newborns. METHODS A neonatologist with portable ultrasound accompanied a sample of newborn retrievals to perform cardiac and cerebral ultrasound before and after transportation. RESULTS A total of fifty-five babies were studied. Median birthweight: 3350 g (2220-5030 g). CPU led to a change in the planned receiving hospital in ten babies. Eleven babies were suspected congenital heart disease (CHD) prior to retrieval: eight confirmed CHD by CPU and three normal structure. One transported to a children's hospital for cardiology review was confirmed as having normal structure; one to a perinatal hospital where normal structure was confirmed and one baby died at the referring hospital and postmortem confirmed normal structure. In five babies with clinical pulmonary hypertension, CPU revealed unsuspected CHD. The destination was changed to a paediatric cardiology centre, avoiding a second retrieval. Eleven babies had evidence of haemodynamic compromise allowing targeting of inotropes. CONCLUSION This is the first study of CPU during retrieval of high-risk infants. Ultrasound in retrieval is feasible, allows accurate triage of babies to cardiac centres and may allow more accurate targeting of fluid and inotrope support.
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Affiliation(s)
- Kathryn Browning Carmo
- Neonatal and Paediatric Emergency Transport Service (NETS); Westmead NSW Australia
- Grace Centre for Newborn Intensive Care CHW; Sydney NSW Australia
- University of Sydney; Sydney NSW Australia
| | - Tracey Lutz
- Neonatal and Paediatric Emergency Transport Service (NETS); Westmead NSW Australia
- University of Sydney; Sydney NSW Australia
- Department of Newborn Care; Royal Prince Alfred Hospital; Sydney NSW Australia
| | - Andrew Berry
- Neonatal and Paediatric Emergency Transport Service (NETS); Westmead NSW Australia
| | - Martin Kluckow
- University of Sydney; Sydney NSW Australia
- Department of Neonatology; Royal North Shore Hospital; Sydney NSW Australia
| | - Nick Evans
- University of Sydney; Sydney NSW Australia
- Department of Newborn Care; Royal Prince Alfred Hospital; Sydney NSW Australia
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16
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Baik N, Urlesberger B, Schwaberger B, Schmölzer GM, Köstenberger M, Avian A, Pichler G. Foramen ovale (FO) - The underestimated sibling of ductus arteriosus (DA): Relevance during neonatal transition. Early Hum Dev 2016; 103:137-140. [PMID: 27648971 DOI: 10.1016/j.earlhumdev.2016.08.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 07/11/2016] [Accepted: 08/24/2016] [Indexed: 11/18/2022]
Affiliation(s)
- Nariae Baik
- Division of Neonatology, Department of Paediatrics, Medical University of Graz, Austria; Research Unit for Neonatal Micro- and Macrocirculation, Department of Paediatrics, Medical University of Graz, Austria
| | - Berndt Urlesberger
- Division of Neonatology, Department of Paediatrics, Medical University of Graz, Austria; Research Unit for Neonatal Micro- and Macrocirculation, Department of Paediatrics, Medical University of Graz, Austria
| | - Bernhard Schwaberger
- Division of Neonatology, Department of Paediatrics, Medical University of Graz, Austria; Research Unit for Neonatal Micro- and Macrocirculation, Department of Paediatrics, Medical University of Graz, Austria
| | - Georg M Schmölzer
- Division of Neonatology, Department of Paediatrics, Medical University of Graz, Austria; Department of Pediatrics, University of Alberta, Edmonton, Canada; Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Canada
| | - Martin Köstenberger
- Division of pediatric Cardiology, Department of Paediatrics, Medical University of Graz, Austria
| | - Alexander Avian
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Austria
| | - Gerhard Pichler
- Division of Neonatology, Department of Paediatrics, Medical University of Graz, Austria; Research Unit for Neonatal Micro- and Macrocirculation, Department of Paediatrics, Medical University of Graz, Austria; Department of Pediatrics, University of Alberta, Edmonton, Canada; Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Canada.
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Hasegawa T, Oshima Y, Tanaka T, Maruo A, Matsuhisa H. Clinical assessment of diastolic retrograde flow in the descending aorta for high-flow systemic-to-pulmonary artery shunting. J Thorac Cardiovasc Surg 2016; 151:1540-6. [PMID: 26979919 DOI: 10.1016/j.jtcvs.2016.02.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Revised: 01/17/2016] [Accepted: 02/07/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To investigate whether echocardiographic characteristics in the descending aorta of patients with cyanotic congenital heart disease who have received a systemic-to-pulmonary artery (SP) shunt can indicate shunt flow volume and predict postoperative adverse events related to high-flow shunting. METHODS Among the 73 consecutive patients who received an SP shunt between 2010 and 2014, data for 53 patients who underwent postoperative Doppler echocardiographic assessment of diastolic retrograde flow in the descending aorta (dAo-RF) were reviewed retrospectively. RESULTS The mean dAo-RF ratio was 0.50 ± 0.15 at intensive care unit admission and reached its peak level (0.56 ± 0.12) at 24 hours after surgery. All of the patients with a maximal dAo-RF ratio of ≥0.80 had experienced acute heart failure or cardiogenic shock due to postoperative high-flow shunting and required emergent surgical interventions to reduce pulmonary blood flow. Pulse oximetry-measured oxygen saturation and serum lactate level were significantly correlated with dAo-RF ratio, but they had some clinical dispersion to match the postoperative adverse events. CONCLUSIONS The dAo-RF ratio is a simple, repeatable, and noninvasive index for postoperative assessment of SP shunt flow volume. A high dAo-RF ratio is a significant predictor of postoperative adverse events of high-flow shunting.
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Affiliation(s)
- Tomomi Hasegawa
- Department of Cardiovascular Surgery, Kobe Children's Hospital, Hyogo, Japan.
| | - Yoshihiro Oshima
- Department of Cardiovascular Surgery, Kobe Children's Hospital, Hyogo, Japan
| | | | - Ayako Maruo
- Department of Cardiovascular Surgery, Kobe Children's Hospital, Hyogo, Japan
| | - Hironori Matsuhisa
- Department of Cardiovascular Surgery, Kobe Children's Hospital, Hyogo, Japan
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18
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Abstract
OBJECTIVE Our aim was to determine the optimal cut-off values, sensitivity, specificity, and diagnostic power of 12 echocardiographic parameters on the second day of life to predict subsequent ductal patency. METHODS We evaluated preterm infants, born at ⩽32 weeks of gestation, starting on their second day of life, and they were evaluated every other day until ductal closure or until there were clinical signs of re-opening. We measured transductal diameter; pulmonary arterial diastolic flow; retrograde aortic diastolic flow; pulsatility index of the left pulmonary artery and descending aorta; left atrium and ventricle/aortic root ratio; left ventricular output; left ventricular flow velocity time integral; mitral early/late diastolic flow; and superior caval vein diameter and flow as well as performed receiver operating curve analysis. RESULTS Transductal diameter (>1.5 mm); pulmonary arterial diastolic flow (>25.6 cm/second); presence of retrograde aortic diastolic flow; ductal diameter by body weight (>1.07 mm/kg); left pulmonary arterial pulsatility index (⩽0.71); and left ventricle to aortic root ratio (>2.2) displayed high sensitivity and specificity (p0.9). Parameters with moderate sensitivity and specificity were as follows: left atrial to aortic root ratio; left ventricular output; left ventricular flow velocity time integral; and mitral early/late diastolic flow ratio (p0.05) had low diagnostic value. CONCLUSION Left pulmonary arterial pulsatility index, left ventricle/aortic root ratio, and ductal diameter by body weight are useful adjuncts offering a broader outlook for predicting ductal patency.
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19
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Sellmer A, Hjortdal VE, Bjerre JV, Schmidt MR, McNamara PJ, Bech BH, Henriksen TB. N-Terminal Pro-B Type Natriuretic Peptide as a Marker of Bronchopulmonary Dysplasia or Death in Very Preterm Neonates: A Cohort Study. PLoS One 2015; 10:e0140079. [PMID: 26452045 PMCID: PMC4599729 DOI: 10.1371/journal.pone.0140079] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 09/21/2015] [Indexed: 02/04/2023] Open
Abstract
Background Bronchopulmonary dysplasia (BPD) is a serious complication of preterm birth. Plasma N-terminal pro-B type natriuretic peptide (NT-proBNP) has been suggested as a marker that may predict BPD within a few days after birth. Objectives To investigate the association between NT-proBNP day three and bronchopulmonary dysplasia (BPD) or death and further to assess the impact of patent ductus arteriosus (PDA) on this association in neonates born before 32 gestational weeks. Methods A cohort study of 183 neonates born before 32 gestational weeks consecutively admitted to the Neonatal Intensive Care Unit, Aarhus University Hospital, Denmark. On day three plasma samples were collected and echocardiography carried out. NT-proBNP was measured by routine immunoassays. The combined outcome BPD or death was assessed at 36 weeks of postmenstrual age. Receiver operator characteristic (ROC) analysis was performed to determine the discrimination ability of NT-proBNP by the natural log continuous measure to recognize BPD or death. The association of BPD or death was assessed in relation to natural log NT-proBNP levels day three. Results The risk of BPD or death increased 1.7-fold with one unit increase of natural log NT-proBNP day three when adjusted for gestational age at birth (OR = 1.7, 95% CI 1.3; 2.3). The association was found both in neonates with and without a PDA. Adjusting for GA, PDA diameter, LA:Ao-ratio, or early onset sepsis did not change the estimate. Conclusion We found NT-proBNP to be associated with BPD or death in very preterm neonates. This association was not only explained by the PDA. We speculate that NT-proBNP may help the identification of neonates at risk of BPD as early as postnatal day three.
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Affiliation(s)
- Anna Sellmer
- Department of Pediatrics, Aarhus University Hospital, Aarhus, Denmark
- Perinatal Epidemiology Research Unit, Aarhus University, Aarhus, Denmark
- Department of Pediatrics, Herning Regional Hospital, Herning, Denmark
- * E-mail:
| | | | | | | | | | - Bodil Hammer Bech
- Department of Public Health, Section for Epidemiology, Aarhus University, Aarhus, Denmark
| | - Tine Brink Henriksen
- Department of Pediatrics, Aarhus University Hospital, Aarhus, Denmark
- Perinatal Epidemiology Research Unit, Aarhus University, Aarhus, Denmark
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20
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Nasu Y, Oyama K, Nakano S, Matsumoto A, Soda W, Takahashi S, Chida S. Longitudinal systolic strain of the bilayered ventricular septum during the first 72 hours of life in preterm infants. J Echocardiogr 2015; 13:90-9. [DOI: 10.1007/s12574-015-0250-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Revised: 06/03/2015] [Accepted: 06/21/2015] [Indexed: 11/30/2022]
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van Vonderen JJ, te Pas AB, Kolster-Bijdevaate C, van Lith JM, Blom NA, Hooper SB, Roest AAW. Non-invasive measurements of ductus arteriosus flow directly after birth. Arch Dis Child Fetal Neonatal Ed 2014; 99:F408-12. [PMID: 24966129 DOI: 10.1136/archdischild-2014-306033] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To assess ductus arteriosus (DA) blood flow directly after birth in healthy term infants after elective caesarean section. DESIGN In healthy term newborns, echocardiography was performed at 2, 5 and 10 min after birth to monitor cardiac output and DA blood flow. Heart rate (HR) was assessed using ECG. SETTING The delivery rooms of the Leiden University Medical Center. PATIENTS 24 healthy term infants born after a caesarean section were included in this study. RESULTS Mean (SD) HR did not change (158 (18) beats per minute (bpm), 5 min (159 (23) bpm) and 10 min (156 (19) bpm). DA diameter decreased from 5.2 (1.3) mm at 2 min to 4.6 (1.3) mm at 5 min (p=0.01) to (3.9 (1.2) mm) (p=0.01) at 10 min. Right-to-left DA shunting was unaltered (median (IQR) 95 (64-154) mL/kg/min to 90 (56-168) mL/kg/min and 80 (64-120) mL/kg/min, respectively (ns)), whereas left-to-right shunting significantly increased between 2 and 5 min (41 (31-70) mL/kg/min vs 67 (37-102) mL/kg/min (p=0.01)) and increased significantly between 2 and 10 min (93 (67-125)) mL/kg/min (p<0.001). Right-to-left/left-to-right shunting ratio decreased significantly from 2.1 (1.4-3.1) at 2 min to 1.4 (1.0-1.8) at 5 min (p<0.0001) and to 0.9 (0.6-1.1) at 10 min (p<0.0001). CONCLUSIONS DA shunting changes swiftly from predominantly right-to-left shunting to predominantly left-to-right shunting at 10 min after birth, reflecting differential changes in pulmonary and systemic vascular resistance.
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Affiliation(s)
- Jeroen J van Vonderen
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Arjan B te Pas
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Clara Kolster-Bijdevaate
- Department of Gynaecology and Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Jan M van Lith
- Department of Gynaecology and Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Nico A Blom
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Stuart B Hooper
- The Ritchie Centre, Monash Institute for Medical Research, Monash University, Clayton, Victoria, Australia
| | - Arno A W Roest
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
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22
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Goudjil S, Imestouren F, Armougon A, Razafimanantsoa L, Mahmoudzadeh M, Wallois F, Leke A, Kongolo G. Noninvasive technique for the diagnosis of patent ductus arteriosus in premature infants by analyzing pulse wave phases on photoplethysmography signals measured in the right hand and the left foot. PLoS One 2014; 9:e98763. [PMID: 24892695 PMCID: PMC4043784 DOI: 10.1371/journal.pone.0098763] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Accepted: 05/07/2014] [Indexed: 11/18/2022] Open
Abstract
Objective To evaluate the impact of patent ductus arteriosus (PDA) on the pulse phase difference (PPD) between the left foot (postductal region) and the right hand (preductal region). Materials and Methods PPD was determined from arterial photoplethysmography signals (pulse waves) measured by infrared sensors routinely used for pulse oximetry in 56 premature infants less than 32 weeks gestation. Only infants with significant PDA (sPDA) diagnosed by echocardiography were treated with ibuprofen (for 3 days). Patients were classified according to whether or not they responded (Success/Failure) to this treatment. The Control group was composed of infants in whom ductus had already closed spontaneously at the time of the first echocardiography. The 3 groups were compared in terms of PPD at the beginning (T1) and at the end (T2) of the study. For patients in the Failure (n = 17) and Success groups (n = 18), T1 corresponded to the first day of treatment and T2 to the day after completion of the course of ibuprofen. In the Control group (n = 21), T1 corresponded to 1 to 3 days of life (DOL), and T2 to 4–6 DOL. Results Compared to the Control group, PPD was higher in the Failure (at T1 and T2) and Success (at T1) groups characterized by sPDA. After ibuprofen therapy, PPD in the Success group decreased to about the level observed in the Control group. The area under the ROC curve of PPD for the diagnosis of sPDA was 0.98 (95% CI 0.96–1); for an optimal cut-off of PPD ≥1.65 deg/cm, the sensitivity was 94.2% and the specificity was 98.3%. Conclusion In this study, PPD was correlated with ductus arteriosus status evaluated by echocardiography, indicating involvement of the ductal shunt in the mechanism of redistribution in systemic vascular territories. PPD can be considered for the diagnosis of hemodynamically significant PDA.
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Affiliation(s)
- Sabrina Goudjil
- Neonatal Intensive Care Unit, Amiens University Hospital, Amiens, France
- INSERM U1105, GRAMFC, Jules Verne University of Picardie, Amiens, France
- * E-mail:
| | - Fatiha Imestouren
- Neonatal Intensive Care Unit, Amiens University Hospital, Amiens, France
| | - Aurelie Armougon
- Neonatal Intensive Care Unit, Amiens University Hospital, Amiens, France
| | | | - Mahdi Mahmoudzadeh
- INSERM U1105, GRAMFC, Jules Verne University of Picardie, Amiens, France
| | - Fabrice Wallois
- INSERM U1105, GRAMFC, Jules Verne University of Picardie, Amiens, France
| | - André Leke
- Neonatal Intensive Care Unit, Amiens University Hospital, Amiens, France
| | - Guy Kongolo
- Neonatal Intensive Care Unit, Amiens University Hospital, Amiens, France
- INSERM U1105, GRAMFC, Jules Verne University of Picardie, Amiens, France
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Abstract
Controversy surrounds the assessment of perfusion and the methods currently utilised to define hypotension, especially blood pressure. There is growing agreement to assess heart function when selecting inotropic therapy and use bedside tools such as echocardiography for assessing at-risk infants. Both dopamine and dobutamine have comparative efficacy, and in certain disease states with immature myocardium there could be potential advantages in using dobutamine. The concomitant use of hydrocortisone has been shown to be beneficial when escalating doses of first-line inotropes are used. Other inotropes require further study through randomised trials for their safety and efficacy to be established.
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Affiliation(s)
- Samir Gupta
- Department of Paediatrics, University Hospital of North Tees and University of Durham, Stockton-on-Tees, UK.
| | - Steven M Donn
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, C.S. Mott Children's Hospital, University of Michigan Health System, Ann Arbor, MI, USA
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Abstract
Ensuring adequate oxygenation of the developing brain is the cornerstone of neonatal critical care. Despite decades of clinical research dedicated to this issue of paramount importance, our knowledge and understanding regarding the physiology and pathophysiology of neonatal cerebral blood flow are still rudimentary. This review primarily focuses on currently available human clinical and experimental data on cerebral blood flow and autoregulation in the preterm and term infant. Limitations of systemic blood pressure values as surrogates for monitoring adequate cerebral oxygen delivery are discussed. Particular emphasis is placed on the high interindividual variability in cerebral blood flow values, vasoreactivity, and autoregulatory thresholds making the applications of normative values highly questionable. Technical and ethical difficulties to conduct such trials leave us with a near complete lack of knowledge on how pharmacological and surgical interventions impact on cerebral autoregulation. The ensemble of these works argues for the necessity of highly individualized care by taking advantage of continuous bedside monitoring of cerebral circulation. They also point to the urgent need for further studies addressing the exciting but difficult issue of cerebral blood flow autoregulation in the neonate.
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Affiliation(s)
- Laszlo Vutskits
- Department of Anesthesiology, Pharmacology and Intensive Care, University Hospital of Geneva, Geneva, Switzerland; Department of Fundamental Neuroscience, Geneva University Medical School, Geneva, Switzerland
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25
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Altered transitional circulation in infants of diabetic mothers with strict antenatal obstetric management: a functional echocardiography study. J Perinatol 2012; 32:508-13. [PMID: 21960130 DOI: 10.1038/jp.2011.135] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Infants born to diabetic mothers (IDMs) even with good glycemic control are at risk for neonatal morbidity. Many of these problems occur during neonatal transition. We assessed (i) systemic and pulmonary blood flow in IDMs compared with controls and (ii) directional blood flow changes within fetal shunts during the first few days of life. STUDY DESIGN In this prospective observational cohort study, we evaluated right (RVO) and left ventricular output, superior vena cava flow, atrial and ductal shunts, and tricuspid regurgitation in 32 IDMs and 18 controls using serial echocardiography after birth and 48 h of life in both groups and at 24 and 72 h in IDMs only. RESULT IDMs had lower RVO after birth and 48 h of life. IDMs also had less left to right atrial shunt and more right to left ductal shunt after birth compared with controls. In all, 15 of the 32 IDMs were admitted to the neonatal intensive care unit and 11 had respiratory symptoms. CONCLUSION Persistence of fetal shunts and decreased RVO in IDMs suggest that even those with good gestational control have impaired transitional hemodynamics.
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Abstract
The current uncertainty in relation to treatment of the preterm patent ductus arteriosus reflects limitations to our understanding of the pathophysiology of ductal shunting, most particularly which ducts matter to which babies and when they matter. Doppler ultrasound offers a pragmatic tool with which to assess ductal patency and shunt significance and to allow prediction of spontaneous and therapeutic closure. Biomarkers, such as B-type natriuretic peptide, and clinical signs may have a diagnostic role where ultrasound is not available and also possibly as an adjunct to echocardiography in determining the pathophysiological impact of a ductal shunt in an individual baby.
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Affiliation(s)
- Nick Evans
- Department of Newborn Care, Royal Prince Alfred Hospital, University of Sydney, Sydney, New South Wales, Australia.
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Regional tissue oxygenation in preterm born infants in association with echocardiographically significant patent ductus arteriosus. J Perinatol 2011; 31:460-4. [PMID: 21252960 DOI: 10.1038/jp.2010.200] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To analyze the levels of regional tissue oxygenation in preterm infants in association with echocardiographically significant patent ductus arteriosus (PDA). STUDY DESIGN Preterm infants with gestational age less than 32 week were enrolled before the first dose of the pharmacological treatment for the PDA. Non-invasive near-infrared spectroscopy (NIRS) technology was utilized to measure cerebral (rSO(2)-C), renal (rSO(2)-R) and mesenteric (rSO(2-M)) tissue oxygenation for approximately 60 min. Regional fractional oxygen extraction (FOE) was calculated using simultaneously measured arterial saturation (SaO(2)). We analyzed regional tissue oxygenation and oxygen extraction, hemodynamic parameters, and demographic and clinical information in association with the size of the PDA (moderate vs large). RESULT Among the 38 enrolled infants, the majority were diagnosed with a large (63.2%, n=24) and the rest with a moderate-sized PDA. Infants with large and moderate PDA were comparable in terms of gestational age, study age and weight, mode of delivery and hemodynamic parameters. A significantly higher proportion of infants with a moderate PDA were mechanically ventilated as compared with those with a large PDA. We found no significant differences in the rSO(2)-C and rSO(2)-R, irrespective of the type of respiratory support. However, in infants with a large PDA on continuous nasal positive airway pressure (NCPAP), the rSO(2)-M was lower and mesenteric FOE was higher than that in mechanically ventilated neonates with a large PDA, and in those with moderate PDA irrespective of the type of respiratory support. CONCLUSION The PDA size did not affect cerebral and renal tissue oxygenation, but the mesenteric tissue oxygenation was decreased in infants with a large PDA on NCPAP.
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Abstract
Perinatal asphyxia commonly results in multi-organ damage, and cardiovascular dysfunction is a frequent association. Myocardial damage, right ventricular dysfunction, abnormal circulatory transition, and impaired autoregulation may all contribute to postnatal neurological damage. Adequate monitoring and appropriate targeted treatment therefore are essential after an asphyxial insult. Standard methods of cardiovascular monitoring in the neonate have limitations. Point of care ultrasound scanning or functional echocardiography offers extra information to assist the clinician in identifying when there is significant cardiovascular impairment, classifying the underlying abnormal physiology and potentially targeting appropriate therapy, thereby optimizing the post-insult cerebral blood flow and oxygen delivery.
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Koestenberger M, Nagel B, Ravekes W, Urlesberger B, Raith W, Avian A, Halb V, Cvirn G, Fritsch P, Gamillscheg A. Systolic right ventricular function in preterm and term neonates: reference values of the tricuspid annular plane systolic excursion (TAPSE) in 258 patients and calculation of Z-score values. Neonatology 2011; 100:85-92. [PMID: 21273793 DOI: 10.1159/000322006] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2010] [Accepted: 10/11/2010] [Indexed: 11/19/2022]
Abstract
BACKGROUND The tricuspid annular plane systolic excursion (TAPSE) is an echocardiographic measurement to assess right ventricular systolic function in adults and children. OBJECTIVE We determined growth- and birth weight-related changes of TAPSE to establish reference values in preterm and term neonates. METHODS A prospective study was conducted in a group of 258 preterm and term neonates (age: 25+0 to 40+6 weeks of gestation, birth weight: 530-4200 g). RESULTS The TAPSE ranged from a mean of 0.44 cm (Z-score ±2: 0.30-0.59 cm) in preterm neonates in the 26th week of gestation to 1.03 cm (Z-score ±2: 0.85-1.21 cm) in term neonates in the 41st week of gestation. The TAPSE values increased in a linear way from the 26th to 41st week of gestation. TAPSE, week of gestation and weight are strongly correlated: Pearson's correlation coefficient was 0.93 for week of gestation - TAPSE (p < 0.001), 0.93 for week of gestation - birth weight (p < 0.001), and 0.89 for birth weight - TAPSE (p < 0.001). There was no statistically significant difference of normal TAPSE values between female and male patients (p = 0.987). CONCLUSION Z-scores of TAPSE values were calculated and percentile charts were established to serve as reference data for ready application in preterm and term neonates with structurally normal hearts and with congenital heart disease in the future.
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Chen S, Tacy T, Clyman R. How useful are B-type natriuretic peptide measurements for monitoring changes in patent ductus arteriosus shunt magnitude? J Perinatol 2010; 30:780-5. [PMID: 20376057 PMCID: PMC9948640 DOI: 10.1038/jp.2010.47] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Although B-type natriuretic peptide (BNP) concentrations seem to be useful for detecting the presence of patent ductus arteriosus, there is no information about their usefulness for monitoring changes in PDA shunt magnitude. STUDY DESIGN We performed a retrospective analysis of paired BNP-echocardiogram measurements (obtained from infants (24 to 32 weeks gestation) with clinical suspicion of PDA). RESULT Individual BNP concentrations (n=146, from 88 infants) were significantly related to shunt magnitude at the time of measurement and had good discriminating power for detecting a moderate-or-large shunt (area under receiver-operator characteristic curves (ROC-AUC)=0.85). In total, 36 infants had serial BNP-echocardiogram pairs (n=91) measured during their hospitalization. Changes (either increases or decreases) in BNP concentrations over time had only fair discriminating power (ROC-AUC=0.76) for detecting increases or decreases, respectively, in shunt magnitude. CONCLUSION The high degree of variability in the BNP measurements made them less useful for monitoring changes in magnitude.
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Affiliation(s)
- Sharon Chen
- Department of Pediatrics, University of California, San Francisco, CA
| | - Theresa Tacy
- Department of Pediatrics, University of California, San Francisco, CA
| | - Ronald Clyman
- Department of Pediatrics, University of California, San Francisco, CA,Department of Cardiovascular Research Institute, University of California, San Francisco, CA
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Jhaveri N, Moon-Grady A, Clyman RI. Early surgical ligation versus a conservative approach for management of patent ductus arteriosus that fails to close after indomethacin treatment. J Pediatr 2010; 157:381-7, 387.e1. [PMID: 20434168 PMCID: PMC2926149 DOI: 10.1016/j.jpeds.2010.02.062] [Citation(s) in RCA: 116] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2009] [Revised: 02/11/2010] [Accepted: 02/25/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To examine whether a more conservative approach to treating patent ductus arteriosus (PDA) is associated with an increase or decrease in morbidity compared with an approach involving early PDA ligation. STUDY DESIGN In January 2005, we changed our approach to infants born at age RESULTS The 2 periods had similar rates of perinatal/neonatal risk factors and indomethacin failure (24%), as well as ventilator management and feeding advance protocols. The conservative approach (period 2) was associated with decreased rates of duct ligation (72% vs 100%; P<.05). Even though infants subjected to this approach were exposed to larger PDA shunts for longer durations, the rates of bronchopulmonary dysplasia, sepsis, retinopathy of prematurity, neurologic injury, and death were similar to those in period 1. The overall rate of necrotizing enterocolitis was significantly lower in period 2 compared with period 1. CONCLUSIONS These findings support the need for new controlled, randomized trials to reexamine the benefits and risks of different approaches to PDA treatment.
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Affiliation(s)
- Nami Jhaveri
- Department of Pediatrics, University of California, San Francisco, CA 94143-0544, USA
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Jantzen DW, Aldoss O, Sanford B, Fletcher SE, Danford DA, Kutty S. Is Combined Atrial Volumetrics by Two-Dimensional Echocardiography a Suitable Measure for Quantitative Assessment of the Hemodynamic Significance of Patent Ductus Arteriosus in Neonates and Infants? Echocardiography 2010; 27:696-701. [DOI: 10.1111/j.1540-8175.2010.01192.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Carmo KB, Evans N, Paradisis M. Duration of indomethacin treatment of the preterm patent ductus arteriosus as directed by echocardiography. J Pediatr 2009; 155:819-822.e1. [PMID: 19643435 DOI: 10.1016/j.jpeds.2009.06.013] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2008] [Revised: 04/01/2009] [Accepted: 06/08/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To determine whether the duration of indomethacin administration could be shortened in infants with good early constrictive response of patent ductus arteriosus (PDA). STUDY DESIGN Infants born at< 30 weeks' gestational age were assessed with echocardiography in the first 12 hours of life and treated with indomethacin (0.1 mg/kg) if the PDA was >2 mm in diameter. Randomization occurred before the second dose to either standard treatment (2 more doses of indomethacin at 0.1 mg/kg irrespective of echocardiographic findings) or to echocardiographically directed duration of indomethacin treatment (ECHO; further doses only if the PDA was>1.6 mm). Serial echocardiography was performed to day 28 of age. The primary outcome was failure of PDA closure. RESULTS The infants were randomized to either the ECHO arm (n=34) or the standard treatment arm (n=40). No differences between the arms were seen in terms of failure of PDA closure, PDA reopening, need for further doses of indomethacin, or need for surgical ligation. More doses of indomethacin were given in the standard treatment arm (median, 3 doses [range, 1 to 12] vs 1 dose [range, 1 to 15]; P < .0001). CONCLUSION Echocardiographically directed duration of indomethacin treatment is effective in achieving PDA closure and offers the potential for dose minimization.
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Bedside detection of low systemic flow in the very low birth weight infant on day 1 of life. Eur J Pediatr 2009; 168:809-13. [PMID: 18818945 DOI: 10.1007/s00431-008-0840-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2008] [Accepted: 09/10/2008] [Indexed: 10/21/2022]
Abstract
We aimed to assess the relationship between the clinical and biochemical parameters of perfusion and superior vena cava (SVC) flow in a prospective observational cohort study of very low birth weight (VLBW) infants. Newborns with congenital heart disease were excluded. Echocardiographic evaluation of SVC flow was performed in the first 24 h of life. Capillary refill time (forehead, sternum and toe), mean blood pressure, urine output and serum lactate concentration were also measured simultaneously. Thirty-eight VLBW infants were examined. Eight patients (21%) had SVC flow less than 40 ml/kg/min. There was a poor correlation between the capillary refill time (in all sites), mean blood pressure, urine output and SVC flow. The correlation coefficient for the serum lactate concentration was r = -0.28, p = 0.15. The median serum lactate concentration was 3.5 (range 2.8-8.5) vs. 2.7 (range 1.2-6.9) mmol/l (p = 0.01) in low flow versus normal flow states. A serum lactate concentration of >2.8 was 100% sensitive and 60% specific for detecting a low flow state. Combining a capillary refill time of >4 s with a serum lactate concentration of >4 mmol/l had a specificity of 97% for detecting a low SVC flow state. Serum lactate concentrations are higher in low SVC flow states. A capillary refill time of >4 s combined with serum lactate concentrations >4 mmol/l increased the specificity and positive and negative predictive values of detecting a low SVC flow state.
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Chiruvolu A, Punjwani P, Ramaciotti C. Clinical and echocardiographic diagnosis of patent ductus arteriosus in premature neonates. Early Hum Dev 2009; 85:147-9. [PMID: 19217224 DOI: 10.1016/j.earlhumdev.2008.12.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2008] [Accepted: 12/11/2008] [Indexed: 10/21/2022]
Abstract
The ductus arteriosus frequently fails to close in premature neonates. Considerable difference in opinion exists around what signifies a hemodynamically significant patent ductus arteriosus (PDA) and how reliable clinical signs are in determining the degree of the left-to-right shunting. Although reliance on clinical signs alone could delay the diagnosis of a PDA, there is insufficient evidence to suggest that early treatment improves outcome. Echocardiography is often used as the gold standard for diagnosing a PDA. A combination of echocardiographic measurements may assist in the early diagnosis of a PDA with a hemodynamically significant degree of left-to-right shunting, especially in extremely premature babies, where closure can be significantly delayed. Decision to treat PDA should be based on a combination of clinical signs and echocardiographic parameters. Monitoring B-type natriuretic peptide may be useful in the diagnosing neonates with symptomatic PDA.
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Affiliation(s)
- Arpitha Chiruvolu
- Department of Pediatrics, Division of Neonatology, Baylor University Medical Center, Dallas, Texas 75246, USA.
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36
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Dempsey EM, Barrington KJ. Evaluation and treatment of hypotension in the preterm infant. Clin Perinatol 2009; 36:75-85. [PMID: 19161866 DOI: 10.1016/j.clp.2008.09.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
A large proportion of very preterm infants receive treatment for hypotension. The definition of hypotension is unclear, and, currently, there is no evidence that treating it improves outcomes or, indeed, which treatment to choose among the available alternatives. Assessment of circulatory adequacy of the preterm infant requires a careful clinical assessment and may also require ancillary investigations. The most commonly used interventions, fluid boluses and dopamine, are problematic: fluid boluses are statistically associated with worse clinical outcomes and may not even increase blood pressure, whereas dopamine increases blood pressure mostly by causing vasoconstriction and may decrease perfusion. For neither intervention is there any reliable data showing clinical benefit. Prospective trials of intervention for hypotension and circulatory compromise are urgently required.
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Affiliation(s)
- E M Dempsey
- Department of Neonatology, Cork University Maternity Hospital, Cork, Ireland
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38
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Czernik C, Lemmer J, Metze B, Koehne PS, Mueller C, Obladen M. B-type natriuretic peptide to predict ductus intervention in infants <28 weeks. Pediatr Res 2008; 64:286-90. [PMID: 18414139 DOI: 10.1203/pdr.0b013e3181799594] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Patent ductus arteriosus (PDA) is frequent in neonates with gestational age of less than 28 wk. Clinical and echocardiographic signs define hemodynamic significance of PDA, but do not reveal the need for PDA intervention in the first days of life. B-type natriuretic peptide (BNP) has been proposed as a screening tool for PDA in preterm infants. To determine whether BNP can predict the need for PDA intervention, plasma BNP was measured by chemiluminescence immunoassay in 67 preterm infants <28 wk (median 26) on the second day of life in a prospective blinded study. PDA intervention was based on specified clinical and echocardiographic findings. Twenty-four patients (intervention group) received treatment for PDA and 43 patients (controls) remained without intervention. BNP concentrations were higher in the intervention (median 1069 pg/mL) than in the control group (247 pg/mL, p < 0.001). BNP correlated positively with ductal size (R = 0.46, p < 0.001) and atrial/aortic root ratio (R = 0.54, p < 0.001). In conclusion, plasma BNP proved to be a good predictor for ductus intervention (area under the curve: 0.86) with the best cutoff at 550 pg/mL on the second day of life in ventilated infants less than 28 wk gestation (sensitivity: 83%; specificity: 86%).
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Affiliation(s)
- Christoph Czernik
- Department of Neonatology, Medical University Berlin, Berlin, Germany.
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Guo L, Tabrizchi R. Haemodynamic effects of vasoactive agents following chronic state of high cardiac output in anaesthetized rats. Eur J Pharmacol 2008; 586:266-74. [DOI: 10.1016/j.ejphar.2008.02.045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2007] [Revised: 01/29/2008] [Accepted: 02/14/2008] [Indexed: 11/17/2022]
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Groves AM, Kuschel CA, Knight DB, Skinner JR. Does retrograde diastolic flow in the descending aorta signify impaired systemic perfusion in preterm infants? Pediatr Res 2008; 63:89-94. [PMID: 18043512 DOI: 10.1203/pdr.0b013e31815b4830] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
High-volume systemic-to-pulmonary ductal shunting occurs frequently in preterm infants and is indicated by diastolic flow reversal in the descending aorta (DAo). We studied the relationship between ductal diameter, diastolic DAo reversal, and left ventricular output (LVO); and superior vena caval (SVC) flow (upper body perfusion) and DAo flow (lower body perfusion) in preterm (<31 wk) infants. Echocardiographic assessments were performed at 5, 12, 24, and 48 h postnatal age (80 infants, median gestation 28 wk, 1060 g). Incidence of ductal patency fell from 100% at 5 h to 72% at 48 h; incidence of pure systemic-to-pulmonary shunting increased from 66% to 95% of infants with patent ducts. In infants with duct diameter greater than the median, 35-48% of infants had DAo flow reversal. In infants with duct diameter greater than median, DAo reversal was associated with 23-29% increases in LVO at 5-48 h, and 35% decreases in DAo flow volume at 24-48 h, but no differences in SVC flow. In conclusion, a large duct with left-to-right shunting is common in preterm infants. Retrograde DAo flow is a marker of high-volume shunt, evidenced by increased LVO. Preterm infants with high-volume ductal shunt may have preserved upper body perfusion but reduced lower body perfusion.
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Affiliation(s)
- Alan M Groves
- Neonatal Unit, Queen Charlotte's and Chelsea Hospital, London, W12 0HS, United Kingdom.
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Groves AM, Kuschel CA, Knight DB, Skinner JR. Relationship between blood pressure and blood flow in newborn preterm infants. Arch Dis Child Fetal Neonatal Ed 2008; 93:F29-32. [PMID: 17475696 DOI: 10.1136/adc.2006.109520] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Arterial blood pressure remains the most frequently monitored indicator of neonatal circulatory status. However, studies of systemic perfusion in neonates have often shown only weakly positive associations with blood pressure. OBJECTIVES To examine the relationship between invasively monitored arterial blood pressure and four measurements of systemic perfusion: left and right ventricular outputs, superior vena caval (SVC) flow and descending aortic (DAo) flow. DESIGN Echocardiographic assessments of perfusion were performed four times in the first 48 h of postnatal life in a cohort of 34 preterm (<30 weeks) infants. Arterial blood pressure was monitored invasively over the exact duration of the echocardiogram. RESULTS In the first 48 h of postnatal life there was no evidence of a positive association between blood pressure and volume of blood flow in any of the four vessels studied. At 5 h postnatal age there was a weak but significant inverse correlation between volume of SVC flow and arterial blood pressure (p = 0.04). A similar but non-significant trend was seen at 12 h postnatal age. CONCLUSIONS Infants with reduced systemic perfusion tend to have normal or high blood pressure in the first hours of life, suggesting that a high systemic vascular resistance may lead to reduced blood flow. Low blood pressure does not correlate with poor perfusion in the first 48 h of postnatal life in sick preterm infants.
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Affiliation(s)
- A M Groves
- Neonatal Unit, Queen Charlotte's and Chelsea Hospital, Du Cane Road, London, UK.
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Noori S, Friedlich P, Seri I, Wong P. Changes in myocardial function and hemodynamics after ligation of the ductus arteriosus in preterm infants. J Pediatr 2007; 150:597-602. [PMID: 17517241 DOI: 10.1016/j.jpeds.2007.01.035] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2006] [Revised: 12/29/2006] [Accepted: 01/26/2007] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To characterize the changes in systemic hemodynamics and systolic, diastolic, and global myocardial performance after patent ductus arteriosus (PDA) ligation in very-low-birth-weight infants. STUDY DESIGN Echocardiograms were performed on 23 neonates (mean gestational age, 26.2 +/- 2.2 weeks) at 2.3 +/- 2.0 hours before PDA ligation (n = 23) and at 2.0 +/- 1.4 hours (n = 23) and 23.5 +/- 2.5 hours after (n = 11) PDA ligation. RESULTS Mean blood pressure, heart rate, load-independent contractility, shortening fraction, left ventricular (LV) afterload, and diastolic function did not change. Preload (early and atrial mitral inflow velocities) decreased immediately after ligation but remained unchanged thereafter. LV output decreased and systemic vascular resistance increased after surgery. The LV myocardial performance index (MPI), a measure of global myocardial performance, deteriorated acutely after ligation but improved by 23.5 hours after surgery. Changes in LV MPI were most closely correlated with changes in LV output. CONCLUSIONS After PDA ligation, LV output and MPI decrease, due primarily to a decrease in LV preload, although LV contractility and diastolic function do not change. However, the changes in LV MPI after ligation also reflect an acute deterioration followed by an improvement in global cardiac function, because LV loading conditions remained unchanged after surgery and thus cannot explain the improvement in MPI by 24 hours after ligation.
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Affiliation(s)
- Shahab Noori
- Division of Neonatal Medicine, Department of Pediatrics, Childrens Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA 90027, USA.
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Osborn DA, Evans N, Kluckow M. Left ventricular contractility in extremely premature infants in the first day and response to inotropes. Pediatr Res 2007; 61:335-40. [PMID: 17314693 DOI: 10.1203/pdr.0b013e318030d1e1] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The aim was to assess myocardial contractility in infants born <30 wk gestation developing low systemic blood flow (SBF) in the first day, and the effect of dobutamine versus dopamine. Superior vena cava (SVC) flow was used as a measure of SBF at 3, 10, and 24 h (n = 106). Infants with low SVC flow randomized to dopamine or dobutamine. Myocardial contractility was determined by the relationship between left ventricular (LV) mean velocity of circumferential fiber shortening (mVcfs) and wall stress. Infants who developed low SVC flow had significantly worse myocardial contractility at 3 h, but not 10 h. At 24 h, low-flow infants had lower than expected mVcfs for any given LV stress. In 37 infants randomized to inotrope, there was no significant difference in contractility at 10 microg/kg/min. At 20 microg/kg/min (n = 21), dopamine increased whereas dobutamine decreased LV stress. Infants on dobutamine had significantly lower than expected mVcfs for any given LV stress compared with infants on dopamine. Contractility was not improved by either inotrope at either dose. In conclusion, infants developing low SVC flow in the first day have worse myocardial contractility at 3 h. Neither inotrope increased contractility, but dopamine increased LV stress at 20 microg/kg/min.
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Affiliation(s)
- David A Osborn
- RPA Newborn Care, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia.
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Kluckow M, Seri I, Evans N. Functional echocardiography: an emerging clinical tool for the neonatologist. J Pediatr 2007; 150:125-30. [PMID: 17236886 DOI: 10.1016/j.jpeds.2006.10.056] [Citation(s) in RCA: 120] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2006] [Revised: 08/19/2006] [Accepted: 10/12/2006] [Indexed: 10/23/2022]
MESH Headings
- Cardiac Output, Low
- Echocardiography, Doppler/methods
- Echocardiography, Doppler/trends
- Echocardiography, Three-Dimensional/methods
- Echocardiography, Three-Dimensional/trends
- Female
- Forecasting
- Heart Defects, Congenital/diagnostic imaging
- Heart Defects, Congenital/physiopathology
- Humans
- Infant, Newborn
- Infant, Premature
- Infant, Very Low Birth Weight
- Intensive Care Units, Neonatal
- Male
- Neonatology/standards
- Neonatology/trends
- Risk Factors
- Sensitivity and Specificity
- Severity of Illness Index
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Affiliation(s)
- Martin Kluckow
- Department of Neonatal Medicine, Royal North Shore Hospital, Sydney, Australia.
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Abstract
There are no clinical outcome data on which to base recommendations on how to assess and support the preterm circulation. Current standards are derived from an assumed proportionality between systemic and organ blood flow and mean blood pressure. Our study of central measures of systemic blood flow suggests preterm haemodynamics are more complex than this. Low systemic blood flow is common in the first 24 h after birth in very preterm babies and is not necessarily reflected by low blood pressure. The causes of this low systemic blood flow are complex but may relate to maladaptation to high extrauterine systemic (and sometimes pulmonary) vascular resistance. After day 1, hypotensive babies are more likely to have normal or high SBF reflecting vasodilatation. Empirically, inotropes that reduce afterload (such as dobutamine) may be more appropriate in the transitional period, while those with more vasoconstrictor actions (such as dopamine) may be more appropriate later on. Defining the haemodynamic in an individual baby needs both blood pressure and echocardiographic measures of systemic blood flow. Research in this area needs to move beyond just demonstrating changes in physiological variables to showing improvements in important clinical outcomes.
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Affiliation(s)
- Nick Evans
- Department of Neonatal Medicine, RPA Women and Babies, Royal Prince Alfred Hospital and University of Sydney, Camperdown, Sydney, NSW, Australia.
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Evans JR, Lou Short B, Van Meurs K, Cheryl Sachs H. Cardiovascular support in preterm infants. Clin Ther 2006; 28:1366-84. [PMID: 17062310 DOI: 10.1016/j.clinthera.2006.09.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2006] [Indexed: 01/09/2023]
Abstract
BACKGROUND Despite increasing investigation in the area of cardiovascular instability in preterm infants, huge gaps in knowledge remain. None of the current treatments for hypotension, including the use of inotropic agents, have been well studied in the preterm population, and data regarding safety and efficacy are lacking. Thus, the labeling information regarding the use of inotropes as therapeutic agents in this population is inadequate. OBJECTIVE This article reviews the current deficiencies in knowledge with respect to measuring and achieving normal organ perfusion; summarizes the clinical, methodological, and ethical issues to consider when designing trials to evaluate medications for hemodynamic instability in the preterm neonate; and proposes 2 possible trial designs. Unanswered questions and potential obstacles for the systematic study of drugs to treat cardiovascular instability in preterm neonates are discussed. METHODS The neonatal Cardiology Group was established in 2003 by the US Food and Drug Administration (FDA) and the National Institute of Child Health and Human Development (NICHD) as part of the Newborn Drug Development Initiative. The Cardiology Group conducted a number of teleconferences and one meeting to develop a document addressing gaps in knowledge regarding cardiovascular drugs commonly used in low-birth-weight neonates and possible approaches to investigate these drugs. This work was presented at a workshop cosponsored by the NICHD and the FDA held in March 2004 in Baltimore, Maryland. Information for this article was gathered during this initiative. RESULTS To develop rational, evidence-based guidelines corroborated by robust scientific data for cardiovascular support in newborns, well-designed and adequately powered pharmacologic studies and clinical trials are needed to evaluate the safety and efficacy of inotropic agents and to determine the short- and long-term effects of these drugs. Trials investigating the currently available and novel therapies for cardiovascular instability in neonates will provide information that can be incorporated into product labeling and a scientific framework for cardiovascular management in critically ill neonates. The Cardiology Group identified and prioritized 2 conditions for investigation of therapeutic options for the management of neonatal cardiovascular instability: (1) cardiovascular instability in preterm neonates; and (2) cardiac dysfunction in neonates after cardiopulmonary bypass surgery. Key research questions in the area of cardiovascular instability in the preterm infant include determining optimal blood pressure (BP) in preterm infants; identifying better measures than BP to determine organ perfusion; optimizing hemodynamic treatments; and clarifying any associations between BP or therapy for low BP and mortality, intraventricular hemorrhage, periventricular leukomalacia, necrotizing enterocolitis, retinopathy of prematurity, and neurodevelopmental outcome. The Cardiology Group concluded that the study of inotropic agents in neonates using outcomes of importance to patients will require a complicated trial design to address the elements discussed. The group proposed 2 clinical trial designs: (1) a placebo-controlled trial with rescue therapy for symptomatic infants; and (2) a targeted BP trial. CONCLUSION This summary is intended to stimulate and assist future research in the area of cardiovascular support for preterm infants.
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Affiliation(s)
- Jacquelyn R Evans
- Division of Neonatology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA.
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Short BL, Van Meurs K, Evans JR. Summary proceedings from the cardiology group on cardiovascular instability in preterm infants. Pediatrics 2006; 117:S34-9. [PMID: 16777820 DOI: 10.1542/peds.2005-0620f] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The appropriate determination of adequate tissue perfusion and the best approach to treatment of perceived abnormalities in blood pressure in the neonate remain controversial. There is no consensus regarding the actual definition of hypotension in the neonate or how best to raise perceived low blood pressure. In addition, there is no direct and prospectively collected information available on the result of treatment of a "low" blood pressure on neonatal morbidity and mortality. It also has not been clearly demonstrated that bringing systemic blood pressure to a "normal" range improve outcomes. However, it is widely accepted by clinicians that early and aggressive treatment of hypotension leads to improved neurologic outcome and survival in the neonate. Commonly used therapeutic maneuvers to correct systemic hypotension in the neonate include volume expansion, inotropic agents, and corticosteroids. Although there is a paucity of research on the cardiovascular response to these commonly used agents in neonates, among the commonly used inotropic drugs dopamine has been shown to be more effective than dobutamine in raising blood pressure in the neonate. The cardiology group focused on the use of inotropes, particularly dopamine and dobutamine, to treat very low birth weight infants with cardiac instability and neonatal postoperative cardiac patients. The cardiology group identified key issues that must be considered when designing studies of inotropic agents in preterm infants and proposed 2 clinical-trial designs: (1) a placebo-controlled trial with rescue for symptomatic infants; and (2) a targeted-blood pressure study. The first trial design would answer questions concerning efficacy of treatment with inotropic agents in this population. The second trial design would address concerns related to the lack of knowledge on normal blood pressure ranges in this population. The group identified specific design elements that would need to be addressed for the complicated trial design to study inotropic agents in neonates.
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Affiliation(s)
- Billie Lou Short
- Division of Neonatology, Children's National Medical Center, Department of Pediatrics, George Washington University School of Medicine, 111 Michigan Ave NW, Washington, DC 20010, USA.
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Freeman-Ladd M, Cohen JB, Carver JD, Huhta JC. The hemodynamic effects of neonatal patent ductus arteriosus shunting on superior mesenteric artery blood flow. J Perinatol 2005; 25:459-62. [PMID: 15815707 DOI: 10.1038/sj.jp.7211294] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To determine if the ratio of the pulsatility index (PI) of the left pulmonary artery to the PI of the descending aorta, the Rp/Rs index, correlates with the degree of ductal steal from the intestine in neonates with a patent ductus arteriosus (PDA). STUDY DESIGN Echocardiograms and Doppler studies of the superior mesenteric artery (SMA) were performed in 41 neonates less than 35 weeks gestational age with a hemodynamically significant PDA (hsPDA). RESULTS There was a significant negative correlation between the Rp/Rs index and the SMA PI after controlling for ductal size (r=-0.476, p<0.008). CONCLUSIONS The Rp/Rs index can be used as an indicator of ductal steal on intestinal blood flow. The Rp/Rs index may be a useful adjunct to existing and new techniques for improving early assessment and treatment of hsPDA, and for evaluating the effects of hsPDA on systemic organs.
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MESH Headings
- Aorta, Thoracic/diagnostic imaging
- Aorta, Thoracic/physiopathology
- Blood Flow Velocity/physiology
- Ductus Arteriosus, Patent/physiopathology
- Humans
- Infant, Low Birth Weight
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/physiopathology
- Mesenteric Artery, Superior/diagnostic imaging
- Mesenteric Artery, Superior/physiopathology
- Pulmonary Artery/diagnostic imaging
- Pulmonary Artery/physiopathology
- Pulse
- Regional Blood Flow/physiology
- Retrospective Studies
- Severity of Illness Index
- Ultrasonography
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Affiliation(s)
- Mayra Freeman-Ladd
- Department of Pediatrics, University of South Florida College of Medicine, Tampa, FL 33606, USA
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Sidwell RU, Daubeney PEF, Porter W, Roberts NM. Neonatal hemangiomatosis and atrial septal defect: a rare cause of right heart failure in infancy. Pediatr Dermatol 2004; 21:66-9. [PMID: 14871331 DOI: 10.1111/j.0736-8046.2004.21115.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Neonatal hemangiomatosis is a well-recognized cause of left ventricular failure. We describe an infant with neonatal hemangiomatosis and an ostium secundum atrial septal defect who developed severe right heart failure. This was due to the combination of increased flow through the right heart as a result of the atrial septal defect, and the background high cardiac output from the massive arteriovenous shunting and multiple hemangiomas. In addition, the multiple hepatic hemangiomas may exert a vasoactive influence on the pulmonary vasculature.
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Affiliation(s)
- Rachel U Sidwell
- Department of Pediatric Dermatology, Chelsea and Westminster Hospital, London, United Kingdom
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