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Kooi EMW, Mintzer JP, Rhee CJ, Ergenekon E, Schwarz CE, Pichler G, de Boode WP. Neonatal somatic oxygenation and perfusion assessment using near-infrared spectroscopy : Part of the series on near-infrared spectroscopy by the European Society of Paediatric Research Special Interest Group "Near-Infrared Spectroscopy". Pediatr Res 2024:10.1038/s41390-024-03226-z. [PMID: 38730022 DOI: 10.1038/s41390-024-03226-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 02/27/2024] [Accepted: 04/09/2024] [Indexed: 05/12/2024]
Abstract
In this narrative review, we summarize the current knowledge and applications of somatic near-infrared spectroscopy (NIRS), with a focus on intestinal, renal, limb, and multi-site applications in neonates. Assessing somatic oxygenation at various body locations in neonates may aid in the understanding of underlying pathophysiology of organ injury. Considering cerebral autoregulation may be active to protect the brain during systemic circulatory failure, peripheral somatic oxygenation may potentially provide an early indication of neonatal cardiovascular failure and ultimate hypoxemic injury to vital organs including the brain. Certain intestinal oxygenation patterns appear to be associated with the onset and course of necrotizing enterocolitis, whereas impaired renal oxygenation may indicate the onset of acute kidney injury after various types of hypoxic events. Peripheral muscle oxygenation measured at a limb may be particularly effective in the early prediction of shock in neonates. Using multi-site NIRS may complement current approaches and clinical investigations to alert for neonatal tissue hypoxemia, and potentially even guide management. However, somatic NIRS has its inherent limitations in regard to accuracy. Interpretation of organ-specific values can also be challenging. Last, currently there are limited prospective intervention studies, and clinical benefits need to be examined further, after the clarification of critical threshold-values. IMPACT: The assessment of somatic oxygenation using NIRS may contribute to the prediction of specific diseases in hemodynamically challenged neonates. Furthermore, it may give early warning signs for impending cardiovascular failure, and impaired cerebral circulation and oxygenation. We present a comprehensive overview of the literature on applications of NIRS to various somatic areas, with a focus on its potential clinical applicability, including future research directions. This paper will enable prospective standardized studies, and multicenter collaboration to obtain statistical power, likely to advance the field.
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Affiliation(s)
- Elisabeth M W Kooi
- Division of Neonatology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
| | - Jonathan P Mintzer
- Division of Newborn Medicine, Department of Pediatrics, Mountainside Medical Center, Montclair, NJ, USA
| | | | | | - Christoph E Schwarz
- Department of Neonatology, Tübingen University Hospital, Tübingen, Germany
- Department of Neonatology, Center for Pediatric and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
| | - Gerhard Pichler
- Department of Pediatrics, Medical University of Graz, Graz, Austria
| | - Willem P de Boode
- Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
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2
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Persad E, Brindefalk B, Rakow A. Blood pressure trends following birth in infants born under 25 weeks' gestational age: a retrospective cohort study. BMJ Paediatr Open 2024; 8:e002438. [PMID: 38531550 DOI: 10.1136/bmjpo-2023-002438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 02/17/2024] [Indexed: 03/28/2024] Open
Abstract
OBJECTIVE The aim of our study was to describe postnatal blood pressure (BP) trends and evaluate relevant dynamics and outcomes for a subgroup of extremely preterm (EPT) infants. DESIGN Retrospective observational cohort study. SETTING Patients admitted to Karolinska University Hospital Stockholm. PATIENTS EPT infants born between 22+0 and 24+6 weeks' gestational age (GA) undergoing invasive, continuous BP monitoring through an umbilical arterial catheter. MAIN OUTCOME MEASURES Physiological BP trends, the influence of cardiovascular active interventions and fluid boluses on BP, and relevant adverse outcomes, including intraventricular haemorrhage (IVH), necrotising enterocolitis (NEC) and death, were mapped over the first week of life. RESULTS We included 125 infants between January 2009 and November 2021. Mean BP values were 31 mm Hg, 32 mm Hg and 35 mm Hg, at 3 hours, 24 hours and 48 hours, respectively. A pronounced BP dip and nadir were observed around 20 hours, with a mean BP value of 32 mm Hg. 84% received fluid boluses within the first week of life; however, we could not observe any noteworthy change in BP following administration. Only 8% of patients received cardiovascular active drugs, which were too few to infer drug-specific effects. Overall, 48% developed IVH, 15% developed NEC and 25% died. CONCLUSIONS Approximating clinically acceptable mean BP values using GA gives underestimations in these infants. The postnatal BP dip should be regarded as a physiological phenomenon and not automatic grounds for interventions which may momentarily stabilise BP but have no appreciable short-term or long-term effects. Further studies are warranted for improved understanding of clinically relevant trends and outcomes.
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Affiliation(s)
- Emma Persad
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Department of Neonatology, Karolinska University Hospital, Stockholm, Sweden
| | - Björn Brindefalk
- Department of Molecular Biosciences, The Wenner-Gren Institute, Stockholm University, Stockholm, Sweden
| | - Alexander Rakow
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Department of Neonatology, Karolinska University Hospital, Stockholm, Sweden
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Cave DG, Bautista MJ, Mustafa K, Bentham JR. Cardiac output monitoring in children: a review. Arch Dis Child 2023; 108:949-955. [PMID: 36927620 DOI: 10.1136/archdischild-2022-325030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 03/02/2023] [Indexed: 03/18/2023]
Abstract
Cardiac output monitoring enables physiology-directed management of critically ill children and aids in the early detection of clinical deterioration. Multiple invasive techniques have been developed and have demonstrated ability to improve clinical outcomes. However, all require invasive arterial or venous catheters, with associated risks of infection, thrombosis and vascular injury. Non-invasive monitoring of cardiac output and fluid responsiveness in infants and children is an active area of interest and several proven techniques are available. Novel non-invasive cardiac output monitors offer a promising alternative to echocardiography and have proven their ability to influence clinical practice. Assessment of perfusion remains a challenge; however, technologies such as near-infrared spectroscopy and photoplethysmography may prove valuable clinical adjuncts in the future.
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Affiliation(s)
- Daniel Gw Cave
- Leeds Congenital Heart Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Leeds Institute for Data Analytics, University of Leeds, Leeds, West Yorkshire, UK
| | - Melissa J Bautista
- General Surgery, St James's University Hospital, Leeds, West Yorkshire, UK
- General Surgery, University of Leeds, Leeds, West Yorkshire, UK
| | - Khurram Mustafa
- Paediatric Intensive Care, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - James R Bentham
- Leeds Congenital Heart Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Deshpande P, Barbosa de Olivera C, Jain A, Hahn C, Shah PS, Guerguerian AM, McNamara PJ. Relationship between cerebral oxygenation, cardiac output, and blood pressure during transitional period in extremely low gestational age neonates. Front Pediatr 2023; 11:1187769. [PMID: 37654688 PMCID: PMC10466030 DOI: 10.3389/fped.2023.1187769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 08/03/2023] [Indexed: 09/02/2023] Open
Abstract
Objective To describe the relationship between cerebral oxygenation, cardiac output, arterial blood pressure (BP), and cerebral blood flow velocity in extremely low gestational age neonates (ELGANs) during transition. Methods This study comprises secondary analyses from a prospective observational study conducted at a tertiary Neonatal Intensive Care Unit. Recruited ELGANs underwent cerebral saturation (CrSO2) monitoring and serial echocardiography during 72 h from birth. Correlative analyses of CrSO2 and cerebral fractional tissue oxygen extraction (CFTOE) with left (LVO) and right ventricular output (RVO), superior vena cava (SVC) flow, middle cerebral artery blood flow mean velocity (MCA.MV), systolic (SBP), diastolic (DBP), and mean (MBP) BP were conducted. Results Fifty ELGANs with median (range) gestational age of 25.9 (23.1-27.9) weeks were recruited. Echocardiography was performed sequentially at a median (range) age 5.0 (3.8-6.6), 17.3 (15.4-19.4), 31.0 (27.0-34.1), and 53.7 (49.3-58.3) hours. RVO, LVO, CrSO2, and SBP increased over time but no changes in MBP, DBP, CFTOE, MCA.MV or SVC flow were noted. A weak correlation was identified between CrSO2 and SBP (r2 = 0.11, p = 0.047) and MBP (r2 = 0.12, p = 0.04) at 17.3 (15.4-19.4) hours. No correlation of either CrSO2 or CFTOE with any measures of blood flow was identified. Conclusion There is a weak correlation between measures of cardiac output, BP, and MCA.MV with both CrSO2 and CFTOE in ELGANs during transition. Whether this finding suggests intact cerebral autoregulation requires prospective evaluation in a cohort of sick ELGANs.
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Affiliation(s)
- Poorva Deshpande
- Department of Pediatrics, Mount Sinai Hospital, Toronto, ON, Canada
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Caio Barbosa de Olivera
- Department of Pediatrics, Mount Sinai Hospital, Toronto, ON, Canada
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Amish Jain
- Department of Pediatrics, Mount Sinai Hospital, Toronto, ON, Canada
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Cecil Hahn
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
- Neurosciences and Mental Health, Hospital for Sick Children, Toronto, ON, Canada
| | - Prakesh S. Shah
- Department of Pediatrics, Mount Sinai Hospital, Toronto, ON, Canada
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Anne-Marie Guerguerian
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
- Neurosciences and Mental Health, Hospital for Sick Children, Toronto, ON, Canada
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5
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Zaveri PG, Walker AM, Upadhyay K, Talati AJ. Use of Vasopressors in Extremely Preterm Infants in First Week of Life. Am J Perinatol 2023; 40:513-518. [PMID: 33990125 DOI: 10.1055/s-0041-1729558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE A significant variability exists for diagnosis and treatment of hypotension in extremely preterm infants. Benefits of the use of vasopressors remain unclear. We wanted to identify the risk factors associated with use of vasopressors in the first week of life and their impact on outcomes of extremely preterm infants. STUDY DESIGN Retrospective review of all newborns ≤28 weeks of gestational age (GA) admitted in neonatal intensive care unit from October 1, 2012, to October 31, 2015, done. Data regarding antenatal and neonatal characteristics and outcomes were recorded. Study infants were divided into two cohorts and compared based on vasopressor use. Chi-square, t-test, and multiple logistic regression were performed as appropriate and significance set at p <0.05. RESULTS Of 213 extremely preterm infants, 90 (42.3%) received vasopressors in first week of life. The mean arterial pressure (MAP) at admission in these infants was significantly lower than that of infants who did not require vasopressors (27 ± 8 vs. 30 ± 6 mm Hg, p < 0.05). Vasopressors were initiated within 24 hours in 91% of babies. After controlling for other variables, use of vasopressors was significantly higher in infants with lower birth weight (odds ratio [OR]: 3.2, 95% confidence interval [CI]: 1.6-8.3), 5-minute Apgar's score ≤5 (OR: 1.8, 95% CI: 1.2-3.12), and admission hypothermia (OR: 2.7, 95% CI: 1.3-4.9). The use of vasopressors was significantly associated with severe intraventricular hemorrhage (IVH), even after controlling for other significant variables (OR: 5.9, 95% CI: 1.6-9.3). CONCLUSION Lower birth weight, low 5-minute Apgar's score, and admission hypothermia are characteristics associated with early use of vasopressors in extremely preterm infants. Infants treated with vasopressors are at a higher risk of developing severe IVH. KEY POINTS · Low systemic blood pressure is a very common problem in the extremely preterm population.. · In clinical practice, mean arterial blood pressure (BP) less than the infants GA in week is typically considered to be "low BP.". · About 50% of infants born at <29 weeks of GA received very preterm in the first week of life.. · Use of vasopressors is associated with a higher incidence of intraventricular hemorrhage in extremely preterm population..
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Affiliation(s)
- Parul G Zaveri
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee
- Division of Neonatology, Regional One Health, Memphis, Tennessee
| | - Amanda M Walker
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Kirtikumar Upadhyay
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | - Ajay J Talati
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee
- Division of Neonatology, Regional One Health, Memphis, Tennessee
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Pfurtscheller D, Wolfsberger CH, Höller N, Schwaberger B, Mileder LP, Baik-Schneditz N, Urlesberger B, Schmölzer GM, Pichler G. Cardiac output and regional-cerebral-oxygen-saturation in preterm neonates during immediate postnatal transition: An observational study. Acta Paediatr 2023. [PMID: 36880893 DOI: 10.1111/apa.16745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 03/02/2023] [Accepted: 03/03/2023] [Indexed: 03/08/2023]
Abstract
AIM To examine potential correlations between cardiac output (CO) with cerebral-regional-oxygen-saturation (crSO2 ) and cerebral-fractional-tissue-oxygen-extraction (cFTOE) during immediate foetal-to-neonatal transition in term and preterm neonates with and without respiratory support. METHODS Post hoc analyses of secondary outcome parameters of prospective observational studies were performed. We included neonates with cerebral near-infrared-spectroscopy (NIRS) monitoring and an oscillometric blood pressure measurement at minute 15 after birth. Heart rate (HR) and arterial oxygen saturation (SpO2 ) were monitored. CO was calculated with Liljestrand and Zander formula and correlated with crSO2 and cFTOE. RESULTS Seventy-nine preterm neonates and 207 term neonates with NIRS measurements and calculated CO were included. In 59 preterm neonates (mean gestational age (GA): 29.4 ± 3.7 weeks) with respiratory support, CO correlated significantly positively with crSO2 and significantly negatively with cFTOE. In 20 preterm neonates (GA 34.9 ± 1.3 weeks) without respiratory support and in 207 term neonates with and without respiratory support, CO correlated neither with crSO2 nor with cFTOE. CONCLUSION In compromised preterm neonates with lower gestational age and in need of respiratory support, CO was associated with crSO2 and cFTOE, whereas in stable preterm neonates with higher gestational age as well as in term neonates with and without respiratory support, no associations were observed.
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Affiliation(s)
- Daniel Pfurtscheller
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Christina H Wolfsberger
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Nina Höller
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Bernhard Schwaberger
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Lukas P Mileder
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Nariae Baik-Schneditz
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Berndt Urlesberger
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Georg M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada.,Department of Pediatrics, Division of Neonatology Department of Pediatrics and Adolescent Medicine Medical, University of Alberta, Edmonton, Alberta, Canada
| | - Gerhard Pichler
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
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7
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Riccardi R, Barone G, Iannotta R, Prontera G, D'Andrea V, Vento G. Normal values for superior vena cava flow in preterm neonates using a new echocardiographic approach. Echocardiography 2023; 40:45-50. [PMID: 36478465 DOI: 10.1111/echo.15507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 10/17/2022] [Accepted: 11/27/2022] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE Recently, a novel approach to imaging Superior Vena Cava (SVC) flow has been presented, showing better repeatability and better agreement with MRI-derived SVC flow measures. The objective was to establish normal values of SVC flow with the novel approach in the first 48 h of life. STUDY DESIGN This was a prospective, observational study. All infants with gestational age (GA) less than 31 weeks were eligible. Echocardiographic evaluation was performed at 5, 12, 24, 48 h of postnatal life. A subgroup of uncomplicated infants was studied to define a normal range for SVC flow. RESULTS Forty-five infants were enrolled. We estimated normative values in a subgroup of 31 uncomplicated infants. The median SVC flow significantly increases from 83 ml/kg/min at 5 h of life to 153 ml/kg/min at 48 h (p < .001). CONCLUSION Using the novel approach we derived normal values of SVC flow in a cohort of uncomplicated preterm population at high risk for developing IVH.
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Affiliation(s)
- Riccardo Riccardi
- Neonatal Intensive Care Unit, "San Giovanni Calibita Fatebenefratelli" Hospital, Isola Tiberina, Rome, Italy
| | - Giovanni Barone
- Neonatal Intensive Care Unit, Infermi Hospital, Rimini, Italy
| | - Rossella Iannotta
- Neonatal Intensive Care Unit, 'Sacro Cuore di Gesù' Fatebenefratelli Hospital, Benevento, Italy
| | - Giorgia Prontera
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Vito D'Andrea
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Giovanni Vento
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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Seyad SV, Shambhu SK, Doreswamy SM. Is perfusion index a surrogate indicator of left ventricular contractility in neonates? A prospective study. Ann Pediatr Cardiol 2023; 16:32-36. [PMID: 37287834 PMCID: PMC10243667 DOI: 10.4103/apc.apc_71_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 08/31/2022] [Accepted: 02/06/2023] [Indexed: 06/09/2023] Open
Abstract
Introduction Noninvasive blood pressure monitoring may not accurately reflect cardiac contractility in neonates due to low vascular tone. The perfusion index (PI) is a noninvasive method of assessing the strength of peripheral pulses. It is shown to have a significant correlation with the left ventricular output. This prospective study estimates the correlation between PI and cardiac contractility in neonates. Methods and Results All hemodynamically stable neonates who were on substantial enteral feeds and not on any respiratory or inotropic support underwent measurement of PI and echocardiography examination. Various indices of left ventricular contractility were estimated, and the correlation coefficient between them and PI was determined. Fifty-six neonates were studied. The median (interquartile range [IQR]) PI was 1.5 (1.25-1.75). The median (IQR) PI in preterm neonates was 1.5 (1.2-1.8) and that in term neonates was 1.8 (1.25-2.7) (P = 0.064). PI had a correlation of 0.205 with fractional shortening (P = 0.129) and 0.13 with left ventricular ejection fraction (P = 0.821). The Spearman's correlation coefficient between PI and velocity of circumference fiber shortening was 0.009 (P = 0.945). The Spearman's correlation coefficient between PI and cardiac output was -0.115 (P = 0.400). Conclusion The PI does not correlate with left ventricular contractility parameters in neonates.
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Affiliation(s)
- Sohail V. Seyad
- Department of Pediatrics, JSS Medical College, JSS Academy of Higher Education and Research, Mysore, Karnataka, India
| | - Sunil Kumar Shambhu
- Department of Pediatrics, JSS Medical College, JSS Academy of Higher Education and Research, Mysore, Karnataka, India
| | - Srinivasa Murthy Doreswamy
- Department of Pediatrics, JSS Medical College, JSS Academy of Higher Education and Research, Mysore, Karnataka, India
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Abstract
Acute pulmonary hypertension (aPH) is a complex, physiology-driven disorder that causes critical illness in newborns, the hallmark of which is elevated pressure in the pulmonary vascular bed. Several underlying hemodynamic phenotypes exist, including classic arterial aPH with resistance-driven elevations in pulmonary arterial pressure (PAP), alongside flow-driven aPH from left-to-right shunt lesions, and primary left ventricular dysfunction with pulmonary venous hypertension and elevated left atrial pressure. Targeted neonatal echocardiography (TnECHO) is an important tool for evaluation of hemodynamics in aPH and is highly useful for evaluating modulators of disease and targeting cardiovascular therapy. The diagnostic approach to aPH includes confirmation of elevation of PAP, evaluation of the cause and exclusion of structural cardiac disease, assessment of the response of the myocardium to adverse loading conditions, and appraisal of the adequacy of systemic blood flow. Therapeutic goals include support of right ventricular (RV) function, RV afterload reduction, and selection of cardiotropic agents that support underlying pathophysiology without adverse effects on heart rate or pulmonary vascular resistance in addition to routine supportive intensive care. Training programs for TnECHO exist across multiple jurisdictions and strong correlation with pediatric cardiology assessment has been demonstrated. Future directions include adapting TnECHO training with a greater focus on achieving competency, and further research into the role of the modality in providing individualized cardiovascular care for patients with heterogenous underlying physiology, and its effect on key neonatal outcomes.
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10
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Hoffman SB, Magder LS, Viscardi RM. Renal versus cerebral saturation trajectories: the perinatal transition in preterm neonates. Pediatr Res 2022; 92:1437-1442. [PMID: 35177816 DOI: 10.1038/s41390-022-01984-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 01/04/2022] [Accepted: 01/26/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND The aim of this study was to develop reference renal saturation (rSrO2) curves in premature infants, depict how they differ from cerebral saturation (rScO2) curves, and evaluate the effect of blood pressure on these values using near-infrared spectroscopy (NIRS). METHODS This is a prospective cohort study of 57 inborn infants <12 h and <30 weeks gestation. rScO2, rSrO2, fractional tissue oxygen extraction (FTOE), and mean arterial blood pressure (MAP) were continuously monitored every 30 s for 96 h. Quantile regression was used to establish nomograms, and mean saturation values were evaluated for different MAP ranges. RESULTS Median rSrO2 at the start of monitoring was ~10% higher than rScO2. rSrO2 showed a significant decline over time while rScO2 peaked at 26 h. FTOE demonstrated a similar but inverse trend to their saturation counterparts. rScO2 declined as MAP increased, while rSrO2 showed a peak and decline as MAP increased. CONCLUSIONS We provide rSrO2 reference curves for the first 4 days of life, which differ in their trajectory from rScO2 and from what has previously been reported for rSrO2 in the full-term population. In addition, we observed a peak and decline in renal saturation with increasing MAP, suggesting a renovascular response to blood pressure changes. IMPACT This article depicts reference renal saturation curves during the perinatal transition in preterm infants. We show how renal saturation compares to cerebral saturation trends over time. We describe a peak and decline in renal saturation with increasing MAP, suggesting a renovascular response to blood pressure changes.
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Affiliation(s)
- Suma B Hoffman
- Department of Pediatrics, University of Maryland Baltimore School of Medicine, Baltimore, MD, USA. .,Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Children's National Health System - Neonatology, Washington, DC, USA.
| | - Laurence S Magder
- Department of Epidemiology and Public Health, University of Maryland Baltimore School of Medicine, Baltimore, MD, USA
| | - Rose M Viscardi
- Department of Pediatrics, University of Maryland Baltimore School of Medicine, Baltimore, MD, USA
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11
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Sarafidis K, Verykouki E, Nikopoulos S, Apostolidou-Kiouti F, Diakonidis T, Agakidou E, Kontou A, Haidich AB. Systematic Review and Meta-Analysis of Cardiovascular Medications in Neonatal Hypotension. Biomed Hub 2022; 7:70-79. [PMID: 35950013 PMCID: PMC9251481 DOI: 10.1159/000525133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 04/20/2022] [Indexed: 11/19/2022] Open
Abstract
Background Comparative studies among the various cardiovascular medications used for the treatment of neonatal hypotension are lacking. Methods This systematic review and pairwise meta-analysis of the anti-hypotensive treatments in preterm and term infants was conducted to evaluate efficacy and impact on outcome. Electronic databases were searched up to February 2021 for relevant articles. As an extension of the current approach for study selection, a machine learning technique was used. Only randomized controlled trials (RCTs) of inotropes, pressors, volume therapy, and corticosteroids were included. Response to treatment was the primary outcome while secondary outcomes included mortality and common morbidities. Results Nineteen RCTs involving 758 preterm and term neonates were found, and 8 treatments were evaluated. Most studies involved subjects with early hypotension associated with prematurity. Pairwise meta-analysis among treatments showed that dopamine was more effective than dobutamine regarding the response to treatment (restoration of normotension or normalization of blood pressure) (7 trials, 286 neonates, odds ratio, 3.06 [95% CI = 1.06–8.87]; I<sup>2</sup> = 49%, very low quality of the evidence per GRADE). Comparisons of other treatments were not significant. No differences were found among regimens regarding survival and other secondary outcomes. Conclusion In this systematic review and pairwise meta-analysis, only the comparison of dopamine versus dobutamine provided evidence for efficacy of treatment and favored dopamine. No safe conclusions could be reached in regard to other treatments. Data regarding the management of arterial hypotension in conditions other than transition after birth in preterm newborns are sparse both in preterm and term infants.
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Affiliation(s)
- Kosmas Sarafidis
- 1st Department of Neonatology, School of Medicine, Aristotle University of Thessaloniki, Hppokrateion General Hospital, Thessaloniki, Greece
- *Kosmas Sarafidis,
| | - Eleni Verykouki
- Department of Hygiene, Social-Preventive Medicine & Medical Statistics, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Stefanos Nikopoulos
- 1st Department of Neonatology, School of Medicine, Aristotle University of Thessaloniki, Hppokrateion General Hospital, Thessaloniki, Greece
| | - Fani Apostolidou-Kiouti
- Department of Hygiene, Social-Preventive Medicine & Medical Statistics, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Theodoros Diakonidis
- Department of Hygiene, Social-Preventive Medicine & Medical Statistics, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleni Agakidou
- 1st Department of Neonatology, School of Medicine, Aristotle University of Thessaloniki, Hppokrateion General Hospital, Thessaloniki, Greece
| | - Aggeliki Kontou
- 1st Department of Neonatology, School of Medicine, Aristotle University of Thessaloniki, Hppokrateion General Hospital, Thessaloniki, Greece
| | - Anna-Bettina Haidich
- Department of Hygiene, Social-Preventive Medicine & Medical Statistics, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
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12
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Dagle JM, Rysavy MA, Hunter SK, Colaizy TT, Elgin TG, Giesinger RE, McElroy SJ, Harmon HM, Klein JM, McNamara PJ, Segar JL, Thomas BA, Bischoff AR, Rios DR, Lindower JB, Bermick JR, Lee SS, Wong SW, Roghair RD, Morgan-Harris AT, Niwas R, Arikat S, Boly TJ, Segar JL. Cardiorespiratory management of infants born at 22 weeks' gestation: The Iowa approach. Semin Perinatol 2022; 46:151545. [PMID: 34893337 DOI: 10.1016/j.semperi.2021.151545] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The approach to clinical care of infants born at 22 weeks' gestation must be consistent and well-designed if optimal results are to be expected. Publications from several international centers have demonstrated that, although there may be variance in aspects of care in this vulnerable population, treatment should be neither random nor inconsistent. In designing a standardized approach, careful attention should be paid to the unique anatomy, physiology, and biochemistry of this vulnerable patient population. Emerging evidence, suggesting a link between cardiopulmonary health and longer-term sequela, highlights the importance of understanding the relationship between cardiorespiratory illnesses of the 22-week infant, treatments provided, and subsequent cardiopulmonary development. In this review we will provide an overview to our approach to cardiopulmonary assessment and treatment, with a particular emphasis on the importance of early recognition of atypical phenotypes, timely interventions with evidence-based treatments, and longitudinal monitoring.
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Affiliation(s)
- John M Dagle
- Stead Family Division of Neonatology and Departments of Pediatrics, Staff Neonatologist, Stead Family Children's Hospital, Biochemistry, and Epidemiology, University of Iowa, USA.
| | - Matthew A Rysavy
- Stead Family Division of Neonatology and Departments of Pediatrics, Staff Neonatologist, Stead Family Children's Hospital, Biochemistry, and Epidemiology, University of Iowa, USA
| | | | - Tarah T Colaizy
- Stead Family Division of Neonatology and Departments of Pediatrics, Staff Neonatologist, Stead Family Children's Hospital, Biochemistry, and Epidemiology, University of Iowa, USA
| | - Timothy G Elgin
- Stead Family Division of Neonatology and Departments of Pediatrics, Staff Neonatologist, Stead Family Children's Hospital, Biochemistry, and Epidemiology, University of Iowa, USA
| | - Regan E Giesinger
- Stead Family Division of Neonatology and Departments of Pediatrics, Staff Neonatologist, Stead Family Children's Hospital, Biochemistry, and Epidemiology, University of Iowa, USA
| | - Steve J McElroy
- Stead Family Division of Neonatology and Departments of Pediatrics, Staff Neonatologist, Stead Family Children's Hospital, Biochemistry, and Epidemiology, University of Iowa, USA
| | - Heidi M Harmon
- Stead Family Division of Neonatology and Departments of Pediatrics, Staff Neonatologist, Stead Family Children's Hospital, Biochemistry, and Epidemiology, University of Iowa, USA
| | - Jonathan M Klein
- Stead Family Division of Neonatology and Departments of Pediatrics, Staff Neonatologist, Stead Family Children's Hospital, Biochemistry, and Epidemiology, University of Iowa, USA
| | - Patrick J McNamara
- Stead Family Division of Neonatology and Departments of Pediatrics, Staff Neonatologist, Stead Family Children's Hospital, Biochemistry, and Epidemiology, University of Iowa, USA; Obstetrics and Gynecology and Internal Medicine, USA; University of Iowa, Iowa City, IA, USA
| | | | | | - Brady A Thomas
- Stead Family Division of Neonatology and Departments of Pediatrics, Staff Neonatologist, Stead Family Children's Hospital,Biochemistry, and Epidemiology, University of Iowa, USA
| | - Adrianne R Bischoff
- Stead Family Division of Neonatology and Departments of Pediatrics, Staff Neonatologist, Stead Family Children's Hospital,Biochemistry, and Epidemiology, University of Iowa, USA
| | - Danielle R Rios
- Stead Family Division of Neonatology and Departments of Pediatrics, Staff Neonatologist, Stead Family Children's Hospital,Biochemistry, and Epidemiology, University of Iowa, USA
| | - Julie B Lindower
- Stead Family Division of Neonatology and Departments of Pediatrics, Staff Neonatologist, Stead Family Children's Hospital,Biochemistry, and Epidemiology, University of Iowa, USA
| | - Jennifer R Bermick
- Stead Family Division of Neonatology and Departments of Pediatrics, Staff Neonatologist, Stead Family Children's Hospital,Biochemistry, and Epidemiology, University of Iowa, USA
| | - Stephanie S Lee
- Stead Family Division of Neonatology and Departments of Pediatrics, Staff Neonatologist, Stead Family Children's Hospital,Biochemistry, and Epidemiology, University of Iowa, USA
| | - Samuel W Wong
- Stead Family Division of Neonatology and Departments of Pediatrics, Staff Neonatologist, Stead Family Children's Hospital,Biochemistry, and Epidemiology, University of Iowa, USA
| | - Robert D Roghair
- Stead Family Division of Neonatology and Departments of Pediatrics, Staff Neonatologist, Stead Family Children's Hospital,Biochemistry, and Epidemiology, University of Iowa, USA
| | - Ana Tracey Morgan-Harris
- Stead Family Division of Neonatology and Departments of Pediatrics, Staff Neonatologist, Stead Family Children's Hospital,Biochemistry, and Epidemiology, University of Iowa, USA
| | - Ram Niwas
- Stead Family Division of Neonatology and Departments of Pediatrics, Staff Neonatologist, Stead Family Children's Hospital,Biochemistry, and Epidemiology, University of Iowa, USA
| | - Sunny Arikat
- Stead Family Division of Neonatology and Departments of Pediatrics, Staff Neonatologist, Stead Family Children's Hospital,Biochemistry, and Epidemiology, University of Iowa, USA
| | - Timothy J Boly
- Stead Family Division of Neonatology and Departments of Pediatrics, Staff Neonatologist, Stead Family Children's Hospital,Biochemistry, and Epidemiology, University of Iowa, USA
| | - Jeffrey L Segar
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
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13
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Awadhare P, Patel R, McCallin T, Mainali K, Jackson K, Starke H, Bhalala U. Non-invasive Cardiac Output Monitoring and Assessment of Fluid Responsiveness in Children With Shock in the Emergency Department. Front Pediatr 2022; 10:857106. [PMID: 35463892 PMCID: PMC9021702 DOI: 10.3389/fped.2022.857106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 03/04/2022] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION The assessment of fluid responsiveness is important in the management of shock but conventional methods of assessing fluid responsiveness are often inaccurate. Our study aims to evaluate changes in objective hemodynamic parameters as measured using electrical cardiometry (ICON® monitor) following the fluid bolus in children presenting with shock and to evaluate whether any specific hemodynamic parameter can best predict fluid responsiveness among children with shock. MATERIALS AND METHODS We conducted a prospective observational study in children presenting with shock to our emergency department between June 2020 and March 2021. We collected the parameters such as heart rate (HR), respiratory rate (RR), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), and hemodynamic data such as cardiac output CO), cardiac index (CI), index of contractility (ICON), stroke volume (SV), stroke index (SI), corrected flow time (FTC), systolic time ratio (STR), variation of index of contractility (VIC), stroke volume variation (SVV), systemic vascular resistance (SVR), and thoracic fluid content (TFC) using the ICON monitor before and after fluid bolus (FB). We assessed percent change (Δ) and used paired-sample Student's t-test to compare pre- and post-hemodynamic data and Mann-Whitney U-test to compare fluid responders and non-responders. P-Values < 0.05 were considered statistically significant. RESULTS We recorded 42 fluid interventions in 40 patients during our study period. The median IQR age was 10.56 (4.8, 14.8) years with male/female ratio (1.2:1). There was a significant decrease in ΔRR [-1.61 (-14.8, 0); p = 0.012], ΔDBP [-5.5 (-14.4, 8); p = 0.027], ΔMAP [-2.2 (-11, 2); p = 0.018], ΔSVR [-5.8 (-20, 5.2); p = 0.025], and ΔSTR [-8.39 (-21, 3); p = 0.001] and significant increase in ΔTFC [6.2 (3.5, 11.4); p = 0.01] following FB. We defined fluid responders by an increase in SV by ≥10% after a single FB of 20 ml/kg crystalloid. Receiver operating curve analysis revealed that among all the parameters, 15% change in ICON had an excellent AUC (0.85) for the fluid responsiveness. CONCLUSION Our study showed significant changes in objective hemodynamic parameters, such as SVR, STR, and TFC following FB in children presenting with shock. A 15% change in ICON had an excellent predictive performance for the fluid responsiveness among our cohort of pediatric shock.
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Affiliation(s)
- Pranali Awadhare
- The Children's Hospital of San Antonio, San Antonio, TX, United States
| | - Radha Patel
- University of the Incarnate Word School of Osteopathic Medicine, San Antonio, TX, United States
| | - Tracy McCallin
- Department of Pediatrics, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH, United States
| | - Kiran Mainali
- University of the Incarnate Word School of Osteopathic Medicine, San Antonio, TX, United States
| | - Kelly Jackson
- The Children's Hospital of San Antonio, San Antonio, TX, United States
| | - Hannah Starke
- The Children's Hospital of San Antonio, San Antonio, TX, United States
| | - Utpal Bhalala
- Driscoll Children's Hospital, Corpus Christi, TX, United States.,Department of Pediatrics, Texas A&M University, College Station, TX, United States.,Department of Anesthesiology and Critical Care Medicine, University of Texas Medical Branch, Galveston, TX, United States
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14
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Weisz DE, Aldana-Aguirre J, Deshpande P, Jain A. Reply. J Pediatr 2022; 240:315-316. [PMID: 34555377 DOI: 10.1016/j.jpeds.2021.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 09/15/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Dany E Weisz
- Department of Pediatrics, University of Toronto, Toronto, Canada; Newborn and Developmental Pediatrics, Sunnybrook Health Sciences Centre, Toronto, Canada
| | | | - Poorva Deshpande
- Department of Pediatrics, University of Toronto, Toronto, Canada; Department of Pediatrics, Mount Sinai Hospital, Toronto, Canada
| | - Amish Jain
- Department of Pediatrics, University of Toronto, Toronto, Canada; Department of Pediatrics, Mount Sinai Hospital, Toronto, Canada
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15
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Berisha G, Solberg R, Klingenberg C, Solevåg AL. Neonatal Impedance Cardiography in Asphyxiated Piglets-A Feasibility Study. Front Pediatr 2022; 10:804353. [PMID: 35281226 PMCID: PMC8913887 DOI: 10.3389/fped.2022.804353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 01/26/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Impedance cardiography (ICG) is a non-invasive method for continuous cardiac output measurement and has the potential to improve monitoring and treatment of sick neonates. PhysioFlow® is a signal-morphology ICG-system showing promising results in adults with low and high cardiac output, but no data from neonates or neonatal models exist. The aim of this study was to investigate PhysioFlow® feasibility in asphyxiated newborn piglets. METHODS Fifteen piglets, under continuous arterial heart rate (HR) and blood pressure (BP) monitoring, were asphyxiated until asystole. Cardiopulmonary resuscitation was performed and the piglets monitored after return of spontaneous circulation (ROSC). Arterial lactate was measured at baseline, every 5 min throughout asphyxiation, at asystole, and at 10 min and later every 30 min after ROSC. PhysioFlow® measured cardiac stroke volume (SV) and HR, and calculated cardiac index (CI) (L/m2/min). Registrations with a signal quality < 75% were excluded, and registrations recorded for 30 min from start of asphyxia analyzed. Pearson correlations were calculated for CI; and HR, mean BP and blood lactate. RESULTS The piglets were asphyxiated for median (interquartile range) 30 (20-35) min and had a lactate at asystole of 15.0 (9.1-17.0) mmol/L. Out of a total of 20.991 registrations in all animals combined, there were 10.148 (48.3%) registrations with a signal quality ≥ 75%. Signal quality ≥ 75% varied in individual piglets from 7 to 82% of registrations. We analyzed 1.254 registrations recorded 30 min from initiation of asphyxia, i.e., in piglets with brief asphyxia times, this included cardiopulmonary resuscitation and post-ROSC observation. There was a positive correlation between CI and SVI (r = 0.90, p < 0.001), and between CI and HR (r = 0.446, p < 0.001). There was no correlation between CI, or mean BP or lactate (p = 0.98 and 0.51, respectively). CONCLUSION About half of ICG-registrations in asphyxiated piglets were of good quality. However, signal quality was highly variable between piglets. In total, there was a higher proportion of reliable ICG-registrations than reported from clinical delivery room studies using electrical velocimetry. Our data are physiologically plausible and supports further research evaluating PhysioFlow® for cardiac output monitoring in perinatal asphyxia. In particular, factors influencing inter-individual variations in signal quality should be explored.
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Affiliation(s)
- Gazmend Berisha
- Department of Paediatric and Adolescent Medicine, Akershus University Hospital, Lørenskog, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Rønnaug Solberg
- Department of Pediatric Research, Institute of Surgical Research, Oslo University Hospital Rikshospitalet, University of Oslo, Oslo, Norway.,Department of Pediatrics, Vestfold Hospital Trust, Tønsberg, Norway
| | - Claus Klingenberg
- Department of Paediatrics, University Hospital of North Norway, Tromsø, Norway.,Paediatric Research Group, Department of Clinical Medicine, UiT, The Arctic University of Norway, Tromsø, Norway
| | - Anne Lee Solevåg
- Department of Paediatric and Adolescent Medicine, Oslo University Hospital, Nydalen, Norway
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16
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Non-invasive continuous cardiac output monitoring in infants with hypoxic ischaemic encephalopathy. J Perinatol 2022; 42:1622-1629. [PMID: 36056257 PMCID: PMC9712087 DOI: 10.1038/s41372-022-01495-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 07/20/2022] [Accepted: 08/09/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To describe early, continuous, non-invasive measures of cardiac output (CO) and evolution over time in infants with hypoxic-ischaemic encephalopathy (HIE). STUDY DESIGN Prospective observational study of 44 infants with HIE (23 mild, 17 moderate, 4 severe) and 17 term controls. Infants with HIE had non-invasive CO monitoring (NICOM) continuously in the neonatal unit. Term controls had NICOM recorded at 6 and 24 h. A mixed-modelling approach was used to assess change in CO over time by group. RESULTS Infants with moderate HIE have significantly lower CO than the mild group at all timepoints (10.7 mls/kg/min lower, 95% CI:1.0,20.4, p = 0.03) which increases over time, driven by a gradual increase in stroke volume (SV). CO increased further during rewarming predominantly due to an increase in HR. CONCLUSION TH has a significant impact on HR but SV appears largely unaffected. NICOM may provide a non-invasive, continuous, low-cost alternative to monitoring CO in infants with HIE however further research is warranted.
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17
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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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18
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Pereira SS, Sinha AK, Shah DK, Kempley ST. Common carotid artery blood flow volume in extremely preterm infants. Acta Paediatr 2021; 110:1157-1165. [PMID: 33145798 DOI: 10.1111/apa.15655] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 10/14/2020] [Accepted: 11/02/2020] [Indexed: 11/28/2022]
Abstract
AIM The aim of this study was to determine carotid blood flow volume, a surrogate for cerebral blood flow, using Doppler ultrasound in extremely preterm infants. METHODS In infants <29 weeks, right common carotid artery flow volume (RCCAF) was calculated from vessel diameter and intensity-weighted mean velocity measured using Doppler ultrasound on days 1 and 3. In addition, left ventricular output (LVO), ductus arteriosus characteristics and invasive mean arterial blood pressure (MABP) were obtained. RESULTS Sixty infants with mean gestation of 25.8 weeks were studied. The median RCCAF increased from 12 (IQR 9-15) mL/kg/min on day 1, to 14 (IQR 12-18) mL/kg/min on day 3 (p = 0.007). RCCAF was positively correlated with invasive MABP on days 1 and 3. RCCAF significantly correlated with LVO in infants with closing or closed ductus arteriosus on day 1. Using multiple regression analysis, RCCAF was significantly associated with invasive MABP on day 1 and to inotropic treatment on day 3. CONCLUSION Doppler ultrasound can be used to measure RCCAF in extremely preterm infants receiving intensive care. RCCAF increased during the first three days and was positively related to invasive MABP on day 1. Values were lower than previously described in more mature infants. CLINICAL TRIAL REGISTRATION ISRCTN 83507686.
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Affiliation(s)
- Sujith S. Pereira
- Centre for Genomics and Child Health Blizard Institute Barts and the London School of Medicine Queen Mary University of London London UK
- Neonatal Unit Homerton University Hospital Foundation NHS Trust London UK
| | - Ajay K. Sinha
- Centre for Genomics and Child Health Blizard Institute Barts and the London School of Medicine Queen Mary University of London London UK
- Neonatal Unit Royal London Hospital, Barts Health NHS Trust London UK
| | - Divyen K. Shah
- Neonatal Unit Royal London Hospital, Barts Health NHS Trust London UK
- Centre for Neuroscience and Trauma Blizard Institute Barts and the London School of Medicine and Dentistry Queen Mary University of London London UK
| | - Stephen T. Kempley
- Centre for Genomics and Child Health Blizard Institute Barts and the London School of Medicine Queen Mary University of London London UK
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19
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Bhogal J, Solevåg AL, O’Reilly M, Lee TF, Joynt C, Hornberger LK, Schmölzer GM, Cheung PY. Hemodynamic effects of high frequency oscillatory ventilation with volume guarantee in a piglet model of respiratory distress syndrome. PLoS One 2021; 16:e0246996. [PMID: 33592023 PMCID: PMC7886162 DOI: 10.1371/journal.pone.0246996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 01/30/2021] [Indexed: 11/24/2022] Open
Abstract
Respiratory failure is a common condition faced by critically ill neonates with respiratory distress syndrome (RDS). High frequency oscillatory ventilation (HFOV) is often used for neonates with refractory respiratory failure related to RDS. Volume guarantee (VG) mode has been added to some HFOV ventilators for providing consistent tidal volume. We sought to examine the impact of adding the VG mode during HFOV on systemic and cerebral hemodynamics, which has not been studied to date. A neonatal piglet model of moderate to severe RDS was induced by saline lavage. Piglets (full term, age 1–3 days, weight 1.5–2.4 kg) were randomized to have RDS induced and receive either HFOV or HFOV+VG (n = 8/group) or sham-operation (n = 6) without RDS. Cardiac function measured by a Millar® catheter placed in the left ventricle as well as systemic and carotid hemodynamic and oxygen tissue saturation parameters were collected over 240 min of ventilation. Mean airway pressure, alveolar-arterial oxygen difference and left ventricular cardiac index of piglets on HFOV vs. HFOV+VG were not significantly different during the experimental period. Right common carotid artery flow index by in-situ ultrasonic flow measurement and cerebral tissue oxygen saturation (near-infrared spectroscopy) significantly decreased in HFOV+VG at 240 min compared to HFOV (14 vs. 31 ml/kg/min, and 30% vs. 43%, respectively; p<0.05). There were no significant differences in lung, brain and heart tissue markers of oxidative stress, ischemia and inflammation. HFOV+VG compared to HFOV was associated with similar left ventricular function, however HFOV+VG had a negative effect on cerebral blood flow and oxygenation.
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Affiliation(s)
- Jagmeet Bhogal
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
- * E-mail:
| | - Anne Lee Solevåg
- Department of Paediatric and Adolescent Medicine, Akershus University Hospital, Lørenskog, Norway
- Department of Paediatric and Adolescent Medicine, Oslo University Hospital, Nydalen, Norway
| | - Megan O’Reilly
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - Tze-Fun Lee
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - Chloe Joynt
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Lisa K. Hornberger
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Georg M. Schmölzer
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - Po-Yin Cheung
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, Alberta, Canada
- Department of Pharmacology, University of Alberta, Edmonton, Alberta, Canada
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20
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Hamza W, AbdElaal N, Awad H, Tawfik S, Elsayed Y. The impact of targeted oxygen reduction test in preterm infants on reducing the oxygen exposure. J Neonatal Perinatal Med 2021; 14:61-65. [PMID: 32538878 DOI: 10.3233/npm-200459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Caring for infants on respiratory support is a challenge in the middle-income countries, applying a protocol of targeted oxygen reduction test (tORT) guided by daily assessment of oxygen histograms is novel and practical approach. OBJECTIVE To study the impact of tORT guided by daily assessment of oxygen histograms as a quality improvement project aiming to decrease days on oxygen support, and duration of hospital admission in preterm infants. STUDY DESIGN A quality project conducted in neonatal intensive care units (NICU) of two hospitals, from 2017- 2018 (Epochs II). After a period of observation of a cohort of preterm Infants, 2016-2017 (Epoch I). The main aims were to reduce days on oxygen and hospital admission days. All infants in Epoch II underwent daily assessment of oxygen histograms and a trial of oxygen reduction if applicable as per a predefined protocol. Comparison was made between these two Epochs, and the primary outcome was the time to successful discontinuation of oxygen support. RESULTS Fifty-nine infants were included; 30 underwent the protocolized tORT (Epoch II) with a median (IQR) of 4 (2-6) tORC per infant. Postanal age at presentation (time of initial tORT assessment was performed at the postnatal age of 8 (5, 13) days. Days on oxygen and total numbers of hospital days were significantly less in Epoch II. Oxygen histograms significantly improved after tORT. CONCLUSIONS Applying tORT guided by oxygen histograms may have a significant impact on oxygen exposure and hospitalization days of patients admitted to the NICU.
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Affiliation(s)
| | | | - H Awad
- Ain Shams University, Egypt
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21
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Wu TW, Noori S. Recognition and management of neonatal hemodynamic compromise. Pediatr Neonatol 2021; 62 Suppl 1:S22-S29. [PMID: 33485823 DOI: 10.1016/j.pedneo.2020.12.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 12/09/2020] [Indexed: 01/22/2023] Open
Abstract
Hemodynamic compromise of the neonate can occur in various clinical situations, including but not limited to maladaptation during the early transitional period, sepsis, congenital heart anomalies, hemodynamically significant patent ductus arteriosus, persistent pulmonary hypertension of the newborn, systemic inflammatory diseases such as necrotizing enterocolitis, and dehydration. Despite the handful of advances in neonatal care through ground-breaking clinical trials, the management of neonatal shock is often dependent on the bedside clinician's experience and training without the aid of high-level evidence. However, the recognition for the importance of comprehensive and serial hemodynamic assessment is growing. There is now a wealth of literature investigating the use of functional echocardiography, near-infrared spectroscopy, and noninvasive impedance-based cardiometry to complement common bedside hemodynamic measures such as blood pressure and heart rate measurement. In this review article, the pathophysiology of neonatal hemodynamic compromise is outlined, and concomitant best-evidence management for hemodynamic compromise in the neonate is proposed.
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Affiliation(s)
- Tai-Wei Wu
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Shahab Noori
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
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22
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Patra A, Thakkar PS, Makhoul M, Bada HS. Objective Assessment of Physiologic Alterations Associated With Hemodynamically Significant Patent Ductus Arteriosus in Extremely Premature Neonates. Front Pediatr 2021; 9:648584. [PMID: 33718311 PMCID: PMC7946992 DOI: 10.3389/fped.2021.648584] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 02/05/2021] [Indexed: 11/23/2022] Open
Abstract
Delay in closure of ductus arteriosus in postnatal life may lead to serious consequences and complications in an extremely premature neonate secondary to hemodynamic alterations in regional blood flow pattern in various organs. Despite the widespread recognition amongst neonatologists to identify a hemodynamically significant patent ductus arteriosus (hsPDA) early in the postnatal course, there is lack of consensus in its definition and thus the threshold to initiate treatment. Echocardiographic assessment of PDA shunt size and volume combined with neonatologists' impression of clinical significance is most frequently used to determine the need for treatment of PDA. Common clinical signs of hsPDA utilized as surrogate for decreased tissue perfusion may lag behind early echocardiographic signs. Although echocardiogram allows direct assessment of PDA shunt and hemodynamic alterations in the heart, it is limited by dependence on pediatric cardiologist availability, interobserver variation and isolated time point assessment. Electrical cardiometry (EC) is a non-invasive continuous real time measurement of cardiac output by applying changes in thoracic electrical impedance. EC has been validated in preterm newborns by concomitant transthoracic echocardiogram assessments and may be beneficial in studying changes in cardiac output in premature newborns with hsPDA. Alterations in perfusion index derived from continuous pulse oximetry monitoring has been used to study changes in cardiac performance and tissue perfusion in infants with PDA. Near infrared spectroscopy (NIRS) has been used to objectively and continuously assess variations in renal, mesenteric, and cerebral oxygen saturation and thus perfusion changes due to diastolic vascular steal from hsPDA in preterm neonates. Doppler ultrasound studies measuring resistive indices in cerebral circulation indicate disturbance in cerebral perfusion secondary to ductal steal. With recent trends of change in practice toward less intervention in care of preterm newborn, treatment strategy needs to be targeted for select preterm population most vulnerable to adverse hemodynamic effects of PDA. Integration of these novel ways of hemodynamic and tissue perfusion assessment in routine clinical care may help mitigate the challenges in defining and targeting treatment of hsPDA thereby improving outcomes in extremely premature neonates.
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Affiliation(s)
- Aparna Patra
- Division of Neonatology, Department of Pediatrics, Kentucky Children's Hospital, University of Kentucky, Lexington, KY, United States
| | - Pratibha S Thakkar
- Division of Neonatology, Department of Pediatrics, Kentucky Children's Hospital, University of Kentucky, Lexington, KY, United States
| | - Majd Makhoul
- Division of Pediatric Cardiology, Department of Pediatrics, Kentucky Children's Hospital, University of Kentucky, Lexington, KY, United States
| | - Henrietta S Bada
- Division of Neonatology, Department of Pediatrics, Kentucky Children's Hospital, University of Kentucky, Lexington, KY, United States
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Abstract
Blood pressure (BP) is routinely measured in newborn infants. Published BP nomograms demonstrate a rise in BP following delivery in healthy infants at all gestational ages (GA) and evidence that BP values are higher with increasing birth weight and GA. However, the complex physiology that occurs in newborn infants and range of BP values observed at all GA make it difficult to identify "normal" BP for a specific infant at a specific time under specific conditions. As such, complete hemodynamic assessment should include the physical examination, perinatal history, other vital signs, and laboratory values in addition to BP values.
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Affiliation(s)
- Beau Batton
- Department of Pediatrics, Southern Illinois University School of Medicine, PO Box 19676, Springfield, IL 62794, USA.
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Pereira S, Reeves J, Birch M, Finton-James S, Verma K, Krug R, Sinha A, Kempley S. A realistic flow phantom model of the carotid artery in preterm infants for training and research. ULTRASOUND : JOURNAL OF THE BRITISH MEDICAL ULTRASOUND SOCIETY 2020; 28:145-154. [PMID: 32831887 DOI: 10.1177/1742271x20902189] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 12/17/2019] [Indexed: 11/15/2022]
Abstract
Introduction Cerebral blood flow is increasingly monitored in preterm infants. Doppler ultrasound of the carotid artery is a widely available method but is operator dependent. Our aim was to design and produce a realistic flow phantom model of the carotid artery of preterm infants. Methods Data from cerebral blood flow measurements using Doppler ultrasound of the right common carotid artery from 21 premature newborn infants were used to produce a Doppler flow phantom model with three different vessel diameters. Vessel diameter, continuous and pulsatile flow volume measurements were performed by two blinded observers (with more than eight and 20 years of experience). Results Vessel diameter measurements using the phantom were underestimated by 7%. Continuous flow volume measurements were overestimated by 7% by both observers (observer 1 mean difference 1.5 ± 1.96 SD -3.3 to 6.3 ml/min versus observer 2, 1.9 ± 1.96 SD -3.6 to 7.4 ml/min). Pulsatile flow measurements were overestimated by 12.6% by observer 1 (2.7 ± 1.96 SD -0.6 to 5.9 ml/min) and by 7.8% by observer 2 (1.7 ± 1.96 SD -1.6 to 4.9 ml/min). There was good interobserver and intraobserver reliability for the majority of measurements using continuous and pulsatile flow. Conclusion It is feasible to produce a realistic flow phantom model of the neonatal carotid artery of preterm infants. Diameter measurements were underestimated and flow measurements were overestimated. These errors fell within acceptable limits for in vivo measurements. If these limitations were related to materials, this could be explored using a wall-less model. The flow phantom could be utilised for research and training clinicians in measuring cerebral blood flow using the carotid artery in this vulnerable group of infants.
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Affiliation(s)
- Sujith Pereira
- Neonatal Unit, Homerton University Hospital NHS Foundation Trust, London, UK.,Centre for Genomics and Child Health, Blizard Institute, Barts and The London School of Medicine and Dentistry, London, UK
| | - Jonathan Reeves
- Clinical Physics, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Malcolm Birch
- Clinical Physics, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Sakthi Finton-James
- Barts and the London School of Medicine and Dentistry, Queen Mary, University of London, London, UK
| | - Komal Verma
- Barts and the London School of Medicine and Dentistry, Queen Mary, University of London, London, UK
| | - Robert Krug
- Barts and the London School of Medicine and Dentistry, Queen Mary, University of London, London, UK
| | - Ajay Sinha
- Centre for Genomics and Child Health, Blizard Institute, Barts and The London School of Medicine and Dentistry, London, UK.,Neonatal Unit, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Stephen Kempley
- Centre for Genomics and Child Health, Blizard Institute, Barts and The London School of Medicine and Dentistry, London, UK
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Non-Invasive Venous waveform Analysis (NIVA) for volume assessment during complex cranial vault reconstruction: A proof-of-concept study in children. PLoS One 2020; 15:e0235933. [PMID: 32640004 PMCID: PMC7343152 DOI: 10.1371/journal.pone.0235933] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 06/24/2020] [Indexed: 12/27/2022] Open
Abstract
Background Non-Invasive Venous waveform Analysis (NIVA) is novel technology that captures and analyzes changes in venous waveforms from a piezoelectric sensor on the wrist for hemodynamic volume assessment. Complex cranial vault reconstruction is performed in children with craniosynostosis and is associated with extensive blood loss, potential life-threatening risks, and significant morbidity. In this preliminary study, we hypothesized that NIVA will provide a reliable, non-invasive, quantitative assessment of intravascular volume changes in children undergoing complex cranial vault reconstruction. Objective To present proof-of-concept results of a novel technology in the pediatric population. Methods The NIVA prototype was placed on each subject’s wrist, and venous waveforms were collected intraoperatively. Estimated blood loss and fluid/blood product administration were recorded in real time. Venous waveforms were analyzed into a NIVA value and then correlated, along with mean arterial pressure (MAP), to volume changes. Concordance was quantified to determine if the direction of change in volume was similar to the direction of change in MAP or change in NIVA. Results Of 18 patients enrolled, 14 had usable venous waveforms, and there was a significant correlation between change in NIVA value and change in volume. Change in MAP did not correlate with change in volume. The concordance between change in MAP and change in volume was less than the concordance between change in NIVA and change in volume. Conclusion NIVA values correlate more closely to intravascular volume changes in pediatric craniofacial patients than MAP. This initial study suggests that NIVA is a potential safe, reliable, non-invasive quantitative method of measuring intravascular volume changes for children undergoing surgery.
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Continuous vital sign analysis for predicting and preventing neonatal diseases in the twenty-first century: big data to the forefront. Pediatr Res 2020; 87:210-220. [PMID: 31377752 PMCID: PMC6962536 DOI: 10.1038/s41390-019-0527-0] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 07/20/2019] [Accepted: 07/25/2019] [Indexed: 01/03/2023]
Abstract
In the neonatal intensive care unit (NICU), heart rate, respiratory rate, and oxygen saturation are vital signs (VS) that are continuously monitored in infants, while blood pressure is often monitored continuously immediately after birth, or during critical illness. Although changes in VS can reflect infant physiology or circadian rhythms, persistent deviations in absolute values or complex changes in variability can indicate acute or chronic pathology. Recent studies demonstrate that analysis of continuous VS trends can predict sepsis, necrotizing enterocolitis, brain injury, bronchopulmonary dysplasia, cardiorespiratory decompensation, and mortality. Subtle changes in continuous VS patterns may not be discerned even by experienced clinicians reviewing spot VS data or VS trends captured in the monitor. In contrast, objective analysis of continuous VS data can improve neonatal outcomes by allowing heightened vigilance or preemptive interventions. In this review, we provide an overview of the studies that have used continuous analysis of single or multiple VS, their interactions, and combined VS and clinical analytic tools, to predict or detect neonatal pathophysiology. We make the case that big-data analytics are promising, and with continued improvements, can become a powerful tool to mitigate neonatal diseases in the twenty-first century.
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O'Neill R, Dempsey EM, Garvey AA, Schwarz CE. Non-invasive Cardiac Output Monitoring in Neonates. Front Pediatr 2020; 8:614585. [PMID: 33585366 PMCID: PMC7880199 DOI: 10.3389/fped.2020.614585] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 12/15/2020] [Indexed: 12/19/2022] Open
Abstract
Circulatory monitoring is currently limited to heart rate and blood pressure assessment in the majority of neonatal units globally. Non-invasive cardiac output monitoring (NiCO) in term and preterm neonates is increasing, where it has the potential to enhance our understanding and management of overall circulatory status. In this narrative review, we summarized 33 studies including almost 2,000 term and preterm neonates. The majority of studies evaluated interchangeability with echocardiography. Studies were performed in various clinical settings including the delivery room, patent ductus arteriosus assessment, patient positioning, red blood cell transfusion, and therapeutic hypothermia for hypoxic ischemic encephalopathy. This review presents an overview of NiCO in neonatal care, focusing on technical and practical aspects as well as current available evidence. We discuss potential goals for future research.
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Affiliation(s)
- Roisin O'Neill
- Department of Neonatology, Cork University Maternity Hospital, Cork, Ireland.,Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Eugene M Dempsey
- Department of Neonatology, Cork University Maternity Hospital, Cork, Ireland.,Department of Paediatrics and Child Health, University College Cork, Cork, Ireland.,Irish Centre for Maternal and Child Health Research (INFANT) Research Centre, University College Cork, Cork, Ireland
| | - Aisling A Garvey
- Department of Neonatology, Cork University Maternity Hospital, Cork, Ireland.,Department of Paediatrics and Child Health, University College Cork, Cork, Ireland.,Irish Centre for Maternal and Child Health Research (INFANT) Research Centre, University College Cork, Cork, Ireland
| | - Christoph E Schwarz
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland.,Irish Centre for Maternal and Child Health Research (INFANT) Research Centre, University College Cork, Cork, Ireland.,Department of Neonatology, University Children's Hospital, Tübingen, Germany
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Pereira SS, Sinha AK, Morris JK, Wertheim DF, Shah DK, Kempley ST. Blood pressure intervention levels in preterm infants: pilot randomised trial. Arch Dis Child Fetal Neonatal Ed 2019; 104:F298-F305. [PMID: 30049724 DOI: 10.1136/archdischild-2017-314159] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 06/06/2018] [Accepted: 06/18/2018] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To examine the feasibility of a trial allocating different blood pressure (BP) intervention levels for treatment in extremely preterm infants. DESIGN Three-arm open randomised controlled trial performed between February 2013 and April 2015. SETTING Single tertiary level neonatal intensive care unit. PATIENTS Infants born <29 weeks' gestation were eligible to participate, if parents consented and they did not have a major congenital malformation. INTERVENTIONS Infants were randomised to different levels of mean arterial BP at which they received cardiovascular support: active (<30 mm Hg), moderate (<gestational age mm Hg) or permissive (signs of poor perfusion or <19 mm Hg). Once this threshold was breached, all were managed using the same treatment guideline. BP profiles were downloaded continuously; cardiac output and carotid blood flow were measured at 1 day and 3 days, and amplitude integrated EEG was recorded during the first week. Cranial ultrasound scans were reviewed blind to study allocation. MAIN OUTCOME MEASURE Inotrope usage and achieved BP. RESULTS Of 134 cases screened, 60 were enrolled, with mean gestation 25.8 weeks (SD 1.5) and birth weight 817 g (SD 190). Invasively measured BP on the first day and inotrope usage were highest in the active and lowest in the permissive arms. There were no differences in haemodynamic or EEG variables or in clinical complications. Predefined cranial ultrasound findings did not differ significantly; no infants in the active arm had parenchymal brain lesions. CONCLUSION The BP threshold used to trigger treatment affects the achieved BP and inotrope usage, and it was possible to explore these effects using this study design. TRIAL REGISTRATION NUMBER ISRCTN83507686.
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Affiliation(s)
- Sujith Stanley Pereira
- Neonatal Unit, Royal London Hospital, Barts Health NHS Trust, London, UK.,Centre for Genomics and Child Health, Blizard Institute, Barts and the London School of Medicine and Dentistry, London, UK
| | - Ajay Kumar Sinha
- Neonatal Unit, Royal London Hospital, Barts Health NHS Trust, London, UK.,Centre for Genomics and Child Health, Blizard Institute, Barts and the London School of Medicine and Dentistry, London, UK
| | - Joan Katherine Morris
- Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - David F Wertheim
- Faculty of Science, Engineering and Computing, Kingston University, Kingston, UK
| | - Divyen K Shah
- Neonatal Unit, Royal London Hospital, Barts Health NHS Trust, London, UK.,Centre for Genomics and Child Health, Blizard Institute, Barts and the London School of Medicine and Dentistry, London, UK
| | - Stephen Terence Kempley
- Neonatal Unit, Royal London Hospital, Barts Health NHS Trust, London, UK.,Centre for Genomics and Child Health, Blizard Institute, Barts and the London School of Medicine and Dentistry, London, UK
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Bussmann N, El-Khuffash A. Future perspectives on the use of deformation analysis to identify the underlying pathophysiological basis for cardiovascular compromise in neonates. Pediatr Res 2019; 85:591-595. [PMID: 30666047 DOI: 10.1038/s41390-019-0293-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 12/28/2018] [Accepted: 01/02/2019] [Indexed: 12/28/2022]
Abstract
The assessment of the wellbeing of the cardiovascular status in premature infants has come to the forefront in recent years. There is an increasing realisation that myocardial performance, systemic blood flow and end-organ perfusion (particularly during the transitional period) play an important role in determining short and long-term outcomes in this population. The recent open access series on Neonatologist Performed Echocardiography (NPE) published in this journal outline the necessary techniques for image acquisition and analysis and provide a framework for the potential clinical applications of NPE in neonatal, and specifically preterm care. In this "Future Perspectives" review, we describe the important determinants of adequate cellular metabolism and myocardial performance (e.g. loading conditions, intrinsic contractility and morphological change), we discuss the maladaptive state of the preterm cardiovascular system, and highlight the emerging role that non-invasive echocardiography techniques, such as deformation analysis, serve in identifying the underlying physiological basis for cardiovascular instability.
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Affiliation(s)
- Neidin Bussmann
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland
| | - Afif El-Khuffash
- School of Medicine, Department of Pediatrics, Royal College of Surgeons in Ireland, Dublin, Ireland.
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30
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Gill AW. Postnatal cardiovascular adaptation. Arch Dis Child Fetal Neonatal Ed 2019; 104:F220-F224. [PMID: 30049726 DOI: 10.1136/archdischild-2017-314453] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 07/12/2018] [Accepted: 07/13/2018] [Indexed: 12/12/2022]
Abstract
The heart undergoes rapid transformations in function during the transition to extrauterine life. Our understanding of the adaptive physiology underlying this process is able to inform the clinical management of infants who are struggling to complete this complex transition. Much of our knowledge of the cardiac transition is derived from the preterm infant in whom the preparative adaptations are incomplete and clinical sequelae all too common. This review will re-examine the cardiac transition highlighting the physiology that drives it and suggest appropriate clinical intervention to support the process.
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Affiliation(s)
- Andrew William Gill
- Centre for Neonatal Research and Education, University of Western Australia, Perth, Western Australia, Australia
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31
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Cerebral Circulation and Hypotension in the Premature Infant. Neurology 2019. [DOI: 10.1016/b978-0-323-54392-7.00001-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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32
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Oulego Erroz I, Alonso Quintela P, Jiménez Gonzalez A, Terroba Seara S, Rodríguez Blanco S, Rosón Varas M, Castañón López L. Impact of screening and treatment of low systemic blood flow in the prevention of severe intraventricular haemorrhage and/or death in pre-term infants. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2018. [DOI: 10.1016/j.anpede.2018.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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33
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Mahoney L, Fernandez-Alvarez JR, Rojas-Anaya H, Aiton N, Wertheim D, Seddon P, Rabe H. Intra- and Inter-rater Agreement of Superior Vena Cava Flow and Right Ventricular Outflow Measurements in Late Preterm and Term Neonates. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2018; 37:2181-2190. [PMID: 29476553 DOI: 10.1002/jum.14568] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 12/18/2017] [Accepted: 12/22/2017] [Indexed: 06/08/2023]
Abstract
OBJECTIVES To explore the intra- and inter-rater agreement of superior vena cava (SVC) flow and right ventricular (RV) outflow in healthy and unwell late preterm neonates (33-37 weeks' gestational age), term neonates (≥37 weeks' gestational age), and neonates receiving total-body cooling. METHODS The intra- and inter-rater agreement (n = 25 and 41 neonates, respectively) rates for SVC flow and RV outflow were determined by echocardiography in healthy and unwell late preterm and term neonates with the use of Bland-Altman plots, the repeatability coefficient, the repeatability index, and intraclass correlation coefficients. RESULTS The intra-rater repeatability index values were 41% for SVC flow and 31% for RV outflow, with intraclass correlation coefficients indicating good agreement for both measures. The inter-rater repeatability index values for SVC flow and RV outflow were 63% and 51%, respectively, with intraclass correlation coefficients indicating moderate agreement for both measures. CONCLUSIONS If SVC flow or RV outflow is used in the hemodynamic treatment of neonates, sequential measurements should ideally be performed by the same clinician to reduce potential variability.
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Affiliation(s)
- Liam Mahoney
- Department of Neonatology, Brighton and Sussex University Hospitals National Health Service Trust, Brighton, England
- Department of Academic Pediatrics, Brighton and Sussex Medical School, Brighton, England
| | - Jose R Fernandez-Alvarez
- Department of Neonatology, Brighton and Sussex University Hospitals National Health Service Trust, Brighton, England
- Department of Academic Pediatrics, Brighton and Sussex Medical School, Brighton, England
| | - Hector Rojas-Anaya
- Department of Neonatology, Brighton and Sussex University Hospitals National Health Service Trust, Brighton, England
| | - Neil Aiton
- Department of Neonatology, Brighton and Sussex University Hospitals National Health Service Trust, Brighton, England
| | - David Wertheim
- Faculty of Science, Engineering, and Computing, Kingston University, Kingston, England
| | - Paul Seddon
- Department of Neonatology, Brighton and Sussex University Hospitals National Health Service Trust, Brighton, England
| | - Heike Rabe
- Department of Neonatology, Brighton and Sussex University Hospitals National Health Service Trust, Brighton, England
- Department of Academic Pediatrics, Brighton and Sussex Medical School, Brighton, England
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35
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Poon WB, Wong KY. Neonatologist-performed point-of-care functional echocardiography in the neonatal intensive care unit. Singapore Med J 2018; 58:230-233. [PMID: 28536728 DOI: 10.11622/smedj.2017036] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Functional echocardiography (fECHO) refers to a bedside, limited assessment of the ductus arteriosus, myocardial performance and pulmonary or systemic haemodynamics that is brief in nature and addresses a specific clinical question or management dilemma. This point-of-care ultrasonography is increasingly used internationally and locally among neonatal units to assist with management of neonatal haemodynamic conditions. This article intends to explain the modality, its indications, interpretation and implications for management, and how it impacts long-term outcomes, particularly in chronic lung disease for premature infants born before 32 weeks of gestation. This review will focus on fECHO as a clinical tool to assess the haemodynamics of sick neonates and how it assists in the logical choice for cardiovascular support. Training should be approached as a combined effort between the paediatric cardiology service and neonatology service.
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Affiliation(s)
- Woei Bing Poon
- Department of Neonatal and Developmental Medicine, Singapore General Hospital, Singapore
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36
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Oulego Erroz I, Alonso Quintela P, Jiménez Gonzalez A, Terroba Seara S, Rodríguez Blanco S, Rosón Varas M, Castañón López L. [Impact of screening and treatment of low systemic blood flow in the prevention of severe intraventricular haemorrhage and/or death in pre-term infants]. An Pediatr (Barc) 2018; 89:369-377. [PMID: 29622414 DOI: 10.1016/j.anpedi.2018.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 02/08/2018] [Accepted: 02/14/2018] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To assess the effect of a protocolised intervention for low systemic blood flow (SBF) in the occurrence of severe intraventricular haemorrhage (IVH) or death in pre-term infants. METHODS A study with a quasi-experimental design with retrospective controls was conducted on pre-term infants of less than 30weeks of gestational age, born between January 2016 and July 2017, who were consecutively included in the intervention period. The control cohort included pre-term infants (born between January 2013 and December 2015) matched by gestational age, birth weight, and gender (two controls for each case). The cases of low SBF diagnosed according to functional echocardiography during the study period received dobutamine (5-10μg/kg/min) for 48hours. RESULTS The study included 29 cases (intervention period) and 54 controls (pre-intervention period). Ten out of 29 (34.5%) infants received dobutamine for low SBF during the intervention period, with 3/29 (10.3%) cases of severe IVH and/or death compared to 17/54 (31.5%) in the control cohort (p=.032). There was an independent association between the intervention and a decreased occurrence of severe IVH/death after adjusting for confounding factors both in the logistic regression model [OR 0.11 (95%CI: 0.01-0.65), p=.015], as well as in the sensitivity analysis using inverse probability of treatment weighting [OR 0.23 (95%CI: 0.09-0.56); p=.001]. CONCLUSIONS In this study with retrospective controls, a protocolised screening, and treatment for low SBF was associated with a decreased occurrence of severe IVH or death in preterm infants. Large, adequately powered trials, are needed in order to determine whether postnatal interventions directed at low SBF can improve neurological outcomes.
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Affiliation(s)
- Ignacio Oulego Erroz
- Unidad de Neonatología, Servicio de Pediatría, Complejo Asistencial Universitario de León, León, España.
| | - Paula Alonso Quintela
- Unidad de Neonatología, Servicio de Pediatría, Complejo Asistencial Universitario de León, León, España
| | - Aquilina Jiménez Gonzalez
- Unidad de Neonatología, Servicio de Pediatría, Complejo Asistencial Universitario de León, León, España
| | - Sandra Terroba Seara
- Unidad de Neonatología, Servicio de Pediatría, Complejo Asistencial Universitario de León, León, España
| | - Silvia Rodríguez Blanco
- Unidad de Neonatología, Servicio de Pediatría, Complejo Asistencial Universitario de León, León, España
| | - María Rosón Varas
- Unidad de Neonatología, Servicio de Pediatría, Complejo Asistencial Universitario de León, León, España
| | - Leticia Castañón López
- Unidad de Neonatología, Servicio de Pediatría, Complejo Asistencial Universitario de León, León, España
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Correlations between near-infrared spectroscopy, perfusion index, and cardiac outputs in extremely preterm infants in the first 72 h of life. Eur J Pediatr 2018; 177:541-550. [PMID: 29374830 DOI: 10.1007/s00431-018-3096-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 12/14/2017] [Accepted: 01/17/2018] [Indexed: 10/18/2022]
Abstract
UNLABELLED Haemodynamic assessment during the transitional period in preterm infants is challenging. We aimed to describe the relationships between cerebral regional tissue oxygen saturation (CrSO2), perfusion index (PI), echocardiographic, and clinical parameters in extremely preterm infants in their first 72 h of life. Twenty newborns born at < 28 weeks of gestation were continuously monitored with CrSO2 and preductal PI. Cardiac output was measured at H6, H24, H48, and H72. The median gestational age and birth weight were 25.0 weeks (24-26) and 750 g (655-920), respectively. CrSO2 and preductal PI had r values < 0.35 with blood gases, lactates, haemoglobin, and mean blood pressure. Cardiac output significantly increased over the 72 h of the study period. Fifteen patients had at least one episode of low left and/or right ventricular output (RVO), during which there was a strong correlation between CrSO2 and superior vena cava (SVC) flow (at H6 (r = 0.74) and H24 (r = 0.86)) and between PI and RVO (at H6 (r = 0.68) and H24 (r = 0.92)). Five patients had low SVC flow (≤ 40 mL/kg/min) at H6, during which PI was strongly correlated with RVO (r = 0.98). CONCLUSION CrSO2 and preductal PI are strongly correlated with cardiac output during low cardiac output states. What is Known: • Perfusion index and near-infrared spectroscopy are non-invasive tools to evaluate haemodynamics in preterm infants. • Pre- and postductal perfusion indexes strongly correlate with left ventricular output in term infants, and near-infrared spectroscopy has been validated to assess cerebral oxygenation in term and preterm infants. What is New: • Cerebral regional tissue oxygen saturation and preductal perfusion index were strongly correlated with cardiac output during low cardiac output states. • The strength of the correlation between cerebral regional tissue oxygen saturation, preductal perfusion index, and cardiac output varied in the first 72 h of life, reflecting the complexity of the transitional physiology.
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Pereira SS, Kempley ST, Wertheim DF, Sinha AK, Morris JK, Shah DK. Investigation of EEG Activity Compared with Mean Arterial Blood Pressure in Extremely Preterm Infants. Front Neurol 2018. [PMID: 29535674 PMCID: PMC5834421 DOI: 10.3389/fneur.2018.00087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Cerebral electrical activity in extremely preterm infants is affected by various factors including blood gas and circulatory parameters. Objective To investigate whether continuously measured invasive mean arterial blood pressure (BP) is associated with electroencephalographic (EEG) discontinuity in extremely preterm infants. Study design This prospective observational study examined 51 newborn infants born <29 weeks gestation in the first 3 days after birth. A single channel of raw EEG was used to quantify discontinuity. Mean BP was acquired using continuous invasive measurement and Doppler ultrasound was used to measure left ventricular output (LVO) and common carotid artery blood flow (CCAF). Results Median gestation and birthweight were 25.6 weeks and 760 g, respectively. Mean discontinuity reduced significantly between days 1 and 3. EEG discontinuity was significantly related to gestation, pH and BP. LVO and CCAF were not associated with EEG discontinuity. Conclusion Continuously measured invasive mean arterial BP was found to have a negative relationship with EEG discontinuity; increasing BP was associated with lower EEG discontinuity. This did not appear to be mediated by surrogates of systemic or cerebral blood flow. Infants receiving inotropic support had significantly increased EEG discontinuity on the first day after birth.
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Affiliation(s)
- Sujith S Pereira
- Neonatal Unit, Royal London Hospital, Barts Health NHS Trust, London, United Kingdom.,Centre for Genomics and Child Health, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Stephen T Kempley
- Neonatal Unit, Royal London Hospital, Barts Health NHS Trust, London, United Kingdom.,Centre for Genomics and Child Health, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - David F Wertheim
- Faculty of Science, Engineering and Computing, Kingston University, Kingston upon Thames, United Kingdom
| | - Ajay K Sinha
- Neonatal Unit, Royal London Hospital, Barts Health NHS Trust, London, United Kingdom.,Centre for Genomics and Child Health, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Joan K Morris
- Centre for Environmental and Preventive Medicine, Wolfson Institute of Preventive Medicine, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Divyen K Shah
- Neonatal Unit, Royal London Hospital, Barts Health NHS Trust, London, United Kingdom.,Centre for Neuroscience and Trauma, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
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39
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Kluckow M. The Pathophysiology of Low Systemic Blood Flow in the Preterm Infant. Front Pediatr 2018; 6:29. [PMID: 29503814 PMCID: PMC5820306 DOI: 10.3389/fped.2018.00029] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 01/31/2018] [Indexed: 11/13/2022] Open
Abstract
Assessment and treatment of the VLBW infant with cardiovascular impairment requires understanding of the underlying physiology of the infant in transition. The situation is dynamic with changes occurring in systemic blood pressure, pulmonary pressures, myocardial function, and ductal shunt in the first postnatal days. New insights into the role of umbilical cord clamping in the transitional circulation have been provided by large clinical trials of early versus later cord clamping and a series of basic science reports describing the physiology in an animal model. Ultrasound assessment is invaluable in assessment of the physiology of the transition and can provide information about the size and shunt direction of the ductus arteriosus, the function of the myocardium and its filling as well as measurements of the cardiac output and an estimate of the state of peripheral vascular resistance. This information not only allows more specific treatment but it will often reduce the need for treatment.
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Affiliation(s)
- Martin Kluckow
- Department of Neonatology, Royal North Shore Hospital, University of Sydney, Sydney, NSW, Australia
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Joynt C, Cheung PY. Treating Hypotension in Preterm Neonates With Vasoactive Medications. Front Pediatr 2018; 6:86. [PMID: 29707527 PMCID: PMC5908904 DOI: 10.3389/fped.2018.00086] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 03/19/2018] [Indexed: 12/23/2022] Open
Abstract
Preterm neonates often have hypotension which may be due to various etiologies. While it is controversial to define hypotension in preterm neonates, various vasoactive medications are commonly used to provide the cardiovascular support to improve the blood pressure, cardiac output, or to treat shock. However, the literature on the systemic and regional hemodynamic effects of these antihypotensive medications in neonates is deficient and incomplete, and cautious translation of findings from other clinical populations and animal studies is required. Based on a literature search on published reports, meta-analytic reviews, and selected abstracts, this review discusses the current available information on pharmacologic actions, clinical effects, and side effects of commonly used antihypotensive medications including dopamine, dobutamine, epinephrine, norepinephrine, vasopressin, and milrinone in preterm neonates.
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Affiliation(s)
- Chloe Joynt
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Po-Yin Cheung
- Department of Pediatrics, University of Alberta, 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
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41
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Pichler G, Höller N, Baik-Schneditz N, Schwaberger B, Mileder L, Stadler J, Avian A, Pansy J, Urlesberger B. Avoiding Arterial Hypotension in Preterm Neonates (AHIP)-A Single Center Randomised Controlled Study Investigating Simultaneous Near Infrared Spectroscopy Measurements of Cerebral and Peripheral Regional Tissue Oxygenation and Dedicated Interventions. Front Pediatr 2018; 6:15. [PMID: 29450194 PMCID: PMC5799241 DOI: 10.3389/fped.2018.00015] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Accepted: 01/16/2018] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Up to 50% of preterm infants admitted to intensive care units require cardiocirculatory support. The aim of the present study was to assess whether simultaneous monitoring of cerebral tissue oxygenation index (cTOI) and peripheral tissue oxygenation index (pTOI) using near-infrared spectroscopy (NIRS) in combination with dedicated intervention guidelines may help avoiding arterial hypotension and catecholamine administration in preterm neonates. STUDY DESIGN Preterm neonates <37 weeks of gestation were included in a single center randomized controlled study. Blood pressure was measured non-invasively or invasively. In the NIRS group, simultaneous cTOI and pTOI monitoring was used starting within 6 h after birth for 24 h to calculate changes in cTOI/pTOI ratio over time. Depending on these changes, interventions including echocardiography, administration of volume or patent ductus arteriosus treatment were performed. In the control group, only routine monitoring and treatment were performed and NIRS signals were not visible. The primary outcome was burden of hypotension within 48 h after initiation of NIRS monitoring. RESULTS 49 preterm neonates were included in each group: NIRS group 33.1 (32.0-34.0) (median: 25-75 centile) weeks of gestation and control group 33.4 (32.3-34.3) weeks of gestation. In the NIRS group, echocardiography was performed in 17 preterm neonates due to NIRS measurements, whereby six neonates received further treatment. Percentage of neonates with any hypotensive episode during the 48-h observational period was 32.6% in the NIRS group and 44.9% in the control group (p = 0.214). Burden of hypotension (i.e., %mmHg of mean arterial pressure < gestational age) was 0.0 (0.0-2.1) mmHg h in the NIRS group and 0.4 (0.0-3.3) mmHg h in the control group (p = 0.313), with observed burden of hypotension being low in both groups. No severe adverse reactions were observed. CONCLUSION In preterm neonates using simultaneous peripheral and cerebral NIRS measurements for early detection of centralization followed by predefined interventions led to a non-significant reduction in burden of arterial hypotension. CLINICAL TRIAL REGISTRATION www.ClinicalTrials.gov, identifier: NCT01910467.
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Affiliation(s)
- Gerhard Pichler
- Research Unit for Neonatal Micro- and Macrocirculation, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Nina Höller
- Research Unit for Neonatal Micro- and Macrocirculation, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Nariae Baik-Schneditz
- Research Unit for Neonatal Micro- and Macrocirculation, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Bernhard Schwaberger
- Research Unit for Neonatal Micro- and Macrocirculation, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Lukas Mileder
- Research Unit for Neonatal Micro- and Macrocirculation, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Jasmin Stadler
- Research Unit for Neonatal Micro- and Macrocirculation, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Alexander Avian
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Jasmin Pansy
- Research Unit for Neonatal Micro- and Macrocirculation, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Berndt Urlesberger
- Research Unit for Neonatal Micro- and Macrocirculation, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
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Abstract
Maintaining optimal circulatory status is a key component of preterm neonatal care. Low-cardiac output (CO) in the preterm neonate leads to inadequate perfusion of vital organs and has been linked to a variety of adverse outcomes with heightened acute morbidity and mortality and adverse neurodevelopmental outcomes. Having technology available to monitor CO allows us to detect low-output states and potentially intervene to mitigate the unwanted effects of reduced organ perfusion. There are many technologies available for the monitoring of CO in the preterm neonatal population and while many act as useful adjuncts to aid clinical decision-making no technique is perfect. In this review, we discuss the relative merits and limitations of various common methodologies available for monitoring CO in the preterm neonatal population. We will discuss the ongoing challenges in monitoring CO in the preterm neonate along with current gaps in our knowledge. We conclude by discussing emerging technologies and areas that warrant further study.
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Affiliation(s)
- Matthew McGovern
- Neonatology Department, Coombe Women and Infant University Hospital, Dublin, Ireland.,Department of Paediatrics, Trinity College Dublin, National Children's Hospital Tallaght, Dublin, Ireland
| | - Jan Miletin
- Neonatology Department, Coombe Women and Infant University Hospital, Dublin, Ireland.,Institute for the Care of Mother and Child, Prague, Czechia.,3rd School of Medicine, Charles University, Prague, Czechia.,UCD School of Medicine and Medical Sciences, Dublin, Ireland
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43
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Van Laere D, Voeten M, O' Toole JM, Dempsey E. Monitoring Circulation During Transition in Extreme Low Gestational Age Newborns: What's on the Horizon? Front Pediatr 2018; 6:74. [PMID: 29632852 PMCID: PMC5879103 DOI: 10.3389/fped.2018.00074] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 03/12/2018] [Indexed: 11/20/2022] Open
Abstract
Echocardiography and near-infrared spectroscopy have significantly changed our view on hemodynamic transition of the extreme preterm infant. Instead of focusing on maintaining an arbitrary target value of blood pressure, we aim for circulatory well-being by a comprehensive holistic assessment of markers of cardiovascular instability. Most of these clinical and biochemical indices are influenced by transition itself and remain poor discriminators to identify patients with a potential need for therapeutic intervention. At the same time, the evolution in data capturing and storage has led to a change in our approach to monitor vital parameters. Continuous trend monitoring has become more and more relevant. By using signal extraction methods, changes in trends over time can be quantified. In this review, we will discuss the impact of these innovations on the current monitoring practices and explore some of the potential benefits these techniques may have in improving real-time detection of extreme low birth weight infants at risk for morbidity related to impaired hemodynamic transition.
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Affiliation(s)
- David Van Laere
- Department of Neonatal Intensive Care, Antwerp University Hospital, Antwerp, Belgium.,Laboratory of Experimental Medicine and Pediatrics, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Michiel Voeten
- Department of Neonatal Intensive Care, Antwerp University Hospital, Antwerp, Belgium.,Laboratory of Experimental Medicine and Pediatrics, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - John M O' Toole
- Irish Centre for Fetal and Neonatal Translational Research, University College Cork, Cork, Ireland
| | - Eugene Dempsey
- Irish Centre for Fetal and Neonatal Translational Research, University College Cork, Cork, Ireland
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44
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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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45
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Abstract
"Golden Hour" of neonatal life is defined as the first hour of post-natal life in both preterm and term neonates. This concept in neonatology has been adopted from adult trauma where the initial first hour of trauma management is considered as golden hour. The "Golden hour" concept includes practicing all the evidence based intervention for term and preterm neonates, in the initial sixty minutes of postnatal life for better long-term outcome. Although the current evidence supports the concept of golden hour in preterm and still there is no evidence seeking the benefit of golden hour approach in term neonates, but neonatologist around the globe feel the importance of golden hour concept equally in both preterm and term neonates. Initial first hour of neonatal life includes neonatal resuscitation, post-resuscitation care, transportation of sick newborn to neonatal intensive care unit, respiratory and cardiovascular support and initial course in nursery. The studies that evaluated the concept of golden hour in preterm neonates showed marked reduction in hypothermia, hypoglycemia, intraventricular hemorrhage (IVH), bronchopulmonary dysplasia (BPD), and retinopathy of prematurity (ROP). In this review article, we will discuss various components of neonatal care that are included in "Golden hour" of preterm and term neonatal care.
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Affiliation(s)
- Deepak Sharma
- National Institute of Medical Science, Jaipur, Rajasthan India
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46
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Escourrou G, Renesme L, Zana E, Rideau A, Marcoux MO, Lopez E, Gascoin G, Kuhn P, Tourneux P, Guellec I, Flamant C. How to assess hemodynamic status in very preterm newborns in the first week of life? J Perinatol 2017; 37:987-993. [PMID: 28471441 DOI: 10.1038/jp.2017.57] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 02/12/2017] [Accepted: 03/28/2017] [Indexed: 01/02/2023]
Abstract
BACKGROUND Assessing hemodynamic status in preterm newborns is an essential task, as many studies have shown increased morbidity when hemodynamic parameters are abnormal. Although oscillometric monitoring of arterial blood pressure (BP) is widely used due to its simplicity and lack of side effects, these values are not always correlated with microcirculation and oxygen delivery. OBJECTIVES This review focuses on different tools for the assessment of hemodynamic status in preterm newborns. These include the measurement of clinical (BP, capillary refill time and urinary output (UO)) or biological parameters (lactate analysis), functional echocardiography, and near-infrared spectroscopy (NIRS). We describe the concepts and techniques involved in these tools in detail, and examine the interest and limitations of each type of assessment. CONCLUSIONS This review highlights the complementarities between the different parameters used to assess hemodynamic status in preterm newborns during the first week of life. The analysis of arterial BP measured by oscillometric monitoring must take into account other clinical data, in particular capillary refill time and UO, and biological data such as lactate levels. Echocardiography improves noninvasive hemodynamic management in newborns but requires specific training. In contrast, NIRS may be useful in monitoring the clinical course of infants at risk of, or presenting with, hypotension. It holds the potential for early and noninvasive identification of silent hypoperfusion in critically ill preterm infants. However, more data are needed to confirm the usefulness of this promising tool in significantly changing the outcome of these infants.
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Affiliation(s)
- G Escourrou
- Department of Neonatal Medicine, CH Montreuil, Montreuil, France
| | - L Renesme
- Department of Neonatal Medicine, CHU Bordeaux, France
| | - E Zana
- Department of Neonatal Medicine, Port Royal Maternity, Paris, France
| | - A Rideau
- Department of Neonatal Medicine, CHU Paris, France
| | - M O Marcoux
- Paediatric Intensive Care Unit, CHU Toulouse, France
| | - E Lopez
- Department of Neonatal Medicine, CHU Tours, France
| | - G Gascoin
- Department of Neonatal Medicine, CHU Angers, France
| | - P Kuhn
- Department of Neonatal Medicine, CHU Strasbourg, France
| | - P Tourneux
- Department of Neonatal Medicine, CHU Amiens, France
| | - I Guellec
- Department of Neonatal Medicine, CHU Paris, France
| | - C Flamant
- Department of Neonatal Medicine, CHU Nantes, Service de Réanimation néonatale, Nantes, France
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47
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Abstract
The management of the hemodynamic status of critically ill preterm infants, particularly around the periviable period, remains a significant challenge in the neonatal intensive care unit for a multitude of reasons. The causes of hemodynamic compromise in this population are heterogeneous and usually superimposed on the complex physiologic processes that occur during transition from fetal to neonatal life. This review outlines the unique nature of low blood flow states in this population and present an overview of the current methods for identification and assessment of hemodynamic compromise.
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Affiliation(s)
- Afif El-Khuffash
- Department of Neonatology, The Rotunda Hospital, Parnell Square, Dublin 1, DO1 P5W9, Ireland; Department of Paediatrics, School of Medicine, Royal College of Surgeons in Ireland, 123 St Stephen's Green, Dublin 2, Ireland
| | - Patrick J McNamara
- Division of Neonatology, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, Ontario MG5 1X8, Canada.
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Use of renal near-infrared spectroscopy measurements in congenital diaphragmatic hernia patients on ECMO. J Pediatr Surg 2017; 52:689-692. [PMID: 28190559 DOI: 10.1016/j.jpedsurg.2017.01.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 01/23/2017] [Indexed: 11/20/2022]
Abstract
INTRODUCTION This study tests the hypothesis that renal tissue oxygen saturation as measured by Near Infrared Spectroscopy (NIRS) would correlate with urine output in neonates with congenital diaphragmatic hernia (CDH) on extracorporeal membrane oxygenation (ECMO). METHODS Between 2012 and 2015, neonates with CDH were enrolled as part of a comprehensive study that provided renal/cerebral/abdominal NIRS monitoring for the duration of ECMO support. Continuous NIRS measurements, mean arterial pressure, and urine output were recorded. Periods of anuria (NU), adequate urine output >1ml/kg/h (AU), and low urine output <1ml/kg/h (LU) were noted and analyzed. RESULTS Over 1500h of continuous renal NIRS were obtained from six neonates. NIRS values were significantly different during periods of AU, LU, and anuria (84±6%, 76±3%, and 67±6%, p<0.01). ROC curves identified NIRS >76% as highly predictive of adequate urine output (AUC=0.96). MAP was significantly lower only in anuric patients, 36.42±10.26, compared to patients with AU and LU - 42.99±5.25 and 42.85±7.4, respectively (p<0.001). CONCLUSION Renal NIRS measurements correlate with urine production. Lower values are noted as urine output declines and precedes a decline in MAP. Renal NIRS may have promise as a non-invasive means of determining adequacy of renal perfusion and urine output in neonates with complex fluid shifts. LEVEL OF EVIDENCE IIb.
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49
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Vesoulis ZA, Rhoades J, Muniyandi P, Conner S, Cahill AG, Mathur AM. Delayed cord clamping and inotrope use in preterm infants. J Matern Fetal Neonatal Med 2017; 31:1327-1334. [PMID: 28372510 DOI: 10.1080/14767058.2017.1315663] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To evaluate the impact of delayed cord clamping (DCC) on need for inotropic support and mean arterial blood pressure (MABP). METHODS This is a single-center, prospective case-control study of premature infants, born <32 weeks gestation, who underwent DCC in comparison to a matched control group who underwent immediate cord clamping (ICC). The primary outcomes were the differences in MABP and inotropic medication used over the first week of life. Secondary outcomes included the admission hemoglobin, need for blood transfusion, and rates of intraventricular hemorrhage (IVH). Infants were matched on EGA, birth weight, sex, antenatal corticosteroid and magnesium exposure, and presence of chorioamnionitis. RESULTS Hundred and fifty-eight infants (DCC n = 79, ICC n = 79) were included. Demographic factors were similar between groups. DCC infants had a higher admission hemoglobin (p < .01), reduced incidence of high-grade IVH (p = .03), fewer median transfusions (p = .03), and were discharged at an earlier post-menstrual age (p = .04). When controlling for other factors, DCC was not associated with a reduction in inotrope use (p = .22) but was associated with a reduction in high-grade IVH (p = .01). There was no difference in MABP between the groups. CONCLUSIONS DCC is not associated with a reduction in the use of inotropes or a difference in MABP.
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Affiliation(s)
- Zachary A Vesoulis
- a Division of Newborn Medicine, Edward Mallinckrodt Department of Pediatrics , Washington University School of Medicine , St. Louis , MO , USA
| | - Janine Rhoades
- b Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology , Washington University School of Medicine , St. Louis , MO , USA
| | - Pournika Muniyandi
- a Division of Newborn Medicine, Edward Mallinckrodt Department of Pediatrics , Washington University School of Medicine , St. Louis , MO , USA
| | - Shayna Conner
- b Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology , Washington University School of Medicine , St. Louis , MO , USA
| | - Alison G Cahill
- b Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology , Washington University School of Medicine , St. Louis , MO , USA
| | - Amit M Mathur
- a Division of Newborn Medicine, Edward Mallinckrodt Department of Pediatrics , Washington University School of Medicine , St. Louis , MO , USA
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50
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Andersen CC, Hodyl NA, Kirpalani HM, Stark MJ. A Theoretical and Practical Approach to Defining "Adequate Oxygenation" in the Preterm Newborn. Pediatrics 2017; 139:peds.2016-1117. [PMID: 28325811 DOI: 10.1542/peds.2016-1117] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/15/2016] [Indexed: 11/24/2022] Open
Abstract
John Scott Haldane recognized that the administration of supplemental oxygen required titration in the individual. Although he made this observation in adults, it is equally applicable to the preterm newborn. But how, in practice, can the oxygen requirements in the preterm newborn be determined to avoid the consequences of too little and too much oxygen? Unfortunately, the current generation of oxygen saturation trials in preterm newborns guides saturation thresholds rather than individual oxygen requirements. For this reason, we propose an alternate model for the description of oxygen sufficiency. This model considers the adequacy of oxygen delivery relative to simultaneous consumption. We describe how measuring oxygen extraction or the venous oxygen reservoir could define a physiologically based definition of adequate oxygen. This definition would provide a clinically useful reference value while making irrelevant the absolute values of both oxygen delivery and consumption. Additional trials to test adjunctive, noninvasive measurements of oxygen status in high-risk preterm newborns are needed to minimize the effects of both insufficient and excessive oxygen exposure.
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Affiliation(s)
- Chad C Andersen
- Department of Neonatal Medicine, Women's and Children's Hospital, North Adelaide, South Australia, Australia; .,Robinson Research Institute, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia; and
| | - Nicolette A Hodyl
- Department of Neonatal Medicine, Women's and Children's Hospital, North Adelaide, South Australia, Australia.,Robinson Research Institute, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia; and
| | - Haresh M Kirpalani
- Neonatal Division, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Michael J Stark
- Department of Neonatal Medicine, Women's and Children's Hospital, North Adelaide, South Australia, Australia.,Robinson Research Institute, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia; and
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