1
|
Chock VY, Kirpalani H, Bell EF, Tan S, Hintz SR, Ball MB, Smith E, Das A, Loggins YC, Sood BG, Chalak LF, Wyckoff MH, Kicklighter SD, Kennedy KA, Patel RM, Carlo WA, Johnson KJ, Watterberg KL, Sánchez PJ, Laptook AR, Seabrook RB, Cotten CM, Mancini T, Sokol GM, Ohls RK, Hibbs AM, Poindexter BB, Reynolds AM, DeMauro SB, Chawla S, Baserga M, Walsh MC, Higgins RD, Van Meurs KP. Tissue Oxygenation Changes After Transfusion and Outcomes in Preterm Infants: A Secondary Near-Infrared Spectroscopy Study of the Transfusion of Prematures Randomized Clinical Trial (TOP NIRS). JAMA Netw Open 2023; 6:e2334889. [PMID: 37733345 PMCID: PMC10514737 DOI: 10.1001/jamanetworkopen.2023.34889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 07/18/2023] [Indexed: 09/22/2023] Open
Abstract
Importance Preterm infants with varying degrees of anemia have different tissue oxygen saturation responses to red blood cell (RBC) transfusion, and low cerebral saturation may be associated with adverse outcomes. Objective To determine whether RBC transfusion in preterm infants is associated with increases in cerebral and mesenteric tissue saturation (Csat and Msat, respectively) or decreases in cerebral and mesenteric fractional tissue oxygen extraction (cFTOE and mFTOE, respectively) and whether associations vary based on degree of anemia, and to investigate the association of Csat with death or neurodevelopmental impairment (NDI) at 22 to 26 months corrected age. Design, Setting, and Participants This was a prospective observational secondary study conducted among a subset of infants between August 2015 and April 2017 in the Transfusion of Prematures (TOP) multicenter randomized clinical trial at 16 neonatal intensive care units of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Preterm neonates with gestational age 22 to 28 weeks and birth weight 1000 g or less were randomized to higher or lower hemoglobin thresholds for transfusion. Data were analyzed between October 2020 and May 2022. Interventions Near-infrared spectroscopy monitoring of Csat and Msat. Main Outcomes and Measures Primary outcomes were changes in Csat, Msat, cFTOE, and mFTOE after transfusion between hemoglobin threshold groups, adjusting for age at transfusion, gestational age, birth weight stratum, and center. Secondary outcome at 22 to 26 months was death or NDI defined as cognitive delay (Bayley Scales of Infant and Toddler Development-III score <85), cerebral palsy with Gross Motor Function Classification System level II or greater, or severe vision or hearing impairment. Results A total of 179 infants (45 [44.6%] male) with mean (SD) gestational age 25.9 (1.5) weeks were enrolled, and valid data were captured from 101 infants during 237 transfusion events. Transfusion was associated with a significant increase in mean Csat of 4.8% (95% CI, 2.7%-6.9%) in the lower-hemoglobin threshold group compared to 2.7% (95% CI, 1.2%-4.2%) in the higher-hemoglobin threshold group, while mean Msat increased 6.7% (95% CI, 2.4%-11.0%) vs 5.6% (95% CI, 2.7%-8.5%). Mean cFTOE and mFTOE decreased in both groups to a similar extent. There was no significant change in peripheral oxygen saturation (SpO2) in either group (0.2% vs -0.2%). NDI or death occurred in 36 infants (37%). Number of transfusions with mean pretransfusion Csat less than 50% was associated with NDI or death (odds ratio, 2.41; 95% CI, 1.08-5.41; P = .03). Conclusions and Relevance In this secondary study of the TOP randomized clinical trial, Csat and Msat were increased after transfusion despite no change in SpO2. Lower pretransfusion Csat may be associated with adverse outcomes, supporting further investigation of targeted tissue saturation monitoring in preterm infants with anemia. Trial Registration ClinicalTrials.gov Identifier: NCT01702805.
Collapse
Affiliation(s)
- Valerie Y. Chock
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, California
| | - Haresh Kirpalani
- Department of Pediatrics, University of Pennsylvania, Philadelphia
| | | | - Sylvia Tan
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, North Carolina
| | - Susan R. Hintz
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, California
| | - M. Bethany Ball
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, California
| | - Emily Smith
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, North Carolina
| | - Abhik Das
- Social, Statistical and Environmental Sciences Unit, RTI International, Rockville, Maryland
| | - Yvonne C. Loggins
- Department of Pediatrics, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | - Beena G. Sood
- Department of Pediatrics, Wayne State University, Detroit, Michigan
| | - Lina F. Chalak
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas
| | - Myra H. Wyckoff
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas
| | - Stephen D. Kicklighter
- Division of Neonatology, Department of Pediatrics, WakeMed Health and Hospitals, Raleigh, North Carolina
| | - Kathleen A. Kennedy
- Department of Pediatrics, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston
| | - Ravi M. Patel
- Department of Pediatrics, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | - Waldemar A. Carlo
- Division of Neonatology, University of Alabama at Birmingham, Birmingham
| | | | | | - Pablo J. Sánchez
- Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus
| | - Abbot R. Laptook
- Department of Pediatrics, Women & Infants Hospital, Brown University, Providence, Rhode Island
| | - Ruth B. Seabrook
- Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus
| | | | - Toni Mancini
- Department of Pediatrics, University of Pennsylvania, Philadelphia
| | - Gregory M. Sokol
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis
| | - Robin K. Ohls
- University of New Mexico Health Sciences Center, Albuquerque
- Division of Neonatology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Anna Maria Hibbs
- Department of Pediatrics, Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, Ohio
| | - Brenda B. Poindexter
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Anne Marie Reynolds
- Department of Pediatrics, University of Buffalo Women’s and Children’s Hospital of Buffalo, Buffalo, New York
| | - Sara B. DeMauro
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sanjay Chawla
- Department of Pediatrics, Wayne State University, Detroit, Michigan
| | - Mariana Baserga
- Division of Neonatology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Michele C. Walsh
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Rosemary D. Higgins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
- Research and Sponsored Programs, Florida Gulf Coast University, Fort Myers
| | - Krisa P. Van Meurs
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, California
| |
Collapse
|
2
|
Bailey SM, Prakash SS, Verma S, Desai P, Kazmi S, Mally PV. Near-infrared spectroscopy in the medical management of infants. Curr Probl Pediatr Adolesc Health Care 2022; 52:101291. [PMID: 36404215 DOI: 10.1016/j.cppeds.2022.101291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Near-infrared spectroscopy (NIRS) is a technology that is easy to use and can provide helpful information about organ oxygenation and perfusion by measuring regional tissue oxygen saturation (rSO2) with near-infrared light. The sensors can be placed in different anatomical locations to monitor rSO2 levels in several organs. While NIRS is not without limitations, this equipment is now becoming increasingly integrated into modern healthcare practice with the goal of achieving better outcomes for patients. It can be particularly applicable in the monitoring of pediatric patients because of their size, and especially so in infant patients. Infants are ideal for NIRS monitoring as nearly all of their vital organs lie near the skin surface which near-infrared light penetrates through. In addition, infants are a difficult population to evaluate with traditional invasive monitoring techniques that normally rely on the use of larger catheters and maintaining vascular access. Pediatric clinicians can observe rSO2 values in order to gain insight about tissue perfusion, oxygenation, and the metabolic status of their patients. In this way, NIRS can be used in a non-invasive manner to either continuously or periodically check rSO2. Because of these attributes and capabilities, NIRS can be used in various pediatric inpatient settings and on a variety of patients who require monitoring. The primary objective of this review is to provide pediatric clinicians with a general understanding of how NIRS works, to discuss how it currently is being studied and employed, and how NIRS could be increasingly used in the near future, all with a focus on infant management.
Collapse
Affiliation(s)
- Sean M Bailey
- Division of Neonatology, Department of Pediatrics, New York University Grossman School of Medicine, New York, NY 10016.
| | - Shrawani Soorneela Prakash
- Division of Neonatology, Department of Pediatrics, NYCHHC/Lincoln Medical and Mental Health Center, Bronx, NY 10451
| | - Sourabh Verma
- Division of Neonatology, Department of Pediatrics, New York University Grossman School of Medicine, New York, NY 10016
| | - Purnahamsi Desai
- Division of Neonatology, Department of Pediatrics, New York University Grossman School of Medicine, New York, NY 10016
| | - Sadaf Kazmi
- Division of Neonatology, Department of Pediatrics, New York University Grossman School of Medicine, New York, NY 10016
| | - Pradeep V Mally
- Division of Neonatology, Department of Pediatrics, New York University Grossman School of Medicine, New York, NY 10016
| |
Collapse
|
3
|
Chock VY, Smith E, Tan S, Ball MB, Das A, Hintz SR, Kirpalani H, Bell EF, Chalak LF, Carlo WA, Cotten CM, Widness JA, Kennedy KA, Ohls RK, Seabrook RB, Patel RM, Laptook AR, Mancini T, Sokol GM, Walsh MC, Yoder BA, Poindexter BB, Chawla S, D’Angio CT, Higgins RD, Van Meurs KP. Early brain and abdominal oxygenation in extremely low birth weight infants. Pediatr Res 2022; 92:1034-1041. [PMID: 35513716 PMCID: PMC9588487 DOI: 10.1038/s41390-022-02082-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 02/24/2022] [Accepted: 04/10/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Extremely low birth weight (ELBW) infants are at risk for end-organ hypoxia and ischemia. Regional tissue oxygenation of the brain and gut as monitored with near-infrared spectroscopy (NIRS) may change with postnatal age, but normal ranges are not well defined. METHODS A prospective study of ELBW preterm infants utilized NIRS monitoring to assess changes in cerebral and mesenteric saturation (Csat and Msat) over the first week after birth. This secondary study of a multicenter trial comparing hemoglobin transfusion thresholds assessed cerebral and mesenteric fractional tissue oxygen extraction (cFTOE and mFTOE) and relationships with perinatal variables. RESULTS In 124 infants, both Csat and Msat declined over the first week, with a corresponding increase in oxygen extraction. With lower gestational age, lower birth weight, and 5-min Apgar score ≤5, there was a greater increase in oxygen extraction in the brain compared to the gut. Infants managed with a lower hemoglobin transfusion threshold receiving ≥2 transfusions in the first week had the lowest Csat and highest cFTOE (p < 0.001). CONCLUSION Brain oxygen extraction preferentially increased in more immature and anemic preterm infants. NIRS monitoring may enhance understanding of cerebral and mesenteric oxygenation patterns and inform future protective strategies in the preterm ELBW population. IMPACT Simultaneous monitoring of cerebral and mesenteric tissue saturation demonstrates the balance of oxygenation between preterm brain and gut and may inform protective strategies. Over the first week, oxygen saturation of the brain and gut declines as oxygen extraction increases. A low hemoglobin transfusion threshold is associated with lower cerebral saturation and higher cerebral oxygen extraction compared to a high hemoglobin transfusion threshold, although this did not translate into clinically relevant differences in the TOP trial primary outcome. Greater oxygen extraction by the brain compared to the gut occurs with lower gestational age, lower birth weight, and 5-min Apgar score ≤5.
Collapse
Affiliation(s)
- Valerie Y. Chock
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, CA,Corresponding author: Valerie Y. Chock, MD, MS Epi, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, 453 Quarry Road, Palo Alto, CA. 94304 USA, (650) 723-5711,
| | - Emily Smith
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, NC
| | - Sylvia Tan
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, NC
| | - M. Bethany Ball
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, CA
| | - Abhik Das
- Social, Statistical and Environmental Sciences Unit, RTI International, Rockville, MD
| | - Susan R. Hintz
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, CA
| | - Haresh Kirpalani
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA
| | - Edward F. Bell
- Department of Pediatrics, University of Iowa, Iowa City, IA
| | - Lina F. Chalak
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Waldemar A. Carlo
- Division of Neonatology, University of Alabama at Birmingham, Birmingham, AL
| | | | | | - Kathleen A. Kennedy
- Department of Pediatrics, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Robin K. Ohls
- University of New Mexico Health Sciences Center, Albuquerque, NM,Department of Pediatrics, Division of Neonatology, University of Utah School of Medicine, Salt Lake City, UT
| | - Ruth B. Seabrook
- Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH
| | - Ravi M. Patel
- Emory University School of Medicine, Department of Pediatrics, Children’s Healthcare of Atlanta, Atlanta, GA
| | - Abbot R. Laptook
- Department of Pediatrics, Women & Infants Hospital, Brown University, Providence, RI
| | - Toni Mancini
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA
| | - Gregory M. Sokol
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Michele C. Walsh
- Department of Pediatrics, Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, OH
| | - Bradley A. Yoder
- Department of Pediatrics, Division of Neonatology, University of Utah School of Medicine, Salt Lake City, UT
| | - Brenda B. Poindexter
- Emory University School of Medicine, Department of Pediatrics, Children’s Healthcare of Atlanta, Atlanta, GA
| | - Sanjay Chawla
- Department of Pediatrics, Wayne State University, Detroit, MI
| | - Carl T. D’Angio
- University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Rosemary D. Higgins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD,College of Health and Human Services, George Mason University, Fairfax, VA
| | - Krisa P. Van Meurs
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, CA
| | | |
Collapse
|
4
|
Le Bouhellec J, Prodhomme O, Mura T, Jacquot A, Combes C, Gamon L, Durand S, Filleron A, Cambonie G. Near-Infrared Spectroscopy: A Tool for Diagnosing Necrotizing Enterocolitis at Onset of Symptoms in Preterm Neonates with Acute Gastrointestinal Symptoms? Am J Perinatol 2021; 38:e299-e308. [PMID: 32325507 DOI: 10.1055/s-0040-1710033] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE In premature neonates, bloody stools and/or abdominal distension with feeding intolerance may be inaugural signs of necrotizing enterocolitis (NEC). We assessed the ability of near-infrared spectroscopy (NIRS) to distinguish those neonates with NEC soon after the occurrence of these symptoms. STUDY DESIGN We prospectively collected NIRS measurements of abdominal and cerebral regional tissue oxygen saturation (r-SO2), with values masked by an opaque cover. Two physicians, blinded to the NIRS data, determined whether the gastrointestinal symptoms were related to NEC 10 days after symptom onset. RESULTS Forty-five neonates with mean (standard deviation [SD]) gestational, birth weight and postnatal ages of 31 (3.9) weeks, 1,486 (794) g, and 18 (14) days were enrolled over 30 months. Gastrointestinal symptoms were related to NEC in 23 patients and associated with other causes in 22. Analysis of the 48 hours of monitoring revealed comparable abdominal r-SO2 and splanchnic-cerebral oxygenation ratio (SCOR) in patients with and without NEC (r-SO2: 47.3 [20.4] vs. 50.4 [17.8], p = 0.59, SCOR: 0.64 [0.26] vs. 0.69 [0.24], p = 0.51). Results were unchanged after NIRS analysis in 6-hour periods, and restriction of the analysis to severe NEC (i.e., grade 2 and 3, 57% of the NEC cases). CONCLUSION In this study, NIRS monitoring was unable to individualize NEC in premature infants with acute gastrointestinal symptoms.
Collapse
Affiliation(s)
- Julia Le Bouhellec
- Neonatal Intensive Care Unit, Arnaud de Villeneuve Hospital, Montpellier University Hospital Center, Montpellier, France
| | - Olivier Prodhomme
- Department of Pediatric Radiology, Arnaud de Villeneuve Hospital, Montpellier University Hospital Center, Montpellier, France
| | - Thibault Mura
- Department of Medical Information, Arnaud de Villeneuve Hospital, Montpellier University Hospital Center, Montpellier, France
| | - Aurélien Jacquot
- Neonatal Intensive Care Unit, Arnaud de Villeneuve Hospital, Montpellier University Hospital Center, Montpellier, France
| | - Clémentine Combes
- Neonatal Intensive Care Unit, Arnaud de Villeneuve Hospital, Montpellier University Hospital Center, Montpellier, France
| | - Lucie Gamon
- Department of Medical Information, Arnaud de Villeneuve Hospital, Montpellier University Hospital Center, Montpellier, France
| | - Sabine Durand
- Neonatal Intensive Care Unit, Arnaud de Villeneuve Hospital, Montpellier University Hospital Center, Montpellier, France
| | - Anne Filleron
- Department of Pediatrics, Carémeau Hospital, Nîmes University Hospital Center, Nîmes, France
| | - Gilles Cambonie
- Neonatal Intensive Care Unit, Arnaud de Villeneuve Hospital, Montpellier University Hospital Center, Montpellier, France
| |
Collapse
|
5
|
Härmä A, Aikio O, Härkin P, Leskinen M, Valkama M, Saarela T, Hallman M. Subgroup analysis of the early paracetamol trial to preterm infants found haemodynamic changes and improved oxygenation. Early Hum Dev 2020; 145:105042. [PMID: 32442828 DOI: 10.1016/j.earlhumdev.2020.105042] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 04/03/2020] [Accepted: 04/03/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND We previously reported in a randomised trial that early intravenous paracetamol accelerated contraction of ductus arteriosus in very preterm infants (<32 gestation weeks). AIMS To monitor sequentially paracetamol effects on the blood pressure and brain tissue oxygenation in the infants participating the trial. METHODS In a double-blind trial, intravenous paracetamol or placebo was infused to 48 very premature infants starting within 24 h of birth for four days. Besides the ductus arteriosus, we systematically measured blood pressure, peripheral (spO2) and regional cerebral oxygen saturation (rcSO2), and cerebral fractional tissue oxygen extraction (cFTOE) during the study period. RESULTS Compared to the placebo, the paracetamol loading dose transiently decreased the arterial blood pressure. During treatment, the paracetamol-treated infants had higher spO2 (p = .042) and rcSO2 (p = .036) values than the placebo group infants. Additionally, the cFTOE values were lower in the paracetamol group during the study without statistical significance. All infants with closed ductus had higher tissue oxygenation and a lower cFTOE than infants with open ductus. CONCLUSIONS Paracetamol caused modest haemodynamic effects and increased cerebral oxygenation. They were mostly due to early contraction of ductus. Additional direct drug-effects in brain are not ruled-out.
Collapse
Affiliation(s)
- Antti Härmä
- PEDEGO Research Unit and Medical Research Center Oulu, University of Oulu, Oulu, Finland; Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland
| | - Outi Aikio
- PEDEGO Research Unit and Medical Research Center Oulu, University of Oulu, Oulu, Finland; Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland.
| | - Pia Härkin
- PEDEGO Research Unit and Medical Research Center Oulu, University of Oulu, Oulu, Finland; Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland
| | - Markku Leskinen
- PEDEGO Research Unit and Medical Research Center Oulu, University of Oulu, Oulu, Finland; Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland
| | - Marita Valkama
- PEDEGO Research Unit and Medical Research Center Oulu, University of Oulu, Oulu, Finland; Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland
| | - Timo Saarela
- PEDEGO Research Unit and Medical Research Center Oulu, University of Oulu, Oulu, Finland; Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland
| | - Mikko Hallman
- PEDEGO Research Unit and Medical Research Center Oulu, University of Oulu, Oulu, Finland; Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland
| |
Collapse
|
6
|
Regional tissue oxygenation monitoring in the neonatal intensive care unit: evidence for clinical strategies and future directions. Pediatr Res 2019; 86:296-304. [PMID: 31247635 DOI: 10.1038/s41390-019-0466-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 05/24/2019] [Accepted: 06/08/2019] [Indexed: 12/19/2022]
Abstract
Near-infrared spectroscopy (NIRS)-based monitoring of regional tissue oxygenation (rSO2) is becoming more commonplace in the neonatal intensive care unit (NICU). While increasing evidence supports rSO2 monitoring, actual standards for applying this noninvasive bedside technique continue to evolve. This review highlights the current strengths and pitfalls surrounding practical NIRS-based monitoring in the neonatal population. The physiologic background of rSO2 monitoring is discussed, with attention to understanding oxygen delivery/consumption mismatch and its effects on tissue oxygen extraction. The bedside utility of both cerebral and peripheral rSO2 monitoring in the NICU is then explored from two perspectives: (1) disease/event-specific "responsive" monitoring and (2) "routine," continuous monitoring. Recent evidence incorporating both monitoring approaches is summarized with emphasis on practical applicability in the NICU. Finally, a future paradigm for a broad-based NIRS monitoring strategy is presented, with attention towards improving personalization of neonatal care and ultimately enhancing long-term outcomes.
Collapse
|
7
|
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.
Collapse
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
| |
Collapse
|
8
|
Kocvarova L, Mackovicova L, Matasova K, Zibolen M. The early postnatal blood flow characteristics in the superior mesenteric and coeliac arteries in late preterm neonates. J Matern Fetal Neonatal Med 2017; 31:3027-3032. [PMID: 28760069 DOI: 10.1080/14767058.2017.1362553] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Lenka Kocvarova
- Jessenius Faculty of Medicine in Martin, Clinic of Neonatology, Comenius University, Bratislava, Slovakia
| | - Lenka Mackovicova
- Institute of Mathematics and Informatics, Matej Bel University, Banska Bystrica, Slovakia
| | - Katarina Matasova
- Jessenius Faculty of Medicine in Martin, Clinic of Neonatology, Comenius University, Bratislava, Slovakia
| | - Mirko Zibolen
- Jessenius Faculty of Medicine in Martin, Clinic of Neonatology, Comenius University, Bratislava, Slovakia
| |
Collapse
|
9
|
Bailey SM, Mally PV. Review of splanchnic oximetry in clinical medicine. JOURNAL OF BIOMEDICAL OPTICS 2016; 21:091306. [PMID: 27165703 DOI: 10.1117/1.jbo.21.9.091306] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 04/13/2016] [Indexed: 06/05/2023]
Abstract
Global tissue perfusion and oxygenation are important indicators of physiologic function in humans. The monitoring of splanchnic oximetry through the use of near-infrared spectroscopy (NIRS) is an emerging method used to assess tissue oxygenation status. Splanchnic tissue oxygenation (SrSO2) is thought to be potentially of high value in critically ill patients because gastrointestinal organs can often be the first to suffer ischemic injury. During conditions of hypovolemia, cardiac dysfunction, or decreased oxygen-carrying capacity, blood flow is diverted toward vital organs, such as the brain and the heart at the expense of the splanchnic circulation. While monitoring SrSO2 has great potential benefit, there are limitations to the technology and techniques. SrSO2 has been found to have a relatively high degree of variability that can potentially make it difficult to interpret. In addition, because splanchnic organs only lie near the skin surface in children and infants, and energy from currently available sensors only penetrates a few centimeters deep, it can be difficult to use clinically in a noninvasive manner in adults. Research thus far is showing that splanchnic oximetry holds great promise in the ability to monitor patient oxygenation status and detect disease states in humans, especially in pediatric populations.
Collapse
|
10
|
Conforti A, Giliberti P, Landolfo F, Valfrè L, Columbo C, Mondi V, Capolupo I, Dotta A, Bagolan P. Effects of ventilation modalities on near-infrared spectroscopy in surgically corrected CDH infants. J Pediatr Surg 2016; 51:349-53. [PMID: 26342630 DOI: 10.1016/j.jpedsurg.2015.07.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 07/25/2015] [Accepted: 07/31/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Near-infrared spectroscopy (NIRS) is a noninvasive technique for monitoring tissue oxygenation and perfusion. The aim of this study was to evaluate cerebral and splanchnic NIRS changes in CDH operated infants enrolled into the VICI trial and therefore randomized for ventilatory modalities. MATERIALS AND METHODS CDH newborns enrolled into the VICI trial (Netherlands Trial Register, NTR 1310) were randomized at birth for high-frequency oscillatory ventilation (HFOV) or conventional mechanical ventilation (CMV) according to the trial. Cerebral oxygenation (rSO2C) and splanchnic oxygenation (rSO2S) were obtained by NIRS (INVOS 5100; Somanetics, Troy, MI) before and after surgery. Variations in rSO2C and rSO2S were evaluated. Mann-Whitney test and one-way ANOVA were used as appropriate. p<0.05 was considered significant. RESULTS Thirteen VICI trial patients underwent surgical repair between March 2011 and December 2012, and were enrolled in the study. Seven patients were assigned to HFOV and six to CMV group respectively. During surgery, a significant reduction in rSO2C (p=0.0001) and rSO2S (p=0.005) were observed. HFOV patients experienced prolonged reduction in rSO2C value (p=0.003) while rSO2S did not vary between HFOV and CMV (p=0.94). CONCLUSIONS Surgical CDH repair was associated with decrease of cerebral and splanchnic oxygenation, regardless of ventilation. Patients ventilated by HFOV need a longer time interval to recovery normal rSO2C values, than those ventilated by CMV. This may be owing to a different impact of HFOV on patients' hemodynamic status with a higher impairment on total venous return and its negative consequences on cardiac output.
Collapse
Affiliation(s)
- Andrea Conforti
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, Rome, Italy.
| | - Paola Giliberti
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, Rome, Italy
| | - Francesca Landolfo
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, Rome, Italy
| | - Laura Valfrè
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, Rome, Italy
| | - Claudia Columbo
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, Rome, Italy
| | - Vito Mondi
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, Rome, Italy
| | - Irma Capolupo
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, Rome, Italy
| | - Andrea Dotta
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, Rome, Italy
| | - Pietro Bagolan
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, Rome, Italy
| |
Collapse
|
11
|
Koch HW, Hansen TG. Perioperative use of cerebral and renal near-infrared spectroscopy in neonates: a 24-h observational study. Paediatr Anaesth 2016; 26:190-8. [PMID: 26725989 DOI: 10.1111/pan.12831] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/18/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND Neonates undergoing surgery and intensive care still carry a significant morbidity and mortality often related to hypoxic/ischemic events; some of which may go undetected by conventional monitoring. Near-infrared spectroscopy (NIRS) is a noninvasive, continuous method of measuring regional tissue oxygen saturation, and may be used to supplement conventional monitoring to improve neonatal perioperative care. However, high costs and lack of evidence regarding improved outcomes have minimized wider perinatal use of NIRS. The aim of this study was to investigate the applicability of NIRS in neonates and premature infants undergoing noncardiac surgeries. METHOD Neonates were monitored with both cerebral and renal NIRS for 24 h after induction of anesthesia and compared with systemic blood pressure (BP), peripheral oxygen saturation (SpO2 ), and heart rate (HR). RESULTS A total of 23 368 min of data were collected from 21 neonates. NIRS reported cerebral/renal hypoxia 2.8 (±8.3)%/19.3 (±25.4)% of the time intraoperatively and 9.6 (±17.0)%/9.9 (±18.9)% of the time postoperatively. A moderate positive correlation was found between SpO2 and NIRS (φcerebral = 0.371, φrenal = 0.542). BP showed a weaker positive correlation (φcerebral = 0.231, φrenal = 0.246), and HR no correlation (φcerebral = -0.083, φrenal = -0.029). NIRS reported hypoxia two to three times more frequently than SpO2 , and SpO2 readings were 10-15 s delayed compared to NIRS. Furthermore, NIRS appeared effective at detecting postoperative apnea. CONCLUSION Near-infrared spectroscopy is an easily applicable technique that appears effective at detecting hypoxic events and postoperative apneas in neonates. The high incidences of regional hypoxia reported by NIRS in this study imply that there is a need for a more specific regional cerebral and renal monitoring. Despite some practical and economical limitations, NIRS may be considered a useful supplement to perinatal perioperative intensive care.
Collapse
Affiliation(s)
- Henrik W Koch
- Department of Anesthesiology and Intensive Care, Odense University Hospital and Institute of Clinical Research - Anesthesiology, University of Southern Denmark, Odense, Denmark
| | - Tom G Hansen
- Department of Anesthesiology and Intensive Care, Odense University Hospital and Institute of Clinical Research - Anesthesiology, University of Southern Denmark, Odense, Denmark
| |
Collapse
|
12
|
Richter AE, Schat TE, Van Braeckel KNJA, Scherjon SA, Bos AF, Kooi EMW. The Effect of Maternal Antihypertensive Drugs on the Cerebral, Renal and Splanchnic Tissue Oxygen Extraction of Preterm Neonates. Neonatology 2016; 110:163-71. [PMID: 27104347 DOI: 10.1159/000445283] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 03/08/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Drugs with antihypertensive action are frequently used in obstetrics for the treatment of preeclampsia (labetalol) and tocolysis (nifedipine) or for neuroprotection (MgSO4), and may affect the hemodynamics of preterm born neonates. OBJECTIVE The aim of this study was to assess whether maternal antihypertensive drugs affect multisite oxygenation levels of the neonate. METHODS Eighty preterm neonates of ≤32 weeks of gestational age were monitored using near-infrared spectroscopy. Mean cerebral, renal and splanchnic fractional tissue oxygen extractions (cFTOE, rFTOE and sFTOE) were calculated for the first 5 postnatal days. We determined the effect of various maternal antihypertensive drugs on cFTOE and rFTOE using multilevel analysis, and on sFTOE using Kruskal-Wallis and Mann-Whitney U tests. RESULTS Eleven infants were exposed to labetalol ± MgSO4, 7 to nifedipine ± MgSO4, 20 to MgSO4 only, and 42 to no maternal antihypertensive drugs. The infants exposed to labetalol ± MgSO4 had a lower cFTOE on days 1 (0.14, p = 0.031), 2 (0.13, p = 0.035) and 4 (0.18, p = 0.046) than nonexposed infants on the corresponding days (0.22, 0.20 and 0.24, respectively). On day 2, cFTOE was also lower in infants exposed to nifedipine ± MgSO4 (0.11, p = 0.028) and to MgSO4 only (0.15, p = 0.047). sFTOE was higher in infants exposed to labetalol ± MgSO4 on days 1 (µ = 0.71) and 2 (µ = 0.82) than in nonexposed infants (µ = 0.26, p = 0.04 and µ = 0.55, p = 0.007, respectively). Maternal antihypertensive drugs did not affect rFTOE. CONCLUSIONS Low neonatal cFTOE found with maternal antihypertensive drug exposure may relate to either increased cerebral perfusion or neurologic depression induced by the medication, or preferential brain perfusion associated with preeclampsia placental insufficiency. Concomitantly high sFTOE found with labetalol exposure supports the latter, while renal autoregulation may explain rFTOE stability.
Collapse
Affiliation(s)
- Anne E Richter
- Department of Neonatology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | | | | | | | | |
Collapse
|
13
|
Cruz SM, Akinkuotu AC, Rusin CG, Cass DL, Lee TC, Welty SE, Olutoye OO. A novel multimodal computational system using near-infrared spectroscopy to monitor cerebral oxygenation during assisted ventilation in CDH patients. J Pediatr Surg 2016; 51:38-43. [PMID: 26585879 DOI: 10.1016/j.jpedsurg.2015.10.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 10/06/2015] [Indexed: 11/15/2022]
Abstract
BACKGROUND/PURPOSE The aim of this study was to create a computational simulator to serve as an early alert system for cerebral hypoxemia prior to the onset of clinical symptoms. METHODS Neonates with congenital diaphragmatic hernia (Jan 2010-Dec 2014) were recruited to collect continuous measurements of cerebral tissue oxygen saturation (cStO2) using a near-infrared spectroscopy (NIRS) device (FORE-SIGHT®, CASMED). Clinicians were blinded to NIRS data and treated infants based on pre-established clinical protocols. Charts were reviewed retrospectively to identify clinical events of hypoxemia (spontaneous, sustained decrease in preductal SpO2<85% leading to ventilator changes). We developed a computational algorithm that determined baseline values, variability and event data for each patient. RESULTS Twenty-three of 36 patients enrolled met data criteria. The algorithm anticipated an event at least 15 minutes prior to the event in 77% of cases, with an average pre-event detection of 47 minutes (range 16-122 minutes). Post-event StO2 (SpO2<85%) was determined to be 63.7% ± 11.7. In this computational model, the sensitivity to distinguish low states of cerebral perfusion was 94% with a specificity of 96%. CONCLUSION We have developed a computational algorithm with an early warning system that has the potential of being translated into a real-time clinical interface that may improve management of neonates.
Collapse
Affiliation(s)
- Stephanie M Cruz
- Texas Children's Fetal Center and the Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Adesola C Akinkuotu
- Texas Children's Fetal Center and the Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Craig G Rusin
- Department of Pediatrics-Cardiology Division, Baylor College of Medicine, Houston, TX, United States
| | - Darrell L Cass
- Texas Children's Fetal Center and the Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States; Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, United States
| | - Timothy C Lee
- Texas Children's Fetal Center and the Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Stephen E Welty
- Department of Pediatrics-Newborn Section, Baylor College of Medicine, Houston, TX, United States
| | - Oluyinka O Olutoye
- Texas Children's Fetal Center and the Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States; Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, United States.
| |
Collapse
|
14
|
Petrova A, Mehta R. Alteration in regional tissue oxygenation of preterm infants during placement in the semi-upright seating position. Sci Rep 2015; 5:8343. [PMID: 25661986 PMCID: PMC4321184 DOI: 10.1038/srep08343] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 01/15/2015] [Indexed: 01/30/2023] Open
Abstract
We investigated whether the cerebral (rSO2-C %) and renal (rSO2-R %) tissue oxygenation of preterm infants is altered by repositioning from the supine to semi-upright position for pre-discharge car seat testing. Near-infrared spectroscopy was used to measure rSO2-C and rSO2-R, which were recorded simultaneously with vital signs in 15 preterm infants for 30 minutes in supine, 60 minutes in the semi-upright (at 45 degrees in a car seat), and 30 minutes in the post-semi-upright (supine) position. Changes in rSO2-C and SO2-R were mostly within 1 Standard Deviation (SD) of baseline mean levels in the supine position. Decrease in rSO2-C and rSO2-R (more than 1SD below baseline mean) was recorded in 26.7% and 6.6% of infants respectively, which persisted even after adjustment for variation in heart and respiratory rate, and pulse oximeter measured oxygen saturation (P, 0.0001). Re-positioning the infants from the car seat to supine position was associated with normalization of the rSO2-C. Alteration in rSO2-C and rSO2-R in a car seat was independent from the gestational and post-conception age, weight and presence of anemia. We concluded that approximately one-third of preterm infants show minor reduction of cerebral tissue oxygenation in the semi-upright (car seat) position.
Collapse
Affiliation(s)
- Anna Petrova
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 08901
| | - Rajeev Mehta
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 08901
| |
Collapse
|
15
|
Mason K. Challenges in paediatric procedural sedation: political, economic, and clinical aspects. Br J Anaesth 2014; 113 Suppl 2:ii48-62. [DOI: 10.1093/bja/aeu387] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
|
16
|
Abstract
Necrotizing enterocolitis (NEC) has largely been present in neonatal intensive care units for the past 60 years. NEC prevalence has corresponded with the continued development and sophistication of neonatal intensive care. Despite major efforts towards its eradication, NEC has persisted and appears to be increasing in some centers. The pathophysiology of this disease remains poorly understood. Several issues have hampered our quest to develop a better understanding of this disease. These include the fact that what we have historically termed 'NEC' appears to be several different diseases. Animal models that are commonly used to study NEC pathophysiology and treatment do not directly reflect the most common form of the disease seen in human infants. The pathophysiology appears to be multifactorial, reflecting several different pathways to intestinal necrosis with different inciting factors. Spontaneous intestinal perforations, ischemic bowel disease secondary to cardiac anomalies as well as other entities that are clearly different from the most common form of NEC seen in preterm infants have been put into the same database. Here I describe some of the different forms of what has been called NEC and make some comments on its pathophysiology, where available studies suggest involvement of genetic factors, intestinal immaturity, hemodynamic instability, inflammation and a dysbiotic microbial ecology. Currently utilized approaches for the diagnosis of NEC are presented and innovative technologies for the development of diagnostic and predictive biomarkers are described. Predictions for future strategies are also discussed.
Collapse
Affiliation(s)
- Josef Neu
- Division of Neonatology, Department of Pediatrics, College of Medicine, University of Florida, Gainesville, Fla., USA
| |
Collapse
|