1
|
Fedriga M, Martini S, Iodice FG, Sortica da Costa C, Pezzato S, Moscatelli A, Beqiri E, Czosnyka M, Smielewski P, Agrawal S. Cerebral autoregulation in paediatric and neonatal intensive care: A scoping review. J Cereb Blood Flow Metab 2024:271678X241261944. [PMID: 38867574 DOI: 10.1177/0271678x241261944] [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] [Indexed: 06/14/2024]
Abstract
Deranged cerebral autoregulation (CA) is associated with worse outcome in adult brain injury. Strategies for monitoring CA and maintaining the brain at its 'best CA status' have been implemented, however, this approach has not yet developed for the paediatric population. This scoping review aims to find up-to-date evidence on CA assessment in children and neonates with a view to identify patient categories in which CA has been measured so far, CA monitoring methods and its relationship with clinical outcome if any. A literature search was conducted for studies published within 31st December 2022 in 3 bibliographic databases. Out of 494 papers screened, this review includes 135 studies. Our literature search reveals evidence for CA measurement in the paediatric population across different diagnostic categories and age groups. The techniques adopted, indices and thresholds used to assess and define CA are heterogeneous. We discuss the relevance of available evidence for CA assessment in the paediatric population. However, due to small number of studies and heterogeneity of methods used, there is no conclusive evidence to support universal adoption of CA monitoring, technique, and methodology. This calls for further work to understand the clinical impact of CA monitoring in paediatric and neonatal intensive care.
Collapse
Affiliation(s)
- Marta Fedriga
- Neonatal and Paediatric Intensive Care Unit, IRCCS Giannina Gaslini Institute, Genoa, Italy
| | - Silvia Martini
- Neonatal Intensive Care Unit, IRCCS AOUBO, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Francesca G Iodice
- Paediatric Cardiac Anaesthesia and Intensive Care Unit, IRCCS, Bambino Gesu' Hospital, Rome, Italy
| | | | - Stefano Pezzato
- Neonatal and Paediatric Intensive Care Unit, IRCCS Giannina Gaslini Institute, Genoa, Italy
| | - Andrea Moscatelli
- Neonatal and Paediatric Intensive Care Unit, IRCCS Giannina Gaslini Institute, Genoa, Italy
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
| | - Shruti Agrawal
- Department of Paediatric Intensive Care, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| |
Collapse
|
2
|
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.
Collapse
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
| | | |
Collapse
|
3
|
Deng B, Ying J, Mu D. Subtypes and Mechanistic Advances of Extracorporeal Membrane Oxygenation-Related Acute Brain Injury. Brain Sci 2023; 13:1165. [PMID: 37626521 PMCID: PMC10452596 DOI: 10.3390/brainsci13081165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 07/31/2023] [Accepted: 08/03/2023] [Indexed: 08/27/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a frequently used mechanical cardiopulmonary support for rescuing critically ill patients for whom conventional medical therapies have failed. However, ECMO is associated with several complications, such as acute kidney injury, hemorrhage, thromboembolism, and acute brain injury (ABI). Among these, ABI, particularly intracranial hemorrhage (ICH) and infarction, is recognized as the primary cause of mortality during ECMO support. Furthermore, survivors often suffer significant long-term morbidities, including neurocognitive impairments, motor disturbances, and behavioral problems. This review provides a comprehensive overview of the different subtypes of ECMO-related ABI and the updated advance mechanisms, which could be helpful for the early diagnosis and potential neuromonitoring of ECMO-related ABI.
Collapse
Affiliation(s)
- Bixin Deng
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu 610041, China;
| | - Junjie Ying
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu 610041, China;
| | - Dezhi Mu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu 610041, China;
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu 610041, China;
| |
Collapse
|
4
|
Pfurtscheller D, Baik-Schneditz N, Schwaberger B, Urlesberger B, Pichler G. Insights into Neonatal Cerebral Autoregulation by Blood Pressure Monitoring and Cerebral Tissue Oxygenation: A Qualitative Systematic Review. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1304. [PMID: 37628303 PMCID: PMC10453558 DOI: 10.3390/children10081304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 07/20/2023] [Accepted: 07/26/2023] [Indexed: 08/27/2023]
Abstract
OBJECTIVE The aim of this qualitative systematic review was to identify publications on blood pressure monitoring in combination with cerebral tissue oxygenation monitoring during the first week after birth focusing on cerebral autoregulation. METHODS A systematic search was performed on PubMed. The following search terms were used: infants/newborn/neonates, blood pressure/systolic/diastolic/mean/MAP/SAP/DAP, near-infrared spectroscopy, oxygenation/saturation/oxygen, and brain/cerebral. Additional studies were identified by a manual search of references in the retrieved studies and reviews. Only human studies were included. RESULTS Thirty-one studies focused on preterm neonates, while five included preterm and term neonates. In stable term neonates, intact cerebral autoregulation was shown by combining cerebral tissue oxygenation and blood pressure during immediate transition, while impaired autoregulation was observed in preterm neonates with respiratory support. Within the first 24 h, stable preterm neonates had reduced cerebral tissue oxygenation with intact cerebral autoregulation, while sick neonates showed a higher prevalence of impaired autoregulation. Further cardio-circulatory treatment had a limited effect on cerebral autoregulation. Impaired autoregulation, with dependency on blood pressure and cerebral tissue oxygenation, increased the risk of intraventricular hemorrhage and abnormal neurodevelopmental outcomes. CONCLUSIONS Integrating blood pressure monitoring with cerebral tissue oxygenation measurements has the potential to improve treatment decisions and optimizes neurodevelopmental outcomes in high-risk neonates.
Collapse
Affiliation(s)
- Daniel Pfurtscheller
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria; (D.P.); (N.B.-S.); (B.S.); (B.U.)
- Research Unit for Neonatal Micro- and Macrocirculation, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria
- Research Unit for Cerebral Development and Oximetry, Division of Neonatology, Medical University of Graz, 8036 Graz, Austria
| | - Nariae Baik-Schneditz
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria; (D.P.); (N.B.-S.); (B.S.); (B.U.)
- Research Unit for Neonatal Micro- and Macrocirculation, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria
- Research Unit for Cerebral Development and Oximetry, Division of Neonatology, Medical University of Graz, 8036 Graz, Austria
| | - Bernhard Schwaberger
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria; (D.P.); (N.B.-S.); (B.S.); (B.U.)
- Research Unit for Neonatal Micro- and Macrocirculation, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria
- Research Unit for Cerebral Development and Oximetry, Division of Neonatology, Medical University of Graz, 8036 Graz, Austria
| | - Berndt Urlesberger
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria; (D.P.); (N.B.-S.); (B.S.); (B.U.)
- Research Unit for Neonatal Micro- and Macrocirculation, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria
- Research Unit for Cerebral Development and Oximetry, Division of Neonatology, Medical University of Graz, 8036 Graz, Austria
| | - Gerhard Pichler
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria; (D.P.); (N.B.-S.); (B.S.); (B.U.)
- Research Unit for Neonatal Micro- and Macrocirculation, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria
- Research Unit for Cerebral Development and Oximetry, Division of Neonatology, Medical University of Graz, 8036 Graz, Austria
| |
Collapse
|
5
|
Merkel CA, Brady KM, Votava-Smith JK, Tran NN. A pilot study: Comparing a novel noninvasive measure of cerebrovascular stability index with an invasive measure of cerebral autoregulation in neonates with congenital heart disease. J Clin Transl Sci 2023; 7:e165. [PMID: 37588677 PMCID: PMC10425865 DOI: 10.1017/cts.2023.581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 06/20/2023] [Accepted: 06/24/2023] [Indexed: 08/18/2023] Open
Abstract
Infants with congenital heart disease (CHD) may have impaired cerebral autoregulation (CA) associated with cerebral fractional tissue oxygen extraction (FTOE). We conducted a pilot study in nine CHD neonates to validate a noninvasive CA measure, cerebrovascular stability index (CSI), by eliciting responses to postural tilts. We compared CSI to an invasive measure of CA and to FTOE collected during tilts (FTOESpot). FTOESpot correlated with CSI, as did the change in FTOE during tilts, but CSI's correlation with impaired CA did not reach significance. Larger trials are indicated to validate CSI, allowing for noninvasive CA measurements and measurements in outpatient settings.
Collapse
Affiliation(s)
| | - Kenneth M. Brady
- Division of Cardiac Anesthesia, Northwestern University Feinberg School of Medicine and Ann & Robert H, Lurie Children’s Hospital of Chicago, Chicago, IL, USA
| | - Jodie K. Votava-Smith
- Keck School of Medicine, Los Angeles, CA, USA
- Division of Cardiology, Department of Pediatrics, Children’s Hospital Los Angeles, Los Angeles, CA, USA
| | - Nhu N. Tran
- Keck School of Medicine, Los Angeles, CA, USA
- Division of Neonatology, Department of Pediatrics, Fetal and Neonatal Institute, Children’s Hospital Los Angeles, Los Angeles, CA, USA
| |
Collapse
|
6
|
Alshafei A. Association of umbilical venous catheters vs peripherally inserted central catheters with death or severe intraventricular hemorrhage among preterm infants < 30 weeks: A randomized clinical trial. J Neonatal Perinatal Med 2023:NPM221126. [PMID: 37092240 DOI: 10.3233/npm-221126] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
BACKGROUND Umbilical venous catheters (UVCs) or peripherally inserted central catheters (PICCs) are routinely inserted in preterm infants for total parenteral nutrition and medications. We aimed to examine whether the rates of severe intraventricular hemorrhage (IVH) or death vary among preterm infants receiving UVCs compared to PICCs. METHODS This randomized controlled trial included preterm infants < 30 weeks gestation assigned after birth to either UVC placement group or PICC group. RESULTS A total of 233 preterm infants (117 infants in UVC group, 116 infants in PICC group) were randomized and collected data was available for intention-to-treat analysis. There were no differences in baseline population characteristics. Severe IVH occurred in 16 infants (13.6%) in the UVC group and 11(9.5%) in the PICC group (risk difference [RD], 4.1% [5% CI, -4 to 12.3]; P = 0.42). The incidence of death before 28 days of life did not differ significantly between groups (10 [8.5% ] in UVC vs 6 [5.1%] in PICC; RD, 3.4% [95% CI, -3.0 to 9.84]; P = 0.44). Seventeen percent (20/117) of the UVC group died or developed severe IVH compared with 12% (14/116) of the PICC group (risk difference, 5% [95% CI, -4.01 -14.06]; P = 0.36). The incidence of necrotizing enterocolitis (NEC) was significantly higher in the UVC group infants than in the PICC group infants (7.7% vs. 1.7%); p = 0.03. CONCLUSIONS The incidence of severe IVH or death did not differ significantly among preterm m infants < 30 weeks gestation subjected to UVC or PICC placement. Early inotropic support was a significant risk factor for the development of severe IVH. UVC maybe an additional risk factor for the development of NEC, but further research is required to validate this finding.
Collapse
Affiliation(s)
- A Alshafei
- Department of Pediatrics, Neonatology Section, Dubai Hospital, Dubai, United Arab Emirates
- Department of Radiology, Dubai Hospital, Dubai, United Arab Emirates
| |
Collapse
|
7
|
Imanishi T, Sumiya W, Kanno C, Kanno M, Kawabata K, Shimizu M. Relationship of cerebral blood volume with arterial and venous flow velocities in extremely low-birth-weight infants. Eur J Pediatr 2023:10.1007/s00431-023-04969-3. [PMID: 37041295 DOI: 10.1007/s00431-023-04969-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 03/23/2023] [Accepted: 04/01/2023] [Indexed: 04/13/2023]
Abstract
Unstable cerebral blood flow is theorised to contribute to the occurrence of intraventricular haemorrhage (IVH) in extremely low-birth-weight infants (ELBWIs), which can be caused by increased arterial flow, increased venous pressure, and impaired autoregulation of brain vasculature. As a preliminary step to investigate such instability, we aimed to check for correlations of cerebral blood volume (CBV), as measured using near-infrared spectroscopy, with the flow velocities of the anterior cerebral artery (ACA) and internal cerebral vein (ICV), as measured using Doppler ultrasonography. Data were retrospectively analysed from 30 ELBWIs uncomplicated by symptomatic patent ductus arteriosus, which can influence ACA velocity, and severe IVH (grade ≥ 3), which can influence ICV velocity and CBV. The correlation between tissue oxygen saturation (StO2) and mean blood pressure was also analysed as an index of autoregulation. CBV was not associated with ACA velocity; however, it was significantly correlated with ICV velocity (Pearson R = 0.59 [95% confidence interval: 0.29-0.78], P = 0.00061). No correlation between StO2 and mean blood pressure was observed, implying that autoregulation was not impaired. Conclusion: Although our findings are based on the premise that cerebral autoregulation was unimpaired in the ELBWIs without complications, the same result cannot be directly applied to severe IVH cases. However, our results may aid future research on IVH prediction by investigating the changes in CBV when severe IVH occurs during ICV velocity fluctuation. What is Known: • The pathogenesis of IVH includes unstable cerebral blood flow affected by increased arterial flow, increased venous pressure, and impaired cerebral autoregulation. • The approaches that can predict IVH are under discussion. What is New: • ACA velocity is not associated with CBV, but ICV velocity is significantly correlated with CBV. • CBV measured using NIRS may be useful in future research on IVH prediction.
Collapse
Affiliation(s)
- Toshiyuki Imanishi
- Division of Neonatology, Department of Maternal and Perinatal Center, Saitama Children's Medical Center, 1-2 Shintoshin, Chuo, Saitama, 330-8777, Japan.
| | - Wakako Sumiya
- Division of Neonatology, Department of Maternal and Perinatal Center, Saitama Children's Medical Center, 1-2 Shintoshin, Chuo, Saitama, 330-8777, Japan
| | - Chika Kanno
- Division of Neonatology, Department of Maternal and Perinatal Center, Saitama Children's Medical Center, 1-2 Shintoshin, Chuo, Saitama, 330-8777, Japan
| | - Masayuki Kanno
- Division of Neonatology, Department of Maternal and Perinatal Center, Saitama Children's Medical Center, 1-2 Shintoshin, Chuo, Saitama, 330-8777, Japan
| | - Ken Kawabata
- Division of Neonatology, Department of Maternal and Perinatal Center, Saitama Children's Medical Center, 1-2 Shintoshin, Chuo, Saitama, 330-8777, Japan
| | - Masaki Shimizu
- Division of Neonatology, Department of Maternal and Perinatal Center, Saitama Children's Medical Center, 1-2 Shintoshin, Chuo, Saitama, 330-8777, Japan
| |
Collapse
|
8
|
Martini S, Thewissen L, Austin T, da Costa CS, de Boode WP, Dempsey E, Kooi E, Pellicer A, Rhee CJ, Riera J, Wolf M, Wong F. Near-infrared spectroscopy monitoring of neonatal cerebrovascular reactivity: where are we now? Pediatr Res 2023:10.1038/s41390-023-02574-6. [PMID: 36997690 DOI: 10.1038/s41390-023-02574-6] [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: 10/27/2022] [Revised: 02/09/2023] [Accepted: 02/17/2023] [Indexed: 06/19/2023]
Abstract
Cerebrovascular reactivity defines the ability of the cerebral vasculature to regulate its resistance in response to both local and systemic factors to ensure an adequate cerebral blood flow to meet the metabolic demands of the brain. The increasing adoption of near-infrared spectroscopy (NIRS) for non-invasive monitoring of cerebral oxygenation and perfusion allowed investigation of the mechanisms underlying cerebrovascular reactivity in the neonatal population, confirming important associations with pathological conditions including the development of brain injury and adverse neurodevelopmental outcomes. However, the current literature on neonatal cerebrovascular reactivity is mainly still based on small, observational studies and is characterised by methodological heterogeneity; this has hindered the routine application of NIRS-based monitoring of cerebrovascular reactivity to identify infants most at risk of brain injury. This review aims (1) to provide an updated review on neonatal cerebrovascular reactivity, assessed using NIRS; (2) to identify critical points that need to be addressed with targeted research; and (3) to propose feasibility trials in order to fill the current knowledge gaps and to possibly develop a preventive or curative approach for preterm brain injury. IMPACT: NIRS monitoring has been largely applied in neonatal research to assess cerebrovascular reactivity in response to blood pressure, PaCO2 and other biochemical or metabolic factors, providing novel insights into the pathophysiological mechanisms underlying cerebral blood flow regulation. Despite these insights, the current literature shows important pitfalls that would benefit to be addressed in a series of targeted trials, proposed in the present review, in order to translate the assessment of cerebrovascular reactivity into routine monitoring in neonatal clinical practice.
Collapse
Affiliation(s)
- Silvia Martini
- Neonatal Intensive Care Unit, IRCCS AOU S. Orsola, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
| | | | - Topun Austin
- Neonatal Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Willem P de Boode
- Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Eugene Dempsey
- Department of Paediatrics and Child Health, INFANT Centre, University College Cork, Cork, Ireland
| | - Elisabeth Kooi
- Division of Neonatology, Beatrix Children's Hospital, University Medical Center, University of Groningen, Groningen, The Netherlands
| | - Adelina Pellicer
- Department of Neonatology, La Paz University Hospital, Madrid, Spain
| | - Christopher J Rhee
- Section of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Joan Riera
- Department of Neonatology, La Paz University Hospital, Madrid, Spain
- Center for Biomedical Technology, Technical University, Madrid, Spain
| | - Martin Wolf
- Biomedical Optics Research Laboratory, Department of Neonatology, University Hospital Zurich, Zurich, Switzerland
| | - Flora Wong
- Monash Newborn, Monash Children's Hospital, Hudson Institute of Medical Research, Department of Paediatrics, Monash University, Melbourne, VIC, Australia
| |
Collapse
|
9
|
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.
Collapse
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
| |
Collapse
|
10
|
Chan KYY, Tran NT, Papagianis PC, Zahra VA, Nitsos I, Moxham AM, LaRosa DA, McDonald C, Miller SL, Galinsky R, Alahmari DM, Stojanovska V, Polglase GR. Investigating Pathways of Ventilation Induced Brain Injury on Cerebral White Matter Inflammation and Injury After 24 h in Preterm Lambs. Front Physiol 2022; 13:904144. [PMID: 35860659 PMCID: PMC9289398 DOI: 10.3389/fphys.2022.904144] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 06/13/2022] [Indexed: 11/13/2022] Open
Abstract
Initiation of respiratory support in the delivery room increases the risk and severity of brain injury in preterm neonates through two major pathways: an inflammatory pathway and a haemodynamic pathway. The relative contribution of each pathway on preterm brain injury is not known. We aimed to assess the role of the inflammatory and haemodynamic pathway on ventilation-induced brain injury (VIBI) in the preterm lamb. Fetal lambs (125 ± 1 day gestation) were exteriorised, instrumented and ventilated with a high tidal-volume (VT) injurious strategy for 15 min either with placental circulation intact to induce the inflammatory pathway only (INJINF; n = 7) or umbilical cord occluded to induce both the inflammatory and haemodynamic pathways (INJINF+HAE; n = 7). Sham controls were exteriorised but not ventilated (SHAM; n = 5) while unoperated controls (UNOP; n = 7) did not undergo fetal instrumentation. Fetuses were returned in utero following intervention and the ewe allowed to recover. Arterial blood gases and plasma were sampled periodically. Twenty-four hours following intervention, lambs were delivered and maintained on non-injurious ventilation for ∼40 min then brains were collected post-mortem for immunohistochemistry and RT-qPCR to assess inflammation, vascular pathology and cell death within white matter regions. Compared to INJINF lambs, INJINF+HAE lambs achieved a consistently higher VT during injurious ventilation and carotid blood flow was significantly lower than baseline by the end of ventilation. Throughout the 24 h recovery period, systemic arterial IL-6 levels of INJINF+HAE lambs were significantly higher than SHAM while there was no difference between INJINF and SHAM animals. At 24 h, mRNA expression levels of pro-inflammatory cytokines, tight junction proteins, markers of cell death, and histological injury indices of gliosis, blood vessel protein extravasation, oligodendrocyte injury and cell death were not different between groups. Injurious ventilation, irrespective of strategy, did not increase brain inflammation or injury 24 h later when compared to control animals. However, the haemodynamic pathway did influence carotid blood flow adaptations during injurious ventilation and increased systemic arterial IL-6 that may underlie long-term pathology. Future studies are required to further characterise the pathways and their long-term effects on VIBI.
Collapse
Affiliation(s)
- Kyra YY Chan
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - Nhi T. Tran
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - Paris C. Papagianis
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
| | - Valerie A. Zahra
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
| | - Ilias Nitsos
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - Alison M. Moxham
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
| | - Domenic A. LaRosa
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - Courtney McDonald
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - Suzanne L. Miller
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - Robert Galinsky
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - Dhafer M. Alahmari
- Monash Biomedicine Discovery Institute and Department of Medical Imaging and Radiation Sciences, Monash University, Clayton, VIC, Australia
- Monash Biomedical Imaging, Monash University, Clayton, VIC, Australia
- Department of Diagnostic Imaging, King Saud Medical City, Riyadh, Saudi Arabia
| | - Vanesa Stojanovska
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - Graeme R. Polglase
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
- *Correspondence: Graeme R. Polglase,
| |
Collapse
|
11
|
Martini S, Czosnyka M, Smielewski P, Iommi M, Galletti S, Vitali F, Paoletti V, Camela F, Austin T, Corvaglia L. Clinical determinants of cerebrovascular reactivity in very preterm infants during the transitional period. Pediatr Res 2022; 92:135-141. [PMID: 35513715 DOI: 10.1038/s41390-022-02090-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: 02/25/2022] [Revised: 03/29/2022] [Accepted: 04/10/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Preterm infants are at enhanced risk of brain injury due to altered cerebral haemodynamics during postnatal transition. This observational study aimed to assess the clinical determinants of transitional cerebrovascular reactivity and its association with intraventricular haemorrhage (IVH). METHODS Preterm infants <32 weeks underwent continuous monitoring of cerebral oxygenation and heart rate over the first 72 h after birth. Serial cranial and cardiac ultrasound assessments were performed to evaluate the ductal status and to diagnose IVH onset. The moving correlation coefficient between cerebral oxygenation and heart rate (TOHRx) was calculated. Linear mixed-effect models were used to analyse the impact of relevant clinical variables on TOHRx. The association between TOHRx and IVH development was also assessed. RESULTS Seventy-seven infants were included. A haemodynamically significant patent ductus arteriosus (hsPDA) (β = 0.044, 95% CI: 0.007-0.081) and ongoing dopamine treatment (β = 0.096, 95% CI: 0.032-0.159) were associated with increasing TOHRx, indicating impaired cerebrovascular reactivity. A significant association between TOHRx, mean arterial blood pressure (β = -0.004, 95% CI: -0.007, -0.001) and CRIB-II score (β = 0.007, 95% CI: 0.001-0.015) was also observed. TOHRx was significantly higher in infants developing high-grade IVH compared to those without IVH. CONCLUSIONS Dopamine treatment, low blood pressure, hsPDA and high CRIB-II are associated with impaired cerebrovascular reactivity during postnatal transition, with potential implications on IVH development. IMPACT The correlation coefficient between cerebral oxygenation and heart rate (TOHRx) provides a non-invasive estimation of cerebrovascular reactivity, whose failure has a potential pathogenic role in the development of IVH in preterm infants. This study shows that cerebrovascular reactivity during the transitional period improves over time and is affected by specific clinical and therapeutic factors, whose knowledge could support the development of individualized neuroprotective strategies in at-risk preterm infants. The evidence of increased TOHRx in infants developing high-grade compared to low-grade or no IVH during the transitional period further supports the role of impaired cerebrovascular reactivity in IVH pathophysiology.
Collapse
Affiliation(s)
- Silvia Martini
- Neonatal Intensive Care Unit, IRCCS S. Orsola-Malpighi Hospital, Bologna, Italy. .,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrookes Hospital, Cambridge, UK
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrookes Hospital, Cambridge, UK
| | - Marica Iommi
- Department of Biomedical and Neuromotor Sciences, Division of Hygiene and Biostatistics, University of Bologna, Bologna, Italy
| | - Silvia Galletti
- Neonatal Intensive Care Unit, IRCCS S. Orsola-Malpighi Hospital, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Francesca Vitali
- Neonatal Intensive Care Unit, IRCCS S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Vittoria Paoletti
- Neonatal Intensive Care Unit, IRCCS S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Federica Camela
- Neonatal Intensive Care Unit, IRCCS S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Topun Austin
- Neonatal Intensive Care Unit, The Rosie Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Luigi Corvaglia
- Neonatal Intensive Care Unit, IRCCS S. Orsola-Malpighi Hospital, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| |
Collapse
|
12
|
Matyas M, Iancu M, Hasmasanu M, Man A, Zaharie G. Association Analysis of the Cerebral Fractional Tissue Oxygen Extraction (cFTOE) and the Cerebral Oxygen Saturation (crSaO 2) with Perinatal Factors in Preterm Neonates: A Single Centre Study. J Clin Med 2022; 11:jcm11123546. [PMID: 35743612 PMCID: PMC9224851 DOI: 10.3390/jcm11123546] [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] [Received: 05/08/2022] [Revised: 06/07/2022] [Accepted: 06/16/2022] [Indexed: 12/03/2022] Open
Abstract
(1) Background: Near-infrared spectroscopy (NIRS) is a non-invasive, easily performed method of monitoring brain oxygenation. The regional cerebral oxygen saturation (crSaO2) and the cerebral fractional tissue oxygen extraction (cFTOE) evaluated by NIRS provide more accurate information on brain oxygenation than the blood oxygen saturation. We investigated the effect of perinatal factors on cerebral oxygenation of preterm newborns. (2) Methods: We conducted a longitudinal study with 48 preterm newborns <34 weeks of gestation who underwent NIRS registration during the first 72 h of life. crSaO2 was measured and cFTOE was calculated foreach patient. (3) Results: One-way ANOVA showed no significant main effect of IVH severity on crSaO2 and cFTOE (p > 0.05); there was a tendency toward statistical significance concerning the difference between the means of crSaO2 (p = 0.083) and cFTOE (p = 0.098). Patients with intraventricular haemorrhage (IVH) had a lower mean of crSaO2 and a higher mean of cFTOE (59.67 ± 10.37% vs. 64.92 ± 10.16% for crSaO2; 0.37 ± 0.11 vs. 0.32 ± 0.11 for cFTOE) compared to those with no IVH. Significantly lower values of crSaO2 and higher values of cFTOE were found in neonates receiving inotropic treatment (p < 0.0001). Episodes of apnoea also proved to influence the cerebral oxygen saturation of the study group (p = 0.0026). No significant association between the maternal hypertension treatment and the cerebral oxygenation of preterms was found. (4) Conclusions: This study showed a decreased cerebral oxygen saturation of preterms with IVH, inotrope support and apnoea episodes.
Collapse
Affiliation(s)
- Melinda Matyas
- Neonatology Department, “Iuliu Hațieganu” University of Medicine and Pharmacy, 3, Clinicilor Street, 400012 Cluj-Napoca, Romania; (M.M.); (M.H.); (G.Z.)
| | - Mihaela Iancu
- Department of Medical Informatics and Biostatistics, “Iuliu Hațieganu” University of Medicine and Pharmacy, 8, Victor Babes Street, 400012 Cluj-Napoca, Romania
- Correspondence: ; Tel.: +40-0740-130-888
| | - Monica Hasmasanu
- Neonatology Department, “Iuliu Hațieganu” University of Medicine and Pharmacy, 3, Clinicilor Street, 400012 Cluj-Napoca, Romania; (M.M.); (M.H.); (G.Z.)
| | - Anca Man
- Neonatology Department, County Emergency Hospital, 3, Clinicilor Street, 400347 Cluj-Napoca, Romania;
| | - Gabriela Zaharie
- Neonatology Department, “Iuliu Hațieganu” University of Medicine and Pharmacy, 3, Clinicilor Street, 400012 Cluj-Napoca, Romania; (M.M.); (M.H.); (G.Z.)
| |
Collapse
|
13
|
Whitaker EE, Johnson AC, Tremble SM, McGinn C, DeLance N, Cipolla MJ. Cerebral Blood Flow Autoregulation in Offspring From Experimentally Preeclamptic Rats and the Effect of Age. Front Physiol 2022; 13:924908. [PMID: 35733984 PMCID: PMC9207211 DOI: 10.3389/fphys.2022.924908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 05/17/2022] [Indexed: 11/13/2022] Open
Abstract
Preeclampsia is a hypertensive disorder of pregnancy that causes significant, long term cardiovascular effects for both the mother and offspring. A previous study demonstrated that middle cerebral arteries in offspring from an experimental rat model of preeclampsia were smaller, stiffer, and did not enlarge over the course of maturation, suggesting potential hemodynamic alterations in these offspring. Here we investigated the effect of experimental preeclampsia on cerebral blood flow autoregulation in juvenile and adult offspring that were born from normal pregnant or experimentally preeclamptic rats. Relative cerebral blood flow was measured using laser Doppler flowmetry, and cerebral blood flow autoregulation curves were constructed by raising blood pressure and controlled hemorrhage to lower blood pressure. Immunohistochemistry was used to assess middle cerebral artery size. Heart rate and blood pressure were measured in awake adult offspring using implanted radiotelemetry. Serum epinephrine was measured using enzyme-linked immunosorbent assay. Offspring from both groups showed maturation of cerebral blood flow autoregulation as offspring aged from juvenile to adulthood as demonstrated by the wider autoregulatory plateau. Experimental preeclampsia did not affect cerebral blood flow autoregulation in juvenile offspring, and it had no effect on cerebral blood flow autoregulation in adult offspring over the lower range of blood pressures. However, experimental preeclampsia caused a right shift in the upper range of blood pressures in adult offspring (compared to normal pregnant). Structurally, middle cerebral arteries from normal pregnant offspring demonstrated growth with aging, while middle cerebral arteries from experimentally preeclamptic offspring did not, and by adulthood normal pregnant offspring had significantly larger middle cerebral arteries. Middle cerebral artery lumen diameters did not significantly change as offspring aged. Serum epinephrine was elevated in juvenile experimentally preeclamptic offspring, and a greater degree of hemorrhage was required to induce hypotension, suggesting increased sympathetic activity. Finally, despite no evidence of increased sympathetic activity, adult experimentally preeclamptic offspring were found to have persistently higher heart rate. These results demonstrate a significant effect of experimental preeclampsia on the upper range of autoregulation and cerebrovascular structure in juvenile and adult offspring that could have an important influence on brain perfusion under conditions of hypo and/or hypertension.
Collapse
Affiliation(s)
- Emmett E. Whitaker
- Department of Anesthesiology, University of Vermont Larner College of Medicine, Burlington, VT, United States
- Department of Neurological Sciences, University of Vermont Larner College of Medicine, Burlington, VT, United States
- Department of Pediatrics, University of Vermont Larner College of Medicine, Burlington, VT, United States
| | - Abbie C. Johnson
- Department of Neurological Sciences, University of Vermont Larner College of Medicine, Burlington, VT, United States
| | - Sarah M. Tremble
- Department of Neurological Sciences, University of Vermont Larner College of Medicine, Burlington, VT, United States
| | - Conor McGinn
- Department of Neurological Sciences, University of Vermont Larner College of Medicine, Burlington, VT, United States
| | - Nicole DeLance
- Department of Pathology and Laboratory Medicine, University of Vermont Larner College of Medicine, Burlington, VT, United States
| | - Marilyn J. Cipolla
- Department of Anesthesiology, University of Vermont Larner College of Medicine, Burlington, VT, United States
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Vermont Larner College of Medicine, Burlington, VT, United States
- Department of Pharmacology, University of Vermont Larner College of Medicine, Burlington, VT, United States
- University of Vermont Department of Electrical and Biomedical Engineering, Burlington, VT, United States
| |
Collapse
|
14
|
Abstract
Advances in perinatal care have seen substantial improvements in survival without disability for extremely preterm infants. Protecting the developing brain and reducing neurodevelopmental sequelae of extremely preterm birth are strategic priorities for both research and clinical care. A number of evidence-based interventions exist for neuroprotection in micropreemies, inclusive of prevention of preterm birth and multiple births with implantation of only one embryo during in vitro fertilisation, as well as antenatal care to optimize fetal wellbeing, strategies for supporting neonatal transition, and neuroprotective developmental care. Avoidance of complications that trigger ischemia and inflammation is vital for minimizing brain dysmaturation and injury, particularly of the white matter. Neurodevelopmental surveillance, early diagnosis of cerebral palsy and early intervention are essential for optimizing long-term outcomes and quality of life. Research priorities include further evaluation of putative neuroprotective agents, and investigation of common neonatal interventions in trials adequately powered to assess neurodevelopmental outcome.
Collapse
|
15
|
Abstract
The cerebral microcirculation undergoes dynamic changes in parallel with the development of neurons, glia, and their energy metabolism throughout gestation and postnatally. Cerebral blood flow (CBF), oxygen consumption, and glucose consumption are as low as 20% of adult levels in humans born prematurely but eventually exceed adult levels at ages 3 to 11 years, which coincide with the period of continued brain growth, synapse formation, synapse pruning, and myelination. Neurovascular coupling to sensory activation is present but attenuated at birth. By 2 postnatal months, the increase in CBF often is disproportionately smaller than the increase in oxygen consumption, in contrast to the relative hyperemia seen in adults. Vascular smooth muscle myogenic tone increases in parallel with developmental increases in arterial pressure. CBF autoregulatory response to increased arterial pressure is intact at birth but has a more limited range with arterial hypotension. Hypoxia-induced vasodilation in preterm fetal sheep with low oxygen consumption does not sustain cerebral oxygen transport, but the response becomes better developed for sustaining oxygen transport by term. Nitric oxide tonically inhibits vasomotor tone, and glutamate receptor activation can evoke its release in lambs and piglets. In piglets, astrocyte-derived carbon monoxide plays a central role in vasodilation evoked by glutamate, ADP, and seizures, and prostanoids play a large role in endothelial-dependent and hypercapnic vasodilation. Overall, homeostatic mechanisms of CBF regulation in response to arterial pressure, neuronal activity, carbon dioxide, and oxygenation are present at birth but continue to develop postnatally as neurovascular signaling pathways are dynamically altered and integrated. © 2021 American Physiological Society. Compr Physiol 11:1-62, 2021.
Collapse
|
16
|
Function and Biomarkers of the Blood-Brain Barrier in a Neonatal Germinal Matrix Haemorrhage Model. Cells 2021; 10:cells10071677. [PMID: 34359845 PMCID: PMC8303246 DOI: 10.3390/cells10071677] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 06/23/2021] [Accepted: 06/29/2021] [Indexed: 01/10/2023] Open
Abstract
Germinal matrix haemorrhage (GMH), caused by rupturing blood vessels in the germinal matrix, is a prevalent driver of preterm brain injuries and death. Our group recently developed a model simulating GMH using intrastriatal injections of collagenase in 5-day-old rats, which corresponds to the brain development of human preterm infants. This study aimed to define changes to the blood-brain barrier (BBB) and to evaluate BBB proteins as biomarkers in this GMH model. Regional BBB functions were investigated using blood to brain 14C-sucrose uptake as well as using biotinylated BBB tracers. Blood plasma and cerebrospinal fluids were collected at various times after GMH and analysed with ELISA for OCLN and CLDN5. The immunoreactivity of BBB proteins was assessed in brain sections. Tracer experiments showed that GMH produced a defined region surrounding the hematoma where many vessels lost their integrity. This region expanded for at least 6 h following GMH, thereafter resolution of both hematoma and re-establishment of BBB function occurred. The sucrose experiment indicated that regions somewhat more distant to the hematoma also exhibited BBB dysfunction; however, BBB function was normalised within 5 days of GMH. This shows that GMH leads to a temporal dysfunction in the BBB that may be important in pathological processes as well as in connection to therapeutic interventions. We detected an increase of tight-junction proteins in both CSF and plasma after GMH making them potential biomarkers for GMH.
Collapse
|
17
|
Liu X, Tekes A, Perin J, Chen MW, Soares BP, Massaro AN, Govindan RB, Parkinson C, Chavez-Valdez R, Northington FJ, Brady KM, Lee JK. Wavelet Autoregulation Monitoring Identifies Blood Pressures Associated With Brain Injury in Neonatal Hypoxic-Ischemic Encephalopathy. Front Neurol 2021; 12:662839. [PMID: 33995258 PMCID: PMC8113412 DOI: 10.3389/fneur.2021.662839] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 03/22/2021] [Indexed: 11/15/2022] Open
Abstract
Dysfunctional cerebrovascular autoregulation may contribute to neurologic injury in neonatal hypoxic-ischemic encephalopathy (HIE). Identifying the optimal mean arterial blood pressure (MAPopt) that best supports autoregulation could help identify hemodynamic goals that support neurologic recovery. In neonates who received therapeutic hypothermia for HIE, we hypothesized that the wavelet hemoglobin volume index (wHVx) would identify MAPopt and that blood pressures closer to MAPopt would be associated with less brain injury on MRI. We also tested a correlation-derived hemoglobin volume index (HVx) and single- and multi-window data processing methodology. Autoregulation was monitored in consecutive 3-h periods using near infrared spectroscopy in an observational study. The neonates had a mean MAP of 54 mmHg (standard deviation: 9) during hypothermia. Greater blood pressure above the MAPopt from single-window wHVx was associated with less injury in the paracentral gyri (p = 0.044; n = 63), basal ganglia (p = 0.015), thalamus (p = 0.013), and brainstem (p = 0.041) after adjustments for sex, vasopressor use, seizures, arterial carbon dioxide level, and a perinatal insult score. Blood pressure exceeding MAPopt from the multi-window, correlation HVx was associated with less injury in the brainstem (p = 0.021) but not in other brain regions. We conclude that applying wavelet methodology to short autoregulation monitoring periods may improve the identification of MAPopt values that are associated with brain injury. Having blood pressure above MAPopt with an upper MAP of ~50–60 mmHg may reduce the risk of brain injury during therapeutic hypothermia. Though a cause-and-effect relationship cannot be inferred, the data support the need for randomized studies of autoregulation and brain injury in neonates with HIE.
Collapse
Affiliation(s)
- Xiuyun Liu
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Aylin Tekes
- Department of Radiology, Johns Hopkins University, Baltimore, MD, United States
| | - Jamie Perin
- Department of Pediatrics, Center for Child and Community Health Research, Johns Hopkins University, Baltimore, MD, United States
| | - May W Chen
- Division of Neonatology, Johns Hopkins University, Baltimore, MD, United States
| | - Bruno P Soares
- Department of Radiology, University of Vermont, Burlington, VT, United States
| | - An N Massaro
- Fetal Medicine Institute, Children's National Health System, Washington, DC, United States.,The George Washington University School of Medicine, Washington, DC, United States.,Division of Neonatology, Children's National Health System, Washington, DC, United States
| | - Rathinaswamy B Govindan
- Fetal Medicine Institute, Children's National Health System, Washington, DC, United States.,The George Washington University School of Medicine, Washington, DC, United States
| | | | - Raul Chavez-Valdez
- Division of Neonatology, Johns Hopkins University, Baltimore, MD, United States
| | | | - Ken M Brady
- Department of Anesthesiology, Lurie Children's Hospital, Chicago, IL, United States
| | - Jennifer K Lee
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, United States
| |
Collapse
|
18
|
Neonatal NIRS monitoring: recommendations for data capture and review of analytics. J Perinatol 2021; 41:675-688. [PMID: 33589724 PMCID: PMC7883881 DOI: 10.1038/s41372-021-00946-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 11/20/2020] [Accepted: 01/19/2021] [Indexed: 01/29/2023]
Abstract
Brain injury is one of the most consequential problems facing neonates, with many preterm and term infants at risk for cerebral hypoxia and ischemia. To develop effective neuroprotective strategies, the mechanistic basis for brain injury must be understood. The fragile state of neonates presents unique research challenges; invasive measures of cerebral blood flow and oxygenation assessment exceed tolerable risk profiles. Near-infrared spectroscopy (NIRS) can safely and non-invasively estimate cerebral oxygenation, a correlate of cerebral perfusion, offering insight into brain injury-related mechanisms. Unfortunately, lack of standardization in device application, recording methods, and error/artifact correction have left the field fractured. In this article, we provide a framework for neonatal NIRS research. Our goal is to provide a rational basis for NIRS data capture and processing that may result in better comparability between studies. It is also intended to serve as a primer for new NIRS researchers and assist with investigation initiation.
Collapse
|
19
|
Hoffman SB, Lakhani A, Viscardi RM. The association between carbon dioxide, cerebral blood flow, and autoregulation in the premature infant. J Perinatol 2021; 41:324-329. [PMID: 33033388 PMCID: PMC7542091 DOI: 10.1038/s41372-020-00835-4] [Citation(s) in RCA: 9] [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: 04/06/2020] [Revised: 08/24/2020] [Accepted: 09/18/2020] [Indexed: 12/03/2022]
Abstract
OBJECTIVE Evaluate the association between carbon dioxide (pCO2), cerebral blood flow (CBF), and cerebral autoregulation (CA) in preterm infants. STUDY DESIGN Cerebral saturations (rScO2, surrogate for CBF using NIRS) and mean arterial blood pressure (MAP) monitored for 96 h in infants <29 weeks gestation. Relationship between rScO2, the rScO2-MAP correlation (CA analysis) and pCO2 category assessed by mixed effects modeling. RESULTS Median pCO2 differed by postnatal day (p < 0.0001)-pCO2 increased between day 1 and 2, and low variability seen on day 4. A 5% increase in rScO2 was noted when pCO2 was >55 mmHg on each postnatal day (p < 0.001). No association observed between the overall rScO2-MAP correlation and pCO2. On day 1 only, the correlation coefficient decreased from 0.26 to -0.09 as pCO2 category increased (p = 0.02). CONCLUSIONS CBF increased above a pCO2 threshold of 55 mmHg, but overall, no association between pCO2 and CA was noted.
Collapse
Affiliation(s)
- Suma Bhat Hoffman
- Department of Pediatrics, University of Maryland Baltimore, School of Medicine, Baltimore, MD, USA.
| | - Anisa Lakhani
- grid.411024.20000 0001 2175 4264Department of Pediatrics, University of Maryland Baltimore, School of Medicine, Baltimore, MD USA
| | - Rose Marie Viscardi
- grid.411024.20000 0001 2175 4264Department of Pediatrics, University of Maryland Baltimore, School of Medicine, Baltimore, MD USA
| |
Collapse
|
20
|
Chock VY, Kwon SH, Ambalavanan N, Batton B, Nelin LD, Chalak LF, Tian L, Van Meurs KP. Cerebral Oxygenation and Autoregulation in Preterm Infants (Early NIRS Study). J Pediatr 2020; 227:94-100.e1. [PMID: 32818482 DOI: 10.1016/j.jpeds.2020.08.036] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Revised: 08/06/2020] [Accepted: 08/13/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine if decreased cerebral oxygenation or altered cerebral autoregulation as measured by near-infrared spectroscopy (NIRS) in the first 96 postnatal hours is associated with an increased risk of death or severe neuroradiographic abnormalities in very preterm infants. STUDY DESIGN The Early NIRS prospective, multicenter study enrolled very preterm infants with a birth weight of <1250 g from 6 tertiary neonatal intensive care units. Mean arterial blood pressure and cerebral oxygen saturation (Csat) were continuously monitored using a neonatal sensor until 96 hours of age. Moving window correlations between Csat and mean arterial blood pressure determined time periods with altered cerebral autoregulation, and percentiles of correlation were compared between infants with and without the adverse outcome of mortality or severe neuroradiographic abnormalities by early cranial ultrasound. RESULTS Of 103 subjects with mean gestational age of 26 weeks, 21 (20%) died or had severe neuroradiographic abnormalities. Infants with adverse outcomes had a lower mean Csat (67 ± 9%) compared with those without adverse outcomes (72 ± 7%; P = .02). A Csat of <50% was identified as a cut-point for identifying infants with adverse outcome (area under the curve, 0.76). Infants with adverse outcomes were more likely to have significant positive or negative correlations between Csat and mean arterial blood pressure, indicating impaired cerebral autoregulation (P = .006). CONCLUSIONS Early NIRS monitoring may detect periods of lower cerebral oxygenation and altered cerebral autoregulation, identifying preterm infants at risk for mortality or neuroradiographic injury. An improved understanding of the relationship between altered hemodynamics and cerebral oxygenation may inform future strategies to prevent brain injury.
Collapse
Affiliation(s)
- Valerie Y Chock
- Division of Neonatology, Stanford University School of Medicine, Stanford, CA
| | - Soo Hyun Kwon
- Division of Neonatology, Yale School of Medicine, New Haven, CT
| | | | - Beau Batton
- Division of Neonatology, Southern Illinois University School of Medicine, Springfield, IL
| | - Leif D Nelin
- Division of Neonatology, Nationwide Children's Hospital, Ohio State University, Columbus, OH
| | - Lina F Chalak
- Division of Neonatology, University of Texas Southwestern, Dallas, TX
| | - Lu Tian
- Division of Neonatology, Stanford University School of Medicine, Stanford, CA
| | - Krisa P Van Meurs
- Division of Neonatology, Stanford University School of Medicine, Stanford, CA
| |
Collapse
|
21
|
Cerebral Hemodynamic Profile in Ischemic and Hemorrhagic Brain Injury Acquired During Pediatric Extracorporeal Membrane Oxygenation. Pediatr Crit Care Med 2020; 21:879-885. [PMID: 32569240 DOI: 10.1097/pcc.0000000000002438] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe the cerebral hemodynamic profiles associated with ischemic and hemorrhagic brain injury during neonatal and pediatric extracorporeal membrane oxygenation. DESIGN A retrospective cohort study. SETTING Tertiary PICU. PATIENTS Forty-seven neonatal and pediatric patients (0-15 yr of age) placed on extracorporeal membrane oxygenation from January 2014 to December 2018. MEASUREMENTS AND MAIN RESULTS Continuous monitoring of mean arterial pressure and cerebral tissue oxygen saturation was conducted through entire extracorporeal membrane oxygenation run. Wavelet analysis was performed to assess changes in cerebral autoregulation and to derive pressure-dependent autoregulation curves based on the mean arterial pressure and cerebral tissue oxygen saturation data. Patients were classified into three brain injury groups: no-injury, ischemic injury, and hemorrhagic injury based on neuroimaging results. No-injury patients (n = 23) had minimal variability in the autoregulation curve over a broad range of blood pressure. Ischemic injury (n = 16) was more common than hemorrhagic injury (n = 8), and the former was associated with increased mortality and morbidity. Ischemic group showed significant abnormalities in cerebral autoregulation in the lower blood pressure range, suggesting pressure-dependent cerebral perfusion. Hemorrhagic group had highest average blood pressure as well as the lowest cerebral tissue oxygenation saturation, suggesting elevated cerebral vascular resistance. Mean heparin dose during extracorporeal membrane oxygenation was lower in both ischemic and hemorrhagic groups compared with the no-injury group. CONCLUSIONS This study outlines distinct differences in underlying cerebral hemodynamics associated with ischemic and hemorrhagic brain injury acquired during extracorporeal membrane oxygenation. Real-time monitoring of cerebral hemodynamics in patients acquiring brain injury during extracorporeal membrane oxygenation can help optimize their management.
Collapse
|
22
|
Abstract
Cerebrovascular autoregulation is the ability to maintain stable cerebral blood flow within a range of cerebral perfusion pressures. When cerebral perfusion pressure is outside the limits of effective autoregulation, the brain is subjected to hypoperfusion or hyperperfusion, which may cause vascular injury, hemorrhage, and/or hypoxic white matter injury. Infants born preterm, after fetal growth restriction, with congenital heart disease, or with hypoxic-ischemic encephalopathy are susceptible to a failure of cerebral autoregulation. Bedside assessment of cerebrovascular autoregulation would offer the opportunity to prevent brain injury. Clinicians need to know which patient populations and circumstances are associated with impaired/absent cerebral autoregulation.
Collapse
Affiliation(s)
- Elisabeth M W Kooi
- Division of Neonatology, University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Hanzeplein 1, PO Box 30001, Groningen 9700 RB, The Netherlands.
| | - Anne E Richter
- Division of Neonatology, University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Hanzeplein 1, PO Box 30001, Groningen 9700 RB, The Netherlands
| |
Collapse
|
23
|
Chan KYY, Miller SL, Schmölzer GM, Stojanovska V, Polglase GR. Respiratory Support of the Preterm Neonate: Lessons About Ventilation-Induced Brain Injury From Large Animal Models. Front Neurol 2020; 11:862. [PMID: 32922358 PMCID: PMC7456830 DOI: 10.3389/fneur.2020.00862] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 07/07/2020] [Indexed: 11/25/2022] Open
Abstract
Many preterm neonates require mechanical ventilation which increases the risk of cerebral inflammation and white matter injury in the immature brain. In this review, we discuss the links between ventilation and brain injury with a focus on the immediate period after birth, incorporating respiratory support in the delivery room and subsequent mechanical ventilation in the neonatal intensive care unit. This review collates insight from large animal models in which acute injurious ventilation and prolonged periods of ventilation have been used to create clinically relevant brain injury patterns. These models are valuable resources in investigating the pathophysiology of ventilation-induced brain injury and have important translational implications. We discuss the challenges of reconciling lung and brain maturation in commonly used large animal models. A comprehensive understanding of ventilation-induced brain injury is necessary to guide the way we care for preterm neonates, with the goal to improve their neurodevelopmental outcomes.
Collapse
Affiliation(s)
- Kyra Y. Y. Chan
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Obstetrics and Gynecology, Monash University, Clayton, VIC, Australia
| | - Suzanne L. Miller
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Obstetrics and Gynecology, Monash University, Clayton, VIC, Australia
| | - Georg M. Schmölzer
- Neonatal Research Unit, Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, AB, Canada
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Vanesa Stojanovska
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Obstetrics and Gynecology, Monash University, Clayton, VIC, Australia
| | - Graeme R. Polglase
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Obstetrics and Gynecology, Monash University, Clayton, VIC, Australia
| |
Collapse
|
24
|
Cimatti AG, Martini S, Galletti S, Vitali F, Aceti A, Frabboni G, Faldella G, Corvaglia L. Cerebral Oxygenation and Autoregulation in Very Preterm Infants Developing IVH During the Transitional Period: A Pilot Study. Front Pediatr 2020; 8:381. [PMID: 32760685 PMCID: PMC7373744 DOI: 10.3389/fped.2020.00381] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 06/04/2020] [Indexed: 12/22/2022] Open
Abstract
Background: The transitional period, defined as the first 72 h after preterm birth, is often characterized by a significant hemodynamic instability, which represents an important risk factor for such neurological complications of prematurity as intraventricular hemorrhage (IVH). The impairment of cerebral autoregulation plays a key role in the pathogenesis of IVH, whose incidence is highest during the transitional period. This pilot study aimed to evaluate whether patterns of cerebral autoregulation and oxygenation differ in relation to IVH development in very preterm infants during the transitional period. Methods: Infants <32 weeks' gestation were enrolled within 12 h from birth. A simultaneous monitoring of cerebral oxygenation (CrSO2) by near-infrared spectroscopy and of heart rate and peripheral oxygen saturation by pulse oximetry was performed over the first 72 h. Cerebral fractional oxygen extraction (cFTOE) and tissue oxygenation-heart rate reactivity index (TOHRx), which represents a marker of cerebrovascular reactivity, were calculated. Daily cranial and cardiac ultrasound scans were performed, in order to assess the hemodynamic status and to detect a possible IVH onset. CrSO2 and cFTOE, clustered on 6-hour epochs, were compared between infants who developed IVH during the study period and those who did not. A between-group comparison of TOHRx before and after IVH detection was also performed. Results: Twenty preterm infants with a median gestational age of 27 weeks (interquartile range, IQR: 25-30 weeks) and median birth weight of 895 g (IQR: 822-1208 g) were enrolled. Of these, 8 developed IVH. The median age at IVH detection was 40 h (IQR: 30-48 h). Pre-IVH TOHRx was significantly higher compared to matched control periods (p <0.001). CrSO2 was significantly lower from 12 to 30 h and from 42 h onwards in cases compared to controls; however, a temporary CrSO2 rise preceded IVH detection. Similarly, cFTOE was significantly higher in IVH infants from 12 to 30 h and from 48 to 72 h, with a transient decrease between the two periods. Conclusions: In preterm infants during the transitional period, the development of IVH is preceded by transient changes in cerebral oxygenation and oxygen extraction which, in turn, may underlie an early impairment of cerebral autoregulation. Larger studies are needed to confirm these preliminary findings.
Collapse
Affiliation(s)
- Anna Giulia Cimatti
- Neonatal Intensive Care Unit, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Silvia Martini
- Neonatal Intensive Care Unit, S. Orsola-Malpighi University Hospital, Bologna, Italy.,Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Silvia Galletti
- Neonatal Intensive Care Unit, S. Orsola-Malpighi University Hospital, Bologna, Italy.,Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Francesca Vitali
- Neonatal Intensive Care Unit, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Arianna Aceti
- Neonatal Intensive Care Unit, S. Orsola-Malpighi University Hospital, Bologna, Italy.,Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Giulia Frabboni
- Neonatal Intensive Care Unit, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Giacomo Faldella
- Neonatal Intensive Care Unit, S. Orsola-Malpighi University Hospital, Bologna, Italy.,Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Luigi Corvaglia
- Neonatal Intensive Care Unit, S. Orsola-Malpighi University Hospital, Bologna, Italy.,Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| |
Collapse
|
25
|
Solanki NS, Hoffman SB. Association between dopamine and cerebral autoregulation in preterm neonates. Pediatr Res 2020; 88:618-622. [PMID: 32005034 PMCID: PMC7223955 DOI: 10.1038/s41390-020-0790-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 01/21/2020] [Accepted: 01/24/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND To test the hypothesis that dopamine is associated with impaired cerebral autoregulation (ICA) in a dose-dependent fashion. METHODS Non a priori designed secondary analysis of a prospectively enrolled cohort study subjects <12 h of life between 240 and 296 weeks gestation. Cerebral saturations (rScO2) and mean arterial blood pressure (MAP) were continuously monitored every 30 s for 96 h. ICA was defined by a 10 min epoch rScO2-MAP correlation coefficient of >0.5. RESULTS Twenty-three of 61 subjects (38%) required dopamine. Time spent with ICA was 23% in dopamine-exposed subjects vs. 14% in those not exposed (p = 0.0001). On the epoch level, time spent with ICA was 15%, 29%, 34%, 37%, and 23% in epochs with dopamine titration of 0, 1-5, 6-10, 11-15, and 16-20 μg/kg/min, respectively. Using mixed-effect modeling, ICA for each dopamine titration was significantly higher than unexposed times when controlling for gestation, presence of a patent ductus arteriosus, day of life, MAP less than gestational age, and illness severity score (p < 0.02). CONCLUSIONS Dopamine exposure during the first 96 h was associated with ICA. Time periods with ICA increased with dopamine exposure in a dose-dependent fashion peaking at a concentration of 11-15 μg/kg/min.
Collapse
Affiliation(s)
- Nina S. Solanki
- grid.411024.20000 0001 2175 4264Department of Pediatrics, School of Medicine, University of Maryland Baltimore, Baltimore, MD USA
| | - Suma B. Hoffman
- grid.411024.20000 0001 2175 4264Department of Pediatrics, School of Medicine, University of Maryland Baltimore, Baltimore, MD USA
| |
Collapse
|
26
|
Hoffman SB, Cheng YJ, Magder LS, Shet N, Viscardi RM. Cerebral autoregulation in premature infants during the first 96 hours of life and relationship to adverse outcomes. Arch Dis Child Fetal Neonatal Ed 2019; 104:F473-F479. [PMID: 30385514 DOI: 10.1136/archdischild-2018-315725] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 09/26/2018] [Accepted: 10/05/2018] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To test the hypothesis that impaired cerebral autoregulation (ICA) increases the susceptibility of premature infants to adverse outcomes, we determined the relationship of ICA and cerebral reactivity (CR) measured in the first 96 hours of life to the outcome of grade 3 or 4 intraventricular haemorrhage (IVH) and/or death within 1 month. SETTING Single-centre level IV neonatal intensive care unit. PATIENTS Neonates 24-29 weeks' gestation less than 12 hours old with invasive blood pressure monitoring. DESIGN Cerebral saturations and mean arterial blood pressure were recorded every 30 s for 96 hours. For each 10 min epoch, the correlation coefficient (r) was calculated for mean arterial blood pressure versus cerebral saturations. The epoch was considered to have ICA if r>0.5 and CR if r<0. RESULTS Sixty-one subjects were included. During the first 96 hours, ICA occurred 17.6% and CR occurred 41% of recorded time. In those without adverse outcomes, ICA decreased and CR increased by postnatal day (p<0.05). Adjusted for birth weight and gestational age, those with IVH and those who died spent more time with ICA and less time with CR (p<0.05) over the entire recording period. Those with IVH had 1.5-fold increase in time with ICA on day 2 (p=0.021), and decrease in time with CR on day 3 (p=0.036). Compared with survivors, non-survivors spent more time with ICA on days 3 and 4 (p<0.005), and less with CR on day 3 (p=0.032). CONCLUSION ICA and CR vary by postnatal day and these patterns are associated with adverse outcomes.
Collapse
Affiliation(s)
- Suma B Hoffman
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Yun-Ju Cheng
- Department of Mathematics and Statistics, University of Maryland Baltimore County, Baltimore, Maryland, USA
| | - Laurence S Magder
- Department of Epidemiology and Preventive Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Narendra Shet
- Department of Diagnostic Imaging and Radiology, Children's National Health System, Michigan Avenue NW, Washington, DC, USA
| | - Rose M Viscardi
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
27
|
Cohen E, Baerts W, Caicedo Dorado A, Naulaers G, van Bel F, Lemmers PMA. Cerebrovascular autoregulation in preterm fetal growth restricted neonates. Arch Dis Child Fetal Neonatal Ed 2019; 104:F467-F472. [PMID: 30355781 DOI: 10.1136/archdischild-2017-313712] [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: 07/11/2017] [Revised: 09/12/2018] [Accepted: 09/22/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To investigate the effect of fetal growth restriction (FGR) on cerebrovascular autoregulation in preterm neonates during the first 3 days of life. DESIGN Case-control study. SETTING Neonatal intensive care unit of the Wilhelmina Children's Hospital, The Netherlands. PATIENTS 57 FGR (birth weight <10th percentile) and 57 appropriate for gestational age (AGA) (birth weight 20th-80th percentiles) preterm neonates, matched for gender, gestational age, respiratory and blood pressure support. METHODS The correlation between continuously measured mean arterial blood pressure and regional cerebral oxygen saturation was calculated to generate the cerebral oximetry index (COx). Mean COx was calculated for each patient for each postnatal day. The percentage of time with impaired autoregulation (COx>0.5) was also calculated. RESULTS FGR neonates had higher mean COx values than their AGA peers on day 2 (0.15 (95% CI 0.11 to 0.18) vs 0.09 (95% CI 0.06 to 0.13), p=0.029) and day 3 (0.17 (95% CI 0.13 to 0.20) vs 0.09 (95% CI 0.06 to 0.12), p=0.003) of life. FGR neonates spent more time with impaired autoregulation (COx value >0.5) than controls on postnatal day 2 (19% (95% CI 16% to 22%) vs 14% (95% CI 12% to 17%), p=0.035) and day 3 (20% (95% CI 17% to 24%) vs 15% (95% CI 12% to 18%), p=0.016). CONCLUSION FGR preterm neonates more frequently display impaired cerebrovascular autoregulation compared with AGA peers on days 2 and 3 of life which may predispose them to brain injury. Further studies are required to investigate whether this impairment persists beyond the first few days of life and whether this impairment is linked to poor neurodevelopmental outcome.
Collapse
Affiliation(s)
- Emily Cohen
- Department of Neonatology, Wilhelmina Children's Hospital/University Medical Centre Utrecht, Utrecht, The Netherlands.,The Ritchie Centre, Hudson Institute of Medical Research and Department of Paediatrics, Monash University, Melbourne, Victoria, Australia
| | - Willem Baerts
- Department of Neonatology, Wilhelmina Children's Hospital/University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Alexander Caicedo Dorado
- Department of Applied Mathematics and Computer Science, Faculty of Natural Sciences and Mathematics, Universidad del Rosario, Bogota, Colombia
| | - Gunnar Naulaers
- Department of Neonatology, University Hospital Leuven, Leuven, Belgium
| | - Frank van Bel
- Department of Neonatology, Wilhelmina Children's Hospital/University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Petra M A Lemmers
- Department of Neonatology, Wilhelmina Children's Hospital/University Medical Centre Utrecht, Utrecht, The Netherlands
| |
Collapse
|
28
|
Tgavalekos K, Pham T, Krishnamurthy N, Sassaroli A, Fantini S. Frequency-resolved analysis of coherent oscillations of local cerebral blood volume, measured with near-infrared spectroscopy, and systemic arterial pressure in healthy human subjects. PLoS One 2019; 14:e0211710. [PMID: 30753203 PMCID: PMC6372153 DOI: 10.1371/journal.pone.0211710] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 01/19/2019] [Indexed: 01/18/2023] Open
Abstract
We report a study on twenty-two healthy human subjects of the dynamic relationship between cerebral hemoglobin concentration ([HbT]), measured with near-infrared spectroscopy (NIRS) in the prefrontal cortex, and systemic arterial blood pressure (ABP), measured with finger plethysmography. [HbT] is a measure of local cerebral blood volume (CBV). We induced hemodynamic oscillations at discrete frequencies in the range 0.04-0.20 Hz with cyclic inflation and deflation of pneumatic cuffs wrapped around the subject's thighs. We modeled the transfer function of ABP and [HbT] in terms of effective arterial (K(a)) and venous (K(v)) compliances, and a cerebral autoregulation time constant (τ(AR)). The mean values (± standard errors) of these parameters across the twenty-two subjects were K(a) = 0.01 ± 0.01 μM/mmHg, K(v) = 0.09 ± 0.05 μM/mmHg, and τ(AR) = 2.2 ± 1.3 s. Spatially resolved measurements in a subset of eight subjects reveal a spatial variability of these parameters that may exceed the inter-subject variability at a set location. This study sheds some light onto the role that ABP and cerebral blood flow (CBF) play in the dynamics of [HbT] measured with NIRS, and paves the way for new non-invasive optical studies of cerebral blood flow and cerebral autoregulation.
Collapse
Affiliation(s)
- Kristen Tgavalekos
- Department of Biomedical Engineering, Tufts University, Medford, Massachusetts, United States of America
| | - Thao Pham
- Department of Biomedical Engineering, Tufts University, Medford, Massachusetts, United States of America
| | - Nishanth Krishnamurthy
- Department of Biomedical Engineering, Tufts University, Medford, Massachusetts, United States of America
| | - Angelo Sassaroli
- Department of Biomedical Engineering, Tufts University, Medford, Massachusetts, United States of America
| | - Sergio Fantini
- Department of Biomedical Engineering, Tufts University, Medford, Massachusetts, United States of America
| |
Collapse
|
29
|
Abdul Aziz AN, Thomas S, Murthy P, Rabi Y, Soraisham A, Stritzke A, Kamaluddeen M, Al-Awad E, Mohammad K. Early inotropes use is associated with higher risk of death and/or severe brain injury in extremely premature infants. J Matern Fetal Neonatal Med 2019; 33:2751-2758. [PMID: 30563374 DOI: 10.1080/14767058.2018.1560408] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Introduction: Extremely premature infants are susceptible to fluctuations in cerebral blood flow due to immaturity of cerebral autoregulation. Inotropes may cause rapid changes to systemic blood pressure and consequently cerebral blood flow, especially within the first 72 hours of life. This period is recognized to carry the greatest risk for cerebral hemorrhage. This study evaluates the incidence of death and/or severe brain injury in extremely preterm infants treated with inotropes in the first 72 hours of life.Methods: Prospective cohort study of infants born ≤29+0 weeks gestational age (GA) between January 2013 and December 2016. Severe brain injury was defined based on head ultrasound as presence of: grade III or IV intraventricular hemorrhage (IVH), moderate to severe post-hemorrhagic ventricular dilatation (PHVD), or cystic periventricular leukomalacia (cPVL). The association between inotrope use and death and/or brain injury was explored via logistic regression controlling for predefined confounding risk factors.Results: Of 497 eligible infants, 97 (19.5%) received inotropes during the first 72 hours. GA at birth, birth weight (BW), and 5-minute Apgar scores were lower among infants who received early inotropes compared to those not treated with inotropes. A stepwise logistic regression of the predefined confounding factors showed GA, exposure for antenatal steroids, and admission hypothermia to be significant confounding factors. Adjusting for those factors, early use of inotropes was associated with increased risk of death and/or severe brain injury (AOR 4.5; 95%CI: 2.4-8.5), severe brain injury (AOR 4.2; 95% CI: 1.9-8.9), and IVH of any grade (AOR 2.9; 95%CI: 1.7-4.9).Conclusion: Early inotropes use was associated with higher risk of death and/or severe brain injury. Strict indications and strategies for minimizing inotrope use while preventing hypotension should be implemented in the early postnatal care of infants at risk for severe brain injury.
Collapse
Affiliation(s)
- Ahmad Nizar Abdul Aziz
- Section of Neonatology, Department of Pediatrics, University of Calgary, Alberta, Canada
| | - Sumesh Thomas
- Section of Neonatology, Department of Pediatrics, University of Calgary, Alberta, Canada
| | - Prashanth Murthy
- Section of Neonatology, Department of Pediatrics, University of Calgary, Alberta, Canada
| | - Yacov Rabi
- Section of Neonatology, Department of Pediatrics, University of Calgary, Alberta, Canada
| | - Amuchou Soraisham
- Section of Neonatology, Department of Pediatrics, University of Calgary, Alberta, Canada
| | - Amelie Stritzke
- Section of Neonatology, Department of Pediatrics, University of Calgary, Alberta, Canada
| | - Majeeda Kamaluddeen
- Section of Neonatology, Department of Pediatrics, University of Calgary, Alberta, Canada
| | - Essa Al-Awad
- Section of Neonatology, Department of Pediatrics, University of Calgary, Alberta, Canada
| | - Khorshid Mohammad
- Section of Neonatology, Department of Pediatrics, University of Calgary, Alberta, Canada
| |
Collapse
|
30
|
Mitra S, Bale G, Highton D, Gunny R, Uria-Avellanal C, Bainbridge A, Sokolska M, Price D, Huertas-Ceballos A, Kendall GS, Meek J, Tachtsidis I, Robertson NJ. Pressure passivity of cerebral mitochondrial metabolism is associated with poor outcome following perinatal hypoxic ischemic brain injury. J Cereb Blood Flow Metab 2019; 39:118-130. [PMID: 28949271 PMCID: PMC6311664 DOI: 10.1177/0271678x17733639] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Hypoxic ischemic encephalopathy (HIE) leads to significant morbidity and mortality. Impaired autoregulation after hypoxia-ischaemia has been suggested to contribute further to injury. Thalamic lactate/N-Acetylasperate (Lac/NAA) peak area ratio of > 0.3 on proton (1H) magnetic resonance spectroscopy (MRS) is associated with poor neurodevelopment outcome following HIE. Cytochrome-c-oxidase (CCO) plays a central role in mitochondrial oxidative metabolism and ATP synthesis. Using a novel broadband NIRS system, we investigated the impact of pressure passivity of cerebral metabolism (CCO), oxygenation (haemoglobin difference (HbD)) and cerebral blood volume (total haemoglobin (HbT)) in 23 term infants following HIE during therapeutic hypothermia (HT). Sixty-minute epochs of data from each infant were studied using wavelet analysis at a mean age of 48 h. Wavelet semblance (a measure of phase difference) was calculated to compare reactivity between mean arterial blood pressure (MABP) with oxCCO, HbD and HbT. OxCCO-MABP semblance correlated with thalamic Lac/NAA ( r = 0.48, p = 0.02). OxCCO-MABP semblance also differed between groups of infants with mild to moderate and severe injury measured using brain MRI score ( p = 0.04), thalamic Lac/NAA ( p = 0.04) and neurodevelopmental outcome at one year ( p = 0.04). Pressure passive changes in cerebral metabolism were associated with injury severity indicated by thalamic Lac/NAA, MRI scores and neurodevelopmental assessment at one year of age.
Collapse
Affiliation(s)
- Subhabrata Mitra
- 1 Institute for Women's Health, University College London, London, UK
| | - Gemma Bale
- 2 Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - David Highton
- 3 Neurocritical Care, National Hospital for Neurology & Neurosurgery, University College London, London, UK
| | - Roxanna Gunny
- 4 Paediatric Neuroradiology, Great Ormond Street Hospital for Children, London, UK
| | | | - Alan Bainbridge
- 5 Department of Medical Physics and Biomedical Engineering, University College London Hospital, London, UK
| | - Magdalena Sokolska
- 5 Department of Medical Physics and Biomedical Engineering, University College London Hospital, London, UK
| | - David Price
- 5 Department of Medical Physics and Biomedical Engineering, University College London Hospital, London, UK
| | | | - Giles S Kendall
- 6 Neonatal Unit, University College London Hospital, London, UK
| | - Judith Meek
- 1 Institute for Women's Health, University College London, London, UK
| | - Ilias Tachtsidis
- 2 Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | | |
Collapse
|
31
|
Elevated midline head positioning of extremely low birth weight infants: effects on cardiopulmonary function and the incidence of periventricular-intraventricular hemorrhage. J Perinatol 2019; 39:54-62. [PMID: 30348960 DOI: 10.1038/s41372-018-0261-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 09/19/2018] [Accepted: 10/05/2018] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Changes in cerebrovascular hemodynamics associated with head position may be important in the pathogenesis of periventricular-intraventricular hemorrhage (PIVH) in premature infants. This study evaluated the effect of elevated midline head positioning on cardiopulmonary function and the incidence of PIVH. STUDY DESIGN ELBW infants were randomized to FLAT (flat, supine) or ELEV (supine, bed elevated 30 degrees) for 96 h. Cardiopulmonary function, complications of prematurity, and the occurrence of PIVH were documented. RESULTS Infants were randomized into FLAT (n = 90) and ELEV groups (n = 90). No significant differences were seen in the incidence of BPD or other respiratory complications. The ELEV group developed significantly fewer grade 4 hemorrhages (p = 0.036) and survival to discharge was significantly higher in the ELEV group (p = 0.037). CONCLUSIONS Managing ELBW infants in an elevated midline head position for the first 4 days of life appears safe and may decrease the likelihood of severe PIVH and improve survival.
Collapse
|
32
|
Autonomic Dysfunction in Neonates with Hypoxic Ischemic Encephalopathy Undergoing Therapeutic Hypothermia Impairs Physiological Responses to Routine Care Events. J Pediatr 2018; 196. [PMID: 29519539 PMCID: PMC7307868 DOI: 10.1016/j.jpeds.2017.12.071] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To evaluate whether infants with hypoxic-ischemic encephalopathy and evidence of autonomic dysfunction have aberrant physiological responses to care events that could contribute to evolving brain injury. STUDY DESIGN Continuous tracings of heart rate (HR), blood pressure (BP), cerebral near infrared spectroscopy, and video electroencephalogram data were recorded from newborn infants with hypoxic-ischemic encephalopathy who were treated with hypothermia. Videos between 16 and 24 hours of age identified 99 distinct care events, including stimulating events (diaper changes, painful procedures), and vagal stimuli (endotracheal tube manipulations, pupil examinations). Pre-event HR variability was used to stratify patients into groups with impaired versus intact autonomic nervous system (ANS) function. Postevent physiological responses were compared between groups with the nearest mean classification approach. RESULTS Infants with intact ANS had increases in HR/BP after stimulating events, whereas those with impaired ANS showed no change or decreased HR/BP. With vagal stimuli, the HR decreased in infants with intact ANS but changed minimally in those with impaired ANS. A pupil examination in infants with an intact ANS led to a stable or increased BP, whereas the BP decreased in the group with an impaired ANS. Near infrared spectroscopy measures of cerebral blood flow/blood volume increased after diaper changes in infants with an impaired ANS, but were stable or decreased in those with an intact ANS. CONCLUSION HR variability metrics identified infants with impaired ANS function at risk for maladaptive responses to care events. These data support the potential use of HR variability as a real-time, continuous physiological biomarker to guide neuroprotective care in high-risk newborns.
Collapse
|
33
|
Utility of prenatal Doppler ultrasound to predict neonatal impaired cerebral autoregulation. J Perinatol 2018; 38:474-481. [PMID: 29410542 DOI: 10.1038/s41372-018-0050-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Revised: 12/06/2017] [Accepted: 01/02/2018] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Determine if abnormal prenatal Doppler ultrasound indices are predictive of postnatal impaired cerebral autoregulation. STUDY DESIGN Prospective cohort study of 46 subjects, 240-296 weeks' gestation. Utilizing near-infrared spectroscopy and receiver-operating characteristic analysis, impaired cerebral autoregulation was defined as >16.5% time spent in a dysregulated state within 96 h of life. Normal and abnormal Doppler indices were compared for perinatal outcomes. RESULTS Subjects with abnormal cerebroplacental ratio (n = 12) and abnormal umbilical artery pulsatility index (n = 13) were likely to develop postnatal impaired cerebral autoregulation (p ≤ 0.02). Abnormal cerebroplacental ratio was associated with impaired cerebral autoregulation between 24 and 48 h of life (p = 0.016). These subjects have increased risk for fetal growth restriction, lower birth weight, lower Apgar scores, acidosis, and severe intraventricular hemorrhage and/or death (p < 0.05). CONCLUSION Abnormal cerebroplacental ratio and umbilical artery pulsatility index are associated with postnatal impairment in cerebral autoregulation and adverse outcome.
Collapse
|
34
|
Kuik SJ, van der Laan ME, Brouwer-Bergsma MT, Hulscher JBF, Absalom AR, Bos AF, Kooi EMW. Preterm infants undergoing laparotomy for necrotizing enterocolitis or spontaneous intestinal perforation display evidence of impaired cerebrovascular autoregulation. Early Hum Dev 2018; 118:25-31. [PMID: 29454185 DOI: 10.1016/j.earlhumdev.2018.01.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 01/24/2018] [Accepted: 01/30/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND Preterm infants requiring surgery are at risk of impaired neurocognitive development caused, possibly, by cerebral ischemia associated with impaired cerebrovascular autoregulation (CAR). We evaluated CAR before, during, and after laparotomy. STUDY DESIGN This was a hypothesis generating prospective observational cohort study. SUBJECTS We included preterm infants requiring surgery for necrotizing enterocolitis (NEC) or spontaneous intestinal perforation (SIP). Before, during, and after surgery we measured cerebral oxygen saturation using NIRS and calculated cerebral fractional tissue oxygen extraction (cFTOE). OUTCOME MEASURES Impaired CAR was defined if correlation coefficients (rho) between mean cFTOE and mean arterial blood pressure values were ≤-0.30 with P < .05. We used logistic regression analyses to determine factors associated with impaired CAR. RESULTS Nineteen infants with median (IQR) GA 27.6 weeks (26.6-31.0), birth weight 1090 g (924-1430), and postnatal age 9 days (7-12) were included. CAR was impaired more often during surgery than before (12 versus 3, P = .02) or after (12 versus 0, P < .01). A higher PCO2 level was associated with impaired CAR during surgery (OR 3.04, 95% CI, 1.11-8.12 for every 1 kPa increase). CONCLUSIONS More than half of preterm infants with NEC or SIP displayed evidence of impaired CAR during laparotomy. Further research should focus on mechanisms contributing to impaired CAR in preterm infants during surgery.
Collapse
Affiliation(s)
- Sara J Kuik
- University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Division of Neonatology, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Michelle E van der Laan
- University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Division of Neonatology, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Margot T Brouwer-Bergsma
- University of Groningen, University Medical Center Groningen, Department of Anesthesiology, Division of Pediatric Anesthesiology, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Jan B F Hulscher
- University of Groningen, University Medical Center Groningen, Department of Surgery, Division of Pediatric Surgery, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Anthony R Absalom
- University of Groningen, University Medical Center Groningen, Department of Anesthesiology, Division of Pediatric Anesthesiology, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Arend F Bos
- University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Division of Neonatology, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Elisabeth M W Kooi
- University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Division of Neonatology, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.
| |
Collapse
|
35
|
Rhee CJ, Rios DR, Kaiser JR, Brady K. Cerebral Hemodynamics in Premature Infants. NEONATAL MEDICINE 2018. [DOI: 10.5385/nm.2018.25.1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Christopher J. Rhee
- Section of Neonatology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, United States
| | - Danielle R. Rios
- Section of Neonatology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, United States
| | - Jeffrey R. Kaiser
- Department of Pediatrics, Obstetrics and Gynecology, Hershey Medical Center, Penn State College of Medicine, Milton S, Hershey, PA, United States
| | - Ken Brady
- Section of Neonatology, Department of Pediatrics, Critical Care Medicine and Anesthesiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, United States
| |
Collapse
|
36
|
Thewissen L, Caicedo A, Lemmers P, Van Bel F, Van Huffel S, Naulaers G. Measuring Near-Infrared Spectroscopy Derived Cerebral Autoregulation in Neonates: From Research Tool Toward Bedside Multimodal Monitoring. Front Pediatr 2018; 6:117. [PMID: 29868521 PMCID: PMC5960703 DOI: 10.3389/fped.2018.00117] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 04/11/2018] [Indexed: 12/30/2022] Open
Abstract
Introduction: Cerebral autoregulation (CAR), the ability of the human body to maintain cerebral blood flow (CBF) in a wide range of perfusion pressures, can be calculated by describing the relation between arterial blood pressure (ABP) and cerebral oxygen saturation measured by near-infrared spectroscopy (NIRS). In literature, disturbed CAR is described in different patient groups, using multiple measurement techniques and mathematical models. Furthermore, it is unclear to what extent cerebral pathology and outcome can be explained by impaired CAR. Aim and methods: In order to summarize CAR studies using NIRS in neonates, a systematic review was performed in the PUBMED and EMBASE database. To provide a general overview of the clinical framework used to study CAR, the different preprocessing methods and mathematical models are described and explained. Furthermore, patient characteristics, definition of impaired CAR and the outcome according to this definition is described organized for the different patient groups. Results: Forty-six articles were included in this review. Four patient groups were established: preterm infants during the transitional period, neonates receiving specific medication/treatment, neonates with congenital heart disease and neonates with hypoxic-ischemic encephalopathy (HIE) treated with therapeutic hypothermia. Correlation, coherence and transfer function (TF) gain are the mathematical models most frequently used to describe CAR. The definition of impaired CAR is depending on the mathematical model used. The incidence of intraventricular hemorrhage in preterm infants is the outcome variable most frequently correlated with impaired CAR. Hypotension, disease severity, dopamine treatment, injury on magnetic resonance imaging (MRI) and long term outcome are associated with impaired CAR. Prospective interventional studies are lacking in all research areas. Discussion and conclusion: NIRS derived CAR measurement is an important research tool to improve knowledge about central hemodynamic fluctuations during the transitional period, cerebral pharmacodynamics of frequently used medication (sedatives-inotropes) and cerebral effects of specific therapies in neonatology. Uniformity regarding measurement techniques and mathematical models is needed. Multimodal monitoring databases of neonatal intensive care patients of multiple centers, together with identical outcome parameters are needed to compare different techniques and make progress in this field. Real-time bedside monitoring of CAR, together with conventional monitoring, seems a promising technique to improve individual patient care.
Collapse
Affiliation(s)
- Liesbeth Thewissen
- Department of Neonatology, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Alexander Caicedo
- Department of Electrical Engineering, ESAT-Stadius, KU Leuven, Leuven, Belgium.,Interuniversity Microelectronics Centre, Leuven, Belgium
| | - Petra Lemmers
- Department of Neonatology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Frank Van Bel
- Department of Neonatology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Sabine Van Huffel
- Department of Electrical Engineering, ESAT-Stadius, KU Leuven, Leuven, Belgium.,Interuniversity Microelectronics Centre, Leuven, Belgium
| | - Gunnar Naulaers
- Department of Neonatology, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| |
Collapse
|
37
|
Sortica da Costa C, Placek MM, Czosnyka M, Cabella B, Kasprowicz M, Austin T, Smielewski P. Complexity of brain signals is associated with outcome in preterm infants. J Cereb Blood Flow Metab 2017; 37:3368-3379. [PMID: 28075691 PMCID: PMC5624386 DOI: 10.1177/0271678x16687314] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A characteristic feature of complex healthy biological systems is the ability to react and adapt to minute changes in the environment. This 'complexity' manifests itself in highly irregular patterns of various physiological measurements. Here, we apply Multiscale Entropy (MSE) analysis to assess the complexity of systemic and cerebral near-infrared spectroscopy (NIRS) signals in a cohort of 61 critically ill preterm infants born at median (range) gestational age of 26 (23-31) weeks, before 24 h of life. We further correlate the complexity of these parameters with brain injury and mortality. Lower complexity index (CoI) of oxygenated haemoglobin (HbO2), deoxygenated haemoglobin (Hb) and tissue oxygenation index (TOI) were observed in those infants who developed intraventricular haemorrhage (IVH) compared to those who did not (P = 0.002, P = 0.010 and P = 0.038, respectively). Mean CoI of HbO2, Hb and total haemoglobin index (THI) were lower in those infants who died compared to those who survived (P = 0.012, P = 0.004 and P = 0.003, respectively). CoI-HbO2 was an independent predictor of IVH (P = 0.010). Decreased complexity of brain signals was associated with mortality and brain injury. Measurement of brain signal complexity in preterm infants is feasible and could represent a significant advance in the brain-oriented care.
Collapse
Affiliation(s)
| | - Michal M Placek
- 2 Department of Biomedical Engineering, Wroclaw University of Science and Technology, Wroclaw, Poland
| | - Marek Czosnyka
- 3 Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Brenno Cabella
- 3 Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Magdalena Kasprowicz
- 2 Department of Biomedical Engineering, Wroclaw University of Science and Technology, Wroclaw, Poland
| | - Topun Austin
- 1 The Rosie Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Peter Smielewski
- 3 Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| |
Collapse
|
38
|
Tian F, Morriss MC, Chalak L, Venkataraman R, Ahn C, Liu H, Raman L. Impairment of cerebral autoregulation in pediatric extracorporeal membrane oxygenation associated with neuroimaging abnormalities. NEUROPHOTONICS 2017; 4:041410. [PMID: 28840161 PMCID: PMC5562949 DOI: 10.1117/1.nph.4.4.041410] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 07/24/2017] [Indexed: 05/27/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a life-supporting therapy for critically ill patients with severe respiratory and/or cardiovascular failure. Cerebrovascular impairment can result in hemorrhagic and ischemic complications commonly seen in the patients supported on ECMO. We investigated the degree of cerebral autoregulation impairment during ECMO as well as whether it is predictive of neuroimaging abnormalities. Spontaneous fluctuations of mean arterial pressure (MAP) and cerebral tissue oxygen saturation ([Formula: see text]) were continuously measured during the ECMO run. The dynamic relationship between the MAP and [Formula: see text] fluctuations was assessed based on wavelet transform coherence (WTC). Neuroimaging was conducted during and/or after ECMO as standard of care, and the abnormalities were evaluated based on a scoring system that had been previously validated among ECMO patients. Of the 25 patients, 8 (32%) had normal neuroimaging, 7 (28%) had mild to moderate neuroimaging abnormalities, and the other 10 (40%) had severe neuroimaging abnormalities. The degrees of cerebral autoregulation impairment quantified based on WTC showed significant correlations with the neuroimaging scores ([Formula: see text]; [Formula: see text]). Evidence that cerebral autoregulation impairment during ECMO was related to the patients' neurological outcomes was provided.
Collapse
Affiliation(s)
- Fenghua Tian
- University of Texas at Arlington, Department of Bioengineering, Arlington, Texas, United States
| | - Michael Craig Morriss
- University of Texas Southwestern Medical Center, Department of Radiology, Dallas, Texas, United States
| | - Lina Chalak
- University of Texas Southwestern Medical Center, Department of Pediatrics, Dallas, Texas, United States
| | - Ramgopal Venkataraman
- University of Texas at Arlington, Department of Accounting, Arlington, Texas, United States
| | - Chul Ahn
- University of Texas Southwestern Medical Center, Department of Clinical Science, Dallas, Texas, United States
| | - Hanli Liu
- University of Texas at Arlington, Department of Bioengineering, Arlington, Texas, United States
| | - Lakshmi Raman
- University of Texas Southwestern Medical Center, Department of Pediatrics, Dallas, Texas, United States
| |
Collapse
|
39
|
Huvanandana J, Thamrin C, Tracy MB, Hinder M, Nguyen CD, McEwan AL. Advanced analyses of physiological signals in the neonatal intensive care unit. Physiol Meas 2017; 38:R253-R279. [DOI: 10.1088/1361-6579/aa8a13] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
|
40
|
The Ontogeny of Cerebrovascular Pressure Autoregulation in Premature Infants. ACTA NEUROCHIRURGICA. SUPPLEMENT 2017; 122:151-5. [PMID: 27165897 DOI: 10.1007/978-3-319-22533-3_31] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Our objective was to quantify cerebrovascular autoregulation as a function of gestational age (GA) and across the phases of the cardiac cycle. One hundred eighty-six premature infants, with a GA range of 23-33 weeks, were monitored using umbilical artery catheters and transcranial Doppler insonation of middle cerebral artery flow velocity (FV) for 1-h sessions over the first week of life. Autoregulation was quantified as a moving correlation coefficient between systolic arterial blood pressure (ABP) and systolic FV (Sx); mean ABP and mean FV (Mx); diastolic ABP and diastolic FV (Dx). Autoregulation was compared across GAs for each aspect of the cardiac cycle. Systolic FV was pressure-passive in infants with the lowest GA, and Sx decreased with increased GA (r = -0.3; p < 0.001). By contrast, Dx was elevated in all subjects, and showed minimal change with increased GA (r = -0.06; p = 0.05). Multivariate analysis confirmed that GA (p < 0.001) and the "closing margin" (p < 0.01) were associated with Sx. Premature infants have low and almost always pressure-passive diastolic cerebral blood FV. Conversely, the regulation of systolic cerebral blood FV by autoregulation was manifested in this cohort at a GA of between 23 and 33 weeks.
Collapse
|
41
|
Kooi EMW, Verhagen EA, Elting JWJ, Czosnyka M, Austin T, Wong FY, Aries MJ. Measuring cerebrovascular autoregulation in preterm infants using near-infrared spectroscopy: an overview of the literature. Expert Rev Neurother 2017. [DOI: 10.1080/14737175.2017.1346472] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Elisabeth M. W. Kooi
- Beatrix Children’s Hospital, Division of Neonatology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Elise A. Verhagen
- Sophia Children’s Hospital, University of Rotterdam, Erasmus University Hospital, Rotterdam, The Netherlands
| | - Jan Willem J. Elting
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Marek Czosnyka
- Department of Academic Neurosurgery, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - Topun Austin
- Cambridge University Hospitals NHS Foundation Trust, Rosie Hospital, Cambridge, UK
| | - Flora Y. Wong
- Monash Newborn, Monash Medical Centre; Department of Paediatrics, Monash University; The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Australia
| | - Marcel J.H. Aries
- Department of Intensive Care, University of Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| |
Collapse
|
42
|
Votava-Smith JK, Statile CJ, Taylor MD, King EC, Pratt JM, Nelson DP, Michelfelder EC. Impaired cerebral autoregulation in preoperative newborn infants with congenital heart disease. J Thorac Cardiovasc Surg 2017. [PMID: 28634025 DOI: 10.1016/j.jtcvs.2017.05.045] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To characterize cerebral autoregulation (CA) in preoperative newborn infants with congenital heart disease (CHD). METHODS This was a prospective, pilot study of term newborns with CHD who required intensive care. Continuous mean arterial blood pressure (MAP), cerebral tissue oxygen saturation (SCTO2) via near-infrared spectroscopy, and arterial oxygen saturation (SaO2) were collected. Significant low-frequency coherence between MAP and SCTO2 was used to define impaired CA in 20-minute epochs. Cerebral fractional tissue oxygen extraction (FTOE) = (SaO2 - SCTO2)/SaO2 was calculated. Spearman's and rank bi-serial correlations and logistic linear models accounting for multiple measures were used to identify associations with impaired CA and coherence. RESULTS Twenty-four term neonates were evaluated for 23.4 ± 1.8 hours starting the first day of life. Periods of SaO2 variability >5% were excluded, leaving 63 ± 10 epochs per subject, 1515 total for analysis. All subjects demonstrated periods of abnormal CA, mean 15.3% ± 12.8% of time studied. Significant associations with impaired CA per epoch included greater FTOE (P = .02) and lack of sedation (P = .02), and associations with coherence included greater FTOE (P = .03), lack of sedation (P = .03), lower MAP (P = .006), and lower hemoglobin (P = .02). CONCLUSIONS Term newborns with CHD display time-varying CA abnormalities. Associations seen between abnormal CA and greater FTOE, lack of sedation, and lower hemoglobin suggest that impaired oxygen delivery and increased cerebral metabolic demand may overwhelm autoregulatory capacity in these infants. Further studies are needed to determine the significance of impaired CA in this population.
Collapse
Affiliation(s)
- Jodie K Votava-Smith
- Division of Cardiology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, Calif.
| | | | - Michael D Taylor
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Eileen C King
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jesse M Pratt
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David P Nelson
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Erik C Michelfelder
- Emory University School of Medicine, Sibley Heart Center Cardiology, Children's Healthcare of Atlanta, Atlanta, Ga
| |
Collapse
|
43
|
Watanabe H, Shitara Y, Aoki Y, Inoue T, Tsuchida S, Takahashi N, Taga G. Hemoglobin phase of oxygenation and deoxygenation in early brain development measured using fNIRS. Proc Natl Acad Sci U S A 2017; 114:E1737-E1744. [PMID: 28196885 PMCID: PMC5338505 DOI: 10.1073/pnas.1616866114] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
A crucial issue in neonatal medicine is the impact of preterm birth on the developmental trajectory of the brain. Although a growing number of studies have shown alterations in the structure and function of the brain in preterm-born infants, we propose a method to detect subtle differences in neurovascular and metabolic functions in neonates and infants. Functional near-infrared spectroscopy (fNIRS) was used to obtain time-averaged phase differences between spontaneous low-frequency (less than 0.1 Hz) oscillatory changes in oxygenated hemoglobin (oxy-Hb) and those in deoxygenated hemoglobin (deoxy-Hb). This phase difference was referred to as hemoglobin phase of oxygenation and deoxygenation (hPod) in the cerebral tissue of sleeping neonates and infants. We examined hPod in term, late preterm, and early preterm infants with no evidence of clinical issues and found that all groups of infants showed developmental changes in the values of hPod from an in-phase to an antiphase pattern. Comparison of hPod among the groups revealed that developmental changes in hPod in early preterm infants precede those in late preterm and term infants at term equivalent age but then, progress at a slower pace. This study suggests that hPod measured using fNIRS is sensitive to the developmental stage of the integration of circular, neurovascular, and metabolic functions in the brains of neonates and infants.
Collapse
Affiliation(s)
- Hama Watanabe
- Graduate School of Education, The University of Tokyo, Tokyo 113-0033, Japan;
| | - Yoshihiko Shitara
- Department of Pediatrics, Graduate School of Medicine, The University of Tokyo, Tokyo 113-0033, Japan
| | - Yoshinori Aoki
- Department of Pediatrics, Graduate School of Medicine, The University of Tokyo, Tokyo 113-0033, Japan
| | - Takanobu Inoue
- Department of Pediatrics, Graduate School of Medicine, The University of Tokyo, Tokyo 113-0033, Japan
| | - Shinya Tsuchida
- Department of Pediatrics, Graduate School of Medicine, The University of Tokyo, Tokyo 113-0033, Japan
| | - Naoto Takahashi
- Department of Pediatrics, Graduate School of Medicine, The University of Tokyo, Tokyo 113-0033, Japan
| | - Gentaro Taga
- Graduate School of Education, The University of Tokyo, Tokyo 113-0033, Japan
| |
Collapse
|
44
|
Abstract
Hypotension is common in low birth weight neonates and less common in term newborns and is associated with significant morbidity and mortality. Determining an adequate blood pressure in neonates remains challenging for the neonatal nurse because of the lack of agreed-upon norms. Values for determining norms for blood pressure at varying gestational and postnatal ages are based on empirical data. Understanding cardiovascular pathophysiology, potential causes of hypotension, and assessment of adequate perfusion in the neonatal population is important and can assist the neonatal nurse in the evaluation of effective blood pressure. This article reviews cardiovascular pathophysiology as it relates to blood pressure and discusses potential causes of hypotension in the term and preterm neonate. Variation in management of hypotension across centers is discussed. Underlying causes and pathophysiology of hypotension in the neonate are described.
Collapse
|
45
|
St Peter D, Gandy C, Hoffman SB. Hypotension and Adverse Outcomes in Prematurity: Comparing Definitions. Neonatology 2017; 111:228-233. [PMID: 27898415 DOI: 10.1159/000452616] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 10/13/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND In the premature neonate, there is no consensus regarding normal blood pressure (BP). The most common definition used is a mean arterial BP (MAP) less than the gestational age (GA); however, studies indicate that the neuroprotective mechanism of autoregulation is lost below a MAP of 30 mm Hg. OBJECTIVE To determine whether hypotension defined as MAP <30 mm Hg or MAP less than the infant's GA better predicts adverse outcomes of intraventricular hemorrhage (IVH) and death. STUDY DESIGN For this retrospective study, demographic, clinical, and BP data in epochs of 12 h were collected during the first 72 h of life in 188 subjects 24-28 weeks of gestation. For each definition, outcomes of severe IVH (grade 3 or 4), death, or the composite outcome of either were evaluated using bivariate testing. Logistic regression determined independent predictors of composite outcome of death and/or grade 3 or 4 IVH. RESULTS Hypotension by either definition was significant for death and the composite outcome (p < 0.0001). Only the MAP <30 mm Hg definition was associated with severe IVH (p = 0.02). On logistic regression, significant predictors of the composite outcome were GA (OR 0.59, 95% CI 0.39-0.89) and vasopressor therapy (OR 5.5, 95% CI 2-17). CONCLUSIONS Neither definition of hypotension independently predicts adverse outcome in multivariate logistic regression. Vasopressor therapy, however, is an independent predictor of IVH and death in premature infants.
Collapse
Affiliation(s)
- Deidre St Peter
- Department of Pediatrics, University of Maryland Medical Center, Baltimore, MD, USA
| | | | | |
Collapse
|
46
|
Addison PS, Antunes A, Montgomery D, Borg UR. Gradient adjustment method for better discriminating correlating and non-correlating regions of physiological signals: application to the partitioning of impaired and intact zones of cerebral autoregulation. J Clin Monit Comput 2016; 31:727-737. [PMID: 27496051 PMCID: PMC5500687 DOI: 10.1007/s10877-016-9913-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 07/25/2016] [Indexed: 11/10/2022]
Abstract
Cerebral blood flow (CBF) is regulated over a range of systemic blood pressures by the cerebral autoregulation (CA) control mechanism. This range lies within the lower and upper limits of autoregulation (LLA, ULA), beyond which blood pressure drives CBF, and CA function is considered impaired. A standard method to determine autoregulation limits noninvasively using NIRS technology is via the COx measure: a moving correlation index between mean arterial pressure and regional oxygen saturation. In the intact region, there should be no correlation between these variables whereas in the impaired region, the correlation index should approximate unity. In practice, however, the data may be noisy and/or the intact region may often exhibit a slightly positive relationship. This positive relationship may render traditional autoregulation limit calculations difficult to perform, resulting in the need for manual interpretation of the data using arbitrary thresholds. Further, the underlying mathematics of the technique are asymmetric in terms of the results produced for impaired and intact regions and are, in fact, not computable for the ideal case within the intact region. In this work, we propose a novel gradient adjustment method (GACOx) to enhance the differences in COx values observed in the intact and impaired regions. Results from a porcine model (N = 8) are used to demonstrate that GACOx is successful in determining LLA values where traditional methods fail. It is shown that the derived GACOx indices exhibit a mean difference between the intact/impaired regions of 1.54 ± 0.26 (mean ± SD), compared to 0.14 ± 0.10 for the traditional COx method. The GACOx effectively polarizes the COx data in order to better differentiate the intact and impaired zones and, in doing so, makes the determination of the LLA and ULA points a simpler and more consistent task. The method lends itself to the automation of the robust determination of autoregulation zone limits.
Collapse
Affiliation(s)
- Paul S Addison
- Medtronic Respiratory and Monitoring Solutions, Edinburgh, Scotland, UK.
| | - André Antunes
- Medtronic Respiratory and Monitoring Solutions, Edinburgh, Scotland, UK
| | - Dean Montgomery
- Medtronic Respiratory and Monitoring Solutions, Edinburgh, Scotland, UK
| | - Ulf R Borg
- Medtronic Respiratory and Monitoring Solutions, Boulder, CO, USA
| |
Collapse
|
47
|
Chalak LF, Tian F, Tarumi T, Zhang R. Cerebral Hemodynamics in Asphyxiated Newborns Undergoing Hypothermia Therapy: Pilot Findings Using a Multiple-Time-Scale Analysis. Pediatr Neurol 2016; 55:30-6. [PMID: 26858217 PMCID: PMC4748172 DOI: 10.1016/j.pediatrneurol.2015.11.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Accepted: 11/21/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Improved quantitative assessment of cerebral hemodynamics in newborns might enable us to optimize cerebral perfusion. Our objective was to develop an approach to assess cerebral hemodynamics across multiple time scales during the first 72 hours of life in newborns during hypothermia therapy. METHODS Spontaneous oscillations in mean arterial pressure and regional cerebral tissue oxygen saturation were analyzed using a moving window correlation method with time scales ranging from 0.15 to 8 hours in this pilot methodology study. Abnormal neurodevelopmental outcome was defined by Bayley III scores and/or cerebral palsy by age 24 months using receiver operating curve. RESULTS Multiple-time-scale correlations between the mean arterial pressure and regional cerebral tissue oxygen saturation oscillations were tested in 10 asphyxiated newborns undergoing hypothermia therapy. Large noninduced fluctuations in the blood pressure were observed during cooling in all five infants with abnormal outcomes. Notably, these infants had two distinct patterns of correlation: a positive in-phase correlation at the short time scales (15 minutes) and/or a negative antiphase correlations observed at long time scales (4 hours.). Both the in-phase (area under the curve 0.6, [95% confidence interval 0.2-0.95]) and antiphase correlations (area under the curve 0.75, [95% confidence interval 0.4-0.95]) appeared to be related to an abnormal outcome. CONCLUSIONS Our observations suggest that the time scale is an important factor that needs to be standardized in the assessment of neonatal cerebral hemodynamics.
Collapse
Affiliation(s)
- Lina F Chalak
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas.
| | - Fenghua Tian
- Department of Bioengineering, University of Texas at Arlington, Dallas, Texas
| | - Takashi Tarumi
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital of Dallas, Dallas, Texas
| | - Rong Zhang
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital of Dallas, Dallas, Texas
| |
Collapse
|
48
|
Tian F, Tarumi T, Liu H, Zhang R, Chalak L. Wavelet coherence analysis of dynamic cerebral autoregulation in neonatal hypoxic-ischemic encephalopathy. NEUROIMAGE-CLINICAL 2016; 11:124-132. [PMID: 26937380 PMCID: PMC4753811 DOI: 10.1016/j.nicl.2016.01.020] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 01/16/2016] [Accepted: 01/23/2016] [Indexed: 12/02/2022]
Abstract
Cerebral autoregulation represents the physiological mechanisms that keep brain perfusion relatively constant in the face of changes in blood pressure and thus plays an essential role in normal brain function. This study assessed cerebral autoregulation in nine newborns with moderate-to-severe hypoxic–ischemic encephalopathy (HIE). These neonates received hypothermic therapy during the first 72 h of life while mean arterial pressure (MAP) and cerebral tissue oxygenation saturation (SctO2) were continuously recorded. Wavelet coherence analysis, which is a time-frequency domain approach, was used to characterize the dynamic relationship between spontaneous oscillations in MAP and SctO2. Wavelet-based metrics of phase, coherence and gain were derived for quantitative evaluation of cerebral autoregulation. We found cerebral autoregulation in neonates with HIE was time-scale-dependent in nature. Specifically, the spontaneous changes in MAP and SctO2 had in-phase coherence at time scales of less than 80 min (< 0.0002 Hz in frequency), whereas they showed anti-phase coherence at time scales of around 2.5 h (~ 0.0001 Hz in frequency). Both the in-phase and anti-phase coherence appeared to be related to worse clinical outcomes. These findings suggest the potential clinical use of wavelet coherence analysis to assess dynamic cerebral autoregulation in neonatal HIE during hypothermia. Cerebral hemodynamics in HIE neonates were continuously recorded in hypothermia. Wavelet coherence can be used to assess dynamic autoregulation in HIE neonates. Wavelet-derived metrics have about 88.9% accuracy in predicting clinical outcomes. Wavelet phase, coherence, and gain are validated against transfer function analysis. Cerebral autoregulation in HIE neonates is time-scale-dependent in a wide range.
Collapse
Affiliation(s)
- Fenghua Tian
- Department of Bioengineering, University of Texas at Arlington, United States
| | - Takashi Tarumi
- Department of Internal Medicine, University of Texas Southwestern Medical Center, United States; Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, United States; Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital of Dallas, United States
| | - Hanli Liu
- Department of Bioengineering, University of Texas at Arlington, United States
| | - Rong Zhang
- Department of Internal Medicine, University of Texas Southwestern Medical Center, United States; Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, United States; Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital of Dallas, United States
| | - Lina Chalak
- Department of Pediatrics, University of Texas Southwestern Medical Center, United States.
| |
Collapse
|
49
|
Abstract
Pressure autoregulation is an important hemodynamic mechanism that protects the brain against inappropriate fluctuations in cerebral blood flow in the face of changing cerebral perfusion pressure (CPP). Static autoregulation represents how far cerebrovascular resistance changes when CPP varies, and dynamic autoregulation represents how fast these changes happen. Both have been monitored in the setting of neurocritical care to aid prognostication and contribute to individualizing CPP targets in patients. Failure of autoregulation is associated with a worse outcome in various acute neurological diseases. Several studies have used transcranial Doppler ultrasound, intracranial pressure (ICP with vascular reactivity as surrogate measure of autoregulation), and near-infrared spectroscopy to continuously monitor the impact of spontaneous fluctuations in CPP on cerebrovascular physiology and to calculate derived variables of autoregulatory efficiency. Many patients who undergo such monitoring demonstrate a range of CPP in which autoregulatory efficiency is optimal. Management of patients at or near this optimal level of CPP is associated with better outcomes in traumatic brain injury. Many of these studies have utilized the concept of the pressure reactivity index, a correlation coefficient between ICP and mean arterial pressure. While further studies are needed, these data suggest that monitoring of autoregulation could aid prognostication and may help identify optimal CPP levels in individual patients.
Collapse
Affiliation(s)
- Marek Czosnyka
- Department of Clinical Neurosciences, Division of Neurosurgery, University of Cambridge, Addenbrooke's Hospital, Box 167, Cambridge, CB2 2QQ, UK,
| | | | | |
Collapse
|
50
|
Montgomery D, Addison PS, Borg U. Data clustering methods for the determination of cerebral autoregulation functionality. J Clin Monit Comput 2015; 30:661-8. [PMID: 26377023 PMCID: PMC5023736 DOI: 10.1007/s10877-015-9774-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 09/10/2015] [Indexed: 11/29/2022]
Abstract
Cerebral blood flow is regulated over a range of systemic blood pressures through the cerebral autoregulation (CA) control mechanism. The COx measure based on near infrared spectroscopy (NIRS) has been proposed as a suitable technique for the analysis of CA as it is non-invasive and provides a simpler acquisition methodology than other methods. The COx method relies on data binning and thresholding to determine the change between intact and impaired autoregulation zones. In the work reported here we have developed a novel method of differentiating the intact and impaired CA blood pressure regimes using clustering methods on unbinned data. K-means and Gaussian mixture model algorithms were used to analyse a porcine data set. The determination of the lower limit of autoregulation (LLA) was compared to a traditional binned data approach. Good agreement was found between the methods. The work highlights the potential application of using data clustering tools in the monitoring of CA function.
Collapse
Affiliation(s)
- Dean Montgomery
- Respiratory and Monitoring Solutions, Medtronic, Technopole Centre, Edinburgh, EH26 0PJ, UK.
| | - Paul S Addison
- Respiratory and Monitoring Solutions, Medtronic, Technopole Centre, Edinburgh, EH26 0PJ, UK
| | - Ulf Borg
- Respiratory and Monitoring Solutions, Medtronic, 6135 Gunbarrel Avenue, Boulder, CO, 80301, USA
| |
Collapse
|