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Te Pas A. Measuring direct effect of cord clamping approaches: getting the right target group. Pediatr Res 2024; 96:5-6. [PMID: 38769402 DOI: 10.1038/s41390-024-03284-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 04/29/2024] [Indexed: 05/22/2024]
Affiliation(s)
- Arjan Te Pas
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands.
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2
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Chioma R, Finn D, Healy DB, Herlihy I, Livingstone V, Panaviene J, Dempsey EM. Impact of cord clamping on haemodynamic transition in term newborn infants. Arch Dis Child Fetal Neonatal Ed 2024; 109:287-293. [PMID: 38071517 DOI: 10.1136/archdischild-2023-325652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 10/27/2023] [Indexed: 04/20/2024]
Abstract
OBJECTIVE To assess the haemodynamic consequences of cord clamping (CC) in healthy term infants. DESIGN Cohort study. SETTING Tertiary maternity hospital. PATIENTS 46 full-term vigorous infants born by caesarean section. INTERVENTIONS Echocardiography was performed before CC, immediately after CC and at 5 min after birth. MAIN OUTCOME MEASURES Pulsed wave Doppler-derived cardiac output and the pulmonary artery acceleration time indexed to the right ventricle ejection time were obtained. As markers of loading fluctuations, the myocardial performance indexes and the velocities of the tricuspid and mitral valve annuli were determined with tissue Doppler imaging. Heart rate was derived from Doppler imaging throughout the assessments. RESULTS Left ventricular output increased throughout the first minutes after birth (mean (SD) 222.4 (32.5) mL/kg/min before CC vs 239.7 (33.6) mL/kg/min at 5 min, p=0.01), while right ventricular output decreased (306.5 (48.2) mL/kg/min before vs 272.8 (55.5) mL/kg/min immediately after CC, p=0.001). The loading conditions of both ventricles were transiently impaired by CC, recovering at 5 min. Heart rate progressively decreased after birth, following a linear trend temporarily increased by CC. The variation in left ventricular output across the CC was directly correlated to the fluctuation of left ventricular preload over the same period (p=0.03). CONCLUSIONS This study illustrates the cardiovascular consequences of CC in term vigorous infants and offers insight into the haemodynamic transition from fetal to neonatal circulation in spontaneously breathing newborns. Strategies that aim to enhance left ventricular preload before CC may prevent complications of perinatal cardiovascular imbalance.
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Affiliation(s)
- Roberto Chioma
- University College Cork, INFANT Research Centre, Cork, Ireland
- Università Cattolica del Sacro Cuore, Roma, Italy
| | - Daragh Finn
- University College Cork, INFANT Research Centre, Cork, Ireland
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - David B Healy
- University College Cork, INFANT Research Centre, Cork, Ireland
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Ita Herlihy
- University College Cork, INFANT Research Centre, Cork, Ireland
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Vicki Livingstone
- University College Cork, INFANT Research Centre, Cork, Ireland
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Jurate Panaviene
- University College Cork, INFANT Research Centre, Cork, Ireland
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Eugene M Dempsey
- University College Cork, INFANT Research Centre, Cork, Ireland
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
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3
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Soliman RM, Elgendy MM, Said RN, Shaarawy BI, Helal OM, Aly H. A Randomized Controlled Trial of a 30- versus a 120-Second Delay in Cord Clamping after Term Birth. Am J Perinatol 2024; 41:739-746. [PMID: 35170013 DOI: 10.1055/a-1772-4543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE Delayed cord clamping (DCC) has been recently adopted in neonatal resuscitation. The immediate cardiac hemodynamic effects related to DCC more than 30 seconds was not studied. We aimed to study the effect of DCC at 120 seconds compared with 30 seconds on multiple hemodynamic variables in full-term infants using an electrical cardiometry (EC) device. STUDY DESIGN Present study is a randomized clinical trial. The study was conducted with full-term infants who were delivered at the Obstetrics and Gynecology Department in Cairo University Hospital. Sixty-eight full term infants were successfully enrolled in this trial. Cardiac output (CO) and other hemodynamic parameters were evaluated in this study by EC device. Hemoglobin, glucose, and bilirubin concentrations were measured at 24 hours. Newborn infants were assigned randomly into group 1: DCC at 30 seconds, and group 2: DCC at 120 seconds, based on the time of cord clamping. RESULTS Stroke volume (SV) (mL) and CO (L/min) were significantly higher in group 2 compared with group 1 at 5 minutes (6.71 vs. 5.35 and 1.09 vs. 0.75), 10 minutes (6.43 vs. 5.59 and 0.88 vs. 0.77), 15 minutes (6.45 vs. 5.60 and 0.89 vs. 0.76), and 24 hours (6.67 vs. 5.75 and 0.91vs. 0.81), respectively. Index of contractility (ICON; units) was significantly increased in group 2 at 5 minutes compared with group1 (114.2 vs. 83.8). Hematocrit (%) and total bilirubin concentrations (mg/dL) at 24 hours were significantly increased in group 2 compared with group 1 (51.5 vs. 40.5 and 3.8 vs. 2.9, respectively). CONCLUSION Stroke volume and cardiac output are significantly higher in neonates with DCC at 120 seconds compared with 30 seconds that continues for the first 24 hours. KEY POINTS · CO is significantly increased with DCC at 120 seconds.. · SV is significantly increased with DCC at 120 seconds.. · Such effects continued during the entire 24 hours of life in full-term infants..
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Affiliation(s)
- Reem M Soliman
- Department of Pediatrics, Cairo University, Cairo, Egypt
| | - Marwa M Elgendy
- Department of Neonatology, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Reem N Said
- Department of Pediatrics, Cairo University, Cairo, Egypt
| | | | - Omneya M Helal
- Department of Obstetrics and Gynecology, Cairo University Obstetrics and Gynecology Hospital, Cairo, Egypt
| | - Hany Aly
- Department of Neonatology, Cleveland Clinic Children's Hospital, Cleveland, Ohio
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4
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Takeuchi Y, Nomura A, Yamoto M, Ohfuji S, Fujii S, Yoshimoto S, Funakoshi T, Shinkai M, Urushihara N, Yokoi A. The Association between the First Cry and Clinical Outcomes in CDH Neonates: A Retrospective Study. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1145. [PMID: 37508642 PMCID: PMC10377899 DOI: 10.3390/children10071145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 06/22/2023] [Accepted: 06/26/2023] [Indexed: 07/30/2023]
Abstract
Congenital diaphragmatic hernia (CDH) is a life-threatening condition characterized by the herniation of abdominal organs into the thorax, resulting in hypoplastic lungs and pulmonary hypertension. The impact of the first cry, a crucial event for lung transition during birth, on CDH patients remains unclear. This study investigated the impact of the first cry during birth on CDH patient survival, along with other prognosis factors. A multi-institutional retrospective study assessed CDH patient characteristics and survival rates by analyzing factors including the first cry, disease severity, birth weight, Apgar scores, oxygenation index (OI) and surgical closure. Among the CDH patients in the study, a positive first cry was linked to 100% survival, regardless of disease severity (p < 0.001). Notably, the presence of a positive first cry did not significantly affect survival rates in patients with worse prognostic factors, such as low birth weight (<2500 g), high CDH severity, low Apgar scores (1 min ≤ 4), high best OI within 24 h after birth (≥8), or those who underwent patch closure. Furthermore, no significant association was found between the first cry and the use of inhaled nitric oxide (iNO) or extracorporeal membrane oxygenation (ECMO). In conclusion, this study suggests that the first cry may not have a negative impact on the prognosis of CDH patients and could potentially have a positive effect.
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Affiliation(s)
- Yuki Takeuchi
- Department of Pediatric Surgery, Kobe Children's Hospital, Kobe 650-0047, Japan
| | - Akiyoshi Nomura
- Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka 420-0953, Japan
| | - Masaya Yamoto
- Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka 420-0953, Japan
| | - Satoko Ohfuji
- Department of Public Health, Osaka Metropolitan University Graduate School of Medicine, Osaka 545-8585, Japan
| | - Shunsuke Fujii
- Department of Pediatric Surgery, Kanagawa Children's Medical Center, Yokohama 232-0066, Japan
| | - Seiji Yoshimoto
- Department of Neonatology, Kobe Children's Hospital, Kobe 650-0047, Japan
| | - Toru Funakoshi
- Department of Obstetrics, Kobe Children's Hospital, Kobe 650-0047, Japan
| | - Masato Shinkai
- Department of Pediatric Surgery, Kanagawa Children's Medical Center, Yokohama 232-0066, Japan
| | - Naoto Urushihara
- Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka 420-0953, Japan
| | - Akiko Yokoi
- Department of Pediatric Surgery, Kobe Children's Hospital, Kobe 650-0047, Japan
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5
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Pfurtscheller D, Wolfsberger CH, Höller N, Schwaberger B, Mileder LP, Baik-Schneditz N, Urlesberger B, Schmölzer GM, Pichler G. Cardiac output and regional-cerebral-oxygen-saturation in preterm neonates during immediate postnatal transition: An observational study. Acta Paediatr 2023. [PMID: 36880893 DOI: 10.1111/apa.16745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 03/02/2023] [Accepted: 03/03/2023] [Indexed: 03/08/2023]
Abstract
AIM To examine potential correlations between cardiac output (CO) with cerebral-regional-oxygen-saturation (crSO2 ) and cerebral-fractional-tissue-oxygen-extraction (cFTOE) during immediate foetal-to-neonatal transition in term and preterm neonates with and without respiratory support. METHODS Post hoc analyses of secondary outcome parameters of prospective observational studies were performed. We included neonates with cerebral near-infrared-spectroscopy (NIRS) monitoring and an oscillometric blood pressure measurement at minute 15 after birth. Heart rate (HR) and arterial oxygen saturation (SpO2 ) were monitored. CO was calculated with Liljestrand and Zander formula and correlated with crSO2 and cFTOE. RESULTS Seventy-nine preterm neonates and 207 term neonates with NIRS measurements and calculated CO were included. In 59 preterm neonates (mean gestational age (GA): 29.4 ± 3.7 weeks) with respiratory support, CO correlated significantly positively with crSO2 and significantly negatively with cFTOE. In 20 preterm neonates (GA 34.9 ± 1.3 weeks) without respiratory support and in 207 term neonates with and without respiratory support, CO correlated neither with crSO2 nor with cFTOE. CONCLUSION In compromised preterm neonates with lower gestational age and in need of respiratory support, CO was associated with crSO2 and cFTOE, whereas in stable preterm neonates with higher gestational age as well as in term neonates with and without respiratory support, no associations were observed.
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Affiliation(s)
- Daniel Pfurtscheller
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Christina H Wolfsberger
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Nina Höller
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Bernhard Schwaberger
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Lukas P Mileder
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Nariae Baik-Schneditz
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Berndt Urlesberger
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Georg M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada.,Department of Pediatrics, Division of Neonatology Department of Pediatrics and Adolescent Medicine Medical, University of Alberta, Edmonton, Alberta, Canada
| | - Gerhard Pichler
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
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Kaufmann J, Schindler E. [Safe and Appropriate Pharmacotherapy in Paediatric Anaesthesia]. Anasthesiol Intensivmed Notfallmed Schmerzther 2022; 57:523-535. [PMID: 36049737 DOI: 10.1055/a-1690-5603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Safe and appropriate pharmacotherapy in children requires knowledge of age-group-specific features regarding pharmacology and drug dosing. In addition, aspects of medication safety must be considered. This review highlights basic principles and discusses key facts; further research in paediatric databases is recommended (www.kinderformularium.de).
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Jones CB, Crossland DS. The interplay between pressure, flow, and resistance in neonatal pulmonary hypertension. Semin Fetal Neonatal Med 2022; 27:101371. [PMID: 35787350 DOI: 10.1016/j.siny.2022.101371] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Pulmonary hypertension, conventionally defined by absolute pulmonary artery pressure, is the result of a range of diagnoses that can result in clinical problems in neonatal practice. Causes include persistent pulmonary hypertension of the newborn, congenital heart disease, and left heart dysfunction, as well as the normally high pulmonary artery resistance in neonates. Elucidating the cause of pulmonary hypertension is vital to guide appropriate management. A first principles approach based on hemodynamic calculations provides a framework for the diagnostic work up and subsequent therapy. Central to this is the equation 'pressure = flow x resistance' and knowledge of factors contributing to flow and resistance and their impact on pulmonary artery pressure. While formal, accurate, calculation of each element is usually not required or deliverable in small infants, clinical and echocardiographic parameters, combined with an understanding of the interplay between pressure, flow, and resistance, significantly improves the assessment and management of neonatal pulmonary hemodynamics.
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Affiliation(s)
- Caroline B Jones
- Consultant Fetal and Paediatric Cardiologist, Alder Hey Children's NHS Foundation Trust, Liverpool, L12 2AP, UK.
| | - David Steven Crossland
- Consultant Interventional Paediatric and ACHD Cardiologist, Freeman Hospital, Newcastle Upon Tyne, NE7 7DN, UK.
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8
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Gupta B, Yengkhom R, Banait N, Chetan C, Pareek P, Suryawanshi P. Hemodynamic parameters after Delayed Cord Clamping (DCC) in term neonates: a prospective observational study. BMC Pediatr 2022; 22:256. [PMID: 35524194 PMCID: PMC9074198 DOI: 10.1186/s12887-022-03303-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 04/18/2022] [Indexed: 12/01/2022] Open
Abstract
Background Delayed cord clamping (DCC) is practiced worldwide, as standard care in both term and preterm babies. Our aim was to determine the hemodynamic effects of DCC on transitional circulation. Material and methods This prospective observational study was carried out in a tertiary care hospital, at Pune, India, from May 2018 to October 2019.Term neonates born during the study period were included. The primary outcome variables of the study were right ventricular output (RVO), left ventricular output (LVO), superior vena cava (SVC) flow (ml/kg/min) and heart rate(HR) at 12 ± 6 and 48 ± 6 h of life measured by point of care functional echocardiography. Inter-observer and intra-observer variability was calculated for these parameters. Results Out of a total of 2744 deliveries during the study period, 620 babies were included. Mean gestational age of the enrolled babies was 38.96 ± 1.08 weeks and mean birth weight was 2.9 ± 0.39 kg. Mean heart rate of babies recorded at 12 ± 6 h of life was 127 beats per minute (bpm) whereas it was 128 bpm at 48 ± 6 h of life. RVO {mean (SD)} was 209.55(44.89) and 205.85(46.35) ml/kg/min, LVO {mean (SD)} was 133.68(31.15) and 134.78(29.84) ml/kg/min whereas SVC flow {mean (SD)} was 106.85(26.21) and 109.29(25.11) ml/kg/min at 12 ± 6 and 48 ± 6 h of life respectively. There was good intra-observer agreement in all the variables. SGA babies had a significantly higher heart rate at 12 ± 6 h of life as compared to AGA babies, although this difference in heart rate could not be appreciated at 48 ± 6 h of life. However SGA babies had a higher LVO, RVO and SVC flow than AGA babies at both the time points of observation. Conclusion After DCC there is less fluctuation in the hemodynamic parameters (heart rate, cardiac output) at the two time points of observation.. As compared to AGA babies, SGA babies had a significantly higher baseline heart rate, LVO, RVO and SVC flow. LVO of SGA babies after delayed cord clamping is found to be significantly lower than LVO seen in other studies, favoring the cardio-stabilizing effect of DCC. Brief rationale This is the first study with a large sample size evaluating the hemodynamic effects of DCC in term neonates by functional echocardiography. The normative data of heart rate and cardiac output of term, stable babies with small for gestational age(SGA) as a special subgroup undergoing DCC requires further evaluation.
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Affiliation(s)
- Bhvya Gupta
- Sparsh Superspeciality Hospital, Ambala city, Haryana, India
| | | | - Nishant Banait
- All India Institute of Medical Sciences, Nagpur, Maharashtra, India
| | - Chinmay Chetan
- Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand, India
| | - Prince Pareek
- Department of Neonatology, Bharati Vidyapeeth University Medical College, Dhankawadi Pune, Maharashtra, 411043, India
| | - Pradeep Suryawanshi
- Department of Neonatology, Bharati Vidyapeeth University Medical College, Dhankawadi Pune, Maharashtra, 411043, India.
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9
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Suppan E, Pichler G, Binder-Heschl C, Schwaberger B, Urlesberger B. Three Physiological Components That Influence Regional Cerebral Tissue Oxygen Saturation. Front Pediatr 2022; 10:913223. [PMID: 35769216 PMCID: PMC9234387 DOI: 10.3389/fped.2022.913223] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 05/09/2022] [Indexed: 11/17/2022] Open
Abstract
Near-infrared spectroscopy (NIRS) measurement of regional cerebral tissue oxygen saturation (rcStO2) has become a topic of high interest in neonatology. Multiple studies have demonstrated that rcStO2 measurements are feasible in the delivery room during immediate transition and resuscitation as well as after admission to the neonatal intensive care unit. Reference ranges for different gestational ages, modes of delivery, and devices have already been published. RcStO2 reflects a mixed tissue saturation, composed of arterial (A), venous (V), and capillary signals, derived from small vessels within the measurement compartment. The A:V signal ratio fluctuates based on changes in oxygen delivery and oxygen consumption, which enables a reliable trend monitoring of the balance between these two parameters. While the increasing research evidence supports its use, the interpretation of the absolute values of and trends in rcStO2 is still challenging, which halts its routine use in the delivery room and at the bedside. To visualize the influencing factors and improve the understanding of rcStO2 values, we have created a flowchart, which focuses on the three major physiological components that affect rcStO2: oxygen content, circulation, and oxygen extraction. Each of these has its defining parameters, which are discussed in detail in each section.
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Affiliation(s)
- Ena Suppan
- Division of Neonatology, Department of Pediatrics, Medical University of Graz, Graz, Austria.,Research Unit for Neonatal Micro- and Macrocirculation, Medical University of Graz, Graz, Austria.,Research Unit for Cerebral Development and Oximetry Research, Medical University of Graz, Graz, Austria
| | - Gerhard Pichler
- Division of Neonatology, Department of Pediatrics, Medical University of Graz, Graz, Austria.,Research Unit for Neonatal Micro- and Macrocirculation, Medical University of Graz, Graz, Austria.,Research Unit for Cerebral Development and Oximetry Research, Medical University of Graz, Graz, Austria
| | - Corinna Binder-Heschl
- Division of Neonatology, Department of Pediatrics, Medical University of Graz, Graz, Austria.,Research Unit for Neonatal Micro- and Macrocirculation, Medical University of Graz, Graz, Austria.,Research Unit for Cerebral Development and Oximetry Research, Medical University of Graz, Graz, Austria
| | - Bernhard Schwaberger
- Division of Neonatology, Department of Pediatrics, Medical University of Graz, Graz, Austria.,Research Unit for Neonatal Micro- and Macrocirculation, Medical University of Graz, Graz, Austria.,Research Unit for Cerebral Development and Oximetry Research, Medical University of Graz, Graz, Austria
| | - Berndt Urlesberger
- Division of Neonatology, Department of Pediatrics, Medical University of Graz, Graz, Austria.,Research Unit for Neonatal Micro- and Macrocirculation, Medical University of Graz, Graz, Austria.,Research Unit for Cerebral Development and Oximetry Research, Medical University of Graz, Graz, Austria
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10
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Cardiovascular fetal-to-neonatal transition: an in silico model. Pediatr Res 2022; 91:116-128. [PMID: 33731808 DOI: 10.1038/s41390-021-01401-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 12/16/2020] [Accepted: 01/21/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Previous models describing the fetal-to-neonatal transition often lack oxygen saturation levels, homeostatic control mechanisms, phasic hemodynamic signals, or describe the heart with a time-varying elastance model. METHODS We incorporated these elements in the adapted CircAdapt model with the one-fiber model for myocardial contraction, to simulate the hemodynamics of the healthy term human fetal circulation and its transition during the first 24 h after birth. The fetal-to-neonatal model was controlled by a time- and event-based script of changes occurring at birth, such as lung aeration and umbilical cord clamping. Model parameters were based on and validated with human and animal data. RESULTS The fetal circulation showed low pulmonary blood flow, right ventricular dominance, and inverted mitral and tricuspid flow velocity patterns, as well as high mean ductus venosus flow velocity. The neonatal circulation showed oxygen saturation levels to gradually increase to 98% in the first 15 min after birth as well as temporary left ventricular volume overload. CONCLUSIONS Hemodynamics of the term fetus and 24-h-old neonate, as well as the events occurring directly after birth and the transition during the first 24 h after birth, were realistically represented, allowing the model to be used for educational purposes and future research. IMPACT With the addition of oxygen saturation levels, homeostatic pressure-flow control mechanisms, and the one-fiber model for myocardial contraction, a new closed-loop cardiovascular model was constructed to give more insight into the healthy term human fetal circulation and its cardiovascular transition during the first 24 h after birth. Extensive validation confirmed that the hemodynamics of the term fetus and the fetal-to-neonatal transition were realistically represented with the model. This well-validated and versatile model can serve as an education as well as a research platform for in silico investigation of fetal-to-neonatal hemodynamic changes under a wide range of physiological and pathophysiological conditions.
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11
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Zestic J, Liley H, Sanderson P. Concordance of expert clinicians' interpretations of the newborn's true physiological state. Pediatr Res 2022; 91:1222-1230. [PMID: 34183769 PMCID: PMC8236569 DOI: 10.1038/s41390-021-01565-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 03/23/2021] [Accepted: 04/26/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Many physiological aspects of the neonatal transition after birth are unobservable because relevant sensors do not yet exist, compromising clinicians' understanding of a neonate's physiological status. Given that a neonate's true physiological state is currently unavailable, we explored the feasibility of using clinicians' degree of concordance as an approximation of the true physiological state. METHODS Two phases of structured interviews were conducted. In Phase 1 (N = 8) and Phase 2 (N = 12), we presented neonatal experts with eight graphical trajectories of real newborns' heart rate and oxygen saturation values in the first 10-15 min after birth. We elicited the participants' interpretations of potential underlying physiological conditions that could explain the vital sign patterns. RESULTS The global differential diagnosis data for each phase produced the same pattern of results: (1) four trajectories produced a substantial degree of concordance among clinicians (61-80%) and (2) four trajectories produced a strong degree of concordance among clinicians (81-100%). CONCLUSIONS It is possible to achieve a strong degree of concordance among neonatal experts' interpretations of newborn trajectories. Thus, using the degree of concordance as an approximation of the neonate's true physiological state in resuscitation after birth may be a promising direction to explore for cognitive aid design. IMPACT Differential diagnoses with a good degree of concordance among expert neonatal clinicians could potentially substitute in part for the direct measurement of key physiological and anatomical variables of the neonatal transition, which is currently unavailable. The concordance of clinicians' judgements or inferences with regards to the true physiological state of the newborn during resuscitation after birth has never been explored. The findings provide a crucial first step toward using consensus of neonatal experts' judgements in the design of a cognitive aid to support clinicians' management of the newborns who require resuscitation after birth.
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Affiliation(s)
- Jelena Zestic
- The University of Queensland, St Lucia, QLD, Australia.
| | - Helen Liley
- grid.1003.20000 0000 9320 7537The University of Queensland, St Lucia, QLD Australia ,grid.416563.30000 0004 0642 1922Mater Mothers’ Hospital and Mater Research Institute, Brisbane, QLD Australia
| | - Penelope Sanderson
- grid.1003.20000 0000 9320 7537The University of Queensland, St Lucia, QLD Australia
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12
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Badurdeen S, Santomartino GA, Thio M, Heng A, Woodward A, Polglase GR, Hooper SB, Blank DA, Davis PG. Respiratory support after delayed cord clamping: a prospective cohort study of at-risk births at ≥35 +0 weeks gestation. Arch Dis Child Fetal Neonatal Ed 2021; 106:627-634. [PMID: 34112723 PMCID: PMC8543210 DOI: 10.1136/archdischild-2020-321503] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 03/30/2021] [Accepted: 04/12/2021] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To identify risk factors associated with delivery room respiratory support in at-risk infants who are initially vigorous and received delayed cord clamping (DCC). DESIGN Prospective cohort study. SETTING Two perinatal centres in Melbourne, Australia. PATIENTS At-risk infants born at ≥35+0 weeks gestation with a paediatric doctor in attendance who were initially vigorous and received DCC for >60 s. MAIN OUTCOME MEASURES Delivery room respiratory support defined as facemask positive pressure ventilation, continuous positive airway pressure and/or supplemental oxygen within 10 min of birth. RESULTS Two hundred and ninety-eight infants born at a median (IQR) gestational age of 39+3 (38+2-40+2) weeks were included. Cord clamping occurred at a median (IQR) of 128 (123-145) s. Forty-four (15%) infants received respiratory support at a median of 214 (IQR 156-326) s after birth. Neonatal unit admission for respiratory distress occurred in 32% of infants receiving delivery room respiratory support vs 1% of infants who did not receive delivery room respiratory support (p<0.001). Risk factors independently associated with delivery room respiratory support were average heart rate (HR) at 90-120 s after birth (determined using three-lead ECG), mode of birth and time to establish regular cries. Decision tree analysis identified that infants at highest risk had an average HR of <165 beats per minute at 90-120 s after birth following caesarean section (risk of 39%). Infants with an average HR of ≥165 beats per minute at 90-120 s after birth were at low risk (5%). CONCLUSIONS We present a clinical decision pathway for at-risk infants who may benefit from close observation following DCC. Our findings provide a novel perspective of HR beyond the traditional threshold of 100 beats per minute.
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Affiliation(s)
- Shiraz Badurdeen
- Newborn Research Centre, Royal Women's Hospital, Parkville, Victoria, Australia .,The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | | | - Marta Thio
- Newborn Research Centre, Royal Women's Hospital, Parkville, Victoria, Australia
| | - Alissa Heng
- Monash University Faculty of Medicine, Nursing and Health Sciences, Clayton, Victoria, Australia
| | - Anthony Woodward
- Department of Obstetrics, Royal Women's Hospital Department of Obstetrics and Gynaecology, Melbourne, Victoria, Australia
| | - Graeme R Polglase
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia,Obstetrics and Gynaecology, Monash University Faculty of Medicine, Nursing and Health Sciences, Clayton, Victoria, Australia
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia,Obstetrics and Gynaecology, Monash University Faculty of Medicine, Nursing and Health Sciences, Clayton, Victoria, Australia
| | - Douglas A Blank
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia,Monash Newborn, Monash Health, Clayton, Victoria, Australia
| | - Peter G Davis
- Newborn Research Centre, Royal Women's Hospital, Parkville, Victoria, Australia
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13
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McCarthy KN, Pavel A, Garvey AA, Hawke AL, Levins C, Livingstone V, Dempsey EM. Feasibility of non-invasive cardiac output monitoring at birth using electrical bioreactance in term infants. Arch Dis Child Fetal Neonatal Ed 2021; 106:431-434. [PMID: 33272934 DOI: 10.1136/archdischild-2019-318244] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 11/03/2020] [Accepted: 11/07/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Non-invasive cardiac output monitoring (NICOM) provides continuous estimation of cardiac output. This has potential for use in the delivery suite in the management of acutely depressed term infants. This study aims to measure cardiac output in term infants at delivery and in the first hours of life. METHODS Parents of term infants due to be born by elective caesarean section or vaginal delivery at Cork University Maternity Hospital, Ireland were approached in the antenatal period to participate. Cardiac output was measured using a CHEETAH NICOM device, which uses electrical bioreactance technology, at birth and at 2 hours of life. RESULTS Forty-nine newborns were included. The median gestational age was 39 (IQR: 39-40) weeks and the median birth weight was 3.50 (IQR: 3.14-3.91) kg. Cardiac output measurements were obtained at a median of 8 (IQR: 5-12) min of life. The mean (SD) cardiac output was 101 (24) mL/kg/min in the delivery room and 89 (22) mL/kg/min at 2 hours of life. There was a statistically significant decrease in cardiac output from birth to 2 hours of life (difference in mean (95% CI): 13.5 (9.2 to 17.9) mL/kg/min, p<0.001, n=47). There were no adverse effects associated with NICOM. DISCUSSION This technique is feasible and safe in the delivery room. Mean cardiac output measures using NICOM are lower than those found in studies which used echocardiography to determine cardiac output at birth.
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Affiliation(s)
- Karen Nora McCarthy
- INFANT Research Centre, University College Cork College of Medicine and Health, Cork, Ireland
| | - Andrea Pavel
- INFANT Research Centre, University College Cork College of Medicine and Health, Cork, Ireland
| | - Aisling A Garvey
- INFANT Research Centre, University College Cork College of Medicine and Health, Cork, Ireland
| | - Ana-Louise Hawke
- INFANT Research Centre, University College Cork College of Medicine and Health, Cork, Ireland
| | - Criona Levins
- INFANT Research Centre, University College Cork College of Medicine and Health, Cork, Ireland
| | - Vicki Livingstone
- INFANT Research Centre, University College Cork College of Medicine and Health, Cork, Ireland
| | - Eugene M Dempsey
- INFANT Research Centre, University College Cork College of Medicine and Health, Cork, Ireland.,Department of Paediatrics and Child Health, University College Cork College of Medicine and Health, Cork, Ireland
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14
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Abduljalil K, Pan X, Pansari A, Jamei M, Johnson TN. A Preterm Physiologically Based Pharmacokinetic Model. Part I: Physiological Parameters and Model Building. Clin Pharmacokinet 2021; 59:485-500. [PMID: 31583613 DOI: 10.1007/s40262-019-00825-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Developmental physiology can alter pharmacotherapy in preterm populations. Because of ethical and clinical constraints in studying this vulnerable age group, physiologically based pharmacokinetic models offer a viable alternative approach to predicting drug pharmacokinetics and pharmacodynamics in this population. However, such models require comprehensive information on the changes of anatomical, physiological and biochemical variables, where such data are not available in a single source. OBJECTIVE The objective of this study was to integrate the relevant physiological parameters required to build a physiologically based pharmacokinetic model for the preterm population. METHODS Published information on developmental preterm physiology and some drug-metabolising enzymes were collated and analysed. Equations were generated to describe the changes in parameter values during growth. RESULTS Data on organ size show different growth patterns that were quantified as functions of bodyweight to retain physiological variability and correlation. Protein binding data were quantified as functions of age as the body weight was not reported in the original articles. Ontogeny functions were derived for cytochrome P450 1A2, 3A4 and 2C9. Tissue composition values and how they change with age are limited. CONCLUSIONS Despite the limitations identified in the availability of some tissue composition values, the data presented in this article provide an integrated resource of system parameters needed for building a preterm physiologically based pharmacokinetic model.
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Affiliation(s)
- Khaled Abduljalil
- Simcyp Division Level 2-Acero, Certara UK Limited, 1 Concourse Way, Sheffield, S1 2BJ, UK.
| | - Xian Pan
- Simcyp Division Level 2-Acero, Certara UK Limited, 1 Concourse Way, Sheffield, S1 2BJ, UK
| | - Amita Pansari
- Simcyp Division Level 2-Acero, Certara UK Limited, 1 Concourse Way, Sheffield, S1 2BJ, UK
| | - Masoud Jamei
- Simcyp Division Level 2-Acero, Certara UK Limited, 1 Concourse Way, Sheffield, S1 2BJ, UK
| | - Trevor N Johnson
- Simcyp Division Level 2-Acero, Certara UK Limited, 1 Concourse Way, Sheffield, S1 2BJ, UK
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15
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Baik-Schneditz N, Schwaberger B, Mileder L, Höller N, Avian A, Urlesberger B, Pichler G. Cardiac Output and Cerebral Oxygenation in Term Neonates during Neonatal Transition. CHILDREN-BASEL 2021; 8:children8060439. [PMID: 34073671 PMCID: PMC8224741 DOI: 10.3390/children8060439] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 05/18/2021] [Accepted: 05/19/2021] [Indexed: 11/16/2022]
Abstract
The immediate transition from foetus to neonate includes substantial changes, especially concerning the cardiovascular system. Furthermore, the brain is one of the most vulnerable organs to hypoxia during this period. According to current guidelines for postnatal stabilization, the recommended parameters for monitoring are heart rate (HR) and arterial oxygen saturation (SpO2). Recently, there is a growing interest in advanced monitoring of the cardio-circulatory system and the brain to get further objective information about the neonate’s condition during the immediate postnatal transition after birth. The aim of the present study was to combine cardiac output (CO) and brain oxygenation monitoring in term neonates after caesarean section in order to analyse the potential influence of CO on cerebral oxygenation during neonatal transition. This was a monocentric, prospective, observational study. For non-invasive cardiac output measurements, the electrical velocimetry (EV) method (Aesculon Monitor, Osypka Medical, CA, USA) was used. The pulse oximeter probe for SpO2 and HR measurements was placed on the right hand or wrist. The cerebral tissue oxygen index (cTOI) was measured using a NIRO-200NX monitor with the near-infrared spectroscopy (NIRS) transducer on the right frontoparietal head. Monitoring started at minute 1 and was continued until minute 15 after birth. At minutes 5, 10, and 15 after birth, mean CO was calculated from six 10 s periods (with beat-to-beat analysis). During the study period, 99 term neonates were enrolled. Data from neonates with uncomplicated transitions were analysed. CO showed a tendency to decrease until minute 10. During the complete observational period, there was no significant correlation between CO and cTOI. The present study was the first to investigate a possible correlation between CO and cerebral oxygenation in term infants during the immediate neonatal transition. In term infants with uncomplicated neonatal transition after caesarean section, CO did not correlate with cerebral oxygenation.
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Affiliation(s)
- Nariae Baik-Schneditz
- Division of Neonatology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria; (N.B.-S.); (B.S.); (L.M.); (N.H.); (B.U.)
- Research Unit for Neonatal Micro- and Macrocirculation, Division of Neonatology, 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 Paediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria; (N.B.-S.); (B.S.); (L.M.); (N.H.); (B.U.)
- Research Unit for Neonatal Micro- and Macrocirculation, Division of Neonatology, Medical University of Graz, 8036 Graz, Austria
- Research Unit for Cerebral Development and Oximetry, Division of Neonatology, Medical University of Graz, 8036 Graz, Austria
| | - Lukas Mileder
- Division of Neonatology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria; (N.B.-S.); (B.S.); (L.M.); (N.H.); (B.U.)
- Research Unit for Neonatal Micro- and Macrocirculation, Division of Neonatology, Medical University of Graz, 8036 Graz, Austria
- Research Unit for Cerebral Development and Oximetry, Division of Neonatology, Medical University of Graz, 8036 Graz, Austria
| | - Nina Höller
- Division of Neonatology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria; (N.B.-S.); (B.S.); (L.M.); (N.H.); (B.U.)
- Research Unit for Neonatal Micro- and Macrocirculation, Division of Neonatology, Medical University of Graz, 8036 Graz, Austria
- Research Unit for Cerebral Development and Oximetry, Division of Neonatology, Medical University of Graz, 8036 Graz, Austria
| | - Alexander Avian
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, 8036 Graz, Austria;
| | - Berndt Urlesberger
- Division of Neonatology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria; (N.B.-S.); (B.S.); (L.M.); (N.H.); (B.U.)
- Research Unit for Neonatal Micro- and Macrocirculation, Division of Neonatology, 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 Paediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria; (N.B.-S.); (B.S.); (L.M.); (N.H.); (B.U.)
- Research Unit for Neonatal Micro- and Macrocirculation, Division of Neonatology, Medical University of Graz, 8036 Graz, Austria
- Research Unit for Cerebral Development and Oximetry, Division of Neonatology, Medical University of Graz, 8036 Graz, Austria
- Correspondence: ; Tel.: +43-316-385-80520
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16
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Baik-Schneditz N, Schwaberger B, Mileder L, Höller N, Avian A, Koestenberger M, Urlesberger B, Martensen J, Pichler G. Sex related difference in cardiac output during neonatal transition in term neonates. Cardiovasc Diagn Ther 2021; 11:342-347. [PMID: 33968613 DOI: 10.21037/cdt-20-844] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The immediate transition from foetus to neonate includes substantial changes especially concerning the cardiovascular system. As sex related differences have been shown in cardiovascular medicine, this topic warrants further investigation in neonatology. Aim: The aim of this present study was to measure cardiac output (CO) and cerebral oxygenation (cTOI) non-invasively in term neonates and to investigate potential sex related differences between female and male neonates after birth. Methods This is a mono-centric prospective observational study. For CO-measurements, the electrical velocimetry method was used. The pulse oximetry for arterial oxygen saturation and heart-rate measurements was placed on the right hand or wrist. cTOI was measured using a NIRO 200NX monitor. The near-infrared spectroscopy probe was positioned on the right side of forehead in each infant. Monitoring started at minute 1 and was continued until minute 15 after birth. At minutes 5, 10, and 15 after birth, CO was calculated as an average out of six 10-second periods. Results 99 term neonates were enrolled. In our study population, we could identify 54 female and 45 male neonates. Males had higher cardiac output compared to females throughout the observational period, with a significant difference in minute 15 after birth (217, 95% CI: 203-231 mL/kg/min versus 178, 95% CI: 163-192 mL/kg/min; P<0.001). cTOI, SpO2, and HR did not differ between male and female neonates. Conclusions The present work is the first to investigate sex related differences concerning cardiac output in term neonates during postnatal transition, showing a significantly higher cardiac output in male neonates 15 minutes after birth.
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Affiliation(s)
- Nariae Baik-Schneditz
- Division of Neonatology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Research Unit for Neonatal Micro- and Macrocirculation, Division of Neonatology, Medical University of Graz, Graz, Austria.,Research Unit for Cerebral Development and Oximetry, Division of Neonatology, Medical University of Graz, Graz, Austria
| | - Bernhard Schwaberger
- Division of Neonatology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Research Unit for Neonatal Micro- and Macrocirculation, Division of Neonatology, Medical University of Graz, Graz, Austria.,Research Unit for Cerebral Development and Oximetry, Division of Neonatology, Medical University of Graz, Graz, Austria
| | - Lukas Mileder
- Division of Neonatology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Research Unit for Neonatal Micro- and Macrocirculation, Division of Neonatology, Medical University of Graz, Graz, Austria.,Research Unit for Cerebral Development and Oximetry, Division of Neonatology, Medical University of Graz, Graz, Austria
| | - Nina Höller
- Division of Neonatology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Research Unit for Neonatal Micro- and Macrocirculation, Division of Neonatology, Medical University of Graz, Graz, Austria.,Research Unit for Cerebral Development and Oximetry, Division of Neonatology, Medical University of Graz, Graz, Austria
| | - Alexander Avian
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Martin Koestenberger
- Division of Cardiology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Berndt Urlesberger
- Division of Neonatology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Research Unit for Neonatal Micro- and Macrocirculation, Division of Neonatology, Medical University of Graz, Graz, Austria.,Research Unit for Cerebral Development and Oximetry, Division of Neonatology, Medical University of Graz, Graz, Austria
| | - Johann Martensen
- Division of Neonatology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Research Unit for Neonatal Micro- and Macrocirculation, Division of Neonatology, Medical University of Graz, Graz, Austria.,Research Unit for Cerebral Development and Oximetry, Division of Neonatology, Medical University of Graz, Graz, Austria
| | - Gerhard Pichler
- Division of Neonatology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Research Unit for Neonatal Micro- and Macrocirculation, Division of Neonatology, Medical University of Graz, Graz, Austria.,Research Unit for Cerebral Development and Oximetry, Division of Neonatology, Medical University of Graz, Graz, Austria
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17
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Bruckner M, Katheria AC, Schmölzer GM. Delayed cord clamping in healthy term infants: More harm or good? Semin Fetal Neonatal Med 2021; 26:101221. [PMID: 33653601 DOI: 10.1016/j.siny.2021.101221] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
It is recommended to delay cord clamping in healthy term infants for at least 60- and 180-s in high- and limited-resource environments, as delayed cord clamping lowers the incidence of anemia and iron deficiency and improves neurodevelopment. There are improvements in hemodynamic parameters such as peripheral arterial oxygen saturation, heart rate, cardiac output, and cerebral oxygenation. Historically, delayed cord clamping caused a higher rate of hyperbilirubinemia and phototherapy, but more recent evidence suggests this may no longer be the case. In limited-resource environments delayed cord clamping may reduce anemia and iron deficiency potentially improving neurodevelopmental outcomes. The use of delayed cord clamping in newborn infants with intrauterine growth restriction or monochorionic twins is limited and further evidence is needed before it can be formally recommended.
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Affiliation(s)
- Marlies Bruckner
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada; Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada; Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Anup C Katheria
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, United States.
| | - Georg M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada; Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada; Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
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18
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Defining information needs in neonatal resuscitation with work domain analysis. J Clin Monit Comput 2020; 35:689-710. [PMID: 32458169 DOI: 10.1007/s10877-020-00526-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Accepted: 05/07/2020] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To gain a deeper understanding of the information requirements of clinicians conducting neonatal resuscitation in the first 10 min after birth. BACKGROUND During the resuscitation of a newborn infant in the first minutes after birth, clinicians must monitor crucial physiological adjustments that are relatively unobservable, unpredictable, and highly variable. Clinicians' access to information regarding the physiological status of the infant is also crucial to determining which interventions are most appropriate. To design displays to support clinicians during newborn resuscitation, we must first carefully consider the information requirements. METHODS We conducted a work domain analysis (WDA) for the neonatal transition in the first 10 min after birth. We split the work domain into two 'subdomains'; the physiology of the neonatal transition, and the clinical resources supporting the neonatal transition. A WDA can reveal information requirements that are not yet supported by resources. RESULTS The physiological WDA acted as a conceptual tool to model the exact processes and functions that clinicians must monitor and potentially support during the neonatal transition. Importantly, the clinical resources WDA revealed several capabilities and limitations of the physical objects in the work domain-ultimately revealing which physiological functions currently have no existing sensor to provide clinicians with information regarding their status. CONCLUSION We propose two potential approaches to improving the clinician's information environment: (1) developing new sensors for the information we lack, and (2) employing principles of ecological interface design to present currently available information to the clinician in a more effective way.
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19
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Han T, Liu H, Zhang H, Guo M, Zhang X, Duan Y, Sun F, Liu X, Zhang X, Zhang M, Liu F, Bao L, Xiao M, Liu W, Jiang R, Zheng J, Tian X, Gao Q, Zhang W, Guo W, Li L, Tong X. Minimally Invasive Surfactant Administration for the Treatment of Neonatal Respiratory Distress Syndrome: A Multicenter Randomized Study in China. Front Pediatr 2020; 8:182. [PMID: 32457854 PMCID: PMC7221055 DOI: 10.3389/fped.2020.00182] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 03/30/2020] [Indexed: 11/13/2022] Open
Abstract
Background/Aims: Nasal continuous positive airway pressure (nCPAP) was recommended as the initial respiratory support for spontaneous breathing in infants with very low birth weight and neonatal respiratory distress syndrome (NRDS). Less invasive surfactant administration (LISA) and minimally invasive surfactant therapy (MIST) have been reported to reduce the incidence of bronchopulmonary dysplasia (BPD). This study aimed to explore the applicability of minimally invasive surfactant administration (MISA) in China. Materials and Methods: MISA was a randomized controlled study conducted at eight level III neonatal intensive care units (NICUs) in China. Spontaneously breathing infants born at 25+0 to 31+6 weeks' gestation who progressively developed respiratory distress during the first 6 h after birth were randomly assigned to receive MISA or endotracheal intubation surfactant administration (EISA). The primary outcome was the difference in the morbidity of BPD between two groups of infants with MISA and EISA at 36 weeks corrected gestational age. Results: Demographic and clinical characteristics of the 151 infants in the MISA group were similar to the 147 infants in the EISA group. The comparison showed no clear benefits in the MISA group in the incidence of BPD, while infants from the EISA group had higher rates of patent ductus arteriosus (PDA) (60.5 vs. 41.1%, p = 0.001). The duration of surfactant infusion and the total time of surfactant administration in the MISA group were significantly longer than in the EISA group. A slightly increased heart rate was noted 1 h post surfactant administration in the EISA group. In subgroup analysis, the comparison of 51 smaller (<30 weeks) preterm infants, named MISAs (n = 31) and EISAs (n = 20), showed a significant reduction of BPD (29.0 vs. 70.0%, p = 0.004) and PDA (29.0 vs. 65.0%, p = 0.011). In the subgroup analysis of blood gas, arterial oxygen saturation (SaO2) value at 1 and 12 h and partial pressure of arterial oxygen (PaO2) at 12 h were all higher in the EISA group compared to the MISA group. Conclusion: MISA had no clear benefit on the incidence of BPD, but it was related to a reduction in PDA. It is an appropriate therapy for spontaneous breathing in infants with extremely low birth weight and NRDS.
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Affiliation(s)
- Tongyan Han
- Department of Pediatrics, Peking University Third Hospital, Beijing, China
| | - Huiqiang Liu
- Department of Pediatrics, Peking University Third Hospital, Beijing, China
| | - Hui Zhang
- Department of Pediatrics, Peking University Third Hospital, Beijing, China
| | - Ming Guo
- Department of Neonatology, Fifth Medical Center, General Hospital of the Chinese People's Liberation Army, Beijing, China
| | - Xuefeng Zhang
- Department of Neonatology, Fifth Medical Center, General Hospital of the Chinese People's Liberation Army, Beijing, China
| | - Yang Duan
- Department of Neonatology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Fuqiang Sun
- Department of Neonatology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Xinjian Liu
- Department of Neonatology, Hebei PetroChina Central Hospital, Langfang, China
| | - Xiang Zhang
- Department of Neonatology, Hebei PetroChina Central Hospital, Langfang, China
| | - Mingtao Zhang
- Department of Neonatology, Hebei PetroChina Central Hospital, Langfang, China
| | - Fang Liu
- Department of Neonatology, Bethune International Peace Hospital, Shijiazhuang, China
| | - Lisha Bao
- Department of Neonatology, Bethune International Peace Hospital, Shijiazhuang, China
| | - Min Xiao
- Department of Neonatology, Cangzhou Central Hospital of Hebei Province, Cangzhou, China
| | - Weili Liu
- Department of Neonatology, Cangzhou Central Hospital of Hebei Province, Cangzhou, China
| | - Rui Jiang
- Department of Neonatology, Cangzhou Central Hospital of Hebei Province, Cangzhou, China
| | - Jun Zheng
- Department of Neonatology, Tianjin Central Hospital of Obstetrics and Gynecology, Tianjing, China
| | - Xiuying Tian
- Department of Neonatology, Tianjin Central Hospital of Obstetrics and Gynecology, Tianjing, China
| | - Qi Gao
- Department of Neonatology, Tianjin Central Hospital of Obstetrics and Gynecology, Tianjing, China
| | - Wanxian Zhang
- Department of Neonatology, Tianjin Central Hospital of Obstetrics and Gynecology, Tianjing, China
| | - Wei Guo
- Department of Neonatology, Xingtai People's Hospital, Xingtai, China
| | - Ling Li
- Department of Neonatology, Xingtai People's Hospital, Xingtai, China
| | - Xiaomei Tong
- Department of Pediatrics, Peking University Third Hospital, Beijing, China
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20
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O'Neill R, Dempsey EM, Garvey AA, Schwarz CE. Non-invasive Cardiac Output Monitoring in Neonates. Front Pediatr 2020; 8:614585. [PMID: 33585366 PMCID: PMC7880199 DOI: 10.3389/fped.2020.614585] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 12/15/2020] [Indexed: 12/19/2022] Open
Abstract
Circulatory monitoring is currently limited to heart rate and blood pressure assessment in the majority of neonatal units globally. Non-invasive cardiac output monitoring (NiCO) in term and preterm neonates is increasing, where it has the potential to enhance our understanding and management of overall circulatory status. In this narrative review, we summarized 33 studies including almost 2,000 term and preterm neonates. The majority of studies evaluated interchangeability with echocardiography. Studies were performed in various clinical settings including the delivery room, patent ductus arteriosus assessment, patient positioning, red blood cell transfusion, and therapeutic hypothermia for hypoxic ischemic encephalopathy. This review presents an overview of NiCO in neonatal care, focusing on technical and practical aspects as well as current available evidence. We discuss potential goals for future research.
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Affiliation(s)
- Roisin O'Neill
- Department of Neonatology, Cork University Maternity Hospital, Cork, Ireland.,Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Eugene M Dempsey
- Department of Neonatology, Cork University Maternity Hospital, Cork, Ireland.,Department of Paediatrics and Child Health, University College Cork, Cork, Ireland.,Irish Centre for Maternal and Child Health Research (INFANT) Research Centre, University College Cork, Cork, Ireland
| | - Aisling A Garvey
- Department of Neonatology, Cork University Maternity Hospital, Cork, Ireland.,Department of Paediatrics and Child Health, University College Cork, Cork, Ireland.,Irish Centre for Maternal and Child Health Research (INFANT) Research Centre, University College Cork, Cork, Ireland
| | - Christoph E Schwarz
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland.,Irish Centre for Maternal and Child Health Research (INFANT) Research Centre, University College Cork, Cork, Ireland.,Department of Neonatology, University Children's Hospital, Tübingen, Germany
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21
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Johnson PA, Morina N, O'Reilly M, Lee TF, Cheung PY, Schmölzer GM. Evaluation of a Tap-Based Smartphone App for Heart Rate Assessment During Asphyxia in a Porcine Model of Neonatal Resuscitation. Front Pediatr 2019; 7:453. [PMID: 31750281 PMCID: PMC6848456 DOI: 10.3389/fped.2019.00453] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 10/18/2019] [Indexed: 02/01/2023] Open
Abstract
Objectives: Heart rate (HR) is the most significant parameter to assess a newborn's clinical status at birth. Recently, novel technologies including smartphone applications have been suggested for HR assessment during neonatal resuscitation. The aim of this study was to evaluate the accuracy, speed, and precision of the NeoTapLifeSupport (NeoTapLS) smartphone application using a digital stethoscope (DS) for HR assessment during neonatal resuscitation. Design: Newborn piglets (n = 20, 1-3 days, 1.7-2.4 kg) were anesthetized, intubated, mechanically ventilated, and subjected to 30 min of hypoxia, followed by asphyxia. Asphyxia was induced by clamping the endotracheal tube and disconnecting the ventilator, until asystole was confirmed by zero carotid blood flow (CBF). Setting: Experimental setting. Subjects: Asphyxia-induced newborn piglets. Interventions: During asphyxia, HR assessments were performed with a DS using the NeoTapLS smartphone application, and compared to 6-s method (6 s), and 10-s method (10 s). Measurements and Main Results: Accuracy of obtained HRs was compared to CBF and electrocardiogram and assessment time using NeoTapLS, 6 s, and 10 s were also measured. The mean(SD) HR with the NeoTapLS was 68(26), compared to CBF with 68(27) bpm, 6 s with 68(27), and 10 s with 66(26) bpm during asphyxia. Bland-Altman analysis revealed no difference between HR using the NeoTapLS, 6 s, 10 s, compared to CBF HR, with NeoTapLS showing the smallest difference between 95% limits of agreement. The median (IQR) time required to obtain a HR using the NeoTapLS was 3(2-4) s, compared to 6(6-7), and 10(10-11) s for 6 and 10 s, respectively. Conclusions: Our data suggests that the NeoTapLS is accurate, fast, and precise during neonatal asphyxia to assess heart rate.
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Affiliation(s)
- Peter A. Johnson
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Nicolò Morina
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Megan O'Reilly
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Tze-Fun Lee
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Po-Yin Cheung
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Georg M. Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
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22
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Hooper SB, Te Pas AB, Polglase GR, Wyckoff M. Animal models in neonatal resuscitation research: What can they teach us? Semin Fetal Neonatal Med 2018; 23:300-305. [PMID: 30001819 DOI: 10.1016/j.siny.2018.07.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Animal models have made and continue to make important contributions to neonatal medicine. For example, studies in fetal sheep have taught us much about the physiology of the fetal-to-neonatal transition. However, whereas animal models allow multiple factors to be investigated in a logical and systematic manner, no animal model is perfect for humans and so we need to understand the fundamental differences in physiology between the species in question and humans. Although most physiological systems are well conserved between species, some small differences exist and so wherever possible the knowledge generated from preclinical studies in animals should be tested in clinical trials. However, with the rise of evidence-based medicine the distinction between scientific knowledge generation and evidence gathering has been confused and the two have been lumped together. This misunderstands the contribution that scientific knowledge can provide. Science should be used to guide the gathering of evidence by informing the design of clinical trials, thereby increasing their likelihood of success. While scientific knowledge is not evidence, in the absence of evidence it is likely to be the best option for guiding clinical practice.
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Affiliation(s)
- Stuart B Hooper
- The Ritchie Centre, Hudson Institute for Medical Research, Melbourne, Australia; Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia.
| | - Arjan B Te Pas
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Centre, Leiden, the Netherlands
| | - Graeme R Polglase
- The Ritchie Centre, Hudson Institute for Medical Research, Melbourne, Australia; Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia
| | - Myra Wyckoff
- Department of Pediatrics, Neonatal and Perinatal Medicine, University of Texas, South Western Medical Center, Dallas, TX, USA
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23
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Abstract
The transition from intrauterine to extrauterine life represents a critical phase of physiological adaptation which impacts many organ systems, most notably the heart and the lungs. The majority of term neonates complete this transition without complications; however, dysregulation of normal postnatal adaptation may lead to acute cardiopulmonary instability, necessitating advanced intensive care support. Although not as well appreciated as changes in vascular resistances, the shunt across the DA plays a crucial physiologic role in the adaptive processes related to normal transitional circulation. Further, we describe key differences in the behavior of the ductal shunt during transition in preterm neonates and we postulate mechanisms through which the DA may modulate major hemodynamic complications during this vulnerable period. Finally, we describe the conditions in which preservation of ductal patency is a desired clinical goal and we discuss clinical factors that may determine adequate balance between pulmonary and systemic circulation.
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24
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Iglesias B, Rodrí Guez MAJ, Aleo E, Criado E, Martí Nez-Orgado J, Arruza L. 3-lead electrocardiogram is more reliable than pulse oximetry to detect bradycardia during stabilisation at birth of very preterm infants. Arch Dis Child Fetal Neonatal Ed 2018; 103:F233-F237. [PMID: 28667190 DOI: 10.1136/archdischild-2016-311492] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 05/22/2017] [Accepted: 06/02/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Current neonatal resuscitation guidelines suggest the use of ECG in the delivery room (DR) to assess heart rate (HR). However, reliability of ECG compared with pulse oximetry (PO) in a situation of bradycardia has not been specifically investigated. The objective of the present study was to compare HR monitoring using ECG or PO in a situation of bradycardia (HR <100 beats per minute (bpm)) during preterm stabilisation in the DR. STUDY DESIGN Video recordings of resuscitations of infants <32 weeks of gestation were reviewed. HR readings in a situation of bradycardia (<100 bpm) at any moment during stabilisation were registered with both devices every 5 s from birth. RESULTS A total of 29 episodes of bradycardia registered by the ECG in 39 video recordings were included in the analysis (n=29). PO did not detect the start of these events in 20 cases (69%). PO detected the start and the end of bradycardia later than the ECG (median (IQR): 5 s (0-10) and 5 s (0-7.5), respectively). A decline in PO accuracy was observed as bradycardia progressed so that by the end of the episode PO offered significantly lower HR readings than ECG. CONCLUSIONS PO detects the start and recovery of bradycardia events slower and less accurately than ECG during stabilisation at birth of very preterm infants. ECG use in this scenario may contribute to an earlier initiation of resuscitation manoeuvres and to avoid unnecessary prolongation of resuscitation efforts after recovery.
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Affiliation(s)
- Beatriz Iglesias
- Division of Neonatology, Instituto del Niño y del Adolescente, Madrid, Spain
| | | | - Esther Aleo
- Division of Neonatology, Instituto del Niño y del Adolescente, Madrid, Spain
| | - Enrique Criado
- Division of Neonatology, Instituto del Niño y del Adolescente, Madrid, Spain
| | | | - Luis Arruza
- Division of Neonatology, Instituto del Niño y del Adolescente, Madrid, Spain
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25
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Vrancken SL, van Heijst AF, de Boode WP. Neonatal Hemodynamics: From Developmental Physiology to Comprehensive Monitoring. Front Pediatr 2018; 6:87. [PMID: 29675404 PMCID: PMC5895966 DOI: 10.3389/fped.2018.00087] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 03/19/2018] [Indexed: 12/16/2022] Open
Abstract
Maintenance of neonatal circulatory homeostasis is a real challenge, due to the complex physiology during postnatal transition and the inherent immaturity of the cardiovascular system and other relevant organs. It is known that abnormal cardiovascular function during the neonatal period is associated with increased risk of severe morbidity and mortality. Understanding the functional and structural characteristics of the neonatal circulation is, therefore, essential, as therapeutic hemodynamic interventions should be based on the assumed underlying (patho)physiology. The clinical assessment of systemic blood flow (SBF) by indirect parameters, such as blood pressure, capillary refill time, heart rate, urine output, and central-peripheral temperature difference is inaccurate. As blood pressure is no surrogate for SBF, information on cardiac output and systemic vascular resistance should be obtained in combination with an evaluation of end organ perfusion. Accurate and reliable hemodynamic monitoring systems are required to detect inadequate tissue perfusion and oxygenation at an early stage before this result in irreversible damage. Also, the hemodynamic response to the initiated treatment should be re-evaluated regularly as changes in cardiovascular function can occur quickly. New insights in the understanding of neonatal cardiovascular physiology are reviewed and several methods for current and future neonatal hemodynamic monitoring are discussed.
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Affiliation(s)
- Sabine L Vrancken
- Department of Perinatology (Neonatology), Amalia Children's Hospital, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Arno F van Heijst
- Department of Perinatology (Neonatology), Amalia Children's Hospital, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Willem P de Boode
- Department of Perinatology (Neonatology), Amalia Children's Hospital, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
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26
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Abstract
The management of the hemodynamic status of critically ill preterm infants, particularly around the periviable period, remains a significant challenge in the neonatal intensive care unit for a multitude of reasons. The causes of hemodynamic compromise in this population are heterogeneous and usually superimposed on the complex physiologic processes that occur during transition from fetal to neonatal life. This review outlines the unique nature of low blood flow states in this population and present an overview of the current methods for identification and assessment of hemodynamic compromise.
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Affiliation(s)
- Afif El-Khuffash
- Department of Neonatology, The Rotunda Hospital, Parnell Square, Dublin 1, DO1 P5W9, Ireland; Department of Paediatrics, School of Medicine, Royal College of Surgeons in Ireland, 123 St Stephen's Green, Dublin 2, Ireland
| | - Patrick J McNamara
- Division of Neonatology, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, Ontario MG5 1X8, Canada.
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27
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Safarulla A. A review of benefits of cord milking over delayed cord clamping in the preterm infant and future directions of research. J Matern Fetal Neonatal Med 2017; 30:2966-2973. [DOI: 10.1080/14767058.2016.1269319] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Azif Safarulla
- Department of Pediatrics, Augusta University, Augusta, GA, USA
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28
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Finn D, Roehr CC, Ryan CA, Dempsey EM. Optimising Intravenous Volume Resuscitation of the Newborn in the Delivery Room: Practical Considerations and Gaps in Knowledge. Neonatology 2017; 112:163-171. [PMID: 28571020 DOI: 10.1159/000475456] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 04/03/2017] [Indexed: 01/14/2023]
Abstract
Volume resuscitation (VR) for the treatment of newborn shock is a rare but potentially lifesaving intervention. Conducting clinical studies to assess the effectiveness of VR in the delivery room during newborn stabilization is challenging. We review the available literature and current management guidelines to determine which infants will benefit from VR, the frequency of VR, and the choice of agents used. In addition, the potential role for placental transfusion in the prevention of newborn shock is explored.
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Affiliation(s)
- Daragh Finn
- Department of Paediatrics and Child Health, Cork University Maternity Hospital and University College Cork, Cork, Ireland
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29
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Freidl T, Baik N, Pichler G, Schwaberger B, Zingerle B, Avian A, Urlesberger B. Haemodynamic Transition after Birth: A New Tool for Non-Invasive Cardiac Output Monitoring. Neonatology 2017; 111:55-60. [PMID: 27529179 DOI: 10.1159/000446468] [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: 01/20/2016] [Accepted: 04/26/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Substantial haemodynamic changes occur during the first minutes after birth. Currently, only heart rate (HR) and arterial oxygen saturation are routinely used to monitor haemodynamic transition after birth. OBJECTIVES The aim of the present study was to continuously assess haemodynamic changes during transition in term infants for the first time by using electrical velocimetry (EV), a new method of non-invasive cardiac output monitoring (NICOM), based on impedance cardiography technology. METHODS In this prospective observational study, term neonates delivered by elective caesarean section underwent NICOM measurements within the first 15 min after birth. The beat-to-beat measurement over a 10-second period was used to calculate cardiac output (CO) for each minute after birth. The data of CO were only accepted when the signal quality index (SQI) remained >80% during the measurement period of 10 s. RESULTS 100 term neonates underwent 1,500 NICOM measurements. 1,143 (76.2%) measurements were excluded because of a SQI <80%. HR and CO showed a trend to increase within the first minutes, and decreased significantly from minute 3 (HR) and 4 (CO), until minute 12 and 10, respectively. Stroke volume remained stable during the observation period. CONCLUSION The present study was the first using EV for NICOM during the transition period in a larger cohort of newborn infants. Results of NICOM were similar to available echocardiography data. The possibility of NICOM offers continuous CO measurement. The present study supports the idea that CO is closely related to HR in newborn infants.
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Affiliation(s)
- Thomas Freidl
- Division of Neonatology, Department of Pediatrics, Medical University of Graz, Graz, Austria
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30
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van Vonderen JJ, Roest AA, Klumper FJ, Hooper SB, te Pas AB. The effect of breathing on ductus arteriosus blood flow directly after birth. Eur J Pediatr 2017; 176:1581-1585. [PMID: 28879564 PMCID: PMC5682873 DOI: 10.1007/s00431-017-2994-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 03/29/2017] [Accepted: 08/09/2017] [Indexed: 11/25/2022]
Abstract
UNLABELLED Spontaneous breathing at birth influences ductus arteriosus (DA) flow. This study quantifies the effect of breathing on DA shunting directly after birth. In healthy term infants born by elective cesarean section, simultaneous measurements of DA shunting and tidal volumes during spontaneous breathing were performed at 2-5, 5-8, and 10-13 min after birth. Eight infants with a mean (SD) gestational age of 40 (1) weeks and 3216 (616) grams were studied. Inspiratory tidal volume was 5.8 (3.3-7.7), 5.7 (4.0-7.1), and 5.2 (4.3-6.1) mL/kg at 2-5, 5-8, and 10-13 min. The velocity time integral of left-to-right shunting significantly increased during inspiration when compared to expiration (8.4 (5.2) vs. 3.7 (2.3) cm, 8.9 (4.4) vs. 5.6 (3.4) cm, and 14.0 (6.7) vs. 8.4 (6.9) cm; all p < 0.0001) at 2-5, 5-8, and 10-13 min, respectively. In contrast, right-to-left shunting was not different between inspiration and expiration at 2-5 and 10-13 min (11.1 (2.4) vs. 11.1 (2.6) cm and 10.7 (2.3) vs. 10.6 (3.0) cm; p > 0.05), but there was a small increase at 5-8 min (12.1 (2.4) vs. 10.8 (2.9) cm; p = 0.001) during expiration. CONCLUSION Directly after birth, ductal shunting is influenced by breathing effort, predominantly with an increase in left-to-right shunt due to inspiration. What is Known: • Spontaneous breathing at birth influences ductus arteriosus flow and pulmonary blood flow. • Crying causes a significant increase in left-to-right ductus arteriosus shunting. What is New: • Left-to-right ductus arteriosus shunting increases during inspiration compared to expiration. • Breathing is important for ductal shunting and contributes to pulmonary blood flow.
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Affiliation(s)
- Jeroen J. van Vonderen
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, J6-S, PO Box 9600, 2300 RC Leiden, the Netherlands
| | - Arno A.W. Roest
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Frans J.C. Klumper
- Department of Gynecology and Obstetrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Stuart B. Hooper
- The Ritchie Centre, MIMR-PHI, Monash University, Clayton, Victoria Australia
| | - Arjan B. te Pas
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, J6-S, PO Box 9600, 2300 RC Leiden, the Netherlands
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31
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Baik N, Urlesberger B, Schwaberger B, Schmölzer GM, Köstenberger M, Avian A, Pichler G. Foramen ovale (FO) - The underestimated sibling of ductus arteriosus (DA): Relevance during neonatal transition. Early Hum Dev 2016; 103:137-140. [PMID: 27648971 DOI: 10.1016/j.earlhumdev.2016.08.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 07/11/2016] [Accepted: 08/24/2016] [Indexed: 11/18/2022]
Affiliation(s)
- Nariae Baik
- Division of Neonatology, Department of Paediatrics, Medical University of Graz, Austria; Research Unit for Neonatal Micro- and Macrocirculation, Department of Paediatrics, Medical University of Graz, Austria
| | - Berndt Urlesberger
- Division of Neonatology, Department of Paediatrics, Medical University of Graz, Austria; Research Unit for Neonatal Micro- and Macrocirculation, Department of Paediatrics, Medical University of Graz, Austria
| | - Bernhard Schwaberger
- Division of Neonatology, Department of Paediatrics, Medical University of Graz, Austria; Research Unit for Neonatal Micro- and Macrocirculation, Department of Paediatrics, Medical University of Graz, Austria
| | - Georg M Schmölzer
- Division of Neonatology, Department of Paediatrics, Medical University of Graz, Austria; Department of Pediatrics, University of Alberta, Edmonton, Canada; Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Canada
| | - Martin Köstenberger
- Division of pediatric Cardiology, Department of Paediatrics, Medical University of Graz, Austria
| | - Alexander Avian
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Austria
| | - Gerhard Pichler
- Division of Neonatology, Department of Paediatrics, Medical University of Graz, Austria; Research Unit for Neonatal Micro- and Macrocirculation, Department of Paediatrics, Medical University of Graz, Austria; Department of Pediatrics, University of Alberta, Edmonton, Canada; Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Canada.
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32
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Perfusion index assessment during transition period of newborns: an observational study. BMC Pediatr 2016; 16:164. [PMID: 27717357 PMCID: PMC5054614 DOI: 10.1186/s12887-016-0701-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 09/27/2016] [Indexed: 11/21/2022] Open
Abstract
Background Perfusion index (PI) is becoming a part of clinical practice in neonatology to monitor peripheral perfusion noninvasively. Hemodynamic and respiratory changes occur in newborns during the transition period after birth in which peripheral perfusion may be affected. Tachypnea is a frequent symptom during this period. While some tachypneic newborns get well in less than 6 h and diagnosed as “delayed transition”, others get admitted to intensive care unit which transient tachypnea of newborn (TTN) being the most common diagnosis among them. We aimed to compare PI of neonates with TTN and delayed transition with controls, and assess its value on discrimination of delayed transition and TTN. Methods Neonates with gestational age between 37 and 40 weeks who were born with elective caesarian section were included. Eligible neonates were monitored with Masimo Set Radical7 pulse-oximeter (Masimo Corp., Irvine, CA, USA). Postductal PI, oxygen saturation and heart rate were manually recorded every 10 s for 3 min for two defined time periods as 10th minute and 1st hour. Axillary temperature were also recorded. Newborn infants were grouped as control, delayed transition, and TTN. Results Forty-nine tachypneic (TTN; 21, delayed transition; 28) and 30 healthy neonates completed the study. PI values were similar between three groups at both periods. There were no correlation between PI and respiratory rate, heart rate, and temperature. Conclusion PI assessment in maternity unit does not discriminate TTN from delayed transitional period in newborns which may indicate that peripheral perfusion is not severely affected in either condition.
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33
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Hooper SB, Binder-Heschl C, Polglase GR, Gill AW, Kluckow M, Wallace EM, Blank D, Te Pas AB. The timing of umbilical cord clamping at birth: physiological considerations. Matern Health Neonatol Perinatol 2016; 2:4. [PMID: 27298730 PMCID: PMC4904360 DOI: 10.1186/s40748-016-0032-y] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 06/10/2016] [Indexed: 11/10/2022] Open
Abstract
While it is now recognized that umbilical cord clamping (UCC) at birth is not necessarily an innocuous act, there is still much confusion concerning the potential benefits and harms of this common procedure. It is most commonly assumed that delaying UCC will automatically result in a time-dependent net placental-to-infant blood transfusion, irrespective of the infant's physiological state. Whether or not this occurs, will likely depend on the infant's physiological state and not on the amount of time that has elapsed between birth and umbilical cord clamping (UCC). However, we believe that this is an overly simplistic view of what can occur during delayed UCC and ignores the benefits associated with maintaining the infant's venous return and cardiac output during transition. Recent experimental evidence and observations in humans have provided compelling evidence to demonstrate that time is not a major factor influencing placental-to-infant blood transfusion after birth. Indeed, there are many factors that influence blood flow in the umbilical vessels after birth, which depending on the dominating factors could potentially result in infant-to-placental blood transfusion. The most dominant factors that influence umbilical artery and venous blood flows after birth are lung aeration, spontaneous inspirations, crying and uterine contractions. It is still not entirely clear whether gravity differentially alters umbilical artery and venous flows, although the available data suggests that its influence, if present, is minimal. While there is much support for delaying UCC at birth, much of the debate has focused on a time-based approach, which we believe is misguided. While a time-based approach is much easier and convenient for the caregiver, ignoring the infant's physiology during delayed UCC can potentially be counter-productive for the infant.
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Affiliation(s)
- Stuart B Hooper
- The Ritchie Centre, Hudson Institute for Medical Research, Melbourne, Australia ; Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia
| | | | - Graeme R Polglase
- The Ritchie Centre, Hudson Institute for Medical Research, Melbourne, Australia ; Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia
| | - Andrew W Gill
- Centre for Neonatal Research and Education, The University of Western Australia, Crawley, WA 6008 Australia
| | - Martin Kluckow
- Department of Neonatology, Royal North Shore Hospital and University of Sydney, Sydney, NSW 2065 Australia
| | - Euan M Wallace
- The Ritchie Centre, Hudson Institute for Medical Research, Melbourne, Australia ; Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia
| | - Douglas Blank
- The Ritchie Centre, Hudson Institute for Medical Research, Melbourne, Australia ; Neonatal Services, The Royal Women's Hospital, Melbourne, Australia
| | - Arjan B Te Pas
- Department of Neonatology, Leiden University Medical Centre, Leiden, The Netherlands
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34
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Kroese JK, van Vonderen JJ, Narayen IC, Walther FJ, Hooper S, te Pas AB. The perfusion index of healthy term infants during transition at birth. Eur J Pediatr 2016; 175:475-9. [PMID: 26498646 PMCID: PMC4799258 DOI: 10.1007/s00431-015-2650-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Revised: 10/02/2015] [Accepted: 10/05/2015] [Indexed: 11/27/2022]
Abstract
UNLABELLED Perfusion index is a continuous parameter provided by pulse oximetry and might be useful for evaluating hemodynamic changes at birth and identifying transitional problems. The objective was to describe perfusion index values in term infants immediately after birth. Perfusion index of 71 healthy term born infants were recorded during the first 10 min after birth, using a pulse oximetry sensor placed preductally. A Wilcoxon signed-rank test was used to compare between time points. No significant trend in perfusion index could be observed in term-delivered infants. There was a significant difference between 2 and 3 min (2.4 (1.6-5.0) vs. 2.3 (1.6-3.7), p = 0.05) and between 3 and 4 min after birth (2.3 (1.6-3.7) vs. 2.1 (1.4-3.2), p < 0.001). There was no significant change in median PI values in the following 8 min. CONCLUSION Perfusion index does not change significantly during transition at birth in healthy term infants born by normal vaginal delivery or cesarean section. Large variation in perfusion index causes monitoring this parameter to have limited value. WHAT IS KNOWN • Perfusion index is a non-invasive indicator for peripheral perfusion. • Perfusion index values <1.24 are seen as an accurate predictor for severity of illness for infants admitted to the neonatal intensive care unit. What is new: • Although significant physiological changes occur during birth, perfusion index remains stable. • Large variation in perfusion index causes monitoring of this value to have limited value as an additional parameter for evaluating transition at birth.
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Affiliation(s)
- Jacco K. Kroese
- />Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, J6-S, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - Jeroen J. van Vonderen
- />Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, J6-S, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - Ilona C. Narayen
- />Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, J6-S, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - Frans J. Walther
- />Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, J6-S, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - Stuart Hooper
- />MIMR-PHI Institute for Medical Research, Monash University, Clayton, Victoria Australia
| | - Arjan B. te Pas
- />Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, J6-S, PO Box 9600, 2300 RC Leiden, The Netherlands
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Finn D, Boylan GB, Ryan CA, Dempsey EM. Enhanced Monitoring of the Preterm Infant during Stabilization in the Delivery Room. Front Pediatr 2016; 4:30. [PMID: 27066463 PMCID: PMC4814766 DOI: 10.3389/fped.2016.00030] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 03/18/2016] [Indexed: 11/13/2022] Open
Abstract
Monitoring of preterm infants in the delivery room (DR) remains limited. Current guidelines suggest that pulse oximetry should be available for all preterm infant deliveries, and that if intubated a colorimetric carbon dioxide detector should provide verification of correct endotracheal tube placement. These two methods of assessment represent the extent of objective monitoring of the newborn commonly performed in the DR. Monitoring non-invasive ventilation effectiveness (either by capnography or respiratory function monitoring) and cerebral oxygenation (near-infrared spectroscopy) is becoming more common within research settings. In this article, we will review the different modalities available for cardiorespiratory and neuromonitoring in the DR and assess the current evidence base on their feasibility, strengths, and limitations during preterm stabilization.
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Affiliation(s)
- Daragh Finn
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland; Irish Centre for Fetal and Neonatal Translational Research, University College Cork, Cork, Ireland
| | - Geraldine B Boylan
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland; Irish Centre for Fetal and Neonatal Translational Research, University College Cork, Cork, Ireland
| | - C Anthony Ryan
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland; Irish Centre for Fetal and Neonatal Translational Research, University College Cork, Cork, Ireland
| | - Eugene M Dempsey
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland; Irish Centre for Fetal and Neonatal Translational Research, University College Cork, Cork, Ireland
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van Vonderen JJ, van Zanten HA, Schilleman K, Hooper SB, Kitchen MJ, Witlox RSGM, Te Pas AB. Cardiorespiratory Monitoring during Neonatal Resuscitation for Direct Feedback and Audit. Front Pediatr 2016; 4:38. [PMID: 27148507 PMCID: PMC4834521 DOI: 10.3389/fped.2016.00038] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 04/04/2016] [Indexed: 12/02/2022] Open
Abstract
Neonatal resuscitation is one of the most frequently performed procedures, and it is often successful if the ventilation applied is adequate. Over the last decade, interest in seeking objectivity in evaluating the infant's condition at birth or the adequacy and effect of the interventions applied has markedly increased. Clinical parameters such as heart rate, color, and chest excursions are difficult to interpret and can be very subjective and subtle. The use of ECG, pulse oximetry, capnography, and respiratory function monitoring can add objectivity to the clinical assessment. These physiological parameters, with or without the combination of video recordings, can not only be used directly to guide care but also be used later for audit and teaching purposes. Further studies are needed to investigate whether this will improve the quality of delivery room management. In this narrative review, we will give an update of the current developments in monitoring neonatal resuscitation.
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Affiliation(s)
- Jeroen J van Vonderen
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center , Leiden , Netherlands
| | - Henriëtte A van Zanten
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center , Leiden , Netherlands
| | - Kim Schilleman
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center , Leiden , Netherlands
| | - Stuart B Hooper
- Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia; Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Marcus J Kitchen
- School of Physics and Astronomy, Monash University , Melbourne, VIC , Australia
| | - Ruben S G M Witlox
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center , Leiden , Netherlands
| | - Arjan B Te Pas
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center , Leiden , Netherlands
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Niermeyer S. A physiologic approach to cord clamping: Clinical issues. Matern Health Neonatol Perinatol 2015; 1:21. [PMID: 27057338 PMCID: PMC4823683 DOI: 10.1186/s40748-015-0022-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 08/20/2015] [Indexed: 11/15/2022] Open
Abstract
Background Recent experimental physiology data and a large, population-based observational study have changed umbilical cord clamping from a strictly time-based construct to a more complex equilibrium involving circulatory changes and the onset of respirations in the newly born infant. However, available evidence is not yet sufficient to optimize the management of umbilical cord clamping. Findings Current guidelines vary in their recommendations and lack advice for clinicians who face practical dilemmas in the delivery room. This review examines the evidence around physiological outcomes of delayed cord clamping and cord milking vs. immediate cord clamping. Gaps in the existing evidence are highlighted, including the optimal time to clamp the cord and the interventions that should be performed before clamping in infants who fail to establish spontaneous respirations or are severely asphyxiated, as well as those who breathe spontaneously. Conclusion Behavioral and technological changes informed by further research are needed to promote adoption and safe practice of physiologic cord clamping.
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Affiliation(s)
- Susan Niermeyer
- Section of Neonatology, University of Colorado School of Medicine, 13121 E. 17th Avenue, Mail Stop 8402, Aurora, CO 80045 USA
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Abstract
Immediate clamping and cutting of the umbilical cord at birth has been the accepted standard of care for decades. The physiologic rationale relating umbilical cord clamping (UCC) to the events of the circulatory transition is not considered in arbitrarily recommended cord clamping times. Systematic review of early versus deferred UCC shows significant hemodynamic benefits to the deferred group. Mechanisms for this protective effect are considered in this review. The original concept of a placental transfusion with a volume load and prevention of low cardiac output relies on the physiological end point of the amount of blood transfused. The newer concept of an ordered physiological transition is increasingly supported. This model places aeration of the lungs and an increase in pulmonary blood flow back at the centre of the circulatory transition with timing of UCC being related to establishment of respiration. The need for "physiologically based" UCC is discussed.
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Affiliation(s)
- Martin Kluckow
- University of Sydney and Royal North Shore Hospital, Sydney, Australia.
| | - Stuart B Hooper
- The Ritchie Centre, MIMR-PHI Institute for Medical Research, Monash University, Melbourne, Australia
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Hemodynamic antecedents of peri/intraventricular hemorrhage in very preterm neonates. Semin Fetal Neonatal Med 2015; 20:232-7. [PMID: 25818879 DOI: 10.1016/j.siny.2015.02.004] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Novel hemodynamic monitoring technologies have contributed to the understanding of developmental cardiovascular physiology and pathophysiology in general, and of developmental hemodynamics in particular. Hemodynamic disturbances play a significant role in the pathogenesis of peri/intraventricular hemorrhage (P/IVH) in preterm infants. Immaturity of the myocardium, delayed and incomplete cardiopulmonary transition, sustained patency of the ductus arteriosus, and unintended consequences of respiratory and cardiovascular supportive care are all likely to be involved in the presentation of low cardiac output syndrome and decreased organ blood flow in a large number of very preterm neonates (gestational age ≤28 weeks). Forebrain vessels in very preterm infants may not have achieved a "high-priority vasculature" status at the time of delivery; in these patients, forebrain perfusion is not protected during the compensated phase of shock. Reperfusion may be attenuated by the careful use of medications decreasing cerebrovascular reactivity, thus providing a potential target for the development of careful pharmacological support of transitional hemodynamics in selected patients at high risk for the development of P/IVH.
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40
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Hooper SB, Polglase GR, te Pas AB. A physiological approach to the timing of umbilical cord clamping at birth. Arch Dis Child Fetal Neonatal Ed 2015; 100:F355-60. [PMID: 25540147 DOI: 10.1136/archdischild-2013-305703] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Accepted: 12/01/2014] [Indexed: 11/03/2022]
Abstract
Umbilical cord clamping at birth has a major impact on an infant's cardiovascular system that varies in significance depending upon whether the infant has commenced breathing. As umbilical venous return is a major source of preload for the left ventricle during fetal life, recent experimental evidence has shown that clamping the umbilical cord severely limits cardiac venous return in the absence of pulmonary ventilation. As a result, cardiac output greatly reduces and remains low until breathing commences. Once the infant begins breathing, aeration of the lung triggers a large increase in pulmonary blood flow, which replaces umbilical venous return as the source of preload for the left ventricle. As a result, cardiac output markedly increases, as indicated by an increase in heart rate immediately after birth. Thus, infants born apnoeic and hypoxic and have their cords immediately clamped, are likely to have a restricted cardiac output combined with hypoxia. As increased cardiac output is a major physiological defence mechanism that counteracts the effects of hypoxaemia, limiting the increase in cardiac output exposes the infant to ischaemia along with hypoxia. However, if the infant commences breathing, aerates its lungs and increases pulmonary blood flow before the umbilical cord is clamped, then pulmonary venous return can immediately take over the supply of left ventricular preload upon cord clamping. As a result, there is no intervening period of reduced preload and cardiac output and the large swings in arterial pressures and flows are reduced leading to a more stable circulatory transition.
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Affiliation(s)
- Stuart B Hooper
- Ritchie Centre, MIMR-PHI Institute of Medical Research, Monash University, Melbourne, Victoria, Australia Department of Obstetrics & Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Graeme R Polglase
- Ritchie Centre, MIMR-PHI Institute of Medical Research, Monash University, Melbourne, Victoria, Australia Department of Obstetrics & Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Arjan B te Pas
- Department of Pediatrics, Leiden University Medical Centre, Leiden, the Netherlands
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van Vonderen JJ, Te Pas AB. The first breaths of life: imaging studies of the human infant during neonatal transition. Paediatr Respir Rev 2015; 16:143-6. [PMID: 25962858 DOI: 10.1016/j.prrv.2015.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Accepted: 03/12/2015] [Indexed: 11/26/2022]
Abstract
The neonatal transition during birth is characterized by major physiological changes in respiratory and hemodynamic function, which are predominantly initiated by labor, lung aeration and clamping of the umbilical cord. Lung liquid clearance and lung aeration are not only important for the establishment of functional residual capacity, but these events also trigger the significant decrease in pulmonary vascular resistance and increase in pulmonary blood flow. Clamping the umbilical cord also contributes to these hemodynamic changes by increasing the systemic vascular resistance and sudden loss of a large proportion of venous return. This results in blood flow changes both through the foramen ovale and ductus arteriosus and eventually leads to closure of these structures and the separation of the pulmonary and systemic circulations. Most of the early theories describing neonatal transition are based on imaging studies of human infants from the 1900s. Some of these theories have been disproven in more recent studies using more accurate and non-invasive imaging techniques. This review will provide an overview of the theories suggested to explain the process of liquid clearance and lung recruitment and also addresses new findings in this field of research.
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Affiliation(s)
- Jeroen J van Vonderen
- Division of neonatology, department of pediatrics, Leiden University Medical Center, Leiden, The Netherlands.
| | - Arjan B Te Pas
- Division of neonatology, department of pediatrics, Leiden University Medical Center, Leiden, The Netherlands
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Measuring cardiac changes using electrical impedance during delayed cord clamping: a feasibility trial. Matern Health Neonatol Perinatol 2015; 1:15. [PMID: 27057332 PMCID: PMC4823677 DOI: 10.1186/s40748-015-0016-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 04/27/2015] [Indexed: 12/29/2022] Open
Abstract
Background To date no study has attempted to continuously evaluate changes in hemodynamics during delayed cord clamping in humans. We aimed to demonstrate 1. the feasibility of measurements of hemodynamics during delayed cord clamping and 2. to describe the changes that occur over each minute. Results After vaginal delivery, term infants (370-416 weeks) were placed on a Life Start® bed 10–20 cm below the placenta. Transcutaneous sensors were placed on the neck and chest to determine heart rate, stroke volume and cardiac output at each beat. Once a signal was obtained, first 5 values (taken every beat) were averaged and the percent change for each subject from baseline was calculated. 20 infants were enrolled and all had a reliable signal obtained from transcutaneous sensors and had a delay in cord clamping for about 5 minutes. Cardiac output increased from 2 to 5 minutes of life (p = 0.008). For every minute of life the cord was kept unclamped, the stroke volume increased 13.1% ± 12.3 (p = 0.0001) and cardiac output increased 12.6% ± 6.3 from baseline (p < 0.0001). While the majority of infants continued to have an increase in cardiac output at 5 minutes of life, 7/20 infants reached their peak cardiac output at 188 ± 41 seconds of life. Conclusions This study demonstrates that hemodynamic measures could be successfully obtained during the first five minutes of birth and while a newborn was receiving delayed cord clamping. This study also provides reference values for changes in cardiac output and stroke volume in well term infants during delayed cord clamping. Trial registration Clinical Trials.gov NCT02195037 Registered 17 July 2014
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van Vonderen JJ, Hooper SB, Kroese JK, Roest AAW, Narayen IC, van Zwet EW, te Pas AB. Pulse oximetry measures a lower heart rate at birth compared with electrocardiography. J Pediatr 2015; 166:49-53. [PMID: 25444526 DOI: 10.1016/j.jpeds.2014.09.015] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Revised: 08/19/2014] [Accepted: 09/08/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To examine the effect of time after birth on heart rate (HR) measured by pulse oximetry (PO) (HRPO) and electrocardiography (ECG) (HRECG). STUDY DESIGN HRECG and HRPO (collected at maximum sensitivity) were assessed in 53 term and preterm infants at birth. ECG electrodes and a PO sensor were attached as soon as possible and HRECG and HRPO were compared every 30 seconds from 1-10 minutes after birth. Data were compared using a Wilkinson signed-rank test. Clinical relevance (eg, HR <100 beats per minute [bpm] was tested using a McNemar test). RESULTS Seven hundred fifty-five data pairs were analyzed. Median (IQR) gestational age was 37 (31-39) weeks. Mean (SD) starting time of PO and ECG data collection was 99 (33) vs 82 (26) seconds after birth (P = .001). In the first 2 minutes after birth, HRPO was significantly lower compared with HRECG (94 (67-144) vs 150 (91-153) bpm at 60 seconds (P < .05), 81 (60-109) vs 148 (83-170) bpm at 90 seconds (P < .001) and 83 (67-145) vs 158 (119-176) at 120 seconds (P < .001). A HR <100 bpm was more frequently observed with a PO than ECG in the first 2 minutes (64% vs 27% at 60 seconds (P = .05), 56% vs 26% at 90 seconds (P < .05) and 53% vs 21% at 120 seconds (P < .05). HR by ECG was verified by ultrasound for outflow from a subset of infants. CONCLUSIONS In infants at birth, HRPO is significantly lower compared with ECG with clinically important differences in the first minutes.
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Affiliation(s)
- Jeroen J van Vonderen
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands.
| | - Stuart B Hooper
- The Ritchie Center, Monash Institute for Medical Research, Monash University, Melbourne, Australia
| | - Jacco K Kroese
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Arno A W Roest
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Ilona C Narayen
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Erik W van Zwet
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, The Netherlands
| | - Arjan B te Pas
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
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Baik N, Urlesberger B, Schwaberger B, Freidl T, Schmölzer GM, Pichler G. Cardiocirculatory monitoring during immediate fetal-to-neonatal transition: a systematic qualitative review of the literature. Neonatology 2015; 107:100-7. [PMID: 25412794 DOI: 10.1159/000368042] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Accepted: 09/02/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND The fetal-to-neonatal transition is a complex process that includes changes in cardiac and respiratory systems. OBJECTIVE The aim of this study is to review the different methods of cardiocirculatory monitoring during the immediate neonatal transition period. METHODS A systematic search of PubMed and Ovid Embase was performed using the following terms: infant, newborn, newborn infant, neonate, neonates, heart, cardiac, blood pressure, haemodynamic, hemodynamics, blood circulation, circulation, echocardiography, ultrasonography, sonography, electrocardiography, ECG, oximetry, pulse, pulse oximetry, monitoring, measurement, acclimatization, adaptation, transition, after birth and delivery room. Additional articles were identified by manual search of cited references. Only human studies describing cardiocirculatory monitoring during the first 15 min after birth were included. RESULTS Thirteen studies were identified that described heart rate (HR). Additional five studies were identified that measured blood pressure. Four studies performed functional echocardiography during neonatal transition; two in addition to blood pressure monitoring and three in addition to HR monitoring. CONCLUSION Routine HR monitoring using electrocardiography or pulse oximetry is used to evaluate adequate hemodynamic transition, and reference ranges have been established. Measuring blood pressure noninvasively though noncontinuously might be of some value in future, considering that the normative data have been established recently. Echocardiographic monitoring during the immediate transition period will improve the knowledge about cardiac function changes, but introduction in clinical routine remains questionable.
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Affiliation(s)
- Nariae Baik
- Division of Neonatology, Medical University, Graz, Austria
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van Vonderen JJ, Roest AAW, Walther FJ, Blom NA, van Lith JMM, Hooper SB, te Pas AB. The influence of crying on the ductus arteriosus shunt and left ventricular output at birth. Neonatology 2015; 107:108-12. [PMID: 25471487 DOI: 10.1159/000368880] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 10/02/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND During neonatal transition, ductus arteriosus (DA) flow changes from right-to-left to left-to-right and contributes considerably to the increase in pulmonary blood flow. Large transpulmonary pressures generated by crying at birth can influence the DA shunt. OBJECTIVE This study aimed to assess differences in DA shunt during quiet breathing and crying directly after birth. METHODS In healthy term infants born by caesarean section, echocardiography was performed at 2, 5 and 10 min after birth. The velocity time integral of DA flow, DA flow ratio (right-to-left/left-to-right flow) and left ventricular output were assessed using echocardiography. Shunting was compared within each patient during crying and quiet breathing, and between time points. RESULTS A total of 23 infants were studied. The velocity time integral of left-to-right shunting was significantly larger during the inspiratory phase of crying than during quiet breathing [12.8 (9.2-17.4) vs. 5.9 (3.9-7.7) cm at 2 min, p < 0.0001; 14.3 (11.5-22.3) vs. 6.7 (4.1-11.1) cm at 5 min, p < 0.0001, and 18.6 (14.8-22.5) vs. 6.7 (4.4-10.7) cm at 10 min, p < 0.0001, after birth]. The increase in left-to-right shunting during crying was independent from the cardiac cycle as the QRS start of shunt interval time was 138 (82) ms during crying and 156 (35) ms during quiet breathing (n.s.). The DA flow ratio was lower in infants who cried at 0-1 time points versus those who cried at 2-3 time points (n.s.) out of the 3 time points measured. Left ventricular output was higher in infants who cried at 2-3 time points versus 0-1 time points (n.s.). CONCLUSION Crying at birth significantly influences the DA shunt during transition.
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Affiliation(s)
- Jeroen J van Vonderen
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
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van Vonderen JJ, te Pas AB, Kolster-Bijdevaate C, van Lith JM, Blom NA, Hooper SB, Roest AAW. Non-invasive measurements of ductus arteriosus flow directly after birth. Arch Dis Child Fetal Neonatal Ed 2014; 99:F408-12. [PMID: 24966129 DOI: 10.1136/archdischild-2014-306033] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To assess ductus arteriosus (DA) blood flow directly after birth in healthy term infants after elective caesarean section. DESIGN In healthy term newborns, echocardiography was performed at 2, 5 and 10 min after birth to monitor cardiac output and DA blood flow. Heart rate (HR) was assessed using ECG. SETTING The delivery rooms of the Leiden University Medical Center. PATIENTS 24 healthy term infants born after a caesarean section were included in this study. RESULTS Mean (SD) HR did not change (158 (18) beats per minute (bpm), 5 min (159 (23) bpm) and 10 min (156 (19) bpm). DA diameter decreased from 5.2 (1.3) mm at 2 min to 4.6 (1.3) mm at 5 min (p=0.01) to (3.9 (1.2) mm) (p=0.01) at 10 min. Right-to-left DA shunting was unaltered (median (IQR) 95 (64-154) mL/kg/min to 90 (56-168) mL/kg/min and 80 (64-120) mL/kg/min, respectively (ns)), whereas left-to-right shunting significantly increased between 2 and 5 min (41 (31-70) mL/kg/min vs 67 (37-102) mL/kg/min (p=0.01)) and increased significantly between 2 and 10 min (93 (67-125)) mL/kg/min (p<0.001). Right-to-left/left-to-right shunting ratio decreased significantly from 2.1 (1.4-3.1) at 2 min to 1.4 (1.0-1.8) at 5 min (p<0.0001) and to 0.9 (0.6-1.1) at 10 min (p<0.0001). CONCLUSIONS DA shunting changes swiftly from predominantly right-to-left shunting to predominantly left-to-right shunting at 10 min after birth, reflecting differential changes in pulmonary and systemic vascular resistance.
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Affiliation(s)
- Jeroen J van Vonderen
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Arjan B te Pas
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Clara Kolster-Bijdevaate
- Department of Gynaecology and Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Jan M van Lith
- Department of Gynaecology and Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Nico A Blom
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Stuart B Hooper
- The Ritchie Centre, Monash Institute for Medical Research, Monash University, Clayton, Victoria, Australia
| | - Arno A W Roest
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
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Bhatt S, Polglase GR, Wallace EM, Te Pas AB, Hooper SB. Ventilation before Umbilical Cord Clamping Improves the Physiological Transition at Birth. Front Pediatr 2014; 2:113. [PMID: 25368858 PMCID: PMC4203108 DOI: 10.3389/fped.2014.00113] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Accepted: 10/03/2014] [Indexed: 12/02/2022] Open
Abstract
The transition from a fetus to a neonate at birth represents a critical phase in our life. Most infants make this transition without complications, but preterm infants usually require some form of assistance due to immature cardiopulmonary systems that predispose them to lifelong sequelae. As the incidence of preterm birth is increasing, there is now an urgent need for the development of management strategies that facilitate this transition, which will likely include improved strategies for the management of the maternal third stage of labor. For instance, recent studies on the physiological transition at birth have led to the discovery that establishing ventilation in the infant before the umbilical cord is clamped greatly stabilizes the cardiovascular transition at birth. While most benefits of delayed clamping previously have been attributed to an increase in placenta to infant blood transfusion, clearly there are other significant benefits for the infant, which are not well understood. Nevertheless, if ventilation can be established before cord clamping in a preterm infant, the large adverse changes in cardiac function that normally accompanies umbilical cord clamping can be avoided. As preterm infants have an immature cerebral vascular bed, large swings in cardiovascular function places them at high risk of cerebral vascular rupture and the associated increased risk of mortality and morbidity. In view of the impact that cord clamping has on the cardiovascular transition at birth, it is also time to re-examine some of the strategies used in the management of the third stage of labor. These include the appropriate timing of uterotonic administration in relation to delivery of the infant and placenta. As there is a lack of evidence on the effects these individual practices have on the infant, there is a necessity to improve our understanding of their impact in order to develop strategies that facilitate the transition to newborn life.
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Affiliation(s)
- Sasmira Bhatt
- The Ritchie Centre, MIMR-PHI Institute of Medical Research, Monash University , Melbourne, VIC , Australia ; Department of Obstetrics and Gynaecology, Monash University , Melbourne, VIC , Australia
| | - Graeme R Polglase
- The Ritchie Centre, MIMR-PHI Institute of Medical Research, Monash University , Melbourne, VIC , Australia ; Department of Obstetrics and Gynaecology, Monash University , Melbourne, VIC , Australia
| | - Euan M Wallace
- The Ritchie Centre, MIMR-PHI Institute of Medical Research, Monash University , Melbourne, VIC , Australia ; Department of Obstetrics and Gynaecology, Monash University , Melbourne, VIC , Australia
| | - Arjan B Te Pas
- Department of Pediatrics, Leiden University Medical Centre , Leiden , Netherlands
| | - Stuart B Hooper
- The Ritchie Centre, MIMR-PHI Institute of Medical Research, Monash University , Melbourne, VIC , Australia ; Department of Obstetrics and Gynaecology, Monash University , Melbourne, VIC , Australia
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