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Arriaga-Redondo M, Rodríguez-Sánchez de la Blanca A, Zunzunegui JL, Ballesteros-Tejerizo F, Rodríguez-Ogando A, González-Navarro P, Blanco-Bravo D, Sánchez-Luna M. Impact of catheterized ductal closure on renal and cerebral oximetry in premature neonates. Eur J Pediatr 2024; 183:2753-2761. [PMID: 38558310 DOI: 10.1007/s00431-024-05541-3] [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: 01/15/2024] [Revised: 03/21/2024] [Accepted: 03/24/2024] [Indexed: 04/04/2024]
Abstract
Percutaneous catheter-based closure is increasingly utilized in premature newborns. While near-infrared spectroscopy (NIRS) has been examined for assessment of interventional closure in surgical ligation, its application in percutaneous transcatheter closure remains unexplored. This study aims to assess cerebral and renal hemodynamic changes using NIRS during percutaneous closure compared to surgical closure in preterm infants. A prospective observational study enrolled preterm infants born at 32 weeks of gestation or less and diagnosed with hsPDA between January 2020 and December 2022. These infants received either surgical or catheter-based closure of the PDA. Cerebral and renal oxygen saturation was monitored using the INVOS 5100 device from 12 h before the intervention until 24 h after. Linear mixed-effects models were used to analyze time-dependent variables. Twenty-two patients were enrolled, with catheter-based closure performed in 16 cases and conventional surgery in 6 cases. Following ductal closure, a significant increase in renal and cerebral oximetry was observed alongside a decrease in renal and cerebral tissue oxygen extraction. These changes were particularly pronounced in the renal territory. No differences were detected between catheterization and surgical closure. Conclusion: An improvement in cerebral and renal oximetry following hsPDA closure was observed. However, we did not identify differences in this pattern based on the type of interventional procedure for PDA, whether surgery or catheterization. What is Known: • The presence of a significant ductus is common in premature patients. Studies have shown that it affects cerebral and renal hemodynamics negatively, leading to decreased oximetry values in these areas. It has been reported that closure of the ductus, either pharmacologically or surgically, results in improved oximetry values. What is New: • This study assess the impact of percutaneous closure of ductus, revealing increased oximetry values in cerebral and renal territories without significant differences compared to surgical ligation. Notably, renal oximetry values showed a greater increase, underscoring the importance of multi-location monitoring.
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Affiliation(s)
- María Arriaga-Redondo
- Neonatology Department, Gregorio Marañón University Hospital (HGU), C/Maiquez 9, Madrid, 28009, Spain.
| | | | - José Luis Zunzunegui
- Pediatric Cardiology Department, Gregorio Marañón University Hospital, Madrid, Spain
| | | | | | - Pablo González-Navarro
- Unidad de Investigación Materno Infantil-Fundación Familia Alonso (UDIMIFFA)-Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - Dorita Blanco-Bravo
- Neonatology Department, Gregorio Marañón University Hospital (HGU), C/Maiquez 9, Madrid, 28009, Spain
| | - Manuel Sánchez-Luna
- Neonatology Department, Gregorio Marañón University Hospital (HGU), C/Maiquez 9, Madrid, 28009, Spain
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2
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De Rose DU, Lapillonne A, Iacobelli S, Capolupo I, Dotta A, Salvatori G. Nutritional Strategies for Preterm Neonates and Preterm Neonates Undergoing Surgery: New Insights for Practice and Wrong Beliefs to Uproot. Nutrients 2024; 16:1719. [PMID: 38892652 PMCID: PMC11174646 DOI: 10.3390/nu16111719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Revised: 05/22/2024] [Accepted: 05/30/2024] [Indexed: 06/21/2024] Open
Abstract
The nutrition of preterm infants remains contaminated by wrong beliefs that reflect inexactitudes and perpetuate old practices. In this narrative review, we report current evidence in preterm neonates and in preterm neonates undergoing surgery. Convictions that necrotizing enterocolitis is reduced by the delay in introducing enteral feeding, a slow advancement in enteral feeds, and the systematic control of residual gastric volumes, should be abandoned. On the contrary, these practices prolong the time to reach full enteral feeding. The length of parenteral nutrition should be as short as possible to reduce the infectious risk. Intrauterine growth restriction, hemodynamic and respiratory instability, and patent ductus arteriosus should be considered in advancing enteral feeds, but they must not translate into prolonged fasting, which can be equally dangerous. Clinicians should also keep in mind the risk of refeeding syndrome in case of high amino acid intake and inadequate electrolyte supply, closely monitoring them. Conversely, when preterm infants undergo surgery, nutritional strategies are still based on retrospective studies and opinions rather than on randomized controlled trials. Finally, this review also highlights how the use of adequately fortified human milk is strongly recommended, as it offers unique benefits for immune and gastrointestinal health and neurodevelopmental outcomes.
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Affiliation(s)
- Domenico Umberto De Rose
- Neonatal Intensive Care Unit, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (I.C.); (A.D.); (G.S.)
- PhD Course in Microbiology, Immunology, Infectious Diseases, and Transplants (MIMIT), Faculty of Medicine and Surgery, “Tor Vergata” University of Rome, 00133 Rome, Italy
| | - Alexandre Lapillonne
- Department of Neonatology, APHP, Necker-Enfants Malades University Hospital, EHU 7328 Paris Cite University Paris, 75015 Paris, France;
- Children’s Nutrition Research Center, Baylor College of Medicine, Houston, TX 77024, USA
| | - Silvia Iacobelli
- Réanimation Néonatale et Pédiatrique, Centre Hospitalier Universitaire Saint-Pierre, BP 350, 97448 Saint Pierre CEDEX, France;
- Centre d’Études Périnatales de l’Océan Indien (UR 7388), Université de La Réunion, BP 350, 97448 Saint Pierre CEDEX, France
| | - Irma Capolupo
- Neonatal Intensive Care Unit, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (I.C.); (A.D.); (G.S.)
| | - Andrea Dotta
- Neonatal Intensive Care Unit, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (I.C.); (A.D.); (G.S.)
| | - Guglielmo Salvatori
- Neonatal Intensive Care Unit, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (I.C.); (A.D.); (G.S.)
- Donor Human Milk Bank, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy
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3
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Rose LA, Frymoyer A, Bhombal S, Chock VY. Renal Oxygen Saturations and Acute Kidney Injury in the Preterm Infant with Patent Ductus Arteriosus. Am J Perinatol 2024; 41:e2606-e2612. [PMID: 37459881 DOI: 10.1055/a-2130-2269] [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: 08/11/2023]
Abstract
OBJECTIVE Decreased near-infrared spectroscopy (NIRS) measures of renal oxygen saturation (Rsat) have identified preterm infants with a hemodynamically significant patent ductus arteriosus (hsPDA). NIRS may further identify infants at risk for acute kidney injury (AKI) in a population with concern for hsPDA. STUDY DESIGN Review of infants ≤29 weeks' gestation undergoing NIRS and echocardiography due to concern for hsPDA. The hsPDA was defined by two of the following: moderate-large size, left to right shunt, aortic flow reversal, left atrial enlargement. AKI was defined by neonatal modified Kidney Disease Improving Global Outcomes (KDIGO). Rsat and cerebral saturation (Csat), averaged over 1 hour, were evaluated for the 24-hour period around echocardiography. RESULTS Among 77 infants, 29 (38%) had AKI by neonatal modified KDIGO criteria. hsPDA was found on echocardiography in 59 (77%). There were no differences in hsPDA in infants with and without AKI (p = 0.1). Rsat was not associated with AKI (p = 0.3). Infants on dopamine had less Rsat variability (p < 0.01). CONCLUSION Rsat prior to echocardiography did not discriminate AKI in this cohort of preterm infants at risk for hsPDA; however, data may not capture optimal timing of Rsat measurement before AKI. KEY POINTS · No Rsat value was found to be associated with the development of AKI.. · The optimal timing of Rsat measurement should be evaluated in infants at risk for hsPDA.. · NIRS bedside monitoring of Csat and Rsat measures may be useful in trending perfusion patterns.. · Identification of those at high risk for AKI may allow for more careful kidney function monitoring..
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Affiliation(s)
- Laura A Rose
- Division of Neonatology, University of California San Diego School of Medicine, La Jolla, California
| | - Adam Frymoyer
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, California
| | - Shazia Bhombal
- Division of Neonatology, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Valerie Y Chock
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, California
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4
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Marin T, Moore J. Understanding Near-Infrared Spectroscopy: An Update. Crit Care Nurs Clin North Am 2024; 36:41-50. [PMID: 38296375 DOI: 10.1016/j.cnc.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Near-infrared spectroscopy (NIRS) is a novel technology that uses infrared light to noninvasively and continuously measure regional oxygen extraction in real time at the bedside. Neonatal research using this device supports its use as an adjunct to routine cardiovascular monitoring because NIRS serves as a surrogate marker for end-organ perfusion and can detect minute changes in cerebral, intestinal, and kidney tissue beds. Multiple conditions affecting premature infants are frequently associated with hypoperfusion; therefore, methods to detect early tissue-specific perfusion alterations may substantially improve the clinician's ability to intervene and prevent further deterioration.
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Affiliation(s)
- Terri Marin
- Department of Nursing Science, Augusta University, College of Nursing, 1120 15th Street, EC-4350, Augusta, GA 30912, USA.
| | - James Moore
- Department of Pediatrics, Division of Neonatology, University of Connecticut School of Medicine, 10 Columbus Boulevard, Hartford, CT 06106, USA
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5
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Surak A, Sidhu A, Ting JY. Should we "eliminate" PDA shunt in preterm infants? A narrative review. Front Pediatr 2024; 12:1257694. [PMID: 38379909 PMCID: PMC10876852 DOI: 10.3389/fped.2024.1257694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 01/24/2024] [Indexed: 02/22/2024] Open
Abstract
The patent ductus arteriosus frequently poses a significant morbidity in preterm infants, subjecting their immature pulmonary vascular bed to substantial volume overload. This, in turn, results in concurrent hypoperfusion to post-ductal organs, and subsequently alters cerebral blood flow. In addition, treatment has not demonstrated definitive improvements in patient outcomes. Currently, the optimal approach remains a subject of considerable debate with ongoing research controversy regarding the best approach. This article provides a comprehensive review of existing literature.
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Affiliation(s)
- Aimann Surak
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Amneet Sidhu
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Joseph Y. Ting
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
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6
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Arslan U, Kavrut Ozturk N, Kavakli AS, Dagdelen HO. Comparison of the Effects of Anaesthesia Methods Used in Caesarean Delivery on Neonatal Cerebral and Renal Oxygenation: A Randomised Controlled Trial. J Clin Med 2024; 13:873. [PMID: 38337566 PMCID: PMC10856314 DOI: 10.3390/jcm13030873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 01/26/2024] [Accepted: 01/30/2024] [Indexed: 02/12/2024] Open
Abstract
Background: During a newborn's adaptation to extrauterine life, many changes take place that are influenced by various factors. The type of delivery and anaesthesia strategy utilised during labour can modify these adaptive modifications. In this regard, this study was designed to compare the effects of general and spinal anaesthesia on cerebral and renal oxygenation after elective caesarean deliveries. Methods: This randomised controlled study comprised sixty parturient women who were over 18 years old and had a gestational age between 37 and 41 weeks. All participants had an ASA (American Society of Anesthesiologists) classification of II. Neonatal cerebral (CrSO2) and renal (RrSO2) regional oxygen saturations were assessed using near-infrared spectroscopy. Additionally, the 1st-5th min Apgar scores, preductal and postductal peripheral oxygen saturation (SpO2), and perfusion index were recorded in both the general anaesthesia and spinal anaesthesia groups. Results: There was no statistically significant difference between the two groups in terms of CrSO2 or RrSO2 values. The values of CrSO2 and RrSO2 in both groups showed a significant rise from the 10th to the 15th min, respectively. Conclusions: General and spinal anaesthesia techniques used for cesarean delivery have similar effects on neonatal cerebral and renal oxygenation.
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Affiliation(s)
- Ulku Arslan
- Department of Anesthesiology and Reanimation, University of Health Sciences, Antalya Training and Research Hospital, 07100 Antalya, Turkey; (N.K.O.); (H.O.D.)
| | - Nilgun Kavrut Ozturk
- Department of Anesthesiology and Reanimation, University of Health Sciences, Antalya Training and Research Hospital, 07100 Antalya, Turkey; (N.K.O.); (H.O.D.)
| | - Ali Sait Kavakli
- Department of Anesthesiology and Reanimation, Istinye University Faculty of Medicine, 34010 Istanbul, Turkey;
| | - Hatice Ozge Dagdelen
- Department of Anesthesiology and Reanimation, University of Health Sciences, Antalya Training and Research Hospital, 07100 Antalya, Turkey; (N.K.O.); (H.O.D.)
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7
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Qin X, Chen X, Zhao X, Yao L, Li B, Pan G, Xu J, Jiang R, Zhao Z, Liang Z, Guo X, Huang J, Li X. Evaluation of brain function in adult patent ductus arteriosus surgery: A multimodal monitoring approach. Curr Probl Cardiol 2024; 49:102334. [PMID: 38142948 DOI: 10.1016/j.cpcardiol.2023.102334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 12/04/2023] [Accepted: 12/12/2023] [Indexed: 12/26/2023]
Abstract
Adult patent ductus arteriosus (PDA) repair surgery often involves hypothermic cardiopulmonary bypass (CPB) and is associated with postoperative neurological complications. Our study evaluates brain function during PDA surgery using regional cerebral oxygen saturation (rSO2) and bispectral index (BIS) monitoring to mitigate these complications. Patients were categorized into moderate (26-31 ℃) and mild (32-35 ℃) hypothermia groups. Findings indicate a positive correlation between PDA diameter and pulmonary artery systolic blood pressure, and a strong correlation between delirium and average rSO2-AUC. The mild hypothermia group had longer extubation and hospitalization times. During CPB, rSO2 levels fluctuated significantly, and EEG analysis revealed changes in brain wave patterns. One case of nerve injury in the mild hypothermia group showed incomplete recovery after a year. Our results advocate for moderate hypothermia during CPB in adult PDA repair, suggesting that combined rSO2 and BIS monitoring can reduce neurological complications post-surgery.
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Affiliation(s)
- Xuewei Qin
- Department of Anesthesiology, Peking University International Hospital, Beijing 102206, China
| | - Xuanling Chen
- Department of Anesthesiology, Peking University International Hospital, Beijing 102206, China
| | - Xin Zhao
- Department of Anesthesiology, Peking University International Hospital, Beijing 102206, China
| | - Lan Yao
- Department of Anesthesiology, Peking University International Hospital, Beijing 102206, China.
| | - Bin Li
- Department of Cardiac Surgery, Peking University International Hospital, Beijing 102206, China
| | - Guangyu Pan
- Department of Cardiac Surgery, Peking University International Hospital, Beijing 102206, China
| | - Jianping Xu
- Department of Cardiac Surgery, Peking University International Hospital, Beijing 102206, China; Department of Cardiac Surgery, National Center for Cardiovascular Diseases and Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Rui Jiang
- Department of Cardiac Surgery, National Center for Cardiovascular Diseases and Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | | | | | - Xiangyang Guo
- Department of Anesthesiology, Peking University Third Hospital, Beijing 100191, China
| | - Jiapeng Huang
- Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY 40202, USA
| | - Xiaoli Li
- The State Key Laboratory of Cognitive Neuroscience and Learning & IDG/McGovern Institute for Brain Research, Beijing Normal University, Beijing 100875, China
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8
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Bailey SM, Mally PV. Near-Infrared Spectroscopy to Guide and Understand Effects of Red Blood Cell Transfusion. Clin Perinatol 2023; 50:895-910. [PMID: 37866855 DOI: 10.1016/j.clp.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
This review is a summary of available evidence regarding the use of near-infrared spectroscopy (NIRS) to help better guide and understand the effects of red blood cell (RBC) transfusion in neonatal patients. We review recent literature demonstrating the changes that take place in regional tissue oxygen saturation (rSO2) resulting from RBC transfusion. We also discuss in detail if any correlation exists between rSO2 and hemoglobin values in neonates. Finally, we review studies that have evaluated the use of NIRS as a transfusion guide during neonatal intensive care.
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Affiliation(s)
- Sean M Bailey
- Division of Neonatology, Department of Pediatrics, NYU Grossman School of Medicine, Hassenfeld Children's Hospital NYU Langone, 317 East 34th Street, Suite 902, New York, NY 10016, USA.
| | - Pradeep V Mally
- Division of Neonatology, Department of Pediatrics, NYU Grossman School of Medicine, Hassenfeld Children's Hospital NYU Langone, 317 East 34th Street, Suite 902, New York, NY 10016, USA
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9
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Chock VY, Van Meurs KP. Editorial: Advances in the use of neuromonitoring in newborns. Front Pediatr 2023; 11:1215991. [PMID: 37284291 PMCID: PMC10240396 DOI: 10.3389/fped.2023.1215991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 05/04/2023] [Indexed: 06/08/2023] Open
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10
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Chock VY, Bhombal S, Variane GFT, Van Meurs KP, Benitz WE. Ductus arteriosus and the preterm brain. Arch Dis Child Fetal Neonatal Ed 2023; 108:96-101. [PMID: 35732482 DOI: 10.1136/archdischild-2022-324111] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 06/08/2022] [Indexed: 11/03/2022]
Abstract
As the approach to the patent ductus arteriosus (PDA) in the preterm infant remains controversial, the potential consequences of a significant ductal shunt on the brain should be evaluated. In this population at high risk of adverse outcomes, including intraventricular haemorrhage and white matter injury, as well as longer-term neurodevelopmental impairment, it is challenging to attribute sequelae to the PDA. Moreover, individual patient characteristics including gestational age and timing of PDA intervention factor into risks of brain injury. Haemodynamic assessment of the ductus combined with bedside neuromonitoring techniques improve our understanding of the role of the PDA in neurological injury. Effects of various PDA management strategies on the brain can similarly be investigated. This review incorporates current understanding of how the PDA impacts the developing brain of preterm infants and examines modalities to measure these effects.
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Affiliation(s)
- Valerie Y Chock
- Pediatrics, Division of Neonatology, Stanford University School of Medicine, Stanford, California, USA
| | - Shazia Bhombal
- Pediatrics, Division of Neonatology, Stanford University School of Medicine, Stanford, California, USA
| | - Gabriel F T Variane
- Pediatrics, Division of Neonatology, Irmandade da Santa Casa de Misericordia de Sao Paulo, Sao Paulo, Brazil
| | - Krisa P Van Meurs
- Pediatrics, Division of Neonatology, Stanford University School of Medicine, Stanford, California, USA
| | - William E Benitz
- Pediatrics, Division of Neonatology, Stanford University School of Medicine, Stanford, California, USA
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11
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Walker SB, Badke CM, Carroll MS, Honegger KS, Fawcett A, Weese-Mayer DE, Sanchez-Pinto LN. Novel approaches to capturing and using continuous cardiorespiratory physiological data in hospitalized children. Pediatr Res 2023; 93:396-404. [PMID: 36329224 DOI: 10.1038/s41390-022-02359-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 08/16/2022] [Accepted: 10/11/2022] [Indexed: 11/06/2022]
Abstract
Continuous cardiorespiratory physiological monitoring is a cornerstone of care in hospitalized children. The data generated by monitoring devices coupled with machine learning could transform the way we provide care. This scoping review summarizes existing evidence on novel approaches to continuous cardiorespiratory monitoring in hospitalized children. We aimed to identify opportunities for the development of monitoring technology and the use of machine learning to analyze continuous physiological data to improve the outcomes of hospitalized children. We included original research articles published on or after January 1, 2001, involving novel approaches to collect and use continuous cardiorespiratory physiological data in hospitalized children. OVID Medline, PubMed, and Embase databases were searched. We screened 2909 articles and performed full-text extraction of 105 articles. We identified 58 articles describing novel devices or approaches, which were generally small and single-center. In addition, we identified 47 articles that described the use of continuous physiological data in prediction models, but only 7 integrated multidimensional data (e.g., demographics, laboratory results). We identified three areas for development: (1) further validation of promising novel devices; (2) more studies of models integrating multidimensional data with continuous cardiorespiratory data; and (3) further dissemination, implementation, and validation of prediction models using continuous cardiorespiratory data. IMPACT: We performed a comprehensive scoping review of novel approaches to capture and use continuous cardiorespiratory physiological data for monitoring, diagnosis, providing care, and predicting events in hospitalized infants and children, from novel devices to machine learning-based prediction models. We identified three key areas for future development: (1) further validation of promising novel devices; (2) more studies of models integrating multidimensional data with continuous cardiorespiratory data; and (3) further dissemination, implementation, and validation of prediction models using cardiorespiratory data.
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Affiliation(s)
- Sarah B Walker
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA. .,Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
| | - Colleen M Badke
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Michael S Carroll
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Kyle S Honegger
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Andrea Fawcett
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Debra E Weese-Mayer
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - L Nelson Sanchez-Pinto
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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12
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Variane GFT, Pietrobom RFR, Noh CY, Van Meurs KP, Chock VY. Newer indications for neuromonitoring in critically ill neonates. Front Pediatr 2023; 11:1111347. [PMID: 37187586 PMCID: PMC10175818 DOI: 10.3389/fped.2023.1111347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 04/07/2023] [Indexed: 05/17/2023] Open
Abstract
Continuous neuromonitoring in the neonatal intensive care unit allows for bedside assessment of brain oxygenation and perfusion as well as cerebral function and seizure identification. Near-infrared spectroscopy (NIRS) reflects the balance between oxygen delivery and consumption, and use of multisite monitoring of regional oxygenation provides organ-specific assessment of perfusion. With understanding of the underlying principles of NIRS as well as the physiologic factors which impact oxygenation and perfusion of the brain, kidneys and bowel, changes in neonatal physiology can be more easily recognized by bedside providers, allowing for appropriate, targeted interventions. Amplitude-integrated electroencephalography (aEEG) allows continuous bedside evaluation of cerebral background activity patterns indicative of the level of cerebral function as well as identification of seizure activity. Normal background patterns are reassuring while abnormal background patterns indicate abnormal brain function. Combining brain monitoring information together with continuous vital sign monitoring (blood pressure, pulse oximetry, heart rate and temperature) at the bedside may be described as multi-modality monitoring and facilitates understanding of physiology. We describe 10 cases in critically ill neonates that demonstrate how comprehensive multimodal monitoring provided greater recognition of the hemodynamic status and its impact on cerebral oxygenation and cerebral function thereby informing treatment decisions. We anticipate that there are numerous other uses of NIRS as well as NIRS in conjunction with aEEG which are yet to be reported.
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Affiliation(s)
- Gabriel F. T. Variane
- Division of Neonatology, Department of Pediatrics, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
- Clinical Research Department, Protecting Brains and Saving Futures Organization, São Paulo, Brazil
- Correspondence: Gabriel Variane
| | - Rafaela F. R. Pietrobom
- Division of Neonatology, Department of Pediatrics, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
- Clinical Research Department, Protecting Brains and Saving Futures Organization, São Paulo, Brazil
| | - Caroline Y. Noh
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Packard Children's Hospital Stanford, Palo Alto, CA, United States
| | - Krisa P. Van Meurs
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Packard Children's Hospital Stanford, Palo Alto, CA, United States
| | - Valerie Y. Chock
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Packard Children's Hospital Stanford, Palo Alto, CA, United States
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13
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Patent ductus arteriosus and spontaneous intestinal perforation in a cohort of preterm infants. J Perinatol 2022; 42:1649-1653. [PMID: 35589970 DOI: 10.1038/s41372-022-01403-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 04/04/2022] [Accepted: 04/11/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To assess whether either duration and magnitude of ductal shunt or medical treatment for patent ductus arteriosus (PDA) are related to spontaneous intestinal perforation (SIP). STUDY DESIGN Clinical charts of infants <29 weeks' gestation born from 2006 to 2018 were reviewed. Echocardiographic examinations were evaluated according to McNamara and Sehgal's staging system. RESULTS A higher percentage of patients with SIP had a hemodynamically significant PDA (HSPDA) and was treated with either NSAIDs or paracetamol (79% vs 53% and 81% vs 54%, respectively). Among non-treated patients, we found a 1.32 increase in the odds of SIP per day of persistence of HSPDA. In the cohort of patients treated despite the absence of HSPDA, we found a 2.35 increase in the odds of SIP per dose of drug administered. CONCLUSION Both treating a non-HSPDA and leaving a HSPDA to its natural history seem to be associated with SIP.
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Renal oxygenation measured by near-infrared spectroscopy in preterm neonates in the first week. Pediatr Res 2022; 92:1744-1748. [PMID: 35354931 PMCID: PMC9522888 DOI: 10.1038/s41390-022-02036-5] [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: 10/04/2021] [Revised: 03/09/2022] [Accepted: 03/13/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To describe renal regional saturation of oxygen (RrSO2) values during the first week of life for preterm neonates born at <32 weeks gestational age (GA). METHODS RrSO2 values recorded over the first week of life using near-infrared spectroscopy were retrospectively analyzed in this two-center cohort study of preterm infants without known congenital anomalies of the kidney. RESULTS A cohort of 109 neonates with a median GA of 26.9 weeks and a median of 120 (IQR: 87-141) hours of continuous RrSO2 monitoring were included. Separately fitted trends in RrSO2 did not differ (p = 0.52) between sites and demonstrated a consistent decrease in RrSO2 by 20 points (95% CI: 9.6-30.1) during the first 60 h of life, followed by a stabilization of RrSO2 thereafter. RrSO2 baseline trends increased by 2.1 (95% CI: 0.8-3.3) percentage points for each additional week GA between 24 and 32 weeks GA. CONCLUSIONS Despite differences in adjusted RrSO2 values between sites, profiles over time are consistent, allowing for the determination of RrSO2 trajectories in preterm infants. This expected pattern of RrSO2 changes in the first week may help guide future investigations and interventions to identify and reduce kidney injury in the preterm neonate. IMPACT Renal regional saturation of oxygen (RrSO2) slowly decreases during the first 60 h of age in <32-week preterm neonates. While site differences were identified with respect to absolute values, RrSO2 trends from two different centers were not different. Lower gestational age neonates have lower RrSO2 levels during the first week.
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Changes in regional oxygen saturation of the kidney and brain of infants during hospitalization. J Clin Monit Comput 2022; 36:1859-1867. [PMID: 35441944 DOI: 10.1007/s10877-022-00836-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 02/22/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND In pre-term infants, the postnatal changes in the regional oxygen saturation (rSO2) of the brain and kidney are unclear. METHODS We performed a prospective observational study. We measured the cerebral/renal rSO2 ratio and recorded the associated clinical features of infants born at 23 to 41 weeks of gestation weekly from the early postnatal period to discharge. RESULTS The median cerebral/renal rSO2 ratios (interquartile ranges) between birth and the expected date of birth were 1.13 (1.06-1.26) at 23-24 weeks (n = 7), 1.18 (1.10-1.32) at 25-26 weeks (n = 11), 1.24 (1.11-1.37) at 27-28 weeks (n = 9), 1.12 (1.05-1.19) at 29-30 weeks (n = 4), 1.11 (1.03-1.15) at 31-32 weeks (n = 5), 1.02 (0.98-1.06) at 33-34 weeks (n = 9), 0.98 (0.94-1.06) at 35-36 weeks (n = 19), and 0.95 (0.86-0.99) at 37-41 weeks of gestation (n = 22). The median cerebral/renal rSO2 ratio did not significantly change after birth, but with increasing gestational age, the cerebral/renal rSO2 ratio at the expected date of birth decreased (r = - 0.74, p < 0.001). Nephrotoxic drugs did not affect cerebral/renal rSO2 at the expected date of birth, after adjustment for clinical factors. CONCLUSIONS Unlike in most infants born after the late pre-term period, the renal rSO2 remained lower than the cerebral rSO2 on the expected date of birth in infants born very pre-term.
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Bailey SM, Prakash SS, Verma S, Desai P, Kazmi S, Mally PV. Near-infrared spectroscopy in the medical management of infants. Curr Probl Pediatr Adolesc Health Care 2022; 52:101291. [PMID: 36404215 DOI: 10.1016/j.cppeds.2022.101291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Near-infrared spectroscopy (NIRS) is a technology that is easy to use and can provide helpful information about organ oxygenation and perfusion by measuring regional tissue oxygen saturation (rSO2) with near-infrared light. The sensors can be placed in different anatomical locations to monitor rSO2 levels in several organs. While NIRS is not without limitations, this equipment is now becoming increasingly integrated into modern healthcare practice with the goal of achieving better outcomes for patients. It can be particularly applicable in the monitoring of pediatric patients because of their size, and especially so in infant patients. Infants are ideal for NIRS monitoring as nearly all of their vital organs lie near the skin surface which near-infrared light penetrates through. In addition, infants are a difficult population to evaluate with traditional invasive monitoring techniques that normally rely on the use of larger catheters and maintaining vascular access. Pediatric clinicians can observe rSO2 values in order to gain insight about tissue perfusion, oxygenation, and the metabolic status of their patients. In this way, NIRS can be used in a non-invasive manner to either continuously or periodically check rSO2. Because of these attributes and capabilities, NIRS can be used in various pediatric inpatient settings and on a variety of patients who require monitoring. The primary objective of this review is to provide pediatric clinicians with a general understanding of how NIRS works, to discuss how it currently is being studied and employed, and how NIRS could be increasingly used in the near future, all with a focus on infant management.
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Affiliation(s)
- Sean M Bailey
- Division of Neonatology, Department of Pediatrics, New York University Grossman School of Medicine, New York, NY 10016.
| | - Shrawani Soorneela Prakash
- Division of Neonatology, Department of Pediatrics, NYCHHC/Lincoln Medical and Mental Health Center, Bronx, NY 10451
| | - Sourabh Verma
- Division of Neonatology, Department of Pediatrics, New York University Grossman School of Medicine, New York, NY 10016
| | - Purnahamsi Desai
- Division of Neonatology, Department of Pediatrics, New York University Grossman School of Medicine, New York, NY 10016
| | - Sadaf Kazmi
- Division of Neonatology, Department of Pediatrics, New York University Grossman School of Medicine, New York, NY 10016
| | - Pradeep V Mally
- Division of Neonatology, Department of Pediatrics, New York University Grossman School of Medicine, New York, NY 10016
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Hoffman SB, Magder LS, Viscardi RM. Renal versus cerebral saturation trajectories: the perinatal transition in preterm neonates. Pediatr Res 2022; 92:1437-1442. [PMID: 35177816 DOI: 10.1038/s41390-022-01984-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 01/04/2022] [Accepted: 01/26/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND The aim of this study was to develop reference renal saturation (rSrO2) curves in premature infants, depict how they differ from cerebral saturation (rScO2) curves, and evaluate the effect of blood pressure on these values using near-infrared spectroscopy (NIRS). METHODS This is a prospective cohort study of 57 inborn infants <12 h and <30 weeks gestation. rScO2, rSrO2, fractional tissue oxygen extraction (FTOE), and mean arterial blood pressure (MAP) were continuously monitored every 30 s for 96 h. Quantile regression was used to establish nomograms, and mean saturation values were evaluated for different MAP ranges. RESULTS Median rSrO2 at the start of monitoring was ~10% higher than rScO2. rSrO2 showed a significant decline over time while rScO2 peaked at 26 h. FTOE demonstrated a similar but inverse trend to their saturation counterparts. rScO2 declined as MAP increased, while rSrO2 showed a peak and decline as MAP increased. CONCLUSIONS We provide rSrO2 reference curves for the first 4 days of life, which differ in their trajectory from rScO2 and from what has previously been reported for rSrO2 in the full-term population. In addition, we observed a peak and decline in renal saturation with increasing MAP, suggesting a renovascular response to blood pressure changes. IMPACT This article depicts reference renal saturation curves during the perinatal transition in preterm infants. We show how renal saturation compares to cerebral saturation trends over time. We describe a peak and decline in renal saturation with increasing MAP, suggesting a renovascular response to blood pressure changes.
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Affiliation(s)
- Suma B Hoffman
- Department of Pediatrics, University of Maryland Baltimore School of Medicine, Baltimore, MD, USA. .,Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Children's National Health System - Neonatology, Washington, DC, USA.
| | - Laurence S Magder
- Department of Epidemiology and Public Health, University of Maryland Baltimore School of Medicine, Baltimore, MD, USA
| | - Rose M Viscardi
- Department of Pediatrics, University of Maryland Baltimore School of Medicine, Baltimore, MD, USA
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Borges-Lujan M, Gonzalez-Luis GE, Roosen T, Huizing MJ, Villamor E. Sex Differences in Patent Ductus Arteriosus Incidence and Response to Pharmacological Treatment in Preterm Infants: A Systematic Review, Meta-Analysis and Meta-Regression. J Pers Med 2022; 12:jpm12071143. [PMID: 35887640 PMCID: PMC9321725 DOI: 10.3390/jpm12071143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/05/2022] [Accepted: 07/08/2022] [Indexed: 11/16/2022] Open
Abstract
A widely accepted concept in perinatal medicine is that boys are more susceptible than girls to complications of prematurity. However, whether this ‘male disadvantage of prematurity’ also involves persistent patent ductus arteriosus (PDA) has been scarcely investigated. Our aim was to conduct a systematic review and meta-analysis on studies addressing sex differences in the risk of developing PDA among preterm infants. We also investigated whether the response to pharmacological treatment of PDA differs between boys and girls. PubMed/Medline and Embase databases were searched. The random-effects male/female risk ratio (RR) and 95% confidence interval (CI) were calculated. We included 146 studies (357,781 infants). Meta-analysis could not demonstrate sex differences in risk of developing any PDA (37 studies, RR 1.03, 95% CI 0.97 to 1.08), hemodynamically significant PDA (81 studies, RR 1.00, 95% CI 0.97 to 1.02), or in the rate of response to pharmacological treatment (45 studies, RR 1.01, 95% CI 0.98 to 1.04). Subgroup analysis and meta-regression showed that the absence of sex differences was maintained over the years and in different geographic settings. In conclusion, both the incidence of PDA in preterm infants and the response rate to pharmacological treatment of PDA are not different between preterm boys and girls.
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Affiliation(s)
- Moreyba Borges-Lujan
- Department of Neonatology, Complejo Hospitalario Universitario Insular Materno-Infantil (CHUIMI) de Canarias, 35016 Las Palmas de Gran Canaria, Spain; (M.B.-L.); (G.E.G.-L.)
| | - Gema E. Gonzalez-Luis
- Department of Neonatology, Complejo Hospitalario Universitario Insular Materno-Infantil (CHUIMI) de Canarias, 35016 Las Palmas de Gran Canaria, Spain; (M.B.-L.); (G.E.G.-L.)
| | - Tom Roosen
- Department of Pediatrics, Maastricht University Medical Centre (MUMC+), School for Oncology Reproduction (GROW), 6202 Maastricht, The Netherlands; (T.R.); (M.J.H.)
| | - Maurice J. Huizing
- Department of Pediatrics, Maastricht University Medical Centre (MUMC+), School for Oncology Reproduction (GROW), 6202 Maastricht, The Netherlands; (T.R.); (M.J.H.)
| | - Eduardo Villamor
- Department of Pediatrics, Maastricht University Medical Centre (MUMC+), School for Oncology Reproduction (GROW), 6202 Maastricht, The Netherlands; (T.R.); (M.J.H.)
- Correspondence:
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Impact of Medical Treatment of Hemodynamically Significant Patent Ductus Arteriosus on Cerebral and Renal Tissue Oxygenation Measured by Near-Infrared Spectroscopy in Very Low-Birth-Weight Infants. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58040475. [PMID: 35454314 PMCID: PMC9033064 DOI: 10.3390/medicina58040475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 02/26/2022] [Accepted: 03/24/2022] [Indexed: 11/16/2022]
Abstract
Background and objective: Hemodynamically significant patent ductus arteriosus (hsPDA) can cause ductal steal and contribute to poor outcomes in preterm infants. Near-infrared spectroscopy (NIRS) allows us to continuously evaluate regional tissue oxygenation (rSpO2) and perfusion changes in underlying organs. The aim of this study was to evaluate the effect of medical treatment for hsPDA on cerebral and renal rSpO2 in infants less than 32 weeks of gestational age, and older than 72 h of life. Materials and methods: Infants with a gestational age of <32 weeks with hsPDA were prospectively studied before and during medical treatment. Two-site (cerebral and renal) rSpO2 monitoring by NIRS was performed 1 h before treatment (T0) and 24 h (T1), 24−48 h (T2), 48−72 h (T3) after the infusion of the first drug dose. Results: A total of 21 infants were studied. The mean day of life at treatment initiation was 8.2 (SD, 2.75). The DA diameter, LA/Ao ratio, and resistive index in the anterior cerebral artery (RI ACA) were significantly lower after treatment (p < 0.05). There were no significant differences in cerebral rSpO2, cerebral fractional tissue oxygen extraction (FTOE), and SpO2 comparing different time points. A significantly higher renal SpO2 value was recorded at T2 as compared with T0 (75.0%, SD 4.9%, vs. 69.4%, SD 7.6%; p < 0.013), while for renal FTOE, a tendency to lower values at T2 was observed (0.18, SD 0.05, vs. 0.24, SD 0.09; p = 0.068). Conclusions: Late (later than 7 days postpartum) hsPDA medical treatment with paracetamol or ibuprofen completely closed the duct only in a small proportion of preterm infants, despite a statistically significant reduction in the DA diameter, LA/Ao ratio, and RI ACA. Continuous renal, not cerebral, NIRS measurements can help to anticipate the efficacy of medical treatment of hsPDA in preterm infants. Large-scale prospective studies are needed to ascertain that renal and cerebral NIRS can be used as a reliable tool for evaluating the effectiveness of medical treatment for hsPDA.
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Variane GFT, Camargo JPV, Rodrigues DP, Magalhães M, Mimica MJ. Current Status and Future Directions of Neuromonitoring With Emerging Technologies in Neonatal Care. Front Pediatr 2022; 9:755144. [PMID: 35402367 PMCID: PMC8984110 DOI: 10.3389/fped.2021.755144] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 11/18/2021] [Indexed: 11/13/2022] Open
Abstract
Neonatology has experienced a significant reduction in mortality rates of the preterm population and critically ill infants over the last few decades. Now, the emphasis is directed toward improving long-term neurodevelopmental outcomes and quality of life. Brain-focused care has emerged as a necessity. The creation of neonatal neurocritical care units, or Neuro-NICUs, provides strategies to reduce brain injury using standardized clinical protocols, methodologies, and provider education and training. Bedside neuromonitoring has dramatically improved our ability to provide assessment of newborns at high risk. Non-invasive tools, such as continuous electroencephalography (cEEG), amplitude-integrated electroencephalography (aEEG), and near-infrared spectroscopy (NIRS), allow screening for seizures and continuous evaluation of brain function and cerebral oxygenation at the bedside. Extended and combined uses of these techniques, also described as multimodal monitoring, may allow practitioners to better understand the physiology of critically ill neonates. Furthermore, the rapid growth of technology in the Neuro-NICU, along with the increasing use of telemedicine and artificial intelligence with improved data mining techniques and machine learning (ML), has the potential to vastly improve decision-making processes and positively impact outcomes. This article will cover the current applications of neuromonitoring in the Neuro-NICU, recent advances, potential pitfalls, and future perspectives in this field.
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Affiliation(s)
- Gabriel Fernando Todeschi Variane
- Division of Neonatology, Department of Pediatrics, Irmandade de Misericordia da Santa Casa de São Paulo, São Paulo, Brazil
- Clinical Research Department, Protecting Brains and Saving Futures Organization, São Paulo, Brazil
- Division of Neonatology, Grupo Santa Joana, São Paulo, Brazil
| | - João Paulo Vasques Camargo
- Clinical Research Department, Protecting Brains and Saving Futures Organization, São Paulo, Brazil
- Data Science Department, OPD Team, São Paulo, Brazil
| | - Daniela Pereira Rodrigues
- Clinical Research Department, Protecting Brains and Saving Futures Organization, São Paulo, Brazil
- Pediatric Nursing Department, Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Maurício Magalhães
- Division of Neonatology, Department of Pediatrics, Irmandade de Misericordia da Santa Casa de São Paulo, São Paulo, Brazil
- Clinical Research Department, Protecting Brains and Saving Futures Organization, São Paulo, Brazil
- Department of Pediatrics, Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, Brazil
| | - Marcelo Jenné Mimica
- Department of Pathology, Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, Brazil
- Department of Pediatrics, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
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Smith A, Armstrong S, Dempsey E, El-Khuffash A. The impact of a PDA on tissue oxygenation and haemodynamics following a blood transfusion in preterm infants. Pediatr Res 2022; 93:1314-1320. [PMID: 35152266 DOI: 10.1038/s41390-022-01967-3] [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: 09/20/2021] [Revised: 01/04/2022] [Accepted: 01/17/2022] [Indexed: 01/08/2023]
Abstract
BACKGROUND To examine the impact of PRBC transfusion on pulmonary vascular resistance (PVR), systemic vascular resistance and myocardial function using echocardiography and cerebral and splanchnic tissue oxygenation using near-infrared spectroscopy (NIRS) in premature babies with and without a PDA. METHODS A prospective observational study of premature infants born <1500 g in receipt of PRBC transfusions beyond 10 days of age. Echocardiography and NIRS monitoring were performed at baseline, during the transfusion and 24 h after transfusion. RESULTS Thirty infants with a median gestation of 26.4 [24.8-28.0] weeks were enrolled. Ten infants had a PDA. Following transfusion, a significant decrease in PVR markers occurred in all infants. Right ventricular (RV) function increased following transfusion in the PDA closed group only. Cerebral oxygen saturation increased following transfusion in all infants. Babies in the PDA open group had significantly lower splanchnic oxygen saturations at baseline compared to the PDA closed group which persisted over the study period and were unaltered by transfusion. CONCLUSIONS PRBC transfusion lowers PVR irrespective of PDA status. Those with a PDA demonstrated a lack of improvement in RV function and splanchnic oxygenation highlighting the impact a PDA has on the neonatal circulation. IMPACT The presence or absence of the PDA imposes differential effects on splanchnic oxygenation during red blood cell (PRBC) transfusion in the premature population. This is the first study to assess the impact of the PDA on splanchnic oxygenation via near-infrared spectroscopy (NIRS) during red blood cell transfusion in premature neonates. New insights have been found into the impact of PRBC transfusion on pulmonary vascular resistance, right ventricular function, cerebral and splanchnic oxygenation in the presence and absence of a PDA and emphasises the ongoing impact of ductal patency on gut oxygenation.
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Affiliation(s)
- Aisling Smith
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland.
| | - Sean Armstrong
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland
| | - Eugene Dempsey
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland.,INFANT Centre, University College Cork, Cork, Ireland
| | - Afif El-Khuffash
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland.,Department of Paediatrics, The Royal College of Surgeons in Ireland, Dublin, Ireland
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22
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Cerebral saturation reflects anterior cerebral artery flow parameters by Doppler ultrasound in the extremely premature newborn. J Perinatol 2022; 42:237-242. [PMID: 34247188 DOI: 10.1038/s41372-021-01145-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 05/30/2021] [Accepted: 06/30/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Near-infrared spectroscopy measures cerebral saturation (Csat), although correlation with cerebral blood flow remains unclear in premature newborns at risk for intraventricular hemorrhage (IVH). OBJECTIVES Compare Doppler markers of anterior cerebral artery (ACA) flow with Csat obtained during head ultrasound (HUS). METHOD Newborns <29 weeks (2013-2017) underwent Csat monitoring with clinical acquisition of HUS. ACA Doppler markers were measured (with and without pressure) and Resistive Index (RI) was calculated. Mixed effects models evaluated the association between Csat and Doppler markers. RESULTS 98 neonates with 175 Csat-HUS observations were analyzed. Age at birth was 26.2 ± 1.5 weeks, with post-menstrual age of 26.9 ± 1.7 weeks at HUS. Csat was associated with RI without pressure (p = 0.045), RI with pressure (p = 0.019), and peak systolic velocity with pressure (p = 0.036). Severe IVH (n = 27 [15%]) was associated with lower Csat (60 ± 11% vs 68 ± 9%, p = 0.01). CONCLUSION Csat was associated with ACA Doppler measurements in extremely premature neonates.
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Variane GFT, Magalhães M, Pietrobom RFR, Netto A, Rodrigues DP, Gasperini R, Sant’Anna GM. Protecting brains and saving futures guidelines: A prospective, multicenter, and observational study on the use of telemedicine for neonatal neurocritical care in Brazil. PLoS One 2022; 17:e0262581. [PMID: 35020756 PMCID: PMC8754327 DOI: 10.1371/journal.pone.0262581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 12/29/2021] [Indexed: 11/19/2022] Open
Abstract
Background
Management of high-risk newborns should involve the use of standardized protocols and training, continuous and specialized brain monitoring with electroencephalography (EEG), amplitude integrated EEG, Near Infrared Spectroscopy, and neuroimaging. Brazil is a large country with disparities in health care assessment and some neonatal intensive care units (NICUs) are not well structured with trained personnel able to provide adequate neurocritical care. To reduce this existing gap, an advanced telemedicine model of neurocritical care called Protecting Brains and Saving Futures (PBSF) Guidelines was developed and implemented in a group of Brazilian NICUs.
Methods
A prospective, multicenter, and observational study will be conducted in all 20 Brazilian NICUs using the PBSF Guidelines as standard-of-care. All infants treated accordingly to the guidelines during Dec 2021 to Nov 2024 will be eligible. Ethical approval was obtained from participating centers. The primary objective is to describe adherence to the PBSF Guidelines and clinical outcomes, by center and over a 3-year period. Adherence will be measured by quantification of neuromonitoring, neuroimaging exams, sub-specialties consultation, and clinical case discussions and videoconference meetings. Clinical outcomes of interest are detection of seizures during hospitalization, use of anticonvulsants, inotropes, and fluid resuscitation, death before hospital discharge, length of hospital stay, and referral of patients to specialized follow-up.
Discussion
The study will provide evaluation of PBSF Guidelines adherence and its impact on clinical outcomes. Thus, data from this large prospective, multicenter, and observational study will help determine whether neonatal neurocritical care via telemedicine can be effective. Ultimately, it may offer the necessary framework for larger scale implementation and development of research projects using remote neuromonitoring.
Trial registration
NCT03786497, Registered 26 December 2018, https://www.clinicaltrials.gov/ct2/show/NCT03786497?term=protecting+brains+and+saving+futures&draw=2&rank=1.
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Affiliation(s)
- Gabriel Fernando Todeschi Variane
- Neonatal Division, Department of Pediatrics, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
- Neonatal Division, Grupo Santa Joana, São Paulo, Brazil
- Protecting Brains and Saving Futures Organization, São Paulo, Brazil
- * E-mail:
| | - Maurício Magalhães
- Neonatal Division, Department of Pediatrics, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
- Protecting Brains and Saving Futures Organization, São Paulo, Brazil
- Neonatal Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, Brazil
| | - Rafaela Fabri Rodrigues Pietrobom
- Neonatal Division, Department of Pediatrics, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
- Protecting Brains and Saving Futures Organization, São Paulo, Brazil
| | - Alexandre Netto
- Neonatal Division, Department of Pediatrics, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
- Protecting Brains and Saving Futures Organization, São Paulo, Brazil
| | - Daniela Pereira Rodrigues
- Protecting Brains and Saving Futures Organization, São Paulo, Brazil
- Pediatric Nursing Department, Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Renato Gasperini
- Neonatal Division, Department of Pediatrics, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
- Protecting Brains and Saving Futures Organization, São Paulo, Brazil
- Neonatal Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil
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Navikiene J, Virsilas E, Vankeviciene R, Liubsys A, Jankauskiene A. Brain and renal oxygenation measured by NIRS related to patent ductus arteriosus in preterm infants: a prospective observational study. BMC Pediatr 2021; 21:559. [PMID: 34886825 PMCID: PMC8656008 DOI: 10.1186/s12887-021-03036-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 11/30/2021] [Indexed: 11/17/2022] Open
Abstract
Background Patent ductus arteriosus (PDA) is common among preterm neonates. Haemodynamically significant ductus arteriosus (hsPDA) can cause ductal steal and contribute to poor outcomes. Our aim was to evaluate ductus arteriosus patency and significance using two-site near-infrared spectroscopy (NIRS) measurements in preterm infants older than 72 h as a supplemental tool to echocardiography. Methods In this prospective observational study, 123 preterm infants (gestational age (GA) < 32 weeks, birth weight < 1500 g) were enrolled. Sixty-four newborns had closed ductus arteriosus (noPDA), and 41 and 18 patients were assigned to the PDA and hsPDA groups, respectively, per predefined echocardiographic criteria. Cerebral and renal oxygenation were assessed during NIRS monitoring. Results A higher renal mean (±SD) regional tissue oxygen saturation (rSpO2) (76.7 (±7.64)) was detected in the noPDA group than in the PDA (71.7 (±9.02)) and hsPDA (67.4 (±13.48)) groups (p < 0.001). Renal fractional tissue oxygen extraction (FTOE) (0.18 (±0.079)) was lower in the noPDA group than in the PDA (0.23 (±0.092)) and hsPDA (0.24 (±0.117))0.117 groups (p = 0.002). Cerebral oxygenation was significantly lower in the hsPDA group (77.0 (±5.16)) than in the noPDA (79.3 (±2.45)) and PDA (79.7 (±2.27)) groups (p = 0.004). There was no significant difference in cerebral fractional tissue oxygen extraction (FTOE) between any of the groups. Conclusions Our results suggest that renal oxygenation is affected by ductus patency in preterm infants older than 72 h. Significant differences in cerebral oxygenation were observed between the hsPDA group and the PDA and noPDA groups. Trial registration ClinicalTrials.gov Identifier: NCT04295395. Registration date: 4 March 2020. This study was retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT04295395.
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Affiliation(s)
- Jurate Navikiene
- Faculty of Medicine, Institute of Clinical Medicine, Vilnius University, Vilnius, Lithuania.
| | - Ernestas Virsilas
- Faculty of Medicine, Institute of Clinical Medicine, Vilnius University, Vilnius, Lithuania
| | - Ramune Vankeviciene
- Faculty of Medicine, Institute of Clinical Medicine, Vilnius University, Vilnius, Lithuania
| | - Arunas Liubsys
- Faculty of Medicine, Institute of Clinical Medicine, Vilnius University, Vilnius, Lithuania
| | - Augustina Jankauskiene
- Faculty of Medicine, Institute of Clinical Medicine, Vilnius University, Vilnius, Lithuania
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Renal tissue oxygenation after caffeine administration in preterm neonates. Pediatr Res 2021; 90:1171-1176. [PMID: 34006983 DOI: 10.1038/s41390-021-01579-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 04/23/2021] [Accepted: 04/28/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Caffeine has been associated with reduced rates of acute kidney injury (AKI) in preterm neonates. The effect of caffeine on preterm neonatal renal regional saturation of oxygen (RrSO2) is unknown. METHODS RrSO2 was recorded continuously in neonates < 32 weeks' gestation until 7 days of age with INVOS™ neonatal near-infrared spectroscopy (NIRS) sensors. Baseline RrSO2 values were established by averaging the saturations in the 20 min prior to caffeine administration. Subgroup analysis was performed based on pre-caffeine RrSO2 averages. Change in RrSO2 was recorded at 0.5, 1, 2, 3, 4, 6, and 12 h after maintenance caffeine administration. RESULTS Of 35 eligible neonates, 31 (median gestational age 28.4 weeks) received 156 caffeine doses (median 8 mg/kg). Analysis of combined doses showed no significant changes in RrSO2 after caffeine administration at any time. However, neonates with baseline 20-29.9% had significant increases from 1 to 12 h (range of increase 5.9-13.9%), and those with baseline 30-39.9 had significant increases at 1 h (8.06%, p < 0.05). CONCLUSIONS Maintenance caffeine dosing increased RrSO2 in neonates with low RrSO2 in the first week. Further research is needed to determine the effect of loading doses of caffeine and if increases in RrSO2 correlate with improved clinical kidney outcomes. IMPACT Caffeine administration is associated with increased renal tissue oxygenation in preterm neonates with low baseline values under 40%. The most significant renal tissue oxygenation changes occur in the first 3 h after IV caffeine administration. With recent studies suggesting low RrSO2 values in preterm neonates are associated with AKI, caffeine should be studied as a potential therapeutic for this common and complex morbidity in preterm neonates.
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Renal Oxygenation (rSO2) Population Parameter Estimates in Premature Infants Routinely Monitored With Near-Infrared Spectroscopy. Adv Neonatal Care 2021; 22:370-377. [PMID: 34417355 DOI: 10.1097/anc.0000000000000927] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Currently, reference ranges for renal oxygenation measured by near-infrared spectroscopy (NIRS) in preterm infants beyond the first days of life are lacking, especially those born prior to 29 weeks' gestation. Population estimates of renal oxygenation (rSO2) levels among preterm infants over time have yet to be established, leading to reluctance in clinical application. PURPOSE To characterize the distribution and estimate population parameters for renal oxygenation measured by NIRS during the first 14 days of life among preterm infants. METHODS We prospectively observed rSO2 trends of 37 infants before 34 weeks' gestation and 1800-g or less birth weight for the first 14 days of life. Analyses included distribution fit tests, ordinary least squares (OLS) regression, and t tests. RESULTS Average daily rSO2 variation steadily increased with 42% difference through the first 14 days of life. For all infants, renal rSO2 means peaked during the first 3 days of life and plateaued around 7 days. Daily rSO2 slopes were significantly lower among males and infants 29 weeks' or less gestation. IMPLICATIONS FOR PRACTICE Renal rSO2 during the first 14 days of life reflects normal extrauterine transition reaching stabilization around 7 days of life. Gestational age, birth weight, and gender may predict the early trajectory of rSO2 patterns. Population estimates provide parameters for renal rSO2 that may indicate early-onset tissue hypoxia when acute or significant drops from baseline occur. IMPLICATIONS FOR RESEARCH We present a framework to guide future research using renal NIRS technology in preterm infants to determine deviations from expected trends that may precede renal injury.
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Abstract
BACKGROUND Acute kidney injury (AKI) affects approximately 30% of infants admitted to the neonatal intensive care unit (NICU), and increases mortality risk by 50%. Current diagnostic criteria (serum creatinine rise with oliguria) cannot detect early-onset AKI, as up to 50% of nephron damage may occur by the time these abnormalities present. Once AKI is established, clinical management is often ineffective; therefore, prevention is key. Near-infrared spectroscopy (NIRS) offers a feasible, noninvasive approach to continuously monitor renal oxygenation trends over time, serving as a surrogate marker for renal perfusion. PURPOSE To provide an overview of NIRS principles for measuring renal oxygenation, and to describe current evidence of how this technology is being used among infants admitted to the NICU relative to the prediction and identification of AKI. METHODS A comprehensive search of PubMed and CINHAL focused on renal NIRS studies in NICU preterm and term infants was conducted. RESULTS Findings from 34 studies were included. In term infants, reduced renal oxygenation correlated to invasive SvO2 monitoring, predicted survivability and AKI. In preterm infants, reduced renal oxygenation was associated with AKI in one study, yet contrasting findings were reported in those with patent ductus arteriosus, including those who received prostaglandin inhibitors. Normative data in all infants were sparse. IMPLICATIONS FOR PRACTICE Renal NIRS may offer a noninvasive measurement of kidney hypoperfusion that may precede conventional diagnostic measures. IMPLICATIONS FOR RESEARCH Normative data are lacking, the threshold for renal ischemia is not defined, and consensus guiding clinical treatment based on NIRS data is nonexistent.
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Altit G, Bhombal S, Chock VY. End-organ saturations correlate with aortic blood flow estimates by echocardiography in the extremely premature newborn - an observational cohort study. BMC Pediatr 2021; 21:312. [PMID: 34253175 PMCID: PMC8274006 DOI: 10.1186/s12887-021-02790-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 06/10/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Near-infrared spectroscopy (NIRS) measures of cerebral saturation (Csat) and renal saturation (Rsat) in extreme premature newborns may be affected by systemic blood flow fluctuations. Despite increasing clinical use of NIRS to monitor tissue saturation in the premature infant, validation of NIRS measures as a correlate of blood flow is still needed. We compared echocardiography (ECHO) derived markers of ascending aorta (AscAo) and descending aorta (DesAo) blood flow with NIRS measurements obtained during the ECHO. METHODS Newborns < 29 weeks' gestation (2013-2017) underwent routine NIRS monitoring. Csat, Rsat and systemic saturation at the time of ECHO were retrospectively analyzed and compared with Doppler markers of aortic flow. Renal and cerebral fractional tissue oxygen extraction (rFTOE and cFTOE, respectively) were calculated. Mixed effects models evaluated the association between NIRS and Doppler markers. RESULTS Forty-nine neonates with 75 Csat-ECHO and 62 Rsat-ECHO observations were studied. Mean post-menstrual age was 28.3 ± 3.8 weeks during the ECHO. Preductal measures including AscAo velocity time integral (VTI) and AscAo output were correlated with Csat or cFTOE, while postductal measures including DesAo VTI, DesAo peak systolic velocity, and estimated DesAo output were more closely correlated with Rsat or rFTOE. CONCLUSIONS NIRS measures are associated with aortic blood flow measurements by ECHO in the extremely premature population. NIRS is a tool to consider when following end organ perfusion in the preterm infant.
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Affiliation(s)
- Gabriel Altit
- Department of Pediatrics, Division of Neonatology, Montreal Children's Hospital, McGill University Health Center, Montreal, Canada.
| | - Shazia Bhombal
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital Stanford, Palo Alto, USA
| | - Valerie Y Chock
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital Stanford, Palo Alto, USA
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Non-invasive continuous renal tissue oxygenation monitoring to identify preterm neonates at risk for acute kidney injury. Pediatr Nephrol 2021; 36:1617-1625. [PMID: 33389091 DOI: 10.1007/s00467-020-04855-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 10/14/2020] [Accepted: 11/10/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Near-infrared spectroscopy (NIRS) is an emerging tool to identify signs of inadequate tissue oxygenation in preterm neonates with acute kidney injury (AKI). Previous studies have shown a correlation between low renal tissue oxygenation (RrSO2) in the first 24 hours of age and the later development of AKI. In this prospective clinical trial, NIRS monitoring was used to identify changes in RrSO2 in comparison to traditional AKI markers, serum creatinine (SCr), and urine output (UOP). METHODS We enrolled 35 preterm neonates born less than 32 weeks' gestation and applied neonatal NIRS sensors at less than 48 hours of age. Neonates underwent 7 days of continuous monitoring. Renal and demographic information were collected for the first 7 days of age. AKI was determined by the modified neonatal Kidney Disease: Improving Global Outcomes (KDIGO) definition including UOP. RESULTS Three patients experienced AKI, all based on both SCr and UOP criteria. Each neonate with AKI had decreases in RrSO2 over 48 hours prior to changes in SCr and UOP. Patients with AKI had lower median RrSO2 values compared to patients without AKI over the first week of age, (32.4% vs. 60%, p < 0.001). CONCLUSION RrSO2 monitoring identified preterm neonates at risk for AKI. NIRS detected a decline in RrSO2 prior to changes in SCr and UOP and was significantly lower in patients with AKI compared to those without AKI. Further studies are needed to evaluate the ability of RrSO2 monitoring to detect signs of kidney stress prior to the diagnosis of AKI. Graphical abstract.
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Huang C, Mazdeyasna S, Mohtasebi M, Saatman KE, Cheng Q, Yu G, Chen L. Speckle contrast diffuse correlation tomography of cerebral blood flow in perinatal disease model of neonatal piglets. JOURNAL OF BIOPHOTONICS 2021; 14:e202000366. [PMID: 33295142 PMCID: PMC8833087 DOI: 10.1002/jbio.202000366] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 12/05/2020] [Accepted: 12/06/2020] [Indexed: 05/11/2023]
Abstract
We adapted and tested an innovative noncontact speckle contrast diffuse correlation tomography (scDCT) system for 3D imaging of cerebral blood flow (CBF) variations in perinatal disease models utilizing neonatal piglets, which closely resemble human neonates. CBF variations were concurrently measured by the scDCT and an established diffuse correlation spectroscopy (DCS) during global ischemia, intraventricular hemorrhage, and asphyxia; significant correlations were observed. Moreover, CBF variations associated reasonably with vital pathophysiological changes. In contrast to DCS measurements of mixed signals from local scalp, skull and brain, scDCT generates 3D images of CBF distributions at prescribed depths within the head, thus enabling specific determination of regional cerebral ischemia. With further optimization and validation in animals and human neonates, scDCT has the potential to be a noninvasive imaging tool for both basic neuroscience research in laboratories and clinical applications in neonatal intensive care units.
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Affiliation(s)
- Chong Huang
- Department of Biomedical Engineering, University of Kentucky, Lexington, Kentucky
| | - Siavash Mazdeyasna
- Department of Biomedical Engineering, University of Kentucky, Lexington, Kentucky
| | - Mehrana Mohtasebi
- Department of Biomedical Engineering, University of Kentucky, Lexington, Kentucky
| | - Kathryn E. Saatman
- Department of Physiology, Spinal Cord and Brain Injury Research Center, University of Kentucky, Lexington, Kentucky
| | - Qiang Cheng
- Division of Biomedical Informatics, Department of Internal Medicine, University of Kentucky, Lexington, Kentucky
| | - Guoqiang Yu
- Department of Biomedical Engineering, University of Kentucky, Lexington, Kentucky
| | - Lei Chen
- Department of Physiology, Spinal Cord and Brain Injury Research Center, University of Kentucky, Lexington, Kentucky
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Patra A, Thakkar PS, Makhoul M, Bada HS. Objective Assessment of Physiologic Alterations Associated With Hemodynamically Significant Patent Ductus Arteriosus in Extremely Premature Neonates. Front Pediatr 2021; 9:648584. [PMID: 33718311 PMCID: PMC7946992 DOI: 10.3389/fped.2021.648584] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 02/05/2021] [Indexed: 11/23/2022] Open
Abstract
Delay in closure of ductus arteriosus in postnatal life may lead to serious consequences and complications in an extremely premature neonate secondary to hemodynamic alterations in regional blood flow pattern in various organs. Despite the widespread recognition amongst neonatologists to identify a hemodynamically significant patent ductus arteriosus (hsPDA) early in the postnatal course, there is lack of consensus in its definition and thus the threshold to initiate treatment. Echocardiographic assessment of PDA shunt size and volume combined with neonatologists' impression of clinical significance is most frequently used to determine the need for treatment of PDA. Common clinical signs of hsPDA utilized as surrogate for decreased tissue perfusion may lag behind early echocardiographic signs. Although echocardiogram allows direct assessment of PDA shunt and hemodynamic alterations in the heart, it is limited by dependence on pediatric cardiologist availability, interobserver variation and isolated time point assessment. Electrical cardiometry (EC) is a non-invasive continuous real time measurement of cardiac output by applying changes in thoracic electrical impedance. EC has been validated in preterm newborns by concomitant transthoracic echocardiogram assessments and may be beneficial in studying changes in cardiac output in premature newborns with hsPDA. Alterations in perfusion index derived from continuous pulse oximetry monitoring has been used to study changes in cardiac performance and tissue perfusion in infants with PDA. Near infrared spectroscopy (NIRS) has been used to objectively and continuously assess variations in renal, mesenteric, and cerebral oxygen saturation and thus perfusion changes due to diastolic vascular steal from hsPDA in preterm neonates. Doppler ultrasound studies measuring resistive indices in cerebral circulation indicate disturbance in cerebral perfusion secondary to ductal steal. With recent trends of change in practice toward less intervention in care of preterm newborn, treatment strategy needs to be targeted for select preterm population most vulnerable to adverse hemodynamic effects of PDA. Integration of these novel ways of hemodynamic and tissue perfusion assessment in routine clinical care may help mitigate the challenges in defining and targeting treatment of hsPDA thereby improving outcomes in extremely premature neonates.
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Affiliation(s)
- Aparna Patra
- Division of Neonatology, Department of Pediatrics, Kentucky Children's Hospital, University of Kentucky, Lexington, KY, United States
| | - Pratibha S Thakkar
- Division of Neonatology, Department of Pediatrics, Kentucky Children's Hospital, University of Kentucky, Lexington, KY, United States
| | - Majd Makhoul
- Division of Pediatric Cardiology, Department of Pediatrics, Kentucky Children's Hospital, University of Kentucky, Lexington, KY, United States
| | - Henrietta S Bada
- Division of Neonatology, Department of Pediatrics, Kentucky Children's Hospital, University of Kentucky, Lexington, KY, United States
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32
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Abu Jawdeh EG, Huang C, Mazdeyasna S, Chen L, Chen L, Bada HS, Yu G. Noncontact optical imaging of brain hemodynamics in preterm infants: a preliminary study. Phys Med Biol 2020; 65:245009. [PMID: 33113516 DOI: 10.1088/1361-6560/abc5a7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Extremely preterm infants' hemodynamic instability places them at high risk of brain injury. Currently there is no reliable bedside method to continuously monitor cerebral hemodynamics in the neonatal intensive care unit (NICU). This paper reports a feasibility study to adapt and test an innovative speckle contrast diffuse correlation tomography (scDCT) device for noncontact, high-density, 3D imaging of cerebral blood flow (CBF) in preterm infants. The scDCT scans a focused point near-infrared illumination to multiple source positions for deep tissue penetration, and controls an electron multiplying charge-coupled-device camera with thousands of pixels to achieve a high-density sampling. The optimized scDCT for use in preterm infants was first evaluated against an established diffuse correlation spectroscopy in an infant-head-simulating phantom with known properties. The observed significant correlation between the two measurements verified the capability of scDCT for transcranial brain imaging. The insignificant influence of transparent incubator wall on scDCT measurements was then confirmed by comparing adult forearm blood flow responses to artery cuff occlusions measured inside and outside the incubator. Finally, the scDCT device was moved to the NICU to image CBF variations in two preterm infants. Infant #1 with no major organ deficits showed little CBF fluctuation over the first 3 weeks of life. Infant #2 showed a significant CBF increase after the 2 h pharmacotherapy for patent ductus arteriosus closure. While these CBF variations meet physiological expectations, the fact that no significant changes are noted with peripheral monitoring of blood oxygen saturation suggests necessity of direct cerebral monitoring. This feasibility study with timely technology development is an important and necessary step towards larger clinical studies with more subjects to further validate it for continuous monitoring and instant management of cerebral pathologies and interventions in the NICU.
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Affiliation(s)
- Elie G Abu Jawdeh
- Deparment of Pediatrics/Neonatology, College of Medicine, University of Kentucky, Lexington, KY, United States of America. Contributed equally as co-first authors
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33
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Hamrick SEG, Sallmon H, Rose AT, Porras D, Shelton EL, Reese J, Hansmann G. Patent Ductus Arteriosus of the Preterm Infant. Pediatrics 2020; 146:e20201209. [PMID: 33093140 PMCID: PMC7605084 DOI: 10.1542/peds.2020-1209] [Citation(s) in RCA: 120] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/30/2020] [Indexed: 02/07/2023] Open
Abstract
Postnatal ductal closure is stimulated by rising oxygen tension and withdrawal of vasodilatory mediators (prostaglandins, nitric oxide, adenosine) and by vasoconstrictors (endothelin-1, catecholamines, contractile prostanoids), ion channels, calcium flux, platelets, morphologic maturity, and a favorable genetic predisposition. A persistently patent ductus arteriosus (PDA) in preterm infants can have clinical consequences. Decreasing pulmonary vascular resistance, especially in extremely low gestational age newborns, increases left-to-right shunting through the ductus and increases pulmonary blood flow further, leading to interstitial pulmonary edema and volume load to the left heart. Potential consequences of left-to-right shunting via a hemodynamically significant patent ductus arteriosus (hsPDA) include increased risk for prolonged ventilation, bronchopulmonary dysplasia, necrotizing enterocolitis or focal intestinal perforation, intraventricular hemorrhage, and death. In the last decade, there has been a trend toward less aggressive treatment of PDA in preterm infants. However, there is a subgroup of infants who will likely benefit from intervention, be it pharmacologic, interventional, or surgical: (1) prophylactic intravenous indomethacin in highly selected extremely low gestational age newborns with PDA (<26 + 0/7 weeks' gestation, <750 g birth weight), (2) early targeted therapy of PDA in selected preterm infants at particular high risk for PDA-associated complications, and (3) PDA ligation, catheter intervention, or oral paracetamol may be considered as rescue options for hsPDA closure. The impact of catheter-based closure of hsPDA on clinical outcomes should be determined in future prospective studies. Finally, we provide a novel treatment algorithm for PDA in preterm infants that integrates the several treatment modalities in a staged approach.
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Affiliation(s)
- Shannon E G Hamrick
- Divisions of Neonatology and
- Cardiology, Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Hannes Sallmon
- Department of Pediatric Cardiology, Charité University Medical Center, Berlin, Germany
| | | | - Diego Porras
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Elaine L Shelton
- Division of Neonatology, Vanderbilt University Medical Center, Nashville, Tennessee; and
| | - Jeff Reese
- Division of Neonatology, Vanderbilt University Medical Center, Nashville, Tennessee; and
| | - Georg Hansmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
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Ruoss JL, Bazacliu C, Giesinger RE, McNamara PJ. Patent ductus arteriosus and cerebral, cardiac, and gut hemodynamics in premature neonates. Semin Fetal Neonatal Med 2020; 25:101120. [PMID: 32513596 DOI: 10.1016/j.siny.2020.101120] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Patent ductus arteriosus is associated with multiple comorbidities in premature infants, however a causal link or strategy to decrease these morbidities has not been found. The association between the patent ductus arteriosus and morbidities has biologic plausibility as, like any cardiac mixing lesion, a significant systemic to pulmonic shunt may lead to pulmonary over-circulation and systemic hypoperfusion. Understanding the underlying pathophysiology of associated morbidities in the setting of a patent ductus arteriosus may aid in risk stratifying infants and offer a patient targeted approach to infants with a pathological ductal shunt. While the deleterious impact of increased pulmonary blood flow maybe easier to identify, the impact on end-organ perfusion is more challenging. In this review, we will discuss the pathophysiology of a hemodynamically significant patent ductus arteriosus in premature infants, impact on end-organ perfusion and associated morbidities, and novel modalities to assess shunt volume and effect on end-organ perfusion.
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Affiliation(s)
- J L Ruoss
- Division of Neonatology, Department of Pediatrics, University of Florida, 1600 SW Archer Rd, Gainesville, FL, 32608, USA
| | - C Bazacliu
- Division of Neonatology, Department of Pediatrics, University of Florida, 1600 SW Archer Rd, Gainesville, FL, 32608, USA
| | - R E Giesinger
- Division of Neonatology, Department of Pediatrics, University of Iowa, 200 Hawkins Drive, Iowa City, IA, 52242, USA
| | - P J McNamara
- Division of Neonatology, Department of Pediatrics, University of Iowa, 200 Hawkins Drive, Iowa City, IA, 52242, USA; Department of Internal Medicine, University of Iowa, 8803 John Pappajohn Pavillion 200 Hawkins Drive, Iowa City, IA, 52242, USA.
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Hummler H. Near-Infrared spectroscopy for perfusion assessment and neonatal management. Semin Fetal Neonatal Med 2020; 25:101145. [PMID: 32830077 DOI: 10.1016/j.siny.2020.101145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Term and preterm infants often present with adverse conditions after birth resulting in abnormal vital functions and severe organ failure, which are associated or sometimes caused by low oxygen and/or blood supply. Brain injury may lead to substantial mortality and morbidity often affecting long-term outcome. Standard monitoring techniques in the NICU focus on arterial oxygen supply and hemodynamics and include respiratory rate, heart rate, blood pressure and arterial oxygen saturation as measured by pulse oximetry but provide only limited information on end organ oxygen delivery. Near-Infrared Spectroscopy can bridge this gap by displaying continuous measurements of tissue oxygen saturation, providing information on the balance of oxygen delivery and consumption in organs of interest. Future techniques using multi-wavelength devices may provide additional information on oxidative metabolism in real time adding important information.
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Affiliation(s)
- Helmut Hummler
- Chief Division of Neonatology, Department of Pediatrics, Sidra Medicine, Al Gharrafa Street, Ar-Rayyan, PO Box 26999, Doha, Qatar; Professor of Pediatrics, Weill Cornell Medicine Qatar, Professor of Pediatrics adj. Ulm University, Germany.
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Martini S, Frabboni G, Rucci P, Czosnyka M, Smielewski P, Galletti S, Cimatti AG, Faldella G, Corvaglia L, Austin T. Cardiovascular and cerebrovascular responses to cardio-respiratory events in preterm infants during the transitional period. J Physiol 2020; 598:4107-4119. [PMID: 32592405 DOI: 10.1113/jp279730] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 06/16/2020] [Indexed: 12/27/2022] Open
Abstract
KEY POINTS Non-invasive simultaneous multiparametric monitoring allows the in vivo evaluation of cerebral and cardiovascular haemodynamic responses to different types of recurrent episodes of intermittent hypoxia and/or bradycardia, also defined as cardio-respiratory events (CRE), in preterm neonates during postnatal transition. By decreasing left cardiac output, bradycardia further contributes to cerebral hypoxia during CRE. The presence of a haemodynamically significant patent ductus arteriosus results in a deeper impairment of cerebral oxygen status in response to CRE, whereas the brain-sparing remodelling of the fetal circulation resulting from placental insufficiency is associated with more favourable haemodynamic responses to intermittent hypoxia. During transition, the haemodynamic impact of CRE is influenced not only by the event type, but also by specific clinical features; this highlights the importance of developing individualized approaches to reduce the hypoxic burden in this delicate phase. ABSTRACT The present observational prospective study aimed to investigate cerebral and cardiovascular haemodynamic responses to different types of cardio-respiratory events (CRE) in preterm infants during postnatal transition, as well as evaluate the impact of relevant clinical characteristics. Infants with gestational age (GA) <32 weeks and/or birth weight <1500 g were enrolled after birth. Cerebral oxygenation index (cTOI), fractional oxygen extraction (cFTOE), cardiac output (CO), cardiac contractility (iCON) and systemic vascular resistances (sVR) were simultaneously monitored over the first 72 h by near-infrared spectroscopy and electrical velocimetry. CRE were clustered into isolated bradycardia (IB), isolated desaturation (ID) and combined desaturation/bradycardia (DB). For each parameter, percentage changes from baseline (%Δ) were calculated. The impact of different CRE types and clinical variables on %Δ was evaluated with generalized estimating equations. In total, 1426 events were analysed. %ΔcTOI significantly differed among ID, IB and DB (P < 0.001), with the latter showing the greatest drop. %ΔcFTOE decreased significantly during DB (P < 0.001) and ID (P < 0.001) compared to IB. DB and IB were associated with more negative %ΔCO (P < 0.001) and more positive %ΔsVR (P < 0.001) compared to ID. A slight iCON reduction was observed during DB compared to ID (P = 0.043). Antenatal umbilical Doppler impairment, GA and the presence of a haemodynamically significant patent ductus arteriosus had a significant independent impact on %ΔcTOI, %ΔcFTOE and %ΔCO. During the transitional period, the haemodynamic responses to CRE are influenced by the event type and by specific neonatal characteristics, suggesting the importance of targeted individualized approaches for minimizing the risk of cerebral injury in the preterm population.
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Affiliation(s)
- Silvia Martini
- Neonatal Intensive Care Unit, St Orsola-Malpighi University Hospital, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Giulia Frabboni
- Neonatal Intensive Care Unit, St Orsola-Malpighi University Hospital, Bologna, Italy
| | - Paola Rucci
- Department of Biomedical and Neuromotor Sciences, Division of Hygiene and Biostatistics, University of Bologna, Bologna, Italy
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrookes Hospital, Cambridge, UK.,Institute of Electronic Systems, Warsaw University of Technology, Poland
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrookes Hospital, Cambridge, UK
| | - Silvia Galletti
- Neonatal Intensive Care Unit, St Orsola-Malpighi University Hospital, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Anna Giulia Cimatti
- Neonatal Intensive Care Unit, St Orsola-Malpighi University Hospital, Bologna, Italy
| | - Giacomo Faldella
- Neonatal Intensive Care Unit, St Orsola-Malpighi University Hospital, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Luigi Corvaglia
- Neonatal Intensive Care Unit, St Orsola-Malpighi University Hospital, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Topun Austin
- Neonatal Intensive Care Unit, The Rosie Hospital, Cambridge University Hospitals, Cambridge, UK
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Su BH, Lin HY, Chiu HY, Tsai ML, Chen YT, Lu IC. Therapeutic strategy of patent ductus arteriosus in extremely preterm infants. Pediatr Neonatol 2020; 61:133-141. [PMID: 31740267 DOI: 10.1016/j.pedneo.2019.10.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 09/15/2019] [Accepted: 10/21/2019] [Indexed: 01/29/2023] Open
Abstract
The ductus arteriosus is likely to close without treatment in most infants born at gestational age (GA) > 28 weeks (73%), and those with birth weight > 1000 g (94%). However, the rates of spontaneous ductal closure among less mature or smaller infants with respiratory distress syndrome are not known. Extremely preterm infants born at GA < 28 weeks are associated with a high risk of severe intraventricular hemorrhage (IVH) or pulmonary hemorrhage, which usually occur within 72 h after birth and affect mortality and long-term neurological development. These serious hemorrhagic complications may be closely related to hemodynamic changes caused by a hemodynamically significant patent ductus arteriosus (hs-PDA). While prophylactic indomethacin has been shown to reduce the rates of PDA, PDA ligation, severe IVH and early pulmonary hemorrhage, the available evidence does not support its prophylactic use in preterm infants. Symptomatic or late treatment is associated with lower success rate, and increased complications of a hs-PDA. The issue of "to treat or not to treat a PDA" is controversial. Considering the relationship between the effectiveness and timing of pharmacological treatment, early targeted treatment may be an alternative approach for the early identification of a hs-PDA in specific high-risk patient population, especially infants <26 weeks GA who are at the highest risk of severe IVH or pulmonary hemorrhage. Serial echocardiographic studies can be used to select patients who are candidates for early targeted medical treatment of hs-PDA. Surgical ligation of PDA, and transcatheter closure if proven to be safe, can be used as back-up therapy for patients who fail medical treatment and continue to have cardiopulmonary compromise.
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Affiliation(s)
- Bai-Horng Su
- Department of Neonatology, China Medical University Children's Hospital, Taichung, Taiwan; Department of Pediatrics, School of Medicine, China Medical University, Taichung, Taiwan.
| | - Hsiang-Yu Lin
- Department of Neonatology, China Medical University Children's Hospital, Taichung, Taiwan; Department of Pediatrics, School of Medicine, China Medical University, Taichung, Taiwan
| | - Hsiao-Yu Chiu
- Department of Neonatology, China Medical University Children's Hospital, Taichung, Taiwan
| | - Ming-Luen Tsai
- Department of Neonatology, China Medical University Children's Hospital, Taichung, Taiwan
| | - Yin-Ting Chen
- Department of Neonatology, China Medical University Children's Hospital, Taichung, Taiwan
| | - I-Chun Lu
- Department of Neonatology, China Medical University Children's Hospital, Taichung, Taiwan
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Kim ES, Kaiser JR, Rios DR, Bornemeier RA, Rhee CJ. Cerebral Hemodynamics Are Not Affected by the Size of the Patent Ductus Arteriosus. Neonatology 2020; 117:182-188. [PMID: 32434188 PMCID: PMC7381380 DOI: 10.1159/000506835] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 02/26/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Although patent ductus arteriosus (PDA) has been implicated to play a role in the development of cerebral ischemia and intraventricular hemorrhage (IVH) through a cerebral steal phenomenon, there is conflicting data on the impact of PDA size on cerebral blood flow (CBF). Cerebral autoregulation is the brain's innate protective mechanism to maintain constant CBF despite changes in blood pressure, and it is unclear if it is influenced by PDA hemodynamics. OBJECTIVE To delineate the relationship between PDA size and CBF velocity (CBFv) in premature infants. METHODS 113 premature infants born at 23-29 weeks' gestation had echocardiograms performed during the first week after birth to evaluate for PDA. The infants were divided into 3 groups according to PDA size: none-to-small, moderate, or large. All infants had continuous recordings of umbilical artery blood pressure (ABP) and CBFv during the first week after birth. Critical closing pressure (CrCP) was calculated from ABP and CBFv tracings. Diastolic closing margin (DCM), defined as diastolic blood pressure minus CrCP, was calculated as a marker for the risk of developing IVH. RESULTS Infants with a large PDA (n = 16) had the lowest ABP across all phases of the cardiac cycle (systole [p = 0.003], mean [p = 0.005], and diastole [p = 0.012]) compared to infants with a moderate (n = 19) or none-to-small PDA (n = 78). Despite blood pressure being different, systolic, mean, and diastolic CBFv were not different across groups. Cerebral autoregulation, as measured during systole, was intact regardless of the PDA size. CrCP and DCM were also not different across groups. CONCLUSIONS In this cohort, CBFv and cerebral autoregulation during systole were not influenced by PDA size. Intact cerebral autoregulation may play a role in maintaining CBFv regardless of PDA size and differences in ABP.
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Affiliation(s)
- Eun Sun Kim
- Department of Pediatrics, Kangwon National University School of Medicine, Chuncheon, Republic of Korea,
| | - Jeffrey R Kaiser
- Division of Neonatal-Perinatal Medicine, Departments of Pediatrics and Obstetrics and Gynecology, Penn State Health Children's Hospital, Hershey, Pennsylvania, USA
| | - Danielle R Rios
- Section of Neonatology, Department of Pediatrics,Texas Children's Hospital/Baylor College of Medicine, Houston, Texas, USA
| | - Renee A Bornemeier
- Department of Pediatrics, Arkansas Children's Hospital/University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Christopher J Rhee
- Section of Neonatology, Department of Pediatrics,Texas Children's Hospital/Baylor College of Medicine, Houston, Texas, USA
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Smith A, El-Khuffash AF. Defining "Haemodynamic Significance" of the Patent Ductus Arteriosus: Do We Have All the Answers? Neonatology 2020; 117:225-232. [PMID: 32450558 DOI: 10.1159/000506988] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 03/03/2020] [Indexed: 11/19/2022]
Abstract
Optimum management of the patent ductus arteriosus (PDA) in preterm infants remains one of the most debated topics within the field of neonatology. Despite numerous observational studies and over 60 randomized control trials, consensus on PDA management remains elusive. In order to make meaningful progress on the controversial issue of PDA management, several key factors must be thoroughly addressed; namely (1) accurate identification of infants at greatest risk of long-term morbidities from PDA exposure, (2) acceptance that the PDA is not a dichotomous entity and an individualised approach to its management is required for each neonate, (3) international consensus on what constitutes a haemodynamically significant PDA and (4) the incorporation of multi-organ assessment when evaluating the impact a PDA may pose on overall neonatal physiology. This review assesses the evidence base available supporting various therapeutic strategies for PDA, the deficits in our current knowledge on the definition of haemodynamic significance and future directions to pursue in order to more successfully address this contentious subject.
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Affiliation(s)
- Aisling Smith
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland
| | - Afif F El-Khuffash
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland, .,Department of Paediatrics, School of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland,
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Harer MW, Chock VY. Renal Tissue Oxygenation Monitoring-An Opportunity to Improve Kidney Outcomes in the Vulnerable Neonatal Population. Front Pediatr 2020; 8:241. [PMID: 32528917 PMCID: PMC7247835 DOI: 10.3389/fped.2020.00241] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 04/20/2020] [Indexed: 12/12/2022] Open
Abstract
Adequate oxygenation of the kidney is of critical importance in the neonate. Non-invasive monitoring of renal tissue oxygenation using near-infrared spectroscopy (NIRS) is a promising bedside strategy for early detection of circulatory impairment as well as recognition of specific renal injury. As a diagnostic tool, renal NIRS monitoring may allow for earlier interventions to prevent or reduce injury in various clinical scenarios in the neonatal intensive care unit. Multiple studies utilizing NIRS monitoring in preterm and term infants have provided renal tissue oxygenation values at different time points during neonatal hospitalization, and have correlated measures with ultrasound and Doppler flow data. With the establishment of normal values, studies have utilized renal tissue oxygenation monitoring in preterm neonates to predict a hemodynamically significant patent ductus arteriosus, to assess response to potentially nephrotoxic medications, to identify infants with sepsis, and to describe changes after red blood cell transfusions. Other neonatal populations being investigated with renal NIRS monitoring include growth restricted infants, those requiring delivery room resuscitation, infants with congenital heart disease, and neonates undergoing extracorporeal membrane oxygenation. Furthermore, as the recognition of acute kidney injury (AKI) and its associated morbidity and mortality in neonates has increased over the last decade, alternative methods are being investigated to diagnose AKI before changes in serum creatinine or urine output occur. Studies have utilized renal NIRS monitoring to diagnose AKI in specific populations, including neonates with hypoxic ischemic encephalopathy after birth asphyxia and in infants after cardiac bypass surgery. The use of renal tissue oxygenation monitoring to improve renal outcomes has yet to be established, but results of studies published to date suggest that it holds significant promise to function as a real time, early indicator of poor renal perfusion that may help with development of specific treatment protocols to prevent or decrease the severity of AKI.
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Affiliation(s)
- Matthew W Harer
- Division of Neonatology, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Valerie Y Chock
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, United States
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41
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Regional tissue oxygenation monitoring in the neonatal intensive care unit: evidence for clinical strategies and future directions. Pediatr Res 2019; 86:296-304. [PMID: 31247635 DOI: 10.1038/s41390-019-0466-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 05/24/2019] [Accepted: 06/08/2019] [Indexed: 12/19/2022]
Abstract
Near-infrared spectroscopy (NIRS)-based monitoring of regional tissue oxygenation (rSO2) is becoming more commonplace in the neonatal intensive care unit (NICU). While increasing evidence supports rSO2 monitoring, actual standards for applying this noninvasive bedside technique continue to evolve. This review highlights the current strengths and pitfalls surrounding practical NIRS-based monitoring in the neonatal population. The physiologic background of rSO2 monitoring is discussed, with attention to understanding oxygen delivery/consumption mismatch and its effects on tissue oxygen extraction. The bedside utility of both cerebral and peripheral rSO2 monitoring in the NICU is then explored from two perspectives: (1) disease/event-specific "responsive" monitoring and (2) "routine," continuous monitoring. Recent evidence incorporating both monitoring approaches is summarized with emphasis on practical applicability in the NICU. Finally, a future paradigm for a broad-based NIRS monitoring strategy is presented, with attention towards improving personalization of neonatal care and ultimately enhancing long-term outcomes.
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Poon WB, Tagamolila V. Cerebral perfusion and assessing hemodynamic significance for patent ductus arteriosus using near infrared red spectroscopy in very low birth weight infants. J Matern Fetal Neonatal Med 2019; 34:1645-1650. [PMID: 31303077 DOI: 10.1080/14767058.2019.1644313] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION/OBJECTIVE To study the impact of hemodynamically significant patent ductus arteriosus (hsPDA), using near infrared red spectroscopy (NIRS) regional cerebral (SrO2), renal (RrO2) saturation measurements, and fractional tissue oxygenation extraction (FTOE) before and after medical and/or surgical treatment. METHODS Prospective cohort study of very low birth weight (VLBW) preterm infants with hsPDA requiring treatment from March 2014 to December 2016 in a tertiary Neonatal Intensive Care Unit in Singapore. NIRS was applied at diagnosis until 24-48 h after the last dose of ibuprofen or postsurgical ligation. All PDAs were documented to be closed by echocardiography. Post-treatment values (control group) were compared against pretreatment values. RESULTS Twenty-nine infants were studied, with mean gestational age of 26.7 weeks and birth weight of 956 g. Median day of life of PDA diagnosis was 4. Seven infants (24.1%) underwent PDA ligation. There was significant reduction in FTOE before treatment till after last dose of medication or ligation by a mean difference of 7.27% (p < .05). Reduction in FTOE was also found between the first dose of medication till after the last dose or ligation. Cerebral SrO2 significantly increased between first dose of medication till last dose of medication by a mean difference of 3.09% (p = .034). RrSO2 values were not significantly affected. No correlation between NIRS values and PDA size was found. CONCLUSIONS Significant increase in cerebral SrO2 and reduction in FTOE by NIRS post PDA closure in hemodynamically significant PDAs suggest that PDA closure may reduce cerebral hypoxia burden.
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Affiliation(s)
- Woei Bing Poon
- Department of Neonatal and Developmental Medicine, Singapore General Hospital, Bukit Merah, Singapore
| | - Vina Tagamolila
- Department of Neonatal and Developmental Medicine, Singapore General Hospital, Bukit Merah, Singapore
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Sung SI. Controversy in the diagnosis and treatment of hemodynamically significant patent ductus arteriosus in preterm infants. KOREAN JOURNAL OF PEDIATRICS 2019; 62:410-411. [PMID: 31319651 PMCID: PMC6881201 DOI: 10.3345/kjp.2019.00570] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 06/17/2019] [Indexed: 12/14/2022]
Affiliation(s)
- Se In Sung
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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44
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Katheria V, Poeltler DM, Brown MK, Hassen KO, Patel D, Rich W, Finer NN, Katheria AC. Early prediction of a significant patent ductus arteriosus in infants <32 weeks gestational age. J Neonatal Perinatal Med 2019; 11:265-271. [PMID: 29843271 DOI: 10.3233/npm-1771] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The optimal thresholds for identification of preterm infants at greatest risk for adverse sequelae related to patent ductus arteriosus have not been well delineated. Our aim was to determine hemodynamic parameters in the first 24 hours using continuous non-invasive vital and structural measurements to predict which infants required PDA treatment in our institution. METHODS Retrospective secondary analysis of data from infants born 23 to 32 weeks gestational age with cardiac output and stroke volume via electrical cardiometry, cerebral tissue oximetry measurements, mean arterial blood pressure (BP), heart rate, and oxygen saturation and functional echocardiography results at 12 hours of life were recorded when available (93 percent of subjects). RESULTS A total of 292 infants, of which 55 (26±2 weeks, 862±268 grams) were treated for PDA. Treated infants demonstrated increased left ventricular output (p < 0.001) and lower mean BP (p = 0.010). The optimal area under the receiver operating characteristic curve (AUC) for predicting PDA treatment in our all gestations cohort is a mean BP at 15 hours of life of <33 mm Hg (AUC = 0.854, p < 0.001, 95% CI 0.792, 0.916). For infants <28 weeks a mean BP at 13 hours of life of <33 mm Hg (AUC = 0.741, p < 0.050, 95% CI 0.642, 0.839). CONCLUSIONS In our cohort increased left ventricular output and lower mean BP predicted a clinically significant PDA requiring treatment.
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Affiliation(s)
- V Katheria
- Neonatal Research Institute at Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA
| | - D M Poeltler
- Neonatal Research Institute at Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA
| | - M K Brown
- Neonatal Research Institute at Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA
| | - K O Hassen
- Neonatal Research Institute at Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA
| | - D Patel
- Neonatal Research Institute at Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA
| | - W Rich
- Neonatal Research Institute at Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA
| | - N N Finer
- Neonatal Research Institute at Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA
| | - A C Katheria
- Neonatal Research Institute at Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA
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Variane GFT, Chock VY, Netto A, Pietrobom RFR, Van Meurs KP. Simultaneous Near-Infrared Spectroscopy (NIRS) and Amplitude-Integrated Electroencephalography (aEEG): Dual Use of Brain Monitoring Techniques Improves Our Understanding of Physiology. Front Pediatr 2019; 7:560. [PMID: 32039117 PMCID: PMC6985148 DOI: 10.3389/fped.2019.00560] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Accepted: 12/23/2019] [Indexed: 01/10/2023] Open
Abstract
Continuous brain monitoring tools are increasingly being used in the neonatal intensive care unit (NICU) to assess brain function and cerebral oxygenation in neonates at high risk for brain injury. Near infrared spectroscopy (NIRS) is useful in critically ill neonates as a trend monitor to evaluate the balance between tissue oxygen delivery and consumption, providing cerebral and somatic oximetry values, and allowing earlier identification of abnormalities in hemodynamics and cerebral perfusion. Amplitude-integrated electroencephalography (aEEG) is a method for continuous monitoring of cerebral function at the bedside. Simultaneous use of both monitoring modalities may improve the understanding of alterations in hemodynamics and risk of cerebral injury. Several studies have described correlations between aEEG and NIRS monitoring, especially in infants with hypoxic-ischemic encephalopathy (HIE), but few describe the combined use of both monitoring techniques in a wider range of clinical scenarios. We review the use of NIRS and aEEG in neonates and describe four cases where abnormal NIRS values were immediately followed by changes in brain activity as seen on aEEG allowing the impact of a hemodynamic disturbance on the brain to be correlated with the changes in the aEEG background pattern. These four clinical scenarios demonstrate how simultaneous neuromonitoring with aEEG and NIRS provides important clinical information. We speculate that routine use of these combined monitoring modalities may become the future standard for neonatal neuromonitoring.
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Affiliation(s)
- Gabriel Fernando Todeschi Variane
- Grupo Santa Joana, Division of Neonatology, São Paulo, Brazil.,Division of Neonatology, Department of Pediatrics, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil.,Protecting Brains and Saving Futures Organization, São Paulo, Brazil
| | - Valerie Y Chock
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Packard Children's Hospital Stanford, Palo Alto, CA, United States
| | - Alexandre Netto
- Division of Neonatology, Department of Pediatrics, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil.,Protecting Brains and Saving Futures Organization, São Paulo, Brazil
| | - Rafaela Fabri Rodrigues Pietrobom
- Division of Neonatology, Department of Pediatrics, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil.,Protecting Brains and Saving Futures Organization, São Paulo, Brazil.,Neonatal Unit, Sociedade Beneficente Israelita Brasileira Hospital Albert Einstein, São Paulo, Brazil
| | - Krisa Page Van Meurs
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Packard Children's Hospital Stanford, Palo Alto, CA, United States
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46
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Shepherd JL, Noori S. What is a hemodynamically significant PDA in preterm infants? CONGENIT HEART DIS 2018; 14:21-26. [PMID: 30548469 DOI: 10.1111/chd.12727] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 10/16/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE There is no consensus on the definition of a hemodynamically significant patent ductus arteriosus (hsPDA). In this review article, our objective is to discuss the main variables that one should consider when determining the hemodynamic significance of a PDA. RESULTS We describe the various approaches that have been utilized over time to define an hsPDA and discuss the strengths and weaknesses of each echocardiographic index. Finally, we propose a comprehensive and individualized approach in determining the hemodynamic significance of the PDA. CONCLUSION There are several PDA-related clinical, echocardiographic, and other objective variables to take into consideration when defining an hsPDA. However, vulnerability based on gestational or chronological age is an important contributor as well.
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Affiliation(s)
- Jennifer L Shepherd
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Shahab Noori
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
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47
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Chock VY, Variane GFT, Netto A, Van Meurs KP. NIRS improves hemodynamic monitoring and detection of risk for cerebral injury: cases in the neonatal intensive care nursery. J Matern Fetal Neonatal Med 2018; 33:1802-1810. [PMID: 30244630 DOI: 10.1080/14767058.2018.1528223] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Near-infrared spectroscopy (NIRS) monitoring provides a noninvasive, bedside measure of cerebral and somatic oxygenation in neonates at risk for hemodynamic instability and brain injury. This technology has been increasingly utilized in the neonatal intensive care unit, however, clinicians perceive a lack of evidence for the added value of NIRS monitoring. We present six clinical scenarios illustrating the value of NIRS monitoring for the diagnosis and management of critically ill newborns.
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Affiliation(s)
- Valerie Y Chock
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Gabriel F T Variane
- Department of Pediatrics, Division of Neonatology, Irmandade da Santa Casa de Misericordia de Sao Paulo, Sao Paulo, Brazil.,Division of Neonatology, Grupo Santa Joana, Sao Paulo, Brazil
| | - Alexandre Netto
- Department of Pediatrics, Division of Neonatology, Irmandade da Santa Casa de Misericordia de Sao Paulo, Sao Paulo, Brazil
| | - Krisa P Van Meurs
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
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48
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Sehgal A, McNamara PJ. International perspective on management of a patent ductus arteriosus: Lessons learned. Semin Fetal Neonatal Med 2018. [PMID: 29534972 DOI: 10.1016/j.siny.2018.03.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Whereas association between a patent ductus arteriosus (PDA) and neonatal morbidities has been well described, consensus has not been reached on whether the relationship is causal, on benefit of (or lack of) treatment, on factors guiding the 'need to treat', and on treatment strategies. Trials to date have primarily focused on the narrow outcome of successful ductal closure. Evidence from several retrospective studies has suggested that management may be modified with increased use of conservative treatment. A paradigm shift has resulted in decreased use of treatments to close the PDA in some centres. This approach cites the lack of demonstrable improvement in short- and long-term respiratory and neurodevelopmental outcomes as an argument. This article reviews current understanding of the wide variation in practice at either institutional, regional, national, or international level. It discusses the potential contributors to variability in diagnostic ascertainment and therapeutic intervention.
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Affiliation(s)
- Arvind Sehgal
- Monash Newborn, Monash Children's Hospital, Melbourne, Australia; Department of Pediatrics, Monash University, Melbourne, Australia.
| | - Patrick J McNamara
- Department of Paediatrics, University of Toronto, Toronto, Canada; Department of Physiology, University of Toronto, Toronto, Canada; Division of Neonatology, Hospital for Sick Children, Toronto, Canada
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49
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Kluckow M, Lemmers P. Hemodynamic assessment of the patent ductus arteriosus: Beyond ultrasound. Semin Fetal Neonatal Med 2018; 23:239-244. [PMID: 29730050 DOI: 10.1016/j.siny.2018.04.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Assessment and management of a patent ductus arteriosus (PDA) in premature infants remains problematic. The more immature the infant, the more likely a PDA is to be present, due to lower spontaneous PDA closure rates. Clinicians now recognize that not all PDAs require treatment and that selection of the group of infants with a more hemodynamically relevant PDA, often manifesting as an increasing systemic-to-pulmonary shunt, is increasingly important. Ultrasound is the mainstay of diagnosis and physiological assessment of the PDA; however, there are other methodologies used to assess hemodynamic importance of the PDA. These range from assessment of clinical signs through biomarkers and finally to physiological assessment of the end-organ effect of the PDA, using methods such as cerebral Doppler or near infra-red spectroscopy. Extended assessment of a PDA's physiological effect may lead to a more individualized approach to PDA treatment.
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Affiliation(s)
- M Kluckow
- Department of Neonatology, Royal North Shore Hospital, University of Sydney, Sydney, Australia.
| | - P Lemmers
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center, Utrecht, The Netherlands
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50
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Interpretation of Cerebral Oxygenation Changes in the Preterm Infant. CHILDREN-BASEL 2018; 5:children5070094. [PMID: 29987227 PMCID: PMC6069134 DOI: 10.3390/children5070094] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 06/28/2018] [Accepted: 07/06/2018] [Indexed: 12/30/2022]
Abstract
Near-infrared spectroscopy (NIRS) allows for continuous, non-invasive monitoring of end-organ tissue oxygenation. The use of NIRS, cerebral NIRS (cNIRS) in particular, in neonatal care has increased significantly over the last few years. This dynamic monitoring technique provides real-time information on the cerebral and haemodynamic status of the neonate and has the potential to serve as an important adjunct to patient care with some centres routinely utilising cNIRS to aid decision-making at the bedside. cNIRS values may be influenced by many variables, including cardiac, respiratory and metabolic parameters, and therefore it is essential to understand the pathophysiology behind alterations in cNIRS values. Correct interpretation is required to direct appropriate patient-specific interventions. This article aims to assist clinicians in deciphering cNIRS values by providing an overview of potential causes of fluctuations in cNIRS values, illustrated by common clinical scenarios, with particular emphasis on the preterm infant.
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