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Joye S, Kharrat A, Zhu F, Deshpande P, Baczynski M, Jasani B, Lee S, Mertens LL, McNamara PJ, Shah PS, Weisz DE, Jain A. Impact of targeted neonatal echocardiography consultations for critically sick preterm neonates. Arch Dis Child Fetal Neonatal Ed 2024:fetalneonatal-2024-327347. [PMID: 39227145 DOI: 10.1136/archdischild-2024-327347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Accepted: 08/21/2024] [Indexed: 09/05/2024]
Abstract
RATIONALE Preterm neonates needing rescue treatments with inotropes and/or inhaled nitric oxide (iNO) (acute critical illnesses, ACIs) in neonatal intensive care units (NICUs) are at high risk of mortality. While targeted neonatal echocardiography consultations (TNE) are increasingly used to guide management, its clinical impact need evaluation. OBJECTIVES To investigate clinical outcomes in relation to TNE utilisation during episodes of ACIs among preterm neonates. METHODS This retrospective cohort study, conducted at two tertiary NICUs over 10 years, included neonates<37 weeks gestational age (GA) who developed ACIs. Patients receiving TNE-guided care (TNE within 24 hours of treatment initiation) were compared with non-TNE management. Outcomes included predischarge mortality, episode-related mortality (<7 days) and a new diagnosis of intraventricular haemorrhage≥grade 3 (IVH-3). Inverse probability of treatment weighting (IPTW) using propensity score was used to account for confounders, including site, birth years and baseline illness severity. MEASUREMENTS AND MAIN RESULTS Of 622 included patients, 297 (48%) had TNE; median (IQR) GA at ACI was 26.4 (25.0-28.4) weeks. TNE group demonstrated higher baseline mean airway pressure, oxygen requirement and heart rate and frequently received both inotrope and iNO during ACI. IPTW analysis revealed TNE was associated with lower mortality (adjusted OR (95% CI) 0.75 (0.59 to 0.95)), episode-related mortality (0.54 (0.40 to 0.72)) and death or IVH-3 (0.78 (0.62 to 0.99)). TNE group received more varied inotropic agents, demonstrated earlier improvements in blood pressures, without increasing overall inotrpoic burden. CONCLUSIONS Among preterm neonates requiring rescue treatments with inotropes/iNO, TNE utilisation to guide clinical management may be associated with improved survival.
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Affiliation(s)
- Sébastien Joye
- Department Mother-Woman-Child, Clinic of Neonatology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Ashraf Kharrat
- Department of Paediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Faith Zhu
- Department of Paediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Poorva Deshpande
- Department of Paediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Michelle Baczynski
- Department of Respiratory Therapy, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Bonny Jasani
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
- Division of Neonatology, Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Seungwoo Lee
- Department of Paediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Luc L Mertens
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
- Division of Cardiology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Patrick J McNamara
- Department of Pediatrics and Internal Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Prakesh S Shah
- Department of Paediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Dany E Weisz
- Newborn and Developmental Paediatrics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Amish Jain
- Department of Paediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
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Condit PE, Chuck JE, Lasarev MR, Chock VY, Harer MW. Renal tissue oxygenation and development of AKI in preterm neonates born < 32 weeks' gestational age in the first week of age. J Perinatol 2024; 44:434-438. [PMID: 38233582 DOI: 10.1038/s41372-024-01873-y] [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] [Received: 08/31/2023] [Revised: 12/29/2023] [Accepted: 01/04/2024] [Indexed: 01/19/2024]
Abstract
OBJECTIVE To evaluate the relationship between regional renal saturation of oxygen (RrSO2) changes and serum creatinine (SCr) during the first eight days of age for preterm neonates born < 32 weeks' gestational age. DESIGN Post-hoc analysis of multicenter prospectively measured neonatal RrSO2 values collected during the first 8 days of age in neonates born at < 32 weeks' gestation. Acute kidney injury (AKI) was defined by the neonatal modified Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Variables were compared between groups of neonates with and with AKI. RESULTS One hundred nine neonates were included and 561 SCr values were obtained. Eight participants developed AKI by SCr criteria. A 10-percentage point increase in mean %RrSO2 was associated with a 40% decrease in risk of AKI (95%CI: 9.6-61%; p = 0.016). CONCLUSIONS Increases in mean %RrSO2 in neonates born at < 32 weeks' GA were associated with a decreased risk of AKI. These findings support the design of further prospective trials utilizing RrSO2 monitoring to evaluate new therapies or clinical protocols to prevent and treat neonatal AKI.
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Affiliation(s)
- Paige E Condit
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
| | - Jennifer E Chuck
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Michael R Lasarev
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Valerie Y Chock
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Matthew W Harer
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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McNamara PJ, Jain A, El-Khuffash A, Giesinger R, Weisz D, Freud L, Levy PT, Bhombal S, de Boode W, Leone T, Richards B, Singh Y, Acevedo JM, Simpson J, Noori S, Lai WW. Guidelines and Recommendations for Targeted Neonatal Echocardiography and Cardiac Point-of-Care Ultrasound in the Neonatal Intensive Care Unit: An Update from the American Society of Echocardiography. J Am Soc Echocardiogr 2024; 37:171-215. [PMID: 38309835 DOI: 10.1016/j.echo.2023.11.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2024]
Abstract
Targeted neonatal echocardiography (TNE) involves the use of comprehensive echocardiography to appraise cardiovascular physiology and neonatal hemodynamics to enhance diagnostic and therapeutic precision in the neonatal intensive care unit. Since the last publication of guidelines for TNE in 2011, the field has matured through the development of formalized neonatal hemodynamics fellowships, clinical programs, and the expansion of scientific knowledge to further enhance clinical care. The most common indications for TNE include adjudication of hemodynamic significance of a patent ductus arteriosus, evaluation of acute and chronic pulmonary hypertension, evaluation of right and left ventricular systolic and/or diastolic function, and screening for pericardial effusions and/or malpositioned central catheters. Neonatal cardiac point-of-care ultrasound (cPOCUS) is a limited cardiovascular evaluation which may include line tip evaluation, identification of pericardial effusion and differentiation of hypovolemia from severe impairment in myocardial contractility in the hemodynamically unstable neonate. This document is the product of an American Society of Echocardiography task force composed of representatives from neonatology-hemodynamics, pediatric cardiology, pediatric cardiac sonography, and neonatology-cPOCUS. This document provides (1) guidance on the purpose and rationale for both TNE and cPOCUS, (2) an overview of the components of a standard TNE and cPOCUS evaluation, (3) disease and/or clinical scenario-based indications for TNE, (4) training and competency-based evaluative requirements for both TNE and cPOCUS, and (5) components of quality assurance. The writing group would like to acknowledge the contributions of Dr. Regan Giesinger who sadly passed during the final revisions phase of these guidelines. Her contributions to the field of neonatal hemodynamics were immense.
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Affiliation(s)
| | - Amish Jain
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Afif El-Khuffash
- Department of Paediatrics, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Regan Giesinger
- Department of Pediatrics, University of Iowa, Iowa City, Iowa
| | - Dany Weisz
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Lindsey Freud
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Philip T Levy
- Division of Newborn Medicine, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Shazia Bhombal
- Department of Pediatrics, Division of Neonatology, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Willem de Boode
- Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, the Netherlands
| | - Tina Leone
- Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | | | - Yogen Singh
- Loma Linda University School of Medicine, Loma Linda, California
| | - Jennifer M Acevedo
- Department of Pediatrics-Cardiology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - John Simpson
- Department of Pediatrics, Evelina London Children's Hospital, London, United Kingdom
| | - 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
| | - Wyman W Lai
- CHOC Children's Hospital, Orange, California; University of California, Irvine, Orange, California
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Deshpande P, Barbosa de Olivera C, Jain A, Hahn C, Shah PS, Guerguerian AM, McNamara PJ. Relationship between cerebral oxygenation, cardiac output, and blood pressure during transitional period in extremely low gestational age neonates. Front Pediatr 2023; 11:1187769. [PMID: 37654688 PMCID: PMC10466030 DOI: 10.3389/fped.2023.1187769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 08/03/2023] [Indexed: 09/02/2023] Open
Abstract
Objective To describe the relationship between cerebral oxygenation, cardiac output, arterial blood pressure (BP), and cerebral blood flow velocity in extremely low gestational age neonates (ELGANs) during transition. Methods This study comprises secondary analyses from a prospective observational study conducted at a tertiary Neonatal Intensive Care Unit. Recruited ELGANs underwent cerebral saturation (CrSO2) monitoring and serial echocardiography during 72 h from birth. Correlative analyses of CrSO2 and cerebral fractional tissue oxygen extraction (CFTOE) with left (LVO) and right ventricular output (RVO), superior vena cava (SVC) flow, middle cerebral artery blood flow mean velocity (MCA.MV), systolic (SBP), diastolic (DBP), and mean (MBP) BP were conducted. Results Fifty ELGANs with median (range) gestational age of 25.9 (23.1-27.9) weeks were recruited. Echocardiography was performed sequentially at a median (range) age 5.0 (3.8-6.6), 17.3 (15.4-19.4), 31.0 (27.0-34.1), and 53.7 (49.3-58.3) hours. RVO, LVO, CrSO2, and SBP increased over time but no changes in MBP, DBP, CFTOE, MCA.MV or SVC flow were noted. A weak correlation was identified between CrSO2 and SBP (r2 = 0.11, p = 0.047) and MBP (r2 = 0.12, p = 0.04) at 17.3 (15.4-19.4) hours. No correlation of either CrSO2 or CFTOE with any measures of blood flow was identified. Conclusion There is a weak correlation between measures of cardiac output, BP, and MCA.MV with both CrSO2 and CFTOE in ELGANs during transition. Whether this finding suggests intact cerebral autoregulation requires prospective evaluation in a cohort of sick ELGANs.
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Affiliation(s)
- Poorva Deshpande
- Department of Pediatrics, Mount Sinai Hospital, Toronto, ON, Canada
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Caio Barbosa de Olivera
- Department of Pediatrics, Mount Sinai Hospital, Toronto, ON, Canada
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Amish Jain
- Department of Pediatrics, Mount Sinai Hospital, Toronto, ON, Canada
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Cecil Hahn
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
- Neurosciences and Mental Health, Hospital for Sick Children, Toronto, ON, Canada
| | - Prakesh S. Shah
- Department of Pediatrics, Mount Sinai Hospital, Toronto, ON, Canada
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Anne-Marie Guerguerian
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
- Neurosciences and Mental Health, Hospital for Sick Children, Toronto, ON, Canada
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Stewart DL, Elsayed Y, Fraga MV, Coley BD, Annam A, Milla SS. Use of Point-of-Care Ultrasonography in the NICU for Diagnostic and Procedural Purposes. Pediatrics 2022; 150:190110. [PMID: 37154781 DOI: 10.1542/peds.2022-060053] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/26/2022] [Indexed: 11/29/2022] Open
Abstract
Point-of-care ultrasonography (POCUS) refers to the use of portable imaging performed by the provider clinician at the bedside for diagnostic, therapeutic, and procedural purposes. POCUS could be considered an extension of the physical examination but not a substitute for diagnostic imaging. Use of POCUS in emergency situations can be lifesaving in the NICU if performed in a timely fashion for cardiac tamponade, pleural effusions, pneumothorax, etc, with potential for enhancing quality of care and improving outcomes.
In the past 2 decades, POCUS has gained significant acceptance in clinical medicine in many parts of the world and in many subspecialties. Formal accredited training and certification programs are available for neonatology trainees as well as for many other subspecialties in Canada, Australia, and New Zealand. Although no formal training program or certification is available to neonatologists in Europe, POCUS is widely available to providers in NICUs. A formal institutional POCUS fellowship is now available in Canada. In the United States, many clinicians have the skills to perform POCUS and have incorporated it in their daily clinical practice. However, appropriate equipment remains limited, and many barriers exist to POCUS program implementation.
Recently, the first international evidence-based POCUS guidelines for use in neonatology and pediatric critical care were published. Considering the potential benefits, a recent national survey of neonatologists confirmed that the majority of clinicians were inclined to adopt POCUS in their clinical practice if the barriers could be resolved.
This technical report describes many potential POCUS applications in the NICU for diagnostic and procedural purposes.
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Affiliation(s)
- Dan L Stewart
- Department of Pediatrics and International Pediatrics, Norton Children's Neonatology Affiliated with University of Louisville School of Medicine, Louisville, Kentucky
| | - Yasser Elsayed
- Department of Pediatrics and Child Health, Max Rady College of Medicine, University of Manitoba-Canada, Health Sciences Centre-Winnipeg, Winnipeg, Manitoba, Canada
| | - María V Fraga
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Brian D Coley
- Departments of Radiology and Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Aparna Annam
- Departments of Radiology and Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Vascular Anomalies Center, Aurora, Colorado
| | - Sarah Sarvis Milla
- Departments of Radiology and Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado
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Amer R, Seshia MM, Elsayed YN. A vasoactive inotropic score predicts the severity of compromised systemic circulation and mortality in preterm infants. J Neonatal Perinatal Med 2022; 15:529-535. [PMID: 35661023 DOI: 10.3233/npm-210932] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To validate the vasoactive inotropic score as a predictor of the severity of compromised systemic circulation and mortality in preterm infants. METHODS A retrospective study was conducted on preterm infants with Compromised systemic circulation [hypotension±lactic acidosis±oliguria] who received a cardiovascular support, we calculated the vasoactive inotropic score (VIS) and cumulative exposure to cardiovascular medications over time (VISct). Receiver operator curve was constructed to predict the primary outcome which was death & refractory hypotension. RESULTS VIS had an area under the curve of 0.73 (95% CI 0.85-0.98, p < 0.001). A VIS cut off of 25 has sensitivity and specificity of 66% and 92%, and positive and negative predictive values of 78.5% and 83%, respectively. CONCLUSION High VIS predicts the severity of Compromised systemic circulation and mortality rate in preterm infants.
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Affiliation(s)
- R Amer
- McMaster University, Section of Neonatology, Pediatrics Department, Hamilton, ON, Canada
| | - M M Seshia
- University of Manitoba, Section of Neonatology, Pediatrics Department, Winnipeg, MB, Canada
| | - Y N Elsayed
- University of Manitoba, Section of Neonatology, Pediatrics Department, Winnipeg, MB, Canada
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Elsayed Y, Seshia M. A new intestinal ultrasound integrated approach for the management of neonatal gut injury. Eur J Pediatr 2022; 181:1739-1749. [PMID: 34981184 DOI: 10.1007/s00431-021-04353-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 12/08/2021] [Accepted: 12/16/2021] [Indexed: 11/27/2022]
Abstract
UNLABELLED Clinical management of gut injury has been a challenge to the clinician since the first description of necrotizing enterocolitis (NEC) about 50 years ago, and it is still poorly defined. Most of the diagnostic markers are non-specific, and there is no consensus yet on a reliable gold standard for diagnosis. This report describes our approach to integrating point of care intestinal ultrasound (IUS) as the primary radiological assessment modality with other clinical and biochemical markers. CONCLUSIONS This is the first clinical guideline integrating point of care IUS as a routine assessment of the gut injury. This integrated algorithm improves the quality of care of the gut injury, provides a more accurate diagnosis of NEC, and differentiates other categories of gut injury. WHAT IS KNOWN • Necrotizing enterocolitis is a poorly defined disease, and the routine assessment relying on AXR does not differentiate NEC from other categories of gut injury. WHAT IS NEW • Integrating point of care IUS with the routine clinical assessment of gut injury enables the gut injury to be classified according to the triggering factors and severity; this helps target the appropriate management.
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Affiliation(s)
- Yasser Elsayed
- Section of Neonatology, Department of Pediatrics and Child Health, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.
| | - Mary Seshia
- Section of Neonatology, Department of Pediatrics and Child Health, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
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Balegar V KK, Low GKK, Nanan RKH. Regional tissue oxygenation and conventional indicators of red blood cell transfusion in anaemic preterm infants. EClinicalMedicine 2022; 46:101365. [PMID: 35399813 PMCID: PMC8987388 DOI: 10.1016/j.eclinm.2022.101365] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 02/26/2022] [Accepted: 03/08/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND It is unresolved whether low haemoglobin (Hb) and symptoms of anaemia reflect oxygen delivery-consumption imbalances (fractional tissue oxygen extraction [FTOE]). Here, we test whether pre-transfusion Hb and symptoms of anaemia correlate with pre-transfusion cerebral and splanchnic FTOE. METHODS This prospective cohort study was carried out between Sept 1, 2014 and Nov 30, 2016 at Nepean Hospital, Sydney, Australia. The study enroled haemodynamically stable preterm infants: gestation <32 weeks; birth weight <1500 gs; postmenstrual age <37weeks, who received 15 mL/kg packed red blood cell transfusion (PRBCT) based on low Hb and symptoms of anaemia. FTOE was determined using simultaneous monitoring of near-infrared spectroscopy and pulse oximetry for 4 h before PRBCT. FINDINGS The study enroled 29 infants born with a median gestation of 26.4 weeks (IQR 25.4-28.1), birth weight 922 g (655-1064), at postmenstrual age 33.6 weeks (31.7-34.9), and weight 1487 g (1110-1785). There was no significant correlation between Hb (median 97 g/L, IQR 87-100) and cerebral FTOE (r=-0.12, 95% CI -0.47 to 0.27; p = 0.54, n = 29) as well as splanchnic FTOE (r=-0.09, 95% CI -0.45 to 0.29; p = 0.64, n = 29). Median cerebral FTOE (p = 0.67) and splanchnic FTOE (p = 0.53) did not differ between symptomatic and asymptomatic groups. INTERPRETATION Our preliminary findings suggest that pre-transfusion Hb and symptoms of anaemia might not accurately reflect oxygen delivery-consumption imbalances in both the brain and the gut. A lack of correlation with cerebral FTOE might be presumed to be due to the brain-sparing effect. However, the lack of correlation with splanchnic FTOE is more concerning. Hence, these results warrant larger studies incorporating FTOE along with the conventional criteria in the transfusion algorithm. FUNDING The study was funded (for the purchase of NIRS sensors) by the Australian Women and Children's Research Foundation.
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Key Words
- Anaemia
- CPAP, Continuous positive airway pressure
- DO2`, Oxygen delivery
- FTOE, Fractional tissue oxygen extraction
- Fractional tissue oxygen extraction
- HFNC, High Flow Nasal Cannula
- Haemoglobin
- Hb, Haemoglobin
- NEC, Necrotising Enterocolitis
- NIRS, Near Infrared Spectroscopy
- PDA, Patent Ductus Arteriosus
- PRBCT, Packed Red Blood Cell Transfusion
- Packed red blood cell transfusions
- Preterm
- StO2, Tissue oxygen saturation
- VO2, Oxygen consumption
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Affiliation(s)
- Kiran Kumar Balegar V
- Department of Neonatology, Nepean Hospital, Nepean Blue Mountains Local Health District, Derby St, Kingswood, NSW 2750, Australia
- Sydney Medical School Nepean, NSW, Australia
- The University of Sydney, NSW, Australia
- Corresponding author at: Department of Neonatology, Nepean Hospital, Nepean Blue Mountains Local Health District, Derby St 2747, Kingswood, NSW 2750, Australia.
| | - Gary KK Low
- Research Operations, Nepean Hospital, Nepean Blue Mountains Local Health District, Derby St, Kingswood, NSW, 2750, Australia
| | - Ralph KH Nanan
- The University of Sydney, NSW, Australia
- Charles Perkins Center Nepean, NSW, Australia
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Elsayed Y, Abdul Wahab MG. A new physiologic-based integrated algorithm in the management of neonatal hemodynamic instability. Eur J Pediatr 2022; 181:1277-1291. [PMID: 34748080 DOI: 10.1007/s00431-021-04307-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 10/27/2021] [Accepted: 10/28/2021] [Indexed: 10/19/2022]
Abstract
Physiologic-based management of hemodynamic instability is proven to guide the logical selection of cardiovascular support and shorten the time to clinical recovery compared to an empiric approach that ignores the heterogeneity of the hemodynamic instability related mechanisms. In this report, we classified neonatal hemodynamic instability, circulatory shock, and degree of compensation into five physiologic categories, based on different phenotypes of blood pressure (BP), other clinical parameters, echocardiography markers, and oxygen indices. This approach is focused on hemodynamic instability in infants with normal cardiac anatomy.Conclusion: The management of hemodynamic instability is challenging due to the complexity of the pathophysiology; integrating different monitoring techniques is essential to understand the underlying pathophysiologic mechanisms and formulate a physiologic-based medical recommendation and approach. What is Known: • Physiologic-based assessment of hemodynamics leads to targeted and pathophysiologic-based medical recommendations. What is New: • Hemodynamic instability in neonates can be categorized according to the underlying mechanism into five main categories, based on blood pressure phenotypes, systemic vascular resistance, and myocardial performance. • The new classification helps with the targeted management and logical selection of cardiovascular support.
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Affiliation(s)
- Yasser Elsayed
- Division of Neonatology, Department of Pediatrics and Child Health, Rady Faculty of Health Sciences, University of Manitoba, Women's Hospital, 820 Sherbrook Street, Winnipeg, MB, R2016, R3A0L8, Canada.
| | - Muzafar Gani Abdul Wahab
- Division of Neonatology, Department of Pediatrics and Child Health, McMaster University, Hamilton, Canada
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Singh Y, Bhombal S, Katheria A, Tissot C, Fraga MV. The evolution of cardiac point of care ultrasound for the neonatologist. Eur J Pediatr 2021; 180:3565-3575. [PMID: 34125292 DOI: 10.1007/s00431-021-04153-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 06/06/2021] [Accepted: 06/09/2021] [Indexed: 01/22/2023]
Abstract
Cardiac point of care ultrasound (POCUS) is increasingly being utilized in neonatal intensive care units to provide information in real time to aid clinical decision making. While training programs and scope of practice have been well defined for other specialties, such as adult critical care and emergency medicine, there is a lack of structure for neonatal cardiac POCUS. A more comprehensive and advanced hemodynamic evaluation by a neonatologist has previously published its own clinical guidelines and specific rigorous training programs have been established to achieve competency in neonatal hemodynamics. However, it is becoming increasingly evident that access and training for basic cardiac assessment by ultrasound enhances bedside clinical care for specific indications. Recently, expert consensus POCUS guidelines for use in neonatal and pediatric intensive care endorsed by the European Society of Pediatric and Neonatal Intensive Care (ESPNIC) have been published to guide the clinicians in using POCUS for specific indications, though the line between cardiac POCUS and advanced hemodynamic evaluation remains somewhat fluid.Conclusion: This article is focused on neonatal cardiac POCUS and its evolution, value, and limitations in the modern neonatal clinical practice. Cardiac POCUS can provide physiological and hemodynamic information in making clinical decisions while dealing with neonatal emergencies. However, it should be applied only for the specific indications and should be performed by a clinician trained in cardiac POCUS. There is an urgent need of developing cardiac POCUS curriculum and certification to support a widespread and safe use in neonates. What is Known: • International training guidelines and curriculum have been published for neonatologist-performed echocardiography (NPE) or targeted neonatal echocardiography (TNE). • International evidence-based guidelines for use of point of care ultrasound (POCUS) in neonates and children have been recently published. What is New: • Cardiac POCUS is increasingly being incorporated in neonatal practice for emergency situations. However, one must be aware of its specific indications and limitations, especially for the neonatal clinical practice. • Cardiac POCUS and NPE/TNE are continuum of cardiac imaging with different indications and training requirements.
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Affiliation(s)
- Yogen Singh
- Department of Pediatrics - Neonatology and Pediatric Cardiology, Addenbrooke's Hospital, Cambridge University Hospitals, Box 402, NICU, Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK. .,Departmet of Pediatrics, Division of Neonatology, Loma Linda University School of Medicine, Loma Linda, CA, USA.
| | - Shazia Bhombal
- Department of Pediatrics, Division of Neonatal and Behavioral Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Anup Katheria
- Department of Neonatology, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, USA
| | - Cecile Tissot
- Centre de Pediatrie, Clinique des Grangettes, 7 ch des Grangettes, 1224 Chêne-Bougeries, Geneva, Switzerland
| | - María V Fraga
- Department of Pediatrics, Division of Neonatology, Children's Hospital of Philadelphia and Perelman School of Medicine, Philadelphia, USA
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Jani PR, Lowe K, Perdomo A, Wakefield L, Hinder M, Galea C, Goyen TA, Halliday R, Waters KA, Badawi N, Tracy M. Cerebral Oxygenation and Perfusion when Positioning Preterm Infants: Clinical Implications. J Pediatr 2021; 235:75-82.e1. [PMID: 33857466 DOI: 10.1016/j.jpeds.2021.04.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 04/04/2021] [Accepted: 04/05/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To evaluate cerebral tissue oxygenation (cTOI) and cerebral perfusion in preterm infants in supine vs prone positions. STUDY DESIGN Sixty preterm infants, born before 32 weeks of gestation, were enrolled; 30 had bronchopulmonary dysplasia (BPD, defined as the need for respiratory support and/or supplemental oxygen at 36 weeks of postmenstrual age). Cerebral perfusion, cTOI, and polysomnography were measured in both the supine and prone position with the initial position being randomized. Infants with a major intraventricular hemorrhage or major congenital abnormality were excluded. RESULTS Cerebral perfusion was unaffected by position or BPD status. In the BPD group, the mean cTOI was higher in the prone position compared with the supine position by a difference of 3.27% (P = .03; 95% CI 6.28-0.25) with no difference seen in the no-BPD group. For the BPD group, the burden of cerebral hypoxemia (cumulative time spent with cTOI <55%) was significantly lower in the prone position (23%) compared with the supine position (29%) (P < .001). In those without BPD, position had no effect on cTOI. CONCLUSIONS In preterm infants with BPD, the prone position improved cerebral oxygenation and reduced cerebral hypoxemia. These findings may have implications for positioning practices. Further research will establish the impact of position on short- and long-term developmental outcomes.
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Affiliation(s)
- Pranav R Jani
- Westmead Hospital, Westmead, New South Wales, Australia; University of Sydney, Sydney, New South Wales, Australia.
| | - Krista Lowe
- Westmead Hospital, Westmead, New South Wales, Australia
| | - Aldo Perdomo
- Westmead Hospital, Westmead, New South Wales, Australia
| | | | - Murray Hinder
- Westmead Hospital, Westmead, New South Wales, Australia; University of Sydney, Sydney, New South Wales, Australia
| | - Claire Galea
- University of Sydney, Sydney, New South Wales, Australia; The Children's Hospital at Westmead, Westmead, New South Wales, Australia; The Cerebral Palsy Alliance, Allambie Heights, New South Wales, Australia
| | | | - Robert Halliday
- University of Sydney, Sydney, New South Wales, Australia; The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Karen Ann Waters
- University of Sydney, Sydney, New South Wales, Australia; The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Nadia Badawi
- University of Sydney, Sydney, New South Wales, Australia; The Children's Hospital at Westmead, Westmead, New South Wales, Australia; The Cerebral Palsy Alliance, Allambie Heights, New South Wales, Australia
| | - Mark Tracy
- Westmead Hospital, Westmead, New South Wales, Australia; University of Sydney, Sydney, New South Wales, Australia
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Osman AA, Albalawi M, Dakshinamurti S, Hinton M, Elhawary F, Mawlana W, Elsayed Y. The perfusion index histograms predict patent ductus arteriosus requiring treatment in preterm infants. Eur J Pediatr 2021; 180:1747-1754. [PMID: 33486603 DOI: 10.1007/s00431-021-03937-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 12/18/2020] [Accepted: 01/08/2021] [Indexed: 11/30/2022]
Abstract
The impact of patent ductus arteriosus (PDA) on vital sign trends represented as histograms, and perfusion index in particular, is unknown. This study aimed to split continuously obtained PI and other vital signs before, during, and after medical treatment of PDA, into histogram bins, and determine the utility of PI and other vital sign histograms in the early prediction of hemodynamically significant PDA (hsPDA). In 34 infants at a mean gestational age of 26 ± 2.1 weeks, we prospectively collected vital signs for three different periods, 24 h before starting treatment of PDA, during PDA treatment, and 24 h after completion of the course of treatment, and confirmed PDA closure by echo. Histograms with three comparable periods were obtained from preterm infants who did not require treatment for PDA and analyzed for comparison. The duration of time spent in each histogram bin was determined for each time epoch. Episodes of low PI < 0.4 and high PI > 2 were significantly longer in duration in infants with PDA before treatment compared to those in infants with PDA during and after treatment. The arterial oxygen saturation (SpO2) < 80% was also longer in duration in infants with PDA before compared to that in infants with PDA during and after treatment. Low PI < 0.4 correlated with most echocardiography indices of hsPDA.Conclusion: We conclude that a patent ductus arteriosus requiring treatment in preterm infants ≤ 29 weeks GA was associated with significant fluctuations between a low PI < 0.4 alternating with a high PI > 2, reflecting the dynamic nature of hsPDA shunt volume. PI variability may be an early marker of hsPDA. What is Known: • The perfusion index is a continuous underutilized parameter provided by pulse oximetry to assess the peripheral perfusion. • The perfusion index helps predict conditions with hemodynamic instability. What is New: • The perfusion index assessed as daily histogram trends can predict patent ductus arteriosus requiring treatment.
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Affiliation(s)
- Asmaa A Osman
- Divison of Neonatology, Department of Pediatrics, King Salman Armed Forces Hospital, Tabuk, Saudi Arabia
| | - Muflih Albalawi
- Department of Pediatric Cardiology, King Salman Armed Forces Hospital, Tabuk, Saudi Arabia
| | - Shyamala Dakshinamurti
- Division of Neonatology, Department of Pediatrics and Child Health, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.,Biology of Breathing Theme, Children's Hospital Research Institute of Manitoba, Winnipeg, Canada
| | - Martha Hinton
- Biology of Breathing Theme, Children's Hospital Research Institute of Manitoba, Winnipeg, Canada
| | - Fatema Elhawary
- Faculty of Medicine, Misr University of Science and Technology, Cairo, Egypt
| | - Wegdan Mawlana
- Department of Pediatrics and Neonatology, Tanta University Hospital, Tanta, Egypt
| | - Yasser Elsayed
- Division of Neonatology, Department of Pediatrics and Child Health, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada. .,Women's Hospital, 820 Sherbrook Street, R2016, Winnipeg, Manitoba, R3A0L8, Canada.
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13
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Perioperative management of arteriovenous malformation guided by integrated evaluation of hemodynamics. Eur J Pediatr 2021; 180:195-200. [PMID: 32656690 DOI: 10.1007/s00431-020-03735-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 07/01/2020] [Accepted: 07/03/2020] [Indexed: 10/23/2022]
Abstract
We aimed to demonstrate the value of monitoring infants with arteriovenous malformation (AVM) during endovascular embolization with integrated evaluation of hemodynamics (IEH) and guiding decisions according to the underlying pathophysiology. This is a retrospective analysis of the perioperative hemodynamics data for 2 complex cases of AVM transferred to Khaula Hospital in Oman for interventional management. We described the value of novel physiological insights gained from comprehensive IEH and provided a systematic approach to the perioperative management. Postoperative targeted neonatal echo (TNE) was used to guide the weaning of the cardiovascular medications within 24 h. Both cases showed significant right ventricle (RV) volume overload before surgery. Narrowing of the pulse pressure (PP) during or after endovascular embolization was used as a marker of compromised systemic blood flow in real time followed by an assessment by TNE to guide the appropriate therapy.Conclusion: Integrated evaluation of hemodynamics is helpful to guide perioperative physiologic-based management of AVM. What is Known: • The preoperative management of hemodynamic compromise due to AVM has been described in many articles. • Perioperative management of AVM and related hemodynamics is a challenge to the intensive care team. What is New: • Integrated evaluation of hemodynamics is a comprehensive assessment and helpful in understanding the underlying physiologic changes during intervention with AVM. • This integrated evaluation can lead to physiologic-based medical recommendation with subsequent improvement.
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Abstract
Clinical assessment of cardiac output by interpretation of indirect parameters has proven to be inaccurate, irrespective of the level of experience of the clinician. Objective cardiac output monitoring is feasible in newborn infants in intensive care. The most promising methods include transthoracic echocardiography, transcutaneous Doppler, electrical biosensing technologies, transpulmonary ultrasound dilution, and arterial pulse contour analysis. Simultaneous assessment of blood pressure and cardiac output enables the identification of the earliest stage of shock. Comprehensive hemodynamic monitoring is pivotal for an individualized pathophysiology-based hemodynamic management.
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Affiliation(s)
- Willem-Pieter de Boode
- Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, PO Box 9101, Nijmegen 6500 HB, The Netherlands.
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15
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Bruckner M, Binder‐Heschl C, Schwaberger B, Mileder LP, Baik‐Schneditz N, Koestenberger M, Avian A, Urlesberger B, Pichler G. Cerebral and peripheral tissue oxygenation in stable neonates: Absent influence of cardiac function. Acta Paediatr 2020; 109:1560-1569. [PMID: 31943338 PMCID: PMC7383825 DOI: 10.1111/apa.15172] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 01/02/2020] [Accepted: 01/10/2020] [Indexed: 01/08/2023]
Abstract
Aim Cardiac function is a major factor for tissue perfusion and therefore may affect the tissue oxygen saturation. Aim was to analyse possible associations between cardiac function parameters and cerebral and peripheral tissue oxygenation in neonates on the first day after birth. Methods For the present study, we analysed secondary outcome parameters of a previously performed prospective single centre observational study. The prospective study was conducted at the Medical University of Graz, Austria between September 2011 and June 2013. We included preterm and term neonates who were admitted to the neonatal intensive care unit and in whom simultaneous near‐infrared spectroscopy measurements and echocardiography were obtained on the first day after birth. Cardiac function parameters were correlated to cerebral and peripheral tissue oxygen saturation and cerebral and peripheral fractional tissue oxygen extraction at the time of echocardiography. Results A total of 60 neonates of whom 47 were preterm and 13 were term (median gestational age: 34; IQR 33‐35 weeks, mean birth weight: 2276 ± 774 grams) were included. There were no statistically significant correlations between cardiac function parameters and regional tissue oxygenation parameters. Conclusion In the present study, we found no correlation between regional tissue oxygenation and parameters of cardiac function in cardio‐circulatory stable neonates on the first day after birth.
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Affiliation(s)
- Marlies Bruckner
- Research Unit for Neonatal Micro‐ and Macrocirculation Department of Pediatrics and Adolescent Medicine Medical University of Graz Graz Austria
- Division of Neonatology Department of Pediatrics and Adolescent Medicine Medical University of Graz Graz Austria
| | - Corinna Binder‐Heschl
- Research Unit for Neonatal Micro‐ and Macrocirculation Department of Pediatrics and Adolescent Medicine Medical University of Graz Graz Austria
- Division of Neonatology Department of Pediatrics and Adolescent Medicine Medical University of Graz Graz Austria
| | - Bernhard Schwaberger
- Research Unit for Neonatal Micro‐ and Macrocirculation Department of Pediatrics and Adolescent Medicine Medical University of Graz Graz Austria
- Division of Neonatology Department of Pediatrics and Adolescent Medicine Medical University of Graz Graz Austria
| | - Lukas Peter Mileder
- Research Unit for Neonatal Micro‐ and Macrocirculation Department of Pediatrics and Adolescent Medicine Medical University of Graz Graz Austria
- Division of Neonatology Department of Pediatrics and Adolescent Medicine Medical University of Graz Graz Austria
| | - Nariae Baik‐Schneditz
- Research Unit for Neonatal Micro‐ and Macrocirculation Department of Pediatrics and Adolescent Medicine Medical University of Graz Graz Austria
- Division of Neonatology Department of Pediatrics and Adolescent Medicine Medical University of Graz Graz Austria
| | - Martin Koestenberger
- Division of Pediatric Cardiology Department of Paediatrics and Adolescent Medicine Medical University of Graz Graz Austria
| | - Alexander Avian
- Institute for Medical Informatics, Statistics and Documentation Medical University of Graz Graz Austria
| | - Berndt Urlesberger
- Research Unit for Neonatal Micro‐ and Macrocirculation Department of Pediatrics and Adolescent Medicine Medical University of Graz Graz Austria
- Division of Neonatology Department of Pediatrics and Adolescent Medicine Medical University of Graz Graz Austria
| | - Gerhard Pichler
- Research Unit for Neonatal Micro‐ and Macrocirculation Department of Pediatrics and Adolescent Medicine Medical University of Graz Graz Austria
- Division of Neonatology Department of Pediatrics and Adolescent Medicine Medical University of Graz Graz Austria
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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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