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Salvo V, Gazzolo D, Zimmermann LJ. The Complex Interrelationship Between Mechanical Ventilation and Therapeutic Hypothermia in Asphyxiated Newborns. A Review. Ther Hypothermia Temp Manag 2024; 14:80-88. [PMID: 37625025 DOI: 10.1089/ther.2023.0032] [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: 08/27/2023] Open
Abstract
Asphyxiated newborns often require both therapeutic hypothermia (TH) and mechanical ventilation (MV) and the complex interrelationship between these two therapeutic interventions is very interesting, which could not only have several synergistic positive effects but also some risks. Perinatal asphyxia is the leading cause of neonatal hypoxic-ischemic encephalopathy (HIE) and TH is the only approved neuroprotective treatment to limit brain injury, improving the mortality rate and long-term neurological outcomes. HIE is often associated with severe respiratory failure, requiring MV, due to different lung diseases or an impairment of the respiratory drive. The respiratory support management of asphyxiated newborns is very difficult, considering (a) various pathophysiological contexts, (b) the strong impact of TH on gas metabolism and (c) on lung mechanics, and (d) complex TH-MV interactions. Therefore, it is necessary to evaluate the real indications of MV for cooled newborns, considering the risks of respiratory overassistance (hypocapnia/hyperoxia), as well as the adequate monitoring systems. To date, specific randomized studies about the optimal respiratory approach for cooled newborns are lacking, and strategies for MV support vary from center to center. Moreover, there are many open questions about the real effects of cooling on lung mechanics and on surfactant, most appropriate method of blood gas analysis, and clear indications for pharmacological sedation. The aim of this review is to propose a reasoned approach for respiratory management of cooled newborns, considering the pathophysiological context, multiple actions of TH, and consequences of TH-MV matched action and its related risks.
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Affiliation(s)
- Vincenzo Salvo
- Mother and Child Health Department, Neonatal Intensive Care Unit, "Giovanni Paolo II" Hospital of Ragusa, ASP Ragusa, Italy
| | - Diego Gazzolo
- Neonatal Intensive Care Unit, "G. D'Annunzio" University, Chieti, Italy
| | - Luc J Zimmermann
- Department of Pediatrics and Neonatology, School for Oncology and Developmental Biology (GROW), Maastricht University Medical Center, Maastricht, The Netherlands
- European Foundation for the Care of Newborn Infants (EFCNI), München
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2
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Papoff P, Caresta E, D’Agostino B, Midulla F, Petrarca L, Giannini L, Pisani F, Montecchia F. Expiratory braking defines the breathing patterns of asphyxiated neonates during therapeutic hypothermia. Front Pediatr 2024; 12:1383689. [PMID: 38832000 PMCID: PMC11146197 DOI: 10.3389/fped.2024.1383689] [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: 02/07/2024] [Accepted: 05/06/2024] [Indexed: 06/05/2024] Open
Abstract
Introduction Although neonatal breathing patterns vary after perinatal asphyxia, whether they change during therapeutic hypothermia (TH) remains unclear. We characterized breathing patterns in infants during TH for hypoxic-ischemic encephalopathy (HIE) and normothermia after rewarming. Methods In seventeen spontaneously breathing infants receiving TH for HIE and in three who did not receive TH, we analyzed respiratory flow and esophageal pressure tracings for respiratory timing variables, pulmonary mechanics and respiratory effort. Breaths were classified as braked (inspiratory:expiratory ratio ≥1.5) and unbraked (<1.5). Results According to the expiratory flow shape braked breaths were chategorized into early peak expiratory flow, late peak expiratory flow, slow flow, and post-inspiratory hold flow (PiHF). The most braked breaths had lower rates, larger tidal volume but lower minute ventilation, inspiratory airway resistance and respiratory effort, except for the PiHF, which had higher resistance and respiratory effort. The braked pattern predominated during TH, but not during normothermia or in the uncooled infants. Conclusions We speculate that during TH for HIE low respiratory rates favor neonatal braked breathing to preserve lung volume. Given the generally low respiratory effort, it seems reasonable to leave spontaneous breathing unassisted. However, if the PiHF pattern predominates, ventilatory support may be required.
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Affiliation(s)
- Paola Papoff
- Pediatric Intensive Care Unit, Department of Pediatrics, Sapienza University of Rome, Rome, Italy
| | - Elena Caresta
- Pediatric Intensive Care Unit, Department of Pediatrics, Sapienza University of Rome, Rome, Italy
| | - Benedetto D’Agostino
- Pediatric Intensive Care Unit, Department of Pediatrics, Sapienza University of Rome, Rome, Italy
| | - Fabio Midulla
- Pediatric Emergency Care, Department of Pediatrics, Sapienza University of Rome, Rome, Italy
| | - Laura Petrarca
- Pediatric Emergency Care, Department of Pediatrics, Sapienza University of Rome, Rome, Italy
| | - Luigi Giannini
- Pediatric Neurology, Department of Pediatrics, Sapienza University of Rome, Rome, Italy
| | - Francesco Pisani
- Child Neurology and Psychiatry Unit, Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Francesco Montecchia
- Medical Engineering Laboratory, Department of Civil Engineering and Computer Science, University of Rome “Tor Vergata”, Rome, Italy
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3
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Mohammad K, Molloy E, Scher M. Training in neonatal neurocritical care: A case-based interdisciplinary approach. Semin Fetal Neonatal Med 2024:101530. [PMID: 38670881 DOI: 10.1016/j.siny.2024.101530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024]
Abstract
Interdisciplinary fetal-neonatal neurology (FNN) training strengthens neonatal neurocritical care (NNCC) clinical decisions. Neonatal neurological phenotypes require immediate followed by sustained neuroprotective care path choices through discharge. Serial assessments during neonatal intensive care unit (NICU) rounds are supplemented by family conferences and didactic interactions. These encounters collectively contribute to optimal interventions yielding more accurate outcome predictions. Maternal-placental-fetal (MPF) triad disease pathways influence postnatal medical complications which potentially reduce effective interventions and negatively impact outcome. The science of uncertainty regarding each neonate's clinical status must consider timing and etiologies that are responsible for fetal and neonatal brain disorders. Shared clinical decisions among all stakeholders' balance "fast" (heuristic) and "slow" (analytic) thinking as more information is assessed regarding etiopathogenetic effects that impair the developmental neuroplasticity process. Two case vignettes stress the importance of FNN perspectives during NNCC that integrates this dual cognitive approach. Clinical care paths evaluations are discussed for an encephalopathic extremely preterm and full-term newborn. Recognition of cognitive errors followed by debiasing strategies can improve clinical decisions during NICU care. Re-evaluations with serial assessments of examination, imaging, placental-cord, and metabolic-genetic information improve clinical decisions that maintain accuracy for interventions and outcome predictions. Discharge planning includes shared decisions among all stakeholders when coordinating primary care, pediatric subspecialty, and early intervention participation. Prioritizing social determinants of healthcare during FNN training strengthens equitable career long NNCC clinical practice, education, and research goals. These perspectives contribute to a life course brain health capital strategy that will benefit all persons across each and successive lifespans.
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Affiliation(s)
| | | | - Mark Scher
- Pediatrics/Neurology, Case Western Reserve University, Cleveland, USA.
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4
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Ristovska S. Respiratory Distress Syndrome (RDS) in Newborns with Hypoxic-Ischemic Encephalopathy (HIE). Pril (Makedon Akad Nauk Umet Odd Med Nauki) 2024; 45:19-30. [PMID: 38575384 DOI: 10.2478/prilozi-2024-0003] [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: 04/06/2024]
Abstract
Respiratory distress syndrome (RDS) and hypoxic-ischemic encephalopathy (HIE) are frequent causes of death and disability in neonates. This study included newborns between January 2021 and July 2022 at the University Clinic for Gynecology and Obstetrics, Skopje. Up to date criteria for HIE/RDS for term and for preterm infants as well for the severity of HIE/RDS were used in a comprehensive analysis of cranial ultrasonography, neurological status, neonatal infections, Apgar score, bradycardia and hypotension, X-ray of the lungs, FiO2, acid-base status, assisted ventilation and use of surfactant. Three groups were created: HIE with RDS (42 babies), HIE without RDS (30 babies) and RDS without HIE in 38 neonates. All newborns with severe (third) degree of HIE died. Intracranial bleeding was found in 35.7% in the first group and 30% in the second group, and in the third group in 53.3%. The need for surfactant in the HIE group with RDS is 59.5%, and in the RDS group without HIE 84.2%. DIC associated with sepsis was found in 13.1-50% in those groups. In newborns with HIE and bradycardia, the probability of having RDS was on average 3.2 times higher than in those without bradycardia. The application of the surfactant significantly improved the pH, pO2, pCO2, BE and chest X-ray in children with RDS. An Apgar score less than 6 at the fifth minute increases the risk of RDS by 3 times. The metabolic acidosis in the first 24 hours increases the risk of death by 23.6 times. The combination of HIE/ RDS significantly worsens the disease outcome. The use of scoring systems improved the early detection of high risk babies and initiation of early treatment increased the chances for survival without disabilities.
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Affiliation(s)
- Sanja Ristovska
- PJU University Clinic for Gynecology and Obstetrics, Faculty of Medicine, University of "St. Cyril and Methodius", Skopje, RN Macedonia
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5
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Serrao F, Tiberi E, Verdolotti T, Romeo DMM, Corsello M, Pede E, Cota F, Costa S, Gallini F, Colosimo C, Mercuri EM, Vento G. pCO2 values in asphyxiated infants under therapeutic hypothermia after tailored respiratory management: a retrospective cohort study. Front Pediatr 2024; 11:1293526. [PMID: 38322242 PMCID: PMC10844519 DOI: 10.3389/fped.2023.1293526] [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: 09/13/2023] [Accepted: 12/29/2023] [Indexed: 02/08/2024] Open
Abstract
Background Hypoxic-ischemic encephalopathy (HIE) represents one of the major causes of neonatal death and long-term neurological disability. Both hypoxic-ischemic insults and therapeutic hypothermia (TH) can affect respiratory function. Currently, there is no evidence regarding optimal respiratory management in these infants. Methods This is a retrospective cohort study examining newborns with HIE treated with TH between January 2015 and September 2020. The study population was divided into two groups based on different respiratory assistance during TH: spontaneous breathing (Group A) or mechanical ventilation (Group B). The primary outcome of the study was the mean pCO2 ± SD evaluation during TH in ventilated and non-ventilated asphyxiated infants. The secondary outcome was the correlation between ventilation strategy and short-term neurologic outcome according to Rutherford et al.'s MRI scoring system. Results A total of 126 newborns were enrolled, 75 in Group A and 51 in Group B. Respiratory management was individualized, and volume guarantee (VG) ventilation was the first choice for ventilated infants. Group B infants showed more severe conditions at birth. During TH, ventilated infants showed optimal mean pCO2 comparable with those breathing spontaneously (40.6 mmHg vs. 42.3 mmHg, respectively, p 0.091), with no significant difference in pCO2 standard deviation between (7.7 mmHg vs. 8.1 mmHg, respectively, p 0.522). Mean pH, pH standard deviation, mean pO2, pO2 standard deviation, and mean respiratory rate also did not differ between groups. MRI patterns of brain injury predictive of abnormal neurodevelopmental outcomes were similar in both groups. Logistic regression analysis demonstrated that only umbilical cord arterial blood pH-affected MRI lesions were associated with poor neurodevelopmental outcomes (OR 1.505; CI 95% 1.069-2.117). Conclusions Infants cooled after HIE should receive individualized respiratory management, not necessarily involving intubation. In those infants requiring mechanical ventilation, a volume-targeted strategy appeared to be effective in maintaining stable blood gas levels. Short-term neurological outcomes appeared comparable in ventilated and non-ventilated infants.
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Affiliation(s)
- Francesca Serrao
- Division of Neonatology, Department of Women, Children and Public Health Sciences, University Hospital Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Eloisa Tiberi
- Division of Neonatology, Department of Women, Children and Public Health Sciences, University Hospital Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Tommaso Verdolotti
- Radiology and Neuroradiology Department, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Rome, Italy
| | - Domenico Marco Maurizio Romeo
- Pediatric Neurology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Rome, Italy
| | - Mirta Corsello
- Division of Neonatology, Department of Women, Children and Public Health Sciences, University Hospital Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Elisa Pede
- Pediatric Neurology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Rome, Italy
| | - Francesco Cota
- Division of Neonatology, Department of Women, Children and Public Health Sciences, University Hospital Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Simonetta Costa
- Division of Neonatology, Department of Women, Children and Public Health Sciences, University Hospital Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Francesca Gallini
- Division of Neonatology, Department of Women, Children and Public Health Sciences, University Hospital Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Cesare Colosimo
- Radiology and Neuroradiology Department, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Rome, Italy
| | - Eugenio Maria Mercuri
- Pediatric Neurology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Rome, Italy
| | - Giovanni Vento
- Division of Neonatology, Department of Women, Children and Public Health Sciences, University Hospital Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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6
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Falsaperla R, Scalia B, Costanza G, Termini D, De Vivo M, Cacace C, Mondello I, Ruggieri M. Respiratory Changes in Ventilated and Not-Ventilated Neonates During and After Whole-Body Hypothermia: A Multicenter Retrospective Study. Ther Hypothermia Temp Manag 2023; 13:200-207. [PMID: 37184915 DOI: 10.1089/ther.2022.0066] [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: 05/16/2023] Open
Abstract
The aim of this study was to describe whether whole-body hypothermia induced different respiratory changes in both invasively and noninvasively ventilated newborns and spontaneously breathing asphyxiated newborns during the course and after therapeutic hypothermia (TH). Data of 44 asphyxiated newborns undergoing TH at five different neonatal intensive care units in southern Italy were collected retrospectively between January 2018 and January 2021. For each type of ventilation, patient data on pH, partial pressure of Carbon Dioxide (pCO2), base excess, lactate, and heart rate were recorded before cooling was started and at 24, 48, 72, and 96 hours from its initiation. Patients were later subgrouped into spontaneously breathing, noninvasively ventilated, and mechanically ventilated groups. The average trend of each parameter was reported, and a nonparametric statistical analysis of differences among groups before initiation and at 96 hours was performed using the Kruskal-Wallis test. Our results confirmed previous findings (supported by a small amount of literature) that no increase in requests for respiratory support is recorded in asphyxiated newborns undergoing TH during and after the rewarming phase. Furthermore, no statistically significant differences in the analyzed parameters were found among spontaneously breathing, noninvasively ventilated, and mechanically ventilated newborns, suggesting that changes in parameters might be attributable to TH itself rather than to an improvement in the respiratory condition over time; otherwise, a difference between spontaneously breathing patients, by definition "stable" from a respiratory point of view, and those requiring any type of respiratory support would have been expected.
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Affiliation(s)
- Raffaele Falsaperla
- Neonatal Intensive Care Unit, A.O.U. Policlinico G. Rodolico-San Marco, Catania, Italy
- Pediatric and Pediatric Emergency Department, University Hospital "Policlinico San Marco," Catania, Italy
| | - Bruna Scalia
- Neonatal Intensive Care Unit, A.O.U. Policlinico G. Rodolico-San Marco, Catania, Italy
| | - Giuseppe Costanza
- Unit of Clinical Pediatrics, Department of Clinical and Experimental Medicine, Pediatric Postgraduate Training Program, University of Catania, Catania, Italy
| | - Donatella Termini
- Neonatal Intensive Care Unit, Hospital "Villa Sofia Cervello," Palermo, Italy
| | | | - Caterina Cacace
- Neonatal Intensive Care Unit, Barone Romeo Hospital, Patti, Italy
| | - Isabella Mondello
- Neonatal Intensive Care Unit, Hospital "Bianchi-Melacrino-Morelli," Reggio Calabria, Italy
| | - Martino Ruggieri
- Unit of Clinical Pediatrics, Department of Clinical and Experimental Medicine, Section of Pediatrics and Child Neuropsychiatry, University of Catania, Catania, Italy
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7
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Lugli L, Garetti E, Goffredo BM, Candia F, Crestani S, Spada C, Guidotti I, Bedetti L, Miselli F, Della Casa EM, Roversi MF, Simeoli R, Cairoli S, Merazzi D, Lago P, Iughetti L, Berardi A. Continuous Fentanyl Infusion in Newborns with Hypoxic-Ischemic Encephalopathy Treated with Therapeutic Hypothermia: Background, Aims, and Study Protocol for Time-Concentration Profiles. Biomedicines 2023; 11:2395. [PMID: 37760835 PMCID: PMC10525845 DOI: 10.3390/biomedicines11092395] [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: 08/05/2023] [Revised: 08/22/2023] [Accepted: 08/24/2023] [Indexed: 09/29/2023] Open
Abstract
Therapeutic hypothermia (TH) is the standard of care for newborns with moderate to severe hypoxic-ischemic encephalopathy (HIE). Discomfort and pain during treatment are common and may affect the therapeutic efficacy of TH. Opioid sedation and analgesia (SA) are generally used in clinical practice, and fentanyl is one of the most frequently administered drugs. However, although fentanyl's pharmacokinetics (PKs) may be altered by hypothermic treatment, the PK behavior of this opioid drug in cooled newborns with HIE has been poorly investigated. The aim of this phase 1 study protocol (Trial ID: FentanylTH; EUDRACT number: 2020-000836-23) is to evaluate the fentanyl time-concentration profiles of full-term newborns with HIE who have been treated with TH. Newborns undergoing TH receive a standard fentanyl regimen (2 mcg/Kg of fentanyl as a loading dose, followed by a continuous infusion-1 mcg/kg/h-during the 72 h of TH and subsequent rewarming). Fentanyl plasma concentrations before bolus administration, at the end of the loading dose, and 24-48-72-96 h after infusion are measured. The median, maximum, and minimum plasma concentrations, together with drug clearance, are determined. This study will explore the fentanyl time-concentration profiles of cooled, full-term newborns with HIE, thereby helping to optimize the fentanyl SA dosing regimen during TH.
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Affiliation(s)
- Licia Lugli
- Neonatal Intensive Care Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (E.G.); (I.G.); (L.B.); (E.M.D.C.); (M.F.R.); (A.B.)
| | - Elisabetta Garetti
- Neonatal Intensive Care Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (E.G.); (I.G.); (L.B.); (E.M.D.C.); (M.F.R.); (A.B.)
| | - Bianca Maria Goffredo
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, Scientific Institute for hospitalization and care (IRCCS), 00100 Rome, Italy; (B.M.G.); (R.S.); (S.C.)
| | - Francesco Candia
- Pediatrics Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (F.C.); (S.C.); (L.I.)
| | - Sara Crestani
- Pediatrics Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (F.C.); (S.C.); (L.I.)
| | - Caterina Spada
- Neonatal Unit, Women’s and Children’s Department, Bufalini Hospital of Cesena, 47521 Cesena, Italy;
| | - Isotta Guidotti
- Neonatal Intensive Care Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (E.G.); (I.G.); (L.B.); (E.M.D.C.); (M.F.R.); (A.B.)
| | - Luca Bedetti
- Neonatal Intensive Care Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (E.G.); (I.G.); (L.B.); (E.M.D.C.); (M.F.R.); (A.B.)
| | - Francesca Miselli
- PhD Program in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, 41100 Modena, Italy;
| | - Elisa Muttini Della Casa
- Neonatal Intensive Care Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (E.G.); (I.G.); (L.B.); (E.M.D.C.); (M.F.R.); (A.B.)
| | - Maria Federica Roversi
- Neonatal Intensive Care Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (E.G.); (I.G.); (L.B.); (E.M.D.C.); (M.F.R.); (A.B.)
| | - Raffaele Simeoli
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, Scientific Institute for hospitalization and care (IRCCS), 00100 Rome, Italy; (B.M.G.); (R.S.); (S.C.)
| | - Sara Cairoli
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, Scientific Institute for hospitalization and care (IRCCS), 00100 Rome, Italy; (B.M.G.); (R.S.); (S.C.)
| | - Daniele Merazzi
- Neonatal Unit, Women’s and Children’s Department, Valduce Hospital, 22100 Como, Italy;
| | - Paola Lago
- Neonatal Intensive Care Unit, Women’s and Children’s Department, Ca’ Foncello Hospital, 31100 Treviso, Italy;
| | - Lorenzo Iughetti
- Pediatrics Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (F.C.); (S.C.); (L.I.)
| | - Alberto Berardi
- Neonatal Intensive Care Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (E.G.); (I.G.); (L.B.); (E.M.D.C.); (M.F.R.); (A.B.)
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8
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Devi U, Pullattayil AK, Chandrasekaran M. Hypocarbia is associated with adverse outcomes in hypoxic ischaemic encephalopathy (HIE). Acta Paediatr 2023; 112:635-641. [PMID: 36662594 DOI: 10.1111/apa.16679] [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: 12/03/2022] [Revised: 01/15/2023] [Accepted: 01/18/2023] [Indexed: 01/21/2023]
Abstract
AIM Hypocarbia in the early postnatal period might exacerbate brain injury in babies with hypoxic ischaemic encephalopathy following birth asphyxia. This mini-review summarised studies on pCO2 values that were monitored periodically in term newborns with moderate/severe hypoxic-ischaemic encephalopathy and correlated with short or long-term outcomes. METHODS We searched the databases MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), web of science and the Cochrane Library and identified nine studies. RESULTS Among the nine included studies, therapeutic hypothermia was administered in seven studies. In most studies, blood pCO2 levels were measured from birth till 72 h of life or till the endpoint of therapeutic hypothermia. Eight studies showed that any hypocarbia (moderate or severe, or cumulative) was associated with an increased risk of adverse outcomes in the form of brain injury in MRI, death or neurodevelopmental disability. CONCLUSION Hypocarbia could lead to adverse short-term and long-term outcomes despite therapeutic hypothermia in neonates with HIE. Hence, it is vital to monitor pCO2 levels closely in these infants and consider strategies to maintain pCO2 levels in the normal range.
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Affiliation(s)
- Usha Devi
- Neonatology, All India Institute of Medical Sciences, Bhubaneswar, India
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9
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Cannavò L, Perrone S, Gitto E. Brain-Oriented Strategies for Neuroprotection of Asphyxiated Newborns in the First Hours of Life. Pediatr Neurol 2023; 143:44-49. [PMID: 36996760 DOI: 10.1016/j.pediatrneurol.2023.02.015] [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: 05/19/2022] [Revised: 01/31/2023] [Accepted: 02/24/2023] [Indexed: 04/01/2023]
Abstract
Perinatal asphyxia represents the first cause of severe neurological disabilities and the second cause of neonatal death in term-born babies. Currently, no treatment can prevent immediate cell death from necrosis, but some therapeutic interventions, such as therapeutic hypothermia (TH), can reduce delayed cell death from apoptosis. TH significantly improves the combined outcome of mortality or major neurodevelopmental disability, but the number of patients to be treated is 7 to get 1 child with no adverse neurological outcome. The aim of this educational review is to analyze the other care strategies to be implemented to improve the neurological outcome of children with hypoxic ischemic encephalopathy (HIE). Hypocapnia, hypoglycemia, pain control, and functional brain monitoring are recognized as appropriate approaches to improve outcome in critically ill infants with HIE. Pharmacologic neuroprotective adjuncts are currently under investigation. New drugs such as allopurinol and melatonin seem to provide positive effects although more randomized controlled trials are required to establish the effective therapeutic scheme. In the meantime, sustaining the respiratory, metabolic, and cardiovascular system during TH can be a valuable aid in managing and treating the patient with HIE in an optimal way.
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Affiliation(s)
- Laura Cannavò
- Neonatal and Pediatric Intensive Care Unit, Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi", University of Messina, Messina, Italy
| | - Serafina Perrone
- Neonatal Unit, University of Parma, Azienda Ospedaliero Universitaria di Parma, Parma, Italy.
| | - Eloisa Gitto
- Neonatal and Pediatric Intensive Care Unit, Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi", University of Messina, Messina, Italy
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10
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Szakmar E, Munster C, El-Shibiny H, Jermendy A, Inder T, El-Dib M. Hypocapnia in early hours of life is associated with brain injury in moderate to severe neonatal encephalopathy. J Perinatol 2022; 42:892-897. [PMID: 35461333 DOI: 10.1038/s41372-022-01398-2] [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: 12/05/2021] [Revised: 04/04/2022] [Accepted: 04/08/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To evaluate the association between hypocapnia within the first 24 h of life and brain injury assessed by a detailed MRI scoring system in infants receiving therapeutic hypothermia (TH) for neonatal encephalopathy (NE) stratified by the stage of NE. STUDY DESIGN This retrospective cohort study included infants who received TH for mild to severe NE. RESULTS 188 infants were included in the study with 48% having mild and 52% moderate-severe NE. Infants with moderate-severe NE spent more time in hypocapnia (PCO2 ≤ 35 mmHg) and presented with more severe brain injury on MRI compared to mild cases. The MRI injury score increased by 6% for each extra hour spent in hypocapnic range in infants with moderate-severe NE. There was no association between hypocapnia and injury scores in mild cases. CONCLUSION In infants with moderate-severe NE, the hours spent in hypocapnia was an independent predictor of brain injury.
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Affiliation(s)
- Eniko Szakmar
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States.,1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Chelsea Munster
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Hoda El-Shibiny
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Agnes Jermendy
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Terrie Inder
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Mohamed El-Dib
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States.
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11
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Chalak L. New Horizons in Mild Hypoxic-ischemic Encephalopathy: A Standardized Algorithm to Move past Conundrum of Care. Clin Perinatol 2022; 49:279-294. [PMID: 35210007 DOI: 10.1016/j.clp.2021.11.016] [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: 12/16/2022]
Abstract
Hypoxic-ischemic encephalopathy (HIE) presents clinically with a neonatal encephalopathy (NE) whereby the mild spectrum is difficult to classify immediately after birth. For decades trials have focused exclusively on infants with moderate-severe HIE s, as these infants were easier to identify after birth and had the highest risk of adverse outcomes. Twenty years after those trials, the PRIME study finally solved the first part of the conundrum by providing a definition of mild HIE in the first 6 hours. There is strong biological plausibility and preclinical evidence supporting the efficacy of therapeutic hypothermia (TH) but there is a lack of comparative clinical data to establish the risk-benefit in mild HIE. The fundamental question of how best to manage mild HIE remains unanswered. This review will summarize (1) the evidence that neonates with mild HIE are at significant risk for adverse outcomes, (2) the gaps/controversies in management, and (3) an algorithm of care is proposed to ensure standardized management of mild HIE and the direction of future trials.
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Affiliation(s)
- Lina Chalak
- Neonatal-Perinatal Medicine, University of Texas Southwestern Medical School, 5323 Harry Hines Boulevard, Dallas, TX 75390-9063, USA.
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12
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Rebollar RE, Rodríguez EB, Olmos ID, Torres Morera LM. Opioid-free anesthesia with interfascial dexmedetomidine in a high-risk infant. Saudi J Anaesth 2021; 15:450-453. [PMID: 34658737 PMCID: PMC8477776 DOI: 10.4103/sja.sja_319_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 05/31/2021] [Accepted: 05/31/2021] [Indexed: 11/17/2022] Open
Abstract
Despite the advances in pediatric anesthesia, infants have higher mortality and critical incidents rates than children, especially ex-prematures and those with comorbidity. We present the case of a high-risk infant who underwent elective laparoscopic gastrostomy under opioid-free anesthesia (OFA) combined with transversus abdominis plane (TAP) block with Dexmedetomidine (DEX). Perioperative opioids were entirely avoided, and intraoperative anesthetics and postoperative analgesic were considerably reduced. The infant showed cardiorespiratory stability and optimal analgesia during the uneventful procedure and the postoperative period. We consider OFA and TAP block with DEX a safe and effective anesthetic combination for high-risk infants.
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Affiliation(s)
- Ramón Eizaga Rebollar
- Department of Anesthesiology and Reanimation, Puerta del Mar University Hospital, Cádiz, Spain
| | | | - Irene Delgado Olmos
- Department of Anesthesiology and Reanimation, Puerta del Mar University Hospital, Cádiz, Spain
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13
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Lugli L, Spada C, Garetti E, Guidotti I, Roversi MF, Della Casa E, Bedetti L, Lucaccioni L, Pugliese M, Ferrari F, Iughetti L, Lago P, Berardi A. Fentanyl analgesia in asphyxiated newborns treated with therapeutic hypothermia. J Matern Fetal Neonatal Med 2021; 35:7764-7770. [PMID: 34486466 DOI: 10.1080/14767058.2021.1937106] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Therapeutic hypothermia is the standard care for asphyxiated newborns. Discomfort and pain during treatment are common and may affect therapeutic efficacy of hypothermia. Opioid analgosedation is commonly used in the clinical setting, but its effects in the cooled newborns is poorly investigated. OBJECTIVE The aim of this study was to assess the safety of fentanyl analgosedation during therapeutic hypothermia, by evaluating severe adverse effects and possible correlation with the neurodevelopmental outcome. METHODS We analyzed asphyxiated newborns treated with hypothermia receiving fentanyl intravenous infusion (years 2013-2018). Severe neurodevelopmental outcome was defined as cerebral palsy or Griffith's developmental quotient <70 or major sensorineural deficit. Severe brain lesions were defined as cortical or/and basal ganglia extensive involvement. RESULTS Fentanyl cumulative dose was variable (61.7 ± 18.5 µg/kg; range 34.3-120.3 µg/kg) among 45 enrolled patients. Respiratory depression was recorded in 13.3% cases of 30 spontaneously breathing patients. Severe brain lesions and severe neurodevelopmental disability were found in 24.4 and 11.1% of all included cases, respectively. Higher cumulative fentanyl dose was not associated with poor outcome. CONCLUSIONS Fentanyl treatment during therapeutic hypothermia does not negatively affect the neurodevelopmental outcome, thus on the contrary, it may contribute to ameliorate neuroprotection in the asphyxiated cooled newborns.
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Affiliation(s)
- Licia Lugli
- Women's and Children's Health Department, Neonatal Intensive Care Unit, University Hospital of Modena, Modena, Italy
| | - Caterina Spada
- Women's and Children's Health Department, Neonatal Intensive Care Unit, University Hospital of Modena, Modena, Italy
| | - Elisabetta Garetti
- Women's and Children's Health Department, Neonatal Intensive Care Unit, University Hospital of Modena, Modena, Italy
| | - Isotta Guidotti
- Women's and Children's Health Department, Neonatal Intensive Care Unit, University Hospital of Modena, Modena, Italy
| | - Maria Federica Roversi
- Women's and Children's Health Department, Neonatal Intensive Care Unit, University Hospital of Modena, Modena, Italy
| | - Elisa Della Casa
- Women's and Children's Health Department, Neonatal Intensive Care Unit, University Hospital of Modena, Modena, Italy
| | - Luca Bedetti
- Pediatrics, Women's and Children's Health Department, University Hospital of Modena, Modena, Italy
| | - Laura Lucaccioni
- Pediatrics, Women's and Children's Health Department, University Hospital of Modena, Modena, Italy
| | - Marisa Pugliese
- Women's and Children's Health Department, Neonatal Intensive Care Unit, University Hospital of Modena, Modena, Italy
| | - Fabrizio Ferrari
- Women's and Children's Health Department, Neonatal Intensive Care Unit, University Hospital of Modena, Modena, Italy
| | - Lorenzo Iughetti
- Pediatrics, Women's and Children's Health Department, University Hospital of Modena, Modena, Italy
| | - Paola Lago
- Women's and Children's Department, Neonatal Intensive Care Unit, Ca' Foncello Hospital, Treviso, Italy
| | - Alberto Berardi
- Women's and Children's Health Department, Neonatal Intensive Care Unit, University Hospital of Modena, Modena, Italy
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14
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El-Dib M, Szakmar E, Chakkarapani E, Aly H. Challenges in respiratory management during therapeutic hypothermia for neonatal encephalopathy. Semin Fetal Neonatal Med 2021; 26:101263. [PMID: 34244080 DOI: 10.1016/j.siny.2021.101263] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Neonatal encephalopathy (NE) is a serious condition with devastating neurological outcomes that can impact oxygenation and ventilation. The currently recommended therapeutic hypothermia (TH) for these infants may also has several respiratory implications. It decreases metabolic rate and oxygen demands; however, it increases oxygen solubility in the blood and impacts its release to peripheral tissue including the brain. Respiratory management of infants treated with TH should aim for minimizing exposure to hypocapnia or hyperoxia. Inspiratory gas should be heated to 37 °C and humidified to prevent airway and alveolar injury. Blood gas values should be corrected to the core temperature during TH and the use of alkaline buffers is discouraged. While mild sedation/analgesia may ameliorate the discomfort related to cooling, paralytic agents/heavy sedation should be used with caution considering their side effects. Finally, the use of caffeine still needs careful investigation in this population.
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Affiliation(s)
- Mohamed El-Dib
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., CWN#418, Boston, MA, 02115, USA.
| | - Eniko Szakmar
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., CWN#418, Boston, MA, 02115, USA; 1st Department of Pediatrics, Semmelweis University, 54 Bokay St., HU-1083, Budapest, Hungary.
| | - Ela Chakkarapani
- Translational Health Sciences, Bristol Medical School, University of Bristol, Regional Neonatal Intensive Care Unit, St Michael's Hospital University Hospitals Bristol NHS Trust, Southwell Street, Bristol, BS2 8EG, United Kingdom.
| | - Hany Aly
- Department of Neonatology, Cleveland Clinic Children's Hospital, 9500 Euclid Avenue # M31-37 Cleveland, OH, 44195, USA.
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15
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Cerebral blood volume increment after resuscitation measured by near-infrared time-resolved spectroscopy can estimate degree of hypoxic-ischemic insult in newborn piglets. Sci Rep 2021; 11:13096. [PMID: 34162942 PMCID: PMC8222402 DOI: 10.1038/s41598-021-92586-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 06/09/2021] [Indexed: 11/13/2022] Open
Abstract
Neonatal hypoxic–ischemic encephalopathy is a notable cause of neonatal death and developmental disabilities. To achieve better outcomes, it is important in treatment strategy selection to categorize the degree of hypoxia ischemia and evaluate dose response. In an asphyxia piglet model with histopathological brain injuries that we previously developed, animals survived 5 days after insult and showed changes in cerebral blood volume (CBV) that reflected the severity of injuries. However, little is known about the relationship between changes in CBV during and after insult. In this study, an HI event was induced by varying the amount and timing of inspired oxygen in 20 anesthetized piglets. CBV was measured using near-infrared time-resolved spectroscopy before, during, and 6 h after insult. Change in CBV was calculated as the difference between the peak CBV value during insult and the value at the end of insult. The decrease in CBV during insult was found to correlate with the increase in CBV within 6 h after insult. Heart rate exhibited a similar tendency to CBV, but blood pressure did not. Because the decrement in CBV was larger in severe HI, the CBV increment immediately after insult is considered useful for assessing degree of HI insult.
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16
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Gundersen JK, Chakkarapani E, Jary S, Menassa DA, Scull-Brown E, Frymoyer A, Walløe L, Thoresen M. Morphine and fentanyl exposure during therapeutic hypothermia does not impair neurodevelopment. EClinicalMedicine 2021; 36:100892. [PMID: 34308308 PMCID: PMC8257990 DOI: 10.1016/j.eclinm.2021.100892] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 04/21/2021] [Accepted: 04/23/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hypothermia-treated and intubated infants with moderate or severe hypoxic-ischemic encephalopathy (HIE) usually receive morphine for sedation and analgesia (SA) during therapeutic hypothermia (TH) and endotracheal ventilation. Altered drug pharmacokinetics in this population increases the risk of drug accumulation. Opioids are neurotoxic in preterm infants. In term infants undergoing TH, the long-term effects of morphine exposure are unknown. We examined the effect of opioid administration during TH on neurodevelopmental outcome and time to extubation after sedation ended. METHODS In this prospectively collected population-based cohort of 282 infants with HIE treated with TH (2007-2017), the cumulative opioid dose of morphine and equipotent fentanyl (10-60 µg/kg/h) administered during the first week of life was calculated. Clinical outcomes and concomitant medications were also collected. Of 258 survivors, 229 underwent Bayley-3 neurodevelopmental assessments of cognition, language and motor function at 18-24 months. Multivariate stepwise linear regression analysis was used to examine the relation between cumulative opioid dose and Bayley-3 scores. Three severity-groups (mild-moderate-severe) were stratified by early (<6 h) amplitude-integrated electroencephalography (aEEG) patterns. FINDINGS The cumulative dose of opioid administered as SA during TH was median (IQR) 2121 µg/kg (1343, 2741). Time to extubation was independent of SA dose (p > 0.2). There was no significant association between cumulative SA dose and any of the Bayley-3 domains when analysing the entire cohort or any of the aEEG severity groups. INTERPRETATION Higher cumulative opioid doses in TH-treated infants with HIE was not associated with worse Bayley-3 scores at 18-24 months of age. FUNDING The Bristol cooling program was funded by the Children's Medical Research Charity SPARKS managing donations for our research from the UK and US, the UK Moulton Foundation, the Lærdal Foundation for Acute Medicine in Norway and the Norwegian Research Council (JKG).
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Affiliation(s)
- Julia K Gundersen
- Division of Physiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
- Translational Health Sciences, St. Michael's Hospital, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Ela Chakkarapani
- Translational Health Sciences, St. Michael's Hospital, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Sally Jary
- Translational Health Sciences, St. Michael's Hospital, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - David A Menassa
- Division of Physiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
- The Queen's College, University of Oxford, Oxford, United Kingdom
| | - Emma Scull-Brown
- Translational Health Sciences, St. Michael's Hospital, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Adam Frymoyer
- Department of Pediatrics, Stanford University, California, United States
| | - Lars Walløe
- Division of Physiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Marianne Thoresen
- Division of Physiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
- Translational Health Sciences, St. Michael's Hospital, Bristol Medical School, University of Bristol, Bristol, United Kingdom
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17
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Giannakis S, Ruhfus M, Markus M, Stein A, Hoehn T, Felderhoff-Mueser U, Sabir H. Mechanical Ventilation, Partial Pressure of Carbon Dioxide, Increased Fraction of Inspired Oxygen and the Increased Risk for Adverse Short-Term Outcomes in Cooled Asphyxiated Newborns. CHILDREN-BASEL 2021; 8:children8060430. [PMID: 34063852 PMCID: PMC8224013 DOI: 10.3390/children8060430] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 05/04/2021] [Accepted: 05/18/2021] [Indexed: 11/26/2022]
Abstract
Neonates treated with therapeutic hypothermia (TH) following perinatal asphyxia (PA) suffer a considerable rate of disability and mortality. Several risk factors associated with adverse outcomes have been identified. Mechanical ventilation might increase the risk for hyperoxia and hypocapnia in cooled newborns. We carried out a retrospective study in 71 asphyxiated cooled newborns. We analyzed the association of ventilation status and adverse short-term outcomes and investigated the effect of the former on pCO2 and oxygen delivery before, during and after TH. Death, abnormal findings on magnetic resonance imaging, and pathological amplitude-integrated electroencephalography traces were used to define short-term outcomes. The need for mechanical ventilation was significantly higher in the newborns with adverse outcomes (38% vs. 5.6%, p = 0.001). Compared to spontaneously breathing neonates, intubated newborns suffered from significantly more severe asphyxia, had significantly lower levels of mean minimum pCO2 over the first 6 and 72 h of life (HOL) (p = 0.03 and p = 0.01, respectively) and increased supply of inspired oxygen, which was, in turn, significantly higher in the newborns with adverse outcomes (p < 0.01). Intubated newborns with adverse short-term outcomes had lower levels of pCO2 over the first 36 HOL. In conclusion, need for mechanical ventilation was significantly higher in newborns with more severe asphyxia. In ventilated newborns, level of encephalopathy, lower pCO2 levels, and increased oxygen supplementation were significantly higher in the adverse short-term outcomes group. Ventilatory parameters need to be carefully monitored in cooled asphyxiated newborns.
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Affiliation(s)
- Stamatios Giannakis
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, Faculty of Medicine, University Children’s Hospital, Heinrich-Heine-University Duesseldorf, 40225 Düsseldorf, Germany; (S.G.); (M.M.); (T.H.)
| | - Maria Ruhfus
- Department of Pediatrics I/Neonatology, University Hospital Essen, University Duisburg Essen, 45147 Essen, Germany; (M.R.); (A.S.); (U.F.-M.)
| | - Mona Markus
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, Faculty of Medicine, University Children’s Hospital, Heinrich-Heine-University Duesseldorf, 40225 Düsseldorf, Germany; (S.G.); (M.M.); (T.H.)
| | - Anja Stein
- Department of Pediatrics I/Neonatology, University Hospital Essen, University Duisburg Essen, 45147 Essen, Germany; (M.R.); (A.S.); (U.F.-M.)
| | - Thomas Hoehn
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, Faculty of Medicine, University Children’s Hospital, Heinrich-Heine-University Duesseldorf, 40225 Düsseldorf, Germany; (S.G.); (M.M.); (T.H.)
| | - Ursula Felderhoff-Mueser
- Department of Pediatrics I/Neonatology, University Hospital Essen, University Duisburg Essen, 45147 Essen, Germany; (M.R.); (A.S.); (U.F.-M.)
| | - Hemmen Sabir
- Department of Pediatrics I/Neonatology, University Hospital Essen, University Duisburg Essen, 45147 Essen, Germany; (M.R.); (A.S.); (U.F.-M.)
- Department of Neonatology and Pediatric Intensive Care, Children’s Hospital University of Bonn, 53127 Bonn, Germany
- German Centre for Neurodegenerative Diseases (DZNE), 53127 Bonn, Germany
- Correspondence:
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19
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Volume guarantee ventilation in neonates treated with hypothermia for hypoxic-ischemic encephalopathy during interhospital transport. J Perinatol 2021; 41:528-534. [PMID: 32989219 PMCID: PMC7520879 DOI: 10.1038/s41372-020-00823-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 08/24/2020] [Accepted: 09/14/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE We investigated if volume guarantee (VG) ventilation in babies with hypoxic-ischemic encephalopathy (HIE) during interhospital transport decreases tidal volumes and prevents hypocapnia. STUDY DESIGN We computationally collected and analyzed ventilator data of babies ventilated with synchronized intermittent mandatory ventilation (SIMV) with VG (n = 28) or without VG (n = 8). RESULT The expiratory tidal volume of ventilator inflations was lower with SIMV-VG (median [IQR]: 4.9 [4.6-5.3] mL/kg) than with SIMV only (median [IQR]: 7.1 [5.3-8.0] mL/kg, p = 0.01). Babies receiving SIMV-VG had lower peak inflating pressures (median: 10.7 cmH2O, versus 17.5 cmH2O, p = 0.01). There was no significant difference in minute ventilation or in pCO2. Babies with strong spontaneous breathing had a mean PIP < 10 cmH2O but this did not result in adverse events or worsening of acidosis. CONCLUSIONS The use of VG ventilation in babies with HIE reduces tidal volumes and frequently results in very low inflating pressures without affecting pCO2.
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20
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Pospelov AS, Puskarjov M, Kaila K, Voipio J. Endogenous brain-sparing responses in brain pH and PO 2 in a rodent model of birth asphyxia. Acta Physiol (Oxf) 2020; 229:e13467. [PMID: 32174009 DOI: 10.1111/apha.13467] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 03/11/2020] [Indexed: 12/12/2022]
Abstract
AIM To study brain-sparing physiological responses in a rodent model of birth asphyxia which reproduces the asphyxia-defining systemic hypoxia and hypercapnia. METHODS Steady or intermittent asphyxia was induced for 15-45 minutes in anaesthetized 6- and 11-days old rats and neonatal guinea pigs using gases containing 5% or 9% O2 plus 20% CO2 (in N2 ). Hypoxia and hypercapnia were induced with low O2 and high CO2 respectively. Oxygen partial pressure (PO2 ) and pH were measured with microsensors within the brain and subcutaneous ("body") tissue. Blood lactate was measured after asphyxia. RESULTS Brain and body PO2 fell to apparent zero with little recovery during 5% O2 asphyxia and 5% or 9% O2 hypoxia, and increased more than twofold during 20% CO2 hypercapnia. Unlike body PO2 , brain PO2 recovered rapidly to control after a transient fall (rat), or was slightly higher than control (guinea pig) during 9% O2 asphyxia. Asphyxia (5% O2 ) induced a respiratory acidosis paralleled by a progressive metabolic (lact)acidosis that was much smaller within than outside the brain. Hypoxia (5% O2 ) produced a brain-confined alkalosis. Hypercapnia outlasting asphyxia suppressed pH recovery and prolonged the post-asphyxia PO2 overshoot. All pH changes were accompanied by consistent shifts in the blood-brain barrier potential. CONCLUSION Regardless of brain maturation stage, hypercapnia can restore brain PO2 and protect the brain against metabolic acidosis despite compromised oxygen availability during asphyxia. This effect extends to the recovery phase if normocapnia is restored slowly, and it is absent during hypoxia, demonstrating that exposure to hypoxia does not mimic asphyxia.
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Affiliation(s)
- Alexey S. Pospelov
- Faculty of Biological and Environmental Sciences, Molecular and Integrative Biosciences University of Helsinki Helsinki Finland
| | - Martin Puskarjov
- Faculty of Biological and Environmental Sciences, Molecular and Integrative Biosciences University of Helsinki Helsinki Finland
| | - Kai Kaila
- Faculty of Biological and Environmental Sciences, Molecular and Integrative Biosciences University of Helsinki Helsinki Finland
- Neuroscience Center (HiLIFE) University of Helsinki Helsinki Finland
| | - Juha Voipio
- Faculty of Biological and Environmental Sciences, Molecular and Integrative Biosciences University of Helsinki Helsinki Finland
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O'Dea M, Sweetman D, Bonifacio SL, El-Dib M, Austin T, Molloy EJ. Management of Multi Organ Dysfunction in Neonatal Encephalopathy. Front Pediatr 2020; 8:239. [PMID: 32500050 PMCID: PMC7243796 DOI: 10.3389/fped.2020.00239] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Accepted: 04/20/2020] [Indexed: 12/16/2022] Open
Abstract
Neonatal Encephalopathy (NE) describes neonates with disturbed neurological function in the first post-natal days of life. NE is an overall term that does not specify the etiology of the encephalopathy although it often involves hypoxia-ischaemia. In NE, although neurological dysfunction is part of the injury and is most predictive of long-term outcome, these infants may also have multiorgan injury and compromise, which further contribute to neurological impairment and long-term morbidities. Therapeutic hypothermia (TH) is the standard of care for moderate to severe NE. Infants with NE may have co-existing immune, respiratory, endocrine, renal, hepatic, and cardiac dysfunction that require individualized management and can be impacted by TH. Non-neurological organ dysfunction not only has a negative effect on long term outcome but may also influence the efficacy of treatments in the acute phase. Post resuscitative care involves stabilization and decisions regarding TH and management of multi-organ dysfunction. This management includes detailed neurological assessment, cardio-respiratory stabilization, glycaemic and fluid control, sepsis evaluation and antibiotics, seizure identification, and monitoring and responding to biochemical and coagulation derangements. The emergence of new biomarkers of specific organ injury may have predictive value and improve the definition of organ injury and prognosis. Further evidence-based research is needed to optimize management of NE, prevent further organ dysfunction and reduce neurodevelopmental impairment.
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Affiliation(s)
- Mary O'Dea
- Discipline of Paediatrics, Trinity College, The University of Dublin, Dublin, Ireland.,Paediatric Research Laboratory, Trinity Translational Institute, St. James' Hospital, Dublin, Ireland.,Neonatology, Coombe Women and Infant's University Hospital, Dublin, Ireland.,National Children's Research Centre, Dublin, Ireland
| | - Deirdre Sweetman
- National Children's Research Centre, Dublin, Ireland.,Paediatrics, National Maternity Hospital, Dublin, Ireland
| | - Sonia Lomeli Bonifacio
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, United States
| | - Mohamed El-Dib
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Topun Austin
- Neonatal Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Eleanor J Molloy
- Discipline of Paediatrics, Trinity College, The University of Dublin, Dublin, Ireland.,Paediatric Research Laboratory, Trinity Translational Institute, St. James' Hospital, Dublin, Ireland.,Neonatology, Coombe Women and Infant's University Hospital, Dublin, Ireland.,National Children's Research Centre, Dublin, Ireland.,Paediatrics, National Maternity Hospital, Dublin, Ireland.,Neonatology, Children's Hospital Ireland (CHI) at Crumlin, Dublin, Ireland.,Paediatrics, CHI at Tallaght, Tallaght University Hospital, Dublin, Ireland
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22
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The therapeutic challenges of respiratory distress syndrome in the newborn – case report. GINECOLOGIA.RO 2020. [DOI: 10.26416/gine.30.4.2020.3945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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