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Liu M, Lu M, Kim SY, Lee HJ, Duffy BA, Yuan S, Chai Y, Cole JH, Wu X, Toga AW, Jahanshad N, Gano D, Barkovich AJ, Xu D, Kim H. Brain age predicted using graph convolutional neural network explains neurodevelopmental trajectory in preterm neonates. Eur Radiol 2024; 34:3601-3611. [PMID: 37957363 PMCID: PMC11166741 DOI: 10.1007/s00330-023-10414-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 09/06/2023] [Accepted: 09/16/2023] [Indexed: 11/15/2023]
Abstract
OBJECTIVES Dramatic brain morphological changes occur throughout the third trimester of gestation. In this study, we investigated whether the predicted brain age (PBA) derived from graph convolutional network (GCN) that accounts for cortical morphometrics in third trimester is associated with postnatal abnormalities and neurodevelopmental outcome. METHODS In total, 577 T1 MRI scans of preterm neonates from two different datasets were analyzed; the NEOCIVET pipeline generated cortical surfaces and morphological features, which were then fed to the GCN to predict brain age. The brain age index (BAI; PBA minus chronological age) was used to determine the relationships among preterm birth (i.e., birthweight and birth age), perinatal brain injuries, postnatal events/clinical conditions, BAI at postnatal scan, and neurodevelopmental scores at 30 months. RESULTS Brain morphology and GCN-based age prediction of preterm neonates without brain lesions (mean absolute error [MAE]: 0.96 weeks) outperformed conventional machine learning methods using no topological information. Structural equation models (SEM) showed that BAI mediated the influence of preterm birth and postnatal clinical factors, but not perinatal brain injuries, on neurodevelopmental outcome at 30 months of age. CONCLUSIONS Brain morphology may be clinically meaningful in measuring brain age, as it relates to postnatal factors, and predicting neurodevelopmental outcome. CLINICAL RELEVANCE STATEMENT Understanding the neurodevelopmental trajectory of preterm neonates through the prediction of brain age using a graph convolutional neural network may allow for earlier detection of potential developmental abnormalities and improved interventions, consequently enhancing the prognosis and quality of life in this vulnerable population. KEY POINTS •Brain age in preterm neonates predicted using a graph convolutional network with brain morphological changes mediates the pre-scan risk factors and post-scan neurodevelopmental outcomes. •Predicted brain age oriented from conventional deep learning approaches, which indicates the neurodevelopmental status in neonates, shows a lack of sensitivity to perinatal risk factors and predicting neurodevelopmental outcomes. •The new brain age index based on brain morphology and graph convolutional network enhances the accuracy and clinical interpretation of predicted brain age for neonates.
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Affiliation(s)
- Mengting Liu
- School of Biomedical Engineering, Sun Yat-Sen University, Shenzhen, 518107, China
- Department of Neurology, USC Stevens Neuroimaging and Informatics Institute, Keck School of Medicine, University of Southern California, 2025 Zonal Ave, Los Angeles, CA, 90033, USA
| | - Minhua Lu
- Guangdong Key Laboratory for Biomedical Measurements and Ultrasound Imaging, School of Biomedical Engineering, Medical School, Shenzhen University, Shenzhen, 518060, China
| | - Sharon Y Kim
- Department of Neurology, USC Stevens Neuroimaging and Informatics Institute, Keck School of Medicine, University of Southern California, 2025 Zonal Ave, Los Angeles, CA, 90033, USA
| | - Hyun Ju Lee
- Division of Neonatology, Department of Pediatrics, Hanyang University, Seoul, Korea
| | - Ben A Duffy
- Department of Neurology, USC Stevens Neuroimaging and Informatics Institute, Keck School of Medicine, University of Southern California, 2025 Zonal Ave, Los Angeles, CA, 90033, USA
| | - Shiyu Yuan
- Department of Neurology, USC Stevens Neuroimaging and Informatics Institute, Keck School of Medicine, University of Southern California, 2025 Zonal Ave, Los Angeles, CA, 90033, USA
| | - Yaqiong Chai
- Department of Neurology, USC Stevens Neuroimaging and Informatics Institute, Keck School of Medicine, University of Southern California, 2025 Zonal Ave, Los Angeles, CA, 90033, USA
| | - James H Cole
- Centre for Medical Image Computing, Department of Computer Science, University College London, London, UK
| | - Xiaotong Wu
- School of Biomedical Engineering, Sun Yat-Sen University, Shenzhen, 518107, China
| | - Arthur W Toga
- Department of Neurology, USC Stevens Neuroimaging and Informatics Institute, Keck School of Medicine, University of Southern California, 2025 Zonal Ave, Los Angeles, CA, 90033, USA
| | - Neda Jahanshad
- Department of Neurology, USC Stevens Neuroimaging and Informatics Institute, Keck School of Medicine, University of Southern California, 2025 Zonal Ave, Los Angeles, CA, 90033, USA
| | - Dawn Gano
- Departments of Neurology and Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Anthony James Barkovich
- Department of Radiology & Biomedical Imaging, University of California, San Francisco, San Francisco, CA, USA
| | - Duan Xu
- Department of Radiology & Biomedical Imaging, University of California, San Francisco, San Francisco, CA, USA
| | - Hosung Kim
- Department of Neurology, USC Stevens Neuroimaging and Informatics Institute, Keck School of Medicine, University of Southern California, 2025 Zonal Ave, Los Angeles, CA, 90033, USA.
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Ramaswamy VV, Kumar G, Abdul Kareem P, Somasekhara Aradhya A, Suryawanshi P, Sahni M, Khurana S, Sharma D, More K. Comparative efficacy of volume expansion, inotropes and vasopressors in preterm neonates with probable transitional circulatory instability in the first week of life: a systematic review and network meta-analysis. BMJ Paediatr Open 2024; 8:e002500. [PMID: 38769048 PMCID: PMC11110579 DOI: 10.1136/bmjpo-2024-002500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 03/12/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND There exists limited agreement on the recommendations for the treatment of transitional circulatory instability (TCI) in preterm neonates OBJECTIVE: To compare the efficacy of various interventions used to treat TCI METHODS: Medline and Embase were searched from inception to 21st July 2023. Two authors extracted the data independently. A Bayesian random effects network meta-analysis was used. Recommendations were formulated using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework. INTERVENTIONS Dopamine, dobutamine, epinephrine, hydrocortisone, vasopressin, milrinone, volume and placebo. MAIN OUTCOME MEASURES Mortality, major brain injury (MBI) (intraventricular haemorrhage > grade 2 or cystic periventricular leukomalacia), necrotising enterocolitis (NEC) ≥stage 2 and treatment response (as defined by the author). RESULTS 15 Randomized Controlled Trials (RCTs) were included from the 1365 titles and abstracts screened. Clinical benefit or harm could not be ruled out for the critical outcome of mortality. For the outcome of MBI, epinephrine possibly decreased the risk when compared to dobutamine and milrinone (very low certainty). Epinephrine was possibly associated with a lesser risk of NEC when compared with dopamine, dobutamine, hydrocortisone and milrinone (very low certainty). Dopamine was possibly associated with a lesser risk of NEC when compared with dobutamine (very low certainty). Vasopressin possibly decreased the risk of NEC compared with dopamine, dobutamine, hydrocortisone and milrinone (very low certainty). Clinical benefit or harm could not be ruled out for the outcome response to treatment. CONCLUSIONS Epinephrine may be used as the first-line drug in preterm neonates with TCI, the evidence certainty being very low. We suggest future trials evaluating the management of TCI with an emphasis on objective criteria to define it.
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Affiliation(s)
| | - Gunjana Kumar
- Neonatology, National Institute of Medical Sciences and Research, Jaipur, Rajasthan, India
| | | | | | - Pradeep Suryawanshi
- Neonatology, Bharati Vidyapeeth University Medical College & Hospital, Pune, Maharashtra, India
| | - Mohit Sahni
- Neonatology, Surat Kids Hospital, Surat, Gujarat, India
| | | | - Deepak Sharma
- Neonatology, National Institute of Medical Sciences and Research, Jaipur, Rajasthan, India
| | - Kiran More
- Neonatology, MRR Children's Hospital, Thane, Maharashtra, India
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Shah S, Dhalait S, Fursule A, Khandare J, Kaul A. Use of Vasopressin as Rescue Therapy in Refractory Hypoxia and Refractory Systemic Hypotension in Term Neonates with Severe Persistent Pulmonary Hypertension-A Prospective Observational Study. Am J Perinatol 2024; 41:e886-e892. [PMID: 36302521 DOI: 10.1055/a-1969-1119] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE Persistent pulmonary hypertension of the newborn (PPHN) is a serious cardiorespiratory problem. PPHN is frequently associated with refractory hypoxia and hypotension, and optimal management has the potential to improve important clinical outcomes including mortality. The primary objective is to evaluate the efficacy and safety of rescue vasopressin (VP) therapy in the management of severe (refractory) hypoxia and refractory systemic hypotension in term neonates with severe PPHN. STUDY DESIGN Neonates with refractory hypoxia and refractory hypotension due to severe PPHN needing VP were prospectively enrolled in the study. Refractory hypoxia was defined as oxygenation index (OI) ≥ 25 for at least 4 hours after the commencement of high-frequency oscillatory ventilation and nitric oxide at 20 ppm. Refractory hypotension was defined as mean blood pressure lesser than mean gestational age lasting for more than 15 minutes in spite of dopamine infusion at 10 µg/kg/min, adrenaline infusion at 0.3 µg/kg/min, and noradrenaline infusion at 0.1 µg/kg/min. RESULTS Thirty-two neonates with PPHN were recruited. The baseline OI (mean ± standard deviation [SD]) before starting VP was 33.43 ± 16.54 which started decreasing significantly between 1 and 6 hours after the commencement of VP (p < 0.05). The mean blood pressure also increased concomitantly with a significant effect seen by 1 hour (p < 0.05). The vasoactive infusion score before the commencement of VP was mean 46.07 (SD = 25.72) and started decreasing after 12 to 24 hours of commencement of VP (p < 0.05). Lactate levels (mean ± SD) before starting VP were 7.8 ± 8.6 mmol/L and started decreasing between 6 and 12 hours (p < 0.05). Two neonates died due to refractory hypoxia and refractory hypotension (overall mortality 6.2%) CONCLUSION: Rescue VP therapy is a useful adjunct in the management of neonates with severe PPHN with refractory hypoxia and/or refractory hypotension. Improvement in oxygenation and hemodynamics with the use of VP results in reduced mortality. KEY POINTS · Rescue vasopressin is a useful adjunct in the management of neonates with severe PPHN.. · Vasopressin helps reduce OI.. · Vasopressin reduces the vasoactive inotrope score..
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Affiliation(s)
- Sachin Shah
- Department of Neonatal and Pediatric Intensive Care Services, Surya Mother & Child Superspeciality Hospital, Pune, Maharashtra, India
| | - Saleha Dhalait
- Department of Neonatal and Pediatric Intensive Care Services, Surya Mother & Child Superspeciality Hospital, Pune, Maharashtra, India
| | - Anurag Fursule
- Department of Neonatal and Pediatric Intensive Care Services, Surya Mother & Child Superspeciality Hospital, Pune, Maharashtra, India
| | - Jayant Khandare
- Department of Neonatal and Pediatric Intensive Care Services, Surya Mother & Child Superspeciality Hospital, Pune, Maharashtra, India
| | - Amita Kaul
- Department of Neonatal and Pediatric Intensive Care Services, Surya Mother & Child Superspeciality Hospital, Pune, Maharashtra, India
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McKim KJ, Lucafo S, Bhombal S, Bain L, Chock VY. Blood Pressure Goals: Is Cerebral Saturation the New Mean Arterial Pressure? Am J Perinatol 2024; 41:498-504. [PMID: 34814195 DOI: 10.1055/a-1704-1851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The objective of this article was to correlate hypotension and cerebral saturation from near-infrared spectroscopy (cNIRS) in neonates on dopamine. STUDY DESIGN Retrospective review of neonates receiving dopamine between August 2018 and 2019 was performed. Hypotension thresholds included mean arterial pressure (MAP) of postmenstrual age (PMA) ± 5 and 30 mm Hg and gestational age (GA) ± 5 mm Hg. Time below threshold MAP was compared with time with cerebral hypoxia (cNIRS <55%). RESULTS Hypotension occurred 6 to 33% of the time on dopamine in 59 cases. Hypotension did not correlate with abnormal cNIRS overall, within PMA subgroups or by outcomes. Hypotensive periods with MAP < GA had fewer corresponding percent time with abnormal cNIRS events (3.7 ± 1.3%) compared with MAP < PMA (11.9 ± 4.9%, p < 0.003) or 30 mm Hg thresholds (12.2 ± 4.7%, p < 0.0001). In most premature infants, mean cNIRS values during hypotension were still within normal range (57 ± 6%). CONCLUSION cNIRS may be a more clinically relevant measure than MAP for the assessment of neonatal hypotension. KEY POINTS · Hypotension occurred 6 to 33% of the time on dopamine in 59 cases.. · Hypotension did not correlate with abnormal cNIRS overall, within PMA subgroups or by outcomes.. · MAP. · We found no cNIRS difference between IVH grades, mortality, average Hct, lactates, or urine output.. · cNIRS may be a more clinically relevant measure than MAP for the assessment of neonatal hypotension..
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Affiliation(s)
- Kevin J McKim
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, California
| | | | - Shazia Bhombal
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, California
| | - Lisa Bain
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, California
| | - Valerie Y Chock
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, California
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Amer R, DeCabo C, Elnagary M, Seshia MM, Elsayed YN. The association of cumulative vasoactive drugs and neurodevelopmental outcomes in preterm Infants <29 weeks gestation. J Neonatal Perinatal Med 2024; 17:71-76. [PMID: 38189716 DOI: 10.3233/npm-230077] [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: 01/09/2024]
Abstract
OBJECTIVE To assess the effect of cardiovascular medications on the neurodevelopment of preterm infants, as measured by calculated cumulative time of vasoactive-inotropic score (VISct). METHODS A retrospective study was conducted on preterm infants who developed significant hypotension defined as a mean BP more than 2SDs below the mean for GA and received treatment with duration > 6 hours for each hypotensive episode, we calculated the vasoactive inotropic score (VIS) and cumulative exposure to cardiovascular medications over time (VISct). The composite Bayley III was reported from the high-risk follow-up clinic for the surviving infants between 18 to 21 months corrected age. RESULTS VISct was significantly higher in infants with abnormal neurodevelopment. Cognitive Bayley was the most affected component with median (IQR) VISct 882.5(249,2047) versus 309(143,471) (p-value 0.012), followed by language function with VISct 786(261,1563.5), versus 343(106.75,473.75) (p-value 0.016) when those with Bayley III <85 were compared with those with normal Bayley IIIs. CONCLUSION High VISct scores may have negative effect on cognitive and language neurodevelopmental outcomes.
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Affiliation(s)
- R Amer
- Pediatrics Department, Section of Neonatology, McMaster University, Hamilton, ON, Canada
| | - C DeCabo
- Pediatrics Department, Section of Neonatology, University of Manitoba, Winnipeg, MB, Canada
| | - M Elnagary
- McMaster University, Hamilton, ON, Canada
| | - M M Seshia
- Pediatrics Department, Section of Neonatology, University of Manitoba, Winnipeg, MB, Canada
| | - Y N Elsayed
- Pediatrics Department, Section of Neonatology, University of Manitoba, Winnipeg, MB, Canada
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Noroozi-Clever MB, Liao SM, Whitehead HV, Vesoulis ZA. Preterm Infants off Positive Pressure Respiratory Support Have a Higher Incidence of Occult Cerebral Hypoxia. J Pediatr 2023; 262:113648. [PMID: 37517651 PMCID: PMC10822026 DOI: 10.1016/j.jpeds.2023.113648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 07/21/2023] [Accepted: 07/25/2023] [Indexed: 08/01/2023]
Abstract
OBJECTIVE To use cerebral near-infrared spectroscopy (NIRS) to quantify occult cerebral hypoxia across respiratory support modes in preterm infants. STUDY DESIGN In this prospective, longitudinal, observational study, infants ≤32 weeks gestation underwent serial pulse oximetry (oxygen saturation [SpO2]) and cerebral NIRS monitoring (4-6 hours per session) following a standardized recording schedule (daily for 2 weeks, every other day for 2 weeks, then weekly until 35 weeks corrected gestational age). Four calculations were made: median cerebral saturation, median cerebral hypoxia burden (proportion of NIRS samples below the hypoxia threshold [<67%]), median systemic saturation, and median systemic hypoxia burden (proportion of SpO2 samples below the desaturation threshold [<85%]). During each recording session, respiratory support mode was noted (room air, low-flow nasal cannula, high-flow nasal cannula, noninvasive positive pressure ventilation, continuous positive airway pressure, and invasive ventilation). RESULTS There were 1013 recording sessions made from 174 infants with a median length of 6.9 hours. Although the systemic (SpO2) hypoxia burden was significantly greater for infants on the highest respiratory support (invasive and noninvasive positive pressure ventilation), the cerebral hypoxia burden was significantly greater during recording sessions made on the lowest respiratory support (8% for room air; 29% for low-flow nasal cannula). CONCLUSIONS Premature infants on the highest levels of respiratory support have less cerebral hypoxia than those on lower respiratory support. These results raise concern about unrecognized cerebral hypoxia during lower acuity periods of neonatal intensive care unit hospitalization and adverse outcomes.
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Affiliation(s)
- Mona B Noroozi-Clever
- Division of Newborn Medicine, Edward Mallinckrodt Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Steve M Liao
- Division of Newborn Medicine, Edward Mallinckrodt Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Halana V Whitehead
- Division of Newborn Medicine, Edward Mallinckrodt Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Zachary A Vesoulis
- Division of Newborn Medicine, Edward Mallinckrodt Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, MO.
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Nissimov S, Joye S, Kharrat A, Zhu F, Ripstein G, Baczynski M, Choudhury J, Jasani B, Deshpande P, Ye XY, Weisz DE, Jain A. Dopamine or norepinephrine for sepsis-related hypotension in preterm infants: a retrospective cohort study. Eur J Pediatr 2023; 182:1029-1038. [PMID: 36544000 DOI: 10.1007/s00431-022-04758-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 12/03/2022] [Accepted: 12/07/2022] [Indexed: 12/24/2022]
Abstract
The purpose of this study is to compare the clinical effectiveness of dopamine (DA) versus norepinephrine (NE) as first-line therapy for sepsis-related hypotension in preterm infants. This is a retrospective cohort study over 10 years at two tertiary neonatal units. Preterm infants born < 35 weeks post-menstrual age (PMA), who received DA or NE as primary therapy for hypotension during sepsis, defined as culture-positive or culture-negative infections or necrotizing enterocolitis (NEC), were included. Episode-related mortality (< 7 days from treatment), pre-discharge mortality, and major morbidities among survivors were compared between two groups. Analyses were adjusted using the inverse probability of treatment weighting estimated by propensity score (PS). A total of 156 infants were included, 113 received DA and 43 NE. The mean ± SD PMA at birth and at treatment for the DA and NE groups were 25.8 ± 2.3 vs. 25.2 ± 2.0 weeks and 27.7 ± 3.0 vs. 27.1 ± 2.6 weeks, respectively (p > 0.05). Pre-treatment, the NE group had higher mean airway pressure (14 ± 4 vs. 12 ± 4 cmH2O), heart rate (185 ± 17 vs. 175 ± 17 beats per minute), and median (IQR) fraction of inspired oxygen [0.67 (0.42, 1.0) vs. 0.52 (0.32, 0.82)] (p < 0.05 for all). After PS adjustment, NE was associated with lower episode-related mortality [adjusted odds ratio (95% CI) 0.55 (0.33, 0.92)], pre-discharge mortality [0.60 (0.37, 0.97)], post-illness new diagnosis of significant neurologic injury [0.32 (0.13, 0.82)], and subsequent occurrence of NEC/sepsis among the survivors [0.34, (0.18, 0.65)]. CONCLUSION NE may be more effective than DA for management of sepsis-related hypotension among preterm infants. These data provide a rationale for prospective evaluation of these commonly used agents. WHAT IS KNOWN •Dopamine is the commonest vasoactive agent used to support blood pressure among preterm infants. •For adult patients, norepinephrine is recommended as the preferred therapy over dopamine for septic shock. WHAT IS NEW •This is the first study examining the relative clinical effectiveness of dopamine and norepinephrine as first-line pharmacotherapy for sepsis-related hypotension among preterm infants. •Norepinephrine use may be associated with lower mortality and morbidity than dopamine in preterm infants with sepsis.
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Affiliation(s)
- Sagee Nissimov
- Department of Paediatrics, Mount Sinai Hospital, ON, Toronto, Canada
| | - Sébastien Joye
- Clinic of Neonatology, Lausanne University Hospital, Lausanne, Switzerland
| | - Ashraf Kharrat
- Department of Paediatrics, Mount Sinai Hospital, ON, Toronto, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Faith Zhu
- Department of Paediatrics, Mount Sinai Hospital, ON, Toronto, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | | | - Michelle Baczynski
- Department of Respiratory Therapy, Mount Sinai Hospital, Toronto, ON, Canada
| | - Julie Choudhury
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Bonny Jasani
- Division of Neonatology, Department of Pediatrics, Hospital for Sick Children, Toronto, ON, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Poorva Deshpande
- Department of Paediatrics, Mount Sinai Hospital, ON, Toronto, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Xiang Y Ye
- Lunnenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada
| | - Dany E Weisz
- Newborn and Developmental Paediatrics, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Amish Jain
- Department of Paediatrics, Mount Sinai Hospital, ON, Toronto, Canada.
- Lunnenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada.
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada.
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Weaver LJ, Travers CP, Ambalavanan N, Askenazi D. Neonatal fluid overload-ignorance is no longer bliss. Pediatr Nephrol 2023; 38:47-60. [PMID: 35348902 PMCID: PMC10578312 DOI: 10.1007/s00467-022-05514-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 01/26/2022] [Accepted: 02/21/2022] [Indexed: 01/10/2023]
Abstract
Excessive accumulation of fluid may result in interstitial edema and multiorgan dysfunction. Over the past few decades, the detrimental impact of fluid overload has been further defined in adult and pediatric populations. Growing evidence highlights the importance of monitoring, preventing, managing, and treating fluid overload appropriately. Translating this knowledge to neonates is difficult as they have different disease pathophysiologies, and because neonatal physiology changes rapidly postnatally in many of the organ systems (i.e., skin, kidneys, and cardiovascular, pulmonary, and gastrointestinal). Thus, evaluations of the optimal targets for fluid balance need to consider the disease state as well as the gestational and postmenstrual age of the infant. Integration of what is known about neonatal fluid overload with individual alterations in physiology is imperative in clinical management. This comprehensive review will address what is known about the epidemiology and pathophysiology of neonatal fluid overload and highlight the known knowledge gaps. Finally, we provide clinical recommendations for monitoring, prevention, and treatment of fluid overload.
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Affiliation(s)
| | - Colm P Travers
- University of Alabama at Birmingham, Birmingham, AL, USA.
| | | | - David Askenazi
- University of Alabama at Birmingham, Birmingham, AL, USA
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Hoffman SB, Magder LS, Viscardi RM. Renal versus cerebral saturation trajectories: the perinatal transition in preterm neonates. Pediatr Res 2022; 92:1437-1442. [PMID: 35177816 DOI: 10.1038/s41390-022-01984-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 01/04/2022] [Accepted: 01/26/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND The aim of this study was to develop reference renal saturation (rSrO2) curves in premature infants, depict how they differ from cerebral saturation (rScO2) curves, and evaluate the effect of blood pressure on these values using near-infrared spectroscopy (NIRS). METHODS This is a prospective cohort study of 57 inborn infants <12 h and <30 weeks gestation. rScO2, rSrO2, fractional tissue oxygen extraction (FTOE), and mean arterial blood pressure (MAP) were continuously monitored every 30 s for 96 h. Quantile regression was used to establish nomograms, and mean saturation values were evaluated for different MAP ranges. RESULTS Median rSrO2 at the start of monitoring was ~10% higher than rScO2. rSrO2 showed a significant decline over time while rScO2 peaked at 26 h. FTOE demonstrated a similar but inverse trend to their saturation counterparts. rScO2 declined as MAP increased, while rSrO2 showed a peak and decline as MAP increased. CONCLUSIONS We provide rSrO2 reference curves for the first 4 days of life, which differ in their trajectory from rScO2 and from what has previously been reported for rSrO2 in the full-term population. In addition, we observed a peak and decline in renal saturation with increasing MAP, suggesting a renovascular response to blood pressure changes. IMPACT This article depicts reference renal saturation curves during the perinatal transition in preterm infants. We show how renal saturation compares to cerebral saturation trends over time. We describe a peak and decline in renal saturation with increasing MAP, suggesting a renovascular response to blood pressure changes.
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Affiliation(s)
- Suma B Hoffman
- Department of Pediatrics, University of Maryland Baltimore School of Medicine, Baltimore, MD, USA. .,Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Children's National Health System - Neonatology, Washington, DC, USA.
| | - Laurence S Magder
- Department of Epidemiology and Public Health, University of Maryland Baltimore School of Medicine, Baltimore, MD, USA
| | - Rose M Viscardi
- Department of Pediatrics, University of Maryland Baltimore School of Medicine, Baltimore, MD, USA
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10
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Dougherty D, Cham P, Church JT. Management of Extreme Prematurity (Manuscript for Seminars in Pediatric Surgery). Semin Pediatr Surg 2022; 31:151198. [PMID: 36038216 DOI: 10.1016/j.sempedsurg.2022.151198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Affiliation(s)
| | - Parul Cham
- Clinical Assistant Professor of Pediatrics, University of Michigan
| | - Joseph T Church
- Assistant Professor of Surgery, UPMC Children's Hospital of Pittsburgh.
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11
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Surak A, Lalitha R, Bitar E, Hyderi A, Hicks M, Cheung PY, Kumaran K. Multimodal Assessment of Systemic Blood Flow in Infants. Neoreviews 2022; 23:e486-e496. [PMID: 35773505 DOI: 10.1542/neo.23-7-e486] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The assessment of systemic blood flow is a complex and comprehensive process with clinical, laboratory, and technological components. Despite recent advancements in technology, there is no perfect bedside tool to quantify systemic blood flow in infants that can be used for clinical decision making. Each option has its own merits and limitations, and evidence on the reliability of these physiology-based assessment processes is evolving. This article provides an extensive review of the interpretation and limitations of methods to assess systemic blood flow in infants, highlighting the importance of a comprehensive and multimodal approach in this population.
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Affiliation(s)
- Aimann Surak
- Division of Neonatology, Stollery Children's Hospital, Edmonton, AB, Canada
| | - Renjini Lalitha
- Division of Neonatology, London Health Sciences Centre, London, ON, Canada
| | - Eyad Bitar
- Division of Neonatology, Stollery Children's Hospital, Edmonton, AB, Canada
| | - Abbas Hyderi
- Division of Neonatology, Stollery Children's Hospital, Edmonton, AB, Canada
| | - Matt Hicks
- Division of Neonatology, Stollery Children's Hospital, Edmonton, AB, Canada
| | - Po Yin Cheung
- Division of Neonatology, Stollery Children's Hospital, Edmonton, AB, Canada.,Department of Pharmacology and Surgery, University of Alberta, Edmonton, AB, Canada.,Centre for the Studies of Asphyxia and Resuscitation, Edmonton, AB, Canada
| | - Kumar Kumaran
- Division of Neonatology, Stollery Children's Hospital, Edmonton, AB, Canada
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12
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Sarafidis K, Verykouki E, Nikopoulos S, Apostolidou-Kiouti F, Diakonidis T, Agakidou E, Kontou A, Haidich AB. Systematic Review and Meta-Analysis of Cardiovascular Medications in Neonatal Hypotension. Biomed Hub 2022; 7:70-79. [PMID: 35950013 PMCID: PMC9251481 DOI: 10.1159/000525133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 04/20/2022] [Indexed: 11/19/2022] Open
Abstract
Background Comparative studies among the various cardiovascular medications used for the treatment of neonatal hypotension are lacking. Methods This systematic review and pairwise meta-analysis of the anti-hypotensive treatments in preterm and term infants was conducted to evaluate efficacy and impact on outcome. Electronic databases were searched up to February 2021 for relevant articles. As an extension of the current approach for study selection, a machine learning technique was used. Only randomized controlled trials (RCTs) of inotropes, pressors, volume therapy, and corticosteroids were included. Response to treatment was the primary outcome while secondary outcomes included mortality and common morbidities. Results Nineteen RCTs involving 758 preterm and term neonates were found, and 8 treatments were evaluated. Most studies involved subjects with early hypotension associated with prematurity. Pairwise meta-analysis among treatments showed that dopamine was more effective than dobutamine regarding the response to treatment (restoration of normotension or normalization of blood pressure) (7 trials, 286 neonates, odds ratio, 3.06 [95% CI = 1.06–8.87]; I<sup>2</sup> = 49%, very low quality of the evidence per GRADE). Comparisons of other treatments were not significant. No differences were found among regimens regarding survival and other secondary outcomes. Conclusion In this systematic review and pairwise meta-analysis, only the comparison of dopamine versus dobutamine provided evidence for efficacy of treatment and favored dopamine. No safe conclusions could be reached in regard to other treatments. Data regarding the management of arterial hypotension in conditions other than transition after birth in preterm newborns are sparse both in preterm and term infants.
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Affiliation(s)
- Kosmas Sarafidis
- 1st Department of Neonatology, School of Medicine, Aristotle University of Thessaloniki, Hppokrateion General Hospital, Thessaloniki, Greece
- *Kosmas Sarafidis,
| | - Eleni Verykouki
- Department of Hygiene, Social-Preventive Medicine & Medical Statistics, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Stefanos Nikopoulos
- 1st Department of Neonatology, School of Medicine, Aristotle University of Thessaloniki, Hppokrateion General Hospital, Thessaloniki, Greece
| | - Fani Apostolidou-Kiouti
- Department of Hygiene, Social-Preventive Medicine & Medical Statistics, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Theodoros Diakonidis
- Department of Hygiene, Social-Preventive Medicine & Medical Statistics, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleni Agakidou
- 1st Department of Neonatology, School of Medicine, Aristotle University of Thessaloniki, Hppokrateion General Hospital, Thessaloniki, Greece
| | - Aggeliki Kontou
- 1st Department of Neonatology, School of Medicine, Aristotle University of Thessaloniki, Hppokrateion General Hospital, Thessaloniki, Greece
| | - Anna-Bettina Haidich
- Department of Hygiene, Social-Preventive Medicine & Medical Statistics, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
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13
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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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14
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Zhong J, Shuai C, Wang Y, Mo J, Ma D, Zhang J, Lin Y, Yang J, Ye X. Baseline Values of Left Ventricular Systolic Function in Preterm Infants With Septic Shock: A Prospective Observational Study. Front Pediatr 2022; 10:839057. [PMID: 35425723 PMCID: PMC9001981 DOI: 10.3389/fped.2022.839057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 02/21/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND AND AIM Guidelines recommended that cardiac index (CI) of term infants with septic shock should reach the target level of 3.3-6.0L/(min⋅m2). However, there are still no standard values for preterm infants with septic shock. Herein, we investigated the functional echocardiographic baseline values of left ventricular (LV) systolic functional parameters at the onset of septic shock in preterm infants and possible correlations between baseline values and poor outcomes. MATERIALS AND METHODS This was a prospective, observational, and longitudinal single-center study. Eligible infants were monitored for LV systolic functional parameters using functional echocardiography at the onset of septic shock. The primary study outcome was the difference in the baseline value of LV systolic functional parameters in preterm infants with septic shock with different gestational age (GA) and birth weight (BW). The secondary outcome was septic shock-associated death or severe brain injury (including grade 3-4 intraventricular hemorrhage or periventricular leukomalacia). RESULTS In total, 43 subjects met the criteria, with a median GA of 321/7 weeks and BW of 1800 grams. No difference was observed in baseline values of LV systolic functional parameters among infants with different GA and BW. Infants were assigned to good and poor outcomes groups based on septic shock-associated death or severe brain injury. Out of 43 infants, 29 (67.4%) had good outcomes vs. 14 (32.6%) with poor outcomes. Stroke index (SI) [18.2 (11.1, 18.9) mL/m2 vs. 23.5 (18.9, 25.8) mL/m2, p = 0.017] and cardiac index (CI)[2.7 (1.6, 3.5) L/(min⋅m2) vs. 3.4 (3.0, 4.8) L/(min⋅m2), p = 0.015] in infants with poor outcomes were significantly lower (P < 0.05). Receiver operating characteristic (ROC) curve analysis showed that the cut-off values of SI and CI for predicting poor outcomes in preterm infants with septic shock were 19.5 mL/m2 (sensitivity, 73.9%; specificity, 81.8%) and 2.9L/(min⋅m2) (sensitivity, 78.3%; specificity, 72.7%), with area under the ROC curve (AUC) value of 0.755 and 0.759, respectively. CONCLUSION There were no differences in baseline LV systolic functional values among preterm infants with septic shock with different GA and BW. However, preterm infants with SI<19.5mL/m2 and/or CI<2.9L/(min⋅m2) at the onset of septic shock were at high risk of having poor outcomes.
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Affiliation(s)
- Junjuan Zhong
- Neonatal Intensive Care Unit, Guangdong Women's and Children's Hospital, Guangzhou, China
| | - Chun Shuai
- Neonatal Intensive Care Unit, Guangdong Women's and Children's Hospital, Guangzhou, China
| | - Yue Wang
- Neonatal Intensive Care Unit, Guangdong Women's and Children's Hospital, Guangzhou, China
| | - Jing Mo
- Neonatal Intensive Care Unit, Guangdong Women's and Children's Hospital, Guangzhou, China
| | - Dongju Ma
- Neonatal Intensive Care Unit, Guangdong Women's and Children's Hospital, Guangzhou, China
| | - Jing Zhang
- Neonatal Intensive Care Unit, Guangdong Women's and Children's Hospital, Guangzhou, China
| | - Yingyi Lin
- Neonatal Intensive Care Unit, Guangdong Women's and Children's Hospital, Guangzhou, China
| | - Jie Yang
- Neonatal Intensive Care Unit, Guangdong Women's and Children's Hospital, Guangzhou, China
| | - Xiuzhen Ye
- Neonatal Intensive Care Unit, Guangdong Women's and Children's Hospital, Guangzhou, China
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15
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Boldt R, Mäkelä PM, Immeli L, Sund R, Leskinen M, Luukkainen P, Andersson S. Blood pressure changes during the first 24 hours of life and the association with the persistence of a patent ductus arteriosus and occurrence of intraventricular haemorrhage. PLoS One 2021; 16:e0260377. [PMID: 34847157 PMCID: PMC8631614 DOI: 10.1371/journal.pone.0260377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 11/08/2021] [Indexed: 11/18/2022] Open
Abstract
Very low birthweight (VLBW) infants are at risk of intraventricular haemorrhage (IVH) and delayed closure of ductus arteriosus. We investigated mean arterially recorded blood pressure (MAP) changes during the first day of life in VLBW infants as potential risk factors for a patent ductus arteriosus (PDA) and IVH. This retrospective cohort study exploring MAP changes during adaption and risk factors for a PDA and IVH comprised 844 VLBW infants admitted to the Helsinki University Children’s Hospital during 2005–2013. For each infant, we investigated 600 time-points of MAP recorded 4–24 hours after birth. Based on blood pressure patterns revealed by a data-driven method, we divided the infants into two groups. Group 1 (n = 327, mean birthweight = 1019 g, mean gestational age = 28 + 1/7 weeks) consisted of infants whose mean MAP was lower at 18–24 hours than at 4–10 hours after birth. Group 2 (n = 517, mean birthweight = 1070 g, mean gestational age = 28 + 5/7 weeks) included infants with a higher mean MAP at 18–24 hours than at 4–10 hours after birth. We used the group assignments, MAP, gestational age at birth, relative size for gestational age, surfactant administration, inotrope usage, invasive ventilation, presence of respiratory distress syndrome or sepsis, fluid intake, and administration of antenatal steroids to predict the occurrence of IVH and use of pharmacological or surgical therapy for a PDA before 42 weeks of gestational age. Infants whose mean MAP is lower at 18–24 hours than at 4–10 hours after birth are more likely to undergo surgical ligation of a PDA (odds ratio = 2.1; CI 1.14–3.89; p = 0.018) and to suffer from IVH (odds ratio = 1.83; CI 1.23–2.72; p = 0.003).
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Affiliation(s)
- Robert Boldt
- New Children’s Hospital, Pediatric Research Center, University of Helsinki, and Helsinki University Hospital, Helsinki, Finland
- * E-mail:
| | - Pauliina M. Mäkelä
- New Children’s Hospital, Pediatric Research Center, University of Helsinki, and Helsinki University Hospital, Helsinki, Finland
| | - Lotta Immeli
- New Children’s Hospital, Pediatric Research Center, University of Helsinki, and Helsinki University Hospital, Helsinki, Finland
| | - Reijo Sund
- University of Eastern Finland, School of Medicine, Kuopio, Finland
| | - Markus Leskinen
- New Children’s Hospital, Pediatric Research Center, University of Helsinki, and Helsinki University Hospital, Helsinki, Finland
| | - Päivi Luukkainen
- New Children’s Hospital, Pediatric Research Center, University of Helsinki, and Helsinki University Hospital, Helsinki, Finland
| | - Sture Andersson
- New Children’s Hospital, Pediatric Research Center, University of Helsinki, and Helsinki University Hospital, Helsinki, Finland
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16
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Aziz KB, Lavilla OC, Wynn JL, Lure AC, Gipson D, de la Cruz D. Maximum vasoactive-inotropic score and mortality in extremely premature, extremely low birth weight infants. J Perinatol 2021; 41:2337-2344. [PMID: 33712712 PMCID: PMC8435049 DOI: 10.1038/s41372-021-01030-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 01/28/2021] [Accepted: 02/25/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To determine the relationship between maximum vasoactive-inotropic (VISmax) and mortality in extremely premature (<29 weeks completed gestation), extremely low birth weight (ELBW, <1000 g) infants. STUDY DESIGN Single center, retrospective, and observational cohort study. RESULTS We identified 436 ELBW, <29 week, inborn infants cared for during the study period. Compared to infants with VISmax of 0, the frequency of mortality based on VISmax ranged from 3.3-fold to 46.1-fold. VISmax > 30 was associated with universal mortality. Multivariable modeling that included gestational age, birth weight, and VISmax revealed significant utility to predict mortality with negative predictive value of 87.0% and positive predictive value of 84.8% [adjusted AUROC: 0.90, (0.86-0.94)] among patients that received vasoactive-inotropic treatment. CONCLUSION VISmax is an objective measure of hemodynamic/cardiovascular support that was directly associated with mortality in extremely premature ELBW infants. The VISmax represents an important step towards neonatal precision medicine and risk stratification of extremely premature ELBW infants.
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Affiliation(s)
- Khyzer B. Aziz
- Department of Pediatrics, Johns Hopkins University, Baltimore, Maryland
| | - Orlyn C. Lavilla
- Department of Pediatrics, University of Florida, Gainesville, Florida
| | - James L. Wynn
- Department of Pediatrics, University of Florida, Gainesville, Florida,Department of Pathology, Immunology, and Laboratory Medicine, University of Florida, Gainesville, Florida
| | - Allison C. Lure
- Department of Pediatrics, University of Florida, Gainesville, Florida
| | - Daniel Gipson
- Department of Pediatrics, University of Florida, Gainesville, Florida
| | - Diomel de la Cruz
- Department of Pediatrics, University of Florida, Gainesville, FL, USA.
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17
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Dempsey EM, Barrington KJ, Marlow N, O'Donnell CPF, Miletin J, Naulaers G, Cheung PY, Corcoran JD, EL-Khuffash AF, Boylan GB, Livingstone V, Pons G, Macko J, Van Laere D, Wiedermannova H, Straňák Z. Hypotension in Preterm Infants (HIP) randomised trial. Arch Dis Child Fetal Neonatal Ed 2021; 106:398-403. [PMID: 33627329 PMCID: PMC8237176 DOI: 10.1136/archdischild-2020-320241] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 11/02/2020] [Accepted: 12/06/2020] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To determine whether restricting the use of inotrope after diagnosis of low blood pressure (BP) in the first 72 hours of life affects survival without significant brain injury at 36 weeks of postmenstrual age (PMA) in infants born before 28 weeks of gestation. DESIGN Double-blind, placebo-controlled randomised trial. Caregivers were masked to group assignment. SETTING 10 sites across Europe and Canada. PARTICIPANTS Infants born before 28 weeks of gestation were eligible if they had an invasive mean BP less than their gestational age that persisted for ≥15 min in the first 72 hours of life and a cerebral ultrasound free of significant (≥ grade 3) intraventricular haemorrhage. INTERVENTION Participants were randomly assigned to saline bolus followed by either a dopamine infusion (standard management) or placebo (5% dextrose) infusion (restrictive management). PRIMARY OUTCOME Survival to 36 weeks of PMA without severe brain injury. RESULTS The trial terminated early due to significant enrolment issues (7.7% of planned recruitment). 58 infants were enrolled between February 2015 and September 2017. The two groups were well matched for baseline variables. In the standard group, 18/29 (62%) achieved the primary outcome compared with 20/29 (69%) in the restrictive group (p=0.58). Additional treatments for low BP were used less frequently in the standard arm (11/29 (38%) vs 19/29 (66%), p=0.038). CONCLUSION Though this study lacked power, we did not detect major differences in clinical outcomes between standard or restrictive approach to treatment. These results will inform future studies in this area. TRIAL REGISTRATION NUMBER NCT01482559, EudraCT 2010-023988-17.
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Affiliation(s)
- Eugene M Dempsey
- Department of Paediatric and Child Health and INFANT Research Centre, University College Cork, Cork, Ireland
| | - Keith J Barrington
- Néonatologie, Centre Hospitalier Universitaire Sainte Justine, Montreal, Quebec, Canada
| | - Neil Marlow
- Institute for Womens Health, University College London, London, UK
| | | | - Jan Miletin
- Paediatric and Newborn Medicine, Coombe Women and Infants University Hospital, Dublin, Ireland
| | - Gunnar Naulaers
- Neonatology, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Po-Yin Cheung
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - John David Corcoran
- Faculty of Medicine and Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Afif Faisal EL-Khuffash
- Faculty of Medicine and Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Geraldine B Boylan
- Department of Paediatric and Child Health and INFANT Research Centre, University College Cork, Cork, Ireland
| | - Vicki Livingstone
- Department of Paediatric and Child Health and INFANT Research Centre, University College Cork, Cork, Ireland
| | - Gerard Pons
- Clinical Pharmacology, Groupe Hospitalier Cochin-Broca, Hôtel Dieu, AP-HP, Paris, France
| | - Jozef Macko
- Department of Neonatology, Tomas Bata University in Zlin, Zlin, Zlínský Kraj, Czech Republic
| | | | - Hana Wiedermannova
- Department of Pediatrics and Neonatal Care, Ostravska Univerzita, Ostrava, Moravskoslezský, Czech Republic
| | - Zbyněk Straňák
- Institute for the Care of Mother and Child, Third Faculty of Medicine, Charles University, Prague, Czech Republic
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18
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Van Wyk L, Smith J, Lawrenson J, Lombard CJ, de Boode WP. Bioreactance-derived haemodynamic parameters in the transitional phase in preterm neonates: a longitudinal study. J Clin Monit Comput 2021; 36:861-870. [PMID: 33983533 DOI: 10.1007/s10877-021-00718-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 05/06/2021] [Indexed: 11/26/2022]
Abstract
Bioreactance (BR) is a novel, non-invasive technology that is able to provide minute-to-minute monitoring of cardiac output and additional haemodynamic variables. This study aimed to determine the values for BR-derived haemodynamic variables in stable preterm neonates during the transitional period. A prospective observational study was performed in a group of stable preterm (< 37 weeks) infants in the neonatal service of Tygerberg Children's Hospital, Cape Town, South Africa. All infants underwent continuous bioreactance (BR) monitoring until 72 h of life. Sixty three preterm infants with a mean gestational age of 31 weeks and mean birth weight of 1563 g were enrolled. Summary data and time series graphs were drawn for BR-derived heart rate, non-invasive blood pressure, stroke volume, cardiac output and total peripheral resistance index. All haemodynamic parameters were significantly associated with postnatal age, after correction for clinical variables (gestational age, birth weight, respiratory support mode). To our knowledge, this is the first paper to present longitudinal BR-derived haemodynamic variable data in a cohort of stable preterm infants, not requiring invasive ventilation or inotropic support, during the first 72 h of life. Bioreactance-derived haemodynamic monitoring is non-invasive and offers the ability to simultaneously monitor numerous haemodynamic parameters of global systemic blood flow. Moreover, it may provide insight into transitional physiology and its pathophysiology.
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Affiliation(s)
- Lizelle Van Wyk
- Division Neonatology, Dept. Pediatrics & Child Health, Stellenbosch University and Tygerberg Children's Hospital, Cape Town, South Africa.
| | - Johan Smith
- Division Neonatology, Dept. Pediatrics & Child Health, Stellenbosch University and Tygerberg Children's Hospital, Cape Town, South Africa
| | - John Lawrenson
- Pediatric Cardiology Unit, Dept. Pediatrics & Child Health, Stellenbosch University, Cape Town, South Africa
| | - Carl J Lombard
- Division of Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, Cape Town, South Africa
- Biostatistics Unit, South African Medical Research Council, Cape Town, South Africa
| | - Willem Pieter de Boode
- Division of Neonatology, Dept. of Perinatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
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19
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Szostek AS, Boucher P, Subtil F, Zerzaihi O, Saunier C, de Queiroz Siqueira M, Merquiol F, Martin P, Granier M, Gerst A, Lambert A, Storme T, Chassard D, Nony P, Kassai B, Gaillard S. Determination of the optimal dose of ephedrine in the treatment of arterial hypotension due to general anesthesia in neonates and infants below 6 months old: the ephedrine study protocol for a randomized, open-label, controlled, dose escalation trial. Trials 2021; 22:208. [PMID: 33712076 PMCID: PMC7953941 DOI: 10.1186/s13063-021-05155-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 02/26/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Arterial hypotension induced by general anesthesia is commonly identified as a risk factor of morbidity, especially neurological, after cardiac or noncardiac surgery in adults and children. Intraoperative hypotension is observed with sevoflurane anesthesia in children, in particular in neonates, infants younger than 6 months, and preterm babies. Ephedrine is commonly used to treat intraoperative hypotension. It is an attractive therapeutic, due to its dual action on receptors alpha and beta and its possible peripheral intravenous infusion. There are few data in the literature on the use of ephedrine in the context of pediatric anesthesia. The actual recommended dose of ephedrine (0.1 to 0.2 mg/Kg) frequently leads to a therapeutic failure in neonates and infants up to 6 months of age. The use of higher doses would probably lead to a better correction of hypotension in this population. The objective of our project is to determine the optimal dose of ephedrine for the treatment of hypotension after induction of general anesthesia with sevoflurane, in neonates and infants up to 6 months of age. METHODS The ephedrine study is a prospective, randomized, open-label, controlled, dose-escalation trial. The dose escalation consists of 6 successive cohorts of 20 subjects. The doses studied are 0.6, 0.8, 1, 1.2, and 1.4 mg/kg. The dose chosen as the reference is 0.1 mg/kg, the actual recommended dose. Neonates and infants younger than 6 months, males and females, including preterm babies who undergo a surgery with general anesthesia inducted with sevoflurane were eligible. Parents of the subject were informed. Then, the subjects were randomized if presenting a decrease in mean blood pressure superior to 20% of their initial mean blood pressure (before induction of anesthesia), despite a vascular filling with sodium chloride 0.9%. The primary outcome is the success of the therapy defined as an mBP superior to 80% of the baseline mBP (prior to anesthesia) within 10 min post ephedrine administration. The subjects were followed-up for 3 days postanesthesia. DISCUSSION This study is the first randomized, controlled trial intending to determine the optimal dose of ephedrine to treat hypotension in neonates and infants below 6 months old. TRIAL REGISTRATION ClinicalTrials.gov NCT02384876 . Registered on March 2015.
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Affiliation(s)
- A S Szostek
- Hospices Civils de Lyon, Service d'anesthésie pédiatrique-HFME, 69677, Bron, France
| | - P Boucher
- Hospices Civils de Lyon, Service d'anesthésie pédiatrique-HFME, 69677, Bron, France
| | - F Subtil
- Hospices Civils de Lyon, Service de Biostatistiques, Lyon, France
| | - O Zerzaihi
- Hospices Civils de Lyon, EPICIME-CIC 1407 de Lyon, Inserm, Département d'épidémiologie clinique, Bron, CHU-Lyon, F-69677, France
| | - C Saunier
- Hospices Civils de Lyon, EPICIME-CIC 1407 de Lyon, Inserm, Département d'épidémiologie clinique, Bron, CHU-Lyon, F-69677, France
| | | | - F Merquiol
- Department of Anesthesiology and Intensive Care, University Hospital of Saint-Etienne, Saint-Etienne Cedex, France
| | - P Martin
- Department of Anesthesiology and Intensive Care, University Hospital of Saint-Etienne, Saint-Etienne Cedex, France
| | - M Granier
- Département de Médecine Périopératoire, Anesthésie et Réanimation, Centre Hospitalier Universitaire Clermont-Ferrand, 63000, Clermont-Ferrand, France
| | - A Gerst
- Département de Médecine Périopératoire, Anesthésie et Réanimation, Centre Hospitalier Universitaire Clermont-Ferrand, 63000, Clermont-Ferrand, France
| | - A Lambert
- Hospices Civils de Lyon, Service d'anesthésie pédiatrique-HFME, 69677, Bron, France
| | - T Storme
- Hospices Civils de Lyon, Service d'anesthésie pédiatrique-HFME, 69677, Bron, France
| | - D Chassard
- Hospices Civils de Lyon, Service d'anesthésie pédiatrique-HFME, 69677, Bron, France
| | - P Nony
- Université de Lyon; CNRS, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, F-69622, Villeurbanne, France
| | - B Kassai
- Hospices Civils de Lyon, EPICIME-CIC 1407 de Lyon, Inserm, Département d'épidémiologie clinique, Bron, CHU-Lyon, F-69677, France.,Université de Lyon; CNRS, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, F-69622, Villeurbanne, France
| | - S Gaillard
- Hospices Civils de Lyon, EPICIME-CIC 1407 de Lyon, Inserm, Département d'épidémiologie clinique, Bron, CHU-Lyon, F-69677, France. .,Université de Lyon; CNRS, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, F-69622, Villeurbanne, France.
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20
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Patra A, Thakkar PS, Makhoul M, Bada HS. Objective Assessment of Physiologic Alterations Associated With Hemodynamically Significant Patent Ductus Arteriosus in Extremely Premature Neonates. Front Pediatr 2021; 9:648584. [PMID: 33718311 PMCID: PMC7946992 DOI: 10.3389/fped.2021.648584] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 02/05/2021] [Indexed: 11/23/2022] Open
Abstract
Delay in closure of ductus arteriosus in postnatal life may lead to serious consequences and complications in an extremely premature neonate secondary to hemodynamic alterations in regional blood flow pattern in various organs. Despite the widespread recognition amongst neonatologists to identify a hemodynamically significant patent ductus arteriosus (hsPDA) early in the postnatal course, there is lack of consensus in its definition and thus the threshold to initiate treatment. Echocardiographic assessment of PDA shunt size and volume combined with neonatologists' impression of clinical significance is most frequently used to determine the need for treatment of PDA. Common clinical signs of hsPDA utilized as surrogate for decreased tissue perfusion may lag behind early echocardiographic signs. Although echocardiogram allows direct assessment of PDA shunt and hemodynamic alterations in the heart, it is limited by dependence on pediatric cardiologist availability, interobserver variation and isolated time point assessment. Electrical cardiometry (EC) is a non-invasive continuous real time measurement of cardiac output by applying changes in thoracic electrical impedance. EC has been validated in preterm newborns by concomitant transthoracic echocardiogram assessments and may be beneficial in studying changes in cardiac output in premature newborns with hsPDA. Alterations in perfusion index derived from continuous pulse oximetry monitoring has been used to study changes in cardiac performance and tissue perfusion in infants with PDA. Near infrared spectroscopy (NIRS) has been used to objectively and continuously assess variations in renal, mesenteric, and cerebral oxygen saturation and thus perfusion changes due to diastolic vascular steal from hsPDA in preterm neonates. Doppler ultrasound studies measuring resistive indices in cerebral circulation indicate disturbance in cerebral perfusion secondary to ductal steal. With recent trends of change in practice toward less intervention in care of preterm newborn, treatment strategy needs to be targeted for select preterm population most vulnerable to adverse hemodynamic effects of PDA. Integration of these novel ways of hemodynamic and tissue perfusion assessment in routine clinical care may help mitigate the challenges in defining and targeting treatment of hsPDA thereby improving outcomes in extremely premature neonates.
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Affiliation(s)
- Aparna Patra
- Division of Neonatology, Department of Pediatrics, Kentucky Children's Hospital, University of Kentucky, Lexington, KY, United States
| | - Pratibha S Thakkar
- Division of Neonatology, Department of Pediatrics, Kentucky Children's Hospital, University of Kentucky, Lexington, KY, United States
| | - Majd Makhoul
- Division of Pediatric Cardiology, Department of Pediatrics, Kentucky Children's Hospital, University of Kentucky, Lexington, KY, United States
| | - Henrietta S Bada
- Division of Neonatology, Department of Pediatrics, Kentucky Children's Hospital, University of Kentucky, Lexington, KY, United States
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21
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Schranz D. Pharmacological Heart Failure Therapy in Children: Focus on Inotropic Support. Handb Exp Pharmacol 2020; 261:177-192. [PMID: 31707469 DOI: 10.1007/164_2019_267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Pediatric heart failure is a clinical syndrome, which needs to be distinctly defined and the pathophysiological consequences considered. Pharmacological treatment depends on the disease- and age-specific myocardial characteristics. Acute and chronic low cardiac output is the result of an inadequate heart rate (rhythm), myocardial contractility, preload and afterload, and also ventriculo-ventricular interaction, synchrony, atrio-ventricular and ventricular-arterial coupling. The treatment of choice is curing the cause of heart failure, if possible.Acute HF therapy is still based to the use of catecholamines and inodilators. The cornerstone of chronic HF treatment consists of blocking the endogenous, neuro-humoral axis, in particular the adrenergic and renin-angiotensin-aldosterone system.Before neprilysin inhibitors are used in young children, their potential side-effect for inducing Alzheimer disease needs to be clarified. The focus of the current review is put on the differential use of the inotropic drugs as epinephrine, norepinephrine, dopamine and dobutamine, and also the inodilators milrinone and levosimendan. Considering effects and side-effects of any cardiac stimulating treatment strategy, co-medication with ß-blockers, angiotensin converting inhibitors (ACEIs), angiotensin blockers (ARBs) and mineralocorticoid receptor antagonists (MRAs) is not a contradiction, but a senseful measure, even still during the acute inotropic treatment.Missing sophisticated clinical trials using accurate entry criteria and clinically relevant endpoints, there is especially in cardiovascular diagnosis and treatment of young children a compromise of evidence-based versus pathophysiology-based procedures. But based on the pharmacological and pathophysiological knowledge a hypothesis-driven individualized treatment is already currently possible and therefore indicated.
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Affiliation(s)
- Dietmar Schranz
- Pediatric Heart Center, Johann Wolfgang Goethe University Clinic, Frankfurt, Germany.
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22
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Wong FY, Gogos A, Hale N, Ingelse SA, Brew N, Shepherd KL, van den Buuse M, Walker DW. Impact of hypoxia-ischemia and dopamine treatment on dopamine receptor binding density in the preterm fetal sheep brain. J Appl Physiol (1985) 2020; 129:1431-1438. [PMID: 33054660 DOI: 10.1152/japplphysiol.00677.2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Dopamine is often used to treat hypotension in preterm infants who are at risk of hypoxic-ischemic (HI) brain injury due to cerebral hypoperfusion and impaired autoregulation. There is evidence that systemically administered dopamine crosses the preterm blood-brain barrier. However, the effects of exogenous dopamine and cerebral HI on dopaminergic signaling in the immature brain are unknown. We determined the effect of HI and dopamine on D1 and D2 receptor binding and expressions of dopamine transporter (DAT) and tyrosine hydroxylase (TH) in the striatum of the preterm fetal sheep. Fetal sheep (99 days of gestation, term = 147days) were unoperated controls (n = 6) or exposed to severe HI using umbilical cord occlusion and saline infusion (UCO + saline, n = 8) or to HI with dopamine infusion (UCO + dopamine, 10 µg/kg/min, n = 7) for 74 h. D1 and D2 receptor densities were measured by autoradiography in vitro. DAT, TH, and cell death were measured using immunohistochemistry. HI resulted in cell death in the caudate nucleus and putamen, and dopamine infusion started before HI did not exacerbate or ameliorate these effects. HI led to reduced D1 and D2 receptor densities in the caudate nucleus and reduction in DAT protein expression in the caudate and putamen. Fetal brains exposed to dopamine in addition to HI were not different from those exposed to HI alone in these changes in dopaminergic parameters. We conclude that dopamine infusion does not alter the striatal cell death or the reductions in D1 and D2 receptor densities and DAT protein expression induced by HI in the preterm brain.NEW & NOTEWORTHY This is the first study on the effects of hypoxia-ischemia and dopamine treatment on the dopaminergic pathway in the preterm brain. In the striatum of fetal sheep (equivalent to ∼26-28 wk of human gestation), we demonstrate that hypoxia-ischemia leads to cell death, reduces D1 and D2 receptors, and reduces dopamine transporter. Intravenous dopamine infusion at clinical dosage used in preterm human infants does not alter the striatal cell death, D1 and D2 receptor density levels, and DAT protein expressions after hypoxia-ischemia in the preterm brain.
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Affiliation(s)
- F Y Wong
- The Ritchie Centre, The Hudson Institute of Medical Research, Melbourne, Australia.,Department of Paediatrics, Monash University, Melbourne, Australia.,Monash Newborn, Monash Medical Centre, Melbourne, Australia
| | - A Gogos
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Australia
| | - N Hale
- The Ritchie Centre, The Hudson Institute of Medical Research, Melbourne, Australia
| | - S A Ingelse
- The Ritchie Centre, The Hudson Institute of Medical Research, Melbourne, Australia
| | - N Brew
- The Ritchie Centre, The Hudson Institute of Medical Research, Melbourne, Australia
| | - K L Shepherd
- The Ritchie Centre, The Hudson Institute of Medical Research, Melbourne, Australia.,Department of Paediatrics, Monash University, Melbourne, Australia
| | - M van den Buuse
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Australia.,School of Psychology and Public Health, La Trobe University, Melbourne, Australia
| | - D W Walker
- The Ritchie Centre, The Hudson Institute of Medical Research, Melbourne, Australia.,School of Health & Biomedical Sciences, RMIT University, Melbourne, Australia
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23
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Abstract
Many questions surround fluid bolus therapy and subsequent fluid management in neonatal critical care as they do in pediatric and adult critical care. This review explores the known key clinical aspects of fluid bolus therapy and fluid balance in the first 7 days of life and provides suggestions for further work in this area. It draws on the pediatric and adult critical care literature to provide thought-provoking data around the potential harms of excessive intravenous fluids, which may prove relevant to neonatology. Current data suggest that fluid bolus therapy and early-life positive fluid balance in neonates may be associated with harm.
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Affiliation(s)
- Erin Grace
- Department of Neonatal Medicine, Women's and Children's Hospital, North Adelaide, South Australia; SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, South Australia; Adelaide Medical School and the Robinson Research Institute, University of Adelaide, Adelaide, South Australia
| | - Amy K Keir
- Department of Neonatal Medicine, Women's and Children's Hospital, North Adelaide, South Australia; SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, South Australia; Adelaide Medical School and the Robinson Research Institute, University of Adelaide, Adelaide, South Australia.
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24
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Barrington K, El-Khuffash A, Dempsey E. Intervention and Outcome for Neonatal Hypotension. Clin Perinatol 2020; 47:563-574. [PMID: 32713451 DOI: 10.1016/j.clp.2020.05.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Many observational studies have shown that infants with blood pressures (BPs) that are in the lower range for their gestational age tend to have increased complications such as an increased rate of significant intraventricular hemorrhage and adverse long-term outcome. This relationship does not prove causation nor should it create an indication for treatment. However, many continue to intervene with medication for low BP on the assumption that an increase in BP will result in improved outcome. Only adequately powered prospective randomized controlled trials can answer the question of whether individual treatments of low BP are beneficial.
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Affiliation(s)
| | - Afif El-Khuffash
- The Rotunda Hospital, Dublin and Royal College of Surgeons, Dublin, Ireland
| | - Eugene Dempsey
- Department of Paediatrics and Child Health, INFANT Centre, University College Cork, Ireland.
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25
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Treatment for hypotension in the first 24 postnatal hours and the risk of hearing loss among extremely low birth weight infants. J Perinatol 2020; 40:774-780. [PMID: 32103159 PMCID: PMC7185479 DOI: 10.1038/s41372-020-0628-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 02/05/2020] [Accepted: 02/11/2020] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To evaluate whether treated hypotension in the first 24 postnatal hours is associated with hearing loss in extremely low birth weight (ELBW) infants. STUDY DESIGN In a cohort of 735 ELBW infants, we identified 25 with sensorineural hearing loss (SNHL) at 12-24 months adjusted age. For each case, we selected three controls with normal hearing. Logistic regression models were used to adjust for confounding variables. RESULTS Sixty percent of cases and 25% of controls were treated for hypotension. After adjusting for confounding variables (gestational age, antenatal glucocorticoids, 5 min Apgar < 6, insertion of an umbilical catheter, treatment with high frequency ventilation, and major cranial ultrasound abnormality), treated hypotension was associated with an increased risk of SNHL (adjusted odds ratio: 3.6; 95% confidence interval: 1.3-9.7). CONCLUSIONS Treated hypotension in ELBW infants in the first 24 h of life is associated with an increased risk of SNHL.
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26
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Do transport factors increase the risk of severe brain injury in outborn infants <33 weeks gestational age? J Perinatol 2020; 40:385-393. [PMID: 31427782 DOI: 10.1038/s41372-019-0447-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 06/03/2019] [Accepted: 06/10/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVE We evaluated transport factors and postnatal practices to identify modifiable risk factors for SBI. STUDY DESIGN Retrospective review of Canadian Neonatal Transport Network data linked to Canadian Neonatal Network data for outborns <33 weeks gestational age (GA), during January 2014 to December 2015. SBI was defined as grade 3 or 4 intraventricular hemorrhage or parenchymal echogenicity, including hemorrhagic and/or ischemic lesions. RESULT Among 781 infants, 115 (14.7%) had SBI with range 5.6-40% among transport teams. In multivariable analysis, SBI was associated with GA [0.77 (0.71, 0.85)] per week, receipt of chest compressions and/or epinephrine at delivery [1.81 (1.08, 3.05)] and receipt of fluid boluses [1.61 (1.00, 2.58)]. CONCLUSIONS Risk factors for SBI were related to the condition at birth and immediate postnatal management and not related to transport factors. These results highlight the importance of maternal transfer to perinatal centers to allow optimization of perinatal management.
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27
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Solanki NS, Hoffman SB. Association between dopamine and cerebral autoregulation in preterm neonates. Pediatr Res 2020; 88:618-622. [PMID: 32005034 PMCID: PMC7223955 DOI: 10.1038/s41390-020-0790-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 01/21/2020] [Accepted: 01/24/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND To test the hypothesis that dopamine is associated with impaired cerebral autoregulation (ICA) in a dose-dependent fashion. METHODS Non a priori designed secondary analysis of a prospectively enrolled cohort study subjects <12 h of life between 240 and 296 weeks gestation. Cerebral saturations (rScO2) and mean arterial blood pressure (MAP) were continuously monitored every 30 s for 96 h. ICA was defined by a 10 min epoch rScO2-MAP correlation coefficient of >0.5. RESULTS Twenty-three of 61 subjects (38%) required dopamine. Time spent with ICA was 23% in dopamine-exposed subjects vs. 14% in those not exposed (p = 0.0001). On the epoch level, time spent with ICA was 15%, 29%, 34%, 37%, and 23% in epochs with dopamine titration of 0, 1-5, 6-10, 11-15, and 16-20 μg/kg/min, respectively. Using mixed-effect modeling, ICA for each dopamine titration was significantly higher than unexposed times when controlling for gestation, presence of a patent ductus arteriosus, day of life, MAP less than gestational age, and illness severity score (p < 0.02). CONCLUSIONS Dopamine exposure during the first 96 h was associated with ICA. Time periods with ICA increased with dopamine exposure in a dose-dependent fashion peaking at a concentration of 11-15 μg/kg/min.
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Affiliation(s)
- Nina S. Solanki
- grid.411024.20000 0001 2175 4264Department of Pediatrics, School of Medicine, University of Maryland Baltimore, Baltimore, MD USA
| | - Suma B. Hoffman
- grid.411024.20000 0001 2175 4264Department of Pediatrics, School of Medicine, University of Maryland Baltimore, Baltimore, MD USA
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28
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Neonatal Hypotension: What Is the Efficacy of Each Anti-Hypotensive Intervention? A Systematic Review. ACTA ACUST UNITED AC 2019. [DOI: 10.1007/s40746-019-00175-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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29
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Lim J, Hagen E. Reducing Germinal Matrix-Intraventricular Hemorrhage: Perinatal and Delivery Room Factors. Neoreviews 2019; 20:e452-e463. [PMID: 31371554 DOI: 10.1542/neo.20-8-e452] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Germinal matrix hemorrhage-intraventricular hemorrhage (IVH) is the most common form of brain injury in preterm infants. Although severe IVH has declined over the years, it still affects approximately 6% of infants born before 32 weeks of gestation. Most IVH cases are detectable by the first 24 hours after birth; therefore interventions to prevent IVH should focus on antenatal management for pregnant women and delivery room management. Obstetrical interventions, including antenatal corticosteroids, maternal rather than infant transport, and possibly elective cesarean delivery have been associated with a decreased risk of IVH. Neonatal interventions in the delivery room, including delayed cord clamping or umbilical cord milking, maintaining normothermia, avoiding fluctuations in cerebral blood flow, and optimal ventilation management are associated with a decreased risk of IVH. Multiple clinical trials are under way to further identify IVH risk factors, ability to monitor or predict IVH, and ideally prevent IVH altogether. This discussion will focus on reviewing current obstetric and neonatal management practices and their associations with germinal matrix hemorrhage-IVH.
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Affiliation(s)
- Jina Lim
- Neonatal-Perinatal Medicine Division, Children's Hospital of Orange County, Orange, CA
| | - Eunice Hagen
- 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, CA
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30
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Stritzke A, Soraisham A, Murthy P, Kowal D, Paul R, Kamaluddeen M, Mohammad K, Al Awad EH, Thomas S. Neonatal Transport Clinician Performed Ultrasound Evaluation of Cardiac Function. Air Med J 2019; 38:338-342. [PMID: 31578971 DOI: 10.1016/j.amj.2019.06.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 04/23/2019] [Accepted: 06/13/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND Limited point-of-care ultrasound skills for ultrasound-naïve neonatal transport clinicians could enhance clinical evaluation and decision making. Teaching Respiratory Therapists and Nurses to assess cardiac filling and contractility may be feasible. METHODS Prospective educational study using educational materials, didactic theoretical, and hands-on practical sessions, followed by assessment of practical and theoretical skills. RESULTS A total of 18 participants completed the study meeting the predefined standard, proving feasibility. Nine (50%) participants had ≤ 10 years of NICU experience. The mean time required for complete training was 8.6 ± 2.1 hours. Time was spent on average on 269 ± 104 minutes for hands-on practice, 171 ± 96 minutes on didactic training, and 76 ± 16 minutes on testing sessions. The median number of hands-on sessions per participant was 5 [Interquartile range (IQR) 5, 7]. The median number of infants required to complete training was 9 infants (IQR 7, 11). RRTs required less time than RNs. Evaluations and feedback from participants on the training program was positive. CONCLUSION Neonatal RNs and RTs can be trained to perform focused cardiac ultrasound examinations with average time of 8.6 hours. This skill could enhance clinical care on neonatal transport with appropriate interventions to manage suspected hypotension or shock.
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Affiliation(s)
- Amelie Stritzke
- Department of Pediatrics, Section of Neonatology, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada; Foothills Medical Centre, Calgary, Alberta, Canada.
| | - Amuchou Soraisham
- Department of Pediatrics, Section of Neonatology, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada; Foothills Medical Centre, Calgary, Alberta, Canada
| | - Prashanth Murthy
- Department of Pediatrics, Section of Neonatology, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada; Rockyview General Hospital, Calgary, Alberta, Canada
| | - Derek Kowal
- Foothills Medical Centre, Calgary, Alberta, Canada
| | - Renee Paul
- Foothills Medical Centre, Calgary, Alberta, Canada
| | - Majeeda Kamaluddeen
- Department of Pediatrics, Section of Neonatology, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada; Foothills Medical Centre, Calgary, Alberta, Canada
| | - Khorshid Mohammad
- Department of Pediatrics, Section of Neonatology, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada; Alberta Children's Hospital/Research Institute, Calgary, Alberta, Canada
| | - Essa Hamdan Al Awad
- Department of Pediatrics, Section of Neonatology, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada; Peter Lougheed Medical Centre, Calgary, Alberta, Canada
| | - Sumesh Thomas
- Department of Pediatrics, Section of Neonatology, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada; Foothills Medical Centre, Calgary, Alberta, Canada
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31
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Abstract
There is a distinct lack of age-appropriate cardiotonic drugs, and adult derived formulations continue to be administered, without evidence-based knowledge on their dosing, safety, efficacy, and long-term effects. Dopamine remains the most commonly studied and prescribed cardiotonic drug in the neonatal intensive care unit (NICU), but evidence of its effect on endorgan perfusion still remains. Unlike adult and pediatric critical care, there are significant gaps in our knowledge on the use of various cardiotonic drugs in various forms of circulatory failure in the NICU.
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Affiliation(s)
- Eugene Dempsey
- Department of Paediatrics and Child Health, Neonatal Intensive Care Unit, University College Cork, Wilton, Cork, Ireland; Irish Centre for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland.
| | - Heike Rabe
- Brighton and Sussex Medical School, University of Sussex, Brighton, UK; Department of Neonatology, Brighton & Sussex University Hospitals NHS Trust, Brighton, UK
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32
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Keir AK, Karam O, Hodyl N, Stark MJ, Liley HG, Shah PS, Stanworth SJ. International, multicentre, observational study of fluid bolus therapy in neonates. J Paediatr Child Health 2019; 55:632-639. [PMID: 30328174 DOI: 10.1111/jpc.14260] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 09/16/2018] [Accepted: 09/17/2018] [Indexed: 12/29/2022]
Abstract
AIM To assess the prevalence, types and indications for fluid bolus therapy in neonates with haemodynamic compromise. METHODS This was a pragmatic, international, multicentre observational study in neonatal units across Australasia, Europe and North America with a predefined study period of 10-15 study days per participating neonatal unit between December 2015 and March 2017. Infants ≤28 days of age who received a fluid bolus for the management of haemodynamic compromise (≥10 mL/kg given at ≤6 h) were included. RESULTS A total of 163 neonates received a bolus over 8479 eligible patient days in 41 neonatal units. Prevalence of fluid bolus therapy varied between centres from 0 to 28.6% of admitted neonates per day, with a pooled prevalence rate of 1.5% (95% confidence interval 1.1-1.9%). The most common fluid used was 0.9% sodium chloride (129/163; 79%), and the volume of fluid administered was most commonly 10 mL/kg (115/163; 71%) over a median of 30 min (interquartile range 20-60). The most frequent indications were hypotension (n = 56; 34%), poor perfusion (n = 20; 12%) and metabolic acidosis (n = 20; 12%). Minimal or no clinical improvement was reported by clinicians in 66 of 163 cases (40%). CONCLUSIONS Wide international variations in types, indications and effects of fluid bolus administration in haemodynamically compromised neonates suggest uncertainty in the risk-benefit profile. This is likely to reflect the lack of robust evidence to support the efficacy of different fluid types, doses and appropriate indications. Together, these highlight a need for further clinically relevant studies.
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Affiliation(s)
- Amy K Keir
- Robinson Research Institute, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia.,Department of Neonatal Medicine, Women's and Children's Hospital, Adelaide, South Australia, Australia.,Healthy Mothers, Babies and Children, South Australian Medical and Research Institute, Adelaide, South Australia, Australia
| | - Oliver Karam
- Pediatric Intensive Care Unit, Geneva University Hospital, Geneva, Switzerland.,Division of Pediatric Critical Care Medicine, Children's Hospital of Richmond at VCU, Virginia Commonwealth University, Richmond, Virginia, United States
| | - Nicolette Hodyl
- Robinson Research Institute, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia.,Department of Neonatal Medicine, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Michael J Stark
- Robinson Research Institute, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia.,Department of Neonatal Medicine, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Helen G Liley
- Department of Neonatology, Mater Mothers' Hospital, Mater Research, Brisbane, Queensland, Australia.,Faculty of Clinical Medicine and Mater Research Institute, University of Queensland, Brisbane, Queensland, Australia
| | - Prakesh S Shah
- Department of Paediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada.,Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Simon J Stanworth
- NHS Blood and Transplant and Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.,Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
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33
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The Relationship between blood pressure parameters and left ventricular output in neonates. J Perinatol 2019; 39:619-625. [PMID: 30770881 DOI: 10.1038/s41372-019-0337-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 11/29/2018] [Accepted: 01/25/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To evaluate the relationship between systolic (SBP), diastolic (DBP), mean (MBP) blood pressures and pulse pressure (PP), and left ventricular output (LVO), a surrogate of systemic blood flow. STUDY DESIGN This retrospective study included neonates who underwent targeted neonatal echocardiography (TNE) in 3-tertiary NICUs over 2 years. Associations between LVO and BP components were investigated. Analysis was adjusted for relevant covariates. RESULT 1060 studies from 485 neonates were included, with a mean GA of 28.4 ± 4.6 weeks and birth weight of 1234 ± 840 grams. LVO was associated positively with SBP and PP, and negatively with GA. PP demonstrated the highest predictive value for identifying infants with LVO < 150 ml/kg/min (area under the curve 0.75 [95% CI 0.68, 0.82]). MBP and DBP demonstrated no correlation with LVO. CONCLUSION BP parameters correlate poorly with LVO, irrespective of GA and underlying etiology. Narrow PP may be more reflective of low LVO than low SBP.
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34
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Sola C, Hertz L, Bringuier S, De La Arena P, Macq C, Deziel-Malouin S, Raux O, Dadure C. Spinal anaesthesia in neonates and infants: what about the cerebral oxygen saturation? Br J Anaesth 2019; 119:964-971. [PMID: 28981572 DOI: 10.1093/bja/aex218] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2017] [Indexed: 01/26/2023] Open
Abstract
Background Spinal Anaesthesia (SA) has been firmly established as an efficient and safe technique, with minimal cardio-respiratory disturbance when administered in the neonatal period. Our objective was to assess the haemodynamic consequences of SA in infants, particularly its impact on cerebral perfusion using near-infrared spectroscopy (NIRS)-based cerebral oximetry (rSco2). Methods All infants up to 60 weeks' postmenstrual age, whether formerly preterm or not, and undergoing spinal anaesthesia, were enrolled. Haemodynamic data records, rSco2 and mean arterial blood pressure (MAP), were prospectively collected before SA (T0) and every five min for 30 min (T30) after the puncture. Compared with baseline measures, any changes of > 10% in rSco2 and of > 20% in MAP were considered clinically significant. Relative variations of data between T0 and T30 were analysed. Results Data of 103 infants were analysed. The mean relative changes in rSco2 were -2.25% (97.5% CI [-3.97; -0.5]) at T15, and 0.11% (97.5% CI [-1.67; 1.90]) at T30. No significant variation of rSco2 was recorded. The mean changes in MAP were respectively -13.94% (97.5% CI [-17.74; -10.14]) at T15 and -20.27% (97.5% CI [-24,25; -16.29]) at T30. MAP decrease was statistically and clinically significant 30 min after SA. No correlation between changes in MAP and rSco2 was found. The subgroup analysis did not reveal any effect of added intrathecal clonidine or preterm birth history on these results. Conclusions In neonate and infants, SA did not cause clinically significant variation in cerebral oxygen saturation. Despite a significant decrease in MAP, cerebral auto-regulation seems to remain effective in neonates and not altered by spinal anaesthesia.
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Affiliation(s)
- C Sola
- Department of Anaesthesia and Critical Care Medicine, Paediatric Anaesthesia Unit, Lapeyronie University Hospital, Montpellier, France
| | - L Hertz
- Department of Anaesthesia and Critical Care Medicine, Paediatric Anaesthesia Unit, Lapeyronie University Hospital, Montpellier, France
| | - S Bringuier
- Biostatistics and Clinical Research Consultant, Department of Anaesthesiology and Critical Care Medicine, Lapeyronie University Hospital, Montpellier, France
| | - P De La Arena
- Department of Anaesthesia and Critical Care Medicine, Paediatric Anaesthesia Unit, Lapeyronie University Hospital, Montpellier, France
| | - C Macq
- Department of Anaesthesia and Critical Care Medicine, Paediatric Anaesthesia Unit, Lapeyronie University Hospital, Montpellier, France
| | - S Deziel-Malouin
- Department of Anaesthesia and Critical Care Medicine, Paediatric Anaesthesia Unit, Lapeyronie University Hospital, Montpellier, France.,Department of Anesthesia, Sherbrooke University Hospital, Sherbrooke, Canada
| | - O Raux
- Department of Anaesthesia and Critical Care Medicine, Paediatric Anaesthesia Unit, Lapeyronie University Hospital, Montpellier, France
| | - C Dadure
- Department of Anaesthesia and Critical Care Medicine, Paediatric Anaesthesia Unit, Lapeyronie University Hospital, Montpellier, France
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Janvier A, Bourque CJ, Dahan S, Robson K, Barrington KJ. Integrating Parents in Neonatal and Pediatric Research. Neonatology 2019; 115:283-291. [PMID: 30799397 DOI: 10.1159/000492502] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 07/26/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Parents and their infants are the beneficiaries of neonatal and pediatric research, but in the past they have been excluded from most stages of research projects. As a result, many projects may fail to produce the most worthwhile information for parents and families. Lately, veteran resource parents and patients have been increasingly integrated in research initiatives. METHODS Benchmarking of neonatal and pediatric research initiatives where resource parents and/or ex neonatal patients have helped to optimize pediatric research. We review ways in which resource parents/patients can be involved in research, with examples and practical ideas of how to proceed. RESULTS Resource parents/patients can be collaborators in research and be integrated in many steps: prioritizing research projects, designing trials, determining the outcomes of interest, ethics review, developing and improving consent procedures, collection and interpretation of data, participation in data safety monitoring committees, publication of results, and presentation to peer groups. Some of the strategies for integration of stakeholders in clinical research are more complex, may involve risk and require more training than others. CONCLUSION We suggest that groups wanting to involve parents in their research endeavors start with simpler tasks that entail less risk and develop teams of resource parents who have differing interests and abilities. Quality control of programs is essential, such as frequently giving and obtaining feedback from resource parents/patients and researchers. In the future, integration of resource parents/patients into every step of clinical research will be essential to ensure that parent and family important outcomes are examined.
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Affiliation(s)
- Annie Janvier
- Department of Pediatrics, Université de Montréal, Montréal, Québec, Canada, .,Division of Neonatology, Hôpital Sainte-Justine, Montréal, Québec, Canada, .,CHU Sainte-Justine Research Center, Montréal, Québec, Canada, .,Bureau de l'Éthique Clinique, Université de Montréal, Montréal, Québec, Canada, .,Unité d'Éthique Clinique, Hôpital Sainte-Justine, Montréal, Québec, Canada, .,Unité de Soins Palliatifs, Hôpital Sainte-Justine, Montréal, Québec, Canada, .,Unité de Recherche en Éthique Clinique et Partenariat Famille (UREPAF), Montréal, Québec, Canada,
| | - Claude Julie Bourque
- CHU Sainte-Justine Research Center, Montréal, Québec, Canada.,Unité d'Éthique Clinique, Hôpital Sainte-Justine, Montréal, Québec, Canada.,Unité de Recherche en Éthique Clinique et Partenariat Famille (UREPAF), Montréal, Québec, Canada
| | - Sonia Dahan
- Division of Neonatology, Hôpital Sainte-Justine, Montréal, Québec, Canada.,Unité d'Éthique Clinique, Hôpital Sainte-Justine, Montréal, Québec, Canada
| | - Kate Robson
- Sunnybrook Hospital, Toronto, Ontario, Canada
| | - Keith James Barrington
- Department of Pediatrics, Université de Montréal, Montréal, Québec, Canada.,Division of Neonatology, Hôpital Sainte-Justine, Montréal, Québec, Canada.,CHU Sainte-Justine Research Center, Montréal, Québec, Canada
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Semenova O, Lightbody G, O'Toole JM, Boylan G, Dempsey E, Temko A. Modelling interactions between blood pressure and brain activity in preterm neonates. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2018; 2017:3969-3972. [PMID: 29060766 DOI: 10.1109/embc.2017.8037725] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Hypotension or low blood pressure (BP) is a common problem in preterm neonates and has been associated with adverse short and long-term outcomes. Deciding when and whether to treat hypotension relies on an understanding of the relations between blood pressure and brain function. This study aims to investigate the interaction between BP and multichannel EEG in preterm infants less than 32 weeks gestational age. The mutual information is chosen to model interaction. This measure is independent of absolute values of BP and electroencephalography (EEG) power and quantifies the level of coupling between the short-term dynamics in both signals. It is shown that while adverse health conditions as measured by higher clinical risk indices for babies (CRIB II) are accompanied by consistently lower blood pressure (r=0.43), no significant correlation was observed between CRIB scores and EEG spectral power. More importantly, the chosen measure of interaction between dynamics of EEG and BP was found to be more closely related to CRIB scores (r=0.49, p-value=0.012), with higher CRIB score associated with lower levels of interaction.
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Carrapato MRG, Andrade T, Caldeira T. Hypotension in small preterms: what does it mean? J Matern Fetal Neonatal Med 2018; 32:4016-4021. [PMID: 29848160 DOI: 10.1080/14767058.2018.1481034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Introduction: Small preterms often have low blood pressure readings in the first few days of life. However, what is hypotension in preterms? Should there be an aggressive approach to its management? What are the immediate and long-term side effects of powerful medications? Alternatively, could a low blood pressure be accepted instead? Materials and methods: Data were collected from files of all live babies with gestational age (GA) between 230/7 and 316/7 weeks over two different periods: years 2000-2004 and 2008-2012. Results: Our data show that, despite extremely low gestational age (ELGA)/extremely low birth weight (ELBW) neonates, almost half of these tiny babies have neither low mean arterial pressure (MAP) readings nor clinical signs of impaired perfusion. Yet, many of them are, variously treated or not, depending on individual decisions, rather than on sound evidence. Discussion: We suggest, should it be required to treat persistent hypotension, rather than treating just a low MAP recording, to address the whole issue of hypotension in the overall picture of clinical settings; we to assess organ dysfunction caused by low output and use the least aggressive measures, preferably within written protocols, tailored to the given unit, but equally, sufficiently flexible to individual babies. Furthermore, allow for "permissive hypotension" especially if transient, in the absence of clinical signs of hypoperfusion, with normal superior vena cava (SVC) flow, normal cardiac output, and normal brain scanning with normal cerebral Doppler flows. Whether treating hypotension, by whichever definition, "per se", will make any difference to both, immediate and late outcomes; in the end, treating remains open to questioning and calls for careful follow-up of these very susceptible preterms.
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Affiliation(s)
- Manuel R G Carrapato
- São Sebastião Hospital , Santa Maria Feira , Portugal.,Faculty of Health Sciences, University Fernando Pessoa , Porto , Portugal
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38
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Coupling between mean blood pressure and EEG in preterm neonates is associated with reduced illness severity scores. PLoS One 2018; 13:e0199587. [PMID: 29933403 PMCID: PMC6014641 DOI: 10.1371/journal.pone.0199587] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 06/11/2018] [Indexed: 11/19/2022] Open
Abstract
Hypotension or low blood pressure (BP) is a common problem in preterm neonates and has been associated with adverse short and long-term neurological outcomes. Deciding when and whether to treat hypotension relies on an understanding of the relationship between BP and brain functioning. This study aims to investigate the interaction (coupling) between BP and continuous multichannel unedited EEG recordings in preterm infants less than 32 weeks of gestational age. The EEG was represented by spectral power in four frequency sub-bands: 0.3-3 Hz, 3-8 Hz, 8-15 Hz and 15-30 Hz. BP was represented as mean arterial pressure (MAP). The level of coupling between the two physiological systems was estimated using linear and nonlinear methods such as correlation, coherence and mutual information. Causality of interaction was measured using transfer entropy. The illness severity was represented by the clinical risk index for babies (CRIB II score) and contrasted to the computed level of interaction. It is shown here that correlation and coherence, which are linear measures of the coupling between EEG and MAP, do not correlate with CRIB values, whereas adjusted mutual information, a nonlinear measure, is associated with CRIB scores (r = -0.57, p = 0.003). Mutual information is independent of the absolute values of MAP and EEG powers and quantifies the level of coupling between the short-term dynamics in both signals. The analysis indicated that the dominant causality is from changes in EEG producing changes in MAP. Transfer entropy (EEG to MAP) is associated with the CRIB score (0.3-3 Hz: r = 0.428, p = 0.033, 3-8 Hz: r = 0.44, p = 0.028, 8-15 Hz: r = 0.416, p = 0.038) and indicates that a higher level of directed coupling from brain activity to blood pressure is associated with increased illness in preterm infants. This is the first study to present the nonlinear measure of interaction between brain activity and blood pressure and to demonstrate its relation to the initial illness severity in the preterm infant. The obtained results allow us to hypothesise that the normal wellbeing of a preterm neonate can be characterised by a nonlinear coupling between brain activity and MAP, whereas the presence of weak coupling with distinctive directionality of information flow is associated with an increased mortality rate in preterms.
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Joynt C, Cheung PY. Treating Hypotension in Preterm Neonates With Vasoactive Medications. Front Pediatr 2018; 6:86. [PMID: 29707527 PMCID: PMC5908904 DOI: 10.3389/fped.2018.00086] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 03/19/2018] [Indexed: 12/23/2022] Open
Abstract
Preterm neonates often have hypotension which may be due to various etiologies. While it is controversial to define hypotension in preterm neonates, various vasoactive medications are commonly used to provide the cardiovascular support to improve the blood pressure, cardiac output, or to treat shock. However, the literature on the systemic and regional hemodynamic effects of these antihypotensive medications in neonates is deficient and incomplete, and cautious translation of findings from other clinical populations and animal studies is required. Based on a literature search on published reports, meta-analytic reviews, and selected abstracts, this review discusses the current available information on pharmacologic actions, clinical effects, and side effects of commonly used antihypotensive medications including dopamine, dobutamine, epinephrine, norepinephrine, vasopressin, and milrinone in preterm neonates.
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Affiliation(s)
- Chloe Joynt
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Po-Yin Cheung
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.,Department of Pharmacology and Surgery, University of Alberta, Edmonton, AB, Canada.,Centre for the Studies of Asphyxia and Resuscitation, Edmonton, AB, Canada
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40
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Joynt C, Cheung PY. Cardiovascular Supportive Therapies for Neonates With Asphyxia - A Literature Review of Pre-clinical and Clinical Studies. Front Pediatr 2018; 6:363. [PMID: 30619782 PMCID: PMC6295641 DOI: 10.3389/fped.2018.00363] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 11/08/2018] [Indexed: 12/13/2022] Open
Abstract
Asphyxiated neonates often have hypotension, shock, and poor tissue perfusion. Various "inotropic" medications are used to provide cardiovascular support to improve the blood pressure and to treat shock. However, there is incomplete literature on the examination of hemodynamic effects of these medications in asphyxiated neonates, especially in the realm of clinical studies (mostly in late preterm or term populations). Although the extrapolation of findings from animal studies and other clinical populations such as children and adults require caution, it seems appropriate that findings from carefully conducted pre-clinical studies are important in answering some of the fundamental knowledge gaps. Based on a literature search, this review discusses the current available information, from both clinical studies and animal models of neonatal asphyxia, on common medications used to provide hemodynamic support including dopamine, dobutamine, epinephrine, milrinone, norepinephrine, vasopressin, levosimendan, and hydrocortisone.
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Affiliation(s)
- Chloe Joynt
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Po-Yin Cheung
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.,Department of Pharmacology, University of Alberta, Edmonton, AB, Canada.,Centre for the Study of Asphyxia and Resuscitation, Edmonton, AB, Canada
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41
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Rabe H, Rojas-Anaya H. Inotropes for preterm babies during the transition period after birth: friend or foe? Arch Dis Child Fetal Neonatal Ed 2017; 102:F547-F550. [PMID: 28818851 DOI: 10.1136/archdischild-2016-311709] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 06/28/2017] [Accepted: 07/06/2017] [Indexed: 11/04/2022]
Abstract
During the transition to extrauterine life, preterm infants are at high risk of developing circulatory failure. Currently, hypotension is used as major diagnostic criteria for starting treatments such as fluid boluses, inotropes or steroids. Most of these treatment options have not been studied in large randomised controlled trials for efficacy and safety and are under discussions. A wide variety in their use is reported in the literature and clear evidence about which inotrope or other treatment should be preferred is lacking. In addition, there is ongoing debate about the appropriate threshold values for blood pressure. Other diagnostic measures for poor circulation are functional echocardiography, near-infrared spectroscopy, capillary refill time, base excess and serum lactate. Large randomised controlled trials for the use of dopamine and dobutamine in preterm infants <32 weeks gestation are under way to fill the knowledge gaps on the assessment of circulatory compromise and on efficacy and safety of the studied age-appropriate drug formulations.
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Affiliation(s)
- Heike Rabe
- Department of Paediatrics, Brighton and Sussex Medical School, Brighton, UK.,Department of Neonatology, Brighton Sussex University Hospitals NHS Trust, Brighton, UK
| | - Hector Rojas-Anaya
- Department of Neonatology, Brighton Sussex University Hospitals NHS Trust, Brighton, UK
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42
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Miletin J. Near infrared spectroscopy and preterm infants-ready for routine use? J Perinatol 2017; 37:1069. [PMID: 28984876 DOI: 10.1038/jp.2017.86] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Jan Miletin
- Department of Neonatology, Coombe Women and Infants Hospital, Dublin, Ireland.,UCD School of Medicine and Medical Sciences, Dublin, Ireland
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43
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Escourrou G, Renesme L, Zana E, Rideau A, Marcoux MO, Lopez E, Gascoin G, Kuhn P, Tourneux P, Guellec I, Flamant C. How to assess hemodynamic status in very preterm newborns in the first week of life? J Perinatol 2017; 37:987-993. [PMID: 28471441 DOI: 10.1038/jp.2017.57] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 02/12/2017] [Accepted: 03/28/2017] [Indexed: 01/02/2023]
Abstract
BACKGROUND Assessing hemodynamic status in preterm newborns is an essential task, as many studies have shown increased morbidity when hemodynamic parameters are abnormal. Although oscillometric monitoring of arterial blood pressure (BP) is widely used due to its simplicity and lack of side effects, these values are not always correlated with microcirculation and oxygen delivery. OBJECTIVES This review focuses on different tools for the assessment of hemodynamic status in preterm newborns. These include the measurement of clinical (BP, capillary refill time and urinary output (UO)) or biological parameters (lactate analysis), functional echocardiography, and near-infrared spectroscopy (NIRS). We describe the concepts and techniques involved in these tools in detail, and examine the interest and limitations of each type of assessment. CONCLUSIONS This review highlights the complementarities between the different parameters used to assess hemodynamic status in preterm newborns during the first week of life. The analysis of arterial BP measured by oscillometric monitoring must take into account other clinical data, in particular capillary refill time and UO, and biological data such as lactate levels. Echocardiography improves noninvasive hemodynamic management in newborns but requires specific training. In contrast, NIRS may be useful in monitoring the clinical course of infants at risk of, or presenting with, hypotension. It holds the potential for early and noninvasive identification of silent hypoperfusion in critically ill preterm infants. However, more data are needed to confirm the usefulness of this promising tool in significantly changing the outcome of these infants.
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Affiliation(s)
- G Escourrou
- Department of Neonatal Medicine, CH Montreuil, Montreuil, France
| | - L Renesme
- Department of Neonatal Medicine, CHU Bordeaux, France
| | - E Zana
- Department of Neonatal Medicine, Port Royal Maternity, Paris, France
| | - A Rideau
- Department of Neonatal Medicine, CHU Paris, France
| | - M O Marcoux
- Paediatric Intensive Care Unit, CHU Toulouse, France
| | - E Lopez
- Department of Neonatal Medicine, CHU Tours, France
| | - G Gascoin
- Department of Neonatal Medicine, CHU Angers, France
| | - P Kuhn
- Department of Neonatal Medicine, CHU Strasbourg, France
| | - P Tourneux
- Department of Neonatal Medicine, CHU Amiens, France
| | - I Guellec
- Department of Neonatal Medicine, CHU Paris, France
| | - C Flamant
- Department of Neonatal Medicine, CHU Nantes, Service de Réanimation néonatale, Nantes, France
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Elsayed YN, Fraser D. Integrated Evaluation of Neonatal Hemodynamics Program Optimizing Organ Perfusion and Performance in Critically Ill Neonates, Part 1: Understanding Physiology of Neonatal Hemodynamics. Neonatal Netw 2017; 35:143-50. [PMID: 27194608 DOI: 10.1891/0730-0832.35.3.143] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Integrated evaluation of neonatal hemodynamics is the integration of information obtained by echocardiography, clinical evaluation, and biochemical markers, in addition to the clinical information obtained from noninvasive and invasive monitoring of blood pressure and arterial and tissue oxygenation, leading to the formulation of a medical recommendation. This review will focus on the physiology of cardiovascular dynamics and oxygen delivery.
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Affiliation(s)
- Yasser N Elsayed
- Pediatrics and Child Health, Faculty of Health Sciences, College of Medicine, University of Manitoba, Canada
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45
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Liebowitz M, Koo J, Wickremasinghe A, Allen IE, Clyman RI. Effects of Prophylactic Indomethacin on Vasopressor-Dependent Hypotension in Extremely Preterm Infants. J Pediatr 2017; 182:21-27.e2. [PMID: 27915200 PMCID: PMC5328836 DOI: 10.1016/j.jpeds.2016.11.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 10/13/2016] [Accepted: 11/02/2016] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine whether a moderate-to-large patent ductus arteriosus (PDA) is responsible for vasopressor-dependent hypotension, occurring at the end of the first postnatal week. STUDY DESIGN We performed a retrospective, double cohort controlled study of infants delivered at ≤27+6 weeks' gestation (n = 313). From January 2004 through April 2011, all infants were treated with prophylactic indomethacin ([PINDO] epoch). From May 2011 through December 2015, no infant was treated with indomethacin until at least 8 postnatal days (conservative epoch). Echocardiograms were performed on postnatal days 6 or 7. Hypotension was managed by a predefined protocol. The primary outcome was the incidence of dopamine-dependent hypotension, defined as having received at least 6 µg/kg/min dopamine for at least 24 hours during postnatal days 4-7. RESULTS As expected, the incidence of moderate-to-large PDA at the end of the first week differed significantly between epochs (PINDO = 8%; conservative = 64%). In multivariate analyses, infants in the PINDO epoch had a significantly lower incidence of vasopressor-dependent hypotension (11%) than infants in the conservative epoch (21%; OR = 0.40, 95% CI 0.20-0.82). Infants in the PINDO epoch also required less mean airway pressure, had a lower respiratory severity score, and lower mode of ventilation score than infants in the conservative epoch during postnatal days 4-7. The effects of PINDO on both the incidence of vasopressor-dependent hypotension and the need for respiratory support were no longer significant when analyses were adjusted for "presence or absence of a moderate-to-large PDA." CONCLUSION PINDO decreases vasopressor-dependent hypotension and the need for respiratory support at the end of the first postnatal week. These effects are mediated by closure of the PDA.
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Affiliation(s)
- Melissa Liebowitz
- Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Jane Koo
- Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Andrea Wickremasinghe
- Department of Pediatrics, Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA
| | - Isabel Elaine Allen
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA
| | - Ronald I Clyman
- Department of Pediatrics, University of California San Francisco, San Francisco, CA; Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA.
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Rasmussen MB, Eriksen VR, Andresen B, Hyttel-Sørensen S, Greisen G. Quantifying cerebral hypoxia by near-infrared spectroscopy tissue oximetry: the role of arterial-to-venous blood volume ratio. JOURNAL OF BIOMEDICAL OPTICS 2017; 22:25001. [PMID: 28152128 DOI: 10.1117/1.jbo.22.2.025001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Accepted: 01/06/2017] [Indexed: 06/06/2023]
Abstract
Tissue oxygenation estimated by near-infrared spectroscopy (NIRS) is a volume-weighted mean of the arterial and venous hemoglobin oxygenation. In vivo validation assumes a fixed arterial-to-venous volume-ratio (AV-ratio). Regulatory cerebro-vascular mechanisms may change the AV-ratio. We used hypotension to investigate the influence of blood volume distribution on cerebral NIRS in a newborn piglet model. Hypotension was induced gradually by inflating a balloon-catheter in the inferior vena cava and the regional tissue oxygenation from NIRS ( rStO 2 , NIRS ) was then compared to a reference ( rStO 2 , COX ) calculated from superior sagittal sinus and aortic blood sample co-oximetry with a fixed AV-ratio. Apparent changes in the AV-ratio and cerebral blood volume (CBV) were also calculated. The mean arterial blood pressure (MABP) range was 14 to 82 mmHg. PaCO 2 and SaO 2 were stable during measurements. rStO 2 , NIRS mirrored only 25% (95% Cl: 21% to 28%, p < 0.001 ) of changes in rStO 2 , COX . Calculated AV-ratio increased with decreasing MABP (slope: ? 0.007 · mmHg ? 1
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Affiliation(s)
- Martin B Rasmussen
- Copenhagen University Hospital-Rigshospitalet, Department of Neonatology, Blegdamsvej 9, Copenhagen 2100, DenmarkbUniversity of Copenhagen, Faculty of Health and Medical Sciences, Blegdamsvej 3, Copenhagen 2200, Denmark
| | - Vibeke R Eriksen
- Copenhagen University Hospital-Rigshospitalet, Department of Neonatology, Blegdamsvej 9, Copenhagen 2100, DenmarkbUniversity of Copenhagen, Faculty of Health and Medical Sciences, Blegdamsvej 3, Copenhagen 2200, Denmark
| | - Bjørn Andresen
- Copenhagen University Hospital-Rigshospitalet, Department of Neonatology, Blegdamsvej 9, Copenhagen 2100, Denmark
| | - Simon Hyttel-Sørensen
- Copenhagen University Hospital-Rigshospitalet, Department of Neonatology, Blegdamsvej 9, Copenhagen 2100, Denmark
| | - Gorm Greisen
- Copenhagen University Hospital-Rigshospitalet, Department of Neonatology, Blegdamsvej 9, Copenhagen 2100, Denmark
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Abstract
Newborns, and especially premature newborns, are at significant risk for developing hypotension in the first week or two after birth. The etiology of hypotension in the newborn may vary, but the very low birth weight and extremely low birth weight preterm infants are less likely to respond to conventional cardiovascular support when they develop hypotension. This article reviews the least conventional treatment using hydrocortisone for hypotension that is refractory to conventional volume replacement and/or vasopressor medications with the underlying assumption that sick and premature newborns have a relative or measured adrenal insufficiency. The addition of hydrocortisone in the treatment of hypotension in the newborn is becoming more common but is not universally advocated. However, the supportive evidence is growing, and, as reviewed, use of hydrocortisone requires judicious and cautious regard.
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48
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Abstract
The management of preterm infants with low blood pressure soon after birth remains unresolved. The definition of what constitutes low blood pressure is uncertain. At birth, mean blood pressure appears to be gestation specific and increases in the first few days of life. Antenatal steroids, delayed cord clamping, and the avoidance of mechanical ventilation are all associated with higher mean blood pressure and less hypotension after birth. Rates of hypotension of 15-50% have been reported in various studies of extremely preterm infants. However, only about 10% of all extremely preterm infants receive inotropes, suggesting that clinicians take into account other factors such as clinical, biochemical, and echocardiographic findings before deciding to intervene. The exact role of functional echocardiography in assessing the need for treatment of low blood pressure in extremely preterm infants remains to be determined. Near- infrared spectroscopy to assess cerebral perfusion may also have a role to play. Volume expansion (usually 10 mL/kg of saline) remains the most commonly used intervention for low blood pressure but evidence of benefit is lacking and there may be safety concerns. Whilst dopamine is the most commonly used inotropic drug, dobutamine, epinephrine, corticosteroids, milrinone, and vasopressin have also been utilised in preterm infants with low blood pressure. Clinical trials with long-term outcomes are needed to determine the most suitable inotrope and when to use it. Early hypotension differs from late hypotension with regard to cause, treatment, and outcome. A number of recent studies aimed at improving the evidence base for the treatment of early hypotension in extremely preterm infants have been terminated early because of poor recruitment. Currently, the answer to the question of what to do about low blood pressure in preterm infants remains unclear.
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St Peter D, Gandy C, Hoffman SB. Hypotension and Adverse Outcomes in Prematurity: Comparing Definitions. Neonatology 2017; 111:228-233. [PMID: 27898415 DOI: 10.1159/000452616] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 10/13/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND In the premature neonate, there is no consensus regarding normal blood pressure (BP). The most common definition used is a mean arterial BP (MAP) less than the gestational age (GA); however, studies indicate that the neuroprotective mechanism of autoregulation is lost below a MAP of 30 mm Hg. OBJECTIVE To determine whether hypotension defined as MAP <30 mm Hg or MAP less than the infant's GA better predicts adverse outcomes of intraventricular hemorrhage (IVH) and death. STUDY DESIGN For this retrospective study, demographic, clinical, and BP data in epochs of 12 h were collected during the first 72 h of life in 188 subjects 24-28 weeks of gestation. For each definition, outcomes of severe IVH (grade 3 or 4), death, or the composite outcome of either were evaluated using bivariate testing. Logistic regression determined independent predictors of composite outcome of death and/or grade 3 or 4 IVH. RESULTS Hypotension by either definition was significant for death and the composite outcome (p < 0.0001). Only the MAP <30 mm Hg definition was associated with severe IVH (p = 0.02). On logistic regression, significant predictors of the composite outcome were GA (OR 0.59, 95% CI 0.39-0.89) and vasopressor therapy (OR 5.5, 95% CI 2-17). CONCLUSIONS Neither definition of hypotension independently predicts adverse outcome in multivariate logistic regression. Vasopressor therapy, however, is an independent predictor of IVH and death in premature infants.
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Affiliation(s)
- Deidre St Peter
- Department of Pediatrics, University of Maryland Medical Center, Baltimore, MD, USA
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Pandey V, Kumar D, Vijayaraghavan P, Chaturvedi T, Raina R. Non-dialytic management of acute kidney injury in newborns. J Renal Inj Prev 2016; 6:1-11. [PMID: 28487864 PMCID: PMC5414511 DOI: 10.15171/jrip.2017.01] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 10/10/2016] [Indexed: 01/04/2023] Open
Abstract
Treating acute kidney injury (AKI) in newborns is often challenging due to the functional immaturity of the neonatal kidney. Because of this physiological limitation, renal replacement therapy (RRT) in this particular patient population is difficult to execute and may lead to unwanted complications. Although fluid overload and electrolyte abnormalities, as seen in neonatal AKI, are indications for RRT initiation, there is limited evidence that RRT initiated in the first year of life improves long-term outcome. The underlying cause of AKI in a newborn patient should determine the treatment strategies to restore appropriate renal function. However, our understanding of this common clinical condition remains limited, as no standardized, evidence-based definition of neonatal AKI currently exists. Non-dialytic management of AKI in these patients may restore appropriate renal function to these patients without exposure to complications often encountered with RRT.
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Affiliation(s)
- Vishal Pandey
- Department of Pediatrics and Neonatology, University of Kansas Hospital, Kansas City, KS, USA
| | - Deepak Kumar
- Department of Pediatrics and Neonatology, MetroHealth Medical Center, Cleveland, OH, USA
| | - Prashant Vijayaraghavan
- Division of Nephrology, Department of Internal Medicine and Research Cleveland Clinic Akron General, Akron, OH, USA 4Akron Children's Hospital, Cleveland, OH, USA
| | - Tushar Chaturvedi
- Division of Nephrology, Department of Internal Medicine and Research Cleveland Clinic Akron General, Akron, OH, USA 4Akron Children's Hospital, Cleveland, OH, USA
| | - Rupesh Raina
- Division of Nephrology, Department of Internal Medicine and Research Cleveland Clinic Akron General, Akron, OH, USA 4Akron Children's Hospital, Cleveland, OH, USA.,Akron Children's Hospital, Cleveland, OH, USA
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