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Vesselinova IV, Jensen KN, Hansen TG. Propofol and thiopental for intravenous induction in neonates: Study protocol for a dose-finding trial. Acta Anaesthesiol Scand 2023; 67:820-828. [PMID: 36919345 DOI: 10.1111/aas.14238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 03/02/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND Propofol and thiopental are commonly used induction agents in neonatal anesthesia. Even though both hypnotics have been used off-label for many years, pharmacological knowledge regarding these agents is scarce in neonates. The significant variability in neonates' body composition, organ function, and maturation makes pharmacological studies highly relevant albeit challenging. As a result, there is currently limited data about the anesthetic induction dose of thiopental and propofol in neonates. In addition, a knowledge gap exists concerning the pharmacodynamics of induction doses. OBJECTIVE To determine the median effective anesthetic induction dose of propofol and thiopental in neonatal patients of different gestational and postnatal ages and evaluate the pharmacodynamics of the anesthesia induction doses on the neonatal systemic and cerebral hemodynamics. METHODS This is a single-center, prospective, open-label, interventional, dose-finding study, including neonatal patients from birth up to 28 postnatal days undergoing general anesthesia for surgical or diagnostic procedures. The patients will be stratified according to their gestational and postnatal age and allocated to one of the two trial arms: anesthesia induction with propofol or anesthesia induction with thiopental. We will use Dixon's up-and-down method to estimate the median effective anesthesia induction dose of both agents in neonates of different gestational and postnatal ages. In addition, we will study the relationship between anesthesia induction doses and changes in systemic and cerebral hemodynamics. DISCUSSION Alterations in the systemic and cerebral regional hemodynamics secondary to anesthesia induction may be harmful in neonates, especially premature and critically ill newborns, due to their immature organ systems, reduced physiological reserves, and impaired cerebral autoregulation. Perfusion homeostasis is considered one of the significant and modifiable determinants of anesthesia-related neurocognitive outcomes. Therefore, dose-finding and safety pharmacological studies of the anesthetic induction agents in neonates are urgently needed and acknowledged as a high priority by the European Medicine Agency. Estimating adequate induction doses to ensure optimal depth of anesthesia while avoiding systemic and cerebral hemodynamic disturbances will help ensure safe anesthesia and potentially improve anesthesia-related outcomes in this group of patients. TRIAL REGISTRATION EudraCT (EudraCT Identifier: 2019-001534-34), 05.07.2022.
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Affiliation(s)
| | - Kristian Nørholm Jensen
- Department of Anesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
| | - Tom Giedsing Hansen
- Department of Anesthesiology and Intensive Care, Akershus University Hospital, Lørenskog, Norway, and Oslo University, Oslo, Norway
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2
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Xiao T, Fu Y, Li B, Li Y, Zhang J, Li H, Zhou X, Zhong L, Zhu L, Qin G, Zou X, Zhang X, Zheng M, Zou P, Hu Y, Chen X, Wang Y, Wu N, Gao S, Hu X, Luo X, Ju R. A study protocol for investigating the sonographic characteristics of neonates with critical illness: an observational cohort study. BMJ Paediatr Open 2023; 7:e001975. [PMID: 37369561 PMCID: PMC10410971 DOI: 10.1136/bmjpo-2023-001975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 05/07/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Haemodynamic instability and hypoxaemia are common and serious threats to the survival of neonates. A growing body of literature indicates that critical care ultrasound has become the optimal evaluation tool for sick neonates. However, few studies have described sonographic characteristics of haemodynamics systematically in the neonates with critical illness. This protocol describes a prospective observational cohort study aimed at (1) characterising the sonographic characteristics of the neonates with critical diseases; and (2) assessing the mortality, significant morbidity, utility of vasoactive medications, fluid resuscitation, duration of ventilation, etc. METHODS AND ANALYSIS: This is a single-centre, prospective and observational study conducted in Chengdu Women's and Children's Central Hospital from 1 December 2022 to 31 December 2027. Neonates admitted to the neonatal intensive care unit will be recruited. After inclusion, the neonates will undergo the neonatal critical care ultrasound. The data collected via case report forms include clinical variables and sonographic measures. The primary outcome is to identify the sonographic characteristics of sick neonates with different diseases, and the secondary outcome is to describe the mortality, significant morbidity, utility of vasoactive medications, fluid resuscitation and duration of ventilation. DISCUSSION Our study provided an organised neonatal critical care ultrasound workflow, which can be applied in practice. Accordingly, this study will first set up large data on the sonographic description of the neonates with critical illness, which can help to understand the pathophysiology of the critical illness, potentially titrating the treatment. TRIAL REGISTRATION NUMBER Chinese Clinical Trial Registry (ChiCTR2200065581; https://www.chictr.org.cn/com/25/showproj.aspx?proj=184095).
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Affiliation(s)
- Tiantian Xiao
- Department of Neonatology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Yiyong Fu
- Department of Neonatology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Biao Li
- Department of Neonatology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Yan Li
- Department of Neonatology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Jingyi Zhang
- Department of Neonatology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Huaying Li
- Department of Neonatology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Xiaofeng Zhou
- Department of Neonatology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Linping Zhong
- Department of Neonatology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Lin Zhu
- Department of Neonatology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Gaoyang Qin
- Department of Neonatology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Xin Zou
- Department of Neonatology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Xiaolong Zhang
- Department of Neonatology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Minsheng Zheng
- Department of Neonatology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Pinli Zou
- Department of Neonatology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Youning Hu
- Department of Neonatology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Xia Chen
- Department of Neonatology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Yuan Wang
- Department of Neonatology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Nana Wu
- Department of Neonatology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Shuqiang Gao
- Department of Neonatology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Xuhong Hu
- Department of Neonatology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Xiaohong Luo
- Department of Neonatology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Rong Ju
- Department of Neonatology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
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3
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Vik SD, Torp H, Jarmund AH, Kiss G, Follestad T, Støen R, Nyrnes SA. Continuous monitoring of cerebral blood flow during general anaesthesia in infants. BJA OPEN 2023; 6:100144. [PMID: 37588175 PMCID: PMC10430850 DOI: 10.1016/j.bjao.2023.100144] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 04/03/2023] [Accepted: 04/22/2023] [Indexed: 08/18/2023]
Abstract
Background General anaesthesia is associated with neurocognitive deficits in infants after noncardiac surgery. Disturbances in cerebral perfusion as a result of systemic hypotension and impaired autoregulation may be a potential cause. Our aim was to study cerebral blood flow (CBF) velocity continuously during general anaesthesia in infants undergoing noncardiac surgery and compare variations in CBF velocity with simultaneously measured near-infrared spectroscopy (NIRS), blood pressure, and heart rate. Methods NeoDoppler, a recently developed ultrasound system, was used to monitor CBF velocity via the anterior fontanelle during induction and maintenance of general anaesthesia until the start of surgery, and during recovery. NIRS, blood pressure, and heart rate were monitored simultaneously and synchronised with the NeoDoppler measurements. Results Thirty infants, with a median postmenstrual age at surgery of 37.6 weeks (range 28.6-60.0) were included. Compared with baseline, the trend curves showed a decrease in CBF velocity during induction and maintenance of anaesthesia and returned to baseline values during recovery. End-diastolic velocity decreased in all infants during anaesthesia, on average by 59%, whereas peak systolic- and time-averaged velocities decreased by 26% and 45%, respectively. In comparison, the reduction in mean arterial pressure was only 20%. NIRS values were high and remained stable. When adjusting for mean arterial pressure, the significant decrease in end-diastolic velocity persisted, whereas there was only a small reduction in peak systolic velocity. Conclusions Continuous monitoring of CBF velocity using NeoDoppler during anaesthesia is feasible and may provide valuable information about cerebral perfusion contributing to a more targeted haemodynamic management in anaesthetised infants.
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Affiliation(s)
- Sigrid D. Vik
- Children's Clinic, St. Olavs University Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Hans Torp
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Anders H. Jarmund
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Gabriel Kiss
- Department of Computer Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Turid Follestad
- Clinical Research Unit Central Norway, St. Olavs Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Ragnhild Støen
- Children's Clinic, St. Olavs University Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Siri Ann Nyrnes
- Children's Clinic, St. Olavs University Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
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Tierradentro-García LO, Saade-Lemus S, Freeman C, Kirschen M, Huang H, Vossough A, Hwang M. Cerebral Blood Flow of the Neonatal Brain after Hypoxic-Ischemic Injury. Am J Perinatol 2023; 40:475-488. [PMID: 34225373 PMCID: PMC8974293 DOI: 10.1055/s-0041-1731278] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Hypoxic-ischemic encephalopathy (HIE) in infants can have long-term adverse neurodevelopmental effects and markedly reduce quality of life. Both the initial hypoperfusion and the subsequent rapid reperfusion can cause deleterious effects in brain tissue. Cerebral blood flow (CBF) assessment in newborns with HIE can help detect abnormalities in brain perfusion to guide therapy and prognosticate patient outcomes. STUDY DESIGN The review will provide an overview of the pathophysiological implications of CBF derangements in neonatal HIE, current and emerging techniques for CBF quantification, and the potential to utilize CBF as a physiologic target in managing neonates with acute HIE. CONCLUSION The alterations of CBF in infants during hypoxia-ischemia have been studied by using different neuroimaging techniques, including nitrous oxide and xenon clearance, transcranial Doppler ultrasonography, contrast-enhanced ultrasound, arterial spin labeling MRI, 18F-FDG positron emission tomography, near-infrared spectroscopy (NIRS), functional NIRS, and diffuse correlation spectroscopy. Consensus is lacking regarding the clinical significance of CBF estimations detected by these different modalities. Heterogeneity in the imaging modality used, regional versus global estimations of CBF, time for the scan, and variables impacting brain perfusion and cohort clinical characteristics should be considered when translating the findings described in the literature to routine practice and implementation of therapeutic interventions. KEY POINTS · Hypoxic-ischemic injury in infants can result in adverse long-term neurologic sequelae.. · Cerebral blood flow is a useful biomarker in neonatal hypoxic-ischemic injury.. · Imaging modality, variables affecting cerebral blood flow, and patient characteristics affect cerebral blood flow assessment..
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Affiliation(s)
| | - Sandra Saade-Lemus
- Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Neurology, Brigham and Women’s Hospital & Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Colbey Freeman
- Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew Kirschen
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Hao Huang
- Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Arastoo Vossough
- Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Misun Hwang
- Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
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5
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Martini S, Thewissen L, Austin T, da Costa CS, de Boode WP, Dempsey E, Kooi E, Pellicer A, Rhee CJ, Riera J, Wolf M, Wong F. Near-infrared spectroscopy monitoring of neonatal cerebrovascular reactivity: where are we now? Pediatr Res 2023:10.1038/s41390-023-02574-6. [PMID: 36997690 DOI: 10.1038/s41390-023-02574-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 02/09/2023] [Accepted: 02/17/2023] [Indexed: 06/19/2023]
Abstract
Cerebrovascular reactivity defines the ability of the cerebral vasculature to regulate its resistance in response to both local and systemic factors to ensure an adequate cerebral blood flow to meet the metabolic demands of the brain. The increasing adoption of near-infrared spectroscopy (NIRS) for non-invasive monitoring of cerebral oxygenation and perfusion allowed investigation of the mechanisms underlying cerebrovascular reactivity in the neonatal population, confirming important associations with pathological conditions including the development of brain injury and adverse neurodevelopmental outcomes. However, the current literature on neonatal cerebrovascular reactivity is mainly still based on small, observational studies and is characterised by methodological heterogeneity; this has hindered the routine application of NIRS-based monitoring of cerebrovascular reactivity to identify infants most at risk of brain injury. This review aims (1) to provide an updated review on neonatal cerebrovascular reactivity, assessed using NIRS; (2) to identify critical points that need to be addressed with targeted research; and (3) to propose feasibility trials in order to fill the current knowledge gaps and to possibly develop a preventive or curative approach for preterm brain injury. IMPACT: NIRS monitoring has been largely applied in neonatal research to assess cerebrovascular reactivity in response to blood pressure, PaCO2 and other biochemical or metabolic factors, providing novel insights into the pathophysiological mechanisms underlying cerebral blood flow regulation. Despite these insights, the current literature shows important pitfalls that would benefit to be addressed in a series of targeted trials, proposed in the present review, in order to translate the assessment of cerebrovascular reactivity into routine monitoring in neonatal clinical practice.
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Affiliation(s)
- Silvia Martini
- Neonatal Intensive Care Unit, IRCCS AOU S. Orsola, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
| | | | - Topun Austin
- Neonatal Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Willem P de Boode
- Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Eugene Dempsey
- Department of Paediatrics and Child Health, INFANT Centre, University College Cork, Cork, Ireland
| | - Elisabeth Kooi
- Division of Neonatology, Beatrix Children's Hospital, University Medical Center, University of Groningen, Groningen, The Netherlands
| | - Adelina Pellicer
- Department of Neonatology, La Paz University Hospital, Madrid, Spain
| | - Christopher J Rhee
- Section of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Joan Riera
- Department of Neonatology, La Paz University Hospital, Madrid, Spain
- Center for Biomedical Technology, Technical University, Madrid, Spain
| | - Martin Wolf
- Biomedical Optics Research Laboratory, Department of Neonatology, University Hospital Zurich, Zurich, Switzerland
| | - Flora Wong
- Monash Newborn, Monash Children's Hospital, Hudson Institute of Medical Research, Department of Paediatrics, Monash University, Melbourne, VIC, Australia
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6
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Suppan E, Pichler G, Binder-Heschl C, Schwaberger B, Urlesberger B. Three Physiological Components That Influence Regional Cerebral Tissue Oxygen Saturation. Front Pediatr 2022; 10:913223. [PMID: 35769216 PMCID: PMC9234387 DOI: 10.3389/fped.2022.913223] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 05/09/2022] [Indexed: 11/17/2022] Open
Abstract
Near-infrared spectroscopy (NIRS) measurement of regional cerebral tissue oxygen saturation (rcStO2) has become a topic of high interest in neonatology. Multiple studies have demonstrated that rcStO2 measurements are feasible in the delivery room during immediate transition and resuscitation as well as after admission to the neonatal intensive care unit. Reference ranges for different gestational ages, modes of delivery, and devices have already been published. RcStO2 reflects a mixed tissue saturation, composed of arterial (A), venous (V), and capillary signals, derived from small vessels within the measurement compartment. The A:V signal ratio fluctuates based on changes in oxygen delivery and oxygen consumption, which enables a reliable trend monitoring of the balance between these two parameters. While the increasing research evidence supports its use, the interpretation of the absolute values of and trends in rcStO2 is still challenging, which halts its routine use in the delivery room and at the bedside. To visualize the influencing factors and improve the understanding of rcStO2 values, we have created a flowchart, which focuses on the three major physiological components that affect rcStO2: oxygen content, circulation, and oxygen extraction. Each of these has its defining parameters, which are discussed in detail in each section.
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Affiliation(s)
- Ena Suppan
- Division of Neonatology, Department of Pediatrics, Medical University of Graz, Graz, Austria.,Research Unit for Neonatal Micro- and Macrocirculation, Medical University of Graz, Graz, Austria.,Research Unit for Cerebral Development and Oximetry Research, Medical University of Graz, Graz, Austria
| | - Gerhard Pichler
- Division of Neonatology, Department of Pediatrics, Medical University of Graz, Graz, Austria.,Research Unit for Neonatal Micro- and Macrocirculation, Medical University of Graz, Graz, Austria.,Research Unit for Cerebral Development and Oximetry Research, Medical University of Graz, Graz, Austria
| | - Corinna Binder-Heschl
- Division of Neonatology, Department of Pediatrics, Medical University of Graz, Graz, Austria.,Research Unit for Neonatal Micro- and Macrocirculation, Medical University of Graz, Graz, Austria.,Research Unit for Cerebral Development and Oximetry Research, Medical University of Graz, Graz, Austria
| | - Bernhard Schwaberger
- Division of Neonatology, Department of Pediatrics, Medical University of Graz, Graz, Austria.,Research Unit for Neonatal Micro- and Macrocirculation, Medical University of Graz, Graz, Austria.,Research Unit for Cerebral Development and Oximetry Research, Medical University of Graz, Graz, Austria
| | - Berndt Urlesberger
- Division of Neonatology, Department of Pediatrics, Medical University of Graz, Graz, Austria.,Research Unit for Neonatal Micro- and Macrocirculation, Medical University of Graz, Graz, Austria.,Research Unit for Cerebral Development and Oximetry Research, Medical University of Graz, Graz, Austria
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7
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Klein SP, De Sloovere V, Meyfroidt G, Depreitere B. Differential Hemodynamic Response of Pial Arterioles Contributes to a Quadriphasic Cerebral Autoregulation Physiology. J Am Heart Assoc 2021; 11:e022943. [PMID: 34935426 PMCID: PMC9075199 DOI: 10.1161/jaha.121.022943] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background Cerebrovascular autoregulation (CA) regulates cerebral vascular tone to maintain near-constant cerebral blood flow during fluctuations in cerebral perfusion pressure (CPP). Preclinical and clinical research has challenged the classic triphasic pressure-flow relationship, leaving the normal pressure-flow relationship unclear. Methods and Results We used in vivo imaging of the hemodynamic response in pial arterioles to study CA in a porcine closed cranial window model during nonpharmacological blood pressure manipulation. Red blood cell flux was determined in 52 pial arterioles during 10 hypotension and 10 hypertension experiments to describe the pressure-flow relationship. We found a quadriphasic pressure-flow relationship with 4 distinct physiological phases. Smaller arterioles demonstrated greater vasodilation during low CPP when compared with large arterioles (P<0.01), whereas vasoconstrictive capacity during high CPP was not significantly different between arterioles (P>0.9). The upper limit of CA was defined by 2 breakpoints. Increases in CPP lead to a point of maximal vasoconstriction of the smallest pial arterioles (upper limit of autoregulation [ULA] 1). Beyond ULA1, only larger arterioles maintain a limited additional vasoconstrictive capacity, extending the buffer for high CPP. Beyond ULA2, vasoconstrictive capacity is exhausted, and all pial arterioles passively dilate. There was substantial intersubject variability, with ranges of 29.2, 47.3, and 50.9 mm Hg for the lower limit, ULA1, and ULA2, respectively. Conclusions We provide new insights into the quadriphasic physiology of CA, differentiating between truly active CA and an extended capacity to buffer increased CPP with progressive failure of CA. In this experimental model, the limits of CA widely varied between subjects.
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Affiliation(s)
- Samuel P Klein
- Department of Neurosurgery University Hospitals Leuven Leuven Belgium
| | | | - Geert Meyfroidt
- Department of Intensive Care Medicine University Hospitals Leuven Leuven Belgium
| | - Bart Depreitere
- Department of Neurosurgery University Hospitals Leuven Leuven Belgium
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8
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Pospelov AS, Ala-Kurikka T, Kurki S, Voipio J, Kaila K. Carbonic anhydrase inhibitors suppress seizures in a rat model of birth asphyxia. Epilepsia 2021; 62:1971-1984. [PMID: 34180051 DOI: 10.1111/epi.16963] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/21/2021] [Accepted: 05/28/2021] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Seizures are common in neonates recovering from birth asphyxia but there is general consensus that current pharmacotherapy is suboptimal and that novel antiseizure drugs are needed. We recently showed in a rat model of birth asphyxia that seizures are triggered by the post-asphyxia recovery of brain pH. Here our aim was to investigate whether carbonic anhydrase inhibitors (CAIs), which induce systemic acidosis, block the post-asphyxia seizures. METHODS The CAIs acetazolamide (AZA), benzolamide (BZA), and ethoxzolamide (EZA) were administered intraperitoneally or intravenously to 11-day-old rats exposed to intermittent asphyxia (30 min; three 7+3 min cycles of 9% and 5% O2 at 20% CO2 ). Electrode measurements of intracortical pH, Po2 , and local field potentials (LFPs) were made under urethane anesthesia. Convulsive seizures and blood acid-base parameters were examined in freely behaving animals. RESULTS The three CAIs decreased brain pH by 0.14-0.17 pH units and suppressed electrographic post-asphyxia seizures. AZA, BZA, and EZA differ greatly in their lipid solubility (EZA > AZA > BZA) and pharmacokinetics. However, there were only minor differences in the delay (range 0.8-3.7 min) from intraperitoneal application to their action on brain pH. The CAIs induced a modest post-asphyxia elevation of brain Po2 that had no effect on LFP activity. AZA was tested in freely behaving rats, in which it induced a respiratory acidosis and decreased the incidence of convulsive seizures from 9 of 20 to 2 of 17 animals. SIGNIFICANCE AZA, BZA, and EZA effectively block post-asphyxia seizures. Despite the differences in their pharmacokinetics, they had similar effects on brain pH, which indicates that their antiseizure mode of action was based on respiratory (hypercapnic) acidosis resulting from inhibition of blood-borne and extracellular vascular carbonic anhydrases. AZA has been used for several indications in neonates, suggesting that it can be safely repurposed for the treatment of neonatal seizures as an add-on to the current treatment regimen.
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Affiliation(s)
- Alexey S Pospelov
- Faculty of Biological and Environmental Sciences, Molecular and Integrative Biosciences, University of Helsinki, Helsinki, Finland.,Neuroscience Center (HiLIFE), University of Helsinki, Helsinki, Finland
| | - Tommi Ala-Kurikka
- Faculty of Biological and Environmental Sciences, Molecular and Integrative Biosciences, University of Helsinki, Helsinki, Finland.,Neuroscience Center (HiLIFE), University of Helsinki, Helsinki, Finland
| | - Samu Kurki
- Faculty of Biological and Environmental Sciences, Molecular and Integrative Biosciences, University of Helsinki, Helsinki, Finland.,Neuroscience Center (HiLIFE), University of Helsinki, Helsinki, Finland
| | - Juha Voipio
- Faculty of Biological and Environmental Sciences, Molecular and Integrative Biosciences, University of Helsinki, Helsinki, Finland
| | - Kai Kaila
- Faculty of Biological and Environmental Sciences, Molecular and Integrative Biosciences, University of Helsinki, Helsinki, Finland.,Neuroscience Center (HiLIFE), University of Helsinki, Helsinki, Finland
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9
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Ala‐Kurikka T, Pospelov A, Summanen M, Alafuzoff A, Kurki S, Voipio J, Kaila K. A physiologically validated rat model of term birth asphyxia with seizure generation after, not during, brain hypoxia. Epilepsia 2021; 62:908-919. [PMID: 33338272 PMCID: PMC8246723 DOI: 10.1111/epi.16790] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 11/24/2020] [Accepted: 11/24/2020] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Birth asphyxia (BA) is often associated with seizures that may exacerbate the ensuing hypoxic-ischemic encephalopathy. In rodent models of BA, exposure to hypoxia is used to evoke seizures, that commence already during the insult. This is in stark contrast to clinical BA, in which seizures are typically seen upon recovery. Here, we introduce a term-equivalent rat model of BA, in which seizures are triggered after exposure to asphyxia. METHODS Postnatal day 11-12 male rat pups were exposed to steady asphyxia (15 min; air containing 5% O2 + 20% CO2 ) or to intermittent asphyxia (30 min; three 5 + 5-min cycles of 9% and 5% O2 at 20% CO2 ). Cortical activity and electrographic seizures were recorded in freely behaving animals. Simultaneous electrode measurements of intracortical pH, Po2 , and local field potentials (LFPs) were made under urethane anesthesia. RESULTS Both protocols decreased blood pH to <7.0 and brain pH from 7.3 to 6.7 and led to a fall in base excess by 20 mmol·L-1 . Electrographic seizures with convulsions spanning the entire Racine scale were triggered after intermittent but not steady asphyxia. In the presence of 20% CO2 , brain Po2 was only transiently affected by 9% ambient O2 but fell below detection level during the steps to 5% O2 , and LFP activity was nearly abolished. Post-asphyxia seizures were strongly suppressed when brain pH recovery was slowed down by 5% CO2 . SIGNIFICANCE The rate of brain pH recovery has a strong influence on post-asphyxia seizure propensity. The recurring hypoxic episodes during intermittent asphyxia promote neuronal excitability, which leads to seizures only after the suppressing effect of the hypercapnic acidosis is relieved. The present rodent model of BA is to our best knowledge the first one in which, consistent with clinical BA, behavioral and electrographic seizures are triggered after and not during the BA-mimicking insult.
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Affiliation(s)
- Tommi Ala‐Kurikka
- Faculty of Biological and Environmental Sciences, Molecular and Integrative BiosciencesUniversity of HelsinkiHelsinkiFinland
- Neuroscience Center (HiLIFE)University of HelsinkiHelsinkiFinland
| | - Alexey Pospelov
- Faculty of Biological and Environmental Sciences, Molecular and Integrative BiosciencesUniversity of HelsinkiHelsinkiFinland
- Neuroscience Center (HiLIFE)University of HelsinkiHelsinkiFinland
| | - Milla Summanen
- Faculty of Biological and Environmental Sciences, Molecular and Integrative BiosciencesUniversity of HelsinkiHelsinkiFinland
- Neuroscience Center (HiLIFE)University of HelsinkiHelsinkiFinland
| | - Aleksander Alafuzoff
- Faculty of Biological and Environmental Sciences, Molecular and Integrative BiosciencesUniversity of HelsinkiHelsinkiFinland
- Neuroscience Center (HiLIFE)University of HelsinkiHelsinkiFinland
| | - Samu Kurki
- Faculty of Biological and Environmental Sciences, Molecular and Integrative BiosciencesUniversity of HelsinkiHelsinkiFinland
- Neuroscience Center (HiLIFE)University of HelsinkiHelsinkiFinland
| | - Juha Voipio
- Faculty of Biological and Environmental Sciences, Molecular and Integrative BiosciencesUniversity of HelsinkiHelsinkiFinland
| | - Kai Kaila
- Faculty of Biological and Environmental Sciences, Molecular and Integrative BiosciencesUniversity of HelsinkiHelsinkiFinland
- Neuroscience Center (HiLIFE)University of HelsinkiHelsinkiFinland
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10
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Effects of different ventilation on cerebral oxygen saturation and cerebral blood flow before and after modified ultrafiltration in infants during ventricular septal defect repair. Cardiol Young 2021; 31:371-376. [PMID: 33541455 DOI: 10.1017/s1047951120003984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To analyse the changes of different ventilation on regional cerebral oxygen saturation and cerebral blood flow in infants during ventricular septal defect repair. METHODS Ninety-two infants younger than 1 year were enrolled in the study. End-expiratory tidal pressure of carbon dioxide was maintained at 40-45 and 35-39 mmHg in relative low and high ventilation groups. Regional cerebral oxygen saturation and flow velocity of the middle cerebral artery were recorded after anaesthesia (T0), cut pericardium (T1), separation from cardiopulmonary bypass (T2), the end of modified ultrafiltration, (T3) and at the end of operation (T4). RESULTS The relative low ventilation group exhibited a significantly high regional cerebral oxygen saturation at each time point except for T2 (T0:77 ± 4, T1:76 ± 5, T3:76 ± 8, T4:76 ± 8, respectively, p < 0.001). Flow velocity of the middle cerebral artery in the relative low ventilation group was higher compared to the relative high ventilation group at each time point except for T2 (T0:53 ± 14, T1:54 ± 15, T3:53 ± 17, T4:52 ± 16, respectively, p < 0.001). Between the two groups, T2 showed the lowest middle cerebral artery flow velocity (relative low ventilation: 39 ± 15, relative high ventilation: 39 ± 11, p < 0.001). CONCLUSION The infants' regional cerebral oxygen saturation and middle cerebral artery flow velocity performed better in the range of 40-45 mmHg end-expiratory tidal pressure of carbon dioxide during CHD surgery. Modified ultrafiltration increased cerebral oxygen saturation. It was important to regulate ventilation in order to balance cerebral oxygen in infants.
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11
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The effect of umbilical cord milking on cerebral blood flow in very preterm infants: a randomized controlled study. J Perinatol 2021; 41:263-268. [PMID: 32782323 DOI: 10.1038/s41372-020-00780-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 07/10/2020] [Accepted: 08/03/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To compare the effect of umbilical cord milking (UCM) vs. early cord clamping (ECC) on cerebral blood flow (CBF). METHOD Preterm infants <31 weeks' gestation were randomized to receive UCM or ECC at birth. Blood flow velocities and resistive & pulsatility indices of middle and anterior cerebral arteries were measured at 4-6 and 10-12 h after birth as an estimate of CBF. RESULTS Randomization allocated 37 infants to UCM and 36 to ECC. Maternal and antenatal variables were similar. There were no significant differences between groups in middle or anterior CBF velocities and resistive indices at either study time point. CBF variables were not correlated with mean blood pressure, systemic blood flow, or intraventricular hemorrhage. CONCLUSIONS In very preterm infants, UCM compared with ECC was not shown to change CBF indices during the first 12 h of age or correlate with other hemodynamic measures or with intraventricular hemorrhage. TRIAL REGISTRATION ClinicalTrials.gov: NCT01487187.
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12
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Effect of Permissive Mild Hypercapnia on Cerebral Vasoreactivity in Infants: A Randomized Controlled Crossover Trial. Anesth Analg 2021; 133:976-983. [PMID: 33410612 DOI: 10.1213/ane.0000000000005325] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Mechanical ventilation interferes with cerebral perfusion via changes in intrathoracic pressure and/or as a consequence of alterations in CO2. Cerebral vascular vasoreactivity is dependent on CO2, and hypocapnia can potentially lead to vasoconstriction and subsequent decrease in cerebral blood flow. Thus, we aimed at characterizing whether protective ventilation with mild permissive hypercapnia improves cerebral perfusion in infants. METHODS Following ethical approval and parental consent, 19 infants were included in this crossover study and randomly assigned to 2 groups for which the initial ventilation parameters were set to achieve an end-tidal carbon dioxide (Etco2) of 6.5 kPa (group H: mild hypercapnia, n = 8) or 5.5 kPa (group N: normocapnia, n = 11). The threshold was then reversed before going back to the initial set value of normo- or hypercapnia. At each step, hemodynamic, respiratory, and near-infrared spectroscopy (NIRS)-derived parameters, including tissue oxygenation index (TOI) and tissue hemoglobin index (THI), concentration of deoxygenated hemoglobin (HHb) and oxygenated hemoglobin (O2Hb), were collected. Concomitantly, sevoflurane maintenance concentration, ventilatory (driving pressure) and hemodynamic parameters, as mean arterial pressure (MAP), were recorded. RESULTS Targeting an Etco2 of 5.5 kPa resulted in significantly higher mean driving pressure than an Etco2 of 6.5 kPa (P < .01) with no difference between the groups in end-tidal sevoflurane, MAP, and heart rate. A large scatter was observed in NIRS-derived parameters, with no evidence for difference in Etco2 changes between or within groups. A mild decrease with time was observed in THI and MAP in infants randomly assigned to group N (P < .036 and P < .017, respectively). When pooling all groups together, a significant correlation was found between the changes in MAP and TOI (r = 0.481, P < .001). CONCLUSIONS Allowing permissive mild hypercapnia during mechanical ventilation of infants led to lower driving pressure and comparable hemodynamic, respiratory, and cerebral oxygenation parameters than during normocapnia. Whereas a large scatter in NIRS-derived parameters was observed at all levels of Etco2, the correlation between TOI and MAP suggests that arterial pressure is an important component of cerebral oxygenation at mild hypercapnia.
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13
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Cui B, Ou-Yang C, Xie S, Lin D, Ma J. Age-related cerebrovascular carbon dioxide reactivity in children with ventricular septal defect younger than 3 years. Paediatr Anaesth 2020; 30:977-983. [PMID: 32648613 DOI: 10.1111/pan.13967] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 06/24/2020] [Accepted: 07/03/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Impaired cerebrovascular reactivity to carbon dioxide was proposed to contribute to neurological morbidity in children undergoing cardiac surgery. The objective of this study was to assess carbon dioxide reactivity and regional cerebral oxygen saturation in children younger than 3 years. METHODS This study enrolled children younger than 3 years undergoing ventricular septal defect repair. The cohort was divided into three age groups: younger than 6 months, 6-12 months, and 12-36 months. Under steady-state anesthesia, carbon dioxide reactivity was calculated by measuring changes in middle cerebral artery blood flow velocity using transcranial Doppler sonography. Regional cerebral oxygen saturation changes were measured by near-infrared spectroscopy while endtidal carbon dioxide pressure was adjusted from 30 to 45 mm Hg. RESULTS Carbon dioxide reactivity showed a statistically significant increasing relationship with age (younger than 6 months group: 4.42% ± 2.73%, 6-12 months group: 5.86% ± 1.91%, 12-36 months group: 7.58% ± 1.49%; P < .001). Regional cerebral oxygen saturation showed a statistically significant increasing relationship with age (younger than 6 months group: 65% ± 6%, 6-12 months group: 68% ± 5%, 12-36 months group: 70% ± 5%; P = .027). Regional cerebral oxygen saturation showed a statistically significant increasing relationship with endtidal carbon dioxide pressure in all children (P < .001). CONCLUSION Abnormal carbon dioxide reactivity is prevalent in children younger than 3 years and the degree varies according to age.
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Affiliation(s)
- Boqun Cui
- Anesthesia Center, Capital Medical University Affiliated Beijing Anzhen Hospital, Beijing, China
| | - Chuan Ou-Yang
- Anesthesia Center, Capital Medical University Affiliated Beijing Anzhen Hospital, Beijing, China
| | - Siyuan Xie
- Anesthesia Center, Capital Medical University Affiliated Beijing Anzhen Hospital, Beijing, China.,Department of Anesthesiology, Capital Institute of Pediatrics affiliated Children's Hospital, Beijing, China
| | - Duomao Lin
- Anesthesia Center, Capital Medical University Affiliated Beijing Anzhen Hospital, Beijing, China
| | - Jun Ma
- Anesthesia Center, Capital Medical University Affiliated Beijing Anzhen Hospital, Beijing, China
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14
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Pereira S, Reeves J, Birch M, Finton-James S, Verma K, Krug R, Sinha A, Kempley S. A realistic flow phantom model of the carotid artery in preterm infants for training and research. ULTRASOUND : JOURNAL OF THE BRITISH MEDICAL ULTRASOUND SOCIETY 2020; 28:145-154. [PMID: 32831887 DOI: 10.1177/1742271x20902189] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 12/17/2019] [Indexed: 11/15/2022]
Abstract
Introduction Cerebral blood flow is increasingly monitored in preterm infants. Doppler ultrasound of the carotid artery is a widely available method but is operator dependent. Our aim was to design and produce a realistic flow phantom model of the carotid artery of preterm infants. Methods Data from cerebral blood flow measurements using Doppler ultrasound of the right common carotid artery from 21 premature newborn infants were used to produce a Doppler flow phantom model with three different vessel diameters. Vessel diameter, continuous and pulsatile flow volume measurements were performed by two blinded observers (with more than eight and 20 years of experience). Results Vessel diameter measurements using the phantom were underestimated by 7%. Continuous flow volume measurements were overestimated by 7% by both observers (observer 1 mean difference 1.5 ± 1.96 SD -3.3 to 6.3 ml/min versus observer 2, 1.9 ± 1.96 SD -3.6 to 7.4 ml/min). Pulsatile flow measurements were overestimated by 12.6% by observer 1 (2.7 ± 1.96 SD -0.6 to 5.9 ml/min) and by 7.8% by observer 2 (1.7 ± 1.96 SD -1.6 to 4.9 ml/min). There was good interobserver and intraobserver reliability for the majority of measurements using continuous and pulsatile flow. Conclusion It is feasible to produce a realistic flow phantom model of the neonatal carotid artery of preterm infants. Diameter measurements were underestimated and flow measurements were overestimated. These errors fell within acceptable limits for in vivo measurements. If these limitations were related to materials, this could be explored using a wall-less model. The flow phantom could be utilised for research and training clinicians in measuring cerebral blood flow using the carotid artery in this vulnerable group of infants.
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Affiliation(s)
- Sujith Pereira
- Neonatal Unit, Homerton University Hospital NHS Foundation Trust, London, UK.,Centre for Genomics and Child Health, Blizard Institute, Barts and The London School of Medicine and Dentistry, London, UK
| | - Jonathan Reeves
- Clinical Physics, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Malcolm Birch
- Clinical Physics, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Sakthi Finton-James
- Barts and the London School of Medicine and Dentistry, Queen Mary, University of London, London, UK
| | - Komal Verma
- Barts and the London School of Medicine and Dentistry, Queen Mary, University of London, London, UK
| | - Robert Krug
- Barts and the London School of Medicine and Dentistry, Queen Mary, University of London, London, UK
| | - Ajay Sinha
- Centre for Genomics and Child Health, Blizard Institute, Barts and The London School of Medicine and Dentistry, London, UK.,Neonatal Unit, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Stephen Kempley
- Centre for Genomics and Child Health, Blizard Institute, Barts and The London School of Medicine and Dentistry, London, UK
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15
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Pospelov AS, Puskarjov M, Kaila K, Voipio J. Endogenous brain-sparing responses in brain pH and PO 2 in a rodent model of birth asphyxia. Acta Physiol (Oxf) 2020; 229:e13467. [PMID: 32174009 DOI: 10.1111/apha.13467] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 03/11/2020] [Indexed: 12/12/2022]
Abstract
AIM To study brain-sparing physiological responses in a rodent model of birth asphyxia which reproduces the asphyxia-defining systemic hypoxia and hypercapnia. METHODS Steady or intermittent asphyxia was induced for 15-45 minutes in anaesthetized 6- and 11-days old rats and neonatal guinea pigs using gases containing 5% or 9% O2 plus 20% CO2 (in N2 ). Hypoxia and hypercapnia were induced with low O2 and high CO2 respectively. Oxygen partial pressure (PO2 ) and pH were measured with microsensors within the brain and subcutaneous ("body") tissue. Blood lactate was measured after asphyxia. RESULTS Brain and body PO2 fell to apparent zero with little recovery during 5% O2 asphyxia and 5% or 9% O2 hypoxia, and increased more than twofold during 20% CO2 hypercapnia. Unlike body PO2 , brain PO2 recovered rapidly to control after a transient fall (rat), or was slightly higher than control (guinea pig) during 9% O2 asphyxia. Asphyxia (5% O2 ) induced a respiratory acidosis paralleled by a progressive metabolic (lact)acidosis that was much smaller within than outside the brain. Hypoxia (5% O2 ) produced a brain-confined alkalosis. Hypercapnia outlasting asphyxia suppressed pH recovery and prolonged the post-asphyxia PO2 overshoot. All pH changes were accompanied by consistent shifts in the blood-brain barrier potential. CONCLUSION Regardless of brain maturation stage, hypercapnia can restore brain PO2 and protect the brain against metabolic acidosis despite compromised oxygen availability during asphyxia. This effect extends to the recovery phase if normocapnia is restored slowly, and it is absent during hypoxia, demonstrating that exposure to hypoxia does not mimic asphyxia.
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Affiliation(s)
- Alexey S. Pospelov
- Faculty of Biological and Environmental Sciences, Molecular and Integrative Biosciences University of Helsinki Helsinki Finland
| | - Martin Puskarjov
- Faculty of Biological and Environmental Sciences, Molecular and Integrative Biosciences University of Helsinki Helsinki Finland
| | - Kai Kaila
- Faculty of Biological and Environmental Sciences, Molecular and Integrative Biosciences University of Helsinki Helsinki Finland
- Neuroscience Center (HiLIFE) University of Helsinki Helsinki Finland
| | - Juha Voipio
- Faculty of Biological and Environmental Sciences, Molecular and Integrative Biosciences University of Helsinki Helsinki Finland
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16
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Abstract
Perioperative risk of morbidity and mortality for neonates is significantly higher than that for older children and adults. At particular risk are neonates born prematurely, neonates with major or severe congenital heart disease, and neonates with pulmonary hypertension. Presently no consensus exists regarding the safest anesthetic regimen for neonates. Regional anesthesia appears to be safe, but does not reduce the overall risk of postoperative apnea. Former preterm infants require postoperative observation for apnea. The anesthesiologist caring for the neonate for major surgery should be knowledgeable of the unique physiology of the neonate and maintain the highest level of vigilance throughout.
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Affiliation(s)
- Calvin C Kuan
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, 300 Pasteur Drive, H3582, Stanford, CA 94305, USA.
| | - Susanna J Shaw
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, 300 Pasteur Drive, H3582, Stanford, CA 94305, USA
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17
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Camfferman FA, de Goederen R, Govaert P, Dudink J, van Bel F, Pellicer A, Cools F. Diagnostic and predictive value of Doppler ultrasound for evaluation of the brain circulation in preterm infants: a systematic review. Pediatr Res 2020; 87:50-58. [PMID: 32218536 PMCID: PMC7098887 DOI: 10.1038/s41390-020-0777-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Very and extremely preterm infants frequently have brain injury-related long-term neurodevelopmental problems. Altered perfusion, for example, seen in the context of a hemodynamically significant patent ductus arteriosus (PDA), has been linked to injury of the immature brain. However, a direct relation with outcome has not been reviewed systematically. METHODS A systematic review was conducted to provide an overview of the value of different cerebral arterial blood flow parameters assessed by Doppler ultrasound, in relation to brain injury, to predict long-term neurodevelopmental outcome in preterm infants. RESULTS In total, 23 studies were included. Because of heterogeneity of studies, a meta-analysis of results was not possible. All included studies on resistance index (RI) showed significantly higher values in subjects with a hemodynamically significant PDA. However, absolute differences in RI values were small. Studies using Doppler parameters to predict brain injury and long-term neurodevelopmental outcome were inconsistent. DISCUSSION There is no clear evidence to support the routine determination of RI or other Doppler parameters in the cerebral arteries to predict brain injury and long-term neurodevelopmental outcome in the preterm infant. However, there is evidence that elevated RI can point to the presence of a hemodynamically significant PDA.
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Affiliation(s)
- Fleur A Camfferman
- Department of Neonatology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium.
| | - Robbin de Goederen
- Dutch Craniofacial Centre Rotterdam, Department of Plastic and Reconstructive Surgery, Erasmus Medical Center University, Rotterdam, The Netherlands
| | - Paul Govaert
- Department of Neonatology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
- Department of Neonatology, Erasmus Medical Center University, Sophia Children's Hospital, Rotterdam, The Netherlands
- Department of Neonatology, ZNA Middelheim, Antwerp, Belgium
- Department of Rehabilitation and Physical Therapy, Gent University Hospital, Gent, Belgium
| | - Jeroen Dudink
- Department of Neonatology, Erasmus Medical Center University, Sophia Children's Hospital, Rotterdam, The Netherlands
- Department of Neonatology, University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Frank van Bel
- Department of Neonatology, University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Adelina Pellicer
- Department of Neonatology, La Paz University Hospital, Madrid, Spain
| | - Filip Cools
- Department of Neonatology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
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18
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NeoDoppler: New ultrasound technology for continous cerebral circulation monitoring in neonates. Pediatr Res 2020; 87:95-103. [PMID: 31404920 PMCID: PMC6960092 DOI: 10.1038/s41390-019-0535-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 07/13/2019] [Accepted: 07/25/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND There is a strong need for continuous cerebral circulation monitoring in neonatal care, since suboptimal cerebral blood flow may lead to brain injuries in preterm infants and other critically ill neonates. NeoDoppler is a novel ultrasound system, which can be gently fixed to the anterior fontanel and measure cerebral blood flow velocity continuously in different depths of the brain simultaneously. We aimed to study the feasibility, accuracy, and potential clinical applications of NeoDoppler in preterm infants and sick neonates. METHOD Twenty-five infants born at different gestational ages with a variety of diagnoses on admission were included. The probe was placed over the anterior fontanel, and blood flow velocity data were continuously recorded. To validate NeoDoppler, we compared the measurements with conventional ultrasound; agreement was assessed using Bland-Altman plots. RESULTS NeoDoppler can provide accurate and continuous data on cerebral blood flow velocity in several depths simultaneously. Limits of agreement between the measurements obtained with the two methods were acceptable. CONCLUSION By monitoring the cerebral circulation continuously, increased knowledge of cerebral hemodynamics in preterm infants and sick neonates may be acquired. Improved monitoring of these vulnerable brains during a very sensitive period of brain development may contribute toward preventing brain injuries.
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19
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Kamata M, Hakim M, Walia H, Tumin D, Tobias JD. Changes in cerebral and renal oxygenation during laparoscopic pyloromyotomy. J Clin Monit Comput 2019; 34:699-703. [PMID: 31325010 DOI: 10.1007/s10877-019-00356-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Accepted: 07/16/2019] [Indexed: 10/26/2022]
Abstract
Although a laparoscopic approach may be preferred over open procedures for abdominal surgery, there are limited data on the effect of laparoscopic procedures on cerebral and renal oxygenation in neonates and young infants. Here, we evaluated the effect in neonates and infants. In this two-center prospective observational study, we evaluated changes in cerebral and renal regional oxygen saturation (rSO2) in infants during laparoscopic pyloromyotomy. Intraoperative hemodynamic and respiratory parameters and rSO2 were recorded. For the primary outcome, these parameters were compared at incision and at the end of pneumoperitoneum. The study cohort included 25 infants with a mean age of 40 ± 10 days and weight of 4.0 ± 0.6 kg. IAP at the beginning of laparoscopy was 10 ± 2 mmHg (range 7-15 mmHg). Although both cerebral and renal rSO2 decreased from incision compared to the end of laparoscopy, the decrease reached statistical significance only for cerebral rSO2 (81 ± 12 to 76 ± 16, p = 0.033). Similarly, the increase in fractional tissue oxygen extraction (FTOE) was only statistically significant for cerebral FTOE (0.18 ± 0.12 to 0.23 ± 0.16, p = 0.037). No change in hemodynamic or respiratory parameters was found. Although there was a decrease in cerebral rSO2 and increase in cerebral FTOE during pneumoperitoneum, the values did not decrease below those noted before anesthetic induction.
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Affiliation(s)
- Mineto Kamata
- Department of Anesthesiology, Saitama Children's Medical Center, 1-2 Shintoshin, Chuo-ku, Saitama-City, Saitama, 330-8777, Japan.
| | - Mohammed Hakim
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Hina Walia
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Dmitry Tumin
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
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20
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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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21
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Badurdeen S, Roberts C, Blank D, Miller S, Stojanovska V, Davis P, Hooper S, Polglase G. Haemodynamic Instability and Brain Injury in Neonates Exposed to Hypoxia⁻Ischaemia. Brain Sci 2019; 9:brainsci9030049. [PMID: 30818842 PMCID: PMC6468566 DOI: 10.3390/brainsci9030049] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 02/24/2019] [Accepted: 02/26/2019] [Indexed: 11/23/2022] Open
Abstract
Brain injury in the asphyxic newborn infant may be exacerbated by delayed restoration of cardiac output and oxygen delivery. With increasing severity of asphyxia, cerebral autoregulatory responses are compromised. Further brain injury may occur in association with high arterial pressures and cerebral blood flows following the restoration of cardiac output. Initial resuscitation aims to rapidly restore cardiac output and oxygenation whilst mitigating the impact of impaired cerebral autoregulation. Recent animal studies have indicated that the current standard practice of immediate umbilical cord clamping prior to resuscitation may exacerbate injury. Resuscitation prior to umbilical cord clamping confers several haemodynamic advantages. In particular, it retains the low-resistance placental circuit that mitigates the rebound hypertension and cerebrovascular injury. Prolonged cerebral hypoxia–ischaemia is likely to contribute to further perinatal brain injury, while, at the same time, tissue hyperoxia is associated with oxidative stress. Efforts to monitor and target cerebral flow and oxygen kinetics, for example, using near-infrared spectroscopy, are currently being evaluated and may facilitate development of novel resuscitation approaches.
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Affiliation(s)
- Shiraz Badurdeen
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Melbourne 3168, Australia.
- Newborn Research Centre, The Royal Women's Hospital, Melbourne 3052, Australia.
| | - Calum Roberts
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Melbourne 3168, Australia.
| | - Douglas Blank
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Melbourne 3168, Australia.
| | - Suzanne Miller
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Melbourne 3168, Australia.
| | - Vanesa Stojanovska
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Melbourne 3168, Australia.
| | - Peter Davis
- Newborn Research Centre, The Royal Women's Hospital, Melbourne 3052, Australia.
| | - Stuart Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Melbourne 3168, Australia.
| | - Graeme Polglase
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Melbourne 3168, Australia.
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Wagenaar N, Rijsman LH, Nieuwets A, Groenendaal F. Cerebral Blood Flow Measured by Phase-Contrast Magnetic Resonance Angiography in Preterm and Term Neonates. Neonatology 2019; 115:226-233. [PMID: 30669149 PMCID: PMC6518870 DOI: 10.1159/000494368] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 10/09/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Preterm infants show a decreased tortuosity in all proximal segments of the cerebral vasculature at term-equivalent age (TEA). Recently MRI techniques were developed to measure cerebral blood flow (CBF) based on phase-contrast images. OBJECTIVES We hypothesized that arterial CBF corrected for brain size differs between full-term and preterm infants at TEA. METHODS 344 infants without major brain abnormalities had a cranial MRI for clinical reasons including phase-contrast magnetic resonance angiography (PC-MRA) around TEA (mean 41.1 ± SD 1.2 weeks). This cohort consisted of 172 preterm infants (gestational age at birth 24.1-31.9 weeks) and 172 term-born infants (gestational age at birth 37.0-42.6 weeks). The total CBF in milliliters/minute was calculated by adding the blood flow of the carotid and basilar arteries, and compared to age at scan, body weight, and several parameters of estimated brain size. RESULTS After logarithmic transformation, total CBF was associated with body weight, estimated brain weight, head circumference, and 2D brain surface measurements at TEA. Total CBF was significantly (9-12%) higher in term compared to preterm infants after correction for 2D brain surface measurements, head circumference or postmenstrual age at MRI (p < 0.05). CONCLUSIONS Total CBF as measured by PC-MRA was associated with body and (estimated) brain weight and 2D brain surface measurements and was higher in term compared to preterm born infants.
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Affiliation(s)
- Nienke Wagenaar
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lucas H Rijsman
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Astrid Nieuwets
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Floris Groenendaal
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands, .,Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands,
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23
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Kamat PP, Kudchadkar SR, Simon HK. Sedative and Anesthetic Neurotoxicity in Infants and Young Children: Not Just an Operating Room Concern. J Pediatr 2019; 204:285-290. [PMID: 30270160 DOI: 10.1016/j.jpeds.2018.08.039] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 07/15/2018] [Accepted: 08/17/2018] [Indexed: 02/07/2023]
Affiliation(s)
- Pradip P Kamat
- Department of Pediatrics, Division of Critical Care Medicine, Emory University School of Medicine, Atlanta, GA; Children's Sedation Services at Egleston, Children's Healthcare of Atlanta at Egleston, Atlanta, GA.
| | - Sapna R Kudchadkar
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Charlotte R. Bloomberg Children's Center, Baltimore, MD; Department of Pediatrics, Johns Hopkins University School of Medicine, Charlotte R. Bloomberg Children's Center, Baltimore, MD; Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Charlotte R. Bloomberg Children's Center, Baltimore, MD
| | - Harold K Simon
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Emory University School of Medicine, Atlanta, GA; Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA
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24
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Morris EA, Juttukonda MR, Lee CA, Patel NJ, Pruthi S, Donahue MJ, Jordan LC. Elevated brain oxygen extraction fraction in preterm newborns with anemia measured using noninvasive MRI. J Perinatol 2018; 38:1636-1643. [PMID: 30254332 DOI: 10.1038/s41372-018-0229-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 08/09/2018] [Accepted: 08/21/2018] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To test the hypothesis that cerebral oxygen extraction fraction (OEF) is elevated and inversely related to hematocrit level in anemic former very-low-birth-weight infants near term. STUDY DESIGN Prospective study of non-sedated preterm infants (post-menstrual age = 36 ± 2 weeks) over a range of hematocrits (0.23-0.49). Anatomical (T1-W, T2-W, and diffusion-weighted), cerebral blood flow (CBF), and OEF 3-T MRI were utilized. Statistical analysis included Spearman's rank-order correlation testing between study variables and intraclass correlation coefficients (ICC) calculated between consecutively acquired OEF scans. RESULTS Consecutive OEF measurements showed moderate-to-good agreement (ICC = 0.71; 95% CI = 0.40-0.87). OEF increased with worsening anemia (ρ = -0.58; p = 0.005), and OEF and basal ganglia CBF were positively correlated (ρ = 0.49; p = 0.023). CONCLUSION Noninvasive OEF MRI has moderate-to-good repeatability in non-sedated former preterm infants nearing term-equivalent age. Strong correlation of elevated OEF with anemia suggests hemodynamic compensation for anemia and could establish OEF as a useful biomarker of transfusion threshold for preterm infants.
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Affiliation(s)
- Emily A Morris
- Department of Pediatrics, Division of Neonatology, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Meher R Juttukonda
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Chelsea A Lee
- Department of Pediatrics, Division of Pediatric Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Niral J Patel
- Department of Pediatrics, Division of Pediatric Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sumit Pruthi
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Manus J Donahue
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Psychiatry, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Physics and Astronomy, Vanderbilt University, Nashville, TN, USA
| | - Lori C Jordan
- Department of Pediatrics, Division of Pediatric Neurology, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
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25
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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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26
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Bukiya AN, Dopico AM. Fetal Cerebral Circulation as Target of Maternal Alcohol Consumption. Alcohol Clin Exp Res 2018; 42:1006-1018. [PMID: 29672868 PMCID: PMC5984173 DOI: 10.1111/acer.13755] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 04/08/2018] [Indexed: 12/29/2022]
Abstract
Alcohol (ethanol [EtOH]) is one of the most widely used psychoactive substances worldwide. Alcohol consumption during pregnancy may result in a wide range of morphological and neurodevelopmental abnormalities termed fetal alcohol spectrum disorders (FASD), with the most severe cases diagnosed as fetal alcohol syndrome (FAS). FAS and FASD are not readily curable and currently represent the leading preventable causes of birth defect and neurodevelopmental delay in the United States. The etiology of FAS/FASD remains poorly understood. This review focuses on the effects of prenatal alcohol exposure (PAE) on fetal cerebrovascular function. A brief introduction to the epidemiology of alcohol consumption and the developmental characteristics of fetal cerebral circulation is followed by several sections that discuss current evidence documenting alcohol-driven alterations of fetal cerebral blood flow, artery function, and microvessel networks. The material offers mechanistic insights at the vascular level itself into the pathophysiology of PAE.
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Affiliation(s)
- Anna N Bukiya
- Department of Pharmacology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Alex M Dopico
- Department of Pharmacology, University of Tennessee Health Science Center, Memphis, Tennessee
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27
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Simakova M, Tobiasz A, Sullivan RD, Bisen S, Duncan J, Sullivan JP, Davison S, Tate DL, Barnett S, Mari G, Dopico AM, Bukiya AN. Gestational Age-Dependent Interplay between Endocannabinoid Receptors and Alcohol in Fetal Cerebral Arteries. ACTA ACUST UNITED AC 2018; 8. [PMID: 31057979 PMCID: PMC6497414 DOI: 10.4303/jdar/236068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Alcohol (ethanol) is one of the most widely consumed drugs. Alcohol consumption by pregnant women may result in a range of fetal abnormalities termed fetal alcohol spectrum disorders (FASDs). The cerebrovascular system is emerging as a critical target of alcohol in the developing brain. We recently showed that three episodes of prenatal alcohol exposure resulting in 80 mg/dL alcohol in maternal blood during mid-pregnancy up-regulated anandamide-induced dilation of fetal cerebral arteries. Moreover, ethanol dilated fetal cerebral arteries via cannabinoid (CB) receptors. Whether a critical role of fetal cerebral artery CB system in responses to alcohol was maintained throughout the gestation, remains unknow.
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Affiliation(s)
- Maria Simakova
- Department of Pharmacology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Ana Tobiasz
- Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Ryan D Sullivan
- Department of Comparative Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Shivantika Bisen
- Department of Pharmacology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Jose Duncan
- Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - J Pierce Sullivan
- Department of Comparative Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Steven Davison
- Department of Comparative Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Danielle L Tate
- Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Stacey Barnett
- Department of Comparative Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Giancarlo Mari
- Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Alex M Dopico
- Department of Pharmacology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Anna N Bukiya
- Department of Pharmacology, University of Tennessee Health Science Center, Memphis, TN, USA
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28
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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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29
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Best practices for our most delicate patients. J Clin Anesth 2017; 39:87-88. [PMID: 28494916 DOI: 10.1016/j.jclinane.2017.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 03/02/2017] [Indexed: 11/23/2022]
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30
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Szpecht D, Gadzinowski J, Seremak-Mrozikiewicz A, Kurzawińska G, Szymankiewicz M. Role of endothelial nitric oxide synthase and endothelin-1 polymorphism genes with the pathogenesis of intraventricular hemorrhage in preterm infants. Sci Rep 2017; 7:42541. [PMID: 28211916 PMCID: PMC5304177 DOI: 10.1038/srep42541] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 01/09/2017] [Indexed: 12/20/2022] Open
Abstract
In the pathogenesis of neonatal intraventricular hemorrhage (IVH) in preterm infants, an important role is played by changes in venous and arterial cerebral flows. It has been shown that the ability of autoregulation of cerebral flows in response to variations in arterial blood pressure in preterm infants is impaired. This impaired autoregulation causes an increased risk of germinal matrix rupture and IVH occurrence. We examined three polymorphisms of genes, related to regulation of blood flow, for an association with IVH in 100 preterm infants born from singleton pregnancy, before 32 + 0 weeks of gestation, exposed to antenatal steroids therapy, and without congenital abnormalities. These polymorphisms include: eNOS (894G > T and -786T > C) and EDN1 (5665G > T ) gene. We found that infants with genotype GT eNOS 894G > T have 3.4-fold higher risk developing of IVH born before 28 + 6 weeks of gestation. Our investigation did not confirm any significant prevalence for IVH development according to eNOS -786T > C genes polymorphism. Our novel investigations in EDN1 5665G > T polymorphism did not show any link between alleles or genotypes and IVH. Future investigations of polymorphisms in blood-flow associated genes may provide valuable insight into the pathogenetic mechanisms underlying the development of IVH.
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Affiliation(s)
- Dawid Szpecht
- Chair and Department of Neonatology, Poznan University of Medical Sciences, Poland
| | - Janusz Gadzinowski
- Chair and Department of Neonatology, Poznan University of Medical Sciences, Poland
| | | | - Grażyna Kurzawińska
- Department of Perinatology and Women’s Diseases, Poznan University of Medical Sciences, Poznan, Poland
| | - Marta Szymankiewicz
- Chair and Department of Neonatology, Poznan University of Medical Sciences, Poland
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31
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Li XF, Cheng TT, Guan RL, Liang H, Lu WN, Zhang JH, Liu MY, Yu X, Liang J, Sun L, Zhang L. Effects of different surfactant administrations on cerebral autoregulation in preterm infants with respiratory distress syndrome. ACTA ACUST UNITED AC 2016; 36:801-805. [DOI: 10.1007/s11596-016-1665-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 06/29/2016] [Indexed: 10/18/2022]
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32
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Sottas CE, Cumin D, Anderson BJ. Blood pressure and heart rates in neonates and preschool children: an analysis from 10 years of electronic recording. Paediatr Anaesth 2016; 26:1064-1070. [PMID: 27515457 DOI: 10.1111/pan.12987] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/11/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND An acceptable systolic or mean arterial blood pressure for children 0-6 years during anesthesia is unknown. Accepted blood pressures reported in standard charts for healthy awake children may not apply to those undergoing anesthesia. AIM Our goal was to define observed blood pressures (BP) and heart rate (HR) in children 0-5 years during anesthesia. METHODS Data from the electronic health record database were available for a 10-year period from June 29, 2005 to July 22, 2015. A simple band-pass filter was applied to remove artifact in the physiologic time-series data for heart rate and blood pressure, with heart rate values 40 or above 250, mean or diastolic blood pressures below 20 or above 200, and systolic blood pressures below 30 or above 200 all excluded. For each anesthetic, the centiles of physiological variables (BP, HR) were calculated. RESULTS Data were available for 54 896 anesthetics in children 6 years and younger. There were 898 anesthesia reports available that included blood pressure measures immediately before induction. A larger number of anesthesia records (n = 30 008) were available for intraoperative blood pressure recording. The BP decrease after anesthesia induction was most pronounced in infants 0-10 weeks of age where there was a mean arterial blood pressure (MAP) decrease of 16.6-34.5% (mean 28.6%). Systolic blood pressure decreased by 16.3-32.6% (mean 25.5%). Values above a systolic blood pressure of 60 mm Hg were only noted in half the neonates during anesthesia. Heart rates, both before and after anesthesia induction, were similar. CONCLUSION Heart rate while under anesthesia appears a poor indicator for blood pressure changes. Recorded blood pressures in this current study, measured immediately before induction, were consistent with those in the literature. A mean MAP decrease of 28.6% was typical in those infants 0-10 weeks of age.
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Affiliation(s)
- Cedric E Sottas
- Paediatric Anaesthesia Department, Auckland Children's Hospital, Auckland, New Zealand
| | - David Cumin
- Department of Anaesthesiology, Auckland University, Auckland, New Zealand
| | - Brian J Anderson
- Paediatric Anaesthesia Department, Auckland Children's Hospital, Auckland, New Zealand. .,Department of Anaesthesiology, Auckland University, Auckland, New Zealand.
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33
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Razlevice I, Rugyte DC, Strumylaite L, Macas A. Assessment of risk factors for cerebral oxygen desaturation during neonatal and infant general anesthesia: an observational, prospective study. BMC Anesthesiol 2016; 16:107. [PMID: 27793105 PMCID: PMC5086037 DOI: 10.1186/s12871-016-0274-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 10/20/2016] [Indexed: 12/03/2022] Open
Abstract
Background Cerebral oxygen saturation (rSO2c) decrease from baseline greater than 20 % during infant cardiac surgery was associated with postoperative neurologic changes and neurodevelopmental impairment at 1 year of age. So far, there is no sufficient evidence to support the routine monitoring of rSO2c during general surgical procedures in children. We aimed to find out the frequency of cerebral desaturation 20 % or more from baseline and to identify possible predictors of change in cerebral oxygen saturation during neonatal and infant general surgery. Methods Forty-four infants up to 3 months of age were recruited. Before induction of anesthesia, two pediatric cerebral sensors were placed bilaterally to the forehead region and monitoring of regional cerebral saturation of oxygen was started and continued throughout the surgery. Simultaneously, mean arterial blood pressure (MAP), pulse oximetry (SpO2), heart rate (HR), endtidal CO2, expired fraction of sevoflurane and rectal temperature were recorded. The main outcome measure was rSO2c value drop-off ≥20 % from baseline. Mann-Whitney U-test, chi-squared test, simple and multiple linear regression models were used for statistical analysis. Results Forty-three infants were analyzed. Drop-off ≥20 % in rSO2c from baseline occurred in 8 (18.6 %) patients. There were no differences in basal rSO2c, SpO2, HR, endtidal CO2, expired fraction of sevoflurane and rectal temperature between patients with and without desaturation 20 % or more from baseline. But the two groups differed with regard to gestation, preoperative mechanical ventilation and the use of vasoactive medications and red blood cell transfusions during surgery. Simple linear regression model showed, that gestation, age, preoperative mechanical ventilation and mean arterial pressure corresponding to minimal rSO2c value during anesthesia (MAPminrSO2c) were associated with a change in rSO2c values. Multiple regression model including all above mentioned variables, revealed that only MAPminrSO2c was predictive for a change in rSO2c values (β (95 % confidence interval) -0.28 (−0.52–(−0.04)) p = 0.02). Conclusions Cerebral oxygen desaturation ≥20 % from baseline occurred in almost one fifth of patients. Although different perioperative factors can predispose to cerebral oxygenation changes, arterial blood pressure seems to be the most important. Gestation as another possible risk factor needs further investigation. Trial registration The international registration number NCT02423369. Retrospectively registered on April 2015. Electronic supplementary material The online version of this article (doi:10.1186/s12871-016-0274-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ilona Razlevice
- Department of Anesthesiology, Lithuanian University of Health Sciences, Eiveniu str. 2, Kaunas, LT-50009, Lithuania.
| | - Danguole C Rugyte
- Department of Anesthesiology, Lithuanian University of Health Sciences, Eiveniu str. 2, Kaunas, LT-50009, Lithuania
| | - Loreta Strumylaite
- Neuroscience Institute, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Andrius Macas
- Department of Anesthesiology, Lithuanian University of Health Sciences, Eiveniu str. 2, Kaunas, LT-50009, Lithuania
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Weber F, Honing GHM, Scoones GP. Arterial blood pressure in anesthetized neonates and infants: a retrospective analysis of 1091 cases. Paediatr Anaesth 2016; 26:815-22. [PMID: 27218872 DOI: 10.1111/pan.12924] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/13/2016] [Indexed: 12/01/2022]
Abstract
BACKGROUND Hypotension during general anesthesia in neonates and infants is considered to contribute to poor neurological outcome. AIM The aim of this retrospective analysis was to determine the incidence of hypotension after induction of anesthesia and sustained hypotension (>10 min) during the anesthesia, and to determine factors contributing to the development of (sustained) hypotension. METHOD We performed a retrospective analysis of 1091 electronic anesthesia records from children <1 year. Patients were stratified for age (group 1: <1 month, group 2: 1-3 months, group 3: 4-6 months, group 4: >6 months). Hypotension was defined as a mean arterial pressure (MAP) <35 mmHg in patients ≤6 months and <43 mmHg in patients >6 months. RESULTS The incidence of hypotension after induction was highest in group 1 (25.5%) [P = 0.009 vs group 2 (13.3%), P < 0.0001 vs groups 3 (3.4%) and 4 (1.0%)], in group 2, it was higher than in groups 3 and 4 (P < 0.0001), and in group 3, it was higher than in group 4 (P = 0.033). The incidence of sustained hypotension was highest in group 1 (43.6%) (P < 0.0001 vs groups 2-4), followed by group 2 (15.7%) [P < 0.0001 vs group 3 (3.4%) and P = 0.006 vs group 4 (8.8%)] and group 4 (P = 0.004 vs group 3). Hypotension after induction occurred more often in emergency procedures than in elective procedures in groups 1 (P = 0.002), 2 (P = 0.029), and 3 (P = 0.037). CONCLUSION Hypotension, both postinduction and sustained during surgery, is a common phenomenon in anesthetized children under 1 year, peaking in neonates. Generally accepted lower limits of MAP in anesthetized infants urgently need to be defined, enabling us to develop anesthesia strategies avoiding cerebral hypoperfusion.
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Affiliation(s)
- Frank Weber
- Department of Anaesthesia, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Gijsbert H M Honing
- Department of Anaesthesia, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Gail P Scoones
- Department of Anaesthesia, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands
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35
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Visram AR. Intraoperative fluid therapy in neonates. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2016. [DOI: 10.1080/22201181.2016.1140705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Use of near-infrared spectroscopy in predicting response to intravenous fluid load in anaesthetized infants. Anaesth Crit Care Pain Med 2015; 34:265-70. [DOI: 10.1016/j.accpm.2015.06.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Accepted: 06/11/2015] [Indexed: 11/23/2022]
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Donnelly J, Aries MJ, Czosnyka M. Further understanding of cerebral autoregulation at the bedside: possible implications for future therapy. Expert Rev Neurother 2015; 15:169-85. [PMID: 25614952 DOI: 10.1586/14737175.2015.996552] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Cerebral autoregulation reflects the ability of the brain to keep the cerebral blood flow (CBF) relatively constant despite changes in cerebral perfusion pressure. It is an intrinsic neuroprotective physiological phenomenon often suggested as part of pathophysiological pathways in brain research. However, despite increasing knowledge of this phenomenon for over 50 years, harnessing cerebral autoregulation as a basis for therapy remains an elegant concept rather than a practical reality. This raises the question is it useful to measure at the bedside or is it merely a scientific curiosity that is too complex and has little pragmatic relevance. In this article, we attempt to answer this question by demonstrating how cerebral autoregulation assessment can have prognostic value, indicate pathological states, and potentially even influence therapy with the use of the 'optimal cerebral perfusion pressure' paradigm. Evidence from the literature is combined with bedside clinical examples to address the following fundamental questions about cerebral autoregulation: What is it? How do we measure it? Why is it important? Can we use it as a basis for therapy?
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Affiliation(s)
- Joseph Donnelly
- Department of Clinical Neurosciences, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Hills Road, Cambridge, CB2 0QQ, UK
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Michelet D, Arslan O, Hilly J, Mangalsuren N, Brasher C, Grace R, Bonnard A, Malbezin S, Nivoche Y, Dahmani S. Intraoperative changes in blood pressure associated with cerebral desaturation in infants. Paediatr Anaesth 2015; 25:681-8. [PMID: 25929346 DOI: 10.1111/pan.12671] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/02/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Intraoperative hypotension has been linked to poor postoperative neurological outcomes. However, the definition of hypotension remains controversial in children. We sought to determine arterial blood pressure threshold values associated with cerebral desaturation in infants. METHODS After ethics committee approval, infants younger than 3 months were included in this prospective observational study. Cerebral saturation was assessed using near-infrared spectroscopy. The primary goal of the study was to determine percentage reductions in intraoperative systolic blood pressure (SBP) and mean blood pressure (MBP) associated with decreases in cerebral blood oxygen saturation of >20%, when compared to baseline. Analyses were performed using a bootstrap receiving operator characteristic (ROC) curves with determination of the gray zone. RESULTS Sixty patients were recruited and 960 measurement points were recorded. Fifty-nine data points (6.1%) recorded cerebral desaturation of >20% when compared to baseline. The areas under the ROC curves were 0.79 (0.74-0.84) and 0.67 (0.6-0.75) for percentage decreases in SBP and MBP, respectively. Gray zone values with false-positive and negative rates <10% were SBP decreases of 20.5% and 37.5%, respectively, and MBP decreases of 15.5% and 44.5%, respectively. CONCLUSION Our results indicate that falls in noninvasive systolic blood pressure of <20% from baseline are associated with a <10% chance of cerebral desaturation in neonates and infants <3 months of age undergoing noncardiac surgery. As such, maintaining systolic blood pressure above this threshold value appears a valid clinical target.
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Affiliation(s)
- Daphné Michelet
- Department of Anesthesia, Intensive Care and Pain Management, AP-HP, Robert Debré University Hospital, Paris, France.,Paris Diderot University (Paris VII), Pres Paris Sorbonne Cité, Paris, France
| | - Ozkan Arslan
- Department of Anesthesia, Intensive Care and Pain Management, AP-HP, Robert Debré University Hospital, Paris, France.,Paris Diderot University (Paris VII), Pres Paris Sorbonne Cité, Paris, France
| | - Julie Hilly
- Department of Anesthesia, Intensive Care and Pain Management, AP-HP, Robert Debré University Hospital, Paris, France.,Paris Diderot University (Paris VII), Pres Paris Sorbonne Cité, Paris, France
| | - Nyamjargal Mangalsuren
- Department of Anesthesia, Intensive Care and Pain Management, AP-HP, Robert Debré University Hospital, Paris, France.,Paris Diderot University (Paris VII), Pres Paris Sorbonne Cité, Paris, France
| | - Christopher Brasher
- Department of Anesthesia, Intensive Care and Pain Management, AP-HP, Robert Debré University Hospital, Paris, France.,Paris Diderot University (Paris VII), Pres Paris Sorbonne Cité, Paris, France
| | - Robert Grace
- Department of Anesthesia, Intensive Care and Peri-operative Medicine, Cairns Hospital, Cairns, Qld, Australia
| | - Arnaud Bonnard
- Paris Diderot University (Paris VII), Pres Paris Sorbonne Cité, Paris, France.,Department of General and Urological Surgery, AP-HP, Robert Debré University Hospital, Paris Diderot University, Paris, France
| | - Serge Malbezin
- Department of Anesthesia, Intensive Care and Pain Management, AP-HP, Robert Debré University Hospital, Paris, France.,Paris Diderot University (Paris VII), Pres Paris Sorbonne Cité, Paris, France
| | - Yves Nivoche
- Department of Anesthesia, Intensive Care and Pain Management, AP-HP, Robert Debré University Hospital, Paris, France.,Paris Diderot University (Paris VII), Pres Paris Sorbonne Cité, Paris, France
| | - Souhayl Dahmani
- Department of Anesthesia, Intensive Care and Pain Management, AP-HP, Robert Debré University Hospital, Paris, France.,Paris Diderot University (Paris VII), Pres Paris Sorbonne Cité, Paris, France.,Department of Anesthesia, Intensive Care and Peri-operative Medicine, Cairns Hospital, Cairns, Qld, Australia.,University and Hospital Department PROTECT, Robert Debré University Hospital, Paris, France
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Abstract
As in adult anesthesia, morbidity and mortality could be significantly reduced in pediatric anesthesia in recent decades. This fact cannot conceal the fact that the incidence of anesthetic complications in children is still much more common than in adults and sometimes with a severe outcome. Newborns and infants in particular but also children with emergency interventions and severe comorbidities are at increased risk of potential complications. Typical complications in pediatric anesthesia are respiratory problems, medication errors, difficulties with the intravenous puncture and pulmonal aspiration. In the postoperative setting, nausea and vomiting, pain, and emergence delirium can be mentioned as typical complications. In addition to the systematic prevention of complications in pediatric anesthesia, it is important to quickly recognize disturbances of homeostasis and treat them promptly and appropriately. In addition to the expertise of the performing anesthesia team, the institutional structure in particular can improve quality and safety in pediatric anesthesia.
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Affiliation(s)
- K Becke
- Abteilung für Anästhesie und Intensivmedizin, Klinik Hallerwiese/Cnopf'sche Kinderklinik, Diakonie Neuendettelsau, St. Johannis-Mühlgasse 19, 90419, Nürnberg, Deutschland,
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Rhondali O, André C, Pouyau A, Mahr A, Juhel S, De Queiroz M, Rhzioual-Berrada K, Mathews S, Chassard D. Sevoflurane anesthesia and brain perfusion. Paediatr Anaesth 2015; 25:180-5. [PMID: 25224780 DOI: 10.1111/pan.12512] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/27/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVE/AIM To assess the impact of sevoflurane and anesthesia-induced hypotension on brain perfusion in children younger than 6 months. BACKGROUND Safe lower limit of blood pressure during anesthesia in infant is unclear, and inadequate anesthesia can lead to hypotension, hypocapnia, and low cerebral perfusion. Insufficient cerebral perfusion in infant during anesthesia is an important factor of neurological morbidity. In two previous studies, we assessed the impact of sevoflurane anesthesia on cerebral blood flow (CBF) by transcranial Doppler (TCD) and on brain oxygenation by NIRS, in children ≤2 years. As knowledge about consequences of anesthesia-induced hypotension on cerebral perfusion in children ≤6 months is scarce, we conducted a retrospective analysis to compare the data of CBF and brain oxygenation, in this specific population. METHODS We performed a retrospective analysis of data collected from our two previous studies. Baseline values of TCD or NIRS were recorded and then during sevoflurane anesthesia. From a database of 338 patients, we excluded all patients older than 6 months. Then, we compared physiological variables of TCD and NIRS population to ensure that the two groups were comparable. We compared rSO2 c and TCD measurements variation according to MAP value during sevoflurane anesthesia, using anova and Student-Newman-Keuls for posthoc analysis. RESULTS One hundred and eighty patients were included in the analysis. TCD and NIRS groups were comparable. CBF velocities (CBFV) or rSO2 c reflects a good cerebral perfusion when MAP is above 45 mmHg. When MAP is between 35 and 45 mmHg, CBFV variation reflects a reduction of CBF, but rSO2 c increase is the consequence of a still positive balance between CMRO2 and O2 supply. Below 35 mmHg of MAP during anesthesia, CBFV decrease and rSO2 c variation from baseline is low. For each category of MAP and for the two groups, etCo2 and expired fraction of sevoflurane (FeSevo) were comparable (anova P > 0.05). CONCLUSION In a healthy infant without dehydration, with normal PaCO2 and hemoglobin value, scheduled for short procedures, MAP is a good proxy of cerebral perfusion as we found that CBF assessed by CBFV and rSO2 c decreased proportionally with cerebral perfusion pressure. During 1 MAC sevoflurane anesthesia, maintaining MAP beyond 35 mmHg during anesthesia is probably safe and sufficient. But when MAP decreases below 35 mmHg, CBF decreases and rSO2 c variation from baseline is low despite CMRO2 reduction. In this situation, cerebral metabolic reserve is low and further changes of systemic conditions may be poorly tolerated by the brain.
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Affiliation(s)
- Ossam Rhondali
- Department of Pediatric Anesthesia, Hôpital Mère-Enfant, Lyon, France; Department of Pediatric Anesthesia, Hôpital Sainte Justine, Montréal, QC, Canada
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42
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Wolf AR. Through the glass darkly: searching for safety signals in physiological monitoring. Paediatr Anaesth 2015; 25:107-10. [PMID: 25308876 DOI: 10.1111/pan.12556] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/17/2014] [Indexed: 11/28/2022]
Abstract
Perioperative monitoring of ventilation, gas exchange, heart rate, blood pressure, and other basic physiological measures give important information on the well-being of the child in the perioperative period. However, despite this level of surveillance, perioperative events that appear to be unheralded still occur. Improvements in alarms and alarm design combined with integrated analysis of monitored parameters that map to adverse outcomes may provide earlier warning of potential danger. Near real-time analysis of heart rate and blood pressure variability can provide information on autonomic function and cardiac reserve, while devices such as tissue oximetry may be beneficial to optimize regional and global blood flow.
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Affiliation(s)
- Andrew R Wolf
- Centre for Structural and Congenital Heart Disease, Rush University Medical Centre, Chicago, IL, USA
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Rhondali O, Juhel S, Mathews S, Cellier Q, Desgranges FP, Mahr A, De Queiroz M, Pouyau A, Rhzioual-Berrada K, Chassard D. Impact of sevoflurane anesthesia on brain oxygenation in children younger than 2 years. Paediatr Anaesth 2014; 24:734-40. [PMID: 24697984 DOI: 10.1111/pan.12397] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/04/2014] [Indexed: 12/01/2022]
Abstract
OBJECTIVE/AIM To assess the impact of sevoflurane and anesthesia-induced hypotension on brain oxygenation in children younger than 2 years. BACKGROUND Inhalational induction with sevoflurane is the most commonly used technique in young children. However, the effect of sevoflurane on cerebral perfusion has been only studied in adults and children older than 1 year. The purpose of this study was to assess the impact of sevoflurane anesthesia on brain oxygenation in neonates and infants, using near-infrared spectroscopy. METHODS Children younger than 2 years, ASA I or II, scheduled for abdominal or orthopedic surgery were included. Induction of anesthesia was started by sevoflurane 6% and maintained with an expired fraction of sevoflurane 3%. Mechanical ventilation was adjusted to maintain an endtidal CO2 around 39 mmHg. Brain oxygenation was assessed measuring regional cerebral saturation of oxygen (rSO2 c), measured by NIRS while awake and 15 min after induction, under anesthesia. Mean arterial pressure (MAP) variation was recorded. RESULTS Hundred and ninety-five children were included. Anesthesia induced a significant decrease in MAP (-27%). rSO2 c increased significantly after induction (+18%). Using children age for subgroup analysis, we found that despite MAP reduction, rSO2 c increase was significant but smaller in children ≤ 6 months than in children >6 months (≤ 6 months: rSO2 c = +13%, >6 months: rSO2 c = +22%; P < 0.0001). Interindividual comparison showed that, during anesthesia at steady-state with comparable CMRO2, rSO2 c values were significantly higher when MAP was above 36 mmHg. And the higher the absolute MAP value during anesthesia was, the higher the rSO2 c was. We observed a rSO2 c variation ≤ 0 in 21 patients among the 195 studied, and the majority of these patients were younger than 6 months (n = 19). No increase or decrease of rSO2 c during anesthesia despite reduction of CMRO2 can be explained by a reduction of oxygen supply. Using the ROC curves, we determined that the threshold value of MAP under anesthesia, associated with rSO2 c variation ≤ 0%, was 39 mmHg in all the studied population (AUC: 0.90 ± 0.02; P < 0.001). In children younger than 6 months, this value of MAP was 33 mmHg, and 43 mmHg in children older than 6 months. CONCLUSION Despite a significant decrease of MAP, 1 MAC of sevoflurane induced a significant increase in regional brain oxygenation. But subgroup analysis showed that MAP decrease had a greater impact on brain oxygenation, in children younger than 6 months. According to our results, MAP value during anesthesia should not go under 33 mmHg in children ≤6 months and 43 mmHg in children >6 months, as further changes in MAP, PaCO2 or hemoglobin during anesthesia may be poorly tolerated by the brain.
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Affiliation(s)
- Ossam Rhondali
- Department of Pediatric Anesthesia, Hôpital Mère-Enfant, Lyon, France; Department of Pediatric Anesthesia, Hôpital Sainte Justine, Montréal, QC, Canada
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