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Fedriga M, Martini S, Iodice FG, Sortica da Costa C, Pezzato S, Moscatelli A, Beqiri E, Czosnyka M, Smielewski P, Agrawal S. Cerebral autoregulation in paediatric and neonatal intensive care: A scoping review. J Cereb Blood Flow Metab 2024:271678X241261944. [PMID: 38867574 DOI: 10.1177/0271678x241261944] [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: 06/14/2024]
Abstract
Deranged cerebral autoregulation (CA) is associated with worse outcome in adult brain injury. Strategies for monitoring CA and maintaining the brain at its 'best CA status' have been implemented, however, this approach has not yet developed for the paediatric population. This scoping review aims to find up-to-date evidence on CA assessment in children and neonates with a view to identify patient categories in which CA has been measured so far, CA monitoring methods and its relationship with clinical outcome if any. A literature search was conducted for studies published within 31st December 2022 in 3 bibliographic databases. Out of 494 papers screened, this review includes 135 studies. Our literature search reveals evidence for CA measurement in the paediatric population across different diagnostic categories and age groups. The techniques adopted, indices and thresholds used to assess and define CA are heterogeneous. We discuss the relevance of available evidence for CA assessment in the paediatric population. However, due to small number of studies and heterogeneity of methods used, there is no conclusive evidence to support universal adoption of CA monitoring, technique, and methodology. This calls for further work to understand the clinical impact of CA monitoring in paediatric and neonatal intensive care.
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Affiliation(s)
- Marta Fedriga
- Neonatal and Paediatric Intensive Care Unit, IRCCS Giannina Gaslini Institute, Genoa, Italy
| | - Silvia Martini
- Neonatal Intensive Care Unit, IRCCS AOUBO, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Francesca G Iodice
- Paediatric Cardiac Anaesthesia and Intensive Care Unit, IRCCS, Bambino Gesu' Hospital, Rome, Italy
| | | | - Stefano Pezzato
- Neonatal and Paediatric Intensive Care Unit, IRCCS Giannina Gaslini Institute, Genoa, Italy
| | - Andrea Moscatelli
- Neonatal and Paediatric Intensive Care Unit, IRCCS Giannina Gaslini Institute, Genoa, Italy
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
| | - Shruti Agrawal
- Department of Paediatric Intensive Care, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
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2
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Guo ZN, Jin H, Sun H, Zhao Y, Liu J, Ma H, Sun X, Yang Y. Antioxidant Melatonin: Potential Functions in Improving Cerebral Autoregulation After Subarachnoid Hemorrhage. Front Physiol 2018; 9:1146. [PMID: 30174621 PMCID: PMC6108098 DOI: 10.3389/fphys.2018.01146] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Accepted: 07/30/2018] [Indexed: 12/30/2022] Open
Abstract
Subarachnoid hemorrhage (SAH) is a subtype of stroke with high mortality and morbidity. Impaired cerebral autoregulation following SAH has been reported owing to effects on sympathetic control, endothelial function, myogenic response, and cerebral metabolism. Impaired cerebral autoregulation is associated with early brain injury, cerebral vasospasm/delayed cerebral ischemia, and SAH prognosis. However, few drugs have been reported to improve cerebral autoregulation after SAH. Melatonin is a powerful antioxidant that is effective (easily crosses the blood brain barrier) and safe (tolerated in large doses without toxicity). Theoretically, melatonin may impact the control mechanisms of cerebral autoregulation via antioxidative effects, protection of endothelial cell integrity, suppression of sympathetic nerve activity, increase in nitric oxide bioavailability, mediation of the myogenic response, and amelioration of hypoxemia. Furthermore, melatonin may have a comprehensive effect on cerebral autoregulation. This review discusses the potential effects of melatonin on cerebral autoregulation following SAH, in terms of the association between pharmacological activities and the mechanisms of cerebral autoregulation.
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Affiliation(s)
- Zhen-Ni Guo
- Department of Neurology, The First Hospital of Jilin University, Changchun, China.,Clinical Trial and Research Center for Stroke, Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Hang Jin
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Huijie Sun
- Cadre Ward, The First Hospital of Jilin University, Changchun, China
| | - Yingkai Zhao
- Cadre Ward, The First Hospital of Jilin University, Changchun, China
| | - Jia Liu
- Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Hongyin Ma
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Xin Sun
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Yi Yang
- Department of Neurology, The First Hospital of Jilin University, Changchun, China.,Clinical Trial and Research Center for Stroke, Department of Neurology, The First Hospital of Jilin University, Changchun, China
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3
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Habli M, Clifford CC, Brady TM, Rodriguez Z, Eschenbacher M, Wu M, DeFranco E, Gresh J, Kamath-Rayne BD. Antenatal exposure to nonsteroidal anti-inflammatory drugs and risk of neonatal hypertension. J Clin Hypertens (Greenwich) 2018; 20:1334-1341. [PMID: 30051971 DOI: 10.1111/jch.13354] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 05/19/2018] [Accepted: 06/07/2018] [Indexed: 11/28/2022]
Abstract
Nonsteroidal anti-inflammatory drugs (NSAIDs) are used as tocolytics, which are medications that suppress uterine contractions for preterm birth prevention. Their effect on cerebral/systemic vascular beds poses the question of whether antenatal NSAID exposure is associated with neonatal hypertension. We performed a retrospective case-control study in a tertiary neonatal intensive care unit, including 40 hypertension cases (hospitalized neonates ≥ 35 weeks with systolic BP > 100 mm Hg on three consecutive days) compared to 134 controls matched by gestational age at delivery, plurality, and delivery date. Cases and controls were compared by antenatal NSAID exposure, other common tocolytics, and maternal/neonatal characteristics and complications. Multivariable logistic regression was used to estimate the odds of hypertension among those with prenatal exposure to NSAIDs versus those without exposure. Newborns with hypertension had a lower gestational age at delivery and increased incidence of neonatal complications, including respiratory distress syndrome, bronchopulmonary dysplasia, surfactant administration, longer duration of ventilation, and history of umbilical artery catheterization. Days of indomethacin exposure were positively associated with greater odds of neonatal hypertension (OR 1.17 [1.00 to 1.38], P = 0.055), even after adjustment for other factors associated with neonatal hypertension. Newborns with hypertension were less likely to have been exposed to calcium channel blockers as a tocolytic. The results of our study suggest an association between prenatal exposure to nonsteroidal anti-inflammatory drugs and neonatal hypertension. Furthermore, our data suggest that prenatal calcium channel blocker exposure may protect against the development of neonatal hypertension. Future multicenter studies are needed to understand the risks of tocolytics and subsequent consequences in preterm infants.
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Affiliation(s)
- Mounira Habli
- Maternal-Fetal Medicine, Good Samaritan Hospital, Cincinnati, Ohio.,Cincinnati Fetal Center, Cincinnati, Ohio
| | - Corey C Clifford
- Obstetrics/Gynecology, TriHealth Hospitals, Cincinnati, Ohio.,Obstetrics/Gynecology, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Tammy M Brady
- Pediatric Nephrology, Johns Hopkins University, Baltimore, Maryland
| | - Zahidee Rodriguez
- Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Malcolm Wu
- University of Cincinnati, Cincinnati, Ohio
| | - Emily DeFranco
- Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Maternal-Fetal Medicine, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | | | - Beena D Kamath-Rayne
- Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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4
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Thewissen L, Caicedo A, Lemmers P, Van Bel F, Van Huffel S, Naulaers G. Measuring Near-Infrared Spectroscopy Derived Cerebral Autoregulation in Neonates: From Research Tool Toward Bedside Multimodal Monitoring. Front Pediatr 2018; 6:117. [PMID: 29868521 PMCID: PMC5960703 DOI: 10.3389/fped.2018.00117] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 04/11/2018] [Indexed: 12/30/2022] Open
Abstract
Introduction: Cerebral autoregulation (CAR), the ability of the human body to maintain cerebral blood flow (CBF) in a wide range of perfusion pressures, can be calculated by describing the relation between arterial blood pressure (ABP) and cerebral oxygen saturation measured by near-infrared spectroscopy (NIRS). In literature, disturbed CAR is described in different patient groups, using multiple measurement techniques and mathematical models. Furthermore, it is unclear to what extent cerebral pathology and outcome can be explained by impaired CAR. Aim and methods: In order to summarize CAR studies using NIRS in neonates, a systematic review was performed in the PUBMED and EMBASE database. To provide a general overview of the clinical framework used to study CAR, the different preprocessing methods and mathematical models are described and explained. Furthermore, patient characteristics, definition of impaired CAR and the outcome according to this definition is described organized for the different patient groups. Results: Forty-six articles were included in this review. Four patient groups were established: preterm infants during the transitional period, neonates receiving specific medication/treatment, neonates with congenital heart disease and neonates with hypoxic-ischemic encephalopathy (HIE) treated with therapeutic hypothermia. Correlation, coherence and transfer function (TF) gain are the mathematical models most frequently used to describe CAR. The definition of impaired CAR is depending on the mathematical model used. The incidence of intraventricular hemorrhage in preterm infants is the outcome variable most frequently correlated with impaired CAR. Hypotension, disease severity, dopamine treatment, injury on magnetic resonance imaging (MRI) and long term outcome are associated with impaired CAR. Prospective interventional studies are lacking in all research areas. Discussion and conclusion: NIRS derived CAR measurement is an important research tool to improve knowledge about central hemodynamic fluctuations during the transitional period, cerebral pharmacodynamics of frequently used medication (sedatives-inotropes) and cerebral effects of specific therapies in neonatology. Uniformity regarding measurement techniques and mathematical models is needed. Multimodal monitoring databases of neonatal intensive care patients of multiple centers, together with identical outcome parameters are needed to compare different techniques and make progress in this field. Real-time bedside monitoring of CAR, together with conventional monitoring, seems a promising technique to improve individual patient care.
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Affiliation(s)
- Liesbeth Thewissen
- Department of Neonatology, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Alexander Caicedo
- Department of Electrical Engineering, ESAT-Stadius, KU Leuven, Leuven, Belgium.,Interuniversity Microelectronics Centre, Leuven, Belgium
| | - Petra Lemmers
- Department of Neonatology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Frank Van Bel
- Department of Neonatology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Sabine Van Huffel
- Department of Electrical Engineering, ESAT-Stadius, KU Leuven, Leuven, Belgium.,Interuniversity Microelectronics Centre, Leuven, Belgium
| | - Gunnar Naulaers
- Department of Neonatology, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
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Kooi EMW, Verhagen EA, Elting JWJ, Czosnyka M, Austin T, Wong FY, Aries MJ. Measuring cerebrovascular autoregulation in preterm infants using near-infrared spectroscopy: an overview of the literature. Expert Rev Neurother 2017. [DOI: 10.1080/14737175.2017.1346472] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Elisabeth M. W. Kooi
- Beatrix Children’s Hospital, Division of Neonatology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Elise A. Verhagen
- Sophia Children’s Hospital, University of Rotterdam, Erasmus University Hospital, Rotterdam, The Netherlands
| | - Jan Willem J. Elting
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Marek Czosnyka
- Department of Academic Neurosurgery, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - Topun Austin
- Cambridge University Hospitals NHS Foundation Trust, Rosie Hospital, Cambridge, UK
| | - Flora Y. Wong
- Monash Newborn, Monash Medical Centre; Department of Paediatrics, Monash University; The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Australia
| | - Marcel J.H. Aries
- Department of Intensive Care, University of Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
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6
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Assessing cerebrovascular autoregulation in infants with necrotizing enterocolitis using near-infrared spectroscopy. Pediatr Res 2016; 79:76-80. [PMID: 26383883 DOI: 10.1038/pr.2015.184] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 07/15/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND We assessed cerebrovascular autoregulation (CAR) in preterm infants with definite necrotizing enterocolitis (NEC), Bell's stage 2 or 3, and infants without NEC, using near-infrared spectroscopy. We hypothesized that CAR would be more often impaired in infants with NEC compared with infants without NEC. METHODS We measured cerebral regional tissue oxygen saturation, arterial oxygen saturation, and mean arterial blood pressure (MABP) during 48 h. We calculated the correlation between cerebral fractional tissue oxygen extraction and MABP for each patient. A statistically significant negative correlation reflected impaired CAR. RESULTS We included 15 infants with definite NEC (median (range) gestational age 27.4 (25.6-34.7) wk; birth weight 1,070 (670-2,400) g) and 13 infants without NEC (gestational age 27.9 (26.3-34.7) wk; birth weight 980 (640-2,640) g). Fourteen infants had a statistically significant negative correlation (ρ -0.468 to-0.104), of whom five were infants without NEC (5/13; 38%) and nine with definite NEC (9/15; 60%). The difference in prevalence of impaired CAR was not statistically significant. CONCLUSION Impaired CAR is present in a substantial proportion of infants with definite NEC, which may predispose them to NEC-associated neurological damage.
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Burton VJ, Gerner G, Cristofalo E, Chung SE, Jennings JM, Parkinson C, Koehler RC, Chavez-Valdez R, Johnston MV, Northington FJ, Lee JK. A pilot cohort study of cerebral autoregulation and 2-year neurodevelopmental outcomes in neonates with hypoxic-ischemic encephalopathy who received therapeutic hypothermia. BMC Neurol 2015; 15:209. [PMID: 26486728 PMCID: PMC4618147 DOI: 10.1186/s12883-015-0464-4] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Accepted: 10/06/2015] [Indexed: 11/17/2022] Open
Abstract
Background Neurodevelopmental disabilities persist in survivors of neonatal hypoxic-ischemic encephalopathy (HIE) despite treatment with therapeutic hypothermia. Cerebrovascular autoregulation, the mechanism that maintains cerebral perfusion during changes in blood pressure, may influence outcomes. Our objective was to describe the relationship between acute autoregulatory vasoreactivity during treatment and neurodevelopmental outcomes at 2 years of age. Methods In a pilot study of 28 neonates with HIE, we measured cerebral autoregulatory vasoreactivity with the hemoglobin volume index (HVx) during therapeutic hypothermia, rewarming, and the first 6 h of normothermia. The HVx, which is derived from near-infrared spectroscopy, was used to identify the individual optimal mean arterial blood pressure (MAPOPT) at which autoregulatory vasoreactivity is greatest. Cognitive and motor neurodevelopmental evaluations were completed in 19 children at 21–32 months of age. MAPOPT, blood pressure in relation to MAPOPT, blood pressure below gestational age + 5 (ga + 5), and regional cerebral oximetry (rSO2) were compared to the neurodevelopmental outcomes. Results Nineteen children who had HIE and were treated with therapeutic hypothermia performed in the average range on cognitive and motor evaluations at 21–32 months of age, although the mean performance was lower than that of published normative samples. Children with impairments at the 2-year evaluation had higher MAPOPT values, spent more time with blood pressure below MAPOPT, and had greater blood pressure deviation below MAPOPT during rewarming in the neonatal period than those without impairments. Greater blood pressure deviation above MAPOPT during rewarming was associated with less disability and higher cognitive scores. No association was observed between rSO2 or blood pressure below ga + 5 and neurodevelopmental outcomes. Conclusion In this pilot cohort, motor and cognitive impairments at 21–32 months of age were associated with greater blood pressure deviation below MAPOPT during rewarming following therapeutic hypothermia, but not with rSO2 or blood pressure below ga + 5. This suggests that identifying individual neonates’ MAPOPT is superior to using hemodynamic goals based on gestational age or rSO2 in the acute management of neonatal HIE. Electronic supplementary material The online version of this article (doi:10.1186/s12883-015-0464-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Vera Joanna Burton
- Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, MD, USA. .,Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Department of Neurology and Developmental Medicine, Kennedy Krieger Institute, Johns Hopkins School of Medicine, 801 N Broadway, Baltimore, MD, 21205, USA.
| | - Gwendolyn Gerner
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Department of Neuropsychology, Kennedy Krieger Institute, Baltimore, MD, USA.
| | - Elizabeth Cristofalo
- Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, MD, USA. .,Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Shang-en Chung
- Center for Child and Community Health Research (CCHR), Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Jacky M Jennings
- Center for Child and Community Health Research (CCHR), Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Charlamaine Parkinson
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Raymond C Koehler
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Raul Chavez-Valdez
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Michael V Johnston
- Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, MD, USA. .,Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Hugo Moser Research Institute, Kennedy Krieger Institute, Baltimore, MD, USA.
| | - Frances J Northington
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Jennifer K Lee
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.
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8
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Burton VJ, Gerner G, Cristofalo E, Chung SE, Jennings JM, Parkinson C, Koehler RC, Chavez-Valdez R, Johnston MV, Northington FJ, Lee JK. A pilot cohort study of cerebral autoregulation and 2-year neurodevelopmental outcomes in neonates with hypoxic-ischemic encephalopathy who received therapeutic hypothermia. BMC Neurol 2015. [PMID: 26486728 DOI: 10.1186/s12883-015-0464-410.1186/s12883-015-0464-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023] Open
Abstract
BACKGROUND Neurodevelopmental disabilities persist in survivors of neonatal hypoxic-ischemic encephalopathy (HIE) despite treatment with therapeutic hypothermia. Cerebrovascular autoregulation, the mechanism that maintains cerebral perfusion during changes in blood pressure, may influence outcomes. Our objective was to describe the relationship between acute autoregulatory vasoreactivity during treatment and neurodevelopmental outcomes at 2 years of age. METHODS In a pilot study of 28 neonates with HIE, we measured cerebral autoregulatory vasoreactivity with the hemoglobin volume index (HVx) during therapeutic hypothermia, rewarming, and the first 6 h of normothermia. The HVx, which is derived from near-infrared spectroscopy, was used to identify the individual optimal mean arterial blood pressure (MAPOPT) at which autoregulatory vasoreactivity is greatest. Cognitive and motor neurodevelopmental evaluations were completed in 19 children at 21-32 months of age. MAPOPT, blood pressure in relation to MAPOPT, blood pressure below gestational age + 5 (ga + 5), and regional cerebral oximetry (rSO2) were compared to the neurodevelopmental outcomes. RESULTS Nineteen children who had HIE and were treated with therapeutic hypothermia performed in the average range on cognitive and motor evaluations at 21-32 months of age, although the mean performance was lower than that of published normative samples. Children with impairments at the 2-year evaluation had higher MAPOPT values, spent more time with blood pressure below MAPOPT, and had greater blood pressure deviation below MAPOPT during rewarming in the neonatal period than those without impairments. Greater blood pressure deviation above MAPOPT during rewarming was associated with less disability and higher cognitive scores. No association was observed between rSO2 or blood pressure below ga + 5 and neurodevelopmental outcomes. CONCLUSION In this pilot cohort, motor and cognitive impairments at 21-32 months of age were associated with greater blood pressure deviation below MAPOPT during rewarming following therapeutic hypothermia, but not with rSO2 or blood pressure below ga + 5. This suggests that identifying individual neonates' MAPOPT is superior to using hemodynamic goals based on gestational age or rSO2 in the acute management of neonatal HIE.
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Affiliation(s)
- Vera Joanna Burton
- Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, MD, USA.
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA.
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA.
- Department of Neurology and Developmental Medicine, Kennedy Krieger Institute, Johns Hopkins School of Medicine, 801 N Broadway, Baltimore, MD, 21205, USA.
| | - Gwendolyn Gerner
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA.
- Department of Neuropsychology, Kennedy Krieger Institute, Baltimore, MD, USA.
| | - Elizabeth Cristofalo
- Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, MD, USA.
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA.
- Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Shang-en Chung
- Center for Child and Community Health Research (CCHR), Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Jacky M Jennings
- Center for Child and Community Health Research (CCHR), Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Charlamaine Parkinson
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA.
- Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Raymond C Koehler
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Raul Chavez-Valdez
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA.
- Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Michael V Johnston
- Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, MD, USA.
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA.
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA.
- Hugo Moser Research Institute, Kennedy Krieger Institute, Baltimore, MD, USA.
| | - Frances J Northington
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA.
- Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Jennifer K Lee
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA.
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.
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9
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Burton VJ, Gerner G, Cristofalo E, Chung SE, Jennings JM, Parkinson C, Koehler RC, Chavez-Valdez R, Johnston MV, Northington FJ, Lee JK. A pilot cohort study of cerebral autoregulation and 2-year neurodevelopmental outcomes in neonates with hypoxic-ischemic encephalopathy who received therapeutic hypothermia. BMC Neurol 2015. [PMID: 26486728 DOI: 10.1186/s12883‐015‐0464‐4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Neurodevelopmental disabilities persist in survivors of neonatal hypoxic-ischemic encephalopathy (HIE) despite treatment with therapeutic hypothermia. Cerebrovascular autoregulation, the mechanism that maintains cerebral perfusion during changes in blood pressure, may influence outcomes. Our objective was to describe the relationship between acute autoregulatory vasoreactivity during treatment and neurodevelopmental outcomes at 2 years of age. METHODS In a pilot study of 28 neonates with HIE, we measured cerebral autoregulatory vasoreactivity with the hemoglobin volume index (HVx) during therapeutic hypothermia, rewarming, and the first 6 h of normothermia. The HVx, which is derived from near-infrared spectroscopy, was used to identify the individual optimal mean arterial blood pressure (MAPOPT) at which autoregulatory vasoreactivity is greatest. Cognitive and motor neurodevelopmental evaluations were completed in 19 children at 21-32 months of age. MAPOPT, blood pressure in relation to MAPOPT, blood pressure below gestational age + 5 (ga + 5), and regional cerebral oximetry (rSO2) were compared to the neurodevelopmental outcomes. RESULTS Nineteen children who had HIE and were treated with therapeutic hypothermia performed in the average range on cognitive and motor evaluations at 21-32 months of age, although the mean performance was lower than that of published normative samples. Children with impairments at the 2-year evaluation had higher MAPOPT values, spent more time with blood pressure below MAPOPT, and had greater blood pressure deviation below MAPOPT during rewarming in the neonatal period than those without impairments. Greater blood pressure deviation above MAPOPT during rewarming was associated with less disability and higher cognitive scores. No association was observed between rSO2 or blood pressure below ga + 5 and neurodevelopmental outcomes. CONCLUSION In this pilot cohort, motor and cognitive impairments at 21-32 months of age were associated with greater blood pressure deviation below MAPOPT during rewarming following therapeutic hypothermia, but not with rSO2 or blood pressure below ga + 5. This suggests that identifying individual neonates' MAPOPT is superior to using hemodynamic goals based on gestational age or rSO2 in the acute management of neonatal HIE.
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Affiliation(s)
- Vera Joanna Burton
- Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, MD, USA. .,Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Department of Neurology and Developmental Medicine, Kennedy Krieger Institute, Johns Hopkins School of Medicine, 801 N Broadway, Baltimore, MD, 21205, USA.
| | - Gwendolyn Gerner
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Department of Neuropsychology, Kennedy Krieger Institute, Baltimore, MD, USA.
| | - Elizabeth Cristofalo
- Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, MD, USA. .,Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Shang-en Chung
- Center for Child and Community Health Research (CCHR), Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Jacky M Jennings
- Center for Child and Community Health Research (CCHR), Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Charlamaine Parkinson
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Raymond C Koehler
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Raul Chavez-Valdez
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Michael V Johnston
- Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, MD, USA. .,Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Hugo Moser Research Institute, Kennedy Krieger Institute, Baltimore, MD, USA.
| | - Frances J Northington
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Jennifer K Lee
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.
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Hammers AL, Sanchez-Ramos L, Kaunitz AM. Antenatal exposure to indomethacin increases the risk of severe intraventricular hemorrhage, necrotizing enterocolitis, and periventricular leukomalacia: a systematic review with metaanalysis. Am J Obstet Gynecol 2015; 212:505.e1-13. [PMID: 25448524 DOI: 10.1016/j.ajog.2014.10.1091] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 10/08/2014] [Accepted: 10/28/2014] [Indexed: 01/01/2023]
Abstract
OBJECTIVE The purpose of this study was to provide an updated summary of the literature regarding the effects of tocolysis with indomethacin on neonatal outcome by systematically reviewing previously and recently reported data. STUDY DESIGN All previously reported studies pertaining to indomethacin tocolysis and neonatal outcomes along with recently reported data were identified with the use of electronic databases that had been supplemented with references that were cited in original studies and review articles. Observational studies that compared neonatal outcomes among preterm infants who were exposed and not exposed to indomethacin were included in this systematic review. Data were extracted and quantitative analyses were performed on those studies that assessed the neonatal outcomes of patients that received antenatal tocolysis with indomethacin. RESULTS Twenty-seven observational studies that met criteria for systematic review and metaanalysis were identified. These studies included 8454 infants, of whom 1731 were exposed to antenatal indomethacin and 6723 were not exposed. Relative risks with 95% confidence intervals were calculated for dichotomous outcomes with the use of random and fixed-effects models. Metaanalysis revealed no statistically significant differences in the rates of respiratory distress syndrome, patent ductus arteriosus, neonatal mortality rate, neonatal sepsis, bronchopulmonary dysplasia, or intraventricular hemorrhage (all grades). However, antenatal exposure to indomethacin was associated with an increased risk of severe intraventricular hemorrhage (grade III-IV based on Papile's criteria; relative risk, 1.29; 95% confidence interval, 1.06-1.56), necrotizing enterocolitis (relative risk, 1.36; 95% confidence interval, 1.08-1.71), and periventricular leukomalacia (relative risk, 1.59; 95% confidence interval, 1.17-2.17). CONCLUSION The use of indomethacin as a tocolytic agent for preterm labor is associated with an increased risk for severe intraventricular hemorrhage, necrotizing enterocolitis, and periventricular leukomalacia.
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