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van Wyk L, Austin T, Barzilay B, Bravo MC, Breindahl M, Czernik C, Dempsey E, de Boode WP, de Vries W, Eriksen BH, Fauchére JC, Kooi EMW, Levy PT, McNamara PJ, Mitra S, Nestaas E, Rabe H, Rabi Y, Rogerson SR, Savoia M, Schena F, Sehgal A, Schwarz CE, Thome U, van Laere D, Zaharie GC, Gupta S. A recommendation for the use of electrical biosensing technology in neonatology. Pediatr Res 2024:10.1038/s41390-024-03369-z. [PMID: 38977797 DOI: 10.1038/s41390-024-03369-z] [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: 02/27/2024] [Revised: 05/17/2024] [Accepted: 06/07/2024] [Indexed: 07/10/2024]
Abstract
Non-invasive cardiac output monitoring, via electrical biosensing technology (EBT), provides continuous, multi-parameter hemodynamic variable monitoring which may allow for timely identification of hemodynamic instability in some neonates, providing an opportunity for early intervention that may improve neonatal outcomes. EBT encompasses thoracic (TEBT) and whole body (WBEBT) methods. Despite the lack of relative accuracy of these technologies, as compared to transthoracic echocardiography, the use of these technologies in neonatology, both in the research and clinical arena, have increased dramatically over the last 30 years. The European Society of Pediatric Research Special Interest Group in Non-Invasive Cardiac Output Monitoring, a group of experienced neonatologists in the field of EBT, deemed it appropriate to provide recommendations for the use of TEBT and WBEBT in the field of neonatology. Although TEBT is not an accurate determinant of cardiac output or stroke volume, it may be useful for monitoring longitudinal changes of hemodynamic parameters. Few recommendations can be made for the use of TEBT in common neonatal clinical conditions. It is recommended not to use WBEBT to monitor cardiac output. The differences in technologies, study methodologies and data reporting should be addressed in ongoing research prior to introducing EBT into routine practice. IMPACT STATEMENT: TEBT is not recommended as an accurate determinant of cardiac output (CO) (or stroke volume (SV)). TEBT may be useful for monitoring longitudinal changes from baseline of hemodynamic parameters on an individual patient basis. TEBT-derived thoracic fluid content (TFC) longitudinal changes from baseline may be useful in monitoring progress in respiratory disorders and circulatory conditions affecting intrathoracic fluid volume. Currently there is insufficient evidence to make any recommendations regarding the use of WBEBT for CO monitoring in neonates. Further research is required in all areas prior to the implementation of these monitors into routine clinical practice.
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Affiliation(s)
- Lizelle van Wyk
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa.
| | - Topun Austin
- Neonatal Intensive Care Unit, Rosie Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, UK
| | - Bernard Barzilay
- Neonatal Intensive Care Unit, Assaf Harofeh Medical Center, Tzrifin, Israel
| | - Maria Carmen Bravo
- Department of Neonatology, La Paz University Hospital and IdiPaz, Madrid, Spain
| | - Morten Breindahl
- Department of Neonatology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Christoph Czernik
- Department of Neonatology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Eugene Dempsey
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Willem-Pieter de Boode
- Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Willem de Vries
- Division of Woman and Baby, Department of Neonatology, University Medical Centre Utrecht, Wilhelmina Children's Hospital, Utrecht University, Utrecht, The Netherlands
| | - Beate Horsberg Eriksen
- Department of Paediatrics, Møre and Romsdal Hospital Trust, Ålesund, Norway
- Clinical Research Unit, Norwegian University of Science and Technology, Trondheim, Norway
| | - Jean-Claude Fauchére
- Department of Neonatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Elisabeth M W Kooi
- Division of Neonatology, Department of Pediatrics, Beatrix Children's Hospital, University of Groningen, University Medical Centre, Groningen, The Netherlands
| | - Philip T Levy
- Department of Newborn Medicine, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | | | - Subhabrata Mitra
- Institute for Women's Health, University College London, London, UK
| | - Eirik Nestaas
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Clinic of Paediatrics and Adolescence, Akershus University Hospital, Lørenskog, Norway
| | - Heike Rabe
- Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | | | - Sheryle R Rogerson
- Newborn Research Centre, The Royal Women's Hospital, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, VIC, Australia
| | - Marilena Savoia
- Neonatal Intensive Care Unit, S Maria Della Misericordia Hospital, Udine, Italy
| | | | - Arvind Sehgal
- Monash Newborn, Monash Children's Hospital, Melbourne, VIC, Australia
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia
| | - Christoph E Schwarz
- Department of Neonatology, Center for Pediatric and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
| | - Ulrich Thome
- Division of Neonatology, Department of Pediatrics, University of Leipzig Medical Centre, Leipzig, Germany
| | - David van Laere
- Neonatal Intensive Care Unit, Universitair Ziekenhuis, Antwerp, Belgium
| | - Gabriela C Zaharie
- Neonatology Department, University of Medicine and Pharmacy, Iuliu Hatieganu, Cluj -Napoca, Romania
| | - Samir Gupta
- Department of Engineering, Durham University, Durham, UK
- Division of Neonatology, Department of Pediatrics, Sidra Medicine, Doha, Qatar
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Termerova J, Kubena AA, Liska K, Tomek V, Plavka R. Association between patent ductus arteriosus flow and home oxygen therapy in extremely preterm infants. Pediatr Res 2024; 96:208-215. [PMID: 38454005 PMCID: PMC11257949 DOI: 10.1038/s41390-024-03120-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 02/09/2024] [Accepted: 02/15/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Central blood flow measurements include the estimation of right and left ventricular output (RVO, LVO), superior vena cava (SVC) flow, and calculated patent ductus arteriosus (PDA) flow. We aimed to provide an overview of the maturation patterns of these values and the relationship between PDA flow and the need for home oxygen therapy. METHODS This prospective single-center study was conducted in infants born at <26 weeks of gestation. We performed echocardiographic measurements five times during their life (from the 4th post-natal day to the 36th postmenstrual week). RESULTS Sixty patients with a mean birth weight of 680 (590, 760) g were included. Postnatal development of LVO and PDA flow peaked at the end of the second postnatal week (427 and 66 mL/kg/min, respectively). The RVO increased between days 4 and 7-8. The SVCF was most stable. The development curves of PDA flow differed between the groups with (n = 28; 47%) and without home oxygen therapy. CONCLUSION We present the central blood flow values and their postnatal development in infants <26 weeks of gestation. This study demonstrates the association between PDA flow and the future need for home oxygen therapy. IMPACT This study enriches our knowledge of the long-term development of central blood flow parameters and derived patent ductus arteriosus (PDA) flow in extremely preterm infants (<26 weeks). While pulmonary resistance decreased, PDA flow continued to increase from day 4 to the end of the second week of life. Similarly, left ventricular output increased as a marker of preload. The superior vena cava flow remained stable. The observed association between PDA flow and an unfavorable respiratory outcome is important for future studies focusing on the prevention of chronic lung disease.
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Affiliation(s)
- Jana Termerova
- Department of Gynecology, Obstetrics and Neonatology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic.
| | - Ales A Kubena
- Institute of Medical Biochemistry and Laboratory Diagnostics, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Karel Liska
- Department of Gynecology, Obstetrics and Neonatology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Viktor Tomek
- Children's Heart Center, Second Faculty of Medicine, Charles University and Motol University Hospital in Prague, Prague, Czech Republic
| | - Richard Plavka
- Department of Gynecology, Obstetrics and Neonatology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
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Surak A, Bischoff A. Should SVC flow be a routine measure when performing targeted neonatal echocardiography? A narrative review. Pediatr Neonatol 2024; 65:323-327. [PMID: 38341334 DOI: 10.1016/j.pedneo.2024.01.001] [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: 08/18/2023] [Revised: 12/05/2023] [Accepted: 01/09/2024] [Indexed: 02/12/2024] Open
Abstract
Superior vena cava is commonly used in neonatal hemodynamics and is suggested to be the best available non-invasive marker for systemic circulation in preterm infants. Inter- and intra-observer variability remain to be an issue. Its association with neonatal outcomes is has not been established. This is a narrative review about this marker, its use, and its potential pitfalls. OBJECTIVE This is a narrative review about SVC flow in preterm infants, physiology, techniques of measurement and its potential association with outcomes. SOURCES Literature revie mainly PubMED. SUMMARY OF THE FINDINGS SVC flow measurement has some limitations and pitfalls. CONCLUSIONS SVC flow association with neonatal outcomes, still needs to be established in further research.
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Affiliation(s)
- Aimann Surak
- Philip C. Etches Neonatal Intensive Care Unit, DTC 5027, 10240 Kingsway NW, Edmonton, Alberta, Canada, T5H 3V9.
| | - Adrianne Bischoff
- University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA.
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Gautam B, Surak A, Campbell SM, Kumar M. Superior Vena Cava Flow in Preterm Infants and Neonatal Outcomes: A Systematic Review. Am J Perinatol 2024; 41:e2356-e2364. [PMID: 37339677 DOI: 10.1055/a-2113-8621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
Superior vena cava (SVC) flow has been considered a surrogate marker of systemic blood flow in neonates. We conducted a systematic review to evaluate the association between low SVC flow recorded during the early neonatal period and neonatal outcomes. We searched the following databases (until December 9, 2020; updated October 21, 2022): PROSPERO, OVID Medline, OVID EMBASE, Cochrane Library (CDSR and Central), Proquest Dissertations and Theses Global, and SCOPUS using controlled vocabulary and key words representing the concepts "superior vena cava" and "flow" and "neonate." Results were exported to COVIDENCE review management software. The search retrieved 593 records after the removal of duplicates, of which 11 studies (nine cohorts) met the inclusion criteria. The majority of the studies included infants born at <30 weeks of gestation. The included studies were assessed as high risk of bias in terms of the incomparability of the study groups, with infants in the low SVC flow group noted to be more immature than those in the normal SVC flow group or subjected to different cointerventions. We did not conduct meta-analyses in view of the significant clinical heterogeneity noted in the included studies. We found little evidence to suggest that SVC flow in the early neonatal period is an independent predictor for adverse clinical outcomes in preterm infants. Included studies were assessed at high risk of bias. We conclude that SVC flow interpretation for prognostication or for making treatment decisions should be restricted to the research setting for now. We highlight the need for strengthened methods in future research studies. KEY POINTS: · We studied whether low SVC flow in the early neonatal period is a marker for adverse outcomes in preterm infants.. · There is insufficient evidence to conclude that low SVC flow is a valid predictor of adverse outcomes.. · There is insufficient evidence to conclude that SVC flow-directed hemodynamic management improves clinical outcomes..
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Affiliation(s)
- Bishal Gautam
- Department of Pediatrics, University of Alberta, Alberta, Canada
- Alberta Health Services, Edmonton, Canada
| | - Aimann Surak
- Department of Pediatrics, University of Alberta, Alberta, Canada
- Alberta Health Services, Edmonton, Canada
| | - Sandra M Campbell
- John W. Scott Health Sciences Library, University of Alberta, Edmonton, Canada
| | - Manoj Kumar
- Department of Pediatrics, University of Alberta, Alberta, Canada
- Alberta Health Services, Edmonton, Canada
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Echocardiographic Quantification of Superior Vena Cava (SVC) Flow in Neonates: Pilot Study of Modified Technique. Diagnostics (Basel) 2022; 12:diagnostics12092083. [PMID: 36140485 PMCID: PMC9498289 DOI: 10.3390/diagnostics12092083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 08/10/2022] [Accepted: 08/25/2022] [Indexed: 11/23/2022] Open
Abstract
Ultrasound Superior Vena Cava (SVC) flow assessment is a common measure of systemic and cerebral perfusion, although accuracy is limited. The aim of this study was to evaluate whether any improvements in accuracy could be achieved by measuring stroke distance from the instantaneous mean velocity, rather than from peak velocity, and by directly tracing area from images obtained with a high frequency linear probe. Paired phase contrast magnetic resonance imaging (PCMRI) and ultrasound assessments of SVC flow were performed in a pilot cohort of 7 infants. Median postnatal age, corrected gestation and weight at scan were 7 (2–74) days, 34.8 (31.7–37.2) weeks 1870 (970–2660) g. Median interval between PCMRI and ultrasound scans was 0.3 (0.2–0.5) h. The methodology trialed here showed a better agreement with PCMRI (mean bias −8 mL/kg/min, LOA −25–+8 mL/kg/min), compared to both the original method reported by Kluckow et al. (mean bias + 42 mL/kg/min, LOA −53–+137 mL/kg/min), and our own prior adaptation (mean bias + 23 mL/kg/min, LOA −25–+71 mL/kg/min). Ultrasound assessment of SVC flow volume using the modifications described led to enhanced accuracy and decreased variability compared to prior techniques in a small cohort of premature infants.
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Nitzan I, Hammerman C, Menahem S, Sehgal A. Mitral valve Doppler for cardiac output assessment in preterm neonates. Echocardiography 2022; 39:717-723. [PMID: 35466433 DOI: 10.1111/echo.15356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/20/2022] [Accepted: 04/10/2022] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Cardiac output (CO) assessment in neonates is commonly done by echocardiography. It is unclear which is the best site to measure the left ventricular (LV) outflow tract for CO assessment (the aortic valve [AV] aortic sinus [AS] or the sinotubular junction [STJ]). In the normal heart, the blood flow entering the LV equals the blood ejected from it. Therefore, measuring the blood flow into the LV through the mitral valve (MV) is an alternative way to measure CO. METHODS In stable preterm infants the MV CO was compared with the right ventricular (RV) CO and the three ways to measure LV CO, in 30 stable preterm neonates. Interobserver variability for MV CO was established. RESULTS In the 30 neonates studied, MV CO was best correlated and had a minimal bias to the RV CO and LV CO measured at the STJ. Left ventricular CO measured at the AV and AS had significant bias relative to RV CO and MV CO. MV CO inter-observer variability was similar to other echocardiographic CO assessment methods. CONCLUSION MV CO may be used as an alternative way to assess CO. The STJ may be the optimal site to measure LV outflow tract.
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Affiliation(s)
- Itamar Nitzan
- Monash Children's Hospital, Monash Newborn, Melbourne, Australia.,Department of Neonatology, Shaare Zedek Medical Center, Jerusalem, Israel.,Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Cathy Hammerman
- Department of Neonatology, Shaare Zedek Medical Center, Jerusalem, Israel.,Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Samuel Menahem
- Melbourne Children's Cardiology, Melbourne, Australia.,Department of Paediatrics, Monash University, Melbourne, Australia
| | - Arvind Sehgal
- Monash Children's Hospital, Monash Newborn, Melbourne, Australia.,Department of Paediatrics, Monash University, Melbourne, Australia
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Hassan MA, Bryant MB, Hummler HD. Comparison of Cardiac Output Measurement by Electrical Velocimetry with Echocardiography in Extremely Low Birth Weight Neonates. Neonatology 2022; 119:18-25. [PMID: 34724661 DOI: 10.1159/000519713] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 09/16/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Electrical velocimetry (EV) offers a noninvasive tool for continuous cardiac output (CO) measurements which might facilitate hemodynamic monitoring and targeted therapy in low birth neonates, in whom other methods of CO measurement are not practicably feasible. METHODS This prospective observational study compared simultaneous cardiac output measurements by electrical velocimetry (COEV) with transthoracic echocardiography (COTTE) in extremely low birth weight (ELBW) neonates in the neonatal intensive care unit (NICU). Echocardiography was performed by 1 single examiner. Data were analyzed by Bland-Altman analysis and independent-samples analysis of variance. A mean percentage error (MPE) of <30% and limits of agreement (LOA) up to ±30% were considered clinically acceptable. RESULTS Thirty-eight ELBW neonates were studied and yielded 85 pairs of COEV and COTTE measurements. Bland-Altman analysis showed an overall bias (the mean difference) and LOA of -126 and -305 to +52 mL min-1, respectively, and an MPE of 66%. Patients with patent ductus arteriosus had a higher bias with LOA and MPE of -166.8, -370.7 to +37 mL min-1, and 69%, respectively. The overall true precision was 58%. CONCLUSION This study showed high bias and lack of agreement between EV and TTE for measurement of CO in ELBW infants in NICU, limiting applicability of EV to monitor absolute values.
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Affiliation(s)
- Mohammad Ahmad Hassan
- Department of Pediatrics, Sohag Faculty of Medicine, Sohag University, Sohag, Egypt.,Division of Neonatology and Pediatric Critical Care, Department of Pediatrics and Adolescent Medicine, Ulm University Medical Center, Ulm, Germany
| | - Manuel B Bryant
- Division of Neonatology and Pediatric Critical Care, Department of Pediatrics and Adolescent Medicine, Ulm University Medical Center, Ulm, Germany.,Neonatal Department, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Helmut D Hummler
- Division of Neonatology and Pediatric Critical Care, Department of Pediatrics and Adolescent Medicine, Ulm University Medical Center, Ulm, Germany.,Department of Neonatology, University of Tuebingen, Tuebingen, Germany
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Altit G, Bhombal S, Chock VY. End-organ saturations correlate with aortic blood flow estimates by echocardiography in the extremely premature newborn - an observational cohort study. BMC Pediatr 2021; 21:312. [PMID: 34253175 PMCID: PMC8274006 DOI: 10.1186/s12887-021-02790-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 06/10/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Near-infrared spectroscopy (NIRS) measures of cerebral saturation (Csat) and renal saturation (Rsat) in extreme premature newborns may be affected by systemic blood flow fluctuations. Despite increasing clinical use of NIRS to monitor tissue saturation in the premature infant, validation of NIRS measures as a correlate of blood flow is still needed. We compared echocardiography (ECHO) derived markers of ascending aorta (AscAo) and descending aorta (DesAo) blood flow with NIRS measurements obtained during the ECHO. METHODS Newborns < 29 weeks' gestation (2013-2017) underwent routine NIRS monitoring. Csat, Rsat and systemic saturation at the time of ECHO were retrospectively analyzed and compared with Doppler markers of aortic flow. Renal and cerebral fractional tissue oxygen extraction (rFTOE and cFTOE, respectively) were calculated. Mixed effects models evaluated the association between NIRS and Doppler markers. RESULTS Forty-nine neonates with 75 Csat-ECHO and 62 Rsat-ECHO observations were studied. Mean post-menstrual age was 28.3 ± 3.8 weeks during the ECHO. Preductal measures including AscAo velocity time integral (VTI) and AscAo output were correlated with Csat or cFTOE, while postductal measures including DesAo VTI, DesAo peak systolic velocity, and estimated DesAo output were more closely correlated with Rsat or rFTOE. CONCLUSIONS NIRS measures are associated with aortic blood flow measurements by ECHO in the extremely premature population. NIRS is a tool to consider when following end organ perfusion in the preterm infant.
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Affiliation(s)
- Gabriel Altit
- Department of Pediatrics, Division of Neonatology, Montreal Children's Hospital, McGill University Health Center, Montreal, Canada.
| | - Shazia Bhombal
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital Stanford, Palo Alto, USA
| | - Valerie Y Chock
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital Stanford, Palo Alto, USA
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de Waal K, Kluckow M. Superior vena cava flow: Role, assessment and controversies in the management of perinatal perfusion. Semin Fetal Neonatal Med 2020; 25:101122. [PMID: 32467039 DOI: 10.1016/j.siny.2020.101122] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The superior vena cava (SVC) is a large vein responsible for the venous return of blood from structures located superior to the diaphragm. The flow in the SVC can be assessed with Doppler ultrasound and can be used as a proxy for cerebral perfusion. Early clinical research studies showed that low SVC flow, particularly if for a prolonged period, was associated with short term morbidity such as intraventricular hemorrhage, mortality, and poorer neurodevelopmental outcomes. However, these findings have not been consistently reported in more recent studies, and the role of SVC flow in early management and as a predictor of poor long-term neurodevelopment has been questioned. This paper provides an overview of SVC assessment, the expected range of findings, and reviews the role of SVC flow as a diagnostic and monitoring tool for the assessment of perinatal perfusion.
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Affiliation(s)
- Koert de Waal
- John Hunter Children's Hospital Department of Neonatology and University of Newcastle, Newcastle, NSW, Australia.
| | - Martin Kluckow
- Royal North Shore Hospital Department of Neonatology and University of Sydney, Sydney, NSW, Australia
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Fiorenzano DM, Leal GN, Sawamura KSS, Lianza AC, Carvalho WBD, Krebs VLJ. Respiratory distress syndrome: influence of management on the hemodynamic status of ≤ 32-week preterm infants in the first 24 hours of life. Rev Bras Ter Intensiva 2019; 31:312-317. [PMID: 31618349 PMCID: PMC7005966 DOI: 10.5935/0103-507x.20190056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 03/09/2019] [Indexed: 11/21/2022] Open
Abstract
Objective To investigate the influence of respiratory distress syndrome management on clinical and echocardiographic parameters used for hemodynamic evaluation in ≤ 32- week newborns. Methods Thirty-three ≤ 32-week newborns were prospectively evaluated and subjected to invasive mechanical ventilation. The need for exogenous surfactant and clinical and echocardiographic parameters in the first 24 hours of life was detailed in this group of patients. Results The mean airway pressure was significantly higher in newborn infants who required inotropes [10.8 (8.8 - 23) cmH2O versus 9 (6.2 - 12) cmH2O; p = 0.04]. A negative correlation was found between the mean airway pressure and velocity-time integral of the pulmonary artery (r = -0.39; p = 0.026), right ventricular output (r = -0.43; p = 0.017) and measurements of the tricuspid annular plane excursion (r = -0.37; p = 0.036). A negative correlation was found between the number of doses of exogenous surfactant and the right ventricular output (r = -0.39; p = 0.028) and pulmonary artery velocity-time integral (r = -0.35; p = 0.043). Conclusion In ≤ 32-week newborns under invasive mechanical ventilation, increases in the mean airway pressure and number of surfactant doses are correlated with the worsening of early cardiac function. Therefore, more aggressive management of respiratory distress syndrome may contribute to the hemodynamic instability of these patients.
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Affiliation(s)
- Daniela Matos Fiorenzano
- Disciplina de Neonatologia, Departamento de Pediatria, Instituto da Criança, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
| | - Gabriela Nunes Leal
- Serviço de Ecocardiografia Neonatal e Pediátrica, Instituto da Criança, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
| | - Karen Saori Shiraishi Sawamura
- Serviço de Ecocardiografia Neonatal e Pediátrica, Instituto da Criança, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
| | - Alessandro Cavalcanti Lianza
- Serviço de Ecocardiografia Neonatal e Pediátrica, Instituto da Criança, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
| | - Werther Brunow de Carvalho
- Disciplina de Neonatologia, Departamento de Pediatria, Instituto da Criança, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
| | - Vera Lúcia Jornada Krebs
- Disciplina de Neonatologia, Departamento de Pediatria, Instituto da Criança, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
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Jamil M, Rezaeimoghaddam M, Cakmak B, Yildiz Y, Rasooli R, Pekkan K, Salihoglu E. Hemodynamics of neonatal double lumen cannula malposition. Perfusion 2019; 35:306-315. [DOI: 10.1177/0267659119874697] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Objective: Malposition of dual lumen cannula is a frequent and challenging complication in neonates and plays a significant role in shaping the in vitro device hemodynamics. This study aims to analyze the effect of the dual lumen cannula malposition on right-atrial hemodynamics in neonatal patients using an experimentally validated computational fluid dynamics model. Methods: A computer model was developed for clinically approved dual lumen cannula (13Fr Origen Biomedical, Austin, Texas, USA) oriented inside the atrium of a 3-kg neonate with normal venous return. Atrial hemodynamics and dual lumen cannula malposition were systematically simulated for two rotations (antero-atrial and atrio-septal) and four translations (two intravascular movements along inferior vena cava and two dislodged configurations in the atrium). A multi-domain compartmentalized mesh was prepared to allow the site-specific evaluation of important hemodynamic parameters. Transport of each blood stream, blood damage levels, and recirculation times are quantified and compared to dual lumen cannula in proper position. Results: High recirculation levels (39 ± 4%) in malpositioned cases resulted in poor oxygen saturation where maximum recirculation of up to 42% was observed. Apparently, Origen dual lumen cannula showed poor inferior vena cava blood–capturing efficiency (48 ± 8%) but high superior vena cava blood–capturing efficiency (86 ± 10%). Dual lumen cannula malposition resulted in corresponding changes in residence time (1.7 ± 0.5 seconds through the tricuspid). No significant differences in blood damage were observed among the simulated cases compared to normal orientation. Compared to the correct dual lumen cannula position, both rotational and translational displacements of the dual lumen cannula resulted in significant hemodynamic differences. Conclusion: Rotational or translational movement of dual lumen cannula is the determining factor for atrial hemodynamics, venous capturing efficiency, blood residence time, and oxygenated blood delivery. Results obtained through computational fluid dynamics methodology can provide valuable foresight in assessing the performance of the dual lumen cannula in patient-specific configurations.
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Affiliation(s)
- Muhammad Jamil
- Department of Mechanical Engineering, Koç University, Istanbul, Turkey
| | | | - Bilgesu Cakmak
- Department of Mechanical Engineering, Koç University, Istanbul, Turkey
| | - Yahya Yildiz
- Department of Anesthesiology and Reanimation, Medipol Mega University Hospital, Istanbul, Turkey
| | - Reza Rasooli
- Department of Mechanical Engineering, Koç University, Istanbul, Turkey
| | - Kerem Pekkan
- Department of Mechanical Engineering, Koç University, Istanbul, Turkey
| | - Ece Salihoglu
- Department of Pediatric Cardiovascular Surgery, Faculty of Medicine, Demiroğlu Bilim Üniversitesi, Istanbul, Turkey
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12
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Ultrasound Assessment of the Change in Carotid Corrected Flow Time in Fluid Responsiveness in Undifferentiated Shock. Crit Care Med 2019; 46:e1040-e1046. [PMID: 30134304 DOI: 10.1097/ccm.0000000000003356] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Adequate assessment of fluid responsiveness in shock necessitates correct interpretation of hemodynamic changes induced by preload challenge. This study evaluates the accuracy of point-of-care Doppler ultrasound assessment of the change in carotid corrected flow time induced by a passive leg raise maneuver as a predictor of fluid responsiveness. Noninvasive cardiac output monitoring (NICOM, Cheetah Medical, Newton Center, MA) system based on a bioreactance method was used. DESIGN Prospective, noninterventional study. SETTING ICU at a large academic center. PATIENTS Patients with new, undifferentiated shock, and vasopressor requirements despite fluid resuscitation were included. Patients with significant cardiac disease and conditions that precluded adequate passive leg raising were excluded. INTERVENTIONS Carotid corrected flow time was measured via ultrasound before and after a passive leg raise maneuver. Predicted fluid responsiveness was defined as greater than 10% increase in stroke volume on noninvasive cardiac output monitoring following passive leg raise. Images and measurements were reanalyzed by a second, blinded physician. The accuracy of change in carotid corrected flow time to predict fluid responsiveness was evaluated using receiver operating characteristic analysis. MEASUREMENTS AND MAIN RESULTS Seventy-seven subjects were enrolled with 54 (70.1%) classified as fluid responders by noninvasive cardiac output monitoring. The average change in carotid corrected flow time after passive leg raise for fluid responders was 14.1 ± 18.7 ms versus -4.0 ± 8 ms for nonresponders (p < 0.001). Receiver operating characteristic analysis demonstrated that change in carotid corrected flow time is an accurate predictor of fluid responsiveness status (area under the curve, 0.88; 95% CI, 0.80-0.96) and a 7 ms increase in carotid corrected flow time post passive leg raise was shown to have a 97% positive predictive value and 82% accuracy in detecting fluid responsiveness using noninvasive cardiac output monitoring as a reference standard. Mechanical ventilation, respiratory rate, and high positive end-expiratory pressure had no significant impact on test performance. Post hoc blinded evaluation of bedside acquired measurements demonstrated agreement between evaluators. CONCLUSIONS Change in carotid corrected flow time can predict fluid responsiveness status after a passive leg raise maneuver. Using point-of-care ultrasound to assess change in carotid corrected flow time is an acceptable and reproducible method for noninvasive identification of fluid responsiveness in critically ill patients with undifferentiated shock.
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13
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Sillesen AS, Pihl C, Raja AA, Davidsen AS, Lind LE, Dannesbo S, Navne J, Raja R, Vejlstrup N, Lange T, Bundgaard H, Iversen K. Repeatability and Reproducibility of Neonatal Echocardiography: The Copenhagen Baby Heart Study. J Am Soc Echocardiogr 2019; 32:895-905.e2. [DOI: 10.1016/j.echo.2019.02.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Indexed: 10/26/2022]
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14
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Oulego Erroz I, Alonso Quintela P, Jiménez Gonzalez A, Terroba Seara S, Rodríguez Blanco S, Rosón Varas M, Castañón López L. Impact of screening and treatment of low systemic blood flow in the prevention of severe intraventricular haemorrhage and/or death in pre-term infants. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2018. [DOI: 10.1016/j.anpede.2018.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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15
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Phad N, de Waal K, Jones M. Agreement and reliability of the velocity time integral method and the method of disks to determine stroke volume in preterm infants. Early Hum Dev 2018; 125:31-34. [PMID: 30196166 DOI: 10.1016/j.earlhumdev.2018.08.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 08/08/2018] [Accepted: 08/27/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Nilkant Phad
- John Hunter Children's Hospital, Department of Neonatology, Newcastle, NSW, Australia; University of Newcastle, NSW, Australia.
| | - Koert de Waal
- John Hunter Children's Hospital, Department of Neonatology, Newcastle, NSW, Australia; University of Newcastle, NSW, Australia
| | - Mark Jones
- Hunter Medical Research Institute, Newcastle, Australia
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16
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de Boode WP, van der Lee R, Horsberg Eriksen B, Nestaas E, Dempsey E, Singh Y, Austin T, El-Khuffash A. The role of Neonatologist Performed Echocardiography in the assessment and management of neonatal shock. Pediatr Res 2018; 84:57-67. [PMID: 30072807 PMCID: PMC6257224 DOI: 10.1038/s41390-018-0081-1] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
One of the major challenges of neonatal intensive care is the early detection and management of circulatory failure. Routine clinical assessment of the hemodynamic status of newborn infants is subjective and inaccurate, emphasizing the need for objective monitoring tools. An overview will be provided about the use of neonatologist-performed echocardiography (NPE) to assess cardiovascular compromise and guide hemodynamic management. Different techniques of central blood flow measurement, such as left and right ventricular output, superior vena cava flow, and descending aortic flow are reviewed focusing on methodology, validation, and available reference values. Recommendations are provided for individualized hemodynamic management guided by NPE.
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Affiliation(s)
- Willem P de Boode
- Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands.
| | - Robin van der Lee
- Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
| | | | - Eirik Nestaas
- Institute of Clinical Medicine, Faculty of Medicine, University of, Oslo, Norway
- Department of Cardiology and Center for Cardiological Innovation, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Department of Paediatrics, Vestfold Hospital Trust, Tønsberg, Norway
| | - Eugene Dempsey
- INFANT Centre, Cork University Maternity Hospital, University College, Cork, Ireland
| | - Yogen Singh
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Topun Austin
- Department of Neonatology, Rosie Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Afif El-Khuffash
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland
- Department of Pediatrics, The Royal College of Surgeons in Ireland, Dublin, Ireland
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17
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Oulego Erroz I, Alonso Quintela P, Jiménez Gonzalez A, Terroba Seara S, Rodríguez Blanco S, Rosón Varas M, Castañón López L. [Impact of screening and treatment of low systemic blood flow in the prevention of severe intraventricular haemorrhage and/or death in pre-term infants]. An Pediatr (Barc) 2018; 89:369-377. [PMID: 29622414 DOI: 10.1016/j.anpedi.2018.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 02/08/2018] [Accepted: 02/14/2018] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To assess the effect of a protocolised intervention for low systemic blood flow (SBF) in the occurrence of severe intraventricular haemorrhage (IVH) or death in pre-term infants. METHODS A study with a quasi-experimental design with retrospective controls was conducted on pre-term infants of less than 30weeks of gestational age, born between January 2016 and July 2017, who were consecutively included in the intervention period. The control cohort included pre-term infants (born between January 2013 and December 2015) matched by gestational age, birth weight, and gender (two controls for each case). The cases of low SBF diagnosed according to functional echocardiography during the study period received dobutamine (5-10μg/kg/min) for 48hours. RESULTS The study included 29 cases (intervention period) and 54 controls (pre-intervention period). Ten out of 29 (34.5%) infants received dobutamine for low SBF during the intervention period, with 3/29 (10.3%) cases of severe IVH and/or death compared to 17/54 (31.5%) in the control cohort (p=.032). There was an independent association between the intervention and a decreased occurrence of severe IVH/death after adjusting for confounding factors both in the logistic regression model [OR 0.11 (95%CI: 0.01-0.65), p=.015], as well as in the sensitivity analysis using inverse probability of treatment weighting [OR 0.23 (95%CI: 0.09-0.56); p=.001]. CONCLUSIONS In this study with retrospective controls, a protocolised screening, and treatment for low SBF was associated with a decreased occurrence of severe IVH or death in preterm infants. Large, adequately powered trials, are needed in order to determine whether postnatal interventions directed at low SBF can improve neurological outcomes.
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Affiliation(s)
- Ignacio Oulego Erroz
- Unidad de Neonatología, Servicio de Pediatría, Complejo Asistencial Universitario de León, León, España.
| | - Paula Alonso Quintela
- Unidad de Neonatología, Servicio de Pediatría, Complejo Asistencial Universitario de León, León, España
| | - Aquilina Jiménez Gonzalez
- Unidad de Neonatología, Servicio de Pediatría, Complejo Asistencial Universitario de León, León, España
| | - Sandra Terroba Seara
- Unidad de Neonatología, Servicio de Pediatría, Complejo Asistencial Universitario de León, León, España
| | - Silvia Rodríguez Blanco
- Unidad de Neonatología, Servicio de Pediatría, Complejo Asistencial Universitario de León, León, España
| | - María Rosón Varas
- Unidad de Neonatología, Servicio de Pediatría, Complejo Asistencial Universitario de León, León, España
| | - Leticia Castañón López
- Unidad de Neonatología, Servicio de Pediatría, Complejo Asistencial Universitario de León, León, España
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18
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Muhammad J, Rezaeimoghaddam M, Cakmak B, Rasooli R, Salihoglu E, Yıldız Y, Pekkan K. Patient-Specific Atrial Hemodynamics of a Double Lumen Neonatal Cannula in Correct Caval Position. Artif Organs 2018; 42:401-409. [PMID: 29572879 PMCID: PMC5947122 DOI: 10.1111/aor.13127] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Revised: 12/19/2017] [Accepted: 01/08/2018] [Indexed: 01/17/2023]
Abstract
Clinical success of pediatric veno‐venous (VV) extracorporeal membrane oxygenation (ECMO) is associated with the double lumen cannula cardiovascular device design as well as its anatomic orientation in the atrium. The positions of cannula ports with respect to the vena cavae and the tricuspid valve are believed to play a significant role on device hemodynamics. Despite various improvements in ECMO catheters, especially for the neonatal and congenital heart patients, it is still challenging to select a catalogue size that would fit to most patients optimally. In effect, the local unfavorable blood flow characteristics of the cannula would translate to an overall loss of efficiency of the ECMO circuit. In this study, the complex flow regime of a neonatal double lumen cannula, positioned in a patient‐specific right atrium, is presented for the first time in literature. A pulsatile computational fluid dynamics (CFD) solver that is validated for cardiovascular device flow regimes was used to perform the detailed flow, oxygenated blood transport, and site‐specific blood damage analysis using an integrated cannula and right atrium model. A standard 13Fr double lumen cannula was scanned using micro‐CT, reconstructed and simulated under physiologic flow conditions. User defined scalar transport equations allowed the quantification of the mixing and convection of oxygenated and deoxygenated blood as well as blood residence times and hemolysis build‐up. Site‐specific CFD analysis provided key insight into the hemodynamic challenges encountered in cannula design and the associated intra‐atrial flow patterns. Due to neonatal flow conditions, an ultra high velocity infusion jet emanated from the infusion port and created a zone of major recirculation in the atrium. This flow regime influenced the delivery of the oxygenated blood to the tricuspid valve. Elevated velocities and complex gradients resulted in higher wall shear stresses (WSS) particularly at the infusion port having the highest value followed by the aspiration hole closest to the drainage port. Our results show that, in a cannula that is perfectly oriented in the atrium, almost 38% of the oxygenated blood is lost to the atrial circulation while only half of the blood from inferior vena cava (IVC) can reach to the tricuspid valve. As such, approximately 6% of venous blood from superior vena cava (SVC) can be delivered to tricuspid. High values of hemolysis index were observed with blood damage encountered around infusion hole (0.025%). These results warrant further improvements in the cannula design to achieve optimal performance of ECMO and better patient outcomes.
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Affiliation(s)
- Jamil Muhammad
- Department of Mechanical Engineering, Koç University, Sarıyer, Turkey
| | | | - Bilgesu Cakmak
- Department of Mechanical Engineering, Koç University, Sarıyer, Turkey
| | - Reza Rasooli
- Department of Mechanical Engineering, Koç University, Sarıyer, Turkey
| | - Ece Salihoglu
- Faculty of Medicine, Department of Cardiovascular Surgery, Istanbul Medipol University, Istanbul, Turkey
| | - Yahya Yıldız
- Department of Anesthesiology and Reanimation, Medipol Mega University Hospital, Istanbul, Turkey
| | - Kerem Pekkan
- Department of Mechanical Engineering, Koç University, Sarıyer, Turkey
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19
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Ing RJ, Twite MD. Toward Improved Neurodevelopmental Outcomes: The Role of Transfontanel Ultrasound Assessment of Cerebral Blood Flow in Infants Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth 2018; 32:1655-1656. [PMID: 29501227 DOI: 10.1053/j.jvca.2018.01.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Richard J Ing
- Children's Hospital Colorado, Anschutz Medical Campus, Aurora, CO; University of Colorado School of Medicine, Aurora, CO
| | - Mark D Twite
- Children's Hospital Colorado, Anschutz Medical Campus, Aurora, CO; University of Colorado School of Medicine, Aurora, CO
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20
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Hwang J, Kim YS, Shin JH, Choi BM. Hemodynamic Effects on Systemic Blood Flow and Ductal Shunting Flow after Loading Dose of Intravenous Caffeine in Preterm Infants according to the Patency of Ductus Arteriosus. J Korean Med Sci 2018; 33:e25. [PMID: 29318792 PMCID: PMC5760810 DOI: 10.3346/jkms.2018.33.e25] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 10/14/2017] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND In preterm infants, caffeine citrate is used to stimulate breathing before they are weaned from mechanical ventilation and to reduce the frequency of apnea. In recent studies, effects of caffeine on the cardiovascular system have been emphasized in preterm infants with patent ductus arteriosus (PDA). METHODS This study aimed to assess the short-term hemodynamic effects on systemic blood flow and ductal shunting flow after loading standard doses of intravenous caffeine in preterm infants. Echocardiographic studies were performed by a single investigator, before and at 1 hour and 4 hours after an intravenous infusion of a loading dose as 20 mg/kg caffeine citrate for 30 minutes. RESULTS In 25 preterm infants with PDA, left ventricular output decreased progressively during 4 hours after caffeine loading. Superior vena cava (SVC) flow decreased and ductal shunting flow increased at 1 hour and then recovered at 4-hour to baseline values. A diameter of PDA significantly decreased only at 4-hour after caffeine loading. There were no significant changes of these hemodynamic parameters in 29 preterm infants without PDA. CONCLUSION In preterm infants with PDA, a standard intravenous loading dose of 20 mg/kg caffeine citrate was associated with increasing ductal shunting flow and decreasing SVC flow (as a surrogate for systemic blood flow) 1 hour after caffeine loading, however, these hemodynamic parameters recovered at 4 hours according to partial constriction of the ductus arteriosus. Close monitoring of hemodynamic changes would be needed to observe the risk for pulmonary over-circulation or systemic hypo-perfusion due to transient increasing ductal shunting flow during caffeine loading in preterm infants with PDA.
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Affiliation(s)
- Jihye Hwang
- Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
| | - Yu Seon Kim
- Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
| | - Jeong Hee Shin
- Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
| | - Byung Min Choi
- Department of Pediatrics, Korea University College of Medicine, Seoul, Korea.
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21
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Barjaktarevic I, Chiem A, Cannesson M. Time to correct the flow of corrected flow time. Crit Ultrasound J 2017; 9:18. [PMID: 28980175 PMCID: PMC5628080 DOI: 10.1186/s13089-017-0076-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 09/26/2017] [Indexed: 01/26/2023] Open
Abstract
Recently published study of Ma et al. evaluates two relatively novel measures of fluid responsiveness, carotid blood flow and corrected carotid flow time (ccFT). Both measures have been recently quoted as possibly useful, technically simple, and noninvasive dynamic tools in predicting fluid responsiveness. Recently, more research interest has been focused on ccFT and, intrigued by the data presented in this study, we discuss here the impact of the data presented in the paper of Ma et al. to the significance of this metric as a potential tool in the assessment of fluid responsiveness.
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Affiliation(s)
- Igor Barjaktarevic
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at University of California, Los Angeles, USA.
| | - Alan Chiem
- Department of Emergency Medicine, Olive View-UCLA Medical Center, University of California, Los Angeles, USA
| | - Maxime Cannesson
- Department of Anesthesiology, David Geffen School of Medicine at University of California, Los Angeles, USA
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22
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Beker F, Davis PG, Sehgal A, Rogerson S. Echocardiographic assessment of left ventricular outflow tract diameter in preterm infants. Australas J Ultrasound Med 2014; 17:146-149. [PMID: 28191229 PMCID: PMC5024927 DOI: 10.1002/j.2205-0140.2014.tb00236.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Introduction: Left ventricular output (LVO) measurement is an important part of the echocardiographic assessment of cardiac function in preterm infants. The accurate measurement of left ventricular outflow tract diameter (LVOD) is key to the calculation of LVO. Given the lack of an appropriate gold standard, we used right ventricular output (RVO) as the comparator and sought to identify the most accurate method of determining LVO in preterm infants. Methods: We studied stable preterm infants without significant cardiac shunts. LVOD was measured at the aortic valve, the aortic sinus and at the sinotubular junction. LVOs were calculated and the precision and accuracy of each was determined relative to the RVO using the Bland-Altman method. Results: 52 infants were included in this analysis. The mean difference between RVO and LVO was largest when LVOD was measured at the aortic valve and aortic sinus, +106 and -115 ml/kg/min, respectively, and smallest when measured at the sinotubular junction, 9 ml/kg/min. Limits of agreement between RVO and LVO were narrowest when LVOD was measured at the STJ. Conclusion: LVOD measurement at the sinotubular junction provides more precise and accurate measurement of LVO, in comparison to RVO, than measurement at the aortic valve or the aortic sinus.
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Affiliation(s)
- Friederike Beker
- Neonatal Intensive and Special CareThe Royal Women's HospitalParkvilleVictoriaAustralia; Newborn Intensive Care UnitThe Mercy Hospital for WomenHeidelbergVictoriaAustralia
| | - Peter G Davis
- Neonatal Intensive and Special Care The Royal Women's Hospital Parkville Victoria Australia
| | - Arvind Sehgal
- Monash Newborn Southern Health Clayton Victoria Australia
| | - Sheryle Rogerson
- Neonatal Intensive and Special Care The Royal Women's Hospital Parkville Victoria Australia
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23
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Lakkundi A, Wright I, de Waal K. Transitional hemodynamics in preterm infants with a respiratory management strategy directed at avoidance of mechanical ventilation. Early Hum Dev 2014; 90:409-12. [PMID: 24951077 DOI: 10.1016/j.earlhumdev.2014.04.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Revised: 04/04/2014] [Accepted: 04/28/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Early respiratory management of very low birth weight infants has changed over recent years to a practice of early use of CPAP with early selective surfactant administration, and decreased use of mechanical ventilation. One strategy is to use the combination of surfactant and prompt extubation to nasal continuous positive airway pressure (INtubate, SURfactant, Extubate, or INSURE). The aim of this study is to describe blood flow and ductal flow in a prospective cohort during the transitional period when this respiratory management strategy is used. METHODS Inborn infants <29week gestation underwent INSURE within 30min of birth using 200mg/kg Curosurf. Blood pressure and blood flow parameters (RVO, LVO, SVC flow, ductus arteriosus) were measured at 6, 24 and 72h of age and information on morbidity was collected. RESULTS Sixty-eight infants with a median (range) weight of 940 (450-1380) g were studied. 13 (19%) patients needed mechanical ventilation within 72h of life (INSURE failure). Blood flows and blood pressure were within reported ranges. Eleven (16%) patients had a blood pressure <gestational age and 9 (13%) patients had low blood flow. CONCLUSION These data show a low prevalence of low blood pressure and low blood flow in the first 3days after INSURE as compared to cohorts where mechanical ventilation was preferred during transition. We speculate that altered ventilation strategies have helped decrease the incidence of low blood flow and low blood pressure.
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Affiliation(s)
- Anil Lakkundi
- Neonatal Intensive Care Unit, John Hunter Children's Hospital, Newcastle NSW, Australia; University of Newcastle, Newcastle, Australia
| | - Ian Wright
- Neonatal Intensive Care Unit, John Hunter Children's Hospital, Newcastle NSW, Australia; University of Newcastle, Newcastle, Australia; University of Wollongong, Wollongong, Australia
| | - Koert de Waal
- Neonatal Intensive Care Unit, John Hunter Children's Hospital, Newcastle NSW, Australia; University of Newcastle, Newcastle, Australia.
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Aquilano G, Galletti S, Aceti A, Vitali F, Faldella G. Bi-level CPAP does not change central blood flow in preterm infants with respiratory distress syndrome. Ital J Pediatr 2014; 40:60. [PMID: 24952579 PMCID: PMC4122055 DOI: 10.1186/1824-7288-40-60] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Accepted: 06/11/2014] [Indexed: 11/16/2022] Open
Abstract
Background Current literature provides limited data on the hemodynamic changes that may occur during bi-level continuous positive airway pressure (CPAP) support in preterm infants. However, the application of a positive end-expiratory pressure may be transmitted to the heart and the great vessels resulting in changes of central blood flow. Objective To assess changes in central blood flow in infants with respiratory distress syndrome (RDS) during bi-level CPAP support. Design A prospective study was performed in a cohort of 18 Very-Low-Birth-Weight Infants who were put on nasal CPAP support (4–5 cmH2O) because they developed RDS within the first 24–72 hours of life. Each subject was switched to bi-level CPAP support (Phigh 8 cmH2O, Plow 4–5 cmH2O, Thigh 0.5-0.6 seconds, 20 breaths/min) for an hour. An echocardiographic study and a capillary gas analysis were performed before and after the change of respiratory support. Results No differences between n-CPAP and bi-level CPAP in left ventricular output (LVO, 222.17 ± 81.4 vs 211.4 ± 75.3 ml/kg/min), right ventricular output (RVO, 287.8 ± 96 vs 283.4 ± 87.4 ml/kg/min) and superior vena cava flow (SVC, 135.38 ± 47.8 vs 137.48 ± 46.6 ml/kg/min) were observed. The hemodynamic characteristics of the ductus arteriosus were similar. A significant decrease in pCO2 levels after bi-level CPAP ventilation was observed; pCO2 variations did not correlate with modifications of central blood flow (LVO: ρ = 0.11, p = 0,657; RVO: ρ = −0.307, p = 0.216; SVC: ρ = −0.13, p = 0.197). Conclusions Central blood flow doesn’t change during bi-level CPAP support, which could become a hemodinamically safe tool for the treatment of RDS in preterm infants.
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Affiliation(s)
| | - Silvia Galletti
- Neonatology and Neonatal Intensive Care Unit, Department of Medical and Surgical Sciences, St, Orsola-Malpighi Hospital - University of Bologna, Via Massarenti, 11 40138 Bologna, Italy.
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Aiken CGA. Arterial blood carbonic Acid inversely determines lactic and organic acids. J Clin Diagn Res 2013; 7:2514-7. [PMID: 24392387 PMCID: PMC3879861 DOI: 10.7860/jcdr/2013/5228.3595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Accepted: 10/25/2013] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To establish that arterial blood carbonic acid varies inversely with lactic acid in accordance with bicarbonate exchanging for lactate across cell membranes through the anion exchange mechanism to maintain the Gibbs-Donnan equilibrium. STUDY DESIGN Over 5 years, lactate was measured on all blood gases taken from neonatal admissions, as well as organic acid whenever electrolytes were required. RESULTS Arterial blood gases from 63 infants given high calcium TPN were analyzed. Twenty two needed continuous positive airways pressure (CPAP) only and 31 intermittent positive pressure ventilation (IPPV) and surfactant followed by CPAP to treat respiratory distress syndrome in 51 and meconium aspiration syndrome in 2. All survived and were free of infection. Excluded gases were those with high and falling lactate soon after delivery representing perinatal asphyxia, and those on dexamethasone. Strong inverse relations between carbonic and lactic acids were found at all gestational ages and, independent of glomerular filtration, between carbonic and organic acids. Lactate (mmol/L) = 62.53 X PCO2 (-0.96)(mmHg) r(2) 0.315, n 1232, p <0.001. Sixty divided by PCO2 is a convenient measure of physiological lactate at any given PCO2. In the first week, 9.13 ± 2.57% of arterial gases from infants on IPPV had lactates above 120/PCO2, significantly more than 4.74 ± 2.73% on CPAP (p<0.05) and 2.47 ± 2.39% on no support. CONCLUSION Changes in arterial blood carbonic acid cause immediate inverse changes in lactic acid, because their anions interchange across cell membranes according to the Gibbs -Donnan equilibrium. Increasing PCO2 from 40 to 120 mmHg decreased lactate from 1.5 mmol/L to 0.5 mmol/L, so that the sum of carbonic and lactic acids increased from 2.72 mmol/L to only 4.17 mmol/L. This helps explain the neuroprotective effect of hypercapnoea and highlights the importance of avoiding any degree of hypocapnoea in infants on IPPV.
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