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Öztürk DY, Öztürk E, Dıkmen RT, Ozcanoglu HD, Toprak HH, Tuzun B, Tanıdır İC, Hatemi AC, Cetinkaya M. Evaluation of perfusion index and left ventricular output changes in low cardiac output syndrome after arterial switch operation. Cardiol Young 2023; 33:2196-2202. [PMID: 36606506 DOI: 10.1017/s1047951122004061] [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] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Transposition of great arteries is one of newborns' most common cyanotic CHDs, and its treatment is arterial switch operation in the first days of life. Low cardiac output syndrome may develop in the early postoperative period. In this study, we evaluated perfusion index and left ventricular output blood flow changes in patients who underwent arterial switch operation and developed low cardiac output syndrome. METHODS This study was conducted prospectively in newborns with transposition of great arteries who underwent arterial switch operation between 1st August 2020 and 1st August 2022. Low cardiac output syndrome score and left ventricular output were investigated. Initially, 6th, 12th, 18th, and 24th hour perfusion index and left ventricular output values of patients with and without low cardiac output syndrome were recorded. The results were evaluated statistically. RESULTS A total of 60 patients were included in the study. Sex distribution was equal. The median age at the time of surgery was 5 days (interquartile range 3-7 days), and the median weight was 3.1 kg (interquartile range 2.9-3. 4). Low cardiac output syndrome was detected in 30% (n = 18) of cases. The median perfusion index of patients who developed low cardiac output syndrome was significantly lower at the 12th, 18th, and 24th hours (p < 0.05) (0.99 versus 1.25, 0.86 versus 1.21, and 0.96 versus 1.33, respectively). Similarly, the median left ventricular output of patients who developed low cardiac output syndrome was significantly lower at 12th, 18th, and 24th hours (p < 0.05) (95 versus 110 ml/kg/min, 89 versus 109 ml/kg/min, and 92 versus 112 ml/kg/min, respectively). There was a significant correlation between perfusion index values and left ventricular output at all measurements (r > 0.500, p < 0.05). CONCLUSION Perfusion index and left ventricular output measurements decreased in newborns who developed low cardiac output syndrome after arterial switch operation, especially at 12th and 18th hours. Serial perfusion index and left ventricular output measurements can be instructive in predicting low cardiac output syndrome development.
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Affiliation(s)
- Dilek Yavuzcan Öztürk
- Department of Neonatology, Istanbul Saglik Bilimleri University Basaksehir Cam and Sakura Hospital, Istanbul, Turkey
| | - Erkut Öztürk
- Department of Pediatric Cardiology, Istanbul Saglik Bilimleri University Basaksehir Cam and Sakura Hospital, Istanbul, Turkey
| | - Rahime Tuten Dıkmen
- Department of Pediatric Cardiology, Istanbul Saglik Bilimleri University Basaksehir Cam and Sakura Hospital, Istanbul, Turkey
| | - Hatice Dilek Ozcanoglu
- Department of Anaesthesiology and Reanimation, Istanbul Saglik Bilimleri University Basaksehir Cam and Sakura Hospital, Istanbul, Turkey
| | - Hamza Halil Toprak
- Department of Pediatric Cardiology, Istanbul Saglik Bilimleri University Basaksehir Cam and Sakura Hospital, Istanbul, Turkey
| | - Behzat Tuzun
- Department of Pediatric Cardiovascular Surgery, Istanbul Saglik Bilimleri University Basaksehir Cam and Sakura Hospital, Istanbul, Turkey
| | - İbrahim Cansaran Tanıdır
- Department of Pediatric Cardiology, Istanbul Saglik Bilimleri University Basaksehir Cam and Sakura Hospital, Istanbul, Turkey
| | - Ali Can Hatemi
- Department of Pediatric Cardiovascular Surgery, Istanbul Saglik Bilimleri University Basaksehir Cam and Sakura Hospital, Istanbul, Turkey
| | - Merih Cetinkaya
- Department of Neonatology, Istanbul Saglik Bilimleri University Basaksehir Cam and Sakura Hospital, Istanbul, Turkey
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Mandala VK, Mendu SB, Bollaboina SKY, Kotha R. Role of Perfusion Index and Pulse Variability Index in the Assessment of Neonatal Hemodynamics: A Systematic Review. Cureus 2023; 15:e48058. [PMID: 38046508 PMCID: PMC10688761 DOI: 10.7759/cureus.48058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2023] [Indexed: 12/05/2023] Open
Abstract
Hemodynamic monitoring of neonates is crucial because neonates are easily and acutely susceptible to hemodynamic disturbances. As such, non-invasive monitoring of hemodynamics is preferable. It has been postulated that non-invasive pulse oximetry determines the perfusion index and pulse variability index and provides accurate measurements to predict hemodynamic changes in preterm or term infants. Equally, numerous studies have investigated the efficacy of perfusion and pulse variability indices in monitoring neonatal hemodynamics. The aim of this study was to systematically review studies that have delved into the role of perfusion and pulse variability indices in the assessment of neonatal hemodynamics. The study collected data from 2010-2023 using the patient, intervention, comparison, outcome (PICO) search strategy using the databases PubMed, Scopus, and Excerpta Medica database (Embase). A total of 616 articles were evaluated based on their appropriateness and relevance; we included seven studies. As per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a systematic review. Our study concluded that these indices were effective in measuring hemodynamics.
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Affiliation(s)
| | | | | | - Rakesh Kotha
- Department of Neonatology, Osmania Medical College, Hyderabad, IND
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Saini SS, Shrivastav AK, Sundaram V, Dutta S, Kumar P. Role of perfusion index and plethysmography variability index for predicting outcomes in neonatal sepsis. Acta Paediatr 2023; 112:1884-1891. [PMID: 37222339 DOI: 10.1111/apa.16856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 05/20/2023] [Accepted: 05/23/2023] [Indexed: 05/25/2023]
Abstract
AIM (i) To compare perfusion index (PI) and plethysmography variability index (PVI) between neonates with proven or probable sepsis versus no-sepsis, (ii) to examine an association of PI and PVI with in-hospital mortality. METHODS We enrolled neonates with clinically presumed sepsis. Culture-proven or probable sepsis were categorised as 'cases' and no-sepsis as 'controls'. PI and PVI were recorded hourly for 120 h and averaged in 20-time epochs (0-6 h to 115-120 h). RESULTS We analysed 148 neonates with sepsis (proven sepsis = 77, probable sepsis = 71) and 126 with no-sepsis. Neonates with proven/probable sepsis and no-sepsis had comparable PI and PVI values. Among 148 neonates with sepsis, 43 (29%) died. Non-survivors had significantly lower PI values than survivors (mean difference 0.21 [95% CI 0.14-0.29], p-value <0.001). PI had a significant but modest discriminative ability to identify non-survivors. However, PI did not independently predict mortality. CONCLUSION Neonates with proven/probable sepsis and no-sepsis had comparable PI and PVI values in the first 120 h of sepsis. PI but not PVI values were significantly lower in non-survivors than survivors. PI did not independently predict in-hospital mortality. Due to modest discriminative ability, PI should be interpreted along with other vital signs to take clinical decisions.
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Affiliation(s)
- Shiv Sajan Saini
- Division of Neonatology, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Amit Kumar Shrivastav
- Division of Neonatology, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Venkataseshan Sundaram
- Division of Neonatology, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sourabh Dutta
- Division of Neonatology, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Praveen Kumar
- Division of Neonatology, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Peripheral perfusion index in well newborns at 6 to 72 h of life at different altitudes: a multi-center study in China. Eur J Pediatr 2023; 182:907-915. [PMID: 36525095 PMCID: PMC9899177 DOI: 10.1007/s00431-022-04725-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 11/17/2022] [Accepted: 11/18/2022] [Indexed: 12/23/2022]
Abstract
The purpose of this study is to obtain the reference range of peripheral perfusion index (PPI) of asymptomatic well newborns at 6 to 72 h of life at different altitudes. A population-based prospective cohort study was conducted in cities at different altitudes in China. Asymptomatic well newborns were enrolled consecutively from six hospitals with an altitude of 4 to 4200 m between February 1, 2020, and April 15, 2021. PPI was measured at 6, 12, 24, 48, and 72 h after birth on the right hand (pre-ductal) and either foot (post-ductal) using a Masimo SET Radical-7 oximeter. Fiftieth percentile reference curves of the pre- and post-ductal PPI values at 6-72 h after birth were generated using the Lambda Mu Sigma method. Linear mixed-effects regression was performed to determine the influence of different altitude levels on PPI values over different measurement time points. A total of 4257 asymptomatic well newborns were recruited for analysis. The median and quartile pre- and post-ductal PPI values at 6-72 h of life at different altitudes were 1.70 (1.20, 2.60) and 1.70 (1.10, 2.70) for all infants, 1.30 (1.10, 1.90) and 1.10 (0.88, 1.80) for infants at low altitude, 1.40 (1.00, 2.00) and 1.30 (0.99, 2.00) at mild altitudes, 1.90 (1.30, 2.50) and 1.80 (1.20, 2.70) at moderate altitudes, 1.80 (1.40, 3.50) and 2.20 (1.60, 4.30) for high altitudes, 3.20 (2.70, 3.70), and 3.10 (2.10, 3.30) for higher altitudes, respectively. Overall, both pre- and post-ductal PPI increased with altitude. The 50th percentile curves of pre- and post-ductal PPI values in well newborns at mild, low, moderate, and high altitudes were relatively similar, while the difference between the PPI curves of infants at higher altitudes and other altitudes was significantly different. Conclusions: With the increase of altitude, pre- and post-ductal PPI of newborns increases. Our study obtained the PPI reference values of asymptomatic well newborns at 6 to 72 h after birth at different altitudes from 4 to ≥ 4000 m. What is Known: • Monitoring hemodynamics is very important to neonates. As an accurate and reliable hemodynamic monitoring index, PPI can detect irreversible damage caused by insufficient tissue perfusion and oxygenation early, directly, noninvasively, and continuously. What is New: • Our study obtained the PPI reference values of asymptomatic well newborns at 6 to 72 h after birth at different altitudes from 4 to ≥ 4000 m. With the increase of altitude, pre- and post-ductal PPI of newborns increase with statistical significance. Therefore, the values and disease thresholds of PPI for asymptomatic neonates should be modified according to altitudes.
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Goldsmith JP, Keels E. Recognition and Management of Cardiovascular Insufficiency in the Very Low Birth Weight Newborn. Pediatrics 2022; 149:184900. [PMID: 35224636 DOI: 10.1542/peds.2021-056051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The measurement of blood pressure in the very low birth weight newborn infant is not simple and may be erroneous because of numerous factors. Assessment of cardiovascular insufficiency in this population should be based on multiple parameters and not only on numeric blood pressure readings. The decision to treat cardiovascular insufficiency should be made after considering the potential complications of such treatment. There are numerous potential strategies to avoid or mitigate hypoperfusion states in the very low birth weight infant.
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Affiliation(s)
- Jay P Goldsmith
- Department of Pediatrics, Division of Newborn Medicine, Tulane University, New Orleans, Louisiana
| | - Erin Keels
- Neonatal Practitioner Program, Neonatal Services, Nationwide Children's Hospital, Columbus, Ohio
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Coutrot M, Dudoignon E, Joachim J, Gayat E, Vallée F, Dépret F. Perfusion index: Physical principles, physiological meanings and clinical implications in anaesthesia and critical care. Anaesth Crit Care Pain Med 2021; 40:100964. [PMID: 34687923 DOI: 10.1016/j.accpm.2021.100964] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 09/01/2021] [Accepted: 09/03/2021] [Indexed: 10/20/2022]
Abstract
Photoplethysmography (PPG) has been extensively used for pulse oximetry monitoring in anaesthesia, perioperative and intensive care. However, some components of PPG signal have been employed for other purposes, such as non-invasive haemodynamic monitoring. Perfusion index (PI) is derived from PPG signal and represents the ratio of pulsatile on non-pulsatile light absorbance or reflectance of the PPG signal. PI determinants are complex and interlinked, involving and reflecting the interaction between peripheral and central haemodynamic characteristics, such as vascular tone and stroke volume. Recently, several studies have shed light on the interesting performances of this variable, especially assessing regional or neuraxial block success, and haemodynamic monitoring in anaesthesia, perioperative and intensive care. Nevertheless, no review has yet been published concerning the interest of PI in these fields. In this narrative review will be exposed first the physiological and pathophysiological determinants of PI, and then the mean to measure this value as well as its potential limitations. In the second part, the existing data concerning usefulness of PI in different clinical settings such as operating theatres, intensive care units and emergency departments will be presented and discussed. Finally, the perspectives concerning the use of PI and mentioned aspects that should be explored regarding this tool will be underlined.
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Affiliation(s)
- Maxime Coutrot
- AP-HP, GH St-Louis-Lariboisière, Department of Anaesthesiology and Critical Care and Burn Unit, Paris, France; FHU PROMICE, Paris, France.
| | - Emmanuel Dudoignon
- AP-HP, GH St-Louis-Lariboisière, Department of Anaesthesiology and Critical Care and Burn Unit, Paris, France; University Paris Diderot, France.
| | - Jona Joachim
- AP-HP, GH St-Louis-Lariboisière, Department of Anaesthesiology and Critical Care and Burn Unit, Paris, France
| | - Etienne Gayat
- AP-HP, GH St-Louis-Lariboisière, Department of Anaesthesiology and Critical Care and Burn Unit, Paris, France; University Paris Diderot, France; UMR INSERM 942, Institut National de la Santé et de la Recherche Médicale (INSERM), France; FHU PROMICE, Paris, France
| | - Fabrice Vallée
- AP-HP, GH St-Louis-Lariboisière, Department of Anaesthesiology and Critical Care and Burn Unit, Paris, France; University Paris Diderot, France; UMR INSERM 942, Institut National de la Santé et de la Recherche Médicale (INSERM), France; FHU PROMICE, Paris, France; Inria, France; LMS, Ecole Polytechnique, CNRS, Institut Polytechnique de Paris, France
| | - François Dépret
- AP-HP, GH St-Louis-Lariboisière, Department of Anaesthesiology and Critical Care and Burn Unit, Paris, France; University Paris Diderot, France; UMR INSERM 942, Institut National de la Santé et de la Recherche Médicale (INSERM), France; FHU PROMICE, Paris, France; F-CRIN INICRCT network, Paris, France
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7
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Lannering K, Elfvin A, Mellander M. Low false-positive rate of perfusion index as a screening tool for neonatal aortic coarctation. Acta Paediatr 2021; 110:1788-1794. [PMID: 33170979 PMCID: PMC8246534 DOI: 10.1111/apa.15661] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 10/20/2020] [Accepted: 11/05/2020] [Indexed: 01/03/2023]
Abstract
Aim Adding perfusion index (PI) to pulse oximetry screening (POS) may increase neonatal detection of CoA (aortic coarctation). A cut‐off <0.7% has been suggested but is associated with a high rate of false positives. We aimed to evaluate the specificity of PI when using repeated instead of single measurements. Methods A pilot study was conducted in 50 neonates. PI was recorded in right hand and a foot by pulse oximeter. If PI was <0.7%, the measurement was immediately repeated up to 3 times. If all three measurements were <0.7% in hand and/or foot the screen was positive and echocardiography was performed. There were 3/50 false‐positive screens. The protocol was therefore modified requiring 30 min intervals between measurements. Results An additional 463 neonates were included using the modified protocol at a median age of 18 h. There were no false positives. The only neonate with CoA had a negative screen (PI hand 1.2% and foot 0.8%). The measurement required on average an extra 3 min and 30 s compared with POS only. Conclusion The false‐positive rate of PI was reduced by using repeated PI measurements. The sensitivity for CoA using this protocol should be evaluated in large‐scale prospective studies.
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Affiliation(s)
- Katarina Lannering
- Department of Pediatrics Institution of Clinical Sciences Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
- Department of Pediatric Cardiology Queen Silvia Children´s Hospital Gothenburg Sweden
| | - Anders Elfvin
- Department of Pediatrics Institution of Clinical Sciences Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
- Department of Neonatology Queen Silvia Children´s Hospital Gothenburg Sweden
| | - Mats Mellander
- Department of Pediatrics Institution of Clinical Sciences Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
- Department of Pediatric Cardiology Queen Silvia Children´s Hospital Gothenburg Sweden
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O'Toole JM, Dempsey EM, Van Laere D. Nonstationary coupling between heart rate and perfusion index in extremely preterm infants in the first day of life. Physiol Meas 2021; 42. [PMID: 33545702 DOI: 10.1088/1361-6579/abe3de] [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: 10/01/2020] [Accepted: 02/05/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Adaptation to the extra-uterine environment presents many challenges for infants born less than 28 weeks of gestation. Quantitative analysis of readily-available physiological signals at the cotside could provide valuable information during this critical time. We aim to assess the time-varying coupling between heart rate (HR) and perfusion index (PI) over the first 24 hours after birth and relate this coupling to gestational age, inotropic therapy, and short-term clinical outcome. APPROACH We develop new nonstationary measures of coupling to summarise both frequency- and direction-dependent coupling. These measures employ a coherence measure capable of measuring time-varying Granger casuality using a short-time information partial directed coherence function. Measures are correlated with gestational age, inotropic therapy (yes/no), and outcome (adverse/normal). MAIN RESULTS In a cohort of 99 extremely preterm infants (<28 weeks of gestation), we find weak but significant coupling in both the HR-to-PI and PI-to-HR directions (P<0.05). HR-to-PI coupling increases with maturation (correlation r=0.26; P=0.011); PI-to-HR coupling increases with inotrope administration (r=0.27; P=0.007). And nonstationary features of PI-to-HR coupling are associated with (r=0.27; P=0.009). SIGNIFICANCE Nonstationary features are necessary to distinguish different coupling types for complex biomedical systems. Time-varying directional coupling between PI and HR provides objective and independent biomarkers of adverse outcome in extremely preterm infants.
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Affiliation(s)
- John M O'Toole
- INFANT Research Centre, University College Cork National University of Ireland, Cork, IRELAND
| | - Eugene M Dempsey
- INFANT Research Centre, , University College Cork National University of Ireland, Cork, IRELAND
| | - David Van Laere
- Department of Neonatal Intensive Care, University Hospital Antwerp, Edegem, Antwerp, BELGIUM
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Buyukeren M, Yiğit Ş, Aykan H, Karagöz T, Çelik H, Yurdakök M. Comparison of perfusion index and echocardiographic parameters in preterm infants with hemodynamically significant patent ductus arteriosus. J Clin Neonatol 2021. [DOI: 10.4103/jcn.jcn_84_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Schwarz CE, O'Toole JM, Livingstone V, Pavel AM, Dempsey EM. Signal Quality of Electrical Cardiometry and Perfusion Index in Very Preterm Infants. Neonatology 2021; 118:672-677. [PMID: 34569547 DOI: 10.1159/000518061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 06/22/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The use of noninvasive monitoring of neonatal hemodynamics is increasing in neonatal care. Methods include noninvasive cardiac output estimated by electrical cardiometry (EC) and peripheral perfusion as perfusion index (PI) using pulse oximetry. Our aim was to evaluate the feasibility to continuously monitor preterm infants with EC and PI during the first 2 postnatal days and the effects of averaging EC data in signal quality (SigQ) analysis. DESIGN Prospective observational study. SETTING Tertiary neonatal academic hospital. PATIENTS Preterm infants <32 weeks gestation from birth until 48 h. MAIN OUTCOME MEASURES Continuous EC and PI measurements. Feasibility was quantified as the time with high SigQ, classified using SigQ index in EC and exception codes in PI. Our predefined threshold for good feasibility was minimum of 24 h with high SigQ for both. RESULTS Twenty-two preterm infants (median [IQR] gestational age 28 + 6 (26 + 0, 30 + 4) weeks + days, birth weight 960 [773, 1,500] g) were included. We recorded a minimum of 24 h with high SigQ in 14 infants for EC (unaveraged data) and 22 infants for PI measurements. The median (range) % of recording time with high SigQ was 74% (50%, 88%) for EC and 94% (82%, 96%) for PI. Using 1 minute averaging for EC data resulted in an increase of infants with minimum 24 h of high SigQ to 21 infants. CONCLUSIONS EC and PI monitoring are feasible in preterm infants within the first 48 h, but SigQ remains problematic for EC. Signal dropout is masked in averaged EC values.
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Affiliation(s)
- Christoph E Schwarz
- Department of Paediatrics & Child Health, University College Cork, Cork, Ireland.,INFANT Research Centre, University College Cork, Cork, Ireland.,Department of Neonatology, University Children's Hospital Tübingen, Tübingen, Germany
| | - John M O'Toole
- Department of Paediatrics & Child Health, University College Cork, Cork, Ireland.,INFANT Research Centre, University College Cork, Cork, Ireland
| | - Vicki Livingstone
- Department of Paediatrics & Child Health, University College Cork, Cork, Ireland.,INFANT Research Centre, University College Cork, Cork, Ireland
| | - Andreea M Pavel
- Department of Paediatrics & Child Health, University College Cork, Cork, Ireland.,INFANT Research Centre, University College Cork, Cork, Ireland
| | - Eugene M Dempsey
- Department of Paediatrics & Child Health, University College Cork, Cork, Ireland.,INFANT Research Centre, University College Cork, Cork, Ireland
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Köksal N, Aygün C, Uras N. Turkish Neonatal Society guideline on the management of patent ductus arteriosus in preterm infants. Turk Arch Pediatr 2018; 53:S76-S87. [PMID: 31236021 PMCID: PMC6568296 DOI: 10.5152/turkpediatriars.2018.01808] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Ductus arteriosus is a physiologic phenomenon in utero and it closes spontaneously in term babies. The closure is problematic in preterm infants due to the intrinsic properties of the preterm ductus arteriosus tissue. Although patent ductus arteriosus has been reported to be associated with many adverse outcomes in this population, treatment has not led to a decrease in outcomes such as bronchopulmonary dysplasia. Treatment modalities also have their own risks and restrictions. The aim of the "Turkish Neonatal Society guidelines for the management of patent ductus arteriosus in preterm babies" is to standardize the diagnosis and treatment of patent ductus arteriosus in preterm infants by combining the current scientific data and the resources of our country.
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Affiliation(s)
- Nilgün Köksal
- Division of Neonatology, Department of Pediatrics, Uludağ University, Faculty of Medicine, Bursa, Turkey
| | - Canan Aygün
- Division of Neonatology, Department of Pediatrics, Ondokuz Mayıs University, Faculty of Medicine, Samsun, Turkey
| | - Nurdan Uras
- Zekai Tahir Burak Womens' Health Training and Research Hospital, Ankara, Turkey
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Nitzan I, Hammerman C, Fink D, Nitzan M, Koppel R, Bromiker R. The effect of patent ductus arteriosus on pre-ductal and post-ductal perfusion index in preterm neonates. Physiol Meas 2018; 39:075006. [PMID: 29943734 DOI: 10.1088/1361-6579/aacf25] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The ductus arteriosus is a blood vessel that connects the pulmonary artery to the descending aorta during fetal life and generally undergoes spontaneous closure shortly after birth. In premature neonates it often fails to close (patent ductus arteriosus-PDA), which can result in diversion of a significant part of the left-ventricular cardiac output to the pulmonary circulation. This left-to-right shunt may result in significant increase of pulmonary blood flow and decrease of systemic perfusion (hemodynamically significant PDA-hsPDA), which may lead to severe neonatal morbidity. The study objective was to find the relationship between hsPDA and perfusion index (PI), a photoplethysmographic parameter related to systemic perfusion. APPROACH PI measures the relative systolic increase in tissue light absorption due to the systolic increase in the tissue blood volume. PI has been found to be directly related to tissue perfusion and is therefore expected to be affected by hsPDA. MAIN RESULTS PI was found to be higher in preterm neonates with hsPDA after first week of life, in comparison to those with closed DA, despite the lower systemic perfusion, probably due to reverse flow during diastole. SIGNIFICANCE In our study, perfusion index increased despite the lower systemic perfusion, indicating that in neonates with hsPDA, perfusion index is not necessarily a measure of perfusion. Nevertheless, PI can be used as a screening tool for suspicious PDA, in order to select a relatively small group of neonates for a more definitive examination by echocardiography, which is not suitable for universal screening.
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Affiliation(s)
- Itamar Nitzan
- Department of Neonatology, Shaare Zedek Medical Center, Jerusalem, Israel
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Singh Y, Katheria AC, Vora F. Advances in Diagnosis and Management of Hemodynamic Instability in Neonatal Shock. Front Pediatr 2018; 6:2. [PMID: 29404312 PMCID: PMC5780410 DOI: 10.3389/fped.2018.00002] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Accepted: 01/05/2018] [Indexed: 01/20/2023] Open
Abstract
Shock in newborn infants has unique etiopathologic origins that require careful assessment to direct specific interventions. Early diagnosis is key to successful management. Unlike adults and pediatric patients, shock in newborn infants is often recognized in the uncompensated phase by the presence of hypotension, which may be too late. The routine methods of evaluation used in the adult and pediatric population are often invasive and less feasible. We aim to discuss the pathophysiology in shock in newborn infants, including the transitional changes at birth and unique features that contribute to the challenges in early identification. Special emphasis has been placed on bedside focused echocardiography/focused cardiac ultrasound, which can be used as an additional tool for early, neonatologist driven, ongoing evaluation and management. An approach to goal oriented management of shock has been described and how bed side functional echocardiography can help in making a logical choice of intervention (fluid therapy, inotropic therapy or vasopressor therapy) in infants with shock.
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Affiliation(s)
- Yogen Singh
- Department of Pediatric Cardiology and Neonatal Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- University of Cambridge Clinical School of Medicine, Cambridge, United Kingdom
| | - Anup C. Katheria
- Department of Neonatology, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, United States
- Department of Neonatology, Loma Linda University School of Medicine, Loma Linda, CA, United States
| | - Farha Vora
- Department of Neonatology, Loma Linda University School of Medicine, Loma Linda, CA, United States
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Van Laere D, Voeten M, O' Toole JM, Dempsey E. Monitoring Circulation During Transition in Extreme Low Gestational Age Newborns: What's on the Horizon? Front Pediatr 2018; 6:74. [PMID: 29632852 PMCID: PMC5879103 DOI: 10.3389/fped.2018.00074] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 03/12/2018] [Indexed: 11/20/2022] Open
Abstract
Echocardiography and near-infrared spectroscopy have significantly changed our view on hemodynamic transition of the extreme preterm infant. Instead of focusing on maintaining an arbitrary target value of blood pressure, we aim for circulatory well-being by a comprehensive holistic assessment of markers of cardiovascular instability. Most of these clinical and biochemical indices are influenced by transition itself and remain poor discriminators to identify patients with a potential need for therapeutic intervention. At the same time, the evolution in data capturing and storage has led to a change in our approach to monitor vital parameters. Continuous trend monitoring has become more and more relevant. By using signal extraction methods, changes in trends over time can be quantified. In this review, we will discuss the impact of these innovations on the current monitoring practices and explore some of the potential benefits these techniques may have in improving real-time detection of extreme low birth weight infants at risk for morbidity related to impaired hemodynamic transition.
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Affiliation(s)
- David Van Laere
- Department of Neonatal Intensive Care, Antwerp University Hospital, Antwerp, Belgium.,Laboratory of Experimental Medicine and Pediatrics, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Michiel Voeten
- Department of Neonatal Intensive Care, Antwerp University Hospital, Antwerp, Belgium.,Laboratory of Experimental Medicine and Pediatrics, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - John M O' Toole
- Irish Centre for Fetal and Neonatal Translational Research, University College Cork, Cork, Ireland
| | - Eugene Dempsey
- Irish Centre for Fetal and Neonatal Translational Research, University College Cork, Cork, Ireland
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15
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Dempsey EM, El-Khuffash AF. Objective cardiovascular assessment in the neonatal intensive care unit. Arch Dis Child Fetal Neonatal Ed 2018; 103:F72-F77. [PMID: 29127152 DOI: 10.1136/archdischild-2017-313837] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 10/11/2017] [Accepted: 10/18/2017] [Indexed: 11/04/2022]
Abstract
Traditionally, cardiovascular well-being was essentially based on whether the mean blood pressure was above or below a certain value. However, this singular crude method of assessment provides limited insight into overall cardiovascular well-being. Echocardiography has become increasingly used and incorporated into clinical care. New objective modality assessments of cardiovascular status continue to evolve and are being evaluated and incorporated into clinical care. In this review article, we will discuss some of the recent advances in objective assessment of cardiovascular well-being, including the concept of multimodal monitoring. Sophisticated haemodynamic monitoring systems are being developed, including mechanisms of data acquisition and analysis. Their incorporation into clinical care represents an exciting next stage in the management of the infant with cardiovascular compromise.
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Affiliation(s)
- Eugene M Dempsey
- Department of Paediatrics and Child Health, Neonatal Intensive Care Unit, University College Cork, Cork, Ireland.,INFANT, Irish Centre for Fetal and Neonatal Translational Research, University College Cork, Cork, Ireland
| | - Afif Faisal El-Khuffash
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland.,Department of Paediatrics, School of Medicine, The Royal College of Surgeons in Ireland, Dublin, Ireland
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16
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De La Peña Sanabria I, Ochoa Martelo M, Baquero Latorre H, Acosta-Reyes J. Índice de perfusión periférica en la UCI neonatal: una respuesta a la monitorización no invasiva del recién nacido crítico. PERINATOLOGÍA Y REPRODUCCIÓN HUMANA 2017. [DOI: 10.1016/j.rprh.2017.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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17
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Gomez-Pomar E, Makhoul M, Westgate PM, Ibonia KT, Patwardhan A, Giannone PJ, Bada HS, Abu Jawdeh EG. Relationship between perfusion index and patent ductus arteriosus in preterm infants. Pediatr Res 2017; 81:775-779. [PMID: 28099422 DOI: 10.1038/pr.2017.10] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 12/27/2016] [Indexed: 11/09/2022]
Abstract
BACKGROUND Perfusion index (PI) is a noninvasive measure of perfusion. ΔPI (difference between pre- and postductal PI) may identify hemodynamically significant PDA. However, studies are limited to brief and intermittent ΔPI sampling. Our objective is to assess the value of continuous high resolution ΔPI monitoring in the diagnosis of PDA. METHODS Continuous ΔPI monitoring in preterm infants was prospectively performed using two high-resolution pulse oximeters. Perfusion Index measures (ΔPI mean and variability, pre- and postductal PI) were analyzed over a 4-h period prior to echocardiography. A cardiologist blinded to the results evaluated for PDA on echocardiography. Linear mixed regression models were utilized for analyses. RESULTS We obtained 31 echocardiography observations. Mean ΔPI (-0.23 vs. 0.16; P < 0.05), mean pre-PI (0.86 vs. 1.26; P < 0.05), and ΔPI variability (0.39 vs. 0.61; P = 0.05) were lower in infants with PDA compared to infants without PDA at the time of echocardiography. CONCLUSION Mean ΔPI, ΔPI variability, and mean pre-PI measured 4 h prior to echocardiography detect PDA in preterm infants. PI is dynamic and should be assessed continuously. Perfusion index is a promising bedside measurement to identify PDA in preterm infants.
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Affiliation(s)
- Enrique Gomez-Pomar
- Division of Neonatology, Department of Pediatrics, University of Kentucky, Lexington, Kentucky
| | - Majd Makhoul
- Division of Cardiology, Department of Pediatrics, University of Kentucky, Lexington, Kentucky
| | - Philip M Westgate
- Department of Biostatistics, University of Kentucky, Lexington, Kentucky
| | - Katrina T Ibonia
- Division of Neonatology, Department of Pediatrics, University of Kentucky, Lexington, Kentucky
| | | | - Peter J Giannone
- Division of Neonatology, Department of Pediatrics, University of Kentucky, Lexington, Kentucky
| | - Henrietta S Bada
- Division of Neonatology, Department of Pediatrics, University of Kentucky, Lexington, Kentucky
| | - Elie G Abu Jawdeh
- Division of Neonatology, Department of Pediatrics, University of Kentucky, Lexington, Kentucky
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18
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Abstract
PURPOSE OF REVIEW Standard hemodynamic monitoring such as heart rate and systemic blood pressure may only provide a crude estimation of organ perfusion during neonatal intensive care. Pulse oximetry monitoring allows for continuous noninvasive monitoring of hemoglobin oxygenation and thus provides estimation of end-organ oxygenation. This review aims to provide an overview of pulse oximetry and discuss its current and potential clinical use during neonatal intensive care. RECENT FINDINGS Technological advances in continuous assessment of dynamic changes in systemic oxygenation with pulse oximetry during transition to extrauterine life and beyond provide additional details about physiological interactions among the key hemodynamic factors regulating systemic blood flow distribution along with the subtle changes that are frequently transient and undetectable with standard monitoring. SUMMARY Noninvasive real-time continuous systemic oxygen monitoring has the potential to serve as biomarkers for early-organ dysfunction, to predict adverse short-term and long-term outcomes in critically ill neonates, and to optimize outcomes. Further studies are needed to establish values predicting adverse outcomes and to validate targeted interventions to normalize abnormal values to improve outcomes.
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Van Laere D, O'Toole JM, Voeten M, McKiernan J, Boylan GB, Dempsey E. Decreased Variability and Low Values of Perfusion Index on Day One Are Associated with Adverse Outcome in Extremely Preterm Infants. J Pediatr 2016; 178:119-124.e1. [PMID: 27593438 DOI: 10.1016/j.jpeds.2016.08.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 06/13/2016] [Accepted: 08/03/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To develop new quantitative features for the Perfusion Index signal recorded continuously over the first 24 hours of life in a cohort of extremely low gestational age newborns and to assess the association of these features with normal and adverse short-term outcome. STUDY DESIGN A cohort study of extremely low gestational age newborns. Adverse outcome was defined as early mortality before 72 hours of life, acquired severe periventricular-intraventricular hemorrhage, or severe cystic leukomalacia. Perfusion Index values were obtained from the plethysmographic signal of a pulse oximeter. Perfusion Index signals were separated into low-frequency (trend) and high-frequency (detrend) components. Three features were extracted during four 6-hour epochs: mean of the trend component (mean-trend), SD of the trend component (SD-trend), and SD of the detrend component (SD-detrend). The SD features represent long-term variability (SD-trend) and short-term variability (SD-detrend) of the Perfusion Index. A mixed-effects model was fitted to each feature. RESULTS Ninety-nine infants were included in the analysis. Quadratic-time mixed-effects models provided the best fit for all 3 features. The mean-trend component was lower for the adverse outcome compared with the normal outcome group with a difference of 0.142 Perfusion Index (P = .001). SD-detrend component was also lower for the adverse compared with the normal outcome group, although this difference of 0.031 Perfusion Index/days2 was dependent on time (P < .001). CONCLUSION Low values and reduced short-term variability of Perfusion Index on day 1 are associated with adverse outcome.
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Affiliation(s)
- David Van Laere
- Department of Neonatal Intensive Care, University Hospital Antwerp, Edegem, Belgium; Department of Medicine and Health Sciences, University of Antwerp, Antwerpen, Belgium.
| | - John M O'Toole
- Irish Centre for Fetal and Neonatal Translational Research, University College Cork, Cork, Ireland
| | - Michiel Voeten
- Department of Neonatal Intensive Care, University Hospital Antwerp, Edegem, Belgium; Department of Medicine and Health Sciences, University of Antwerp, Antwerpen, Belgium
| | - Joanne McKiernan
- Irish Centre for Fetal and Neonatal Translational Research, University College Cork, Cork, Ireland
| | - Geraldine B Boylan
- Irish Centre for Fetal and Neonatal Translational Research, University College Cork, Cork, Ireland
| | - Eugene Dempsey
- Irish Centre for Fetal and Neonatal Translational Research, University College Cork, Cork, Ireland
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Kroese JK, van Vonderen JJ, Narayen IC, Walther FJ, Hooper S, te Pas AB. The perfusion index of healthy term infants during transition at birth. Eur J Pediatr 2016; 175:475-9. [PMID: 26498646 PMCID: PMC4799258 DOI: 10.1007/s00431-015-2650-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Revised: 10/02/2015] [Accepted: 10/05/2015] [Indexed: 11/27/2022]
Abstract
UNLABELLED Perfusion index is a continuous parameter provided by pulse oximetry and might be useful for evaluating hemodynamic changes at birth and identifying transitional problems. The objective was to describe perfusion index values in term infants immediately after birth. Perfusion index of 71 healthy term born infants were recorded during the first 10 min after birth, using a pulse oximetry sensor placed preductally. A Wilcoxon signed-rank test was used to compare between time points. No significant trend in perfusion index could be observed in term-delivered infants. There was a significant difference between 2 and 3 min (2.4 (1.6-5.0) vs. 2.3 (1.6-3.7), p = 0.05) and between 3 and 4 min after birth (2.3 (1.6-3.7) vs. 2.1 (1.4-3.2), p < 0.001). There was no significant change in median PI values in the following 8 min. CONCLUSION Perfusion index does not change significantly during transition at birth in healthy term infants born by normal vaginal delivery or cesarean section. Large variation in perfusion index causes monitoring this parameter to have limited value. WHAT IS KNOWN • Perfusion index is a non-invasive indicator for peripheral perfusion. • Perfusion index values <1.24 are seen as an accurate predictor for severity of illness for infants admitted to the neonatal intensive care unit. What is new: • Although significant physiological changes occur during birth, perfusion index remains stable. • Large variation in perfusion index causes monitoring of this value to have limited value as an additional parameter for evaluating transition at birth.
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Affiliation(s)
- Jacco K. Kroese
- />Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, J6-S, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - Jeroen J. van Vonderen
- />Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, J6-S, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - Ilona C. Narayen
- />Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, J6-S, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - Frans J. Walther
- />Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, J6-S, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - Stuart Hooper
- />MIMR-PHI Institute for Medical Research, Monash University, Clayton, Victoria Australia
| | - Arjan B. te Pas
- />Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, J6-S, PO Box 9600, 2300 RC Leiden, The Netherlands
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21
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Dempsey EM. Challenges in Treating Low Blood Pressure in Preterm Infants. CHILDREN-BASEL 2015; 2:272-88. [PMID: 27417363 PMCID: PMC4928758 DOI: 10.3390/children2020272] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 06/05/2015] [Indexed: 01/02/2023]
Abstract
Whilst the prevalence of low blood pressure in preterm infants seems to have fallen over the last number of years, the problem is still frequently encountered in the neonatal intensive care unit and many babies continue to receive intervention. Great variability in practice persists, with a significant number of extremely low gestational age newborns in some institutions receiving some form of intervention, and in other units substantially less. A great degree of this variability relates to the actual criteria used to define hypotension, with some using blood pressure values alone to direct therapy and others using a combination of clinical, biochemical and echocardiography findings. The choice of intervention remains unresolved with the majority of centres continuing to administer volume followed by dopamine as a first line inotrope/vasopressor agent. Despite over 40 years of use there is little evidence that dopamine is of benefit both in the short term and long-term. Long-term follow up is available in only two randomised trials, which included a total of 99 babies. An under recognized problem relates to the administration of inotrope infusions in very preterm infants. There are no pediatric specific inotrope formulations available and so risks of errors in preparation and administration remain. This manuscript outlines these challenges and proposes some potential solutions.
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Affiliation(s)
- Eugene M Dempsey
- Department of Paediatrics and Child Health, University College Cork, Cork City post code, Ireland.
- Irish Centre for Fetal and Neonatal Translational Research (INFANT), Cork, Ireland.
- Department of Paediatrics and Child Health, Cork University Maternity Hospital, Wilton Cork, Ireland.
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