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Mohammad K, Molloy E, Scher M. Training in neonatal neurocritical care: A case-based interdisciplinary approach. Semin Fetal Neonatal Med 2024:101530. [PMID: 38670881 DOI: 10.1016/j.siny.2024.101530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024]
Abstract
Interdisciplinary fetal-neonatal neurology (FNN) training strengthens neonatal neurocritical care (NNCC) clinical decisions. Neonatal neurological phenotypes require immediate followed by sustained neuroprotective care path choices through discharge. Serial assessments during neonatal intensive care unit (NICU) rounds are supplemented by family conferences and didactic interactions. These encounters collectively contribute to optimal interventions yielding more accurate outcome predictions. Maternal-placental-fetal (MPF) triad disease pathways influence postnatal medical complications which potentially reduce effective interventions and negatively impact outcome. The science of uncertainty regarding each neonate's clinical status must consider timing and etiologies that are responsible for fetal and neonatal brain disorders. Shared clinical decisions among all stakeholders' balance "fast" (heuristic) and "slow" (analytic) thinking as more information is assessed regarding etiopathogenetic effects that impair the developmental neuroplasticity process. Two case vignettes stress the importance of FNN perspectives during NNCC that integrates this dual cognitive approach. Clinical care paths evaluations are discussed for an encephalopathic extremely preterm and full-term newborn. Recognition of cognitive errors followed by debiasing strategies can improve clinical decisions during NICU care. Re-evaluations with serial assessments of examination, imaging, placental-cord, and metabolic-genetic information improve clinical decisions that maintain accuracy for interventions and outcome predictions. Discharge planning includes shared decisions among all stakeholders when coordinating primary care, pediatric subspecialty, and early intervention participation. Prioritizing social determinants of healthcare during FNN training strengthens equitable career long NNCC clinical practice, education, and research goals. These perspectives contribute to a life course brain health capital strategy that will benefit all persons across each and successive lifespans.
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Affiliation(s)
| | | | - Mark Scher
- Pediatrics/Neurology, Case Western Reserve University, Cleveland, USA.
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2
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Stroe MS, Van Bockstal L, Valenzuela A, Ayuso M, Leys K, Annaert P, Carpentier S, Smits A, Allegaert K, Zeltner A, Mulder A, Van Ginneken C, Van Cruchten S. Development of a neonatal Göttingen Minipig model for dose precision in perinatal asphyxia: technical opportunities, challenges, and potential further steps. Front Pediatr 2023; 11:1163100. [PMID: 37215599 PMCID: PMC10195037 DOI: 10.3389/fped.2023.1163100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 04/21/2023] [Indexed: 05/24/2023] Open
Abstract
Animal models provide useful information on mechanisms in human disease conditions, but also on exploring (patho)physiological factors affecting pharmacokinetics, safety, and efficacy of drugs in development. Also, in pediatric patients, nonclinical data can be critical for better understanding the disease conditions and developing new drug therapies in this age category. For perinatal asphyxia (PA), a condition defined by oxygen deprivation in the perinatal period and possibly resulting in hypoxic ischemic encephalopathy (HIE) or even death, therapeutic hypothermia (TH) together with symptomatic drug therapy, is the standard approach to reduce death and permanent brain damage in these patients. The impact of the systemic hypoxia during PA and/or TH on drug disposition is largely unknown and an animal model can provide useful information on these covariates that cannot be assessed separately in patients. The conventional pig is proven to be a good translational model for PA, but pharmaceutical companies do not use it to develop new drug therapies. As the Göttingen Minipig is the commonly used pig strain in nonclinical drug development, the aim of this project was to develop this animal model for dose precision in PA. This experiment consisted of the instrumentation of 24 healthy male Göttingen Minipigs, within 24 h of partus, weighing approximately 600 g, to allow the mechanical ventilation and the multiple vascular catheters inserted for maintenance infusion, drug administration and blood sampling. After premedication and induction of anesthesia, an experimental protocol of hypoxia was performed, by decreasing the inspiratory oxygen fraction (FiO2) at 15%, using nitrogen gas. Blood gas analysis was used as an essential tool to evaluate oxygenation and to determine the duration of the systemic hypoxic insult to approximately 1 h. The human clinical situation was mimicked for the first 24 h after birth in case of PA, by administering four compounds (midazolam, phenobarbital, topiramate and fentanyl), frequently used in a neonatal intensive care unit (NICU). This project aimed to develop the first neonatal Göttingen Minipig model for dose precision in PA, allowing to separately study the effect of systemic hypoxia versus TH on drug disposition. Furthermore, this study showed that several techniques that were thought to be challenging or even impossible in these very small animals, such as endotracheal intubation and catheterization of several veins, are feasible by trained personnel. This is relevant information for laboratories using the neonatal Göttingen Minipig for other disease conditions or drug safety testing.
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Affiliation(s)
| | | | - Allan Valenzuela
- Comparative Perinatal Development, University of Antwerp, Antwerp, Belgium
| | - Miriam Ayuso
- Comparative Perinatal Development, University of Antwerp, Antwerp, Belgium
| | - Karen Leys
- Drug Delivery and Disposition, KU Leuven, Leuven, Belgium
| | - Pieter Annaert
- Drug Delivery and Disposition, KU Leuven, Leuven, Belgium
- BioNotus GCV, Niel, Belgium
| | | | - Anne Smits
- Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Karel Allegaert
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- Department of Hospital Pharmacy, Erasmus MC, Rotterdam, Netherlands
| | | | - Antonius Mulder
- Neonatal Intensive Care Unit, Antwerp University Hospital, Antwerp, Belgium
| | - Chris Van Ginneken
- Comparative Perinatal Development, University of Antwerp, Antwerp, Belgium
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Mandal K, Sangabathuni S, Haghniaz R, Kawakita S, Mecwan M, Nakayama A, Zhang X, Edalati M, Huang W, Lopez Hernandez A, Jucaud V, Dokmeci MR, Khademhosseini A. Oxygen-generating microparticles downregulate HIF-1α expression, increase cardiac contractility, and mitigate ischemic injury. Acta Biomater 2023; 159:211-225. [PMID: 36669549 PMCID: PMC9992239 DOI: 10.1016/j.actbio.2023.01.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 12/20/2022] [Accepted: 01/11/2023] [Indexed: 01/19/2023]
Abstract
Myocardial hypoxia is the low oxygen tension in the heart tissue implicated in many diseases, including ischemia, cardiac dysfunction, or after heart procurement for transplantation. Oxygen-generating microparticles have recently emerged as a potential strategy for supplying oxygen to sustain cell survival, growth, and tissue functionality in hypoxia. Here, we prepared oxygen-generating microparticles with poly D,L-lactic-co-glycolic acid, and calcium peroxide (CPO), which yielded a continuous morphology capable of sustained oxygen release for up to 24 h. We demonstrated that CPO microparticles increased primary rat cardiomyocyte metabolic activity while not affecting cell viability during hypoxia. Moreover, hypoxia-inducible factor (HIF)-1α, which is upregulated during hypoxia, can be downregulated by delivering oxygen using CPO microparticles. Single-cell traction force microscopy data demonstrated that the reduced energy generated by hypoxic cells could be restored using CPO microparticles. We engineered cardiac tissues that showed higher contractility in the presence of CPO microparticles compared to hypoxic cells. Finally, we observed reduced myocardial injuries in ex vivo rabbit hearts treated with CPO microparticles. In contrast, an acute early myocardial injury was observed for the hearts treated with control saline solution in hypoxia. In conclusion, CPO microparticles improved cell and tissue contractility and gene expression while reducing hypoxia-induced myocardial injuries in the heart. STATEMENT OF SIGNIFICANCE: Oxygen-releasing microparticles can reduce myocardial ischemia, allograft rejection, or irregular heartbeats after heart transplantation. Here we present biodegradable oxygen-releasing microparticles that are capable of sustained oxygen release for more than 24 hrs. We then studied the impact of sustained oxygen release from microparticles on gene expresseion and cardiac cell and tissue function. Previous studies have not measured cardiac tissue or cell mechanics during hypoxia, which is important for understanding proper cardiac function and beating. Using traction force microscopy and an engineered tissue-on-a-chip, we demonstrated that our oxygen-releasing microparticles improve cell and tissue contractility during hypoxia while downregulating the HIF-1α expression level. Finally, using the microparticles, we showed reduced myocardial injuries in rabbit heart tissue, confirming the potential of the particles to be used for organ transplantation or tissue engineering.
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Affiliation(s)
- Kalpana Mandal
- Terasaki Institute for Biomedical Innovation, Los Angeles, California 90064, USA.
| | - Sivakoti Sangabathuni
- Terasaki Institute for Biomedical Innovation, Los Angeles, California 90064, USA; California NanoSystems Institute, University of California, Los Angeles, California 90095, USA
| | - Reihaneh Haghniaz
- Terasaki Institute for Biomedical Innovation, Los Angeles, California 90064, USA; California NanoSystems Institute, University of California, Los Angeles, California 90095, USA; Department of Bioengineering, University of California, Los Angeles, California 90095, USA
| | - Satoru Kawakita
- Terasaki Institute for Biomedical Innovation, Los Angeles, California 90064, USA
| | - Marvin Mecwan
- Terasaki Institute for Biomedical Innovation, Los Angeles, California 90064, USA
| | - Aya Nakayama
- Terasaki Institute for Biomedical Innovation, Los Angeles, California 90064, USA
| | - Xuexiang Zhang
- Department of Bioengineering, University of California, Los Angeles, California 90095, USA
| | - Masoud Edalati
- Terasaki Institute for Biomedical Innovation, Los Angeles, California 90064, USA
| | - Wei Huang
- Terasaki Institute for Biomedical Innovation, Los Angeles, California 90064, USA
| | - Ana Lopez Hernandez
- Terasaki Institute for Biomedical Innovation, Los Angeles, California 90064, USA
| | - Vadim Jucaud
- Terasaki Institute for Biomedical Innovation, Los Angeles, California 90064, USA
| | - Mehmet R Dokmeci
- Terasaki Institute for Biomedical Innovation, Los Angeles, California 90064, USA.
| | - Ali Khademhosseini
- Terasaki Institute for Biomedical Innovation, Los Angeles, California 90064, USA.
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Subclinical Left Ventricular Systolic Dysfunction due to Coronary Arterial Thrombosis in a Neonate with Hypoxic Ischemic Encephalopathy Undergoing Therapeutic Hypothermia. CASE 2022; 6:330-334. [PMID: 36172471 PMCID: PMC9510624 DOI: 10.1016/j.case.2022.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Routine clinical parameters are not reliable surrogates of “low cardiac output” in HIE. TnECHO screening may identify subclinical myocardial dysfunction in neonates. TH may positively modulate myocardial oxygen consumption in myocardial ischemia. Rigorous echo training and collaboration with pediatric cardiology are imperative.
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5
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Ovali F. Hemodynamic changes and evaluation during hypoxic-ischemic encephalopathy and therapeutic hypothermia. Early Hum Dev 2022; 167:105563. [PMID: 35248984 DOI: 10.1016/j.earlhumdev.2022.105563] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 02/17/2022] [Accepted: 02/22/2022] [Indexed: 11/03/2022]
Abstract
Multiorgan damage is a hallmark of hypoxic-ischemic encephalopathy and cardiovascular and hemodynamic changes during asphyxia contribute significantly to the brain damage. The main insult to the heart is myocardial damage and associated ventricular dysfunction, which is manifested by reduced preload and afterload. The immature myocardium reacts to asphyxia by bradycardia and reduced contractile capacity. Pulmonary hypertension aggrevates cardiac dysfunction. Hypothermia is the only effective treatment for HIE but it may also affect the heart and peripheral vascular system leading to bradycardia and peripheral vasoconstriction. In fact, these effects might be cardioprotective also. Rewarming after hypothermia may increase the heart rate and cardiac metabolism, augmenting the cardiac output. Monitoring of patient with HIE during and after hypothermia is possible by using near-infrared spectroscopy, echocardiography and electrocardiography. Cerebral effects may be monitored by magnetic resonance imaging also. Management should include the physiological status of the patient and appropriate treatments, including inotropes, vasopressors or rarely fluid boluses. Dopamine should not be used unless absolutely necessary. Drugs like melatonin and magnesium are under investigation. All treatments should be evidence-based and targeted echocardiography should be used more often in these vulnerable infants.
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Affiliation(s)
- Fahri Ovali
- Istanbul Medeniyet University, Medical Faculty, Department of Pediatrics, Division of Neonatology, Göztepe, İstanbul, Turkey.
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6
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Zare gashti R, Mohammadi H. Sodium dithionate (Na2S2O4) induces oxidative damage in mice mitochondria heart tissue. Toxicol Rep 2022; 9:1391-1397. [DOI: 10.1016/j.toxrep.2022.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 06/18/2022] [Accepted: 06/22/2022] [Indexed: 10/17/2022] Open
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Rios DR, Lapointe A, Schmolzer GM, Mohammad K, VanMeurs KP, Keller RL, Sehgal A, Lakshminrusimha S, Giesinger RE. Hemodynamic optimization for neonates with neonatal encephalopathy caused by a hypoxic ischemic event: Physiological and therapeutic considerations. Semin Fetal Neonatal Med 2021; 26:101277. [PMID: 34481738 DOI: 10.1016/j.siny.2021.101277] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Neonatal encephalopathy due to a hypoxic-ischemic event is commonly associated with cardiac dysfunction and acute pulmonary hypertension; both therapeutic hypothermia and rewarming modify loading conditions and blood flow. The pathophysiological contributors to disease are complex with a high degree of clinical overlap and traditional bedside measures used to assess circulatory adequacy have multiple confounders. Comprehensive, quantitative echocardiography may be used to delineate the relative contribution of lung parenchymal, pulmonary vascular, and cardiac disease to hypotension and/or hypoxemic respiratory failure. In this review, we provide a detailed overview of the contributors to hemodynamic instability following perinatal hypoxic-ischemic injury. Our proposed approach to therapy focuses on physiopathological considerations with interventions individualized to this potentially complex condition and considers the pharmacological idiosyncrasies, which may occur among neonates with NE presenting with multiorgan dysfunction while undergoing therapeutic hypothermia.
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Affiliation(s)
- Danielle R Rios
- Department of Pediatrics, Division of Neonatology, University of Iowa, MS 200 Hawkins Drive 8800 JPP, Iowa City, IA, 52242, USA.
| | - Anie Lapointe
- CHU Ste-Justine, Montreal University, CHU Sainte-Justine 3175, chemin Côte Sainte-Catherine Montréal (Québec), H3T 1C5, Canada.
| | - Georg M Schmolzer
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, 10240 Kingsway Avenue NW AB, Edmonton, T5H 3V9, Canada.
| | - Khorshid Mohammad
- Department of Pediatrics, Section of Neonatology, University of Calgary, 28 Oki Drive NW, Calgary, AB, T3B 6A8, Canada.
| | - Krisa P VanMeurs
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital, Center for Academic Medicine Division of Neonatology - MC 5660 453 Quarry Road, Palo Alto, CA, 94304, USA.
| | - Roberta L Keller
- Department of Pediatrics, University of California San Francisco, 550 16th. Street, San Francisco, CA, 94158, USA.
| | - Arvind Sehgal
- Department of Pediatrics, Monash University, 246 Clayton Road, Clayton, Melbourne, VIC, 3168, Australia.
| | - Satyan Lakshminrusimha
- Department of Pediatrics, Division of Neonatology, University of California, Davis, 2516 Stockton Blvd, Sacramento, CA 95817, USA.
| | - Regan E Giesinger
- Department of Pediatrics, Division of Neonatology, University of Iowa, MS 200 Hawkins Drive 8800 JPP, Iowa City, IA, 52242, USA.
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8
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Li S, Li J, Zhou H, Xiong L. Research progress of IGF-1 and cerebral ischemia. IBRAIN 2021; 7:57-67. [PMID: 37786870 PMCID: PMC10528794 DOI: 10.1002/j.2769-2795.2021.tb00066.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 02/26/2021] [Accepted: 03/20/2021] [Indexed: 10/04/2023]
Abstract
Cerebral ischemic disease is a group of diseases that cause insufficient blood supply to the cerebrum, cerebellum or brain stem for different reasons, resulting in corresponding nervous system symptoms. Cardiovascular disease is the leading cause of death in the world. Among them, the death caused by cerebral ischemia accounts for the vast majority, and it is one of the fatal diseases in the middle-aged and elderly at present. Epidemiologic studies have projected increasing mortality due to cardiovascular disease worldwide (about 23.3 million people by 2030) because of the aging population. However, related studies have shown that insulin-like growth factor I (IGF-1) is a multifunctional cell proliferation regulator. It plays an important role in cerebral ischemia. It is effective in promoting cell differentiation, proliferation and individual development. Studies have shown that IGF-1 signaling pathway is a key pathway controlling cell growth and survival. There may be five mechanisms in cerebral ischemia: prevention of intracellular calcium overload, inhibition of the upregulation of nNOS, IGF-1upregulations activating HIF-1α, regulation of Bcl-2 to resist apoptosis, and enhancement of vascular endothelial function. Three critical nodes in the IGF-1 signaling pathway have been described in cardiomyocytes: protein kinase Akt/mammalian target of rapamycin (mTOR), Ras/Raf/extracellular signal-regulated kinase (ERK), and phospholipase C (PLC)/inositol 1,4,5-triphosphate (InsP3)/Ca2+. IGF-1 plays an important role in cerebral ischemia and myocardial ischemia, mainly by activating downstream of IGF-1, controlling cell death and differentiation or transcription work, improving the function of heart muscle cells, reducing the myocardial cell apoptosis induced by myocardial infarction, regulating endogenous protection and restoration of cerebral ischemia injury, thus protecting cerebral and myocardial injury. Related studies have shown that bcl-2 exerts great influence on both cerebral ischemia and myocardial ischemia. Therefore, the relevant pathways and targets of cerebral ischemia and myocardial ischemia and the role of IGF-1 in protecting the heart are reviewed in this paper.
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Affiliation(s)
- Shun‐Lian Li
- Clinical and Health Sciences, University of South AustraliaAdelaide5000South AustraliaAustralia
- Department of AnesthesiaZunyi Medical UniversityZunyiGuizhouPeople's Republic of China
| | - Jing Li
- Clinical and Health Sciences, University of South AustraliaAdelaide5000South AustraliaAustralia
| | - Hong‐Su Zhou
- Clinical and Health Sciences, University of South AustraliaAdelaide5000South AustraliaAustralia
| | - Liu‐Lin Xiong
- Clinical and Health Sciences, University of South AustraliaAdelaide5000South AustraliaAustralia
- Department of AnesthesiaZunyi Medical UniversityZunyiGuizhouPeople's Republic of China
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van Wincoop M, de Bijl-Marcus K, Lilien M, van den Hoogen A, Groenendaal F. Effect of therapeutic hypothermia on renal and myocardial function in asphyxiated (near) term neonates: A systematic review and meta-analysis. PLoS One 2021; 16:e0247403. [PMID: 33630895 PMCID: PMC7906340 DOI: 10.1371/journal.pone.0247403] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 02/08/2021] [Indexed: 01/20/2023] Open
Abstract
Background Therapeutic hypothermia (TH) is a well-established neuroprotective therapy applied in (near) term asphyxiated infants. However, little is known regarding the effects of TH on renal and/or myocardial function. Objectives To describe the short- and long-term effects of TH on renal and myocardial function in asphyxiated (near) term neonates. Methods An electronic search strategy incorporating MeSH terms and keywords was performed in October 2019 and updated in June 2020 using PubMed and Cochrane databases. Inclusion criteria consisted of a RCT or observational cohort design, intervention with TH in a setting of perinatal asphyxia and available long-term results on renal and myocardial function. We performed a meta-analysis and heterogeneity and sensitivity analyses using a random effects model. Subgroup analysis was performed on the method of cooling. Results Of the 107 studies identified on renal function, 9 were included. None of the studies investigated the effects of TH on long-term renal function after perinatal asphyxia. The nine included studies described the effect of TH on the incidence of acute kidney injury (AKI) after perinatal asphyxia. Meta-analysis showed a significant difference between the incidence of AKI in neonates treated with TH compared to the control group (RR = 0.81; 95% CI 0.67–0.98; p = 0.03). No studies were found investigating the long-term effects of TH on myocardial function after neonatal asphyxia. Possible short-term beneficial effects were presented in 4 out of 5 identified studies, as observed by significant reductions in cardiac biomarkers and less findings of myocardial dysfunction on ECG and cardiac ultrasound. Conclusions TH in asphyxiated neonates reduces the incidence of AKI, an important risk factor for chronic kidney damage, and thus is potentially renoprotective. No studies were found on the long-term effects of TH on myocardial function. Short-term outcome studies suggest a cardioprotective effect.
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Affiliation(s)
- Maureen van Wincoop
- Department of Neonatology, Wilhelmina Children’s Hospital, University Medical Centre Utrecht and Utrecht University, Utrecht, The Netherlands
| | - Karen de Bijl-Marcus
- Department of Neonatology, Wilhelmina Children’s Hospital, University Medical Centre Utrecht and Utrecht University, Utrecht, The Netherlands
- * E-mail:
| | - Marc Lilien
- Department of Pediatric Nephrology, Wilhelmina Children’s Hospital, University Medical Centre Utrecht and Utrecht University, Utrecht, The Netherlands
| | - Agnes van den Hoogen
- Department of Neonatology, Wilhelmina Children’s Hospital, University Medical Centre Utrecht and Utrecht University, Utrecht, The Netherlands
| | - Floris Groenendaal
- Department of Neonatology, Wilhelmina Children’s Hospital, University Medical Centre Utrecht and Utrecht University, Utrecht, The Netherlands
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10
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Pang R, Mintoft A, Crowley R, Sellwood M, Mitra S, Robertson NJ. Optimizing hemodynamic care in neonatal encephalopathy. Semin Fetal Neonatal Med 2020; 25:101139. [PMID: 33223016 DOI: 10.1016/j.siny.2020.101139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Hemodynamic impairment occurs in up to 80% of infants with neonatal encephalopathy (NE). Not all infants benefit from therapeutic hypothermia (HT); there are some indications that the trajectory of brain injury might be modified by neurologic monitoring and early management over the first 72-h period. It is also possible that optimizing hemodynamic management may further improve outomes. The coupling between cerebral blood flow and cerebral metabolism is disrupted in NE, increasing the vulnerability of the newborn brain to secondary injury. Hemodynamic monitoring is usually limited to blood pressure and functional echocardiographic measurements, which may not accurately reflect brain perfusion. This review explores the evidence base for hemodynamic assessment and management of infants with NE while undergoing HT. We discuss the literature behind a systematic approach to a baby with NE with the aim to define best therapies to optimize brain perfusion and reduce secondary injury.
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Affiliation(s)
- Raymand Pang
- Institute for Women's Health, University College London, London, UK
| | - Alison Mintoft
- Institute for Women's Health, University College London, London, UK
| | - Rose Crowley
- Department of Neonatology, University College London Hospital, London, UK
| | - Mark Sellwood
- Department of Neonatology, University College London Hospital, London, UK
| | - Subhabrata Mitra
- Institute for Women's Health, University College London, London, UK
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Abstract
Severely asphyxiated neonates have acute heart failure as part of their multiorgan dysfunction syndrome during the first days of life. Supporting the cardiovascular system during this phase is part of contemporary treatment and regarded as vital for limiting the neurodevelopmental injury. The decision to treat cardiovascular instability should be based on evaluation of end-organ function. Neonatologist-performed echocardiography in combination with other diagnostic modalities enables comprehensive real-time assessment. This review discusses associations between hemodynamics and adverse outcome, modalities for evaluating the hemodynamic state of the infant, and therapeutic approaches during intensive care.
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O'Dea M, Sweetman D, Bonifacio SL, El-Dib M, Austin T, Molloy EJ. Management of Multi Organ Dysfunction in Neonatal Encephalopathy. Front Pediatr 2020; 8:239. [PMID: 32500050 PMCID: PMC7243796 DOI: 10.3389/fped.2020.00239] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Accepted: 04/20/2020] [Indexed: 12/16/2022] Open
Abstract
Neonatal Encephalopathy (NE) describes neonates with disturbed neurological function in the first post-natal days of life. NE is an overall term that does not specify the etiology of the encephalopathy although it often involves hypoxia-ischaemia. In NE, although neurological dysfunction is part of the injury and is most predictive of long-term outcome, these infants may also have multiorgan injury and compromise, which further contribute to neurological impairment and long-term morbidities. Therapeutic hypothermia (TH) is the standard of care for moderate to severe NE. Infants with NE may have co-existing immune, respiratory, endocrine, renal, hepatic, and cardiac dysfunction that require individualized management and can be impacted by TH. Non-neurological organ dysfunction not only has a negative effect on long term outcome but may also influence the efficacy of treatments in the acute phase. Post resuscitative care involves stabilization and decisions regarding TH and management of multi-organ dysfunction. This management includes detailed neurological assessment, cardio-respiratory stabilization, glycaemic and fluid control, sepsis evaluation and antibiotics, seizure identification, and monitoring and responding to biochemical and coagulation derangements. The emergence of new biomarkers of specific organ injury may have predictive value and improve the definition of organ injury and prognosis. Further evidence-based research is needed to optimize management of NE, prevent further organ dysfunction and reduce neurodevelopmental impairment.
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Affiliation(s)
- Mary O'Dea
- Discipline of Paediatrics, Trinity College, The University of Dublin, Dublin, Ireland
- Paediatric Research Laboratory, Trinity Translational Institute, St. James' Hospital, Dublin, Ireland
- Neonatology, Coombe Women and Infant's University Hospital, Dublin, Ireland
- National Children's Research Centre, Dublin, Ireland
| | - Deirdre Sweetman
- National Children's Research Centre, Dublin, Ireland
- Paediatrics, National Maternity Hospital, Dublin, Ireland
| | - Sonia Lomeli Bonifacio
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, United States
| | - Mohamed El-Dib
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Topun Austin
- Neonatal Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Eleanor J. Molloy
- Discipline of Paediatrics, Trinity College, The University of Dublin, Dublin, Ireland
- Paediatric Research Laboratory, Trinity Translational Institute, St. James' Hospital, Dublin, Ireland
- Neonatology, Coombe Women and Infant's University Hospital, Dublin, Ireland
- National Children's Research Centre, Dublin, Ireland
- Paediatrics, National Maternity Hospital, Dublin, Ireland
- Neonatology, Children's Hospital Ireland (CHI) at Crumlin, Dublin, Ireland
- Paediatrics, CHI at Tallaght, Tallaght University Hospital, Dublin, Ireland
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13
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Huun MU, Garberg H, Løberg EM, Escobar J, Martinez-Orgado J, Saugstad OD, Solberg R. DHA and therapeutic hypothermia in a short-term follow-up piglet model of hypoxia-ischemia: Effects on H+MRS biomarkers. PLoS One 2018; 13:e0201895. [PMID: 30086156 PMCID: PMC6080779 DOI: 10.1371/journal.pone.0201895] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 07/24/2018] [Indexed: 12/22/2022] Open
Abstract
Background Therapeutic hypothermia has become the standard of care for newborns with hypoxic-ischemic encephalopathy in high and middle income countries. Docosahexaenoic acid (DHA) has neuroprotective properties of reducing excitotoxicity, neuroinflammation and apoptosis in rodent models. We aim to study whether post hypoxic administration of i.v. DHA will reduce H+MRS biomarkers and gene expression of inflammation and apoptosis both with and without hypothermia in a large animal model. Methods Fifty-five piglets were randomized to severe global hypoxia (N = 48) or not (Sham, N = 7). Hypoxic piglets were further randomized by factorial design: Vehicle (VEH), DHA, VEH + Hypothermia (HT), or DHA + HT. 5 mg/kg DHA was given intravenously 210 min after end of hypoxia. Two-way ANOVA analyses were performed with DHA and hypothermia as main effects. Results Cortical lactate/N-acetylaspartate (Lac/NAA) was significantly reduced in DHA + HT compared to HT. DHA had significant main effects on increasing N-acetylaspartate and glutathione in hippocampus. Therapeutic hypothermia significantly reduced the Lac/NAA ratio and protein expression of IL-1β and TNFα in hippocampus and reduced Troponin T in serum. Neuropathology showed significant differences between sham and hypoxia, but no differences between intervention groups. Conclusion DHA and therapeutic hypothermia significantly improve specific H+MRS biomarkers in this short-term follow up model of hypoxia-ischemia. Longer recovery periods are needed to evaluate whether DHA can offer translational neuroprotection.
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Affiliation(s)
- Marianne Ullestad Huun
- Department of Pediatric Research, Women and Children's Division and Institute for Surgical Research, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- University of Oslo, Oslo, Norway
- * E-mail:
| | - Håvard Garberg
- Department of Pediatric Research, Women and Children's Division and Institute for Surgical Research, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Else Marit Løberg
- Department of Pathology, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Javier Escobar
- Department of Pediatric Research, Women and Children's Division and Institute for Surgical Research, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Neonatal Research Unit, Health Research Institute Hospital La Fe, Valencia, Spain
| | | | - Ola Didrik Saugstad
- Department of Pediatric Research, Women and Children's Division and Institute for Surgical Research, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- University of Oslo, Oslo, Norway
| | - Rønnaug Solberg
- Department of Pediatric Research, Women and Children's Division and Institute for Surgical Research, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Department of Pediatrics, Vestfold Hospital Trust, Tønsberg, Norway
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14
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Natarajan G, Laptook A, Shankaran S. Therapeutic Hypothermia: How Can We Optimize This Therapy to Further Improve Outcomes? Clin Perinatol 2018; 45:241-255. [PMID: 29747886 PMCID: PMC5953210 DOI: 10.1016/j.clp.2018.01.010] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Neonatal hypoxic-ischemic encephalopathy remains associated with considerable death and disability. In multiple randomized controlled trials, therapeutic hypothermia for neonatal moderate or severe hypoxic-ischemic encephalopathy among term infants has been shown to be safe and effective in reducing death and disability in survivors. In this article, the current status of infant and childhood outcomes following this therapy is reviewed. The clinical approaches that may help to optimize this innovative neuroprotective therapy are presented.
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Affiliation(s)
- Girija Natarajan
- Department of Pediatrics, Wayne State University, Children’s Hospital of Michigan and Hutzel Women’s Hospital, Detroit, MI
| | - Abbot Laptook
- Department of Pediatrics, Women and Infants Hospital of Rhode Island, Brown University, Providence, RI
| | - Seetha Shankaran
- Department of Pediatrics, Division of Neonatology, Wayne State University, Children's Hospital of Michigan and Hutzel Women's Hospital, 3901 Beaubien Boulevard, Detroit, MI 48201, USA.
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15
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Abiramalatha T, Kumar M, Chandran S, Sudhakar Y, Thenmozhi M, Thomas N. Troponin-T as a biomarker in neonates with perinatal asphyxia. J Neonatal Perinatal Med 2018; 10:275-280. [PMID: 28854510 DOI: 10.3233/npm-16119] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Troponin-T is a commonly used cardiac biomarker, which could be useful in perinatal asphyxia. We aimed to analyze troponin-T concentrations in asphyxiated neonates and to correlate the concentrations with clinical outcomes. METHODS Data were collected from electronic medical records of neonates diagnosed with perinatal asphyxia over a period of four years. RESULTS There were 63 neonates with moderate to severe encephalopathy, in whom serial troponin-T concentrations had been done on days 1, 3, and 7. 53 (84%) asphyxiated infants had troponin-T concentration >100 pg/ml at 2-4 h of life.The difference in troponin-T concentrations between moderate and severe encephalopathy was not statistically significant (173 vs. 263 pg/ml, p value 0.40). The difference in the concentrations at 72 hours between cooled and non-cooled neonates was not significant (48.5 vs. 62.5 pg/ml, p value 0.22). Troponin-T concentration was significantly higher in babies with hypotensive shock and hepatic injury, but not acute kidney injury. There was no significant correlation between troponin-T and the extent of resuscitation needed.Troponin-T concentration on day 1 of life was significantly higher in babies who died than who survived (407 vs. 168 pg/ml, p value 0.03). ROC curve for troponin-T to predict mortality had an area under the curve (AUC) of 0.803; the best cut-off value (190 pg/ml) had 82% sensitivity and 80% specificity. CONCLUSION There was no significant difference in troponin-T concentrations between cooled and non-cooled neonates. Troponin-T concentration had a good predictive accuracy for mortality before discharge.
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Affiliation(s)
- T Abiramalatha
- Department of Neonatology, Christian Medical College, Vellore, Tamil Nadu, India
| | - M Kumar
- Department of Neonatology, Christian Medical College, Vellore, Tamil Nadu, India
| | - S Chandran
- Department of Neonatology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Y Sudhakar
- Department of Biochemistry, Christian Medical College, Vellore, Tamil Nadu, India
| | - M Thenmozhi
- Department of Biostatistics, Christian Medical College, Vellore, Tamil Nadu, India
| | - N Thomas
- Department of Neonatology, Christian Medical College, Vellore, Tamil Nadu, India
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Goulding RM, Stevenson NJ, Murray DM, Livingstone V, Filan PM, Boylan GB. Heart rate variability in hypoxic ischemic encephalopathy during therapeutic hypothermia. Pediatr Res 2017; 81:609-615. [PMID: 27855152 DOI: 10.1038/pr.2016.245] [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: 03/18/2016] [Accepted: 09/12/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Therapeutic hypothermia (TH) aims to ameliorate further injury in infants with moderate and severe hypoxic ischemic encephalopathy (HIE). We aim to assess the effect of TH on heart rate variability (HRV) in infants with HIE. METHODS Multichannel video-electroencephalography (EEG) and electrocardiography were assessed at 6-72 h after birth in full-term infants with HIE, recruited prior to (pre-TH group) and following (TH group) the introduction of TH in our neonatal unit. HIE severity was graded using EEG. HRV features investigated include: mean NN interval (mean NN), standard deviation of NN interval (SDNN), triangular interpolation (TINN), high-frequency (HF), low-frequency (LF), very low-frequency (VLF), and LF/HF ratio. Linear mixed model comparisons were used. RESULTS 118 infants (pre-TH: n = 44, TH: n = 74) were assessed. The majority of HRV features decreased with increasing EEG grade. Infants with moderate HIE undergoing TH had significantly different HRV features compared with the pre-TH group (HF: P = 0.016, LF/HF ratio: P = 0.006). In the pre-TH group, LF/HF ratio was significantly different between moderate and severe HIE grades (P = 0.002). In the TH group, significant differences were observed between moderate and severe HIE grades for SDNN: P = 0.020, TINN: P = 0.005, VLF: P = 0.029, LF: P = 0.010, and HF: P = 0.006. CONCLUSION The HF component of HRV is increased in infants with moderate HIE undergoing TH.
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Affiliation(s)
- Robert M Goulding
- INFANT Centre, Neonatal Brain Research Group, University College Cork, Cork, Ireland.,Department of Pediatrics and Child Health, Cork University Maternity Hospital, Cork, Ireland
| | - Nathan J Stevenson
- INFANT Centre, Neonatal Brain Research Group, University College Cork, Cork, Ireland
| | - Deirdre M Murray
- INFANT Centre, Neonatal Brain Research Group, University College Cork, Cork, Ireland.,Department of Pediatrics and Child Health, Cork University Maternity Hospital, Cork, Ireland
| | - Vicki Livingstone
- INFANT Centre, Neonatal Brain Research Group, University College Cork, Cork, Ireland
| | - Peter M Filan
- Department of Pediatrics and Child Health, Cork University Maternity Hospital, Cork, Ireland
| | - Geraldine B Boylan
- INFANT Centre, Neonatal Brain Research Group, University College Cork, Cork, Ireland.,Department of Pediatrics and Child Health, Cork University Maternity Hospital, Cork, Ireland
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17
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Giesinger RE, Bailey LJ, Deshpande P, McNamara PJ. Hypoxic-Ischemic Encephalopathy and Therapeutic Hypothermia: The Hemodynamic Perspective. J Pediatr 2017; 180:22-30.e2. [PMID: 27742125 DOI: 10.1016/j.jpeds.2016.09.009] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 07/13/2016] [Accepted: 09/07/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Regan E Giesinger
- Division of Neonatology, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Liane J Bailey
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Poorva Deshpande
- Division of Neonatology, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Patrick J McNamara
- Division of Neonatology, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Department of Physiology, University of Toronto, Toronto, Ontario, Canada.
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18
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Helmer C, Skranes JH, Liestøl K, Fugelseth D. Using adrenaline during neonatal resuscitation may have an impact on serum cardiac troponin-T levels. Acta Paediatr 2015; 104:e378-83. [PMID: 26032882 DOI: 10.1111/apa.13055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Revised: 02/05/2015] [Accepted: 03/11/2015] [Indexed: 11/29/2022]
Abstract
AIM It has been suggested that serum cardiac troponin-T (cTnT) can predict the severity of neonatal hypoxic-ischaemic encephalopathy. We evaluated whether cTnT was better correlated with adrenaline during cardiopulmonary resuscitation (CPR) than with the severity of the insult itself, based on the Apgar scores. METHODS Serum cTnT was analysed in 47 asphyxiated newborn infants treated with hypothermia. Blood samples and resuscitation data were collected from medical records, and multiple linear regressions were used to evaluate the effect of the treatment and the Apgar scores on cTnT levels. RESULTS The infants were divided into three groups: the no CPR group (n = 29) just received stimulation and ventilation, the CPR minus adrenaline group (n = 9) received cardiac compression and ventilation and the CPR plus adrenaline group (n = 9) received complete CPR, including adrenaline. In the univariate analysis, the five and ten-minute Apgar scores were significantly lower in the CPR plus adrenaline group and the cTnT was significantly higher. Multiple regression analysis showed significantly higher cTnT values in the CPR plus adrenaline group, but no significant relationship between cTnT and the Apgar scores. CONCLUSION Although cTnT correlated with the severity of the insult in neonatal hypoxic-ischaemic encephalopathy, the levels may have been affected by adrenaline administered during CPR.
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Affiliation(s)
- Caroline Helmer
- Faculty of Medicine; Medical School; University of Oslo; Oslo Norway
| | - Janne H. Skranes
- Department of Neonatal Intensive Care; Oslo University Hospital Ullevål; Oslo Norway
- Institute of Clinical Medicine; Faculty of Medicine; University of Oslo; Oslo Norway
| | - Knut Liestøl
- Institute of Informatic; University of Oslo; Oslo Norway
| | - Drude Fugelseth
- Department of Neonatal Intensive Care; Oslo University Hospital Ullevål; Oslo Norway
- Institute of Clinical Medicine; Faculty of Medicine; University of Oslo; Oslo Norway
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19
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Kyng KJ, Skajaa T, Kerrn-Jespersen S, Andreassen CS, Bennedsgaard K, Henriksen TB. A Piglet Model of Neonatal Hypoxic-Ischemic Encephalopathy. J Vis Exp 2015:e52454. [PMID: 26068784 DOI: 10.3791/52454] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Birth asphyxia, which causes hypoxic-ischemic encephalopathy (HIE), accounts for 0.66 million deaths worldwide each year, about a quarter of the world's 2.9 million neonatal deaths. Animal models of HIE have contributed to the understanding of the pathophysiology in HIE, and have highlighted the dynamic process that occur in brain injury due to perinatal asphyxia. Thus, animal studies have suggested a time-window for post-insult treatment strategies. Hypothermia has been tested as a treatment for HIE in pdiglet models and subsequently proven effective in clinical trials. Variations of the model have been applied in the study of adjunctive neuroprotective methods and piglet studies of xenon and melatonin have led to clinical phase I and II trials(1,2). The piglet HIE model is further used for neonatal resuscitation- and hemodynamic studies as well as in investigations of cerebral hypoxia on a cellular level. However, it is a technically challenging model and variations in the protocol may result in either too mild or too severe brain injury. In this article, we demonstrate the technical procedures necessary for establishing a stable piglet model of neonatal HIE. First, the newborn piglet (< 24 hr old, median weight 1500 g) is anesthetized, intubated, and monitored in a setup comparable to that found in a neonatal intensive care unit. Global hypoxia-ischemia is induced by lowering the inspiratory oxygen fraction to achieve global hypoxia, ischemia through hypotension and a flat trace amplitude integrated EEG (aEEG) indicative of cerebral hypoxia. Survival is promoted by adjusting oxygenation according to the aEEG response and blood pressure. Brain injury is quantified by histopathology and magnetic resonance imaging after 72 hr.
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Affiliation(s)
- Kasper J Kyng
- The Perinatal Research Unit, Department of Pediatrics, Institute of Clinical Medicine, Aarhus University Hospital;
| | - Torjus Skajaa
- The Perinatal Research Unit, Department of Pediatrics, Institute of Clinical Medicine, Aarhus University Hospital
| | - Sigrid Kerrn-Jespersen
- The Perinatal Research Unit, Department of Pediatrics, Institute of Clinical Medicine, Aarhus University Hospital
| | - Christer S Andreassen
- Department of Otorhinolaryngology and Head & Neck Surgery, Institute of Clinical Medicine, Aarhus University Hospital
| | - Kristine Bennedsgaard
- The Perinatal Research Unit, Department of Pediatrics, Institute of Clinical Medicine, Aarhus University Hospital
| | - Tine B Henriksen
- The Perinatal Research Unit, Department of Pediatrics, Institute of Clinical Medicine, Aarhus University Hospital
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20
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Tang XJ, Xing F. Calcium-permeable AMPA receptors in neonatal hypoxic-ischemic encephalopathy (Review). Biomed Rep 2013; 1:828-832. [PMID: 24649036 DOI: 10.3892/br.2013.154] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Accepted: 07/18/2013] [Indexed: 11/06/2022] Open
Abstract
Hypoxic-ischemic encephalopathy (HIE) is an important cause of brain injury in the newborn and may result in long-term devastating consequences. Excessive stimulation of glutamate receptors (GluRs) is a pivotal mechanism underlying ischemia-induced selective and delayed neuronal death. Although initial studies focused on N-methyl-D-aspartic acid (NMDA) receptors as critical mediators in HIE, subsequent studies supported a more central role for α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptors (AMPARs), particularly Ca2+-permeable AMPARs, in brain damage associated with hypoxia-ischemia. This study reviewed the important role of Ca2+-permeable AMPARs in HIE and the future potential neuroprotective strategies associated with Ca2+-permeable AMPARs.
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Affiliation(s)
- Xiao-Juan Tang
- Department of Neonatology, Children's Hospital Affiliated to Soochow University, Suzhou, Jiangsu 215003, P.R. China
| | - Feng Xing
- Department of Neonatology, Children's Hospital Affiliated to Soochow University, Suzhou, Jiangsu 215003, P.R. China
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21
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Effect of cardiac compressions and hypothermia treatment on cardiac troponin I in newborns with perinatal asphyxia. Resuscitation 2013; 84:1562-7. [PMID: 23856603 DOI: 10.1016/j.resuscitation.2013.07.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Revised: 06/21/2013] [Accepted: 07/01/2013] [Indexed: 01/15/2023]
Abstract
BACKGROUND The American Heart Association, the European Resuscitation and the International Liaison Committee issued new neonatal resuscitation guidelines (2010) where therapeutic hypothermia is introduced after hypoxic-ischaemic encephalopathy (HIE) in term infants to prevent brain injury. Our study aimed to investigate whether hypothermia can reduce the release of a cardiac cellular marker, cardiac troponin I (cTnI), in HIE infants compared to normothermia care, if cTnI can be used as a prognostic marker for long term neuro-developmental outcome and if cardiac compression at birth affects the level of cTnI. METHODS We retrospectively collected resuscitation data at birth and cTnI levels for the first 3 days in HIE infants who fulfilled cooling entry criteria. These infants received either normothermia care or induced hypothermia treatment in the neonatal period and were then followed up and tested by standard cognitive and motor assessments. The outcome is defined as death, disability or good. RESULTS We confirmed an increase in cTnI after cardiac compressions (p=0.003, Mann-Whitney test). We found that hypothermia significantly reduced the release of cTnI (peak level and area under the curve within 24h of age), p=0.002, linear regression. Receiver operating characteristic curves showed a level of cTnI at 24 h of age <0.22 ng/ml for normothermic and <0.15 ng/ml for hypothermic infants predicts a good outcome. CONCLUSIONS Our results suggest that hypothermia is cardio protective after HIE. The level of cTnI at 24h of age is a good prognostic marker for neuro-developmental outcome at 18-22 months in both normothermia and hypothermia infants.
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22
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Ramanantsoa N, Fleiss B, Bouslama M, Matrot B, Schwendimann L, Cohen-Salmon C, Gressens P, Gallego J. Bench to cribside: the path for developing a neuroprotectant. Transl Stroke Res 2012; 4:258-77. [PMID: 24323277 DOI: 10.1007/s12975-012-0233-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2012] [Revised: 11/06/2012] [Accepted: 11/29/2012] [Indexed: 12/29/2022]
Abstract
The consequences of perinatal brain injury include immeasurable anguish for families and substantial ongoing costs for care and support of effected children. Factors associated with perinatal brain injury in the preterm infant include inflammation and infection, and with increasing gestational age, a higher proportion is related to hypoxic-ischemic events, such as stroke and placental abruption. Over the past decade, we have acquired new insights in the mechanisms underpinning injury and many new tools to monitor outcome in perinatal brain injury in our experimental models. By embracing these new technologies, we can expedite the screening of novel therapies. This is critical as despite enormous efforts of the research community, hypothermia is the only viable neurotherapeutic, and this procedure is limited to term birth and postcardiac arrest hypoxic-ischemic events. Importantly, experimental and preliminary data in humans also indicate a considerable therapeutic potential for melatonin against perinatal brain injury. However, even if this suggested potential is proven, the complexity of the human condition means we are likely to need additional neuroprotective and regenerative strategies. Thus, within this review, we will outline what we consider the key stages of preclinical testing and development for a neuroprotectant or regenerative neurotherapy for perinatal brain injury. We will also highlight examples of novel small animal physiological and behavioral testing that gives small animal preclinical models greater clinical relevance. We hope these new tools and an integrated bench to cribside strategic plan will facilitate the fulfillment of our overarching goal, improving the long-term brain health and quality of life for infants suffering perinatal brain injury.
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Affiliation(s)
- Nelina Ramanantsoa
- Inserm U676, Hopital Robert Debre, 48 Blvd Serurier, 75019, Paris, France
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Abstract
This article covers the outcome of full-term infants with encephalopathy due to hypoxic-ischemia and pathophysiology of brain injury following hypoxic-ischemia. Clinical and imaging evidence for hypothermia for neuroprotection is presented. The outcome of infants with hypothermia for encephalopathy due to hypoxic-ischemia from recent trials is summarized. Facts regarding the clinical application of cooling obtained from the randomized trials and knowledge gaps in hypothermic therapy are presented. The review concludes with the future of hypothermia for neuroprotection.
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Vijlbrief DC, Benders MJNL, Kemperman H, van Bel F, de Vries WB. Use of cardiac biomarkers in neonatology. Pediatr Res 2012; 72:337-43. [PMID: 22797141 DOI: 10.1038/pr.2012.88] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Cardiac biomarkers are used to identify cardiac disease in term and preterm infants. This review discusses the roles of natriuretic peptides and cardiac troponins. Natriuretic peptide levels are elevated during atrial strain (atrial natriuretic peptide (ANP)) or ventricular strain (B-type natriuretic peptide (BNP)). These markers correspond well with cardiac function and can be used to identify cardiac disease. Cardiac troponins are used to assess cardiomyocyte compromise. Affected cardiomyocytes release troponin into the bloodstream, resulting in elevated levels of cardiac troponin. Cardiac biomarkers are being increasingly incorporated into clinical trials as indicators of myocardial strain. Furthermore, cardiac biomarkers can possibly be used to guide therapy and improve outcome. Natriuretic peptides and cardiac troponins are potential tools in the diagnosis and treatment of neonatal disease that is complicated by circulatory compromise. However, clear reference ranges need to be set and validation needs to be carried out in a population of interest.
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Affiliation(s)
- Daniel C Vijlbrief
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
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25
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Kerenyi A, Kelen D, Faulkner SD, Bainbridge A, Chandrasekaran M, Cady EB, Golay X, Robertson NJ. Systemic effects of whole-body cooling to 35 °C, 33.5 °C, and 30 °C in a piglet model of perinatal asphyxia: implications for therapeutic hypothermia. Pediatr Res 2012; 71:573-82. [PMID: 22314664 PMCID: PMC4241373 DOI: 10.1038/pr.2012.8] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
INTRODUCTION The precise temperature for optimal neuroprotection in infants with neonatal encephalopathy is unclear. Our aim was to assess systemic effects of whole-body cooling to 35 °C, 33.5 °C, and 30 °C in a piglet model of perinatal asphyxia. METHODS Twenty-eight anesthetized male piglets aged <24 h underwent hypoxia-ischemia (HI) and were randomized to normothermia or cooling to rectal temperature (Trec) 35 °C, 33.5 °C, or 30 °C during 2-26 h after insult (n = 7 in each group). HR, MABP, and Trec were recorded continuously. RESULTS Five animals cooled to 30 °C had fatal cardiac arrests. During 30 °C cooling, heart rate (HR) was lower vs. normothermia (P < 0.001). Although mean arterial blood pressure (MABP) did not vary between groups, more fluid boluses were needed at 30 °C than at normothermia (P < 0.02); dopamine use was higher at 30 °C than at normothermia or 35 °C (P = 0.005 and P = 0.02, respectively). Base deficit was increased at 30 °C at 12, 24, and 36 h vs. all other groups (P < 0.05), pH was acidotic at 36 h vs. normothermia (P = 0.04), and blood glucose was higher for the 30 °C group at 12 h vs. the normothermia and 35 °C groups (P < 0.05). Potassium was lower at 12 h in the 30 °C group vs. the 33.5 °C and 35 °C groups. There was no difference in cortisol level between groups. DISCUSSION Cooling to 30 °C led to metabolic derangement and more cardiac arrests and deaths than cooling to 33.5 °C or 35 °C. Inadvertent overcooling should be avoided.
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Affiliation(s)
- Aron Kerenyi
- Institute for Women’s Health (AK, DK, SDF, MC, NJR), University College London, London WCIE 6AU, UK
| | - Dorottya Kelen
- Institute for Women’s Health (AK, DK, SDF, MC, NJR), University College London, London WCIE 6AU, UK
| | - Stuart D Faulkner
- Institute for Women’s Health (AK, DK, SDF, MC, NJR), University College London, London WCIE 6AU, UK
| | - Alan Bainbridge
- Medical Physics and Bio-engineering (AB, EBC), University College London, London WC1E 6DB, UK
| | | | - Ernest B Cady
- Medical Physics and Bio-engineering (AB, EBC), University College London, London WC1E 6DB, UK
| | - Xavier Golay
- Institute of Neurology (XG), University College London, London WC1N 3BG, UK
| | - Nicola J Robertson
- Institute for Women’s Health (AK, DK, SDF, MC, NJR), University College London, London WCIE 6AU, UK
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Gill RS, Pelletier JS, LaBossiere J, Bigam DL, Cheung PY. Therapeutic strategies to protect the immature newborn myocardium during resuscitation following asphyxia. Can J Physiol Pharmacol 2012; 90:689-95. [PMID: 22510108 DOI: 10.1139/y2012-041] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Perinatal asphyxia contributes to over one million newborn deaths worldwide annually, and may progress to multiorgan failure. Cardiac dysfunction, of varying severity, is seen in 50%-70% of asphyxiated newborns. Resuscitation is necessary to restore oxygenation to deprived tissues, including the heart. However, reoxygenation of asphyxiated newborns may lead to generation of reactive oxygen species (ROS) and further myocardial damage, termed reperfusion injury. The newborn heart is especially vulnerable to oxidative stress and reperfusion injury due to immature antioxidant defense mechanisms and increased vulnerability to apoptosis. Currently, newborn myocardial protective strategies are aimed at reducing the generation of ROS through controlled reoxygenation, boosting antioxidant defenses, and attenuating cellular injury via mitochondrial stabilization.
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Affiliation(s)
- Richdeep S Gill
- Department of Surgery, University of Alberta, Edmonton, AB T6G 2R3, Canada
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Chakkarapani E, Thoresen M, Liu X, Walloe L, Dingley J. Xenon offers stable haemodynamics independent of induced hypothermia after hypoxia-ischaemia in newborn pigs. Intensive Care Med 2011; 38:316-23. [PMID: 22160201 DOI: 10.1007/s00134-011-2442-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2011] [Accepted: 11/17/2011] [Indexed: 10/14/2022]
Abstract
PURPOSE To assess the effect of 18 hour (h) 50% xenon (Xe) inhalation at normothermia (NT, 38.5°C) or hypothermia (HT, 33.5°C) on mean arterial blood pressure (MABP), inotropic support and heart rate (HR) following an induced perinatal global hypoxic-ischaemic insult (HI) in newborn pigs. METHODS Newborn pigs ventilated under inhalational anaesthesia, following a 45 min HI (inhaled oxygen fraction reduced until amplitude integrated electroencephalogram was less than 7 μV), were randomised to three Xe (n = 45) (50% Xe 18 h with NT, HT 12 h or HT 24 h) or three non-Xe groups (n = 53) (0% Xe with NT, HT 12 h or HT 24 h) under otherwise identical conditions. We measured MABP and HR every minute. Hypotension (MABP <40 mmHg) was treated sequentially with 2 × 10 mL/kg saline, dopamine, norepinephrine and hydrocortisone if required. RESULTS Xe maintained higher MABP during HT (5.1 mmHg, 95% CI 2.34, 7.89), rewarming (10.1 mmHg, 95% CI 6.26, 13.95) and after cessation (4.1 mmHg, 95% CI 0.37, 7.84) independent of HT, inotropic support and acidosis. Xe reduced the duration of inotropic support by 12.6 h (95% CI 5.5, 19.73). Inotropic support decreased the HR reduction induced by HT from 9 to 5 bpm/°C during cooling and from 10-7 to 4-3 bpm/°C during rewarming. There was no interaction between Xe, HT, inotropic support and acidosis. Xe during HT cleared lactate faster; 3 h post-HI median (IQR) values of (Xe HT) 2.8 mmol/L (0.9, 3.1) vs. (HT) 5.9 mmol/L (2.5, 7.9), p = 0.0004. CONCLUSION Xe maintained stable blood pressure, thereby reducing the inotropic support requirements during and after administration independently of induced HT-current neonatal encephalopathy treatment. Xe may offer haemodynamic benefits in clinical neuroprotection studies.
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Affiliation(s)
- Elavazhagan Chakkarapani
- Department of Child Health, School of Clinical Sciences, St Michael's Hospital, Level D, University of Bristol, Southwell Street, BS2 8EG Bristol, UK
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