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Agakidou E, Chatziioannidis I, Kontou A, Stathopoulou T, Chotas W, Sarafidis K. An Update on Pharmacologic Management of Neonatal Hypotension: When, Why, and Which Medication. CHILDREN (BASEL, SWITZERLAND) 2024; 11:490. [PMID: 38671707 PMCID: PMC11049273 DOI: 10.3390/children11040490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 03/30/2024] [Accepted: 04/15/2024] [Indexed: 04/28/2024]
Abstract
Anti-hypotensive treatment, which includes dopamine, dobutamine, epinephrine, norepinephrine, milrinone, vasopressin, terlipressin, levosimendan, and glucocorticoids, is a long-established intervention in neonates with arterial hypotension (AH). However, there are still gaps in knowledge and issues that need clarification. The main questions and challenges that neonatologists face relate to the reference ranges of arterial blood pressure in presumably healthy neonates in relation to gestational and postnatal age; the arterial blood pressure level that potentially affects perfusion of critical organs; the incorporation of targeted echocardiography and near-infrared spectroscopy for assessing heart function and cerebral perfusion in clinical practice; the indication, timing, and choice of medication for each individual patient; the limited randomized clinical trials in neonates with sometimes conflicting results; and the sparse data regarding the potential effect of early hypotension or anti-hypotensive medications on long-term neurodevelopment. In this review, after a short review of AH definitions used in neonates and existing data on pathophysiology of AH, we discuss currently available data on pharmacokinetic and hemodynamic effects, as well as the effectiveness and safety of anti-hypotensive medications in neonates. In addition, data on the comparisons between anti-hypotensive medications and current suggestions for the main indications of each medication are discussed.
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Affiliation(s)
- Eleni Agakidou
- 1st Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Ippokrateion General Hospital, 54642 Thessaloniki, Greece; (I.C.); (A.K.); (T.S.); (K.S.)
| | - Ilias Chatziioannidis
- 1st Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Ippokrateion General Hospital, 54642 Thessaloniki, Greece; (I.C.); (A.K.); (T.S.); (K.S.)
| | - Angeliki Kontou
- 1st Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Ippokrateion General Hospital, 54642 Thessaloniki, Greece; (I.C.); (A.K.); (T.S.); (K.S.)
| | - Theodora Stathopoulou
- 1st Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Ippokrateion General Hospital, 54642 Thessaloniki, Greece; (I.C.); (A.K.); (T.S.); (K.S.)
| | - William Chotas
- Department of Neonatology, University of Vermont, Burlington, VT 05405, USA
| | - Kosmas Sarafidis
- 1st Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Ippokrateion General Hospital, 54642 Thessaloniki, Greece; (I.C.); (A.K.); (T.S.); (K.S.)
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Stathopoulou T, Agakidou E, Paschaloudis C, Kontou A, Chatzioannidis I, Sarafidis K. Strong Association between Inotrope Administration and Intraventricular Hemorrhage, Gestational Age, and the Use of Fentanyl in Very Low Gestational Age Infants: A Retrospective Study. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1667. [PMID: 37892330 PMCID: PMC10605532 DOI: 10.3390/children10101667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 10/05/2023] [Accepted: 10/07/2023] [Indexed: 10/29/2023]
Abstract
This was a single center, retrospective cohort study designed to evaluate the association between the administration of inotropes to hypotensive very low gestational age infants (VLGAI) and prenatal and neonatal risk factors. Inpatient medical records were reviewed to identify neonates treated with inotropes (treated group) and a control group for comparison. Two hundred and twenty two (222) VLGAI (less than 32 weeks' gestation) were included in the final analysis and were stratified based on timing of treatment with 83 infants (37.4%) and 139 infants (62.6%) in the treated and control groups, respectively. A total of 56/83 (67%) received inotropes for arterial hypotension during the first 3 days (early treatment subgroup) and 27/83 (32.5%) after 3 days of life (late-treated subgroup). Fentanyl, severe intraventricular hemorrhage (IVH), and gestational age (GA) were the risk factors most significantly associated with the need for inotrope use both during the first 3 days of life and the whole NICU stay, before and after adjustment for confounders. In conclusion, fentanyl, severe IVH, and GA are the risk factors most strongly associated with the need for inotrope treatment in VLGAI. Measures to modify these risk factors may decrease the need for cardiovascular medications and improve outcomes.
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Affiliation(s)
| | - Eleni Agakidou
- Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Ippokrateion General Hospital, 54642 Thessaloniki, Greece; (T.S.); (C.P.); (A.K.); (I.C.); (K.S.)
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Blood pressure values and hypotension management in extremely preterm infants: a multi-center study. J Perinatol 2022; 42:1169-1175. [PMID: 35715600 DOI: 10.1038/s41372-022-01425-2] [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] [Received: 08/20/2021] [Revised: 05/10/2022] [Accepted: 06/07/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To describe high/low daily blood pressures (BP) and variability in BP management with vasoactive infusions (VI) and/or hydrocortisone (HC) in extremely preterm infants. STUDY DESIGN Analysis of data from 24-27 weeks' gestation infants in the Preterm Erythropoietin Neuroprotection (PENUT) Trial. Daily high/low BPs, the use of VI and/or HC, and adverse outcomes were compared descriptively and using regression models. RESULTS 936 infants were included; 64% untreated, 20% VI, 3% HC, and 13% VI + HC. BP ranges are described for the 602 untreated infants. Considerable inter- and intra-center variability was demonstrated in the rate of VI and/or HC use and the lowest BP on the day of VI or HC initiation. CONCLUSIONS Despite published expert opinion guidance regarding BP management in extremely preterm infants, our results suggest a continued lack of consensus result in both inter- and intra-center variability in practice. Well-designed studies in the field are urgently needed.
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Gupta S, Agrawal G, Thakur S, Gupta A, Wazir S. The effect of norepinephrine on clinical and hemodynamic parameters in neonates with shock: a retrospective cohort study. Eur J Pediatr 2022; 181:2379-2387. [PMID: 35277734 DOI: 10.1007/s00431-022-04437-4] [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: 01/06/2022] [Revised: 03/02/2022] [Accepted: 03/06/2022] [Indexed: 11/29/2022]
Abstract
UNLABELLED There is limited data on the cardiovascular effects of norepinephrine (NE) in neonates. Our objective was to describe the clinical responses in neonates treated with NE infusion. This retrospective cohort study included neonates with evidence of shock and those who received NE infusion. PRIMARY OUTCOME changes in mean blood pressure (MBP) at 6, 12, and 24 h post-initiation of NE. SECONDARY OUTCOMES Changes in (i) diastolic BP, systolic BP, and vasoactive inotrope score (VIS) at 6, 12, and 24 h, (ii) urine output after initiation of NE ii) pH, lactate, fraction of inspired oxygen (FiO2) after initiation of NE, and (iv) adverse outcomes. Fifty infants received NE with mean (SD) gestational age of 34.3 (4.3) weeks and a mean birth weight of 2215 (911) g. Treatment began at a median age of 36 (IQR: 15.2, 67.2) hours of life and lasted 30.5 (IQR: 12.7, 58) hours. MBP improved from 34.4 mm Hg (SD: 6.6) at baseline to 39.4 mm Hg (SD: 10.5, p < 0.001) at 6 h, to 39.6 mm Hg (SD: 12.1, p = 0.002) at 12 h and to 40.4 mm Hg (SD: 15.5, p = 0.004) at 24 h after NE initiation. Vasoactive inotrope score declined from 30 (20, 32) to 10 (4, 30; p < 0.001) at 24 h. Urine output improved within 24 h [1.5 ml/kg/h (0.5, 2.3) at baseline to 3 (1.9, 4.3) at 24 h; p = 0.04]. Oxygen requirement decreased after NE initiation. CONCLUSION The use of NE appears to be effective and safe for treating systemic hypotension in neonates. TRIAL REGISTRATION Being a retrospective study, trial registration was not considered. WHAT IS KNOWN • Dopamine has traditionally been used as the initial agent for treatment of neonatal hypotension. • Norepinephrine has recently been recommended as the first-choice vasopressor agent to correct hypotension in adults and pediatric patients, with insufficient data on the cardiovascular effects of NE in neonates What is new: • Mean blood pressure improved significantly at 6, 12, and 24 h with reduction in vasoactive infusion score at 12 and 24 h after norepinephrine infusion. • No significant change in heart rate or abnormal abdominal adverse effects noted in this study.
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Affiliation(s)
- Shelly Gupta
- Department of Paediatrics and Neonatology, Cloudnine Hospital, Gurugram, Haryana, 122003, India
| | - Gopal Agrawal
- Department of Paediatrics and Neonatology, Cloudnine Hospital, Gurugram, Haryana, 122003, India.
| | - Sarvesh Thakur
- Department of Paediatrics and Neonatology, Cloudnine Hospital, Gurugram, Haryana, 122003, India
| | - Ankit Gupta
- Department of Paediatrics and Neonatology, Cloudnine Hospital, Gurugram, Haryana, 122003, India
| | - Sanjay Wazir
- Department of Paediatrics and Neonatology, Cloudnine Hospital, Gurugram, Haryana, 122003, India
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Gupta S, Donn SM. Hemodynamic management of the micropreemie: When inotropes are not enough. Semin Fetal Neonatal Med 2022; 27:101329. [PMID: 35382998 DOI: 10.1016/j.siny.2022.101329] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Managing perfusion in the micropreemie is challenging and should be guided by the patho-physiology, gestational and postnatal age of the baby, perinatal history, and the persistence of fetal shunts. The assessment should incorporate bedside tools such as blood pressure, clinical perfusion markers, and functional echocardiography. The multimodal approach to diagnose and identify the cause of hemodynamic compromise paves the way to a targeted approach to treatment. Characterizing the predominant pathophysiologic cause of low cardiac output and impaired cellular metabolism enables a more accurate use of inotropes, vasopressors, and volume support to suit a particular pathophysiologic situation.
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Affiliation(s)
- Samir Gupta
- Division of Neonatal Medicine, Department of Pediatrics, Sidra Medicine, Doha, Qatar; Department of Engineering & Medical Physics, Durham University, United Kingdom.
| | - Steven M Donn
- Division of Neonatal-Perinatal Medicine, C.S. Mott Children's Hospital, Michigan Medicine, Ann Arbor, Michigan, USA
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Korada S, Jebbia MR, Pavlek LR. Linking the Perinatal Environment to Neonatal Cardiovascular Outcomes. Neoreviews 2022; 23:e400-e408. [PMID: 35641456 DOI: 10.1542/neo.23-6-e400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Cases of high-risk pregnancies continue to rise throughout the United States and globally, increasing rates of maternal and neonatal morbidity. Common pregnancy complications and morbidities include preterm birth, hypertensive disorders, fetal growth restriction, diabetes mellitus, and chorioamnionitis. Exposure to these perinatal conditions contributes to cardiac morbidities in the fetus and neonate, including altered cardiac growth, congenital heart disease, and cardiac dysfunction. Significant research has demonstrated lasting effects of these pregnancy complications, with increased rates of cardiac morbidities seen in children and adults after these perinatal exposures. The link between the perinatal environment and long-term outcomes has not been fully elucidated. The aim of this review is to discuss the current understanding of the implications of a high-risk pregnancy on fetal and neonatal cardiac development.
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Affiliation(s)
- Saichidroopi Korada
- Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Maria R Jebbia
- Division of Neonatology, Nationwide Children's Hospital, Columbus, OH.,Department of Pediatrics, The Ohio State University, Columbus, OH
| | - Leeann R Pavlek
- Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH.,Division of Neonatology, Nationwide Children's Hospital, Columbus, OH.,Department of Pediatrics, The Ohio State University, Columbus, OH
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Gonçalves-Ferri WA, Albuquerque AAS, Evora PM, Evora PRB. Methylene Blue not Contraindicated in Treating Hemodynamic Instability in Pediatric and Neonate Patients. Curr Pediatr Rev 2022; 18:2-8. [PMID: 34397332 DOI: 10.2174/1573396317666210816105812] [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: 10/10/2020] [Revised: 06/14/2021] [Accepted: 06/17/2021] [Indexed: 11/22/2022]
Abstract
The present review was carried out to describe publications on the use of methylene blue (MB) in pediatrics and neonatology, discussing dose, infusion rate, action characteristics, and possible benefits for a pediatric patient group. The research was performed on the data sources PubMed, BioMed Central, and Embase (updated on Aug 31, 2020) by two independent investigators. The selected articles included human studies that evaluated MB use in pediatric or neonatal patients with vasoplegia due to any cause, regardless of the applied methodology. The MB use and 0 to 18-years-old patients with vasodilatory shock were the adopted criteria. Exclusion criteria were the use of MB in patients without vasoplegia and patients ≥ 18-years-old. The primary endpoint was the increase in mean arterial pressure (MAP). Side effects and dose were also evaluated. Eleven studies were found, of which 10 were case reports, and 1 was a randomized clinical study. Only two of these studies were with neonatal patients (less than 28 days-old), reporting a small number of cases (1 and 6). All studies described the positive action of MB on MAP, allowing the decrease of vasoactive amines in several of them. No severe side effects or death related to the use of the medication were reported. The maximum dose used was 2 mg/kg, but there was no consensus on the infusion rate and drug administration timing. Finally, no theoretical or experimental basis sustains the decision to avoid MB in children claiming it can cause pulmonary hypertension. The same goes for the concern of a possible deleterious effect on inflammatory distress syndrome.
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Affiliation(s)
- Walusa A Gonçalves-Ferri
- Department of Pediatrics, Ribeirão Preto Medical School-University of São Paulo, São Paulo, Brazil
| | - Agnes A S Albuquerque
- Department of Surgery and Anatomy, Ribeirão Preto Medical School-University of São Paulo, São Paulo, Brazil
| | - Patricia Martinez Evora
- Department of Surgery and Anatomy, Ribeirão Preto Medical School-University of São Paulo, São Paulo, Brazil
| | - Paulo R B Evora
- Department of Surgery and Anatomy, Ribeirão Preto Medical School-University of São Paulo, São Paulo, Brazil
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Belfort MB, Ramel SE, Martin CR, Fichorova R, Kuban KCK, Heeren T, Fry RC, O’Shea TM. Systemic Inflammation in the First 2 Weeks after Birth as a Determinant of Physical Growth Outcomes in Hospitalized Infants with Extremely Low Gestational Age. J Pediatr 2022; 240:37-43.e1. [PMID: 34508750 PMCID: PMC8712377 DOI: 10.1016/j.jpeds.2021.09.006] [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: 05/14/2021] [Revised: 08/31/2021] [Accepted: 09/03/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To examine associations of systemic inflammation with growth outcomes at neonatal intensive care unit discharge or transfer among infants with extremely low gestational ages. STUDY DESIGN We studied 850 infants at born at 23-27 weeks of gestation. We defined inflammatory protein elevation as the highest quartile of C-reactive protein (CRP), Interleukin (IL)-6, tumor necrosis factor-∝, or IL-8 on postnatal days 1, 7, and 14. We compared z-scores of weight, length, and head circumference at neonatal intensive care unit discharge or transfer between infants with vs without inflammatory protein elevation, adjusting in linear regression for birth size z-score, sex, gestational age, diet, comorbidities, medications, and length of hospitalization. RESULTS The mean gestational age was 25 weeks (range, 23-27 weeks) and birth weight z-score 0.14 (range, -2.73 to 3.28). Infants with a high CRP on day 7 had lower weights at discharge or transfer (-0.17 z-score; 95% CI, -0.27 to -0.06) than infants without CRP elevation, with similar results on day 14. Infants with CRP elevation on day 14 were also shorter (-0.21 length z-scores; 95% CI, -0.38 to -0.04), and had smaller head circumferences (-0.18 z-scores; 95% CI, -0.33 to -0.04) at discharge or transfer. IL-6 elevation on day 14 was associated with lower weight (-0.12; 95% CI, -0.22 to -0.02); IL-6 elevation on day 7 was associated with shorter length (-0.27; 95% CI, -0.43 to -0.12). Tumor necrosis factor-∝ and IL-8 elevation on day 14 were associated with a lower weight at discharge or transfer. CONCLUSIONS Postnatal systemic inflammation may contribute to impaired nutrient accretion during a critical period in development in infants with extremely low gestational ages.
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Affiliation(s)
- Mandy B. Belfort
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Sara E. Ramel
- University of Minnesota School of Medicine, Minneapolis, MN
| | - Camilia R. Martin
- Harvard Medical School, Boston, MA,Beth Israel Deaconess Medical Center, Boston, MA
| | - Raina Fichorova
- Harvard Medical School, Boston, MA,Department of Obstetrics and Gynecology, Brigham and Women’s Hospital, Boston, MA
| | | | | | - Rebecca C. Fry
- Department of Environmental Sciences and Engineering, University of North Carolina School of Medicine, Chapel Hill, NC
| | - T. Michael O’Shea
- Division of Neonatal-Perinatal Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
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Song YH, Lee JA, Choi BM, Lim JW. Risk factors and prognosis in very low birth weight infants treated for hypotension during the first postnatal week from the Korean Neonatal Network. PLoS One 2021; 16:e0258328. [PMID: 34648528 PMCID: PMC8516276 DOI: 10.1371/journal.pone.0258328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 09/26/2021] [Indexed: 11/18/2022] Open
Abstract
Hypotension in the early stages of life appears in 20% of very low birth weight (VLBW) infants. The gestational age and birth weight are the risk factors highly related to the postnatal hypotension. Other risk factors slightly differ between different studies. So, we evaluated the risk factors and prognosis that are associated with infants treated with hypotension in the early stages of life, after excluding the influences of gestational age and small for gestational age (SGA). VLBW infants registered in the Korean Neonatal Network between 2013 and 2015 treated for hypotension within a week after their birth were selected as study subjects. The rest were used as a control group. Risk factors and the prevalence of severe complications, including mortality, were investigated and compared after matching for gestational age and SGA. The treatment rate for hypotension within the first postnatal week was inversely related to decreasing gestational ages and birth weights. In particular, 63.4% of preterm infants born at ≤ 24 weeks’ gestation and 66.9% of those with a birth weight < 500 g were treated for hypotension within a week of birth. Regression analysis after matching showed that 1-minute Apgar score, neonatal cardiac massage or epinephrine administration, symptomatic patent ductus arteriosus, early onset sepsis, and chorioamnionitis were significantly associated with hypotension. In the hypotension group, mortality, grade 3 or higher intraventricular hemorrhage, periventricular leukomalacia, and moderate to severe bronchopulmonary dysplasia rates were significantly higher after the matching for gestational age and SGA. Hypotension during the first postnatal week is very closely related to the prematurity and the condition of the infant shortly after birth. Regular prenatal care including careful monitoring and appropriate neonatal resuscitation are very crucial to decrease the risk of hypotension in the early stages of life.
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Affiliation(s)
- Young Hwa Song
- Department of Pediatrics, Konyang University College of Medicine, Daejeon, Korea
| | - Jin A. Lee
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
- Department of Pediatrics, Seoul National University-Seoul metropolitan government Boramae Medical Center, Seoul, Korea
| | - Byung Min Choi
- Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
| | - Jae Woo Lim
- Department of Pediatrics, Konyang University College of Medicine, Daejeon, Korea
- * E-mail:
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10
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Vasoactive medications in extremely low gestational age neonates during the first postnatal week. J Perinatol 2021; 41:2330-2336. [PMID: 33758384 PMCID: PMC9204669 DOI: 10.1038/s41372-021-01031-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 02/16/2021] [Accepted: 02/24/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The management of early hypotension in extremely low gestational age neonates (ELGANs) varies greatly between centers. The objective of this study was to provide updated data on the use of vasoactive medications in ELGANs during the first postnatal week. STUDY DESIGN We identified ELGANs (22-27 weeks gestational age) cared for at Pediatrix neonatal intensive care units from 2009 to 2018. We evaluated the frequency of exposure to vasoactive medications by gestational age, and compared use of vasoactive medications between two epochs (2009-2013 and 2014-2018). RESULTS A total of 10,070/34,234 (29%) ELGANs received ≥1 vasoactive medication. Dopamine was the most frequently used vasoactive medication. The majority (83%) of treated ELGANs initiated therapy on postnatal days 0-1. Overall use of vasoactive medications was slightly lower in 2014-2018 than 2009-2013 (28 vs 31%, p < 0.001). CONCLUSION A substantial proportion of ELGANs were exposed to vasoactive medications during the first postnatal week.
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Aziz KB, Lavilla OC, Wynn JL, Lure AC, Gipson D, de la Cruz D. Maximum vasoactive-inotropic score and mortality in extremely premature, extremely low birth weight infants. J Perinatol 2021; 41:2337-2344. [PMID: 33712712 PMCID: PMC8435049 DOI: 10.1038/s41372-021-01030-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 01/28/2021] [Accepted: 02/25/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To determine the relationship between maximum vasoactive-inotropic (VISmax) and mortality in extremely premature (<29 weeks completed gestation), extremely low birth weight (ELBW, <1000 g) infants. STUDY DESIGN Single center, retrospective, and observational cohort study. RESULTS We identified 436 ELBW, <29 week, inborn infants cared for during the study period. Compared to infants with VISmax of 0, the frequency of mortality based on VISmax ranged from 3.3-fold to 46.1-fold. VISmax > 30 was associated with universal mortality. Multivariable modeling that included gestational age, birth weight, and VISmax revealed significant utility to predict mortality with negative predictive value of 87.0% and positive predictive value of 84.8% [adjusted AUROC: 0.90, (0.86-0.94)] among patients that received vasoactive-inotropic treatment. CONCLUSION VISmax is an objective measure of hemodynamic/cardiovascular support that was directly associated with mortality in extremely premature ELBW infants. The VISmax represents an important step towards neonatal precision medicine and risk stratification of extremely premature ELBW infants.
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Affiliation(s)
- Khyzer B. Aziz
- Department of Pediatrics, Johns Hopkins University, Baltimore, Maryland
| | - Orlyn C. Lavilla
- Department of Pediatrics, University of Florida, Gainesville, Florida
| | - James L. Wynn
- Department of Pediatrics, University of Florida, Gainesville, Florida,Department of Pathology, Immunology, and Laboratory Medicine, University of Florida, Gainesville, Florida
| | - Allison C. Lure
- Department of Pediatrics, University of Florida, Gainesville, Florida
| | - Daniel Gipson
- Department of Pediatrics, University of Florida, Gainesville, Florida
| | - Diomel de la Cruz
- Department of Pediatrics, University of Florida, Gainesville, FL, USA.
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Dempsey EM, Barrington KJ, Marlow N, O'Donnell CPF, Miletin J, Naulaers G, Cheung PY, Corcoran JD, EL-Khuffash AF, Boylan GB, Livingstone V, Pons G, Macko J, Van Laere D, Wiedermannova H, Straňák Z. Hypotension in Preterm Infants (HIP) randomised trial. Arch Dis Child Fetal Neonatal Ed 2021; 106:398-403. [PMID: 33627329 PMCID: PMC8237176 DOI: 10.1136/archdischild-2020-320241] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 11/02/2020] [Accepted: 12/06/2020] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To determine whether restricting the use of inotrope after diagnosis of low blood pressure (BP) in the first 72 hours of life affects survival without significant brain injury at 36 weeks of postmenstrual age (PMA) in infants born before 28 weeks of gestation. DESIGN Double-blind, placebo-controlled randomised trial. Caregivers were masked to group assignment. SETTING 10 sites across Europe and Canada. PARTICIPANTS Infants born before 28 weeks of gestation were eligible if they had an invasive mean BP less than their gestational age that persisted for ≥15 min in the first 72 hours of life and a cerebral ultrasound free of significant (≥ grade 3) intraventricular haemorrhage. INTERVENTION Participants were randomly assigned to saline bolus followed by either a dopamine infusion (standard management) or placebo (5% dextrose) infusion (restrictive management). PRIMARY OUTCOME Survival to 36 weeks of PMA without severe brain injury. RESULTS The trial terminated early due to significant enrolment issues (7.7% of planned recruitment). 58 infants were enrolled between February 2015 and September 2017. The two groups were well matched for baseline variables. In the standard group, 18/29 (62%) achieved the primary outcome compared with 20/29 (69%) in the restrictive group (p=0.58). Additional treatments for low BP were used less frequently in the standard arm (11/29 (38%) vs 19/29 (66%), p=0.038). CONCLUSION Though this study lacked power, we did not detect major differences in clinical outcomes between standard or restrictive approach to treatment. These results will inform future studies in this area. TRIAL REGISTRATION NUMBER NCT01482559, EudraCT 2010-023988-17.
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Affiliation(s)
- Eugene M Dempsey
- Department of Paediatric and Child Health and INFANT Research Centre, University College Cork, Cork, Ireland
| | - Keith J Barrington
- Néonatologie, Centre Hospitalier Universitaire Sainte Justine, Montreal, Quebec, Canada
| | - Neil Marlow
- Institute for Womens Health, University College London, London, UK
| | | | - Jan Miletin
- Paediatric and Newborn Medicine, Coombe Women and Infants University Hospital, Dublin, Ireland
| | - Gunnar Naulaers
- Neonatology, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Po-Yin Cheung
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - John David Corcoran
- Faculty of Medicine and Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Afif Faisal EL-Khuffash
- Faculty of Medicine and Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Geraldine B Boylan
- Department of Paediatric and Child Health and INFANT Research Centre, University College Cork, Cork, Ireland
| | - Vicki Livingstone
- Department of Paediatric and Child Health and INFANT Research Centre, University College Cork, Cork, Ireland
| | - Gerard Pons
- Clinical Pharmacology, Groupe Hospitalier Cochin-Broca, Hôtel Dieu, AP-HP, Paris, France
| | - Jozef Macko
- Department of Neonatology, Tomas Bata University in Zlin, Zlin, Zlínský Kraj, Czech Republic
| | | | - Hana Wiedermannova
- Department of Pediatrics and Neonatal Care, Ostravska Univerzita, Ostrava, Moravskoslezský, Czech Republic
| | - Zbyněk Straňák
- Institute for the Care of Mother and Child, Third Faculty of Medicine, Charles University, Prague, Czech Republic
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13
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Doucette SM, Kelly EN, Church PT, Lee S, Shah V. Association of inotrope use with neurodevelopmental outcomes in infants <29 weeks gestation: a retrospective cohort study. J Matern Fetal Neonatal Med 2021; 35:6044-6052. [PMID: 33827395 DOI: 10.1080/14767058.2021.1904872] [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: 10/21/2022]
Abstract
OBJECTIVE The primary objective was to compare neurodevelopmental (ND) outcomes at 18-24 months in preterm infants <29 weeks gestational age (GA) who received versus those who did not receive inotropes in the first week of life. The secondary objective was to assess ND outcomes according to the duration of inotropic support in the first week of life (≤3 or >3 days). STUDY DESIGN Retrospective population-based cohort study of preterm infants <29 weeks GA admitted to participating neonatal intensive care units (NICUs) of the Canadian Neonatal Network (CNN) from January 2010 to September 2011 with follow-up data available at 18-24 months. Neurodevelopmental outcomes were assessed using the Bayley Scales of Infant and Toddler Development-Third Edition (BSID-III). Long-term outcomes were categorized as neurodevelopmental impairment (NDI) and significant neurodevelopmental impairment (sNDI), and effect modification due to other neonatal morbidities including receipt of antenatal steroids, GA, small for gestational age (SGA) status, sex, score for neonatal acute physiology (SNAP-II) >20, postnatal steroids, bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH) grade ≥3/periventricular leukomalacia (PVL), early- and late-onset sepsis, retinopathy of prematurity (ROP) and necrotizing enterocolitis (NEC) was assessed. Maternal and infant demographic characteristics and short- and long-term outcomes were compared using Pearson's Chi-square test for categorical variables and Student's t-test or the Wilcoxon rank test for continuous variables. Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) were calculated using multivariable regression analysis. RESULTS Of the 491 (18.7%) eligible preterm infants who received inotropes during the first week of life, 314 (64%) survived to NICU discharge and 245 (78%) had ND outcome data available. A total of 1775 eligible preterm infants did not receive inotropes in the first week of life; 1647 (92.7%) survived to NICU discharge and 1149 (70%) had ND outcome data. Maternal and infant characteristics associated with infants receiving inotropes included: younger maternal age, clinical chorioamnionitis, no antenatal steroids, outborn, lower GA, BW and Apgar scores at both one and five minutes; and higher SNAP-II scores (p < .05). Infants who received inotropes in the first week of life were more likely to be require postnatal steroids, had higher rates of BPD, IVH grade ≥3/PVL, early- and late-onset sepsis, ROP, NEC and mortality (p < .05). Infants who received inotropes in the first week of life also had higher rates of sensorineural or mixed hearing loss with an AOR (95% CI) of 1.99 (1.13, 3.49). After adjusting for confounding variables, there was no difference in the risk of NDI or sNDI between infants who did and did not receive inotropes in the first week of life. Of the infants with neurodevelopmental outcome data available, 186 received inotropes for ≤3 days and 59 for >3 days. After adjusting for confounding variables there was no difference in the risk of NDI or sNDI. Infants who received inotropes for >3 days were more likely to have lower BSID-III cognitive [AOR 2.43 95% CI (1.03, 5.76)] and motor scores <85 [AOR 2.38 95% CI (1.07, 5.30)] respectively. CONCLUSIONS In this large, population-based cohort, infants who received inotropes in the first week of life were at increased risk for sensorineural or mixed hearing loss. There was no difference in NDI or sNDI after adjusting for confounding variables. A longer duration of inotrope use in the first week of life was associated with lower BSID-III cognitive and motor scores, but no difference in overall NDI or sNDI.
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Affiliation(s)
- Stefani M Doucette
- Division of Neonatology, Department of Pediatrics, Foothills Medical Centre, University of Calgary, Calgary, Canada
| | - Edmond N Kelly
- Department of Paediatrics, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Paige T Church
- Department of Newborn and Developmental Paediatrics, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Shoo Lee
- Department of Paediatrics, Mount Sinai Hospital, University of Toronto, Toronto, Canada.,Department of Obstetrics and Gynecology, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.,Maternal-Infant Care Research Centre, Mount Sinai Hospital, Toronto, Canada
| | - Vibhuti Shah
- Department of Paediatrics, Mount Sinai Hospital, University of Toronto, Toronto, Canada.,Maternal-Infant Care Research Centre, Mount Sinai Hospital, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
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14
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Baik-Schneditz N, Schwaberger B, Mileder L, Höller N, Avian A, Koestenberger M, Urlesberger B, Martensen J, Pichler G. Sex related difference in cardiac output during neonatal transition in term neonates. Cardiovasc Diagn Ther 2021; 11:342-347. [PMID: 33968613 DOI: 10.21037/cdt-20-844] [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: 11/06/2022]
Abstract
Background The immediate transition from foetus to neonate includes substantial changes especially concerning the cardiovascular system. As sex related differences have been shown in cardiovascular medicine, this topic warrants further investigation in neonatology. Aim: The aim of this present study was to measure cardiac output (CO) and cerebral oxygenation (cTOI) non-invasively in term neonates and to investigate potential sex related differences between female and male neonates after birth. Methods This is a mono-centric prospective observational study. For CO-measurements, the electrical velocimetry method was used. The pulse oximetry for arterial oxygen saturation and heart-rate measurements was placed on the right hand or wrist. cTOI was measured using a NIRO 200NX monitor. The near-infrared spectroscopy probe was positioned on the right side of forehead in each infant. Monitoring started at minute 1 and was continued until minute 15 after birth. At minutes 5, 10, and 15 after birth, CO was calculated as an average out of six 10-second periods. Results 99 term neonates were enrolled. In our study population, we could identify 54 female and 45 male neonates. Males had higher cardiac output compared to females throughout the observational period, with a significant difference in minute 15 after birth (217, 95% CI: 203-231 mL/kg/min versus 178, 95% CI: 163-192 mL/kg/min; P<0.001). cTOI, SpO2, and HR did not differ between male and female neonates. Conclusions The present work is the first to investigate sex related differences concerning cardiac output in term neonates during postnatal transition, showing a significantly higher cardiac output in male neonates 15 minutes after birth.
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Affiliation(s)
- Nariae Baik-Schneditz
- Division of Neonatology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Research Unit for Neonatal Micro- and Macrocirculation, Division of Neonatology, Medical University of Graz, Graz, Austria.,Research Unit for Cerebral Development and Oximetry, Division of Neonatology, Medical University of Graz, Graz, Austria
| | - Bernhard Schwaberger
- Division of Neonatology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Research Unit for Neonatal Micro- and Macrocirculation, Division of Neonatology, Medical University of Graz, Graz, Austria.,Research Unit for Cerebral Development and Oximetry, Division of Neonatology, Medical University of Graz, Graz, Austria
| | - Lukas Mileder
- Division of Neonatology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Research Unit for Neonatal Micro- and Macrocirculation, Division of Neonatology, Medical University of Graz, Graz, Austria.,Research Unit for Cerebral Development and Oximetry, Division of Neonatology, Medical University of Graz, Graz, Austria
| | - Nina Höller
- Division of Neonatology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Research Unit for Neonatal Micro- and Macrocirculation, Division of Neonatology, Medical University of Graz, Graz, Austria.,Research Unit for Cerebral Development and Oximetry, Division of Neonatology, Medical University of Graz, Graz, Austria
| | - Alexander Avian
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Martin Koestenberger
- Division of Cardiology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Berndt Urlesberger
- Division of Neonatology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Research Unit for Neonatal Micro- and Macrocirculation, Division of Neonatology, Medical University of Graz, Graz, Austria.,Research Unit for Cerebral Development and Oximetry, Division of Neonatology, Medical University of Graz, Graz, Austria
| | - Johann Martensen
- Division of Neonatology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Research Unit for Neonatal Micro- and Macrocirculation, Division of Neonatology, Medical University of Graz, Graz, Austria.,Research Unit for Cerebral Development and Oximetry, Division of Neonatology, Medical University of Graz, Graz, Austria
| | - Gerhard Pichler
- Division of Neonatology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Research Unit for Neonatal Micro- and Macrocirculation, Division of Neonatology, Medical University of Graz, Graz, Austria.,Research Unit for Cerebral Development and Oximetry, Division of Neonatology, Medical University of Graz, Graz, Austria
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15
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Abstract
The blood pressure (BP) of neonates, especially those born premature, changes rapidly over the first days and weeks of life. Neonatal BPs may be affected by maternal factors, perinatal factors or events, and intrinsic or extrinsic infant factors. Unfortunately, the effect of many maternal health and disease states has only been studied in small numbers or has shown conflicting results. Many events around the time of delivery have the potential to influence the neonatal BP, and while definitive studies are often lacking, some observational data support physiological expectations. The strongest determinants of neonatal BP are the infant factors of gestational age at birth, birth weight, and postmenstrual age. Understanding the expected pattern of BP changes, identifying the potential influencing factors, and accurately measuring the BP are all essential to determine whether there is a BP abnormality present but are also more complex in the neonatal population. This review describes the evidence for maternal conditions, perinatal events, and infant factors to affect neonatal BP. It also explains what is currently known about the changing BP patterns in neonates including those born preterm. In addition, by examining the physiological process of hemodynamic adaptation to the extrauterine environment and compensatory cardiovascular responses, we can gain insight into the expected and unexpected vascular responses, making the variability of neonatal BP seem a little more predictable.
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Affiliation(s)
- Janis M Dionne
- Department of Pediatrics, Division of Nephrology, University of British Columbia, BC Children's Hospital, Vancouver, British Columbia, Canada
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16
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Luo N, Jiang S, McNamara PJ, Li X, Guo Y, Wang Y, Han J, Deng Y, Yang Y, Lee SK, Cao Y. Cardiovascular Pharmacological Support Among Preterm Infants in Chinese Referral Center Neonatal Intensive Care Units. Front Pediatr 2021; 9:638540. [PMID: 33968845 PMCID: PMC8100183 DOI: 10.3389/fped.2021.638540] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 03/29/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: To describe cardiovascular pharmacological support in infants born at <34 weeks' gestation within the first postnatal week in Chinese neonatal intensive care units (NICUs). Design: A secondary analysis of data from a multicenter randomized controlled study (REIN-EPIQ). A questionnaire regarding cardiovascular support practices was also completed by all participating NICUs. Setting: Twenty-five tertiary hospitals from 19 provinces in China. Patients: All infants born at <34 weeks' gestation and admitted to participating NICUs within the first postnatal week from May 2015 to April 2018 were included. Infants who were discharged against medical advice were excluded. Measures and Main Results: Among the 26,212 preterm infants <34 weeks, 16.1% received cardiovascular pharmacological support. The use rates increased with decreasing gestational age and birth weight, with 32.5% among infants <28 weeks and 35.9% among infants <1,000 g. Cardiovascular pharmacological support was independently associated with higher risks of death (aOR 2.8; 95% CI 2.4-3.3), severe intraventricular hemorrhage (IVH) (aOR 2.1; 95% CI 1.8-2.5) and bronchopulmonary dysplasia (BPD) (aOR 2.2; 95% CI 2.0-2.5). Overall 63.1% courses of cardiovascular pharmacological support were >3 days. Prolonged cardiovascular pharmacological support (>3 days) was independently associated with lower rates of survival without morbidity in very-low-birth-weight infants, compared with infants with shorter durations. Dopamine was the most commonly used cardiovascular agent. The cardiovascular pharmacological support rates varied from 1.9 to 65.8% among the participating NICUs. Conclusions: The rate of cardiovascular pharmacological support within the first postnatal week was high with prolonged durations in Chinese NICUs. Marked variation in cardiovascular support existed among participating NICUs. Cardiovascular pharmacological support during the early postnatal period, especially prolonged, may be associated with adverse neonatal outcomes. Clinical Trial Registration: The original trial was registered as "Reduction of Infection in Neonatal Intensive Care Units using the Evidence-based Practice for Improving Quality" (ID: NCT02600195) on clinicaltrials.gov. https://clinicaltrials.gov/ct2/show/NCT02600195?term=NCT02600195&draw=2&rank=1.
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Affiliation(s)
- Ningxin Luo
- Children's Hospital of Fudan University, Shanghai, China
| | - Siyuan Jiang
- Children's Hospital of Fudan University, Shanghai, China
| | - Patrick J McNamara
- Department of Pediatrics and Internal Medicine, University of Iowa, Iowa City, IA, United States
| | - Xiaoying Li
- Qilu Children's Hospital of Shandong University, Jinan, China
| | - Yan Guo
- Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Yang Wang
- The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Junyan Han
- Children's Hospital of Fudan University, Shanghai, China
| | - Yingping Deng
- Children's Hospital of Fudan University, Shanghai, China
| | - Yi Yang
- National Health Commision (NHC) Key Laboratory of Neonatal Diseases (Fudan University), Children's Hospital of Fudan University, Shanghai, China
| | - Shoo K Lee
- Maternal-Infant Care Research Centre and Department of Pediatrics, Mount Sinai Hospital, Toronto, ON, Canada.,Department of Pediatrics, University of Toronto, Toronto, ON, Canada.,Department of Obstetrics and Gynecology, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Yun Cao
- Children's Hospital of Fudan University, Shanghai, China
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17
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Wong FY, Gogos A, Hale N, Ingelse SA, Brew N, Shepherd KL, van den Buuse M, Walker DW. Impact of hypoxia-ischemia and dopamine treatment on dopamine receptor binding density in the preterm fetal sheep brain. J Appl Physiol (1985) 2020; 129:1431-1438. [PMID: 33054660 DOI: 10.1152/japplphysiol.00677.2020] [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: 01/02/2023] Open
Abstract
Dopamine is often used to treat hypotension in preterm infants who are at risk of hypoxic-ischemic (HI) brain injury due to cerebral hypoperfusion and impaired autoregulation. There is evidence that systemically administered dopamine crosses the preterm blood-brain barrier. However, the effects of exogenous dopamine and cerebral HI on dopaminergic signaling in the immature brain are unknown. We determined the effect of HI and dopamine on D1 and D2 receptor binding and expressions of dopamine transporter (DAT) and tyrosine hydroxylase (TH) in the striatum of the preterm fetal sheep. Fetal sheep (99 days of gestation, term = 147days) were unoperated controls (n = 6) or exposed to severe HI using umbilical cord occlusion and saline infusion (UCO + saline, n = 8) or to HI with dopamine infusion (UCO + dopamine, 10 µg/kg/min, n = 7) for 74 h. D1 and D2 receptor densities were measured by autoradiography in vitro. DAT, TH, and cell death were measured using immunohistochemistry. HI resulted in cell death in the caudate nucleus and putamen, and dopamine infusion started before HI did not exacerbate or ameliorate these effects. HI led to reduced D1 and D2 receptor densities in the caudate nucleus and reduction in DAT protein expression in the caudate and putamen. Fetal brains exposed to dopamine in addition to HI were not different from those exposed to HI alone in these changes in dopaminergic parameters. We conclude that dopamine infusion does not alter the striatal cell death or the reductions in D1 and D2 receptor densities and DAT protein expression induced by HI in the preterm brain.NEW & NOTEWORTHY This is the first study on the effects of hypoxia-ischemia and dopamine treatment on the dopaminergic pathway in the preterm brain. In the striatum of fetal sheep (equivalent to ∼26-28 wk of human gestation), we demonstrate that hypoxia-ischemia leads to cell death, reduces D1 and D2 receptors, and reduces dopamine transporter. Intravenous dopamine infusion at clinical dosage used in preterm human infants does not alter the striatal cell death, D1 and D2 receptor density levels, and DAT protein expressions after hypoxia-ischemia in the preterm brain.
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Affiliation(s)
- F Y Wong
- The Ritchie Centre, The Hudson Institute of Medical Research, Melbourne, Australia.,Department of Paediatrics, Monash University, Melbourne, Australia.,Monash Newborn, Monash Medical Centre, Melbourne, Australia
| | - A Gogos
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Australia
| | - N Hale
- The Ritchie Centre, The Hudson Institute of Medical Research, Melbourne, Australia
| | - S A Ingelse
- The Ritchie Centre, The Hudson Institute of Medical Research, Melbourne, Australia
| | - N Brew
- The Ritchie Centre, The Hudson Institute of Medical Research, Melbourne, Australia
| | - K L Shepherd
- The Ritchie Centre, The Hudson Institute of Medical Research, Melbourne, Australia.,Department of Paediatrics, Monash University, Melbourne, Australia
| | - M van den Buuse
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Australia.,School of Psychology and Public Health, La Trobe University, Melbourne, Australia
| | - D W Walker
- The Ritchie Centre, The Hudson Institute of Medical Research, Melbourne, Australia.,School of Health & Biomedical Sciences, RMIT University, Melbourne, Australia
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18
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Ruoss JL, Bazacliu C, Giesinger RE, McNamara PJ. Patent ductus arteriosus and cerebral, cardiac, and gut hemodynamics in premature neonates. Semin Fetal Neonatal Med 2020; 25:101120. [PMID: 32513596 DOI: 10.1016/j.siny.2020.101120] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Patent ductus arteriosus is associated with multiple comorbidities in premature infants, however a causal link or strategy to decrease these morbidities has not been found. The association between the patent ductus arteriosus and morbidities has biologic plausibility as, like any cardiac mixing lesion, a significant systemic to pulmonic shunt may lead to pulmonary over-circulation and systemic hypoperfusion. Understanding the underlying pathophysiology of associated morbidities in the setting of a patent ductus arteriosus may aid in risk stratifying infants and offer a patient targeted approach to infants with a pathological ductal shunt. While the deleterious impact of increased pulmonary blood flow maybe easier to identify, the impact on end-organ perfusion is more challenging. In this review, we will discuss the pathophysiology of a hemodynamically significant patent ductus arteriosus in premature infants, impact on end-organ perfusion and associated morbidities, and novel modalities to assess shunt volume and effect on end-organ perfusion.
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Affiliation(s)
- J L Ruoss
- Division of Neonatology, Department of Pediatrics, University of Florida, 1600 SW Archer Rd, Gainesville, FL, 32608, USA
| | - C Bazacliu
- Division of Neonatology, Department of Pediatrics, University of Florida, 1600 SW Archer Rd, Gainesville, FL, 32608, USA
| | - R E Giesinger
- Division of Neonatology, Department of Pediatrics, University of Iowa, 200 Hawkins Drive, Iowa City, IA, 52242, USA
| | - P J McNamara
- Division of Neonatology, Department of Pediatrics, University of Iowa, 200 Hawkins Drive, Iowa City, IA, 52242, USA; Department of Internal Medicine, University of Iowa, 8803 John Pappajohn Pavillion 200 Hawkins Drive, Iowa City, IA, 52242, USA.
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19
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Bakshi S, Koerner T, Knee A, Singh R, Vaidya R. Effect of Fluid Bolus on Clinical Outcomes in Very Low Birth Weight Infants. J Pediatr Pharmacol Ther 2020; 25:437-444. [PMID: 32641914 DOI: 10.5863/1551-6776-25.5.437] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Administration of fluid bolus in very low birth weight (VLBW) infants is a common practice in the NICU, but one without clear evidence demonstrating benefits in clinical outcomes. On the contrary, recent observational studies have suggested a potential detrimental effect of empiric fluid bolus in preterm infants, especially in the absence of clear indications. The aim of this study was to assess the impact of fluid bolus on various clinical outcomes in VLBW infants. METHODS Retrospective cohort study of VLBW infants born at ≤34 weeks' gestation and/or ≤1500-g birth weight at a single level III NICU from January 1, 2008, to December 31, 2013, and who received at least one fluid bolus within the first 48 hours of life. Outcomes studied were in-hospital mortality, need for home oxygen, incidence of chronic lung disease (CLD), prevalence of patent ductus arteriosus (PDA), and intraventricular hemorrhage (IVH). RESULTS Of 516 infants, 112 (21.7%) received a fluid bolus within the first 48 hours of life for various indications. Propensity models suggested no statistical difference for CLD or mortality, but exposed infants had an increased incidence of home on oxygen (p = 0.018), PDA prevalence (p = 0.008), and IVH prevalence (p = 0.038). CONCLUSIONS Fluid bolus in the first 48 hours of life may be associated with increased incidence of need for home oxygen and higher prevalence of PDA and IVH in VLBW infants. Future studies are needed to address these important adverse outcomes.
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20
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Lombardo P, Nguyen VB, Flores TJ, Sutherland MR, Nitsos I, Allison BJ, Parkington H, Tare M, Harding R, De Matteo R, Schneider M, Polglase GR, Black MJ. Early impact of moderate preterm birth on the structure, function and gene expression of conduit arteries. Exp Physiol 2020; 105:1256-1267. [PMID: 32436635 DOI: 10.1113/ep088117] [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: 08/22/2019] [Accepted: 05/19/2020] [Indexed: 11/08/2022]
Abstract
NEW FINDINGS What is the central question of this study? What is the immediate impact of moderate preterm birth on the structure and function of major conduit arteries using a pre-clinical sheep model? What is the main finding and its importance? Postnatal changes in conduit arteries, including a significant decrease in collagen within the thoracic aortic wall (predominately males), narrowed carotid arteries, reduced aortic systolic blood flow, and upregulation of the mRNA expression of cell adhesion and inflammatory markers at 2 days of age in preterm lambs compared to controls, may increase the risk of cardiovascular impairment in later life. ABSTRACT The aim of this work was to compare the structure and function of the conduit arteries of moderately preterm and term-born lambs and to determine whether vascular injury-associated genes were upregulated. Time-mated ewes were induced to deliver either preterm (132 ± 1 days of gestation; n = 11 females and n = 10 males) or at term (147 ± 1 days of gestation; n = 10 females and n = 5 males). Two days after birth, ultrasound imaging of the proximal ascending aorta, main, right and left pulmonary arteries, and right and left common carotid arteries was conducted in anaesthetized lambs. Lambs were then killed and segments of the thoracic aorta and left common carotid artery were either snap frozen for real-time PCR analyses or immersion-fixed for histological quantification of collagen, smooth muscle and elastin within the medial layer. Overall there were few differences in vascular structure between moderately preterm and term lambs. However, there was a significant decrease in the proportion of collagen within the thoracic aortic wall (predominantly in males), narrowing of the common carotid arteries and a reduction in peak aortic systolic blood flow in preterm lambs. In addition, there was increased mRNA expression of the cell adhesion marker P-selectin in the thoracic aortic wall and the pro-inflammatory marker IL-1β in the left common carotid artery in preterm lambs, suggestive of postnatal vascular injury. Early postnatal differences in the function and structure of conduit arteries and evidence of vascular injury in moderately preterm offspring may place them at greater risk of cardiovascular impairment later in life.
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Affiliation(s)
- Paul Lombardo
- Department of Medical Imaging and Radiation Sciences, Monash University, Victoria, Clayton, Australia
| | - Vivian B Nguyen
- Department of Anatomy and Developmental Biology and the Biomedicine Discovery Institute, Monash University, Victoria, Clayton, Australia
| | - Tracey J Flores
- Department of Anatomy and Developmental Biology and the Biomedicine Discovery Institute, Monash University, Victoria, Clayton, Australia
| | - Megan R Sutherland
- Department of Anatomy and Developmental Biology and the Biomedicine Discovery Institute, Monash University, Victoria, Clayton, Australia
| | - Ilias Nitsos
- The Ritchie Centre, Department of Obstetrics & Gynaecology, Monash University and Hudson Institute of Medical Research, Victoria, Clayton, Australia
| | - Beth J Allison
- The Ritchie Centre, Department of Obstetrics & Gynaecology, Monash University and Hudson Institute of Medical Research, Victoria, Clayton, Australia
| | - Helena Parkington
- Department of Physiology and the Biomedicine Discovery Institute, Monash University, Victoria, Clayton, Australia
| | - Marianne Tare
- Department of Physiology and the Biomedicine Discovery Institute, Monash University, Victoria, Clayton, Australia
| | - Richard Harding
- Department of Anatomy and Developmental Biology and the Biomedicine Discovery Institute, Monash University, Victoria, Clayton, Australia
| | - Robert De Matteo
- Department of Anatomy and Developmental Biology and the Biomedicine Discovery Institute, Monash University, Victoria, Clayton, Australia
| | - Michal Schneider
- Department of Medical Imaging and Radiation Sciences, Monash University, Victoria, Clayton, Australia
| | - Graeme R Polglase
- The Ritchie Centre, Department of Obstetrics & Gynaecology, Monash University and Hudson Institute of Medical Research, Victoria, Clayton, Australia
| | - M Jane Black
- Department of Anatomy and Developmental Biology and the Biomedicine Discovery Institute, Monash University, Victoria, Clayton, Australia
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21
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Treatment for hypotension in the first 24 postnatal hours and the risk of hearing loss among extremely low birth weight infants. J Perinatol 2020; 40:774-780. [PMID: 32103159 PMCID: PMC7185479 DOI: 10.1038/s41372-020-0628-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 02/05/2020] [Accepted: 02/11/2020] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To evaluate whether treated hypotension in the first 24 postnatal hours is associated with hearing loss in extremely low birth weight (ELBW) infants. STUDY DESIGN In a cohort of 735 ELBW infants, we identified 25 with sensorineural hearing loss (SNHL) at 12-24 months adjusted age. For each case, we selected three controls with normal hearing. Logistic regression models were used to adjust for confounding variables. RESULTS Sixty percent of cases and 25% of controls were treated for hypotension. After adjusting for confounding variables (gestational age, antenatal glucocorticoids, 5 min Apgar < 6, insertion of an umbilical catheter, treatment with high frequency ventilation, and major cranial ultrasound abnormality), treated hypotension was associated with an increased risk of SNHL (adjusted odds ratio: 3.6; 95% confidence interval: 1.3-9.7). CONCLUSIONS Treated hypotension in ELBW infants in the first 24 h of life is associated with an increased risk of SNHL.
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22
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Gentle SJ, Tipple TE, Patel R. Neonatal comorbidities and gasotransmitters. Nitric Oxide 2020; 97:27-32. [PMID: 32014495 DOI: 10.1016/j.niox.2020.01.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 12/10/2019] [Accepted: 01/29/2020] [Indexed: 01/28/2023]
Abstract
Hydrogen sulfide, nitric oxide, and carbon monoxide are endogenously produced gases that regulate various signaling pathways. The role of these transmitters is complex as constitutive production of these molecules may have anti-inflammatory, anti-microbial, and/or vasodilatory effects whereas induced production or formation of secondary metabolites may lead to cellular death. Given this fine line between friend and foe, therapeutic attenuation of these molecules' production has involved both inhibition of endogenous formation and therapeutic supplementation. All three gases have been implicated as regulators of critical aspects of neonatal physiology, and in turn, comorbidities including necrotizing enterocolitis, hypoxic ischemic encephalopathy, and pulmonary hypertension. In this review, we present current perspectives on these associations, highlight areas where insights remain sparse, and identify areas for potential for future investigations.
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Affiliation(s)
- Samuel J Gentle
- Department of Pediatrics, The University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Trent E Tipple
- Section of Neonatal-Perinatal Medicine, University of Oklahoma College of Medicine, Oklahoma City, OK, USA
| | - Rakesh Patel
- Department of Pathology and Center for Free Radical Biology, The University of Alabama at Birmingham, Birmingham, AL, USA
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Alternative facts? Using big data to identify high and low blood pressure values. Pediatr Res 2020; 87:13-14. [PMID: 31652434 DOI: 10.1038/s41390-019-0636-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 10/08/2019] [Accepted: 10/13/2019] [Indexed: 02/06/2023]
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Semenova O, Carra G, Lightbody G, Boylan G, Dempsey E, Temko A. Prediction of short-term health outcomes in preterm neonates from heart-rate variability and blood pressure using boosted decision trees. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2019; 180:104996. [PMID: 31421605 DOI: 10.1016/j.cmpb.2019.104996] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 07/11/2019] [Accepted: 07/25/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND AND OBJECTIVE Efficient management of low blood pressure (BP) in preterm neonates remains challenging with considerable variability in clinical practice. There is currently no clear consensus on what constitutes a limit for low BP that is a risk to the preterm brain. It is argued that a personalised approach rather than a population based threshold is more appropriate. This work aims to assist healthcare professionals in assessing preterm wellbeing during episodes of low BP in order to decide when and whether hypotension treatment should be initiated. In particular, the study investigates the relationship between heart rate variability (HRV) and BP in preterm infants and its relevance to a short-term health outcome. METHODS The study is performed on a large clinically collected dataset of 831 h from 23 preterm infants of less than 32 weeks gestational age. The statistical predictive power of common HRV features is first assessed with respect to the outcome. A decision support system, based on boosted decision trees (XGboost), was developed to continuously estimate the probability of neonatal morbidity based on the feature vector of HRV characteristics and the mean arterial blood pressure. RESULTS It is shown that the predictive power of the extracted features improves when observed during episodes of hypotension. A single best HRV feature achieves an AUC of 0.87. Combining multiple HRV features extracted during hypotensive episodes with the classifier achieves an AUC of 0.97, using a leave-one-patient-out performance assessment. Finally it is shown that good performance can even be achieved using continuous HRV recordings, rather than only focusing on hypotensive events - this had the benefit of not requiring invasive BP monitoring. CONCLUSIONS The work presents a promising step towards the use of multimodal data in providing objective decision support for the prediction of short-term outcome in preterm infants with hypotensive episodes.
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Affiliation(s)
- Oksana Semenova
- Department of Electrical and Electronic Engineering, University College Cork, 60 College Rd, Cork, Ireland; Irish Center for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland.
| | - Giorgia Carra
- Department of Electrical and Electronic Engineering, University College Cork, 60 College Rd, Cork, Ireland; Irish Center for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland
| | - Gordon Lightbody
- Department of Electrical and Electronic Engineering, University College Cork, 60 College Rd, Cork, Ireland; Irish Center for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland
| | - Geraldine Boylan
- Department of Pediatrics and Child Health, University College Cork, Cork, Ireland; Irish Center for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland
| | - Eugene Dempsey
- Department of Pediatrics and Child Health, University College Cork, Cork, Ireland; Irish Center for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland
| | - Andriy Temko
- Department of Electrical and Electronic Engineering, University College Cork, 60 College Rd, Cork, Ireland; Irish Center for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland
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25
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Observed and calculated cerebral critical closing pressure are highly correlated in preterm infants. Pediatr Res 2019; 86:242-246. [PMID: 31003233 PMCID: PMC6658334 DOI: 10.1038/s41390-019-0403-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 04/04/2019] [Accepted: 04/11/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Cerebrovascular critical closing pressure (CrCP) is the arterial blood pressure (ABP) at which cerebral blood flow ceases. Preterm ABP is low and close to CrCP. The diastolic closing margin (diastolic ABP minus CrCP) has been associated with intraventricular hemorrhage in preterm infants. CrCP is estimated from middle cerebral artery cerebral blood flow velocity (CBFV) and ABP waveforms. However, these estimations have not been validated due to a lack of gold standard. Direct observation of the CrCP in preterm infants with hypotension is an opportunity to validate synchronously estimated CrCP. METHODS ABP and CBFV tracings were obtained from 24 extremely low birth weight infants. Recordings where diastolic CBFV was zero were identified. The gold standard CrCP was delineated using piecewise regression of ABP and CBFV values paired by rank ordering and then estimated using a published formula. The measured and estimated values were compared using linear regression and Bland-Altman analysis. RESULTS Linear regression showed a high degree of correlation between measured and calculated CrCP (r2 = 0.93). CONCLUSIONS This is the first study to validate a calculated CrCP by comparing it to direct measurements of CrCP from preterm infants when ABP is lower than CrCP.
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Abstract
There is a distinct lack of age-appropriate cardiotonic drugs, and adult derived formulations continue to be administered, without evidence-based knowledge on their dosing, safety, efficacy, and long-term effects. Dopamine remains the most commonly studied and prescribed cardiotonic drug in the neonatal intensive care unit (NICU), but evidence of its effect on endorgan perfusion still remains. Unlike adult and pediatric critical care, there are significant gaps in our knowledge on the use of various cardiotonic drugs in various forms of circulatory failure in the NICU.
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Affiliation(s)
- Eugene Dempsey
- Department of Paediatrics and Child Health, Neonatal Intensive Care Unit, University College Cork, Wilton, Cork, Ireland; Irish Centre for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland.
| | - Heike Rabe
- Brighton and Sussex Medical School, University of Sussex, Brighton, UK; Department of Neonatology, Brighton & Sussex University Hospitals NHS Trust, Brighton, UK
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Pereira SS, Sinha AK, Morris JK, Wertheim DF, Shah DK, Kempley ST. Blood pressure intervention levels in preterm infants: pilot randomised trial. Arch Dis Child Fetal Neonatal Ed 2019; 104:F298-F305. [PMID: 30049724 DOI: 10.1136/archdischild-2017-314159] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 06/06/2018] [Accepted: 06/18/2018] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To examine the feasibility of a trial allocating different blood pressure (BP) intervention levels for treatment in extremely preterm infants. DESIGN Three-arm open randomised controlled trial performed between February 2013 and April 2015. SETTING Single tertiary level neonatal intensive care unit. PATIENTS Infants born <29 weeks' gestation were eligible to participate, if parents consented and they did not have a major congenital malformation. INTERVENTIONS Infants were randomised to different levels of mean arterial BP at which they received cardiovascular support: active (<30 mm Hg), moderate (<gestational age mm Hg) or permissive (signs of poor perfusion or <19 mm Hg). Once this threshold was breached, all were managed using the same treatment guideline. BP profiles were downloaded continuously; cardiac output and carotid blood flow were measured at 1 day and 3 days, and amplitude integrated EEG was recorded during the first week. Cranial ultrasound scans were reviewed blind to study allocation. MAIN OUTCOME MEASURE Inotrope usage and achieved BP. RESULTS Of 134 cases screened, 60 were enrolled, with mean gestation 25.8 weeks (SD 1.5) and birth weight 817 g (SD 190). Invasively measured BP on the first day and inotrope usage were highest in the active and lowest in the permissive arms. There were no differences in haemodynamic or EEG variables or in clinical complications. Predefined cranial ultrasound findings did not differ significantly; no infants in the active arm had parenchymal brain lesions. CONCLUSION The BP threshold used to trigger treatment affects the achieved BP and inotrope usage, and it was possible to explore these effects using this study design. TRIAL REGISTRATION NUMBER ISRCTN83507686.
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Affiliation(s)
- Sujith Stanley Pereira
- Neonatal Unit, Royal London Hospital, Barts Health NHS Trust, London, UK.,Centre for Genomics and Child Health, Blizard Institute, Barts and the London School of Medicine and Dentistry, London, UK
| | - Ajay Kumar Sinha
- Neonatal Unit, Royal London Hospital, Barts Health NHS Trust, London, UK.,Centre for Genomics and Child Health, Blizard Institute, Barts and the London School of Medicine and Dentistry, London, UK
| | - Joan Katherine Morris
- Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - David F Wertheim
- Faculty of Science, Engineering and Computing, Kingston University, Kingston, UK
| | - Divyen K Shah
- Neonatal Unit, Royal London Hospital, Barts Health NHS Trust, London, UK.,Centre for Genomics and Child Health, Blizard Institute, Barts and the London School of Medicine and Dentistry, London, UK
| | - Stephen Terence Kempley
- Neonatal Unit, Royal London Hospital, Barts Health NHS Trust, London, UK.,Centre for Genomics and Child Health, Blizard Institute, Barts and the London School of Medicine and Dentistry, London, UK
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Bravo MC, López-Ortego P, Sánchez L, Madero R, Cabañas F, Koch A, Rojas-Anaya H, Rabe H, Pellicer A. Validity of Biomarkers of Early Circulatory Impairment to Predict Outcome: A Retrospective Analysis. Front Pediatr 2019; 7:212. [PMID: 31192178 PMCID: PMC6548875 DOI: 10.3389/fped.2019.00212] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 05/10/2019] [Indexed: 11/13/2022] Open
Abstract
Objectives: The definition of circulatory impairment in the premature infant is controversial. Current research suggests overdiagnosis and overtreatment. We aimed to analyse which biomarkers move clinicians to initiate cardiovascular treatment (CVT). The prognostic capacity for adverse outcome (death and/or moderate-severe brain damage by cranial ultrasound at term equivalent) of these biomarkers was evaluated. Study Design: Retrospective data analysis from preterm infants enrolled in a placebo-controlled trial on dobutamine for low superior vena cava (SVC) flow, who showed normal SVC flow within the first 24 h (not randomized). Five positive biomarkers were considered: MABP < gestational age (GA)-1 mmHg; MABP < GA-5 mmHg; lactate > 4 mmol/L; BE < -9 mmol/L; SVC flow <51 ml/kg/min. Results: Ninety eight infants formed the study cohort. Thirty six received CVT (2-95 h). Logistic regression models adjusted for gestational age showed a positive association between CVT and the risk of death or moderate-severe abnormal cranial ultrasound at term equivalent [(OR 5.2, 95%CI: 1.8-15.1) p = 0.002]. MABP < GA-1 mmHg and lactate > 4 mmol/L were the most prevalent biomarkers at start of treatment. Low BE, high serum lactate and low SVC flow at first echocardiography showed a trend toward being associated with adverse outcome, although not statistically significant. Conclusions: Low blood pressure and high lactate are the most prevalent biomarkers used for CVT prescription. Lactic acidosis and low SVC flow early after birth showed a trend toward being associated with adverse outcome. These findings support using a combination of biomarkers for inclusion in a placebo-controlled trial on CVT during transitional circulation.
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Affiliation(s)
| | | | - Laura Sánchez
- Department of Neonatology, La Paz University Hospital, Madrid, Spain
| | - Rosario Madero
- Division of Statistics, La Paz University Hospital, Madrid, Spain
| | - Fernando Cabañas
- Department of Neonatology, La Paz University Hospital, Madrid, Spain.,Department of Pediatrics and Neonatology, Quironsalud Madrid University Hospital, Madrid, Spain
| | - Armin Koch
- Medizinische Hochschule Hannover, Institut für Biometrie, Hannover, Germany
| | - Héctor Rojas-Anaya
- Academic Department of Paediatrics, Brighton and Sussex Medical School, Brighton, United Kingdom
| | - Heike Rabe
- Academic Department of Paediatrics, Brighton and Sussex Medical School, Brighton, United Kingdom
| | - Adelina Pellicer
- Department of Neonatology, La Paz University Hospital, Madrid, Spain
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Kurtom W, Jain D, Quan M, Vanbuskirk S, Bancalari E, Claure N. The Impact of Late Onset Arterial Hypotension on Respiratory Outcome in Extremely Premature Infants. Neonatology 2019; 115:164-168. [PMID: 30485857 DOI: 10.1159/000494104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Accepted: 09/27/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND In extremely premature infants, arterial hypotension in the first days after birth has been associated with an increased risk for bronchopulmonary dysplasia (BPD). Some infants present with hypotension at a later postnatal age, but the relationship between late onset hypotension (LOH) and BPD has not been evaluated. OBJECTIVE To evaluate the association between LOH and BPD and to identify pre- and postnatal factors associated with LOH. METHODS Prospectively collected data from a cohort of 23-28 weeks gestational age (GA) infants born during years 2005-2015 and alive at day 28 were analyzed. LOH was defined as the receipt of vasopressor treatment during days 8-28. BPD was defined as need for oxygen at 36 weeks postmenstrual age. Late mortality was defined as death after day 28. RESULTS Of 1,058 infants in the cohort, 90 (9%) had LOH during days 8-28. Infants with LOH had a higher incidence of BPD than normotensive infants (55 vs. 21%, p < 0.001). Multivariate logistic regression analysis (LRA) showed that LOH was associated with an increased risk for BPD (OR 1.87, 95% CI 1.10-3.17). LOH was also associated with an increased risk for late mortality. LRA showed the risk for LOH increased with lower GA, sepsis and patent ductus arteriosus during days 8-28. CONCLUSIONS In this cohort of extremely premature infants, LOH was associated with an increased the risk for BPD. This association could be secondary to underlying factors that predispose to LOH and BPD or to the deleterious effects of LOH or its treatments on the lung. Further investigation is needed to assess causality.
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Affiliation(s)
- Waleed Kurtom
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine-Jackson Memorial Hospital, Miami, Florida, USA
| | - Deepak Jain
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine-Jackson Memorial Hospital, Miami, Florida, USA
| | - Meiying Quan
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine-Jackson Memorial Hospital, Miami, Florida, USA
| | - Silvia Vanbuskirk
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine-Jackson Memorial Hospital, Miami, Florida, USA
| | - Eduardo Bancalari
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine-Jackson Memorial Hospital, Miami, Florida, USA
| | - Nelson Claure
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine-Jackson Memorial Hospital, Miami, Florida, USA,
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Rhee CJ, da Costa CS, Austin T, Brady KM, Czosnyka M, Lee JK. Neonatal cerebrovascular autoregulation. Pediatr Res 2018; 84:602-610. [PMID: 30196311 PMCID: PMC6422675 DOI: 10.1038/s41390-018-0141-6] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 06/04/2018] [Accepted: 07/27/2018] [Indexed: 12/12/2022]
Abstract
Cerebrovascular pressure autoregulation is the physiologic mechanism that holds cerebral blood flow (CBF) relatively constant across changes in cerebral perfusion pressure (CPP). Cerebral vasoreactivity refers to the vasoconstriction and vasodilation that occur during fluctuations in arterial blood pressure (ABP) to maintain autoregulation. These are vital protective mechanisms of the brain. Impairments in pressure autoregulation increase the risk of brain injury and persistent neurologic disability. Autoregulation may be impaired during various neonatal disease states including prematurity, hypoxic-ischemic encephalopathy (HIE), intraventricular hemorrhage, congenital cardiac disease, and infants requiring extracorporeal membrane oxygenation (ECMO). Because infants are exquisitely sensitive to changes in cerebral blood flow (CBF), both hypoperfusion and hyperperfusion can cause significant neurologic injury. We will review neonatal pressure autoregulation and autoregulation monitoring techniques with a focus on brain protection. Current clinical therapies have failed to fully prevent permanent brain injuries in neonates. Adjuvant treatments that support and optimize autoregulation may improve neurologic outcomes.
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Affiliation(s)
- Christopher J. Rhee
- Baylor College of Medicine, Texas Children’s Hospital, Department of Pediatrics, Section of Neonatology, Houston, TX, USA
| | | | - Topun Austin
- Neonatal Unit, Rosie Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Ken M. Brady
- Baylor College of Medicine, Texas Children’s Hospital, Department of Pediatrics, Critical Care Medicine and Anesthesiology, Houston, TX, USA
| | - Marek Czosnyka
- Department of Academic Neurosurgery, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - Jennifer K. Lee
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
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31
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O'Driscoll DN, McGovern M, Greene CM, Molloy EJ. Gender disparities in preterm neonatal outcomes. Acta Paediatr 2018; 107:1494-1499. [PMID: 29750838 DOI: 10.1111/apa.14390] [Citation(s) in RCA: 84] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 04/26/2018] [Accepted: 05/03/2018] [Indexed: 01/04/2023]
Abstract
AIM From birth to old age, males generally have poorer disease outcomes compared to females. Preterm infants display a marked gender disparity in disease outcomes, and the underlying mechanisms are not well delineated. Our aim was to review the literature on clinical outcomes between preterm infants of different genders and discuss the potential mechanisms underlying the differences observed. METHODS A literature review was undertaken for experimental and clinical research related to gender differences in preterm outcomes. RESULTS Preterm male infants appear to have consistently worse outcomes compared to females, and the aetiology of these differences, while mostly undetermined, is likely multifactorial. CONCLUSION The male disadvantage in preterm outcomes is likely multifactorial with hormonal, genetic and immunological differences likely playing key roles. Gender is an important variable in preterm outcome and should be considered when designing clinical and experimental research.
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Affiliation(s)
- David N O'Driscoll
- Paediatrics, Academic Centre, Tallaght Hospital, Trinity College and Trinity Translational Medicine Institute, St James' Hospital, the University of Dublin, Dublin, Ireland
| | - Matthew McGovern
- Paediatrics, Academic Centre, Tallaght Hospital, Trinity College and Trinity Translational Medicine Institute, St James' Hospital, the University of Dublin, Dublin, Ireland
| | - Catherine M Greene
- Clinical Microbiology, Royal College of Surgeons in Ireland, Education and Research Centre, Beaumont Hospital, Dublin, Ireland
| | - Eleanor J Molloy
- Paediatrics, Academic Centre, Tallaght Hospital, Trinity College and Trinity Translational Medicine Institute, St James' Hospital, the University of Dublin, Dublin, Ireland
- Neonatology, Coombe Women and Infants' University Hospital, Dublin, Ireland
- Neonatology, Our Lady's Children's Hospital, Dublin, Ireland
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32
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Semenova O, Lightbody G, O'Toole JM, Boylan G, Dempsey E, Temko A. Modelling interactions between blood pressure and brain activity in preterm neonates. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2018; 2017:3969-3972. [PMID: 29060766 DOI: 10.1109/embc.2017.8037725] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Hypotension or low blood pressure (BP) is a common problem in preterm neonates and has been associated with adverse short and long-term outcomes. Deciding when and whether to treat hypotension relies on an understanding of the relations between blood pressure and brain function. This study aims to investigate the interaction between BP and multichannel EEG in preterm infants less than 32 weeks gestational age. The mutual information is chosen to model interaction. This measure is independent of absolute values of BP and electroencephalography (EEG) power and quantifies the level of coupling between the short-term dynamics in both signals. It is shown that while adverse health conditions as measured by higher clinical risk indices for babies (CRIB II) are accompanied by consistently lower blood pressure (r=0.43), no significant correlation was observed between CRIB scores and EEG spectral power. More importantly, the chosen measure of interaction between dynamics of EEG and BP was found to be more closely related to CRIB scores (r=0.49, p-value=0.012), with higher CRIB score associated with lower levels of interaction.
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33
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Coupling between mean blood pressure and EEG in preterm neonates is associated with reduced illness severity scores. PLoS One 2018; 13:e0199587. [PMID: 29933403 PMCID: PMC6014641 DOI: 10.1371/journal.pone.0199587] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 06/11/2018] [Indexed: 11/19/2022] Open
Abstract
Hypotension or low blood pressure (BP) is a common problem in preterm neonates and has been associated with adverse short and long-term neurological outcomes. Deciding when and whether to treat hypotension relies on an understanding of the relationship between BP and brain functioning. This study aims to investigate the interaction (coupling) between BP and continuous multichannel unedited EEG recordings in preterm infants less than 32 weeks of gestational age. The EEG was represented by spectral power in four frequency sub-bands: 0.3-3 Hz, 3-8 Hz, 8-15 Hz and 15-30 Hz. BP was represented as mean arterial pressure (MAP). The level of coupling between the two physiological systems was estimated using linear and nonlinear methods such as correlation, coherence and mutual information. Causality of interaction was measured using transfer entropy. The illness severity was represented by the clinical risk index for babies (CRIB II score) and contrasted to the computed level of interaction. It is shown here that correlation and coherence, which are linear measures of the coupling between EEG and MAP, do not correlate with CRIB values, whereas adjusted mutual information, a nonlinear measure, is associated with CRIB scores (r = -0.57, p = 0.003). Mutual information is independent of the absolute values of MAP and EEG powers and quantifies the level of coupling between the short-term dynamics in both signals. The analysis indicated that the dominant causality is from changes in EEG producing changes in MAP. Transfer entropy (EEG to MAP) is associated with the CRIB score (0.3-3 Hz: r = 0.428, p = 0.033, 3-8 Hz: r = 0.44, p = 0.028, 8-15 Hz: r = 0.416, p = 0.038) and indicates that a higher level of directed coupling from brain activity to blood pressure is associated with increased illness in preterm infants. This is the first study to present the nonlinear measure of interaction between brain activity and blood pressure and to demonstrate its relation to the initial illness severity in the preterm infant. The obtained results allow us to hypothesise that the normal wellbeing of a preterm neonate can be characterised by a nonlinear coupling between brain activity and MAP, whereas the presence of weak coupling with distinctive directionality of information flow is associated with an increased mortality rate in preterms.
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34
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Rizk MY, Lapointe A, Lefebvre F, Barrington KJ. Norepinephrine infusion improves haemodynamics in the preterm infants during septic shock. Acta Paediatr 2018; 107:408-413. [PMID: 28992392 DOI: 10.1111/apa.14112] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 09/13/2017] [Accepted: 10/05/2017] [Indexed: 01/02/2023]
Abstract
AIM This study evaluated the clinical and haemodynamic effects of norepinephrine infusion in preterm infants. METHODS The effects of norepinephrine therapy for refractory hypotension were evaluated in preterm infants between April 2009 and April 2011 at the neonatal intensive care unit of Sainte-Justine Hospital, Montreal, Quebec. Changes in haemodynamics and clinical parameters were analysed eight hours before and eight hours after the start of norepinephrine infusion, and eight hours after its cessation. RESULTS During the study, 30 preterm infants at a mean gestational age of 26.5 ± 2.6 weeks (median: 25.7, 23.4-34) and birthweight of 903 ± 437 g (median 827, 450-2550) received norepinephrine infusion for neonatal septic shock. After eight hours of treatment, mean blood pressure, urine output and FiO2 significantly improved. Eight hours after cessation of norepinephrine infusion, the number of patients treated with other inotropes decreased significantly, 24 patients (80%) had normal mean blood pressure and 27 patients (90%) had normal urine output. CONCLUSION Norepinephrine therapy could be considered to improve blood pressure and urine output during neonatal septic shock in preterm infants. Further studies are needed to prove the efficacy and safety of norepinephrine infusion in neonates.
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Affiliation(s)
- MY Rizk
- Department of Pediatrics; CHU Ste-Justine; University of Montreal; Montreal QC Canada
| | - A Lapointe
- Department of Pediatrics; CHU Ste-Justine; University of Montreal; Montreal QC Canada
| | - F Lefebvre
- Department of Pediatrics; CHU Ste-Justine; University of Montreal; Montreal QC Canada
| | - KJ Barrington
- Department of Pediatrics; CHU Ste-Justine; University of Montreal; Montreal QC Canada
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35
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Kluckow M. The Pathophysiology of Low Systemic Blood Flow in the Preterm Infant. Front Pediatr 2018; 6:29. [PMID: 29503814 PMCID: PMC5820306 DOI: 10.3389/fped.2018.00029] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 01/31/2018] [Indexed: 11/13/2022] Open
Abstract
Assessment and treatment of the VLBW infant with cardiovascular impairment requires understanding of the underlying physiology of the infant in transition. The situation is dynamic with changes occurring in systemic blood pressure, pulmonary pressures, myocardial function, and ductal shunt in the first postnatal days. New insights into the role of umbilical cord clamping in the transitional circulation have been provided by large clinical trials of early versus later cord clamping and a series of basic science reports describing the physiology in an animal model. Ultrasound assessment is invaluable in assessment of the physiology of the transition and can provide information about the size and shunt direction of the ductus arteriosus, the function of the myocardium and its filling as well as measurements of the cardiac output and an estimate of the state of peripheral vascular resistance. This information not only allows more specific treatment but it will often reduce the need for treatment.
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Affiliation(s)
- Martin Kluckow
- Department of Neonatology, Royal North Shore Hospital, University of Sydney, Sydney, NSW, Australia
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36
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Rhee CJ, Rios DR, Kaiser JR, Brady K. Cerebral Hemodynamics in Premature Infants. NEONATAL MEDICINE 2018. [DOI: 10.5385/nm.2018.25.1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Christopher J. Rhee
- Section of Neonatology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, United States
| | - Danielle R. Rios
- Section of Neonatology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, United States
| | - Jeffrey R. Kaiser
- Department of Pediatrics, Obstetrics and Gynecology, Hershey Medical Center, Penn State College of Medicine, Milton S, Hershey, PA, United States
| | - Ken Brady
- Section of Neonatology, Department of Pediatrics, Critical Care Medicine and Anesthesiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, United States
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37
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Balakrishnan M, Raghavan A, Suresh GK. Eliminating Undesirable Variation in Neonatal Practice: Balancing Standardization and Customization. Clin Perinatol 2017; 44:529-540. [PMID: 28802337 DOI: 10.1016/j.clp.2017.04.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Consistency of care and elimination of unnecessary and harmful variation are underemphasized aspects of health care quality. This article describes the prevalence and patterns of practice variation in health care and neonatology; discusses the potential role of standardization as a solution to eliminating wasteful and harmful practice variation, particularly when it is founded on principles of evidence-based medicine; and proposes ways to balance standardization and customization of practice to ultimately improve the quality of neonatal care.
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Affiliation(s)
- Maya Balakrishnan
- Division of Neonatology, Department of Pediatrics, University of South Florida Morsani College of Medicine, 2 Tampa General Circle, Tampa, FL 33606, USA
| | - Aarti Raghavan
- Division of Neonatology, Department of Pediatrics, UIC Hospital, University of Illinois College of Medicine at Chicago, 1740 West Taylor Street, Chicago, IL 60612, USA
| | - Gautham K Suresh
- Division of Neonatology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, 6621 Fannin Street, W6104, Houston, TX 77030, USA.
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The Ontogeny of Cerebrovascular Pressure Autoregulation in Premature Infants. ACTA NEUROCHIRURGICA. SUPPLEMENT 2017; 122:151-5. [PMID: 27165897 DOI: 10.1007/978-3-319-22533-3_31] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Our objective was to quantify cerebrovascular autoregulation as a function of gestational age (GA) and across the phases of the cardiac cycle. One hundred eighty-six premature infants, with a GA range of 23-33 weeks, were monitored using umbilical artery catheters and transcranial Doppler insonation of middle cerebral artery flow velocity (FV) for 1-h sessions over the first week of life. Autoregulation was quantified as a moving correlation coefficient between systolic arterial blood pressure (ABP) and systolic FV (Sx); mean ABP and mean FV (Mx); diastolic ABP and diastolic FV (Dx). Autoregulation was compared across GAs for each aspect of the cardiac cycle. Systolic FV was pressure-passive in infants with the lowest GA, and Sx decreased with increased GA (r = -0.3; p < 0.001). By contrast, Dx was elevated in all subjects, and showed minimal change with increased GA (r = -0.06; p = 0.05). Multivariate analysis confirmed that GA (p < 0.001) and the "closing margin" (p < 0.01) were associated with Sx. Premature infants have low and almost always pressure-passive diastolic cerebral blood FV. Conversely, the regulation of systolic cerebral blood FV by autoregulation was manifested in this cohort at a GA of between 23 and 33 weeks.
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Rhee CJ, Kibler KK, Easley RB, Andropoulos DB, Czosnyka M, Smielewski P, Varsos GV, Brady KM, Rusin CG, Fraser CD, Gauss CH, Williams DK, Kaiser JR. The Diastolic Closing Margin Is Associated with Intraventricular Hemorrhage in Premature Infants. ACTA NEUROCHIRURGICA. SUPPLEMENT 2017; 122:147-50. [PMID: 27165896 DOI: 10.1007/978-3-319-22533-3_30] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
Premature infants are at an increased risk of intraventricular hemorrhage (IVH). The roles of hypotension and hyperemia are still debated. Critical closing pressure (CrCP) is the arterial blood pressure (ABP) at which cerebral blood flow (CBF) ceases. When diastolic ABP is equal to CrCP, CBF occurs only during systole. The difference between diastolic ABP and CrCP is the diastolic closing margin (DCM). We hypothesized that a low DCM was associated with IVH. One hundred eighty-six premature infants, with a gestational age (GA) range of 23-33 weeks, were monitored with umbilical artery catheters and transcranial Doppler insonation of middle cerebral artery flow velocity for 1-h sessions over the first week of life. CrCP was calculated linearly and using an impedance model. A multivariate generalized linear regression model was used to determine associations with severe IVH (grades 3-4). An elevated DCM by either method was associated with IVH (p < 0.0001 for the linear method; p < 0.001 for the impedance model). Lower 5-min Apgar scores, elevated mean CBF velocity, and lower mean ABP were also associated with IVH (p < 0.0001). Elevated DCM, not low DCM, was associated with severe IVH in this cohort.
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Affiliation(s)
- Christopher J Rhee
- Department of Pediatrics, Section of Neonatology, Texas Children's Hospital/Baylor College of Medicine, 6621 Fannin Street, W6-104, Houston, TX, USA.
| | - Kathleen K Kibler
- Departments of Anesthesiology, Critical Care Medicine, and Pediatrics, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
| | - R Blaine Easley
- Departments of Anesthesiology, Critical Care Medicine, and Pediatrics, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
| | - Dean B Andropoulos
- Departments of Anesthesiology, Critical Care Medicine, and Pediatrics, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
| | - Marek Czosnyka
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Peter Smielewski
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Georgios V Varsos
- Department of Academic Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Ken M Brady
- Departments of Anesthesiology, Critical Care Medicine, and Pediatrics, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
| | - Craig G Rusin
- Department of Cardiology, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
| | - Charles D Fraser
- University of Texas at Houston School of Medicine, Houston, TX, USA
| | - C Heath Gauss
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - D Keith Williams
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Jeffrey R Kaiser
- Department of Pediatrics, Section of Neonatology, Texas Children's Hospital/Baylor College of Medicine, 6621 Fannin Street, W6-104, Houston, TX, USA
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Logan JW, Dammann O, Allred EN, Dammann C, Beam K, Joseph RM, O'Shea TM, Leviton A, Kuban KCK. Early postnatal illness severity scores predict neurodevelopmental impairments at 10 years of age in children born extremely preterm. J Perinatol 2017; 37:606-614. [PMID: 28079875 PMCID: PMC5407946 DOI: 10.1038/jp.2016.242] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 10/20/2016] [Accepted: 11/01/2016] [Indexed: 12/23/2022]
Abstract
OBJECTIVE A neonatal illness severity score, The Score for Neonatal Acute Physiology-II (SNAP-II), predicts neurodevelopmental impairments at two years of age among children born extremely preterm. We sought to evaluate to what extent SNAP-II is predictive of cognitive and other neurodevelopmental impairments at 10 years of age. STUDY DESIGN In a cohort of 874 children born before 28 weeks of gestation, we prospectively collected clinical, physiologic and laboratory data to calculate SNAP-II for each infant. When the children were 10 years old, examiners who were unaware of the child's medical history assessed neurodevelopmental outcomes, including neurocognitive, gross motor, social and communication functions, diagnosis and treatment of seizures or attention deficit hyperactivity disorder (ADHD), academic achievement, and quality of life. We used logistic regression to adjust for potential confounders. RESULTS An undesirably high SNAP-II (⩾30), present in 23% of participants, was associated with an increased risk of cognitive impairment (IQ, executive function, language ability), adverse neurological outcomes (epilepsy, impaired gross motor function), behavioral abnormalities (attention deficit disorder and hyperactivity), social dysfunction (autistic spectrum disorder) and education-related adversities (school achievement and need for educational supports. In analyses that adjusted for potential confounders, Z-scores ⩽-1 on 11 of 18 cognitive outcomes were associated with SNAP-II in the highest category, and 6 of 18 were associated with SNAP-II in the intermediate category. Odds ratios and 95% confidence intervals ranged from 1.4 (1.01, 2.1) to 2.1 (1.4, 3.1). Similarly, 2 of the 8 social dysfunctions were associated with SNAP-II in the highest category, and 3 of 8 were associated with SNAP-II in the intermediate category. Odds ratios and 95% confidence intervals were slightly higher for these assessments, ranging from 1.6 (1.1, 2.4) to 2.3 (1.2, 4.6). CONCLUSION Among very preterm newborns, physiologic derangements present in the first 12 postnatal hours are associated with dysfunctions in several neurodevelopmental domains at 10 years of age. We are unable to make inferences about causality.
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Affiliation(s)
- J. Wells Logan
- Department of Pediatrics and Neonatology, Nationwide Children's Hospital, and The Ohio State University, Columbus, OH
| | - Olaf Dammann
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA,Perinatal Neuroepidemiology Unit, Hannover Medical School, Hannover, Germany
| | | | - Christiane Dammann
- Department of Pediatrics and Neonatology, Tufts University School of Medicine, Boston, MA
| | - Kristyn Beam
- Department of Pediatrics and Neonatology, Tufts University School of Medicine, Boston, MA
| | - Robert M. Joseph
- Department of Anatomy and Neurobiology, Boston University School of Medicine, Boston, MA
| | - T. Michael O'Shea
- Department of Pediatrics and Neonatology, University of North Carolina, Chapel Hill, NC
| | - Alan Leviton
- Harvard Medical School, Boston, MA,Boston Children's Hospital, Boston, MA
| | - Karl C. K. Kuban
- Department of Pediatrics, Division of Pediatric Neurology, Boston University School of Medicine, Boston, MA
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Liebowitz M, Koo J, Wickremasinghe A, Allen IE, Clyman RI. Effects of Prophylactic Indomethacin on Vasopressor-Dependent Hypotension in Extremely Preterm Infants. J Pediatr 2017; 182:21-27.e2. [PMID: 27915200 PMCID: PMC5328836 DOI: 10.1016/j.jpeds.2016.11.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 10/13/2016] [Accepted: 11/02/2016] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine whether a moderate-to-large patent ductus arteriosus (PDA) is responsible for vasopressor-dependent hypotension, occurring at the end of the first postnatal week. STUDY DESIGN We performed a retrospective, double cohort controlled study of infants delivered at ≤27+6 weeks' gestation (n = 313). From January 2004 through April 2011, all infants were treated with prophylactic indomethacin ([PINDO] epoch). From May 2011 through December 2015, no infant was treated with indomethacin until at least 8 postnatal days (conservative epoch). Echocardiograms were performed on postnatal days 6 or 7. Hypotension was managed by a predefined protocol. The primary outcome was the incidence of dopamine-dependent hypotension, defined as having received at least 6 µg/kg/min dopamine for at least 24 hours during postnatal days 4-7. RESULTS As expected, the incidence of moderate-to-large PDA at the end of the first week differed significantly between epochs (PINDO = 8%; conservative = 64%). In multivariate analyses, infants in the PINDO epoch had a significantly lower incidence of vasopressor-dependent hypotension (11%) than infants in the conservative epoch (21%; OR = 0.40, 95% CI 0.20-0.82). Infants in the PINDO epoch also required less mean airway pressure, had a lower respiratory severity score, and lower mode of ventilation score than infants in the conservative epoch during postnatal days 4-7. The effects of PINDO on both the incidence of vasopressor-dependent hypotension and the need for respiratory support were no longer significant when analyses were adjusted for "presence or absence of a moderate-to-large PDA." CONCLUSION PINDO decreases vasopressor-dependent hypotension and the need for respiratory support at the end of the first postnatal week. These effects are mediated by closure of the PDA.
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Affiliation(s)
- Melissa Liebowitz
- Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Jane Koo
- Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Andrea Wickremasinghe
- Department of Pediatrics, Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA
| | - Isabel Elaine Allen
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA
| | - Ronald I Clyman
- Department of Pediatrics, University of California San Francisco, San Francisco, CA; Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA.
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Abstract
Hypotension is common in low birth weight neonates and less common in term newborns and is associated with significant morbidity and mortality. Determining an adequate blood pressure in neonates remains challenging for the neonatal nurse because of the lack of agreed-upon norms. Values for determining norms for blood pressure at varying gestational and postnatal ages are based on empirical data. Understanding cardiovascular pathophysiology, potential causes of hypotension, and assessment of adequate perfusion in the neonatal population is important and can assist the neonatal nurse in the evaluation of effective blood pressure. This article reviews cardiovascular pathophysiology as it relates to blood pressure and discusses potential causes of hypotension in the term and preterm neonate. Variation in management of hypotension across centers is discussed. Underlying causes and pathophysiology of hypotension in the neonate are described.
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Abstract
The management of preterm infants with low blood pressure soon after birth remains unresolved. The definition of what constitutes low blood pressure is uncertain. At birth, mean blood pressure appears to be gestation specific and increases in the first few days of life. Antenatal steroids, delayed cord clamping, and the avoidance of mechanical ventilation are all associated with higher mean blood pressure and less hypotension after birth. Rates of hypotension of 15-50% have been reported in various studies of extremely preterm infants. However, only about 10% of all extremely preterm infants receive inotropes, suggesting that clinicians take into account other factors such as clinical, biochemical, and echocardiographic findings before deciding to intervene. The exact role of functional echocardiography in assessing the need for treatment of low blood pressure in extremely preterm infants remains to be determined. Near- infrared spectroscopy to assess cerebral perfusion may also have a role to play. Volume expansion (usually 10 mL/kg of saline) remains the most commonly used intervention for low blood pressure but evidence of benefit is lacking and there may be safety concerns. Whilst dopamine is the most commonly used inotropic drug, dobutamine, epinephrine, corticosteroids, milrinone, and vasopressin have also been utilised in preterm infants with low blood pressure. Clinical trials with long-term outcomes are needed to determine the most suitable inotrope and when to use it. Early hypotension differs from late hypotension with regard to cause, treatment, and outcome. A number of recent studies aimed at improving the evidence base for the treatment of early hypotension in extremely preterm infants have been terminated early because of poor recruitment. Currently, the answer to the question of what to do about low blood pressure in preterm infants remains unclear.
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St Peter D, Gandy C, Hoffman SB. Hypotension and Adverse Outcomes in Prematurity: Comparing Definitions. Neonatology 2017; 111:228-233. [PMID: 27898415 DOI: 10.1159/000452616] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 10/13/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND In the premature neonate, there is no consensus regarding normal blood pressure (BP). The most common definition used is a mean arterial BP (MAP) less than the gestational age (GA); however, studies indicate that the neuroprotective mechanism of autoregulation is lost below a MAP of 30 mm Hg. OBJECTIVE To determine whether hypotension defined as MAP <30 mm Hg or MAP less than the infant's GA better predicts adverse outcomes of intraventricular hemorrhage (IVH) and death. STUDY DESIGN For this retrospective study, demographic, clinical, and BP data in epochs of 12 h were collected during the first 72 h of life in 188 subjects 24-28 weeks of gestation. For each definition, outcomes of severe IVH (grade 3 or 4), death, or the composite outcome of either were evaluated using bivariate testing. Logistic regression determined independent predictors of composite outcome of death and/or grade 3 or 4 IVH. RESULTS Hypotension by either definition was significant for death and the composite outcome (p < 0.0001). Only the MAP <30 mm Hg definition was associated with severe IVH (p = 0.02). On logistic regression, significant predictors of the composite outcome were GA (OR 0.59, 95% CI 0.39-0.89) and vasopressor therapy (OR 5.5, 95% CI 2-17). CONCLUSIONS Neither definition of hypotension independently predicts adverse outcome in multivariate logistic regression. Vasopressor therapy, however, is an independent predictor of IVH and death in premature infants.
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Affiliation(s)
- Deidre St Peter
- Department of Pediatrics, University of Maryland Medical Center, Baltimore, MD, USA
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McGovern M, Miletin J. A review of superior vena cava flow measurement in the neonate by functional echocardiography. Acta Paediatr 2017; 106:22-29. [PMID: 27611695 DOI: 10.1111/apa.13584] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 08/29/2016] [Accepted: 09/07/2016] [Indexed: 11/27/2022]
Abstract
Neonatologists have begun using superior vena cava flow as assessed by functional echocardiography to facilitate real-time decision-making on cardiovascular care. This review aims to describe the basis of the technique, summarise the evidence for its use and compare the technique to existing clinical, biochemical and radiological techniques for assessing neonatal circulatory status. CONCLUSION Although echocardiographic measurements of superior vena cava flow, like other measures of perfusion, are not perfect, their noninvasive nature and ability to facilitate real-time decision-making means that at present, they remain the best available methodology of monitoring central perfusion in the neonatal population.
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Affiliation(s)
- Matthew McGovern
- Neonatology Department; Coombe Women and Infant University Hospital; Dublin Ireland
| | - Jan Miletin
- Neonatology Department; Coombe Women and Infant University Hospital; Dublin Ireland
- Institute for the Care of Mother and Child; Prague Czech Republic
- 3rd School of Medicine; Charles University; Prague Czech Republic
- UCD School of Medicine and Medical Sciences; Dublin Ireland
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Noradrenaline in preterm infants with cardiovascular compromise. Eur J Pediatr 2016; 175:1967-1973. [PMID: 27744568 DOI: 10.1007/s00431-016-2794-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 10/04/2016] [Accepted: 10/07/2016] [Indexed: 10/20/2022]
Abstract
UNLABELLED Noradrenaline (NA) is beneficial in the treatment of term newborns with cardiovascular compromise due to sepsis or pulmonary hypertension, but experiences with NA in preterm infants are limited. The aim of this study is to describe the efficacy and safety of NA in preterm infants. Patient records of preterm infants ≤32 weeks' gestation admitted to two hospitals between 2004 and 2015 and who received NA were reviewed for perinatal morbidities and mortality. Clinical details were collected at the time of NA use, and response on blood pressure, perfusion and oxygenation was documented as well as possible side effects. Forty-eight infants with primary diagnoses of sepsis (63 %) and pulmonary hypertension (23 %) received NA. Normotension was achieved at a median of 1 h in all but one infant at a median dose of 0.5 mcg/kg/min. Infants who died (46 %) were of younger gestational age and had worse cardiovascular function at start of NA compared to infants who survived. Tachycardia was common (31 %), but no additional effects were found on kidney or liver function. CONCLUSION NA appears to be tolerated safely by preterm infants with no major side effects. However, effectiveness needs to be studies further in structured trials. What is Known: • Noradrenaline is beneficial in the treatment of term newborns and infants with cardiovascular compromise. • Noradrenaline is known for its potent vasoconstrictive effects and, therefore, infrequently used in preterm infants. What is New: • Noradrenaline used in relative low dose and as first or second line support increases blood pressure in preterm infants with cardiovascular compromise. • Tachycardia was common, but no additional side effects were found.
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Abstract
OBJECTIVE To describe the use of inotropic drugs and the characteristics of neonates receiving such treatment in a national cohort of patients admitted to neonatal ICUs in Norway. DESIGN A national registry study of patients included in the Norwegian Neonatal Network database 2009-2014. Demographic and treatment data, including the use of inotropic drugs (dopamine, dobutamine, epinephrine, norepinephrine, milrinone, and levosimendan) and outcomes, were retrieved and analyzed. SETTING Neonatal ICUs in Norway. PATIENTS All patients admitted to Norwegian neonatal ICUs 2009-2014 with a postmenstrual age of less than 310 days at admission, corresponding to a postnatal age of less than 28 days for a child born at term (n = 36 397). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Inotropic drugs were administered to 974 of 361,803 live born infants (0.27%) in the study period, representing 2.7% of the neonatal ICU patient population. The relative proportion of neonatal ICU patients receiving inotropes decreased with increasing gestational age, yet 41% of the patients receiving inotropes were born at term. Of note, 89.8% of treated patients received dopamine. Use of inotropes was particularly prevalent in patients with necrotizing enterocolitis (72.4%) and pulmonary hypertension (42.1%) and in patients with gestational age less than 28 weeks (28.2%). Inotropic treatment initiated in the first week of life (84.2%) was associated with birth asphyxia and pulmonary hypertension, whereas treatment initiated after the first week of life was associated with extremely preterm birth, neonatal surgery, neonatal sepsis, cardiac disease, and necrotizing enterocolitis. CONCLUSIONS This comprehensive epidemiologic study indicates that less than 0.3% of newborns receive inotropic support in the neonatal period. Dopamine was the most commonly used drug. Relating inotrope use to clinical condition, gestational age, and postnatal age may be useful for clinicians and helpful in delineating relevant patient populations for future clinical trials.
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Rhee CJ, Kaiser JR, Rios DR, Kibler KK, Easley RB, Andropoulos DB, Czosnyka M, Smielewski P, Varsos GV, Rusin CG, Gauss CH, Williams DK, Brady KM. Elevated Diastolic Closing Margin Is Associated with Intraventricular Hemorrhage in Premature Infants. J Pediatr 2016; 174:52-6. [PMID: 27112042 PMCID: PMC4925245 DOI: 10.1016/j.jpeds.2016.03.066] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 03/11/2016] [Accepted: 03/24/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To determine whether the diastolic closing margin (DCM), defined as diastolic blood pressure minus critical closing pressure, is associated with the development of early severe intraventricular hemorrhage (IVH). STUDY DESIGN A reanalysis of prospectively collected data was conducted. Premature infants (gestational age 23-31 weeks) receiving mechanical ventilation (n = 185) had ∼1-hour continuous recordings of umbilical arterial blood pressure, middle cerebral artery cerebral blood flow velocity, and PaCO2 during the first week of life. Models using multivariate generalized linear regression and purposeful selection were used to determine associations with severe IVH. RESULTS Severe IVH (grades 3-4) was observed in 14.6% of the infants. Irrespective of the model used, Apgar score at 5 minutes and DCM were significantly associated with severe IVH. A clinically relevant 5-mm Hg increase in DCM was associated with a 1.83- to 1.89-fold increased odds of developing severe IVH. CONCLUSION Elevated DCM was associated with severe IVH, consistent with previous animal data showing that IVH is associated with hyperperfusion. Measurement of DCM may be more useful than blood pressure in defining cerebral perfusion in premature infants.
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Affiliation(s)
- Christopher J Rhee
- Section of Neonatology, Department of Pediatrics, Texas Children's Hospital/Baylor College of Medicine, Houston, TX.
| | - Jeffrey R Kaiser
- Section of Neonatology, Department of Pediatrics, Texas Children's Hospital/Baylor College of Medicine, Houston, TX; Department of Obstetrics and Gynecology, Texas Children's Hospital/Baylor College of Medicine, Houston, TX
| | - Danielle R Rios
- Section of Neonatology, Department of Pediatrics, Texas Children's Hospital/Baylor College of Medicine, Houston, TX
| | - Kathleen K Kibler
- Department of Anesthesiology, Texas Children's Hospital/Baylor College of Medicine, Houston, TX; Department of Critical Care Medicine, Texas Children's Hospital/Baylor College of Medicine, Houston, TX; Department of Pediatrics, Texas Children's Hospital/Baylor College of Medicine, Houston, TX
| | - R Blaine Easley
- Department of Anesthesiology, Texas Children's Hospital/Baylor College of Medicine, Houston, TX; Department of Critical Care Medicine, Texas Children's Hospital/Baylor College of Medicine, Houston, TX; Department of Pediatrics, Texas Children's Hospital/Baylor College of Medicine, Houston, TX
| | - Dean B Andropoulos
- Department of Anesthesiology, Texas Children's Hospital/Baylor College of Medicine, Houston, TX; Department of Critical Care Medicine, Texas Children's Hospital/Baylor College of Medicine, Houston, TX; Department of Pediatrics, Texas Children's Hospital/Baylor College of Medicine, Houston, TX
| | - Marek Czosnyka
- Department of Academic Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Peter Smielewski
- Department of Academic Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Georgios V Varsos
- Department of Academic Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Craig G Rusin
- Section of Cardiology, Department of Pediatrics, Texas Children's Hospital/Baylor College of Medicine, Houston, TX
| | - C Heath Gauss
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR
| | - D Keith Williams
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Ken M Brady
- Department of Anesthesiology, Texas Children's Hospital/Baylor College of Medicine, Houston, TX; Department of Critical Care Medicine, Texas Children's Hospital/Baylor College of Medicine, Houston, TX; Department of Pediatrics, Texas Children's Hospital/Baylor College of Medicine, Houston, TX
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Vesoulis ZA, El Ters N, Foster A, Trivedi SB, Liao SM, Mathur AM. Response to dopamine in prematurity: a biomarker for brain injury? J Perinatol 2016; 36:453-8. [PMID: 26890555 PMCID: PMC4882223 DOI: 10.1038/jp.2016.5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 01/07/2016] [Accepted: 01/08/2016] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To identify factors associated with responsiveness to dopamine therapy for hypotension and the relationship to brain injury in a cohort of preterm infants. STUDY DESIGN The pharmacy database at St Louis Children's Hospital was retrospectively queried to identify infants who (a) were born <28 weeks gestation between 2012 and 2014, (b) received dopamine and (c) had blood pressure measurements from an umbilical arterial catheter. A control group was constructed from contemporaneous infants who did not receive dopamine. Mean arterial blood pressure (MABP) at baseline, 1 h and 3 h after initiating dopamine were obtained for each dopamine-exposed infant. MABP measurements at matched time points were obtained in the control group. RESULT Sixty-nine dopamine-treated and 45 control infants were included. Mean ΔMABP at 3 h was 4.5±6.3 mm of Hg for treated infants vs 1±2.9 for the control. Median dopamine starting dose was 2.5 μg kg(-1) min(-1). Dopamine-treated infants were less mature and of lower birth weight while also more likely to be intubated at 72 h, diagnosed with intraventricular hemorrhage (IVH) and to die. Failure to respond to dopamine was associated with greater likelihood of developing IVH (odds ratio (OR) 5.8, 95% confidence interval (CI) 1.1-42.3), while a strong response (ΔMABP>10 mm Hg) was associated with a reduction in risk of IVH (OR 0.1, 95% CI 0.01-0.8). CONCLUSION Low-moderate dose dopamine administration results in modest blood pressure improvements. A lack of response to dopamine is associated with a greater risk of IVH, whereas a strong response is associated with a decreased risk. Further research into underlying mechanisms and management strategies is needed.
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Affiliation(s)
- Zachary A. Vesoulis
- Division of Newborn Medicine, Edward Mallinckrodt Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Nathalie El Ters
- Division of Newborn Medicine, Edward Mallinckrodt Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Allison Foster
- Division of Newborn Medicine, Edward Mallinckrodt Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Shamik B. Trivedi
- Division of Newborn Medicine, Edward Mallinckrodt Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Steve M. Liao
- Division of Newborn Medicine, Edward Mallinckrodt Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Amit M. Mathur
- Division of Newborn Medicine, Edward Mallinckrodt Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
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Batton B, Li L, Newman NS, Das A, Watterberg KL, Yoder BA, Faix RG, Laughon MM, Stoll BJ, Higgins RD, Walsh MC. Early blood pressure, antihypotensive therapy and outcomes at 18-22 months' corrected age in extremely preterm infants. Arch Dis Child Fetal Neonatal Ed 2016; 101:F201-6. [PMID: 26567120 PMCID: PMC4849123 DOI: 10.1136/archdischild-2015-308899] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 10/19/2015] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To investigate the relationships between early blood pressure (BP) changes, receipt of antihypotensive therapy and 18-22 months' corrected age (CA) outcomes for extremely preterm infants. DESIGN Prospective observational study of infants 23(0/7)-26(6/7) weeks' gestational age (GA). Hourly BP values and antihypotensive therapy exposure in the first 24 h were recorded. Four groups were defined: infants who did or did not receive antihypotensive therapy in whom BP did or did not rise at the expected rate (defined as an increase in the mean arterial BP of ≥5 mm Hg/day). Random-intercept logistic modelling controlling for centre clustering, GA and illness severity was used to investigate the relationship between BP, antihypotensive therapies and infant outcomes. SETTING Sixteen academic centres of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. MAIN OUTCOME MEASURES Death or neurodevelopmental impairment/developmental delay (NIDD) at 18-22 months' CA. RESULTS Of 367 infants, 203 (55%) received an antihypotensive therapy, 272 (74%) survived to discharge and 331 (90%) had a known outcome at 18-22 months' CA. With logistic regression, there was an increased risk of death/NIDD with antihypotensive therapy versus no treatment (OR 1.836, 95% CI 1.092 to 3.086), but not NIDD alone (OR 1.53, 95% CI 0.708 to 3.307). CONCLUSIONS Independent of early BP changes, antihypotensive therapy exposure was associated with an increased risk of death/NIDD at 18-22 months' CA when controlling for risk factors known to affect survival and neurodevelopment. CLINICAL TRIAL REGISTRATION NUMBER clinicaltrials.gov #NCT00874393.
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Affiliation(s)
- Beau Batton
- Department of Pediatrics, Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, OH,Department of Pediatrics, Southern Illinois University School of Medicine, Springfield, IL
| | - Lei Li
- Statistics & Epidemiology Unit, RTI International, Research Triangle Park, NC
| | - Nancy S. Newman
- Department of Pediatrics, Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, OH
| | - Abhik Das
- Statistics & Epidemiology Unit, RTI International, Rockville, MD
| | | | - Bradley A. Yoder
- Department of Pediatrics, Division of Neonatology, University of Utah School of Medicine, Salt Lake City, UT
| | - Roger G. Faix
- Department of Pediatrics, Division of Neonatology, University of Utah School of Medicine, Salt Lake City, UT
| | - Matthew M. Laughon
- Department of Pediatrics, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Barbara J. Stoll
- Department of Pediatrics, Emory University School of Medicine & Children’s Healthcare of Atlanta, Atlanta, GA
| | - Rosemary D. Higgins
- Eunice Kennedy Shriver National Institute of Child Health & Human Development, National Institutes of Health, Bethesda, MD
| | - Michele C. Walsh
- Department of Pediatrics, Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, OH
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