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Jhaveri V, Vali P, Giusto E, Singh Y, Lakshminrusimha S. Pneumothorax in a term newborn. J Perinatol 2024; 44:465-471. [PMID: 38409329 DOI: 10.1038/s41372-024-01899-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 12/21/2023] [Accepted: 01/26/2024] [Indexed: 02/28/2024]
Abstract
With the advent of surfactant and gentle ventilation, the incidence of neonatal pneumothorax has decreased over the last two decades. Pneumothorax associated with respiratory distress syndrome is more common in preterm infants, but term infants often present with isolated pneumothorax. The use of CPAP or non-invasive respiratory support in the delivery room for a term infant with respiratory distress increases transpulmonary pressures and increases the risk of pneumothorax. Prompt diagnosis with a high index of suspicion, quick evaluation by transillumination, chest X-ray or lung ultrasound is critical. Management includes observation, needle thoracocentesis and if necessary, chest tube placement. This manuscript reviews the incidence, pathogenesis, diagnosis and management of a term infant with isolated pneumothorax, summarizing the combination of established knowledge with new understanding, including data on diagnostic modes such as ultrasound, reviewing preventative measures, and therapeutic interventions such as needle thoracocentesis and a comparison of pigtail vs. straight chest tubes.
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Affiliation(s)
- Vidhi Jhaveri
- Department of Pediatrics, UC Davis Children's Hospital, Sacramento, CA, USA.
| | - Payam Vali
- Department of Pediatrics, UC Davis Children's Hospital, Sacramento, CA, USA
| | - Evan Giusto
- Department of Pediatrics, UC Davis Children's Hospital, Sacramento, CA, USA
| | - Yogen Singh
- Department of Pediatrics, Loma Linda University School of Clinical Medicine, Loma Linda, CA, USA
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Zeinali L, Giusto E, Knych H, Lesneski A, Joudi H, Hardie M, Sankaran D, Lakshminrusimha S, Vali P. Caffeine pharmacokinetics following umbilical vein injection during delayed cord clamping in preterm lambs. Pediatr Res 2024:10.1038/s41390-024-03117-3. [PMID: 38429570 DOI: 10.1038/s41390-024-03117-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 02/08/2024] [Accepted: 02/12/2024] [Indexed: 03/03/2024]
Abstract
BACKGROUND Spontaneous breathing during and after delayed cord clamping (DCC) stabilizes cardiopulmonary transition at birth. Caffeine stimulates breathing and decreases apnea in premature newborns. We evaluated the pharmacokinetics and physiological effects of early caffeine administration-direct injection into the umbilical vein (UV) during DCC or administered through a UV catheter (UVC) after delivery. METHODS Eighteen extremely premature lambs (125-127d, term gestation 145d) were exteriorized and instrumented. Lambs received caffeine-citrate at high (40 mg/kg) or standard-dose (20 mg/kg) via direct UV (DUV) injection during DCC, or via the UVC. RESULTS Mean peak plasma caffeine concentrations were lower with high-dose DUV compared to UVC (18 ± 4.3 vs. 46 ± 12 mg/L, p < 0.05). With standard-dose caffeine, mean peak plasma levels were 7.48 ± 2.6 with DUV and 28.73 ± 9.4 mg/L with UVC. The volume of distribution was higher in the DUV group compared to UVC (2.5 ± 1.0 vs. 0.69 ± 0.15 L/kg) with an estimated 39 ± 18% entering the maternal circulation. Maternal peak concentrations were 0.79 ± 0.71 and 1.43 ± 0.74 mg/L with standard and high-dose DUV, respectively. CONCLUSIONS Caffeine injected directly into the UV during DCC is feasible but achieves lower concentrations due to high volume of distribution including maternal circulation. Further trials evaluating DUV caffeine injection should use higher caffeine doses. IMPACT Respiratory stimulation with early caffeine may reduce the need for intubation in preterm infants. In the preterm lambs, caffeine injection directly into the umbilical vein during delayed cord clamping is feasible. Plasma caffeine concentrations are less than half when administered directly into the umbilical vein during delayed cord clamping compared to administration via an umbilical venous catheter following birth likely attributed to a larger volume of distribution or injection site leak. There were no significant hemodynamic alterations following caffeine injection.
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Affiliation(s)
- Lida Zeinali
- Department of Pediatrics, UC Davis School of Medicine, Sacramento, CA, USA
| | - Evan Giusto
- Department of Pediatrics, UC Davis School of Medicine, Sacramento, CA, USA
| | - Heather Knych
- UC Davis, School of Veterinary Medicine, Davis, CA, USA
| | - Amy Lesneski
- Stem Cell Program, UC Davis School of Medicine, Davis, CA, USA
| | - Houssam Joudi
- Department of Pediatrics, UC Davis School of Medicine, Sacramento, CA, USA
| | - Morgan Hardie
- UC Davis, School of Veterinary Medicine, Davis, CA, USA
| | - Deepika Sankaran
- Department of Pediatrics, UC Davis School of Medicine, Sacramento, CA, USA
| | | | - Payam Vali
- Department of Pediatrics, UC Davis School of Medicine, Sacramento, CA, USA.
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Garlapati P, Vali P, Lakshminrusimha S, Smith BJ, Zavorsky GS. The Precision Between Transcutaneous Carbon Dioxide Versus P aCO2 in Infants Undergoing Therapeutic Hypothermia. Respir Care 2024; 69:339-344. [PMID: 37253608 PMCID: PMC10984588 DOI: 10.4187/respcare.10696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND Infants with hypoxic-ischemic encephalopathy are often treated with therapeutic hypothermia and high-frequency ventilation. Fluctuations in PaCO2 during therapeutic hypothermia are associated with poor neurodevelopmental outcomes. Transcutaneous CO2 monitors offer a noninvasive estimate of PaCO2 represented by transcutaneously measured partial pressure of carbon dioxide (PtcCO2 ). We aimed to assess the precision between PtcCO2 and PaCO2 values in neonates undergoing therapeutic hypothermia. METHODS This was a retrospective chart review of 10 neonates who underwent therapeutic hypothermia requiring respiratory support over 2 y. A range of 2-27 simultaneous PtcCO2 and PaCO2 pairs of measurements per neonate were analyzed via linear mixed models and a Bland-Altman plot for multiple observations per neonate. RESULTS A linear mixed-effect model demonstrated that PtcCO2 and PaCO2 (controlling for sex) were similar. The 95% CI of the mean difference ranged from -2.3 to 5.7 mm Hg (P = .41). However, precision was poor as the PtcCO2 ranged from > 18 mm Hg to < 13 mm Hg than PaCO2 values for 95% of observations. CONCLUSIONS The neonates' PtcCO2 was as much as 18 mm Hg higher to 13 mm Hg lower than the PaCO2 95% of the time. Transcutaneous CO2 monitoring may not be a good trending tool, nor is it appropriate for estimating PaCO2 in patients undergoing therapeutic hypothermia.
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Affiliation(s)
- Pranav Garlapati
- Dr Garlapati is affiliated with Newborn Specialists of Tulsa, Tulsa, Oklahoma. Drs Vali and Lakshminrusimha are affiliated with Department of Pediatrics, UC Davis Medical Center, Sacramento, California. Mr Smith is affiliated with Department of Respiratory Care, UC Davis Medical Center, Sacramento, California. Dr Zavorsky is affiliated with Department of Physiology and Membrane Biology, University of California, Davis, Sacramento, California
| | - Payam Vali
- Dr Garlapati is affiliated with Newborn Specialists of Tulsa, Tulsa, Oklahoma. Drs Vali and Lakshminrusimha are affiliated with Department of Pediatrics, UC Davis Medical Center, Sacramento, California. Mr Smith is affiliated with Department of Respiratory Care, UC Davis Medical Center, Sacramento, California. Dr Zavorsky is affiliated with Department of Physiology and Membrane Biology, University of California, Davis, Sacramento, California
| | - Satyan Lakshminrusimha
- Dr Garlapati is affiliated with Newborn Specialists of Tulsa, Tulsa, Oklahoma. Drs Vali and Lakshminrusimha are affiliated with Department of Pediatrics, UC Davis Medical Center, Sacramento, California. Mr Smith is affiliated with Department of Respiratory Care, UC Davis Medical Center, Sacramento, California. Dr Zavorsky is affiliated with Department of Physiology and Membrane Biology, University of California, Davis, Sacramento, California
| | - Brian J Smith
- Dr Garlapati is affiliated with Newborn Specialists of Tulsa, Tulsa, Oklahoma. Drs Vali and Lakshminrusimha are affiliated with Department of Pediatrics, UC Davis Medical Center, Sacramento, California. Mr Smith is affiliated with Department of Respiratory Care, UC Davis Medical Center, Sacramento, California. Dr Zavorsky is affiliated with Department of Physiology and Membrane Biology, University of California, Davis, Sacramento, California
| | - Gerald S Zavorsky
- Dr Garlapati is affiliated with Newborn Specialists of Tulsa, Tulsa, Oklahoma. Drs Vali and Lakshminrusimha are affiliated with Department of Pediatrics, UC Davis Medical Center, Sacramento, California. Mr Smith is affiliated with Department of Respiratory Care, UC Davis Medical Center, Sacramento, California. Dr Zavorsky is affiliated with Department of Physiology and Membrane Biology, University of California, Davis, Sacramento, California.
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Giusto E, Sankaran D, Lesneski A, Joudi H, Hardie M, Hammitt V, Zeinali L, Lakshminrusimha S, Vali P. Neonatal resuscitation with continuous chest compressions and high frequency percussive ventilation in preterm lambs. Pediatr Res 2024; 95:160-166. [PMID: 37726545 DOI: 10.1038/s41390-023-02820-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 08/16/2023] [Accepted: 09/05/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Cerebral oxygen delivery (cDO2) is low during chest compressions (CC). We hypothesized that gas exchange and cDO2 are better with continuous CC with high frequency percussive ventilation (CCC + HFPV) compared to conventional 3:1 compressions-to-ventilation (C:V) resuscitation during neonatal resuscitation in preterm lambs with cardiac arrest induced by umbilical cord compression. METHODS Fourteen lambs in cardiac arrest were randomized to 3:1 C:V resuscitation (90CC + 30 breaths/min) per the Neonatal Resuscitation Program guidelines or CCC + HFPV (120CC + HFPV continuously). Intravenous epinephrine was given every 3 min until return of spontaneous circulation (ROSC). RESULTS There was no difference in the incidence and time to ROSC between both groups. Median (IQR) PaCO2 was significantly lower with CCC + HFPV during CC, at ROSC and 15 min post-ROSC-[104 (99-112), 83 (77-99), and 43 (40-64)], respectively compared to 3:1 C:V-[149 (139-167), 153 (143-168), and 153 (138-178) mmHg. PaO2 and cDO2 were higher with CCC + HFPV during CC and at ROSC. PaO2 was similar 15 min post-ROSC with a lower FiO2 in the CCC + HFPV group 0.4 (0.4-0.5) vs. 1 (0.6-1). CONCLUSION In preterm lambs with perinatal cardiac-arrest, continuous chest compressions with HFPV does not improve ROSC but enhances gas exchange and increases cerebral oxygen delivery compared to 3:1 C:V during neonatal resuscitation. IMPACT STATEMENT Ventilation is the most important intervention in newborn resuscitation. Currently recommended 3:1 compression-to-ventilation ratio is associated with hypercarbia and poor oxygen delivery to the brain. Providing uninterrupted continuous chest compressions during high frequency percussive ventilation is feasible in a lamb model of perinatal cardiac arrest, and demonstrates improved gas exchange and oxygen delivery to the brain. This is the first study in premature lambs evaluating high frequency percussive ventilation with asynchronous chest compressions and lays the groundwork for future clinical studies to optimize gas exchange and hemodynamics during chest compressions in newborns.
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Affiliation(s)
- Evan Giusto
- Department of Pediatrics, School of Medicine, University of California, Davis, Sacramento, CA, USA.
- D-5 Neonatal Units, Patient Care Services, University of California, Davis Health, Sacramento, CA, USA.
| | - Deepika Sankaran
- Department of Pediatrics, School of Medicine, University of California, Davis, Sacramento, CA, USA
| | - Amy Lesneski
- Stem Cell Program, School of Medicine, University of California, Davis, Sacramento, CA, USA
| | - Houssam Joudi
- Department of Pediatrics, School of Medicine, University of California, Davis, Sacramento, CA, USA
| | - Morgan Hardie
- Department of Pediatrics, School of Medicine, University of California, Davis, Sacramento, CA, USA
| | - Victoria Hammitt
- Stem Cell Program, School of Medicine, University of California, Davis, Sacramento, CA, USA
| | - Lida Zeinali
- Department of Pediatrics, School of Medicine, University of California, Davis, Sacramento, CA, USA
| | - Satyan Lakshminrusimha
- Department of Pediatrics, School of Medicine, University of California, Davis, Sacramento, CA, USA
| | - Payam Vali
- Department of Pediatrics, School of Medicine, University of California, Davis, Sacramento, CA, USA
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Mike JK, White Y, Hutchings RS, Vento C, Ha J, Manzoor H, Lee D, Losser C, Arellano K, Vanhatalo O, Seifert E, Gunewardena A, Wen B, Wang L, Wang A, Goudy BD, Vali P, Lakshminrusimha S, Gobburu JV, Long-Boyle J, Wu YW, Fineman JR, Ferriero DM, Maltepe E. Perinatal Azithromycin Provides Limited Neuroprotection in an Ovine Model of Neonatal Hypoxic-Ischemic Encephalopathy. Stroke 2023; 54:2864-2874. [PMID: 37846563 PMCID: PMC10589434 DOI: 10.1161/strokeaha.123.043040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 07/17/2023] [Accepted: 08/11/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND Hypoxic-ischemic brain injury/encephalopathy affects about 1.15 million neonates per year, 96% of whom are born in low- and middle-income countries. Therapeutic hypothermia is not effective in this setting, possibly because injury occurs significantly before birth. Here, we studied the pharmacokinetics, safety, and efficacy of perinatal azithromycin administration in near-term lambs following global ischemic injury to support earlier treatment approaches. METHODS Ewes and their lambs of both sexes (n=34, 141-143 days) were randomly assigned to receive azithromycin or placebo before delivery as well as postnatally. Lambs were subjected to severe global hypoxia-ischemia utilizing an acute umbilical cord occlusion model. Outcomes were assessed over a 6-day period. RESULTS While maternal azithromycin exhibited relatively low placental transfer, azithromycin-treated lambs recovered spontaneous circulation faster following the initiation of cardiopulmonary resuscitation and were extubated sooner. Additionally, peri- and postnatal azithromycin administration was well tolerated, demonstrating a 77-hour plasma elimination half-life, as well as significant accumulation in the brain and other tissues. Azithromycin administration resulted in a systemic immunomodulatory effect, demonstrated by reductions in proinflammatory IL-6 (interleukin-6) levels. Treated lambs exhibited a trend toward improved neurodevelopmental outcomes while histological analysis revealed that azithromycin supported white matter preservation and attenuated inflammation in the cingulate and parasagittal cortex. CONCLUSIONS Perinatal azithromycin administration enhances neonatal resuscitation, attenuates neuroinflammation, and supports limited improvement of select histological outcomes in an ovine model of hypoxic-ischemic brain injury/encephalopathy.
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Affiliation(s)
- Jana Krystofova Mike
- Department of Pediatrics (J.K.M., Y.W., R.S.H., C.V., J.H., C.L., K.A., O.V., E.S., A.G., J.L.-B., Y.W.W., J.R.F., D.M.F., E.M.), University of California San Francisco
| | - Yasmine White
- Department of Pediatrics (J.K.M., Y.W., R.S.H., C.V., J.H., C.L., K.A., O.V., E.S., A.G., J.L.-B., Y.W.W., J.R.F., D.M.F., E.M.), University of California San Francisco
| | - Rachel S. Hutchings
- Department of Pediatrics (J.K.M., Y.W., R.S.H., C.V., J.H., C.L., K.A., O.V., E.S., A.G., J.L.-B., Y.W.W., J.R.F., D.M.F., E.M.), University of California San Francisco
| | - Christian Vento
- Department of Pediatrics (J.K.M., Y.W., R.S.H., C.V., J.H., C.L., K.A., O.V., E.S., A.G., J.L.-B., Y.W.W., J.R.F., D.M.F., E.M.), University of California San Francisco
| | - Janica Ha
- Department of Pediatrics (J.K.M., Y.W., R.S.H., C.V., J.H., C.L., K.A., O.V., E.S., A.G., J.L.-B., Y.W.W., J.R.F., D.M.F., E.M.), University of California San Francisco
| | - Hadiya Manzoor
- Department of Biomedical Engineering (H.M., A.W.), University of California Davis
| | - Donald Lee
- School of Pharmacy, University of Maryland, Baltimore (D.L., J.V.S.G.)
| | - Courtney Losser
- Department of Pediatrics (J.K.M., Y.W., R.S.H., C.V., J.H., C.L., K.A., O.V., E.S., A.G., J.L.-B., Y.W.W., J.R.F., D.M.F., E.M.), University of California San Francisco
| | - Kimberly Arellano
- Department of Pediatrics (J.K.M., Y.W., R.S.H., C.V., J.H., C.L., K.A., O.V., E.S., A.G., J.L.-B., Y.W.W., J.R.F., D.M.F., E.M.), University of California San Francisco
| | - Oona Vanhatalo
- Department of Pediatrics (J.K.M., Y.W., R.S.H., C.V., J.H., C.L., K.A., O.V., E.S., A.G., J.L.-B., Y.W.W., J.R.F., D.M.F., E.M.), University of California San Francisco
- Department of Pediatrics (B.D.G., P.V., B.D.G., P.V., S.L., J.-L.B., O.V.), University of California Davis
| | - Elena Seifert
- Department of Pediatrics (J.K.M., Y.W., R.S.H., C.V., J.H., C.L., K.A., O.V., E.S., A.G., J.L.-B., Y.W.W., J.R.F., D.M.F., E.M.), University of California San Francisco
| | - Anya Gunewardena
- Department of Pediatrics (J.K.M., Y.W., R.S.H., C.V., J.H., C.L., K.A., O.V., E.S., A.G., J.L.-B., Y.W.W., J.R.F., D.M.F., E.M.), University of California San Francisco
| | - Bo Wen
- College of Pharmacy, University of Michigan, Ann Arbor (B.W., L.W.)
| | - Lu Wang
- College of Pharmacy, University of Michigan, Ann Arbor (B.W., L.W.)
- Department of Biomedical Engineering (H.M., A.W.), University of California Davis
| | - Aijun Wang
- Department of Biomedical Engineering (H.M., A.W.), University of California Davis
| | - Brian D. Goudy
- Department of Pediatrics (B.D.G., P.V., B.D.G., P.V., S.L., J.-L.B., O.V.), University of California Davis
| | - Payam Vali
- Department of Pediatrics (B.D.G., P.V., B.D.G., P.V., S.L., J.-L.B., O.V.), University of California Davis
| | - Satyan Lakshminrusimha
- Department of Pediatrics (B.D.G., P.V., B.D.G., P.V., S.L., J.-L.B., O.V.), University of California Davis
| | - Jogarao V.S. Gobburu
- School of Pharmacy, University of Maryland, Baltimore (D.L., J.V.S.G.)
- Initiative for Pediatric Drug and Device Development, San Francisco, CA (J.V.S.G., J.R.F., E.M.)
| | - Janel Long-Boyle
- Department of Pediatrics (J.K.M., Y.W., R.S.H., C.V., J.H., C.L., K.A., O.V., E.S., A.G., J.L.-B., Y.W.W., J.R.F., D.M.F., E.M.), University of California San Francisco
- School of Pharmacy (J.L.-B.), University of California San Francisco
- Department of Pediatrics (B.D.G., P.V., B.D.G., P.V., S.L., J.-L.B., O.V.), University of California Davis
| | - Yvonne W. Wu
- Department of Pediatrics (J.K.M., Y.W., R.S.H., C.V., J.H., C.L., K.A., O.V., E.S., A.G., J.L.-B., Y.W.W., J.R.F., D.M.F., E.M.), University of California San Francisco
- Department of Neurology, Weill Institute for Neurosciences (Y.W.W., D.M.F.), University of California San Francisco
| | - Jeffrey R. Fineman
- Department of Pediatrics (J.K.M., Y.W., R.S.H., C.V., J.H., C.L., K.A., O.V., E.S., A.G., J.L.-B., Y.W.W., J.R.F., D.M.F., E.M.), University of California San Francisco
- Initiative for Pediatric Drug and Device Development, San Francisco, CA (J.V.S.G., J.R.F., E.M.)
| | - Donna M. Ferriero
- Department of Pediatrics (J.K.M., Y.W., R.S.H., C.V., J.H., C.L., K.A., O.V., E.S., A.G., J.L.-B., Y.W.W., J.R.F., D.M.F., E.M.), University of California San Francisco
- Department of Neurology, Weill Institute for Neurosciences (Y.W.W., D.M.F.), University of California San Francisco
| | - Emin Maltepe
- Department of Pediatrics (J.K.M., Y.W., R.S.H., C.V., J.H., C.L., K.A., O.V., E.S., A.G., J.L.-B., Y.W.W., J.R.F., D.M.F., E.M.), University of California San Francisco
- Department of Biomedical Sciences (E.M.), University of California San Francisco
- Initiative for Pediatric Drug and Device Development, San Francisco, CA (J.V.S.G., J.R.F., E.M.)
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Sankaran D, Giusto EM, Lesneski AL, Hardie ME, Joudi HM, Lane ECA, Hammitt VL, Tully KC, Vali P, Lakshminrusimha S. Randomized Trial of 21% versus 100% Oxygen during Chest Compressions Followed by Gradual versus Abrupt Oxygen Titration after Return of Spontaneous Circulation in Neonatal Lambs. Children 2023; 10:children10030575. [PMID: 36980132 PMCID: PMC10047452 DOI: 10.3390/children10030575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/15/2023] [Accepted: 03/16/2023] [Indexed: 03/19/2023]
Abstract
The combination of perinatal acidemia with postnatal hyperoxia is associated with a higher incidence of hypoxic-ischemic encephalopathy (HIE) in newborn infants. In neonatal cardiac arrest, current International Liaison Committee on Resuscitation (ILCOR) and Neonatal Resuscitation Program (NRP) guidelines recommend increasing inspired O2 to 100% during chest compressions (CC). Following the return of spontaneous circulation (ROSC), gradual weaning from 100% O2 based on pulse oximetry (SpO2) can be associated with hyperoxia and risk for cerebral tissue injury owing to oxidative stress. We hypothesize that compared to gradual weaning from 100% O2 with titration based on preductal SpO2, abrupt or rapid weaning of inspired O2 to 21% after ROSC or use of 21% O2 during CC followed by upward titration of inspired O2 to achieve target SpO2 after ROSC will limit hyperoxia after ROSC. Nineteen lambs were randomized before delivery and asphyxial arrest was induced by umbilical cord occlusion. There was no difference in oxygenation during chest compressions between the three groups. Gradual weaning of inspired O2 from 100% O2 after ROSC resulted in supraphysiological PaO2 and higher cerebral oxygen delivery compared to 21% O2 during CC or 100% O2 during CC followed by abrupt weaning to 21% O2 after ROSC. The use of 21% O2 during CC was associated with very low PaO2 after ROSC and higher brain tissue lactic acid compared to other groups. Our findings support the current recommendations to use 100% O2 during CC and additionally suggest the benefit of abrupt decrease in inspired oxygen to 21% O2 after ROSC. Clinical studies are warranted to investigate optimal oxygen titration after chest compressions and ROSC during neonatal resuscitation.
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Affiliation(s)
- Deepika Sankaran
- Department of Pediatrics, University of California, Davis, Sacramento, CA 95817, USA
- Correspondence:
| | - Evan M. Giusto
- Department of Pediatrics, University of California, Davis, Sacramento, CA 95817, USA
| | - Amy L. Lesneski
- Department of Stem Cell Research, University of California, Davis, Sacramento, CA 95817, USA
| | - Morgan E. Hardie
- Department of Pediatrics, University of California, Davis, Sacramento, CA 95817, USA
| | - Houssam M. Joudi
- Department of Pediatrics, University of California, Davis, Sacramento, CA 95817, USA
| | - Emily C. A. Lane
- Department of Pediatrics, University of California, Davis, Sacramento, CA 95817, USA
| | - Victoria L. Hammitt
- Department of Stem Cell Research, University of California, Davis, Sacramento, CA 95817, USA
| | - Kirstie C. Tully
- Department of Stem Cell Research, University of California, Davis, Sacramento, CA 95817, USA
| | - Payam Vali
- Department of Pediatrics, University of California, Davis, Sacramento, CA 95817, USA
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7
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Affiliation(s)
- Payam Vali
- University of California Davis, Sacramento, CA, 95817, USA.
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8
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Mike JK, Wu KY, White Y, Pathipati P, Ndjamen B, Hutchings RS, Losser C, Vento C, Arellano K, Vanhatalo O, Ostrin S, Windsor C, Ha J, Alhassen Z, Goudy BD, Vali P, Lakshminrusimha S, Gobburu JVS, Long-Boyle J, Chen P, Wu YW, Fineman JR, Ferriero DM, Maltepe E. Defining longer term outcomes in an ovine model of moderate perinatal hypoxia-ischemia. Dev Neurosci 2022; 44:277-294. [PMID: 35588703 DOI: 10.1159/000525150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 04/06/2022] [Indexed: 11/19/2022] Open
Abstract
Hypoxic-ischemic encephalopathy (HIE) is the leading cause of neonatal morbidity and mortality worldwide. Approximately 1 million infants born with HIE each year survive with cerebral palsy (CP) and/or serious cognitive disabilities. While infants born with mild and severe HIE frequently result in predictable outcomes, infants born with moderate HIE exhibit variable outcomes that are highly unpredictable. Here, we describe an umbilical cord occlusion (UCO) model of moderate HIE with a 6-day follow-up. Near term lambs (n=27) are resuscitated after the induction of 5 minutes of asystole. Following recovery, lambs are assessed to define neurodevelopmental outcomes. At the end of this period, lambs are euthanized, and brains harvested for histological analysis. Compared with prior models that typically follow lambs for 3 days, the observation of neurobehavioral outcomes for 6 days enables identification of animals that recover significant neurological function. Approximately 35 % of lambs exhibited severe motor deficits throughout the entirety of the 6-day course and, in the most severely affected lambs, developed spastic diparesis similar to that observed in infants who survive severe neonatal HIE (severe, UCOs). Importantly, and similar to outcomes in human neonates, while initially developing significant acidosis and encephalopathy, the remainder of the lambs in this model recovered normal motor activity and exhibited normal neurodevelopmental outcomes by 6 days of life (improved, UCOi). The UCOs group exhibited gliosis and inflammation in both white and gray matter, oligodendrocyte loss, and neuronal loss and cellular death in the hippocampus and cingulate cortex. While the UCOi group exhibited more cellular death and gliosis in the parasagittal cortex and demonstrated more preserved white matter markers, along with reduced markers of inflammation and lower cellular death and neuronal loss in Ca3 of the hippocampus compared with UCOs lambs. Our large animal model of moderate HIE with prolonged follow-up will help further define pathophysiologic drivers of brain injury while enabling identification of predictive biomarkers that correlate with disease outcomes and ultimately help support development of therapeutic approaches to this challenging clinical scenario.
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Affiliation(s)
- Jana Krystofova Mike
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Katherine Y Wu
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Yasmine White
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Praneeti Pathipati
- Department of Neurology, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, California, USA
| | - Blaise Ndjamen
- Histology and Microscopy Core, Gladstone Institutes University of California San Francisco, San Francisco, California, USA
| | - Rachel S Hutchings
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Courtney Losser
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Christian Vento
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Kimberly Arellano
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Oona Vanhatalo
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Samuel Ostrin
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Christine Windsor
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Janica Ha
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Ziad Alhassen
- Department of Pediatrics, University of California Davis, Davis, California, USA
| | - Brian D Goudy
- Department of Pediatrics, University of California Davis, Davis, California, USA
| | - Payam Vali
- Department of Pediatrics, University of California Davis, Davis, California, USA
| | | | - Jogarao V S Gobburu
- School of Pharmacy, University of Maryland, Baltimore, Maryland, USA
- Initiative for Pediatric Drug and Device Development, San Francisco, California, USA
| | - Janel Long-Boyle
- Initiative for Pediatric Drug and Device Development, San Francisco, California, USA
- School of Pharmacy, University of California San Francisco, San Francisco, California, USA
| | - Peggy Chen
- Department of Pediatrics, University of California Davis, Davis, California, USA
| | - Yvonne W Wu
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
- Department of Neurology, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, California, USA
| | - Jeffrey R Fineman
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
- Initiative for Pediatric Drug and Device Development, San Francisco, California, USA
| | - Donna M Ferriero
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
- Department of Neurology, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, California, USA
| | - Emin Maltepe
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
- Initiative for Pediatric Drug and Device Development, San Francisco, California, USA
- Department of Biomedical Sciences, University of California San Francisco, San Francisco, California, USA
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9
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Berkelhamer SK, Vali P, Nair J, Gugino S, Helman J, Koenigsknecht C, Nielsen L, Lakshminrusimha S. Inadequate Bioavailability of Intramuscular Epinephrine in a Neonatal Asphyxia Model. Front Pediatr 2022; 10:828130. [PMID: 35265564 PMCID: PMC8899212 DOI: 10.3389/fped.2022.828130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 01/27/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Over half a million newborn deaths are attributed to intrapartum related events annually, the majority of which occur in low resource settings. While progress has been made in reducing the burden of asphyxia, novel approaches may need to be considered to further decrease rates of newborn mortality. Administration of intravenous, intraosseous or endotracheal epinephrine is recommended by the Newborn Resuscitation Program (NRP) with sustained bradycardia at birth. However, delivery by these routes requires both advanced skills and specialized equipment. Intramuscular (IM) epinephrine may represent a simple, low cost and highly accessible alternative for consideration in the care of infants compromised at birth. At present, the bioavailability of IM epinephrine in asphyxia remains unclear. METHODS Four term fetal lambs were delivered by cesarean section and asphyxiated by umbilical cord occlusion with resuscitation after 5 min of asystole. IM epinephrine (0.1 mg/kg) was administered intradeltoid after 1 min of positive pressure ventilation with 30 s of chest compressions. Serial blood samples were obtained for determination of plasma epinephrine concentrations by ELISA. RESULTS Epinephrine concentrations failed to increase following administration via IM injection. Delayed absorption was observed after return of spontaneous circulation (ROSC) in half of the studies. CONCLUSIONS Inadequate absorption of epinephrine occurs with IM administration during asphyxial cardiac arrest, implying this route would be ineffective in infants who are severely compromised at birth. Late absorption following ROSC raises concerns for risks of side effects. However, the bioavailability and efficacy of intramuscular epinephrine in less profound asphyxia may warrant further evaluation.
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Affiliation(s)
- Sara K Berkelhamer
- Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA, United States
| | - Payam Vali
- Department of Pediatrics, University California Davis School of Medicine, Sacramento, CA, United States
| | - Jayasree Nair
- Department of Pediatrics, University at Buffalo SUNY, Buffalo, NY, United States
| | - Sylvia Gugino
- Department of Pediatrics, University at Buffalo SUNY, Buffalo, NY, United States
| | - Justin Helman
- Department of Pediatrics, University at Buffalo SUNY, Buffalo, NY, United States
| | - Carmon Koenigsknecht
- Department of Pediatrics, University at Buffalo SUNY, Buffalo, NY, United States
| | - Lori Nielsen
- Department of Pediatrics, University at Buffalo SUNY, Buffalo, NY, United States
| | - Satyan Lakshminrusimha
- Department of Pediatrics, University California Davis School of Medicine, Sacramento, CA, United States
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10
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Sankaran D, Chandrasekharan PK, Gugino SF, Koenigsknecht C, Helman J, Nair J, Mathew B, Rawat M, Vali P, Nielsen L, Tancredi DJ, Lakshminrusimha S. Randomised trial of epinephrine dose and flush volume in term newborn lambs. Arch Dis Child Fetal Neonatal Ed 2021; 106:578-583. [PMID: 33687959 PMCID: PMC8543198 DOI: 10.1136/archdischild-2020-321034] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 01/31/2021] [Accepted: 02/21/2021] [Indexed: 01/26/2023]
Abstract
OBJECTIVES Neonatal resuscitation guidelines recommend 0.5-1 mL saline flush following 0.01-0.03 mg/kg of epinephrine via low umbilical venous catheter for persistent bradycardia despite effective positive pressure ventilation (PPV) and chest compressions (CC). We evaluated the effects of 1 mL vs 3 mL/kg flush volumes and 0.01 vs 0.03 mg/kg doses on return of spontaneous circulation (ROSC) and epinephrine pharmacokinetics in lambs with cardiac arrest. DESIGN Forty term lambs in cardiac arrest were randomised to receive 0.01 or 0.03 mg/kg epinephrine followed by 1 mL or 3 mL/kg flush after effective PPV and CC. Epinephrine (with 1 mL flush) was repeated every 3 min until ROSC or until 20 min. Haemodynamics, blood gases and plasma epinephrine concentrations were monitored. RESULTS Ten lambs had ROSC before epinephrine administration and 2 died during instrumentation. Among 28 lambs that received epinephrine, 2/6 in 0.01 mg/kg-1 mL flush, 3/6 in 0.01 mg/kg-3 mL/kg flush, 5/7 in 0.03 mg/kg-1 mL flush and 9/9 in 0.03 mg/kg-3 mL/kg flush achieved ROSC (p=0.02). ROSC was five times faster with 0.03 mg/kg epinephrine compared with 0.01 mg/kg (adjusted HR (95% CI) 5.08 (1.7 to 15.25)) and three times faster with 3 mL/kg flush compared with 1 mL flush (3.5 (1.27 to 9.71)). Plasma epinephrine concentrations were higher with 0.01 mg/kg-3 mL/kg flush (adjusted geometric mean ratio 6.0 (1.4 to 25.7)), 0.03 mg/kg-1 mL flush (11.3 (2.1 to 60.3)) and 0.03 mg/kg-3 mL/kg flush (11.0 (2.2 to 55.3)) compared with 0.01 mg/kg-1 mL flush. CONCLUSIONS 0.03 mg/kg epinephrine dose with 3 mL/kg flush volume is associated with the highest ROSC rate, increases peak plasma epinephrine concentrations and hastens time to ROSC. Clinical trials evaluating optimal epinephrine dose and flush volume are warranted.
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Affiliation(s)
- Deepika Sankaran
- Department of Pediatrics, University of California Davis, Sacramento, California, USA
| | - Praveen K Chandrasekharan
- Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Sylvia F Gugino
- Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Carmon Koenigsknecht
- Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Justin Helman
- Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Jayasree Nair
- Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Bobby Mathew
- Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Munmun Rawat
- Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Payam Vali
- Department of Pediatrics, University of California Davis, Sacramento, California, USA
| | - Lori Nielsen
- Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Daniel J Tancredi
- Department of Pediatrics, University of California Davis, Sacramento, California, USA
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11
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Vali P, Lesneski A, Hardie M, Alhassen Z, Chen P, Joudi H, Sankaran D, Lakshminrusimha S. Continuous chest compressions with asynchronous ventilations increase carotid blood flow in the perinatal asphyxiated lamb model. Pediatr Res 2021; 90:752-758. [PMID: 33469187 PMCID: PMC8286977 DOI: 10.1038/s41390-020-01306-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 11/10/2020] [Accepted: 11/13/2020] [Indexed: 01/30/2023]
Abstract
BACKGROUND The neonatal resuscitation program (NRP) recommends interrupted chest compressions (CCs) with ventilation in the severely bradycardic neonate. The conventional 3:1 compression-to-ventilation (C:V) resuscitation provides 90 CCs/min, significantly lower than the intrinsic newborn heart rate (120-160 beats/min). Continuous CC with asynchronous ventilation (CCCaV) may improve the success of return of spontaneous circulation (ROSC). METHODS Twenty-two near-term fetal lambs were randomized to interrupted 3:1 C:V (90 CCs + 30 breaths/min) or CCCaV (120 CCs + 30 breaths/min). Asphyxiation was induced by cord occlusion. After 5 min of asystole, resuscitation began following NRP guidelines. The first dose of epinephrine was given at 6 min. Invasive arterial blood pressure and left carotid blood flow were continuously measured. Serial arterial blood gases were collected. RESULTS Baseline characteristics between groups were similar. Rate of and time to ROSC was similar between groups. CCCaV was associated with a higher PaO2 (partial oxygen tension) (22 ± 5.3 vs. 15 ± 3.5 mmHg, p < 0.01), greater left carotid blood flow (7.5 ± 3.1 vs. 4.3 ± 2.6 mL/kg/min, p < 0.01) and oxygen delivery (0.40 ± 0.15 vs. 0.13 ± 0.07 mL O2/kg/min, p < 0.01) compared to 3:1 C:V. CONCLUSIONS In a perinatal asphyxiated cardiac arrest lamb model, CCCaV showed greater carotid blood flow and cerebral oxygen delivery compared to 3:1 C:V resuscitation. IMPACT In a perinatal asphyxiated cardiac arrest lamb model, CCCaV improved carotid blood flow and oxygen delivery to the brain compared to the conventional 3:1 C:V resuscitation. Pre-clinical studies assessing neurodevelopmental outcomes and tissue injury comparing continuous uninterrupted chest compressions to the current recommended 3:1 C:V during newborn resuscitation are warranted prior to clinical trials.
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Affiliation(s)
- Payam Vali
- Department of Pediatrics, University of California Davis, Sacramento, CA, USA.
| | - Amy Lesneski
- Department of Pediatrics, University of California Davis, Sacramento, CA
| | - Morgan Hardie
- Department of Pediatrics, University of California Davis, Sacramento, CA
| | - Ziad Alhassen
- Department of Pediatrics, University of California Davis, Sacramento, CA
| | - Peggy Chen
- Department of Pediatrics, University of California Davis, Sacramento, CA
| | - Houssam Joudi
- Department of Pediatrics, University of California Davis, Sacramento, CA
| | - Deepika Sankaran
- Department of Pediatrics, University of California Davis, Sacramento, CA
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12
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Sankaran D, Vali P, Chen P, Lesneski AL, Hardie ME, Alhassen Z, Wedgwood S, Wyckoff MH, Lakshminrusimha S. Randomized trial of oxygen weaning strategies following chest compressions during neonatal resuscitation. Pediatr Res 2021; 90:540-548. [PMID: 33941864 PMCID: PMC8530847 DOI: 10.1038/s41390-021-01551-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 02/08/2021] [Accepted: 04/10/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND The Neonatal Resuscitation Program (NRP) recommends using 100% O2 during chest compressions and adjusting FiO2 based on SpO2 after return of spontaneous circulation (ROSC). The optimal strategy for adjusting FiO2 is not known. METHODS Twenty-five near-term lambs asphyxiated by umbilical cord occlusion to cardiac arrest were resuscitated per NRP. Following ROSC, lambs were randomized to gradual decrease versus abrupt wean to 21% O2 followed by FiO2 titration to achieve NRP SpO2 targets. Carotid blood flow and blood gases were monitored. RESULTS Three minutes after ROSC, PaO2 was 229 ± 32 mmHg in gradual wean group compared to 57 ± 13 following abrupt wean to 21% O2 (p < 0.001). PaO2 remained high in the gradual wean group at 10 min after ROSC (110 ± 10 vs. 67 ± 12, p < 0.01) despite similar FiO2 (~0.3) in both groups. Cerebral O2 delivery (C-DO2) was higher above physiological range following ROSC with gradual wean (p < 0.05). Lower blood oxidized/reduced glutathione ratio (suggesting less oxidative stress) was observed with abrupt wean. CONCLUSION Weaning FiO2 abruptly to 0.21 with adjustment based on SpO2 prevents surge in PaO2 and C-DO2 and minimizes oxidative stress compared to gradual weaning from 100% O2 following ROSC. Clinical trials with neurodevelopmental outcomes comparing post-ROSC FiO2 weaning strategies are warranted. IMPACT In a lamb model of perinatal asphyxial cardiac arrest, abrupt weaning of inspired oxygen to 21% prevents excessive oxygen delivery to the brain and oxidative stress compared to gradual weaning from 100% oxygen following return of spontaneous circulation. Clinical studies assessing neurodevelopmental outcomes comparing abrupt and gradual weaning of inspired oxygen after recovery from neonatal asphyxial arrest are warranted.
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Affiliation(s)
- Deepika Sankaran
- Division of Neonatology, Department of Pediatrics, University of California Davis, Sacramento, CA, USA.
| | - Payam Vali
- Division of Neonatology, Department of Pediatrics, University of California Davis, Sacramento, CA, USA
| | - Peggy Chen
- Division of Neonatology, Department of Pediatrics, University of California Davis, Sacramento, CA, USA
| | - Amy L Lesneski
- Division of Neonatology, Department of Pediatrics, University of California Davis, Sacramento, CA, USA
| | - Morgan E Hardie
- Division of Neonatology, Department of Pediatrics, University of California Davis, Sacramento, CA, USA
| | - Ziad Alhassen
- Division of Neonatology, Department of Pediatrics, University of California Davis, Sacramento, CA, USA
| | - Stephen Wedgwood
- Division of Neonatology, Department of Pediatrics, University of California Davis, Sacramento, CA, USA
| | - Myra H Wyckoff
- Division of Neonatology, Department of Pediatrics, University of Texas South Western (UTSW), Dallas, TX, USA
| | - Satyan Lakshminrusimha
- Division of Neonatology, Department of Pediatrics, University of California Davis, Sacramento, CA, USA
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13
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Vali P, Weiner GM, Sankaran D, Lakshminrusimha S. What is the optimal initial dose of epinephrine during neonatal resuscitation in the delivery room? J Perinatol 2021; 41:1769-1773. [PMID: 33712718 DOI: 10.1038/s41372-021-01032-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/29/2021] [Accepted: 02/25/2021] [Indexed: 01/25/2023]
Abstract
The neonatal resuscitation program recommends a wide dose range of epinephrine for newborns who receive chest compressions (endotracheal tube [ET] dose of 0.05-0.1 mg/kg or intravenous [IV] dose of 0.01-0.03 mg/kg), which presents a challenge to neonatal care providers when attempting to determine the optimal initial dose. Dosing errors are common when preparing epinephrine for neonatal resuscitation. Based on animal data, we suggest preparing 0.1 mg/kg or 1 ml/kg of 1 mg/10 ml epinephrine in a 5 ml syringe for ET administration. For IV epinephrine, we suggest preparing an initial dose of 0.02 mg/kg or 0.2 ml/kg of 1 mg/10 ml epinephrine in a 1 ml syringe. A dose of 0.02 mg/kg enables use of a 1 ml syringe for a wide range of birth weights from 500 g to 5 kg. The use of a color-coded syringe may decrease errors in dose preparation.
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Affiliation(s)
- Payam Vali
- Department of Pediatrics, University of California, Davis, Sacramento, CA, USA.
| | - Gary M Weiner
- Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, USA
| | - Deepika Sankaran
- Department of Pediatrics, University of California, Davis, Sacramento, CA, USA
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14
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Lakshminrusimha S, Vali P, Chandrasekharan P, Rich W, Katheria A. Differential Alveolar and Systemic Oxygenation during Preterm Resuscitation with 100% Oxygen during Delayed Cord Clamping. Am J Perinatol 2021; 40:630-637. [PMID: 34062568 DOI: 10.1055/s-0041-1730362] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Delayed cord clamping (DCC) and 21 to 30% O2 resuscitation is recommended for preterm infants but is commonly associated with low pulmonary blood flow (Qp) and hypoxia. 100% O2 supplementation during DCC for 60 seconds followed by 30% O2 may increase Qp and oxygen saturation (SpO2). STUDY DESIGN Preterm lambs (125-127 days of gestation) were resuscitated with 100% O2 with immediate cord clamping (ICC, n = 7) or ICC + 30% O2, and titrated to target SpO2 (n = 7) or DCC + 100% O2 for 60 seconds, which followed by cord clamping and 30% O2 titration (n = 7). Seven preterm (23-27 weeks of gestation) human infants received continuous positive airway pressure (CPAP) + 100% O2 for 60 seconds during DCC, cord clamping, and 30% O2 supplementation after cord clamping. RESULTS Preterm lambs in the ICC + 100% O2 group resulted in PaO2 (77 ± 25 mmHg), SpO2 (77 ± 11%), and Qp (27 ± 9 mL/kg/min) at 60 seconds. ICC + 30% O2 led to low Qp (14 ± 3 mL/kg/min), low SpO2 (43 ± 26%), and PaO2 (19 ± 7 mmHg). DCC + 100% O2 led to similar Qp (28 ± 6 mL/kg/min) as ICC + 100% O2 with lower PaO2. In human infants, DCC + CPAP with 100% O2 for 60 seconds, which followed by weaning to 30% resulted in SpO2 of 92 ± 11% with all infants >80% at 5 minutes with 100% survival without severe intraventricular hemorrhage. CONCLUSION DCC + 100% O2 for 60 seconds increased Qp probably due to transient alveolar hyperoxia with systemic normoxia due to "dilution" by umbilical venous return. Larger translational and clinical studies are warranted to confirm these findings. KEY POINTS · Transient alveolar hyperoxia during delayed cord clamping can enhance pulmonary vasodilation.. · Placental transfusion buffers systemic oxygen tension and limits hyperoxia.. · Use of 100% oxygen for 60 seconds during DCC was associated with SpO2 ≥80% by 5 minutes..
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Affiliation(s)
| | - Payam Vali
- Department of Pediatrics, University of California Davis, Sacramento, California
| | | | - Wade Rich
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women and Newborns, San Diego, California
| | - Anup Katheria
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women and Newborns, San Diego, California
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15
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Affiliation(s)
| | - Payam Vali
- University of California, Department of Pediatrics, Davis, United States.
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16
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Lakshminrusimha S, Vali P. Congenital diaphragmatic hernia: 25 years of shared knowledge; what about survival? Jornal de Pediatria (Versão em Português) 2020. [DOI: 10.1016/j.jpedp.2019.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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17
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Haynes SC, Dharmar M, Hill BC, Hoffman KR, Donohue LT, Kuhn-Riordon KM, Rottkamp CA, Vali P, Tancredi DJ, Romano PS, Steinhorn R, Marcin JP. The Impact of Telemedicine on Transfer Rates of Newborns at Rural Community Hospitals. Acad Pediatr 2020; 20:636-641. [PMID: 32081766 DOI: 10.1016/j.acap.2020.02.013] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 02/12/2020] [Accepted: 02/13/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND AND OBJECTIVE Telemedicine may have the ability to reduce avoidable transfers by allowing remote specialists the opportunity to more effectively assess patients during consultations. In this study, we examined whether telemedicine consultations were associated with reduced transfer rates compared to telephone consultations among a cohort of term and late preterm newborns. We hypothesized that neonatologist consultations conducted over telemedicine would result in fewer interfacility transfers than consultations conducted over telephone. METHODS We collected data on all newborns who received a neonatal telemedicine or telephone consultation at 6 rural hospitals in northern and central California between August 2014 and June 2018. We used adjusted analyses to compare transfer rates between telemedicine and telephone cohorts. RESULTS A total of 317 patients were included in the analysis; 89 (28.1%) of these patients received a telemedicine consultation and 228 (71.9%) received a telephone consultation only. The overall transfer rate was 77.0%. Patient consultations conducted using telemedicine were significantly less likely to result in a transfer than patient consultations conducted using the telephone (64.0% vs 82.0%, P = .001). After controlling for 5-minute Apgar score, birthweight, gestational age, site of consultation, and Transport Risk Index of Physiologic Stability score, the odds of transfer for telemedicine consultations was 0.48 (95% confidence interval: 0.26, 0.90, P = .02). CONCLUSIONS Our findings suggest that telemedicine may have the potential to reduce potentially avoidable transfers of term and late preterm newborns. Future research on potentially avoidable transfers and patient outcomes is needed to better understand the ways in which telemedicine affects clinical decision-making.
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Affiliation(s)
- Sarah C Haynes
- Department of Pediatrics, UC Davis Health (SC Haynes, M Dharmar, KR Hoffman, LT Donohue, KM Kuhn-Riordon, CA Rottkamp, P Vali, DJ Tancredi, and JP Marcin), Sacramento, Calif.
| | - Madan Dharmar
- Department of Pediatrics, UC Davis Health (SC Haynes, M Dharmar, KR Hoffman, LT Donohue, KM Kuhn-Riordon, CA Rottkamp, P Vali, DJ Tancredi, and JP Marcin), Sacramento, Calif
| | - Barry C Hill
- Center for Healthcare Policy and Research, University of California Davis (BC Hill, DJ Tancredi, and PS Romano), Sacramento, Calif
| | - Kristin R Hoffman
- Department of Pediatrics, UC Davis Health (SC Haynes, M Dharmar, KR Hoffman, LT Donohue, KM Kuhn-Riordon, CA Rottkamp, P Vali, DJ Tancredi, and JP Marcin), Sacramento, Calif
| | - Lee T Donohue
- Department of Pediatrics, UC Davis Health (SC Haynes, M Dharmar, KR Hoffman, LT Donohue, KM Kuhn-Riordon, CA Rottkamp, P Vali, DJ Tancredi, and JP Marcin), Sacramento, Calif
| | - Kara M Kuhn-Riordon
- Department of Pediatrics, UC Davis Health (SC Haynes, M Dharmar, KR Hoffman, LT Donohue, KM Kuhn-Riordon, CA Rottkamp, P Vali, DJ Tancredi, and JP Marcin), Sacramento, Calif
| | - Catherine A Rottkamp
- Department of Pediatrics, UC Davis Health (SC Haynes, M Dharmar, KR Hoffman, LT Donohue, KM Kuhn-Riordon, CA Rottkamp, P Vali, DJ Tancredi, and JP Marcin), Sacramento, Calif
| | - Payam Vali
- Department of Pediatrics, UC Davis Health (SC Haynes, M Dharmar, KR Hoffman, LT Donohue, KM Kuhn-Riordon, CA Rottkamp, P Vali, DJ Tancredi, and JP Marcin), Sacramento, Calif
| | - Daniel J Tancredi
- Department of Pediatrics, UC Davis Health (SC Haynes, M Dharmar, KR Hoffman, LT Donohue, KM Kuhn-Riordon, CA Rottkamp, P Vali, DJ Tancredi, and JP Marcin), Sacramento, Calif; Center for Healthcare Policy and Research, University of California Davis (BC Hill, DJ Tancredi, and PS Romano), Sacramento, Calif
| | - Patrick S Romano
- Center for Healthcare Policy and Research, University of California Davis (BC Hill, DJ Tancredi, and PS Romano), Sacramento, Calif; Department of Internal Medicine, UC Davis Health (PS Romano), Sacramento, Calif
| | - Robin Steinhorn
- Children's National Health System (JP Marcin), Washington, DC
| | - James P Marcin
- Department of Pediatrics, UC Davis Health (SC Haynes, M Dharmar, KR Hoffman, LT Donohue, KM Kuhn-Riordon, CA Rottkamp, P Vali, DJ Tancredi, and JP Marcin), Sacramento, Calif
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DOGRA L, Sahay M, Ismal K, Vali P. SAT-391 TO STUDY THE RESPONSE TO IMMUNOSUPPRESSION THERAPY IN IDIOPATHIC MEMBRANOUS NEPHROPATHY (IMN): A RANDOMIZED, SINGLE CENTRE STUDY. Kidney Int Rep 2020. [DOI: 10.1016/j.ekir.2020.02.414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Vali P, Sankaran D, Rawat M, Berkelhamer S, Lakshminrusimha S. Epinephrine in Neonatal Resuscitation. Children (Basel) 2019; 6:children6040051. [PMID: 30987062 PMCID: PMC6518253 DOI: 10.3390/children6040051] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 03/28/2019] [Accepted: 03/29/2019] [Indexed: 12/20/2022]
Abstract
Epinephrine is the only medication recommended by the International Liaison Committee on Resuscitation for use in newborn resuscitation. Strong evidence from large clinical trials is lacking owing to the infrequent use of epinephrine during neonatal resuscitation. Current recommendations are weak as they are extrapolated from animal models or pediatric and adult studies that do not adequately depict the transitioning circulation and fluid-filled lungs of the newborn in the delivery room. Many gaps in knowledge including the optimal dosing, best route and timing of epinephrine administration warrant further studies. Experiments on a well-established ovine model of perinatal asphyxial cardiac arrest closely mimicking the newborn infant provide important information that can guide future clinical trials.
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Affiliation(s)
- Payam Vali
- UC Davis School of Medicine, Sacramento, CA 95817, USA;
- Correspondence:
| | | | - Munmun Rawat
- SUNY Buffalo, Buffalo, NY 14222, USA; (D.S.); (M.R.); (S.B.)
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Nair J, Vali P, Gugino SF, Koenigsknecht C, Helman J, Nielsen LC, Chandrasekharan P, Rawat M, Berkelhamer S, Mathew B, Lakshminrusimha S. Bioavailability of endotracheal epinephrine in an ovine model of neonatal resuscitation. Early Hum Dev 2019; 130:27-32. [PMID: 30660015 PMCID: PMC6402978 DOI: 10.1016/j.earlhumdev.2019.01.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 12/22/2018] [Accepted: 01/08/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Distressed infants in the delivery room and those that have completed postnatal transition are both resuscitated according to established neonatal resuscitation guidelines, often with endotracheal (ET) epinephrine at the same dose. We hypothesized that ET epinephrine would have higher bioavailability in a post-transitional compared to transitioning newborn model due to absence of fetal lung liquid and intra-cardiac shunts. METHODS 15 term fetal (transitioning newborn) and 6 postnatal lambs were asphyxiated by umbilical cord and ET tube occlusion respectively. Lambs were resuscitated after 5 min of asystole. ET epinephrine (0.1 mg/kg) was administered after 1 min of positive pressure ventilation (PPV) and chest compressions, and repeated 3 min later, followed by intravenous (IV) epinephrine (0.03 mg/kg) every 3 min until return of spontaneous circulation (ROSC). Serial plasma epinephrine concentrations were measured. RESULTS Peak plasma epinephrine concentrations were lower in transitioning newborns as compared to postnatal lambs: after a single ET dose (145.36 ± 135.5 ng/ml vs 553.54 ± 215 ng/ml, p < 0.01) and after two ET doses (443 ± 192.49 ng/ml vs 1406 ± 420.8 ng/ml, p < 0.01). The rates of ROSC with a single ET dose were similar in both groups (40% vs 50% in newborn and postnatal respectively, p > 0.99). There was a higher incidence of post-ROSC tachycardia and increased carotid blood flow in the postnatal group. CONCLUSIONS In the postnatal period, ET epinephrine at currently recommended doses resulted in higher peak epinephrine concentrations, post-ROSC tachycardia and cerebral reperfusion without significant differences in incidence of ROSC. Further studies evaluating the optimal dose of ET epinephrine during the postnatal period are warranted.
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Affiliation(s)
- Jayasree Nair
- Department of Pediatrics, University at Buffalo, The State University of New York, Buffalo, NY, United States of America.
| | - Payam Vali
- Department of Pediatrics, UC Davis School of Medicine, Sacramento, CA
| | - Sylvia F. Gugino
- Department of Pediatrics, University at Buffalo, The State University of New York, Buffalo, NY
| | - Carmon Koenigsknecht
- Department of Pediatrics, University at Buffalo, The State University of New York, Buffalo, NY
| | - Justin Helman
- Department of Pediatrics, University at Buffalo, The State University of New York, Buffalo, NY
| | - Lori C. Nielsen
- Department of Pediatrics, University at Buffalo, The State University of New York, Buffalo, NY
| | - Praveen Chandrasekharan
- Department of Pediatrics, University at Buffalo, The State University of New York, Buffalo, NY
| | - Munmun Rawat
- Department of Pediatrics, University at Buffalo, The State University of New York, Buffalo, NY
| | - Sara Berkelhamer
- Department of Pediatrics, University at Buffalo, The State University of New York, Buffalo, NY
| | - Bobby Mathew
- Department of Pediatrics, University at Buffalo, The State University of New York, Buffalo, NY
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Affiliation(s)
- Payam Vali
- Division of Neonatology; University of California Davis; CA USA
| | - Maximo Vento
- Division of Neonatology; University & Polytechnic Hospital La Fe; Valencia Spain
| | - Mark Underwood
- Division of Neonatology; University of California Davis; CA USA
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Chandrasekharan P, Rawat M, Gugino SF, Koenigsknecht C, Helman J, Nair J, Vali P, Lakshminrusimha S. Effect of various inspired oxygen concentrations on pulmonary and systemic hemodynamics and oxygenation during resuscitation in a transitioning preterm model. Pediatr Res 2018; 84:743-750. [PMID: 29967523 PMCID: PMC6275138 DOI: 10.1038/s41390-018-0085-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 05/23/2018] [Accepted: 05/25/2018] [Indexed: 01/23/2023]
Abstract
BACKGROUND The Neonatal Resuscitation Program recommends initial resuscitation of preterm infants with low oxygen (O2) followed by titration to target preductal saturations (SpO2). We studied the effect of resuscitation with titrated O2 on gas exchange, pulmonary, and systemic hemodynamics. METHODOLOGY Twenty-nine preterm lambs (127 d gestation) were randomized to resuscitation with 21% O2 (n = 7), 100% O2 (n = 6), or initiation at 21% and titrated to target SpO2 (n = 16). Seven healthy term control lambs were ventilated with 21% O2. RESULTS Preductal SpO2 achieved by titrating O2 was within the desired range similar to term lambs in 21% O2. Resuscitation of preterm lambs with 21% and 100% O2 resulted in SpO2 below and above the target, respectively. Ventilation of preterm lambs with 100% O2 and term lambs with 21% O2 effectively decreased pulmonary vascular resistance (PVR). In contrast, preterm lambs with 21% O2 and titrated O2 demonstrated significantly higher PVR than term lambs on 21% O2. CONCLUSION(S) Initial resuscitation with 21% O2 followed by titration of O2 led to suboptimal pulmonary vascular transition at birth in preterm lambs. Ventilation with 100% O2 in preterm lambs caused hyperoxia but reduced PVR similar to term lambs on 21% O2. Studies evaluating the initiation of resuscitation at a higher O2 concentration followed by titration based on SpO2 in preterm neonates are needed.
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Affiliation(s)
| | - Munmun Rawat
- Department of Pediatrics, University at Buffalo, Buffalo, NY
| | | | | | - Justin Helman
- Department of Pediatrics, University at Buffalo, Buffalo, NY
| | - Jayasree Nair
- Department of Pediatrics, University at Buffalo, Buffalo, NY
| | - Payam Vali
- Department of Pediatrics, UC Davis, Sacramento, CA
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Vali P, Underwood M, Lakshminrusimha S. Hemoglobin oxygen saturation targets in the neonatal intensive care unit: Is there a light at the end of the tunnel? 1. Can J Physiol Pharmacol 2018; 97:174-182. [PMID: 30365906 DOI: 10.1139/cjpp-2018-0376] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The optimal oxygenation target needed to prevent the extremes of hypoxia and oxygen toxicity in premature and sick newborns has been the subject of much research and debate. The advent of the pulse oximeter has allowed the continuous monitoring of oxyhemoglobin saturation and the delivery of oxygen with greater precision. Well-run, large clinical trials to determine the safest oxygen concentration have led to several revisions in guidelines for neonatal care. However, monitoring of oxyhemoglobin saturation has its limitations and does not provide a comprehensive assessment of tissue oxygenation. To identify optimal oxygen therapy, various other factors (partial pressure of arterial carbon dioxide, hemoglobin concentration, blood pH, and tissue metabolic demand) that influence perfusion and tissue oxygenation need to be considered.
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Affiliation(s)
- Payam Vali
- Department of Pediatrics, UC Davis School of Medicine, Sacramento, CA 95817, USA.,Department of Pediatrics, UC Davis School of Medicine, Sacramento, CA 95817, USA
| | - Mark Underwood
- Department of Pediatrics, UC Davis School of Medicine, Sacramento, CA 95817, USA.,Department of Pediatrics, UC Davis School of Medicine, Sacramento, CA 95817, USA
| | - Satyan Lakshminrusimha
- Department of Pediatrics, UC Davis School of Medicine, Sacramento, CA 95817, USA.,Department of Pediatrics, UC Davis School of Medicine, Sacramento, CA 95817, USA
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Vali P, Gugino S, Koenigsknecht C, Helman J, Chandrasekharan P, Rawat M, Lakshminrusimha S, Nair J. The Perinatal Asphyxiated Lamb Model: A Model for Newborn Resuscitation. J Vis Exp 2018. [PMID: 30175999 DOI: 10.3791/57553] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Birth asphyxia accounts for nearly one million deaths worldwide each year, and is one of the primary causes of early neonatal morbidity and mortality. Many aspects of the current neonatal resuscitation guidelines remain controversial given the difficulties in conducting randomized clinical trials owing to the infrequent and often unpredictable need for extensive resuscitation. Most studies on neonatal resuscitation stem from manikin models that fail to truly reflect physiologic changes or piglet models that have cleared their lung fluid and that have completed the transition from fetal to neonatal circulation. The present protocol provides a detailed step-by-step description on how to create a perinatal asphyxiated fetal lamb model. The proposed model has a transitioning circulation and fluid-filled lungs, which mimics human newborns following delivery, and is, therefore, an excellent animal model to study newborn physiology. An important limitation to lamb experiments is the higher associated cost.
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Affiliation(s)
- Payam Vali
- Department of Pediatrics, University of California Davis
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Vali P, Mathew B, Lakshminrusimha S. In quest of epinephrine's optimal route and dose in neonatal cardiopulmonary resuscitation-are we there yet? J Pediatr 2017; 189:239. [PMID: 28668448 DOI: 10.1016/j.jpeds.2017.06.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 06/05/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Payam Vali
- Department of Pediatrics UC Davis School of Medicine Sacramento, California
| | - Bobby Mathew
- Department of Pediatrics University at Buffalo Buffalo, New York
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Vali P, Lakshminrusimha S. Case 2: Beware of Lumps and Bumps after Cooling! Neoreviews 2017; 18:e441-e444. [PMID: 29861664 PMCID: PMC5975253 DOI: 10.1542/neo.18-7-e441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- Payam Vali
- Department of Pediatrics, University of California Davis, Sacramento, CA
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Vali P, Chandrasekharan P, Rawat M, Gugino S, Koenigsknecht C, Helman J, Mathew B, Berkelhamer S, Nair J, Wyckoff M, Lakshminrusimha S. Hemodynamics and gas exchange during chest compressions in neonatal resuscitation. PLoS One 2017; 12:e0176478. [PMID: 28441439 PMCID: PMC5404764 DOI: 10.1371/journal.pone.0176478] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 04/11/2017] [Indexed: 01/14/2023] Open
Abstract
PURPOSE Current knowledge about pulmonary/systemic hemodynamics and gas exchange during neonatal resuscitation in a model of transitioning fetal circulation with fetal shunts and fluid-filled alveoli is limited. Using a fetal lamb asphyxia model, we sought to determine whether hemodynamic or gas-exchange parameters predicted successful return of spontaneous circulation (ROSC). METHODS The umbilical cord was occluded in 22 lambs to induce asphyxial cardiac arrest. Following five minutes of asystole, resuscitation as per AHA-Neonatal Resuscitation Program guidelines was initiated. Hemodynamic parameters and serial arterial blood gases were assessed during resuscitation. RESULTS ROSC occurred in 18 lambs (82%) at a median (IQR) time of 120 (105-180) seconds. There were no differences in hemodynamic parameters at baseline and at any given time point during resuscitation between the lambs that achieved ROSC and those that did not. Blood gases at arrest prior to resuscitation were comparable between groups. However, lambs that achieved ROSC had lower PaO2, higher PaCO2, and lower lactate during resuscitation. Increase in diastolic blood pressures induced by epinephrine in lambs that achieved ROSC (11 ±4 mmHg) did not differ from those that were not resuscitated (10 ±6 mmHg). Low diastolic blood pressures were adequate to achieve ROSC. CONCLUSIONS Hemodynamic parameters in a neonatal lamb asphyxia model with transitioning circulation did not predict success of ROSC. Lactic acidosis, higher PaO2 and lower PaCO2 observed in the lambs that did not achieve ROSC may represent a state of inadequate tissue perfusion and/or mitochondrial dysfunction.
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Affiliation(s)
- Payam Vali
- Pediatrics, UC Davis, Sacramento, California, United States of America
- * E-mail:
| | | | - Munmun Rawat
- Pediatrics, SUNY University at Buffalo, Buffalo, New York, United States of America
| | - Sylvia Gugino
- Pediatrics, SUNY University at Buffalo, Buffalo, New York, United States of America
| | - Carmon Koenigsknecht
- Pediatrics, SUNY University at Buffalo, Buffalo, New York, United States of America
| | - Justin Helman
- Pediatrics, SUNY University at Buffalo, Buffalo, New York, United States of America
| | - Bobby Mathew
- Pediatrics, SUNY University at Buffalo, Buffalo, New York, United States of America
| | - Sara Berkelhamer
- Pediatrics, SUNY University at Buffalo, Buffalo, New York, United States of America
| | - Jayasree Nair
- Pediatrics, SUNY University at Buffalo, Buffalo, New York, United States of America
| | - Myra Wyckoff
- Pediatrics, UT Southwestern, Dallas, Texas, United States of America
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Vali P, Chandrasekharan P, Rawat M, Gugino S, Koenigsknecht C, Helman J, Jusko WJ, Mathew B, Berkelhamer S, Nair J, Wyckoff MH, Lakshminrusimha S. Evaluation of Timing and Route of Epinephrine in a Neonatal Model of Asphyxial Arrest. J Am Heart Assoc 2017; 6:JAHA.116.004402. [PMID: 28214793 PMCID: PMC5523751 DOI: 10.1161/jaha.116.004402] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background Epinephrine administered by low umbilical venous catheter (UVC) or endotracheal tube (ETT) is indicated in neonates who fail to respond to positive pressure ventilation and chest compressions at birth. Pharmacokinetics of ETT epinephrine via fluid‐filled lungs or UVC epinephrine in the presence of fetal shunts is unknown. We hypothesized that epinephrine administered by ETT or low UVC results in plasma epinephrine concentrations and rates of return of spontaneous circulation (ROSC) similar to right atrial (RA) epinephrine. Methods and Results Forty‐four lambs were randomized into the following groups: RA epinephrine (0.03 mg/kg), low UVC epinephrine (0.03 mg/kg), postcompression ETT epinephrine (0.1 mg/kg), and precompression ETT epinephrine (0.1 mg/kg). Asystole was induced by umbilical cord occlusion. Resuscitation was initiated following 5 minutes of asystole. Thirty‐eight of 44 lambs achieved ROSC (10/11, 9/11, and 12/22 in the RA, UVC, and ETT groups, respectively; subsequent RA epinephrine resulted in a total ROSC of 19/22 in the ETT groups). Median time (interquartile range) to achieve ROSC was significantly longer in the ETT group (including those that received RA epinephrine) compared to the intravenous group (4.5 [2.9–7.4] versus 2 [1.9–3] minutes; P=0.02). RA and low UVC epinephrine administration achieved comparable peak plasma epinephrine concentrations (470±250 versus 450±190 ng/mL) by 1 minute compared to ETT values of 130±60 ng/mL at 5 minutes; P=0.03. Following ROSC with ETT epinephrine alone, there was a delayed peak epinephrine concentration (652±240 ng/mL). Conclusions The absorption of ETT epinephrine is low and delayed at birth. RA and low UVC epinephrine rapidly achieve high plasma concentrations resulting in ROSC.
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Rawat M, Chandrasekharan PK, Swartz DD, Mathew B, Nair J, Gugino SF, Koenigsknecht C, Vali P, Lakshminrusimha S. Neonatal resuscitation adhering to oxygen saturation guidelines in asphyxiated lambs with meconium aspiration. Pediatr Res 2016; 79:583-8. [PMID: 26672734 PMCID: PMC4837048 DOI: 10.1038/pr.2015.259] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 09/21/2015] [Indexed: 01/21/2023]
Abstract
BACKGROUND The Neonatal Resuscitation Program (NRP) recommends upper and lower limits of preductal saturations (SpO2) extrapolated from studies in infants resuscitated in room air. These limits have not been validated in asphyxia and lung disease. METHODS Seven control term lambs delivered by cesarean section were ventilated with 21% O2. Thirty lambs with asphyxia with meconium aspiration were randomly assigned to resuscitation with 21% O2 (n = 6), 100% O2 (n = 6), or initiation with 21% O2 followed by variable FIO2 to maintain NRP target SpO2 ranges (n = 18). Hemodynamic and ventilation parameters were recorded for 15 min. RESULTS Control lambs maintained preductal SpO2 near the lower limit of NRP target range. Asphyxiated lambs had low SpO2 (38 ± 2%), low arterial pH (6.99 ± 0.01), and high PaCO2 (96 ± 7 mm Hg) at birth. Resuscitation with 21% O2 resulted in SpO2 values below the target range with low pulmonary blood flow (Qp) compared to variable FIO2 group. The increase in PaO2 and Qp with variable FIO2 resuscitation was similar to control lambs. CONCLUSION Maintaining SpO2 as recommended by NRP by actively adjusting inspired O2 leads to effective oxygenation and higher Qp in asphyxiated lambs with lung disease. Our findings support the current NRP SpO2 guidelines for O2 supplementation during resuscitation of an asphyxiated neonate.
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Affiliation(s)
- Munmun Rawat
- Department of Pediatrics, University at Buffalo, Buffalo, New York
| | | | - Daniel D. Swartz
- Department of Pediatrics, University at Buffalo, Buffalo, New York,Department of Physiology and Biophysics, University at Buffalo, Buffalo, New York
| | - Bobby Mathew
- Department of Pediatrics, University at Buffalo, Buffalo, New York
| | - Jayasree Nair
- Department of Pediatrics, University at Buffalo, Buffalo, New York
| | - Sylvia F. Gugino
- Department of Pediatrics, University at Buffalo, Buffalo, New York,Department of Physiology and Biophysics, University at Buffalo, Buffalo, New York
| | | | - Payam Vali
- Department of Pediatrics, University at Buffalo, Buffalo, New York
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Chandrasekharan PK, Rawat M, Nair J, Gugino SF, Koenigsknecht C, Swartz DD, Vali P, Mathew B, Lakshminrusimha S. Continuous End-Tidal Carbon Dioxide Monitoring during Resuscitation of Asphyxiated Term Lambs. Neonatology 2016; 109:265-73. [PMID: 26866711 PMCID: PMC4893001 DOI: 10.1159/000443303] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 12/12/2015] [Indexed: 01/24/2023]
Abstract
BACKGROUND The Neonatal Resuscitation Program (NRP) recommends close monitoring of oxygenation during the resuscitation of newborns using a pulse oximeter. However, there are no guidelines for monitoring carbon dioxide (CO2) to assess ventilation. Considering that cerebral blood flow (CBF) correlates directly with PaCO2, continuous capnography monitoring of end-tidal CO2 (ETCO2) may limit fluctuations in PaCO2 and, therefore, CBF during resuscitation of asphyxiated infants. OBJECTIVE To evaluate whether continuous monitoring of ETCO2 with capnography during resuscitation of asphyxiated term lambs with meconium aspiration will prevent fluctuations in PaCO2 and carotid arterial blood flow (CABF). METHODS Fifty-four asphyxiated term lambs with meconium aspiration syndrome were mechanically ventilated from birth to 60 min of age. Ventilatory parameters were adjusted based on clinical observation (chest excursion) and frequent arterial blood gas analysis in 24 lambs (control group) and 30 lambs (capnography group) received additional continuous ETCO2 monitoring. Left CABF was monitored. We aimed to maintain PaCO2 between 35 and 50 mm Hg and ETCO2 between 30 and 45 mm Hg. RESULTS There was a significant correlation between ETCO2 and PaCO2 (R = 0.7, p < 0.001), between PaCO2 and carotid flow (R = 0.52, p < 0.001) and between ETCO2 and carotid flow (R = 0.5, p < 0.001). PaCO2 and CABF during the first 60 min of age showed significantly higher fluctuation in the control group compared to the capnography group. CONCLUSION Continuous monitoring of ETCO2 using capnography with mechanical ventilation during and after resuscitation in asphyxiated term lambs with meconium aspiration limits fluctuations in PaCO2 and CABF and may potentially limit brain injury.
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Vali P, Lakshminrusimha S. ECG monitoring: One step closer to the modernization of the delivery room. Resuscitation 2015; 98:e4-5. [PMID: 26610375 DOI: 10.1016/j.resuscitation.2015.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 11/05/2015] [Indexed: 11/26/2022]
Affiliation(s)
- Payam Vali
- Department of Pediatrics, State University of New York Buffalo, 219 Bryant Street, Buffalo, NY 14216, United States.
| | - Satyan Lakshminrusimha
- Department of Pediatrics, State University of New York Buffalo, 219 Bryant Street, Buffalo, NY 14216, United States
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Abstract
Birth asphyxia accounts for about 23% of the approximately 4 million neonatal deaths each year worldwide (Black et al., Lancet, 2010, 375(9730):1969-87). The majority of newborn infants require little assistance to undergo physiologic transition at birth and adapt to extrauterine life. Approximately 10% of infants require some assistance to establish regular respirations at birth. Less than 1% need extensive resuscitative measures such as chest compressions and approximately 0.06% require epinephrine (Wyllie et al. Resuscitation, 2010, 81 Suppl 1:e260–e287). Transition at birth is mediated by significant changes in circulatory and respiratory physiology. Ongoing research in the field of neonatal resuscitation has expanded our understanding of neonatal physiology enabling the implementation of improved recommendations and guidelines on how to best approach newborns in need for intervention at birth. Many of these recommendations are extrapolated from animal models and clinical trials in adults. There are many outstanding controversial issues in neonatal resuscitation that need to be addressed. This article provides a comprehensive and critical literature review on the most relevant and current research pertaining to evolving new strategies in neonatal resuscitation. The key elements to a successful neonatal resuscitation include ventilation of the lungs while minimizing injury, the judicious use of oxygen to improve pulmonary blood flow, circulatory support with chest compressions, and vasopressors and volume that would hasten return of spontaneous circulation. Several exciting new avenues in neonatal resuscitation such as delayed cord clamping, sustained inflation breaths, and alternate vasopressor agents are briefly discussed. Finally, efforts to improve resuscitative efforts in developing countries through education of basic steps of neonatal resuscitation are likely to decrease birth asphyxia and neonatal mortality.
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Affiliation(s)
- Payam Vali
- Department of Pediatrics (Neonatology), University at Buffalo, Buffalo, NY, USA ; Division of Neonatology, Department of Pediatrics, Women and Children's Hospital of Buffalo, 219 Bryant St, Buffalo, NY 14222, USA
| | - Bobby Mathew
- Department of Pediatrics (Neonatology), University at Buffalo, Buffalo, NY, USA ; Women and Children's Hospital of Buffalo, 219 Bryant St, Buffalo, NY 14222, USA
| | - Satyan Lakshminrusimha
- Department of Pediatrics (Neonatology), University at Buffalo, Buffalo, NY, USA ; Division of Neonatology, Department of Pediatrics, Women and Children's Hospital of Buffalo, 219 Bryant St, Buffalo, NY 14222, USA
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Dennington D, Vali P, Finer NN, Kim JH. Ultrasound confirmation of endotracheal tube position in neonates. Neonatology 2012; 102:185-9. [PMID: 22777009 DOI: 10.1159/000338585] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2011] [Accepted: 04/03/2012] [Indexed: 01/21/2023]
Abstract
BACKGROUND The placement of the endotracheal tube (ETT) in neonates is a challenging procedure that currently requires timely confirmation of tip placement by radiographic imaging. OBJECTIVE We sought to determine if bedside ultrasound (US) could demonstrate ETT tip location in preterm and term newborns and offer a quick alternative method of ETT positioning. METHODS We conducted a prospective pilot study of 30 newborns admitted to the UC San Diego Medical Center who had their ETT placement confirmed by chest radiographs. After a radiograph, each infant had a US exam with a 13-MHz linear transducer on a portable US machine. To assist localization, gentle longitudinal movement of the ETT of less than 0.5 cm was performed. Measurements from the tip of the ETT tip to the carina were made on chest radiograph and midsagittal US images. RESULTS Study infants had a mean gestational age of 30.2 ± 4.9 (SD) weeks and mean birth weight of 1,595.2 ± 862 g. US images were taken a mean 2.9 ± 2.2 h after radiographs. Data from 2 infants were excluded for poor radiograph image quality and extreme outlier values. The ETT was visualized by US in all newborns examined. We observed a good correlation between ETT tip-to-carina distance on US and radiograph (r(2) = 0.68) with minimal bias. Each study took less than 5 min to obtain without any clinical deterioration. CONCLUSIONS Bedside US can visualize the anatomic position of the ETT position in preterm and term infants but further validation is required before routine clinical implementation.
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Affiliation(s)
- Debra Dennington
- Division of Neonatology, Department of Pediatrics, University of California San Diego, San Diego, CA 92103-8774, USA
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Abstract
BACKGROUND The placement of umbilical catheters is an essential part of initial newborn resuscitation and stabilization in the delivery room and later in the neonatal intensive care unit. While a variety of calculations have been derived based on patient morphometrics to determine the insertional length of the catheters, these equations remain inexact. OBJECTIVE To determine a new method to calculate umbilical catheter insertion length using the anatomic pathway of catheters on lateral radiographs. METHODS This was a retrospective study of infants who had umbilical catheters placed in our institution based on a diagnostic imaging database from 2004 to 2007 for all lateral abdominal and corresponding chest radiographs with umbilical vein and/or artery catheters in neonates. From a total of 82 umbilical venous catheter (UVC) and 55 umbilical arterial catheter (UAC) radiographs, the anatomic pathways were traced using Sigmascan Pro v4.0 software. An equation was derived for both UVC and UAC lengths that best approximated the traced length. RESULTS The UVC length could be a simple measurement from the umbilicus to the mid-xiphoid-to-bed distance, measured on the lateral aspect of the abdomen (r(2) = 0.90). The UAC length was approximated by the following regression equation: 1.1 × (xiphoid-ASIS + umbilicus-ASIS) + 1.6, where ASIS is the anterior superior iliac spine (r(2) = 0.94). CONCLUSIONS Anatomic path-based calculations of umbilical catheters can accurately predict radiographic measured lengths. Prospective studies to validate this method against actual inserted length are required before promoting this approach.
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Affiliation(s)
- Payam Vali
- Department of Pediatrics, University of California San Diego, San Diego, Calif 92103-8774, USA
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