Changes in cardiac output and stroke volume as measured by non-invasive CO monitoring in infants with RSV bronchiolitis

Neonatal Septic Shock and Hemodynamic Monitoring in Preterm Neonates in an NICU: Added Value of Electrical Cardiometry in Real-Time Tailoring of Management and Therapeutic Strategies

OBJECTIVE

Electrical cardiometry is an impedance-based monitoring technique that provides data on several hemodynamic parameters in a noninvasive way. There is limited information on clinical utility of the application of this technique in neonates.

STUDY DESIGN

In this study, we describe the case of a preterm neonate born at 30^2/7 weeks of gestational age who developed severe systemic infection with fluid refractory septic shock on day 2 of life.

DISCUSSION

Electrical cardiometry was used and proved very helpful in real-time guiding the choice and the dosing of the most appropriate inotrope drugs in this patient. In addition, it promptly underlined an abrupt drop of systemic vascular resistances occurring after administration of the first dose of antibiotic, thus warning the attending neonatologist to institute appropriate treatment before the clinical conditions could further worsen.

CONCLUSION

This case report suggests that electrical cardiometry could be a useful tool in assessing, monitoring, and guiding care of neonates who develop severe septic shock. We suggest that electrical cardiometry is a promising approach in the management strategies of such patients that warrants informative clinical trials.

KEY POINTS

· Electrical cardiometry was helpful in real-time decision-making.. · Electrical cardiometry reported hemodynamic perturbations before worsening of clinical conditions.. · Electrical cardiometry should be included in the management of critical patients..

Characterization of Cardiopulmonary Interactions and Exploring Their Prognostic Value in Acute Bronchiolitis: A Prospective Cardiopulmonary Ultrasound Study

We aimed to delineate cardiopulmonary interactions in acute bronchiolitis and to evaluate the capacity of a combined cardiopulmonary ultrasonography to predict the need for respiratory support. This was a prospective observational single-center study that includes infants <12 month of age admitted to a hospital due to acute bronchiolitis. All the included patients underwent clinical, laboratory and cardiopulmonary ultrasonographic evaluation at the same time point within 24 h of hospital admission. The existence of significant correlation between cardiac and respiratory parameters was the primary outcome. The association of different cardiopulmonary variables with the need of respiratory support higher than O2, the length of stay hospitalization, the PICU stay and the duration of respiratory support were a secondary outcome. We enrolled 112 infants (median age 1 (0.5-3) months; 62% males) hospitalized with acute bronchiolitis. Increased values of the pulmonary variables (BROSJOD score, pCO2 and LUS) showed moderate correlations with NT-proBNP and all echocardiographic parameters indicative of pulmonary hypertension and myocardial dysfunction (Tei index). Up to 36 (32%) infants required respiratory support during the hospitalization. This group presented with higher lung ultrasound score (p < 0.001) and increased values of NT-proBNP (p < 0.001), the Tei index (p < 0.001) and pulmonary artery pressures (p < 0.001). All the analyzed respiratory and cardiac variables showed moderate-to-strong correlations with the LOS of hospitalization and the time of respiratory support. Lung ultrasound and echocardiography showed a moderate-to-strong predictive accuracy for the need of respiratory support in the ROC analysis, with the AUC varying from 0.74 to 0.87. Those cases of bronchiolitis with a worse pulmonary status presented with a more impaired cardiac status. Cardiopulmonary ultrasonography could be a useful tool to easily identify high-risk populations for complicated acute bronchiolitis hospitalization.

Non-invasive measurement of cardiac output in children with repaired coarctation of the aorta using electrical cardiometry compared to transthoracic Doppler echocardiography

OBJECTIVE

To evaluate the equivalence of the ICON^® electrical cardiometry (EC) haemodynamic monitor to measure cardiac output (CO) relative to transthoracic Doppler echocardiography (TTE) in paediatric patients with repaired coarctation of the aorta (CoA).

APPROACH

A group of n  =  28 CoA patients and n  =  27 matched controls were enrolled. EC and TTE were performed synchronously on each participant and CO measurements compared using linear regression and Bland-Altman analysis. The CoA group was further subdivided into two groups, with n  =  10 and without n  =  18 increased left ventricular outflow tract velocity (iLVOTv) for comparison.

MAIN RESULTS

CO measurements from EC and TTE in controls showed a strong correlation (R  =  0.80, p  <  0.001) and an acceptable percentage error (PE) of 28.1%. However, combining CoA and control groups revealed a moderate correlation (R  =  0.57, p  <  0.001) and a poor PE (44.2%). We suspected that the CO in a subset of CoA participants with iLVOTv was overestimated by TTE. Excluding the iLVOTv CoA participants improved the correlation (R  =  0.77, p  <  0.001) and resulted in an acceptable PE of 31.2%.

SIGNIFICANCE

CO measurements in paediatric CoA patients in the absence of iLVOTv are clinically equivalent between EC and TTE. The presence of iLVOTv may impact the accuracy of CO measurement by TTE, but not EC.

Right and left ventricular function in hospitalized children with respiratory syncytial virus infection

Background

Extrapulmonary manifestations including cardiac dysfunction have been demonstrated in children with respiratory syncytial virus (RSV) infection requiring intensive care. The aim of this study was to examine cardiac function in hospitalized children with moderate RSV infection admitted to a regular pediatric ward.

Methods

We used echocardiography to determine cardiac output, and right and left ventricular function in 26 patients (aged 2 weeks to 24 months) with RSV infection. The echocardiographic results were compared with s-troponin, the need for supplementary oxygen or noninvasive respiratory support, and capillary refill time.

Results

The number of measured s-troponins (ten [38%] of the included children) was too low to assess differences between children with elevated levels and those with normal levels. There were no differences in cardiac function between patients receiving oxygen treatment or respiratory support and those who did not. Capillary refill time did not correlate with any of the echocardiographic parameters. Both left and right ventricular output (mL/kg/min) was higher than published reference values. All other echocardiographic parameters were within the reference range.

Conclusion

Children with moderate RSV infection had an increased left and right ventricular output, and cardiac function was well maintained. We conclude that routine cardiac ultrasound is not warranted in children with moderate RSV infection. The role of an elevated s-troponin in these patients remains to be determined.

Age-related incidence of desaturation events and the cardiac responses on stroke index, cardiac index, and heart rate measured by continuous bioimpedance noninvasive cardiac output monitoring in infants and children undergoing general anesthesia

STUDY OBJECTIVE

To assess the effects of desaturation on stroke index (SI), cardiac index (CI), and heart rate (HR) using the ICON continuous noninvasive cardiac output monitor in children undergoing general anesthesia.

DESIGN

Retrospective analysis of a prospectively collected data set.

SETTING

Pediatric operating rooms in a tertiary academic medical center.

PATIENTS

Children younger than 20 years who experienced desaturation while undergoing general anesthesia.

INTERVENTION

All records were retrospectively searched for desaturation events defined as a recorded Spo2 ≤ 90%. We compared the data from the prior 4 minutes (baseline) with mild, moderate, and severe levels of desaturation.

MEASUREMENTS

The relationship between Spo2 and percent change in SI, CI, and HR from baseline was assessed using a generalized linear model with repeated measures and the least-squares method.

MAIN RESULTS

Data from 446 patients were reviewed; 38 events were eligible for analysis after exclusions. There were significant decreases in SI at all saturation ranges below 95%: -6.5% (P < .001) for 85%-95%, -8.9% (P = .002) for 71%-84%, and -11% (P < .001) for ≤70%. Based on the result from the regression, Spo2 was associated with change in SI with borderline significance (P = .053) but not that of HR and CI. There was a strong relationship to desaturation events with young age (P < .001), particularly infants younger than 6 months.

CONCLUSION

Events associated with desaturation in children under general anesthesia were significantly associated with decreased SI with a greater effect with lower saturation nadirs. It is unclear if other concurrent events could have also contributed to adverse hemodynamic responses during desaturation. In most children, a compensatory increase in HR generally offsets concurrent decreases in CI. It would appear that bradycardia is a late manifestation of hypoxemia.

Continuous noninvasive cardiac output in children: is this the next generation of operating room monitors? Initial experience in 402 pediatric patients

BACKGROUND

Electrical Cardiometry(™) (EC) estimates cardiac parameters by measuring changes in thoracic electrical bioimpedance during the cardiac cycle. The ICON(®), using four electrocardiogram electrodes (EKG), estimates the maximum rate of change of impedance to peak aortic blood acceleration (based on the premise that red blood cells change from random orientation during diastole (high impedance) to an aligned state during systole (low impedance)).

OBJECTIVE

To determine whether continuous cardiac output (CO) data provide additional information to current anesthesia monitors that is useful to practitioners.

METHODS

After IRB approval and verbal consent, 402 children were enrolled. Data were uploaded to our anesthesia record at one-minute intervals. Ten-second measurements (averaged over the previous 20 heart beats) were downloaded to separate files for later comparison with routine OR monitors.

RESULTS

Data from 374 were in the final cohort (loss of signal or improper lead placement); 292,012 measurements during 58,049 min of anesthesia were made in these children (1 day to 19 years and 1 to 107 kg). Four events had a ≥25% reduction in cardiac index at least 1 min before a clinically important change in other monitored parameters; 18 events in 14 children confirmed manifestations of other hemodynamic measures; eight events may have represented artifacts because the observed measurements did not seem to fit the clinical parameters of the other monitors; three other events documented decreased stroke index with extreme tachycardia.

CONCLUSIONS

Electrical cardiometry provides real-time cardiovascular information regarding developing hemodynamic events and successfully tracked the rapid response to interventions in children of all sizes. Intervention decisions must be based on the combined data from all monitors and the clinical situation. Our experience suggests that this type of monitor may be an important addition to real-time hemodynamic monitoring.

Prevention and prophylaxis of respiratory syncytial virus in pediatric cardiology: a UK perspective

ABSTRACT: 

Respiratory syncytial virus (RSV) is a common infection, causing bronchiolitis in over 70% of infants each year and almost all children by the age of 2. It is the leading cause of acute lower respiratory tract infections and admissions to hospital worldwide. Previously healthy infants may have a prolonged cough or wheezing following RSV infection but up to 20% of those with congenital cardiac disease will be hospitalized and have significant morbidity and mortality. For this reason, it is generally recommended that many such infants should receive prophylaxis against RSV infection with palivizumab. This paper reviews the current state of knowledge about RSV affecting children with congenital heart disease from the perspective of those living in the UK and the current protection offered to such children. We also discuss the plans for the future of protection against RSV.

Cardiac output assessed by non-invasive monitoring is associated with ECG changes in children with critical asthma

The primary aim of this study was to determine changes in CI and SI, if any, in children hospitalized with status asthmatics during the course of treatment as measured by non-invasive EC monitoring. The secondary aim was to determine if there is an association between Abnormal CI (defined as <5 or >95 % tile adjusted for age) and Abnormal ECG (defined as ST waves changes) Non-invasive cardiac output (CO) recordings were obtained daily from admission (Initial) to discharge (Final). Changes in CI and SI measurements were compared using paired t tests or 1-way ANOVA. The association between Abnormal CI on Initial CO recording and Abnormal ECG was analyzed by Fischer's exact test. Data are presented as mean ± SEM with mean differences reported with 95 % confidence interval; p < 0.05 was considered significant. Thirty-five children with critical asthma were analyzed. CI decreased from 6.2 ± 0.2 to 4.5 ± 0.1 [-1.6 (-0.04 to -0.37)] L/min/m(2) during hospitalization. There was no change in SI. There was a significant association between Abnormal Initial CI and Abnormal ECG (p = 0.02). In 11 children requiring prolonged hospitalization CI significantly decreased from 7.2 ± 0.5 to 4.0 ± 0.2 [-3.2 (-4.0 to -2.3)] L/min/m(2) and SI decreased from 51.2 ± 3.8 to 40.3 ± 2.0 [-11.0 (-17.6 to -4.4)] ml/beat/m(2) There was a significant decrease in CI in all children treated for critical asthma. In children that required a prolonged course of treatment, there was also a significant decrease in SI. Abnormal CI at Initial CO recording was associated with ST waves changes on ECG during hospitalization. Future studies are required to determine whether non-invasive CO monitoring can predict which patients are at risk for developing abnormal ECG.

Cardiac parameters in children recovered from acute illness as measured by electrical cardiometry and comparisons to the literature

Electrical cardiometry (EC) is a non-invasive cardiac output method that can assess cardiac index (CI) and stroke index (SI) but there are no reference values for children per se. The primary aim of this study was to develop reference values for clinical application. The secondary aim was to compare the EC measurements to published values. We performed a prospective observational study in patients (<21 years of age) without structural heart disease who had recovered from an acute illness. EC recordings in children that had normal heart rate and mean arterial blood pressure at discharge were eligible for analysis. The relationship of CI or SI and age in children was performed by regression analysis. Similar analysis was performed comparing measurements by EC to cardiac parameters values compiled from reference sources to assess bias in EC. Eighty-three children (2 weeks-21 years of age) were studied. There was a significant curvilinear relationship between CI or SI and age by EC (F-test, p < 0.05). Regression curves of cardiac parameters reported in the literature using 6 Fick's method, thermodilution, echocardiography and cardiac MRI were the same or higher than (0-19.6 %) values obtained with EC, with higher values being statistically significant (p < 0.05 all). There is a curvilinear relationship of CI or SI and age by EC in normal children. Cardiac parameters reported in the literature using alternative methods are different from those obtained with EC but are within acceptable ranges, with EC biased to underestimate CI. Adjustment of target value is required for EC goal-directed therapies.