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Bultmann CR, Qiu J, Belmonte B, Fairchild KD, Sullivan BA. Heart rate and oxygen saturation patterns in very low birth weight infants with early onset sepsis and histologic chorioamnionitis. J Neonatal Perinatal Med 2024; 17:209-215. [PMID: 38578905 DOI: 10.3233/npm-230093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024]
Abstract
BACKGROUND Chorioamnionitis and early onset sepsis (EOS) in very low birth weight (VLBW,< 1500 g) infants may cause a systemic inflammatory response reflected in patterns of heart rate (HR) and oxygenation measured by pulse oximetry (SpO2). Identification of these patterns might inform decisions about duration of antibiotic therapy after birth. OBJECTIVE Compare early HR and SpO2 patterns in VLBW infants with or without early onset sepsis (EOS) or histologic chorioamnionitis (HC). STUDY DESIGN Retrospective study of placental pathology and HR and SpO2 in the first 72 h from birth in relation to EOS status for inborn VLBW NICU patients 2012-2019. RESULT Among 362 VLBW infants with HR and SpO2 data available, clinical, or culture-positive EOS occurred in 91/362 (25%) and HC in 81/355 (22%). In univariate analysis, EOS was associated with higher mean HR, lower mean SpO2, and less negative skewness of HR in the first 3 days after birth. HC was associated with higher standard deviation and skewness of HR but no difference in SpO2. In multivariable modeling, significant risk factors for EOS were mean HR, gestational age, HC, mean SpO2, and skewness of SpO2. CONCLUSION HR and SpO2 patterns differ shortly after birth in VLBW infants exposed to HC or with EOS, likely reflecting a systemic inflammatory response.
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Affiliation(s)
| | - Jiaxang Qiu
- Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Briana Belmonte
- Department of Pediatrics, University of Texas Southwestern, Dallas, TX, USA
| | - Karen D Fairchild
- Department of Pediatrics, University of Virginia, Charlottesville, VA, USA
| | - Brynne A Sullivan
- Department of Pediatrics, University of Virginia, Charlottesville, VA, USA
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Everhart KC, Donevant SB, Iskersky VN, Wirth MD, Dail RB. Case Comparison of Preterm Infant Stability During Packed Red Blood Cell Transfusions. Nurs Res 2023; 72:301-309. [PMID: 37350698 DOI: 10.1097/nnr.0000000000000658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/24/2023]
Abstract
BACKGROUND Very preterm infants (less than 32 weeks gestational age) experience acute morbidity during their stay in a neonatal intensive care unit. Because of their prematurity and frequent laboratory testing, they experience anemia, requiring correction with packed red blood cell (PRBC) transfusion(s). PRBC transfusions have been linked to neonatal morbidity, such as necrotizing enterocolitis, but never signs and symptoms of physiological stability. OBJECTIVE The secondary data analysis aimed to examine very preterm infants' physiological stability before, during, and after PRBC transfusions. METHODS A within-case, mixed-methods design was used in a secondary data analysis for 16 transfusion cases from 13 very preterm infants. RESULTS The findings showed very preterm infants with physiological variables falling within defined limits based on gestational age during the transfusion. Two contrasting case exemplars will be presented. DISCUSSION PRBC transfusions are necessary and prevent morbidity in very preterm infants. Observing instability during transfusions and prospectively studying hypothermia, cardiac instability, and thermal gradients is essential to design interventions to decrease morbidity associated with PRBC transfusions.
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3
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Lee SS, El Ters N, Vesoulis ZA, Zempel JM, Mathur AM. Variable Association of Physiologic Changes With Electrographic Seizure-Like Events in Infants Born Preterm. J Pediatr 2023; 257:113348. [PMID: 36801212 PMCID: PMC10575679 DOI: 10.1016/j.jpeds.2022.12.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 11/22/2022] [Accepted: 12/20/2022] [Indexed: 02/17/2023]
Abstract
OBJECTIVES To determine the incidence of seizure-like events in a cohort of infants born preterm as well as the prevalence of associated vital sign changes (heart rate [HR], respiratory rate, and pulse oximetry [SpO2]). STUDY DESIGN We performed prospective conventional video electroencephalogram monitoring on infants born at 23-30 weeks of gestational age during the first 4 postnatal days. For detected seizure-like events, simultaneously captured vital sign data were analyzed during the pre-event baseline and during the event. Significant vital sign changes were defined as HR or respiratory rate >±2 SD from the infant's own baseline physiologic mean, derived from a 10-minute interval before the seizure-like event. Significant change in SpO2 was defined as oxygen desaturation during the event with a mean SpO2 <88%. RESULTS Our sample included 48 infants with median gestational age of 28 weeks (IQR 26-29) and birth weight of 1125 g (IQR 963-1265). Twelve (25%) infants had seizure-like discharges with a total of 201 events; 83% (10/12) of infants had vital sign changes during these events, and 50% (6/12) had significant vital sign changes during the majority of the seizure-like events. Concurrent HR changes occurred the most frequently. CONCLUSIONS Individual infant variability was observed in the prevalence of concurrent vital sign changes with electroencephalographic seizure-like events. Physiologic changes associated with preterm electrographic seizure-like events should be investigated further as a potential biomarker to assess the clinical significance of such events in the preterm population.
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Affiliation(s)
- Stephanie S Lee
- Division of Neonatology, Department of Pediatrics, University of Iowa Stead Family Children's Hospital, Iowa City, IA
| | - Nathalie El Ters
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine in St Louis, St Louis, MO.
| | - Zachary A Vesoulis
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine in St Louis, St Louis, MO
| | - John M Zempel
- Department of Neurology, Washington University School of Medicine in St Louis, St Louis, MO
| | - Amit M Mathur
- Saint Louis University School of Medicine, St Louis, MO
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4
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Greene ND, Riley T, Mastroianni R, Billimoria ZC, Enquobahrie DA, Baker C, Gray MM, Umoren RA. Neonatal Vital Sign Trajectories and Risk Factors During Transport Within a Regional Care Network. Air Med J 2022; 41:542-548. [PMID: 36494170 DOI: 10.1016/j.amj.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 08/15/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The aim of this study was to characterize vital sign abnormalities, trajectories, and related risk factors during neonatal transport. METHODS We performed a retrospective analysis of neonates transported within a US regional care network in 2020 to 2021. Demographic and clinical data were collected from electronic records. Group-based trajectory modeling was applied to identify groups of neonates who followed distinct vital sign trajectories during transport. Patients with conditions likely to impact the assessed vital were excluded. Risk factors for trajectories were examined using modified Poisson regression models. RESULTS Of the 620 neonates in the study, 92% had one abnormal systolic blood pressure (SBP) measure, approximately half had an abnormal heart rate (47%) or temperature (56%), and 28% had an abnormal oxygen saturation measure during transport. Over half (53%) were in a low and decreasing SBP trajectory, and 36% were in a high and increasing heart rate trajectory. Most infants ≤ 28 weeks postmenstrual age had 2 or more concerning vital sign trajectories during transport. CONCLUSION Abnormal vital signs were common during neonatal transport, and potentially negative trajectories in heart rate and SBP were more common than temperature or oxygen saturation. Transport teams should be trained and equipped to detect concerning trends and respond appropriately while en route.
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Affiliation(s)
- Nancy D Greene
- Department of Health Services, University of Washington, Seattle, WA.
| | - Taylor Riley
- Department of Epidemiology, University of Washington, Seattle, WA
| | - Rossella Mastroianni
- Division of Neonatology, University of Washington School of Medicine, Seattle, WA
| | - Zeenia C Billimoria
- Division of Neonatology, University of Washington School of Medicine, Seattle, WA
| | | | | | - Megan M Gray
- Division of Neonatology, University of Washington School of Medicine, Seattle, WA
| | - Rachel A Umoren
- Division of Neonatology, University of Washington School of Medicine, Seattle, WA
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Evaluation of Pulse Rate, Oxygen Saturation, and Respiratory Effort after Different Types of Feeding Methods in Preterm Newborns. Int J Pediatr 2022; 2022:9962358. [PMID: 35747393 PMCID: PMC9213138 DOI: 10.1155/2022/9962358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 05/21/2022] [Accepted: 05/30/2022] [Indexed: 11/17/2022] Open
Abstract
Background During the initial days of hospitalization, preterm newborns are given combinations of breastfeeding, spoon/paladai feeding, and/or gavage feeding. Each method of feeding may have a different effect on vital parameters. Objective To study changes in vital parameters in relation to different feeding methods and postmenstrual age (PMA) in preterm newborns. Study Design. This prospective observational study was carried out at a tertiary care neonatal unit. Participants. Physiologically stable preterm newborns with PMA less than 37 weeks on full enteral feeds were included in the study. Intervention. None. Outcomes. Respiratory rate (RR), pulse rate (PR), oxygen saturation (SPO2), nasal flaring, and lower chest indrawing were monitored before and up to 3 h after the breastfeeding/spoon (paladai) feeding/gavage feeding or their combinations. These vital parameters were assessed in relation to the feeding methods and PMA groups using ANOVA. Results A total of 383 records were analyzed from 110 newborns. No infant developed chest indrawing or nasal flaring after any feeding method. During the 3 h period of monitoring, vital parameters changed significantly except in the gavage feeding group. The mean PR did not change, but the mean RR and SPO2 changed significantly at different PMA. Conclusion Vital parameters changed after different types of feeding methods and at different PMA. A further multicentric prospective study is needed to understand the effect of different feeding methods and PMA on vital parameters.
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Elliott M, Burnsed J, Heinan K, Letzkus L, Andris R, Fairchild K, Zanelli S. Effect of dexmedetomidine on heart rate in neonates with hypoxic ischemic encephalopathy undergoing therapeutic hypothermia. J Neonatal Perinatal Med 2022; 15:47-54. [PMID: 34334427 DOI: 10.3233/npm-210737] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND Sedation is recommended to optimize neuroprotection in neonates with hypoxic ischemic encephalopathy (HIE) undergoing therapeutic hypothermia (TH). Dexmedetomidine is an alternative agent to opioids, which are commonly used but have adverse effects. Both TH and dexmedetomidine can cause bradycardia. In this study, we describe our experience with dexmedetomidine and fentanyl in neonates undergoing TH for HIE, with a focus on heart rate (HR). METHODS We performed a retrospective chart review from 2011-2019 at a level IV NICU comparing sedation with dexmedetomidine (n = 14), fentanyl (n = 120), or both (n = 32) during TH for HIE. HR trends were compared based on sedation and gestational age. Neonates were included if they underwent TH and received sedation and were excluded if cooling was initiated past 24hours (h) from birth or if they required ECMO. RESULTS Of the 166 neonates included, 46 received dexmedetomidine, 14 as monotherapy and 32 in combination with fentanyl. Mean hourly HR from 12-36 h after birth was significantly lower for infants on dexmedetomidine versus fentanyl monotherapy (91±9 vs. 103±11 bpm, p < 0.002). Dexmedetomidine was decreased or discontinued in 22 (47.8%) neonates, most commonly due to inadequate sedation with a low HR. Lower gestational age was associated with higher HR but no significant difference in dexmedetomidine-related HR trends. CONCLUSIONS Despite an association with lower HR, dexmedetomidine may be successfully used in neonates with HIE undergoing TH. Implementation of a standardized protocol may facilitate dexmedetomidine titration in this population.
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Affiliation(s)
- M Elliott
- Division of Neonatology, Department of Pediatrics, University of Virginia, Charlottesville, VA, USA
| | - J Burnsed
- Division of Neonatology, Department of Pediatrics, University of Virginia, Charlottesville, VA, USA
| | - K Heinan
- Division of Neurology, Department of Pediatrics, University of Virginia, Charlottesville, VA, USA
| | - L Letzkus
- Division of Developmental Pediatrics, Department of Pediatrics, University of Virginia, Charlottesville, VA, USA
| | - R Andris
- UVA School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - K Fairchild
- Division of Neonatology, Department of Pediatrics, University of Virginia, Charlottesville, VA, USA
| | - S Zanelli
- Division of Neonatology, Department of Pediatrics, University of Virginia, Charlottesville, VA, USA
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7
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Sullivan BA, Fairchild KD. Vital signs as physiomarkers of neonatal sepsis. Pediatr Res 2022; 91:273-282. [PMID: 34493832 DOI: 10.1038/s41390-021-01709-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 07/24/2021] [Accepted: 07/27/2021] [Indexed: 02/08/2023]
Abstract
Neonatal sepsis accounts for significant morbidity and mortality, particularly among premature infants in the Neonatal Intensive Care Unit. Abnormal vital sign patterns serve as physiomarkers of sepsis and provide early warning of illness before overt clinical decompensation. The systemic inflammatory response to pathogens signals the autonomic nervous system, leading to changes in temperature, respiratory rate, heart rate, and blood pressure. In infants with comorbidities of prematurity, vital sign abnormalities often occur in the absence of infection, which confounds sepsis diagnosis. This review will cover the mechanisms of vital sign changes in neonatal sepsis, including the cholinergic anti-inflammatory pathway mediated by the vagus nerve, which is critical to the host response to infectious and inflammatory insults. We will also review the clinical implications of vital sign changes in neonatal sepsis, including their use in early warning scores and systems to direct clinicians to the bedside of infants with physiologic changes that might be due to sepsis. IMPACT: This manuscript summarizes and reviews the relevant literature on the physiological manifestations of neonatal sepsis and how we monitor and analyze these through vital signs and advanced analytics.
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Affiliation(s)
- Brynne A Sullivan
- Division of Neonatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, USA.
| | - Karen D Fairchild
- Division of Neonatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, USA
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Coggins SA, Haggerty M, Herrick HM. Post-cardiac arrest physiology and management in the neonatal intensive care unit. Resuscitation 2021; 169:11-19. [PMID: 34648922 DOI: 10.1016/j.resuscitation.2021.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 09/28/2021] [Accepted: 10/01/2021] [Indexed: 11/27/2022]
Abstract
AIM The importance of high-quality post-cardiac arrest care is well-described in adult and paediatric populations, but data are lacking to inform post-cardiac arrest care in the neonatal intensive care unit (NICU). The objective of this study was to describe post-cardiac arrest physiology and management in a quaternary NICU. METHODS Retrospective descriptive study of post-cardiac arrest physiology and management. Data were abstracted from electronic medical records and an institutional resuscitation database. A cardiac arrest was defined as ≥1 minute of chest compressions. Only index arrests were analysed. Descriptive statistics were used to report patient, intra-arrest, and post-arrest characteristics. RESULTS There were 110 index cardiac arrests during the 5-year study period from 1/2017-2/2021. The majority (69%) were acute respiratory compromise leading to cardiopulmonary arrest (ARC-CPA) and 26% were primary cardiopulmonary arrests (CPA). Vital sign monitoring within 24 hours post-arrest was variable, especially non-invasive blood pressure frequency (median 5, range 1-44 measurements). There was a high prevalence of hypothermia (73% of arrest survivors). There was substantial variability in laboratory frequency within 24 hours post-arrest. Patients with primary CPA received significantly more lab testing and had a higher prevalence of acidosis (pH < 7.2) than those with ARC-CPA. CONCLUSIONS We identified significant variation in post-arrest management and a high prevalence of hypothermia. These data highlight the need for post-arrest management guidelines specific to neonatal physiology, as well as opportunities for quality improvement initiatives. Further research is needed to ascertain the impact of neonatal post-arrest management on long-term outcomes and survival.
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Affiliation(s)
- Sarah A Coggins
- Department of Pediatrics, Division of Neonatology, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Mary Haggerty
- Department of Pediatrics, Division of Neonatology, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Heidi M Herrick
- Department of Pediatrics, Division of Neonatology, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
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9
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Paliwoda M, New K, Bogossian F, Ballard E. Physiological vital sign reference ranges for well late preterm newborns calculated during a typical two-hour newborn period between 2 hours and 7 days of life. Physiol Meas 2021; 42. [PMID: 34271562 DOI: 10.1088/1361-6579/ac155b] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 07/16/2021] [Indexed: 11/12/2022]
Abstract
Objectives To calculate 95% reference ranges for heart rate, respiratory rate, oxygen saturation, temperature and blood pressure for well late preterm newborns between 34+0/7 and 36+6/7 weeks of gestation during typical neonatal behaviour. Approach A single site, prospective cohort study in a major Australian quaternary hospital between February and September 2019. A total of 120 late preterm newborns had their heart rate, respiratory rate and oxygen saturation measurements recorded every two seconds for up to two hours with unconditional 95% reference ranges determined using a linear mixed model with random intercept for total standard deviation calculation including repeated measures. Temperature and blood pressure measurements were collected twice - at the start and conclusion of the data recording period, with weighted 2.5th and 97.5th percentiles calculated using the mean value. Main results A total of 364,577 heart rate, 365,208 respiratory rate, 360,494 peripheral oxygen saturation, and 240 temperature and blood pressure values were obtained. The 95% reference ranges were: heart rate 102 - 164 bpm; respiratory rate 15 - 67 rpm; oxygen saturation 94 - 100%; temperature 36.4 - 37.6°C; systolic blood pressure 51 - 86 mmHg; diastolic blood pressure 28 - 61 mmHg; mean arterial pressure 35 - 68 mmHg. Significance Seven vital sign references ranges were reported for the late preterm population during a typical newborn period (such as crying, sleeping, feeding, awake and alert, and during nappy hygiene cares); internal and external validation should be completed prior to clinical use. Cut off points for escalation of care have previously been generalised to all newborns irrespective of gestational age which may result in over-treatment or a delay in recognising subtle signs of deterioration.
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Affiliation(s)
- Michelle Paliwoda
- School of Nursing, Midwifery, and Social Work, The University of Queensland, Saint Lucia, Queensland, 4072, AUSTRALIA
| | - Karen New
- The University of Queensland, Saint Lucia, Queensland, AUSTRALIA
| | - Fiona Bogossian
- University of the Sunshine Coast, Maroochydore DC, Queensland, AUSTRALIA
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10
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Zimmet AM, Sullivan BA, Fairchild KD, Moorman JR, Isler JR, Wallman-Stokes AW, Sahni R, Vesoulis ZA, Ratcliffe SJ, Lake DE. Vital sign metrics of VLBW infants in three NICUs: implications for predictive algorithms. Pediatr Res 2021; 90:125-130. [PMID: 33767372 PMCID: PMC8376742 DOI: 10.1038/s41390-021-01428-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 02/03/2021] [Accepted: 02/04/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Continuous heart rate (HR) and oxygenation (SpO2) metrics can be useful for predicting adverse events in very low birth weight (VLBW) infants. To optimize the utility of these tools, inter-site variability must be taken into account. METHODS For VLBW infants at three neonatal intensive care units (NICUs), we analyzed the mean, standard deviation, skewness, kurtosis, and cross-correlation of electrocardiogram HR, pulse oximeter pulse rate, and SpO2. The number and durations of bradycardia and desaturation events were also measured. Twenty-two metrics were calculated hourly, and mean daily values were compared between sites. RESULTS We analyzed data from 1168 VLBW infants from birth through day 42 (35,238 infant-days). HR and SpO2 metrics were similar at the three NICUs, with mean HR rising by ~10 beats/min over the first 2 weeks and mean SpO2 remaining stable ~94% over time. The number of bradycardia events was higher at one site, and the duration of desaturations was longer at another site. CONCLUSIONS Mean HR and SpO2 were generally similar among VLBW infants at three NICUs from birth through 6 weeks of age, but bradycardia and desaturation events differed in the first 2 weeks after birth. This highlights the importance of developing predictive analytics tools at multiple sites. IMPACT HR and SpO2 analytics can be useful for predicting adverse events in VLBW infants in the NICU, but inter-site differences must be taken into account in developing predictive algorithms. Although mean HR and SpO2 patterns were similar in VLBW infants at three NICUs, inter-site differences in the number of bradycardia events and duration of desaturation events were found. Inter-site differences in bradycardia and desaturation events among VLBW infants should be considered in the development of predictive algorithms.
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Affiliation(s)
- Amanda M. Zimmet
- Department of Medicine, University of Virginia, Charlottesville, VA
| | | | | | | | | | | | - Rakesh Sahni
- Department of Pediatrics, Columbia University, New York, NY
| | | | - Sarah J. Ratcliffe
- Department of Public Health Science, University of Virginia, Charlottesville, VA
| | - Douglas E. Lake
- Department of Medicine, University of Virginia, Charlottesville, VA,Sepsis Challenges Response Unit, University of Virginia, Charlottesville, VA
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Van Wyk L, Smith J, Lawrenson J, Lombard CJ, de Boode WP. Bioreactance-derived haemodynamic parameters in the transitional phase in preterm neonates: a longitudinal study. J Clin Monit Comput 2021; 36:861-870. [PMID: 33983533 DOI: 10.1007/s10877-021-00718-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 05/06/2021] [Indexed: 11/26/2022]
Abstract
Bioreactance (BR) is a novel, non-invasive technology that is able to provide minute-to-minute monitoring of cardiac output and additional haemodynamic variables. This study aimed to determine the values for BR-derived haemodynamic variables in stable preterm neonates during the transitional period. A prospective observational study was performed in a group of stable preterm (< 37 weeks) infants in the neonatal service of Tygerberg Children's Hospital, Cape Town, South Africa. All infants underwent continuous bioreactance (BR) monitoring until 72 h of life. Sixty three preterm infants with a mean gestational age of 31 weeks and mean birth weight of 1563 g were enrolled. Summary data and time series graphs were drawn for BR-derived heart rate, non-invasive blood pressure, stroke volume, cardiac output and total peripheral resistance index. All haemodynamic parameters were significantly associated with postnatal age, after correction for clinical variables (gestational age, birth weight, respiratory support mode). To our knowledge, this is the first paper to present longitudinal BR-derived haemodynamic variable data in a cohort of stable preterm infants, not requiring invasive ventilation or inotropic support, during the first 72 h of life. Bioreactance-derived haemodynamic monitoring is non-invasive and offers the ability to simultaneously monitor numerous haemodynamic parameters of global systemic blood flow. Moreover, it may provide insight into transitional physiology and its pathophysiology.
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Affiliation(s)
- Lizelle Van Wyk
- Division Neonatology, Dept. Pediatrics & Child Health, Stellenbosch University and Tygerberg Children's Hospital, Cape Town, South Africa.
| | - Johan Smith
- Division Neonatology, Dept. Pediatrics & Child Health, Stellenbosch University and Tygerberg Children's Hospital, Cape Town, South Africa
| | - John Lawrenson
- Pediatric Cardiology Unit, Dept. Pediatrics & Child Health, Stellenbosch University, Cape Town, South Africa
| | - Carl J Lombard
- Division of Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, Cape Town, South Africa
- Biostatistics Unit, South African Medical Research Council, Cape Town, South Africa
| | - Willem Pieter de Boode
- Division of Neonatology, Dept. of Perinatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
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12
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Affiliation(s)
- F. Sessions Cole
- grid.4367.60000 0001 2355 7002Division of Newborn Medicine, Edward Mallinckrodt Department of Pediatrics, Washington University School of Medicine and St. Louis Children’s Hospital, St. Louis, MO USA
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13
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Chiera M, Cerritelli F, Casini A, Barsotti N, Boschiero D, Cavigioli F, Corti CG, Manzotti A. Heart Rate Variability in the Perinatal Period: A Critical and Conceptual Review. Front Neurosci 2020; 14:561186. [PMID: 33071738 PMCID: PMC7544983 DOI: 10.3389/fnins.2020.561186] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 08/28/2020] [Indexed: 12/18/2022] Open
Abstract
Neonatal intensive care units (NICUs) greatly expand the use of technology. There is a need to accurately diagnose discomfort, pain, and complications, such as sepsis, mainly before they occur. While specific treatments are possible, they are often time-consuming, invasive, or painful, with detrimental effects for the development of the infant. In the last 40 years, heart rate variability (HRV) has emerged as a non-invasive measurement to monitor newborns and infants, but it still is underused. Hence, the present paper aims to review the utility of HRV in neonatology and the instruments available to assess it, showing how HRV could be an innovative tool in the years to come. When continuously monitored, HRV could help assess the baby’s overall wellbeing and neurological development to detect stress-/pain-related behaviors or pathological conditions, such as respiratory distress syndrome and hyperbilirubinemia, to address when to perform procedures to reduce the baby’s stress/pain and interventions, such as therapeutic hypothermia, and to avoid severe complications, such as sepsis and necrotizing enterocolitis, thus reducing mortality. Based on literature and previous experiences, the first step to efficiently introduce HRV in the NICUs could consist in a monitoring system that uses photoplethysmography, which is low-cost and non-invasive, and displays one or a few metrics with good clinical utility. However, to fully harness HRV clinical potential and to greatly improve neonatal care, the monitoring systems will have to rely on modern bioinformatics (machine learning and artificial intelligence algorithms), which could easily integrate infant’s HRV metrics, vital signs, and especially past history, thus elaborating models capable to efficiently monitor and predict the infant’s clinical conditions. For this reason, hospitals and institutions will have to establish tight collaborations between the obstetric, neonatal, and pediatric departments: this way, healthcare would truly improve in every stage of the perinatal period (from conception to the first years of life), since information about patients’ health would flow freely among different professionals, and high-quality research could be performed integrating the data recorded in those departments.
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Affiliation(s)
- Marco Chiera
- Research and Assistance for Infants to Support Experience Lab, Foundation Center for Osteopathic Medicine Collaboration, Pescara, Italy.,Research Commission on Manual Therapies and Mind-Body Disciplines, Societ Italiana di Psico Neuro Endocrino Immunologia, Rome, Italy
| | - Francesco Cerritelli
- Research and Assistance for Infants to Support Experience Lab, Foundation Center for Osteopathic Medicine Collaboration, Pescara, Italy
| | - Alessandro Casini
- Research and Assistance for Infants to Support Experience Lab, Foundation Center for Osteopathic Medicine Collaboration, Pescara, Italy
| | - Nicola Barsotti
- Research and Assistance for Infants to Support Experience Lab, Foundation Center for Osteopathic Medicine Collaboration, Pescara, Italy.,Research Commission on Manual Therapies and Mind-Body Disciplines, Societ Italiana di Psico Neuro Endocrino Immunologia, Rome, Italy
| | | | - Francesco Cavigioli
- Neonatal Intensive Care Unit, "V. Buzzi" Children's Hospital, Azienda Socio Sanitaria Territoriale Fatebenefratelli-Sacco, Milan, Italy
| | - Carla G Corti
- Pediatric Cardiology Unit-Pediatric Department, Azienda Socio Sanitaria Territoriale Fatebenefratelli-Sacco, Milan, Italy
| | - Andrea Manzotti
- Research and Assistance for Infants to Support Experience Lab, Foundation Center for Osteopathic Medicine Collaboration, Pescara, Italy.,Neonatal Intensive Care Unit, "V. Buzzi" Children's Hospital, Azienda Socio Sanitaria Territoriale Fatebenefratelli-Sacco, Milan, Italy.,Research Department, SOMA, Istituto Osteopatia Milano, Milan, Italy
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Challenges in developing a consensus definition of neonatal sepsis. Pediatr Res 2020; 88:14-26. [PMID: 32126571 DOI: 10.1038/s41390-020-0785-x] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 12/24/2019] [Accepted: 01/13/2020] [Indexed: 01/03/2023]
Abstract
Sepsis remains a leading cause of morbidity and mortality in the neonatal population, and at present, there is no unified definition of neonatal sepsis. Existing consensus sepsis definitions within paediatrics are not suited for use in the NICU and do not address sepsis in the premature population. Many neonatal research and surveillance networks have criteria for the definition of sepsis within their publications though these vary greatly and there is typically a heavy emphasis on microbiological culture. The concept of organ dysfunction as a diagnostic criterion for sepsis is rarely considered in neonatal literature, and it remains unclear how to most accurately screen neonates for organ dysfunction. Accurately defining and screening for sepsis is important for clinical management, health service design and future research. The progress made by the Sepsis-3 group provides a roadmap of how definitions and screening criteria may be developed. Similar initiatives in neonatology are likely to be more challenging and would need to account for the unique presentation of sepsis in term and premature neonates. The outputs of similar consensus work within neonatology should be twofold: a validated definition of neonatal sepsis and screening criteria to identify at-risk patients earlier in their clinical course. IMPACT: There is currently no consensus definition of neonatal sepsis and the definitions that are currently in use are varied.A consensus definition of neonatal sepsis would benefit clinicians, patients and researchers.Recent progress in adults with publication of Sepsis-3 provides guidance on how a consensus definition and screening criteria for sepsis could be produced in neonatology.We discuss common themes and potential shortcomings in sepsis definitions within neonatology.We highlight the need for a consensus definition of neonatal sepsis and the challenges that this task poses.
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Coggins S, Harris MC, Grundmeier R, Kalb E, Nawab U, Srinivasan L. Performance of Pediatric Systemic Inflammatory Response Syndrome and Organ Dysfunction Criteria in Late-Onset Sepsis in a Quaternary Neonatal Intensive Care Unit: A Case-Control Study. J Pediatr 2020; 219:133-139.e1. [PMID: 32037153 DOI: 10.1016/j.jpeds.2019.12.064] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 12/03/2019] [Accepted: 12/30/2019] [Indexed: 01/01/2023]
Abstract
OBJECTIVES To evaluate accuracy of systemic inflammatory response syndrome (SIRS) criteria in identifying culture-proven late-onset neonatal sepsis and to assess prevalence of organ dysfunction and its relationship with SIRS criteria. STUDY DESIGN This was a retrospective case-control study of patients in the Children's Hospital of Philadelphia level IV neonatal intensive care unit undergoing sepsis evaluations (concurrent blood culture and antibiotics). During calendar years 2016-2017, 77 case and 77 control sepsis evaluations were identified. Cases included infants who had sepsis evaluations with positive blood cultures and antibiotic duration ≥7 days. Controls were matched by gestational and postmenstrual age, and had sepsis evaluations with negative blood cultures and antibiotic duration ≤48 hours. SIRS criteria were determined at time of sepsis evaluation, and organ dysfunction evaluated in the 72 hours following sepsis evaluation. Statistical analysis included descriptive statistics, Mann-Whitney tests, and χ2 (Fisher exact) tests. RESULTS At time of sepsis evaluation, 42% of cases and 26% of controls met SIRS criteria. Among infants of ≤37 weeks postmenstrual age, SIRS criteria were met in only 17% of sepsis evaluations (4 of 23 in both cases and controls). Test characteristics for SIRS at diagnosis of culture-proven sepsis included sensitivity 42% and specificity 74%. Cases had higher rates of new organ dysfunction within 72 hours (40% vs 21%); however, 58% of cases developing organ dysfunction did not meet SIRS criteria at time of sepsis evaluation. Of 6 deaths (all cases with organ dysfunction), 2 did not meet SIRS criteria at sepsis evaluation. CONCLUSIONS SIRS criteria did not accurately identify culture-proven late-onset sepsis, with poorest accuracy in preterm infants. SIRS criteria did not predict later organ dysfunction or mortality.
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Affiliation(s)
- Sarah Coggins
- Department of Pediatrics, Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Mary Catherine Harris
- Department of Pediatrics, Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Robert Grundmeier
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Department of Pediatrics, Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Elizabeth Kalb
- Department of Pediatrics, Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Ursula Nawab
- Department of Pediatrics, Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Lakshmi Srinivasan
- Department of Pediatrics, Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
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Continuous vital sign analysis for predicting and preventing neonatal diseases in the twenty-first century: big data to the forefront. Pediatr Res 2020; 87:210-220. [PMID: 31377752 PMCID: PMC6962536 DOI: 10.1038/s41390-019-0527-0] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 07/20/2019] [Accepted: 07/25/2019] [Indexed: 01/03/2023]
Abstract
In the neonatal intensive care unit (NICU), heart rate, respiratory rate, and oxygen saturation are vital signs (VS) that are continuously monitored in infants, while blood pressure is often monitored continuously immediately after birth, or during critical illness. Although changes in VS can reflect infant physiology or circadian rhythms, persistent deviations in absolute values or complex changes in variability can indicate acute or chronic pathology. Recent studies demonstrate that analysis of continuous VS trends can predict sepsis, necrotizing enterocolitis, brain injury, bronchopulmonary dysplasia, cardiorespiratory decompensation, and mortality. Subtle changes in continuous VS patterns may not be discerned even by experienced clinicians reviewing spot VS data or VS trends captured in the monitor. In contrast, objective analysis of continuous VS data can improve neonatal outcomes by allowing heightened vigilance or preemptive interventions. In this review, we provide an overview of the studies that have used continuous analysis of single or multiple VS, their interactions, and combined VS and clinical analytic tools, to predict or detect neonatal pathophysiology. We make the case that big-data analytics are promising, and with continued improvements, can become a powerful tool to mitigate neonatal diseases in the twenty-first century.
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Joshi R, Kommers D, Guo C, Bikker JW, Feijs L, van Pul C, Andriessen P. Statistical Modeling of Heart Rate Variability to Unravel the Factors Affecting Autonomic Regulation in Preterm Infants. Sci Rep 2019; 9:7691. [PMID: 31118460 PMCID: PMC6531452 DOI: 10.1038/s41598-019-44209-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 05/08/2019] [Indexed: 12/28/2022] Open
Abstract
Analyzing heart rate variability (HRV) in preterm infants can help track maturational changes and subclinical signatures of disease. We conducted an observational study to characterize the effect of demographic and cardiorespiratory factors on three features of HRV using a linear mixed-effects model. HRV-features were tailored to capture the unique physiology of preterm infants, including the contribution of transient pathophysiological heart rate (HR) decelerations. Infants were analyzed during stable periods in the incubator and subsequent sessions of Kangaroo care (KC) - an intervention that increases comfort. In total, 957 periods in the incubator and during KC were analyzed from 66 preterm infants. Our primary finding was that gestational age (GA) and postmenstrual age (PMA) have the largest influence on HRV while the HR and breathing rate have a considerably smaller effect. Birth weight and gender do not affect HRV. We identified that with increasing GA and PMA, overall HRV decreased and increased respectively. Potentially these differences can be attributed to distinct trajectories of intra- and extrauterine development. With increasing GA, the propensity towards severe HR decelerations decreases, thereby reducing overall variability, while with increasing PMA, the ratio of decelerations and accelerations approaches unity, increasing overall HRV.
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Affiliation(s)
- Rohan Joshi
- Department of Industrial Design, Eindhoven University of Technology, Eindhoven, The Netherlands
- Department of Clinical Physics, Máxima Medical Centre Veldhoven, Veldhoven, The Netherlands
- Department of Family Care Solutions, Philips Research, Eindhoven, The Netherlands
| | - Deedee Kommers
- Department of Neonatology, Máxima Medical Centre, Veldhoven, The Netherlands.
- Department of Applied Physics, Eindhoven University of Technology, Eindhoven, The Netherlands.
| | - Chengcheng Guo
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | | | - Loe Feijs
- Department of Industrial Design, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Carola van Pul
- Department of Clinical Physics, Máxima Medical Centre Veldhoven, Veldhoven, The Netherlands
- Department of Applied Physics, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Peter Andriessen
- Department of Neonatology, Máxima Medical Centre, Veldhoven, The Netherlands
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