1
|
Carlson AP, Mayer AR, Cole C, van der Horn HJ, Marquez J, Stevenson TC, Shuttleworth CW. Cerebral autoregulation, spreading depolarization, and implications for targeted therapy in brain injury and ischemia. Rev Neurosci 2024; 35:651-678. [PMID: 38581271 PMCID: PMC11297425 DOI: 10.1515/revneuro-2024-0028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 03/25/2024] [Indexed: 04/08/2024]
Abstract
Cerebral autoregulation is an intrinsic myogenic response of cerebral vasculature that allows for preservation of stable cerebral blood flow levels in response to changing systemic blood pressure. It is effective across a broad range of blood pressure levels through precapillary vasoconstriction and dilation. Autoregulation is difficult to directly measure and methods to indirectly ascertain cerebral autoregulation status inherently require certain assumptions. Patients with impaired cerebral autoregulation may be at risk of brain ischemia. One of the central mechanisms of ischemia in patients with metabolically compromised states is likely the triggering of spreading depolarization (SD) events and ultimately, terminal (or anoxic) depolarization. Cerebral autoregulation and SD are therefore linked when considering the risk of ischemia. In this scoping review, we will discuss the range of methods to measure cerebral autoregulation, their theoretical strengths and weaknesses, and the available clinical evidence to support their utility. We will then discuss the emerging link between impaired cerebral autoregulation and the occurrence of SD events. Such an approach offers the opportunity to better understand an individual patient's physiology and provide targeted treatments.
Collapse
Affiliation(s)
- Andrew P. Carlson
- Department of Neurosurgery, University of New Mexico School of Medicine, MSC10 5615, 1 UNM, Albuquerque, NM, 87131, USA
- Department of Neurosciences, University of New Mexico School of Medicine, 915 Camino de Salud NE, Albuquerque, NM, 87106, USA
| | - Andrew R. Mayer
- Mind Research Network, 1101 Yale, Blvd, NE, Albuquerque, NM, 87106, USA
| | - Chad Cole
- Department of Neurosurgery, University of New Mexico School of Medicine, MSC10 5615, 1 UNM, Albuquerque, NM, 87131, USA
| | | | - Joshua Marquez
- University of New Mexico School of Medicine, 915 Camino de Salud NE, Albuquerque, NM, 87106, USA
| | - Taylor C. Stevenson
- Department of Neurosurgery, University of New Mexico School of Medicine, MSC10 5615, 1 UNM, Albuquerque, NM, 87131, USA
| | - C. William Shuttleworth
- Department of Neurosciences, University of New Mexico School of Medicine, 915 Camino de Salud NE, Albuquerque, NM, 87106, USA
| |
Collapse
|
2
|
Lahr BE, Brunsch CL, Dikkers R, Bos AF, Kooi EMW. Cerebrovascular Autoregulation in Preterm Infants Using Heart Rate or Blood Pressure: A Pilot Study. CHILDREN (BASEL, SWITZERLAND) 2024; 11:765. [PMID: 39062215 PMCID: PMC11276379 DOI: 10.3390/children11070765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 06/17/2024] [Accepted: 06/21/2024] [Indexed: 07/28/2024]
Abstract
BACKGROUND Cerebrovascular autoregulation (CAR) is often impaired in preterm infants but requires invasive mean arterial blood pressure (MABP) measurements for continuous assessment. We aimed to assess whether using heart rate (HR) results in different CAR assessment compared with using MABP. METHODS We compared CAR (moving window correlation-coefficient with cerebral oxygenation saturation (rcSO2)), and percentage of time with impaired CAR (%timeCARi) calculated by either HR (TOHRx, tissue oxygenation heart rate reactivity index) or MABP (COx, cerebral oximetry index) during the first 72 h after birth, and its association with short-term cerebral injury. RESULTS We included 32 infants, median gestational age of 25 + 5/7 weeks (interquartile range 24 + 6/7-27 + 5/7). COx and TOHRx correlation coefficients (cc) were significantly different in the first two days after birth (individual means ranging from 0.02 to 0.07 and -0.05 to 0.01). %TimeCARi using MABP (cc cut-off 0.3), was higher on day 1 (26.1% vs. 17.7%) and day 3 (23.4% vs. 16.9%) compared with HR (cc cutoff -0.3). During 65.7-69.6% of the time, both methods indicated impaired CAR simultaneously. The aforementioned calculations were not associated with early cerebral injury. CONCLUSIONS In conclusion, HR and MABP do not seem interchangeable when assessing CAR in preterm infants.
Collapse
Affiliation(s)
- Bineta E. Lahr
- Department of Neonatology, Beatrix Children’s Hospital, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands; (B.E.L.); (C.L.B.)
| | - Celina L. Brunsch
- Department of Neonatology, Beatrix Children’s Hospital, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands; (B.E.L.); (C.L.B.)
| | - Riksta Dikkers
- Department of Pediatric Radiology, Beatrix Children’s Hospital, University Medical Center of Groningen, 9713 GZ Groningen, The Netherlands
| | - Arend F. Bos
- Department of Neonatology, Beatrix Children’s Hospital, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands; (B.E.L.); (C.L.B.)
| | - Elisabeth M. W. Kooi
- Department of Neonatology, Beatrix Children’s Hospital, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands; (B.E.L.); (C.L.B.)
| |
Collapse
|
3
|
Fedriga M, Martini S, Iodice FG, Sortica da Costa C, Pezzato S, Moscatelli A, Beqiri E, Czosnyka M, Smielewski P, Agrawal S. Cerebral autoregulation in paediatric and neonatal intensive care: A scoping review. J Cereb Blood Flow Metab 2024:271678X241261944. [PMID: 38867574 DOI: 10.1177/0271678x241261944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/14/2024]
Abstract
Deranged cerebral autoregulation (CA) is associated with worse outcome in adult brain injury. Strategies for monitoring CA and maintaining the brain at its 'best CA status' have been implemented, however, this approach has not yet developed for the paediatric population. This scoping review aims to find up-to-date evidence on CA assessment in children and neonates with a view to identify patient categories in which CA has been measured so far, CA monitoring methods and its relationship with clinical outcome if any. A literature search was conducted for studies published within 31st December 2022 in 3 bibliographic databases. Out of 494 papers screened, this review includes 135 studies. Our literature search reveals evidence for CA measurement in the paediatric population across different diagnostic categories and age groups. The techniques adopted, indices and thresholds used to assess and define CA are heterogeneous. We discuss the relevance of available evidence for CA assessment in the paediatric population. However, due to small number of studies and heterogeneity of methods used, there is no conclusive evidence to support universal adoption of CA monitoring, technique, and methodology. This calls for further work to understand the clinical impact of CA monitoring in paediatric and neonatal intensive care.
Collapse
Affiliation(s)
- Marta Fedriga
- Neonatal and Paediatric Intensive Care Unit, IRCCS Giannina Gaslini Institute, Genoa, Italy
| | - Silvia Martini
- Neonatal Intensive Care Unit, IRCCS AOUBO, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Francesca G Iodice
- Paediatric Cardiac Anaesthesia and Intensive Care Unit, IRCCS, Bambino Gesu' Hospital, Rome, Italy
| | | | - Stefano Pezzato
- Neonatal and Paediatric Intensive Care Unit, IRCCS Giannina Gaslini Institute, Genoa, Italy
| | - Andrea Moscatelli
- Neonatal and Paediatric Intensive Care Unit, IRCCS Giannina Gaslini Institute, Genoa, Italy
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
| | - Shruti Agrawal
- Department of Paediatric Intensive Care, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| |
Collapse
|
4
|
Oyang M, Piscopo BR, Zahra V, Malhotra A, Sutherland AE, Sehgal A, Hooper SB, Miller SL, Polglase GR, Allison BJ. Cardiovascular responses to mild perinatal asphyxia in growth-restricted preterm lambs. Am J Physiol Heart Circ Physiol 2023; 325:H1081-H1087. [PMID: 37656131 PMCID: PMC10908401 DOI: 10.1152/ajpheart.00485.2023] [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: 08/07/2023] [Revised: 08/29/2023] [Accepted: 08/30/2023] [Indexed: 09/02/2023]
Abstract
Growth-restricted neonates have worse outcomes after perinatal asphyxia, with more severe metabolic acidosis than appropriately grown neonates. The cardiovascular physiology associated with fetal growth restriction (FGR) may alter their response to asphyxia. However, research on asphyxia in FGR is limited. Here we compared cardiovascular hemodynamics in preterm FGR and control lambs during mild perinatal asphyxia. We induced FGR in one twin at 89 days gestation (term 148 days), while the other served as a control. At 126 days gestation, lambs were instrumented to allow arterial blood pressure and regional blood flow recording, and then mild perinatal asphyxia was induced by umbilical cord clamping, and resuscitation followed neonatal guidelines. FGR lambs maintained carotid blood flow (CBF) for 7 min, while control lambs rapidly decreased CBF (P < 0.05). Fewer growth-restricted lambs needed chest compressions for return of spontaneous circulation (ROSC) (17 vs. 83%, P = 0.02). The extent of blood pressure overshoot after ROSC was similar, but it took longer for MAP to return to baseline in FGR lambs (18.83 ± 0.00 vs. 47.67 ± 0.00 min, P = 0.003). Growth-restricted lambs had higher CBF after ROSC (P < 0.05) and displayed CBF overshoot, unlike control lambs (P < 0.03). In conclusion, preterm growth-restricted lambs show resilience during perinatal asphyxia based on prolonged CBF maintenance and reduced need for chest compressions during resuscitation. However, CBF overshoot after ROSC may increase the risk of cerebrovascular injury in FGR.NEW & NOTEWORTHY Preterm growth-restricted lambs maintain carotid blood flow for longer than control lambs during asphyxia and have a lower requirement for chest compressions than control lambs during resuscitation. Preterm growth-restricted, but not control, lambs displayed an overshoot in carotid blood flow following return of spontaneous circulation.
Collapse
Affiliation(s)
- Matthew Oyang
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Beth R Piscopo
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Valerie Zahra
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Atul Malhotra
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Monash Newborn, Monash Children's Hospital, Clayton, Victoria, Australia
- Department of Paediatrics, Monash University, Clayton, Victoria, Australia
| | - Amy E Sutherland
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Arvind Sehgal
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Monash Newborn, Monash Children's Hospital, Clayton, Victoria, Australia
- Department of Paediatrics, Monash University, Clayton, Victoria, Australia
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Suzanne L Miller
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Graeme R Polglase
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Beth J Allison
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| |
Collapse
|
5
|
Bo Q, Xie Y, Lin Q, Fu L, Hu C, Zhang Z, Meng Q, Xu F, Wang G, Miao Z, Wang H, Xu D. Docosahexaenoic acid protects against lipopolysaccharide-induced fetal growth restriction via inducing the ubiquitination and degradation of NF-κB p65 in placental trophoblasts. J Nutr Biochem 2023; 118:109359. [PMID: 37085060 DOI: 10.1016/j.jnutbio.2023.109359] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 02/17/2023] [Accepted: 04/14/2023] [Indexed: 04/23/2023]
Abstract
Lipopolysaccharide (LPS) could induce adverse birth outcomes by evoking inflammation. We investigated the effect and mechanism of docosahexaenoic acid (DHA) on LPS-induced placental inflammation and fetal growth restriction (FGR). In vivo, pregnant CD-1 mice were divided into four groups: Ctrl, DHA, LPS and DHA+LPS group. We found that DHA pretreatment reduced the incidence of FGR induced by LPS and activated the expression of peroxisome proliferators-activated receptor gamma (PPARγ) in placental tissue. Moreover, the LPS-induced increase of mRNA levels of Tnf-α, Il-6, Il-1β, Mip-2 and Kc in placental tissue was significantly attenuated by DHA pretreatment. A similar effect of DHA was observed in serum of pregnant mice and amniotic fluid. In contrast, the levels of the IL-10 were significantly increased after DHA pretreatment. In vitro, we clarified that DHA antagonized the activation of the NF-κB signaling pathway induced by LPS, which was dependent on PPARγ. Subsequently, CHX (translation inhibitor) was used to indicated that PPARγ significantly increased the degradation rate of p65, an effect that was inhibited by MG132 (proteasome inhibitor) treatment. Finally, it was confirmed that the activation of PPARγ could significantly promote the ubiquitination and degradation of p65. Our results suggested that DHA alleviated LPS-induced inflammatory responses and FGR by activating PPARγ expression, leading to p65 ubiquitination and degradation.
Collapse
Affiliation(s)
- Qingli Bo
- Department of Nutrition and Food Hygiene, School of Public Health, Anhui Medical University, Hefei 230032, China; Key Laboratory of Environmental Toxicology of Anhui Higher Education Institutes, Hefei 230032, China
| | - Yali Xie
- Department of Nutrition and Food Hygiene, School of Public Health, Anhui Medical University, Hefei 230032, China
| | - Qiulin Lin
- Department of Nutrition and Food Hygiene, School of Public Health, Anhui Medical University, Hefei 230032, China
| | - Lin Fu
- Key Laboratory of Environmental Toxicology of Anhui Higher Education Institutes, Hefei 230032, China
| | - Chunqiu Hu
- Department of Nutrition and Food Hygiene, School of Public Health, Anhui Medical University, Hefei 230032, China
| | - Zhiqiang Zhang
- Department of Nutrition and Food Hygiene, School of Public Health, Anhui Medical University, Hefei 230032, China
| | - Qingchong Meng
- Department of Nutrition and Food Hygiene, School of Public Health, Anhui Medical University, Hefei 230032, China
| | - Feixiang Xu
- Department of Toxicology, School of Public Health, Anhui Medical University, Hefei 230032, China;; Key Laboratory of Environmental Toxicology of Anhui Higher Education Institutes, Hefei 230032, China
| | - Guoxiu Wang
- Department of Nutrition and Food Hygiene, School of Public Health, Anhui Medical University, Hefei 230032, China
| | - Ziyang Miao
- Department of Nutrition and Food Hygiene, School of Public Health, Anhui Medical University, Hefei 230032, China
| | - Hua Wang
- Department of Toxicology, School of Public Health, Anhui Medical University, Hefei 230032, China;; Key Laboratory of Environmental Toxicology of Anhui Higher Education Institutes, Hefei 230032, China
| | - Dexiang Xu
- Department of Toxicology, School of Public Health, Anhui Medical University, Hefei 230032, China;; Key Laboratory of Environmental Toxicology of Anhui Higher Education Institutes, Hefei 230032, China.
| |
Collapse
|
6
|
Martini S, Thewissen L, Austin T, da Costa CS, de Boode WP, Dempsey E, Kooi E, Pellicer A, Rhee CJ, Riera J, Wolf M, Wong F. Near-infrared spectroscopy monitoring of neonatal cerebrovascular reactivity: where are we now? Pediatr Res 2023:10.1038/s41390-023-02574-6. [PMID: 36997690 DOI: 10.1038/s41390-023-02574-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 02/09/2023] [Accepted: 02/17/2023] [Indexed: 06/19/2023]
Abstract
Cerebrovascular reactivity defines the ability of the cerebral vasculature to regulate its resistance in response to both local and systemic factors to ensure an adequate cerebral blood flow to meet the metabolic demands of the brain. The increasing adoption of near-infrared spectroscopy (NIRS) for non-invasive monitoring of cerebral oxygenation and perfusion allowed investigation of the mechanisms underlying cerebrovascular reactivity in the neonatal population, confirming important associations with pathological conditions including the development of brain injury and adverse neurodevelopmental outcomes. However, the current literature on neonatal cerebrovascular reactivity is mainly still based on small, observational studies and is characterised by methodological heterogeneity; this has hindered the routine application of NIRS-based monitoring of cerebrovascular reactivity to identify infants most at risk of brain injury. This review aims (1) to provide an updated review on neonatal cerebrovascular reactivity, assessed using NIRS; (2) to identify critical points that need to be addressed with targeted research; and (3) to propose feasibility trials in order to fill the current knowledge gaps and to possibly develop a preventive or curative approach for preterm brain injury. IMPACT: NIRS monitoring has been largely applied in neonatal research to assess cerebrovascular reactivity in response to blood pressure, PaCO2 and other biochemical or metabolic factors, providing novel insights into the pathophysiological mechanisms underlying cerebral blood flow regulation. Despite these insights, the current literature shows important pitfalls that would benefit to be addressed in a series of targeted trials, proposed in the present review, in order to translate the assessment of cerebrovascular reactivity into routine monitoring in neonatal clinical practice.
Collapse
Affiliation(s)
- Silvia Martini
- Neonatal Intensive Care Unit, IRCCS AOU S. Orsola, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
| | | | - Topun Austin
- Neonatal Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Willem P de Boode
- Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Eugene Dempsey
- Department of Paediatrics and Child Health, INFANT Centre, University College Cork, Cork, Ireland
| | - Elisabeth Kooi
- Division of Neonatology, Beatrix Children's Hospital, University Medical Center, University of Groningen, Groningen, The Netherlands
| | - Adelina Pellicer
- Department of Neonatology, La Paz University Hospital, Madrid, Spain
| | - Christopher J Rhee
- Section of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Joan Riera
- Department of Neonatology, La Paz University Hospital, Madrid, Spain
- Center for Biomedical Technology, Technical University, Madrid, Spain
| | - Martin Wolf
- Biomedical Optics Research Laboratory, Department of Neonatology, University Hospital Zurich, Zurich, Switzerland
| | - Flora Wong
- Monash Newborn, Monash Children's Hospital, Hudson Institute of Medical Research, Department of Paediatrics, Monash University, Melbourne, VIC, Australia
| |
Collapse
|
7
|
Kim F, Bateman DA, Goldshtrom N, Sheen JJ, Garey D. Intracranial ultrasound abnormalities and mortality in preterm infants with and without fetal growth restriction stratified by fetal Doppler study results. J Perinatol 2023; 43:560-567. [PMID: 36717608 DOI: 10.1038/s41372-023-01621-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 01/12/2023] [Accepted: 01/20/2023] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To evaluate whether fetal growth restriction (FGR) with or without abnormal Dopplers is associated with intracranial abnormalities and death in premature infants. STUDY DESIGN Premature infants with and without FGR born between 2016 and 2019 were included. Primary outcome was death, severe intraventricular hemorrhage (IVH) or periventricular leukomalacia (PVL). Groups were compared using standard bivariate testing and multivariable regression. RESULTS Among 168 FGR and 560 non-FGR infants, FGR infants with abnormal Dopplers had an increased incidence of death, severe IVH or PVL compared to non-FGR infants (13% (16/123) vs. 7% (41/560); p = 0.03) while FGR infants with normal Dopplers had a nonsignificant decrease. In a logistic regression model, FGR with abnormal Dopplers was associated with more than three times higher odds of death, severe IVH or PVL (OR 3.2, 95% CI 1.54,6.49; p < 0.001). CONCLUSIONS Growth-restricted infants with abnormal Dopplers had an increased risk of death, intracranial abnormalities, and prematurity-related morbidities.
Collapse
Affiliation(s)
- Faith Kim
- Division of Neonatology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons and NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY, USA.
| | - David A Bateman
- Division of Neonatology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons and NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY, USA
| | - Nimrod Goldshtrom
- Division of Neonatology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons and NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY, USA
| | - Jean-Ju Sheen
- Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons and NewYork-Presbyterian, New York, NY, USA
| | - Donna Garey
- Division of Neonatology, Department of Pediatrics, Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, AZ, USA
| |
Collapse
|
8
|
Lu Y, Zhang ZQ. Neonatal hemorrhage stroke and severe coagulopathy in a late preterm infant after receiving umbilical cord milking: A case report. World J Clin Cases 2022; 10:5365-5372. [PMID: 35812658 PMCID: PMC9210894 DOI: 10.12998/wjcc.v10.i16.5365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 12/23/2021] [Accepted: 04/04/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Umbilical cord milking (UCM) is an alternative placental transfusion method for delayed umbilical cord clamping in routine obstetric practice, allowing prompt resuscitation of an infant. Thus, UCM has been adopted at some tertiary neonatal centers for preterm infants to enhance placental-to-fetal transfusion. It is not suggested for babies less than 28 wk of gestational age because it is associated with severe brain hemorrhage. For late preterm or term infants who do not require resuscitation, cord management is recommended to increase iron levels and prevent the development of iron deficiency anemia, which is associated with impaired motor development, behavioral problems, and cognitive delays. Concerns remain about whether UCM increases the incidence of intraventricular hemorrhage. However, there are very few reports of late preterm infants presenting with neonatal hemorrhage stroke (NHS) and severe coagulopathy after receiving UCM. Here, we report a case of a late preterm infant born at 34 wk of gestation. She abruptly deteriorated, exhibiting signs and symptoms of NHS and severe coagulopathy after receiving UCM on the first day of life.
CASE SUMMARY A female preterm infant born at 34 wk of gestation received UCM after birth. She was small for her gestational age and described as vigorous with Apgar scores of 9 and 10 at one minute and five minutes of life, respectively. After hospitalization in the neonatal intensive care unit, she showed hypoglycemia and metabolic acidosis. The baby was administered glucose and sodium bicarbonate infusions. Intramuscular vitamin K1 was also used to prevent vitamin K deficiency. The baby developed umbilical cord bleeding and gastric bleeding on day 1 of life; a physical examination showed bilateral conjunctival hemorrhage, and a blood test showed thrombocytopenia, prolonged prothrombin time, prolonged activated partial thromboplastin time, low fibrinogen, raised D-dimer levels and anemia. A subsequent cranial ultrasound and computed tomography scan showed a left parenchymal brain hemorrhage with extension into the ventricular and subarachnoid spaces. The patient was diagnosed with NHS in addition to disseminated intravascular coagulation (DIC). Fresh frozen plasma (FFP) and prothrombin complex concentrate were given for coagulopathy. Red blood cell and platelet transfusions were provided for thrombocytopenia and anemia. A bolus of midazolam, intravenous calcium and phenobarbital sodium were administered to control seizures. The baby’s clinical condition improved on day 5 of life, and the baby was hospitalized for 46 d and recovered well without seizure recurrence. Our case report suggests that preterm infants who receive UCM should undergo careful clinical assessment for intracranial hemorrhage, NHS and severe coagulopathy that may develop under certain circumstances. Supportive management, such as intensive care, FFP and blood transfusion, is recommended when the development of massive NHS and associated DIC is suspected.
CONCLUSION Our case report suggests that for late preterm infants who are small for gestational age and who receive UCM for alternative placental transfusion, neonatal health care professionals should be cautious in assessing the development of NHS and severe coagulopathy. Neonatal health care professionals should also be more cautious in assessing the complications of late preterm infants after they receive UCM.
Collapse
Affiliation(s)
- Yan Lu
- Department of Neonatology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
| | - Zhi-Qun Zhang
- Department of Neonatology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
| |
Collapse
|
9
|
Dudink I, Hüppi PS, Sizonenko SV, Castillo-Melendez M, Sutherland AE, Allison BJ, Miller SL. Altered trajectory of neurodevelopment associated with fetal growth restriction. Exp Neurol 2021; 347:113885. [PMID: 34627856 DOI: 10.1016/j.expneurol.2021.113885] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 09/23/2021] [Accepted: 10/02/2021] [Indexed: 12/17/2022]
Abstract
Fetal growth restriction (FGR) is principally caused by suboptimal placental function. Poor placental function causes an under supply of nutrients and oxygen to the developing fetus, restricting development of individual organs and overall growth. Estimated fetal weight below the 10th or 3rd percentile with uteroplacental dysfunction, and knowledge regarding the onset of growth restriction (early or late), provide diagnostic criteria for fetuses at greatest risk for adverse outcome. Brain development and function is altered with FGR, with ongoing clinical and preclinical studies elucidating neuropathological etiology. During the third trimester of pregnancy, from ~28 weeks gestation, neurogenesis is complete and neuronal complexity is expanding, through axonal and dendritic outgrowth, dendritic branching and synaptogenesis, accompanied by myelin production. Fetal compromise over this period, as occurs in FGR, has detrimental effects on these processes. Total brain volume and grey matter volume is reduced in infants with FGR, first evident in utero, with cortical volume particularly vulnerable. Imaging studies show that cerebral morphology is disturbed in FGR, with altered cerebral cortex, volume and organization of brain networks, and reduced connectivity of long- and short-range circuits. Thus, FGR induces a deviation in brain development trajectory affecting both grey and white matter, however grey matter volume is preferentially reduced, contributed by cell loss, and reduced neurite outgrowth of surviving neurons. In turn, cell-to-cell local networks are adversely affected in FGR, and whole brain left and right intrahemispheric connections and interhemispheric connections are altered. Importantly, disruptions to region-specific brain networks are linked to cognitive and behavioral impairments.
Collapse
Affiliation(s)
- Ingrid Dudink
- The Ritchie Centre, Hudson Institute of Medical Research, Translational Research Facility, Clayton, Victoria, Australia; Department of Obstetrics and Gynecology, Monash University, Clayton, Victoria, Australia
| | - Petra S Hüppi
- Department of Pediatrics, Obstetrics and Gynecology, University of Geneva, Switzerland
| | - Stéphane V Sizonenko
- Department of Pediatrics, Obstetrics and Gynecology, University of Geneva, Switzerland
| | - Margie Castillo-Melendez
- The Ritchie Centre, Hudson Institute of Medical Research, Translational Research Facility, Clayton, Victoria, Australia
| | - Amy E Sutherland
- The Ritchie Centre, Hudson Institute of Medical Research, Translational Research Facility, Clayton, Victoria, Australia; Department of Obstetrics and Gynecology, Monash University, Clayton, Victoria, Australia
| | - Beth J Allison
- The Ritchie Centre, Hudson Institute of Medical Research, Translational Research Facility, Clayton, Victoria, Australia; Department of Obstetrics and Gynecology, Monash University, Clayton, Victoria, Australia
| | - Suzanne L Miller
- The Ritchie Centre, Hudson Institute of Medical Research, Translational Research Facility, Clayton, Victoria, Australia; Department of Obstetrics and Gynecology, Monash University, Clayton, Victoria, Australia.
| |
Collapse
|
10
|
Cerebral oxygen saturation and autoregulation during hypotension in extremely preterm infants. Pediatr Res 2021; 90:373-380. [PMID: 33879849 DOI: 10.1038/s41390-021-01483-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 02/23/2021] [Accepted: 03/04/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND The impact of the permissive hypotension approach in clinically well infants on regional cerebral oxygen saturation (rScO2) and autoregulatory capacity (CAR) remains unknown. METHODS Prospective cohort study of blinded rScO2 measurements within a randomized controlled trial of management of hypotension (HIP trial) in extremely preterm infants. rScO2, mean arterial blood pressure, duration of cerebral hypoxia, and transfer function (TF) gain inversely proportional to CAR, were compared between hypotensive infants randomized to receive dopamine or placebo and between hypotensive and non-hypotensive infants, and related to early intraventricular hemorrhage or death. RESULTS In 89 potentially eligible HIP trial patients with rScO2 measurements, the duration of cerebral hypoxia was significantly higher in 36 hypotensive compared to 53 non-hypotensive infants. In 29/36 hypotensive infants (mean GA 25 weeks, 69% males) receiving the study drug, no significant difference in rScO2 was observed after dopamine (n = 13) compared to placebo (n = 16). Duration of cerebral hypoxia was associated with early intraventricular hemorrhage or death. Calculated TF gain (n = 49/89) was significantly higher reflecting decreased CAR in 16 hypotensive compared to 33 non-hypotensive infants. CONCLUSIONS Dopamine had no effect on rScO2 compared to placebo in hypotensive infants. Hypotension and cerebral hypoxia are associated with early intraventricular hemorrhage or death. IMPACT Treatment of hypotension with dopamine in extremely preterm infants increases mean arterial blood pressure, but does not improve cerebral oxygenation. Hypotensive extremely preterm infants have increased duration of cerebral hypoxia and reduced cerebral autoregulatory capacity compared to non-hypotensive infants. Duration of cerebral hypoxia and hypotension are associated with early intraventricular hemorrhage or death in extremely preterm infants. Since systematic treatment of hypotension may not be associated with better outcomes, the diagnosis of cerebral hypoxia in hypotensive extremely preterm infants might guide treatment.
Collapse
|
11
|
Inocencio IM, Tran NT, Khor SJ, Wiersma M, Nakamura S, Walker DW, Wong FY. The cerebral haemodynamic response to somatosensory stimulation in preterm newborn lambs is reduced with dopamine or dobutamine infusion. Exp Neurol 2021; 341:113687. [PMID: 33713656 DOI: 10.1016/j.expneurol.2021.113687] [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: 11/19/2020] [Revised: 03/03/2021] [Accepted: 03/07/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND In the adult brain, increases in neural activity lead to increases in local blood flow. However, in the preterm neonate, studies of cerebral functional haemodynamics have yielded inconsistent results, including negative responses suggesting decreased perfusion and localised tissue hypoxia, probably due to immature neurovascular coupling. Furthermore, the impact of vasoactive medications, such as dopamine and dobutamine used as inotropic therapies in preterm neonates, on cerebrovascular responses to somatosensory input is unknown. We aimed to characterise the cerebral haemodynamic functional response after somatosensory stimulation in the preterm newborn brain, with and without dopamine or dobutamine treatment. METHODS We studied the cerebral haemodynamic functional response in 13 anaesthetised preterm lambs, using near infrared spectroscopy to measure changes in cerebral oxy- and deoxyhaemoglobin (ΔoxyHb, ΔdeoxyHb) following left median nerve stimulation using stimulus trains of 1.8, 4.8 and 7.8 s. The 4.8 and 7.8 s stimulations were repeated during dopamine or dobutamine infusion. RESULTS Stimulation always produced a somatosensory evoked response. Majority of preterm lambs demonstrated positive functional responses (i.e. increased ΔoxyHb) in the contralateral cortex following stimulus trains of all durations. Dopamine increased baseline oxyHb and total Hb, whereas dobutamine increased baseline deoxyHb. Both dopamine and dobutamine reduced the evoked ΔoxyHb responses to 4.8 and 7.8 s stimulations. CONCLUSIONS Somatosensory stimulation increases cerebral oxygenation in the preterm brain, consistent with increased cerebral blood flow due to neurovascular coupling. Notably, our results show that dopamine/dobutamine reduces oxygen delivery relative to consumption in the preterm brain during somatosensory stimulations, suggesting there may be a risk of intermittent localised tissue hypoxia which has clear implications for clinical practice and warrants further investigation.
Collapse
Affiliation(s)
- Ishmael M Inocencio
- The Ritchie Centre, The Hudson Institute of Medical Research, Melbourne, Australia; Department of Paediatrics, Monash University, Melbourne, Australia
| | - Nhi T Tran
- The Ritchie Centre, The Hudson Institute of Medical Research, Melbourne, Australia; School of Health & Biomedical Sciences, RMIT University, Melbourne, Australia
| | - Song J Khor
- The Ritchie Centre, The Hudson Institute of Medical Research, Melbourne, Australia; Department of Paediatrics, Monash University, Melbourne, Australia
| | - Manon Wiersma
- The Ritchie Centre, The Hudson Institute of Medical Research, Melbourne, Australia; Department of Paediatrics, Monash University, Melbourne, Australia
| | - Shinji Nakamura
- The Ritchie Centre, The Hudson Institute of Medical Research, Melbourne, Australia; Department of Pediatrics, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - David W Walker
- The Ritchie Centre, The Hudson Institute of Medical Research, Melbourne, Australia; School of Health & Biomedical Sciences, RMIT University, Melbourne, Australia
| | - Flora Y Wong
- The Ritchie Centre, The Hudson Institute of Medical Research, Melbourne, Australia; Department of Paediatrics, Monash University, Melbourne, Australia; Monash Newborn, Monash Medical Centre, Melbourne, Australia.
| |
Collapse
|
12
|
Chock VY, Kwon SH, Ambalavanan N, Batton B, Nelin LD, Chalak LF, Tian L, Van Meurs KP. Cerebral Oxygenation and Autoregulation in Preterm Infants (Early NIRS Study). J Pediatr 2020; 227:94-100.e1. [PMID: 32818482 DOI: 10.1016/j.jpeds.2020.08.036] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Revised: 08/06/2020] [Accepted: 08/13/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine if decreased cerebral oxygenation or altered cerebral autoregulation as measured by near-infrared spectroscopy (NIRS) in the first 96 postnatal hours is associated with an increased risk of death or severe neuroradiographic abnormalities in very preterm infants. STUDY DESIGN The Early NIRS prospective, multicenter study enrolled very preterm infants with a birth weight of <1250 g from 6 tertiary neonatal intensive care units. Mean arterial blood pressure and cerebral oxygen saturation (Csat) were continuously monitored using a neonatal sensor until 96 hours of age. Moving window correlations between Csat and mean arterial blood pressure determined time periods with altered cerebral autoregulation, and percentiles of correlation were compared between infants with and without the adverse outcome of mortality or severe neuroradiographic abnormalities by early cranial ultrasound. RESULTS Of 103 subjects with mean gestational age of 26 weeks, 21 (20%) died or had severe neuroradiographic abnormalities. Infants with adverse outcomes had a lower mean Csat (67 ± 9%) compared with those without adverse outcomes (72 ± 7%; P = .02). A Csat of <50% was identified as a cut-point for identifying infants with adverse outcome (area under the curve, 0.76). Infants with adverse outcomes were more likely to have significant positive or negative correlations between Csat and mean arterial blood pressure, indicating impaired cerebral autoregulation (P = .006). CONCLUSIONS Early NIRS monitoring may detect periods of lower cerebral oxygenation and altered cerebral autoregulation, identifying preterm infants at risk for mortality or neuroradiographic injury. An improved understanding of the relationship between altered hemodynamics and cerebral oxygenation may inform future strategies to prevent brain injury.
Collapse
Affiliation(s)
- Valerie Y Chock
- Division of Neonatology, Stanford University School of Medicine, Stanford, CA
| | - Soo Hyun Kwon
- Division of Neonatology, Yale School of Medicine, New Haven, CT
| | | | - Beau Batton
- Division of Neonatology, Southern Illinois University School of Medicine, Springfield, IL
| | - Leif D Nelin
- Division of Neonatology, Nationwide Children's Hospital, Ohio State University, Columbus, OH
| | - Lina F Chalak
- Division of Neonatology, University of Texas Southwestern, Dallas, TX
| | - Lu Tian
- Division of Neonatology, Stanford University School of Medicine, Stanford, CA
| | - Krisa P Van Meurs
- Division of Neonatology, Stanford University School of Medicine, Stanford, CA
| |
Collapse
|
13
|
Abstract
Cerebrovascular autoregulation is the ability to maintain stable cerebral blood flow within a range of cerebral perfusion pressures. When cerebral perfusion pressure is outside the limits of effective autoregulation, the brain is subjected to hypoperfusion or hyperperfusion, which may cause vascular injury, hemorrhage, and/or hypoxic white matter injury. Infants born preterm, after fetal growth restriction, with congenital heart disease, or with hypoxic-ischemic encephalopathy are susceptible to a failure of cerebral autoregulation. Bedside assessment of cerebrovascular autoregulation would offer the opportunity to prevent brain injury. Clinicians need to know which patient populations and circumstances are associated with impaired/absent cerebral autoregulation.
Collapse
Affiliation(s)
- Elisabeth M W Kooi
- Division of Neonatology, University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Hanzeplein 1, PO Box 30001, Groningen 9700 RB, The Netherlands.
| | - Anne E Richter
- Division of Neonatology, University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Hanzeplein 1, PO Box 30001, Groningen 9700 RB, The Netherlands
| |
Collapse
|
14
|
Gilard V, Tebani A, Bekri S, Marret S. Intraventricular Hemorrhage in Very Preterm Infants: A Comprehensive Review. J Clin Med 2020; 9:E2447. [PMID: 32751801 PMCID: PMC7465819 DOI: 10.3390/jcm9082447] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 07/20/2020] [Accepted: 07/25/2020] [Indexed: 11/30/2022] Open
Abstract
Germinal matrix-intraventricular-intraparenchymal hemorrhage (GMH-IVH-IPH) is a major complication of very preterm births before 32 weeks of gestation (WG). Despite progress in clinical management, its incidence remains high before 27 WG. In addition, severe complications may occur such as post-hemorrhagic hydrocephalus and/or periventricular intraparenchymal hemorrhage. IVH is strongly associated with subsequent neurodevelopmental disabilities. For this review, an automated literature search and a clustering approach were applied to allow efficient filtering as well as topic clusters identification. We used a programmatic literature search for research articles related to intraventricular hemorrhage in preterms that were published between January 1990 and February 2020. Two queries ((Intraventricular hemorrhage) AND (preterm)) were used in PubMed. This search resulted in 1093 articles. The data manual curation left 368 documents that formed 12 clusters. The presentation and discussion of the clusters provide a comprehensive overview of existing data on the pathogenesis, complications, neuroprotection and biomarkers of GMH-IVH-IPH in very preterm infants. Clinicians should consider that the GMH-IVH-IPH pathogenesis is mainly due to developmental immaturity of the germinal matrix and cerebral autoregulation impairment. New multiomics investigations of intraventricular hemorrhage could foster the development of predictive biomarkers for the benefit of very preterm newborns.
Collapse
Affiliation(s)
- Vianney Gilard
- Department of Pediatric Neurosurgery, Rouen University Hospital, 76000 Rouen, France;
- Department of Metabolic Biochemistry, Rouen University Hospital, 76000 Rouen, France;
| | - Abdellah Tebani
- Department of Metabolic Biochemistry, Rouen University Hospital, 76000 Rouen, France;
| | - Soumeya Bekri
- Department of Metabolic Biochemistry, Rouen University Hospital, 76000 Rouen, France;
- Normandie University, UNIROUEN, CHU Rouen, INSERM U1245, 76000 Rouen, France;
| | - Stéphane Marret
- Normandie University, UNIROUEN, CHU Rouen, INSERM U1245, 76000 Rouen, France;
- Department of Neonatal Pediatrics, Intensive Care and Neuropediatrics, Rouen University Hospital, 76000 Rouen, France
| |
Collapse
|
15
|
Richter AE, Salavati S, Kooi EMW, den Heijer AE, Foreman AB, Schoots MH, Bilardo CM, Scherjon SA, Tanis JC, Bos AF. Fetal Brain-Sparing, Postnatal Cerebral Oxygenation, and Neurodevelopment at 4 Years of Age Following Fetal Growth Restriction. Front Pediatr 2020; 8:225. [PMID: 32435629 PMCID: PMC7218090 DOI: 10.3389/fped.2020.00225] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 04/15/2020] [Indexed: 01/06/2023] Open
Abstract
Objectives: To assess the role of fetal brain-sparing and postnatal cerebral oxygen saturation (rcSO2) as determinants of long-term neurodevelopmental outcome following fetal growth restriction (FGR). Methods: This was a prospective follow-up study of an FGR cohort of 41 children. Prenatally, the presence of fetal brain-sparing (cerebroplacental ratio < 1) was assessed by Doppler ultrasound. During the first two days after birth, rcSO2 was measured with near-infrared spectroscopy. At 4 years of age, intelligence (IQ points), behavior (T-scores), and executive function (T-scores) were assessed using the Wechsler Preschool and Primary Scale of Intelligence, Child Behavior Checklist, and Behavior Rating Inventory of Executive Function-Preschool Version, respectively. Using linear regression analyses, we tested the association (p < 0.05) between brain-sparing/rcSO2 and normed neurodevelopmental scores. Results: Twenty-six children (gestational age ranging from 28.0 to 39.9 weeks) participated in the follow-up at a median age of 4.3 (range: 3.6 to 4.4) years. Autism spectrum disorder was reported in three children (11.5%). Fetal brain-sparing was associated with better total and externalizing behavior (betas: -0.519 and -0.494, respectively). RcSO2 levels above the lowest quartile, particularly on postnatal day 2 (≥ 77%), were associated with better total and internalizing behavior and executive functioning (betas: -0.582, -0.489, and -0.467, respectively), but also lower performance IQ (beta: -0.530). Brain-sparing mediated some but not all of these associations. Conclusions: In this FGR cohort, fetal brain-sparing and high postnatal rcSO2 were-independently, but also as a reflection of the same mechanism-associated with better behavior and executive function. Postnatal cerebral hyperoxia, however, was negatively associated with brain functions responsible for performance IQ.
Collapse
Affiliation(s)
- Anne E Richter
- University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Division of Neonatology, Groningen, Netherlands
| | - Sahar Salavati
- University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Division of Neonatology, Groningen, Netherlands
| | - Elisabeth M W Kooi
- University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Division of Neonatology, Groningen, Netherlands
| | - Anne E den Heijer
- University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Division of Neonatology, Groningen, Netherlands
| | - Anne B Foreman
- University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Division of Neonatology, Groningen, Netherlands
| | - Mirthe H Schoots
- University of Groningen, University Medical Center Groningen, Department of Obstetrics and Gynecology, Groningen, Netherlands
| | - Caterina M Bilardo
- University of Groningen, University Medical Center Groningen, Department of Pathology and Medical Biology, Groningen, Netherlands.,Department of Obstetrics and Gynecology, Amsterdam University Medical Center, VU University Medical Center, Amsterdam, Netherlands
| | - Sicco A Scherjon
- University of Groningen, University Medical Center Groningen, Department of Pathology and Medical Biology, Groningen, Netherlands
| | - Jozien C Tanis
- University of Groningen, University Medical Center Groningen, Department of Pathology and Medical Biology, Groningen, Netherlands
| | - Arend F Bos
- University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Division of Neonatology, Groningen, Netherlands
| |
Collapse
|
16
|
Terstappen F, Richter AE, Lely AT, Hoebeek FE, Elvan-Taspinar A, Bos AF, Ganzevoort W, Pels A, Lemmers PM, Kooi EMW. Prenatal Use of Sildenafil in Fetal Growth Restriction and Its Effect on Neonatal Tissue Oxygenation-A Retrospective Analysis of Hemodynamic Data From Participants of the Dutch STRIDER Trial. Front Pediatr 2020; 8:595693. [PMID: 33344386 PMCID: PMC7744464 DOI: 10.3389/fped.2020.595693] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 11/16/2020] [Indexed: 11/13/2022] Open
Abstract
Objective: Sildenafil is under investigation as a potential agent to improve uteroplacental perfusion in fetal growth restriction (FGR). However, the STRIDER RCT was halted after interim analysis due to futility and higher rates of persistent pulmonary hypertension and mortality in sildenafil-exposed neonates. This hypothesis-generating study within the Dutch STRIDER trial sought to understand what happened to these neonates by studying their regional tissue oxygen saturation (rSO2) within the first 72 h after birth. Methods: Pregnant women with FGR received 25 mg placebo or sildenafil thrice daily within the Dutch STRIDER trial. We retrospectively analyzed the cerebral and renal rSO2 monitored with near-infrared spectroscopy (NIRS) in a subset of neonates admitted to two participating neonatal intensive care units, in which NIRS is part of standard care. Secondarily, blood pressure and heart rate were analyzed to aid interpretation. Differences in oxygenation levels and interaction with time (slope) between placebo- and sildenafil-exposed groups were tested using mixed effects analyses with multiple comparisons tests. Results: Cerebral rSO2 levels were not different between treatment groups (79 vs. 77%; both n = 14) with comparable slopes. Sildenafil-exposed infants (n = 5) showed lower renal rSO2 than placebo-exposed infants (n = 6) during several time intervals on day one and two. At 69-72 h, however, the sildenafil group showed higher renal rSO2 than the placebo group. Initially, diastolic blood pressure was higher and heart rate lower in the sildenafil than the placebo group, which changed during day two. Conclusions: Although limited by sample size, our data suggest that prenatal sildenafil alters renal but not cerebral oxygenation in FGR neonates during the first 72 post-natal hours. The observed changes in renal oxygenation could reflect a vasoconstrictive rebound from sildenafil. Similar changes observed in accompanying vital parameters support this hypothesis.
Collapse
Affiliation(s)
- Fieke Terstappen
- University Medical Center Utrecht, Wilhelmina Children's Hospital, Department of Obstetrics, Utrecht University, Utrecht, Netherlands.,University Medical Center Utrecht, Wilhelmina Children's Hospital and Brain Center, Department for Developmental Origins of Disease, Utrecht University, Utrecht, Netherlands
| | - Anne E Richter
- University Medical Center Groningen, Beatrix Children's Hospital, Division of Neonatology, University of Groningen, Groningen, Netherlands
| | - A Titia Lely
- University Medical Center Utrecht, Wilhelmina Children's Hospital, Department of Obstetrics, Utrecht University, Utrecht, Netherlands
| | - Freek E Hoebeek
- University Medical Center Utrecht, Wilhelmina Children's Hospital and Brain Center, Department for Developmental Origins of Disease, Utrecht University, Utrecht, Netherlands
| | - Ayten Elvan-Taspinar
- University Medical Center Groningen, Department of Obstetrics, University of Groningen, Groningen, Netherlands
| | - Arend F Bos
- University Medical Center Groningen, Beatrix Children's Hospital, Division of Neonatology, University of Groningen, Groningen, Netherlands
| | - Wessel Ganzevoort
- Amsterdam University Medical Centers, Department of Obstetrics, University of Amsterdam, Amsterdam, Netherlands
| | - Anouk Pels
- Amsterdam University Medical Centers, Department of Obstetrics, University of Amsterdam, Amsterdam, Netherlands
| | - Petra M Lemmers
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Elisabeth M W Kooi
- University Medical Center Groningen, Beatrix Children's Hospital, Division of Neonatology, University of Groningen, Groningen, Netherlands
| |
Collapse
|
17
|
Dix LML, Shepherd K, Polglase GR, Miller SL, Sehgal A, Wong FY. The Cerebral Hemodynamic Response to Pain in Preterm Infants With Fetal Growth Restriction. Front Pediatr 2020; 8:268. [PMID: 32537447 PMCID: PMC7267032 DOI: 10.3389/fped.2020.00268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 04/28/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Preterm infants undergoing intensive care often experience painful procedures such as heel lance for blood sampling. Knowledge of the cerebral hemodynamic response to painful stimuli contributes to understanding of cortical pain processing and the neurovascular network in the preterm brain. Previous research has demonstrated cerebral hemodynamic responses using near-infrared spectroscopy (NIRS) after noxious stimuli in infants appropriately grown for age (AGA). But this has not been studied in infants born small for gestational age after fetal growth restriction (FGR). FGR infants differ in brain development due to utero-placental insufficiency leading to the intrauterine growth restriction, and cerebral response to pain may be altered. Objectives: We aimed to compare the cerebral hemodynamic response to painful stimuli (heel lance) in FGR and AGA infants. Methods: Preterm FGR infants (n = 20) and AGA infants (n = 15) born at 28-32 weeks' gestation were studied at mean ± SD postnatal age of 11.5 ± 2.4 and 10.5 ± 2.4 days, respectively. Infants had baseline echocardiographic assessment of ductus arteriosus and stroke volume. They were monitored with NIRS for changes in tissue oxygenation index (TOI, %), and oxygenated, deoxygenated, and total hemoglobin (ΔO2Hb, ΔHHb, and ΔTHb) in contralateral and ipsilateral cerebral hemispheres, during a heel lance. Results: At baseline, FGR infants had significantly lower TOI, higher heart rate, and lower stroke volume compared to AGA infants. Most infants in both groups showed increase in each of the NIRS parameters in the contralateral hemisphere following heel lance. However, more AGA infants (6/15) showed decreased ΔTHb compared to FGR infants (1/20) (p = 0.016). The magnitude of cerebral hemodynamic response and time to response did not differ between FGR and AGA infants. FGR infants showed larger ΔO2Hb in the contralateral compared to ipsilateral cortex (p = 0.05). Conclusion: Preterm FGR infants have reduced stroke volume and lower cerebral oxygenation compared to AGA infants in the second to third week of life. FGR infants show similar cerebral hemodynamic responses to noxious stimuli compared to AGA infants. However, FGR infants are less likely to have a cerebral vasoconstrictive response, possibly due to cerebrovascular changes following placental insufficiency and brain sparing in-utero.
Collapse
Affiliation(s)
- Laura M L Dix
- Department of Paediatrics, The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Melbourne, VIC, Australia.,Monash Newborn, Monash Medical Centre, Melbourne, VIC, Australia.,Neonatology, Wilhelmina Children's Hospital, Utrecht Medical Centre, Utrecht, Netherlands
| | - Kelsee Shepherd
- Department of Paediatrics, The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Melbourne, VIC, Australia
| | - Graeme R Polglase
- Department of Paediatrics, The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Melbourne, VIC, Australia
| | - Suzanne L Miller
- Department of Paediatrics, The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Melbourne, VIC, Australia
| | - Arvind Sehgal
- Department of Paediatrics, The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Melbourne, VIC, Australia.,Monash Newborn, Monash Medical Centre, Melbourne, VIC, Australia
| | - Flora Y Wong
- Department of Paediatrics, The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Melbourne, VIC, Australia.,Monash Newborn, Monash Medical Centre, Melbourne, VIC, Australia
| |
Collapse
|
18
|
Regional tissue oxygenation monitoring in the neonatal intensive care unit: evidence for clinical strategies and future directions. Pediatr Res 2019; 86:296-304. [PMID: 31247635 DOI: 10.1038/s41390-019-0466-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 05/24/2019] [Accepted: 06/08/2019] [Indexed: 12/19/2022]
Abstract
Near-infrared spectroscopy (NIRS)-based monitoring of regional tissue oxygenation (rSO2) is becoming more commonplace in the neonatal intensive care unit (NICU). While increasing evidence supports rSO2 monitoring, actual standards for applying this noninvasive bedside technique continue to evolve. This review highlights the current strengths and pitfalls surrounding practical NIRS-based monitoring in the neonatal population. The physiologic background of rSO2 monitoring is discussed, with attention to understanding oxygen delivery/consumption mismatch and its effects on tissue oxygen extraction. The bedside utility of both cerebral and peripheral rSO2 monitoring in the NICU is then explored from two perspectives: (1) disease/event-specific "responsive" monitoring and (2) "routine," continuous monitoring. Recent evidence incorporating both monitoring approaches is summarized with emphasis on practical applicability in the NICU. Finally, a future paradigm for a broad-based NIRS monitoring strategy is presented, with attention towards improving personalization of neonatal care and ultimately enhancing long-term outcomes.
Collapse
|