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Solvik-Olsen T, Kåsin JI, Hagemo J, Heyerdahl F. Manikin study showed that neonates are exposed to high sound and vibration levels during helicopter incubator transports. Acta Paediatr 2024. [PMID: 38884542 DOI: 10.1111/apa.17326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 05/19/2024] [Accepted: 06/10/2024] [Indexed: 06/18/2024]
Abstract
AIM This initial Norwegian study aimed to quantify the vibrations and sounds experienced by neonates when they were transported by helicopter in an incubator. METHODS Two neonatal manikins weighing 500 and 2000 g were placed in a transport incubator and transported in an Airbus H145 D3 helicopter during standard flight profiles. The vibrations were measured on the mattress inside the incubator and the sound levels were measured inside and outside the incubator. RESULTS The highest vibration levels were recorded during standard flight profiles when the lighter manikin was used. These ranged 0.27-0.94 m/s2, compared to 0.27-0.76 m/s2 for the heavier manikin. The measurements exceeded the action levels set by the European Union Vibration Directive for adult work environments. The sound levels inside the incubator ranged 84.6-86.3 A-weighted decibels, with a C-weighted peak level of 122 decibels. The sound levels inside the incubator were approximately 10 decibels lower than outside, but amplification was observed in the incubator at frequencies below 160 Hz. CONCLUSION Vibrations were highest for the lighter manikin. The sound levels during helicopter transport were higher than recommended for neonatal environments and sounds were amplified within the incubator at lower frequencies.
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Affiliation(s)
- Tone Solvik-Olsen
- Division of Pediatric and Adolescent Medicine, Department of Neonatology, Oslo University Hospital, Oslo, Norway
- Department of Research and Development, Norwegian Air Ambulance Foundation, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Jan Ivar Kåsin
- Norwegian Armed Forces, Occupational Health Services, Oslo, Norway
| | - Jostein Hagemo
- Department of Research and Development, Norwegian Air Ambulance Foundation, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Division of Prehospital Services, Air Ambulance Department, Oslo University Hospital, Oslo, Norway
| | - Fridtjof Heyerdahl
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Division of Prehospital Services, Air Ambulance Department, Oslo University Hospital, Oslo, Norway
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2
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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.
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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
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3
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Rodriguez-Fanjul J, Corsini I, Ortí CS, Misis M, Bobillo-Pérez S. Premature newborns with intraventricular hemorrhage do not have vasospasm pattern by cranial Doppler ultrasound: A pilot study. Eur J Pediatr 2024:10.1007/s00431-024-05616-1. [PMID: 38795136 DOI: 10.1007/s00431-024-05616-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 05/10/2024] [Accepted: 05/16/2024] [Indexed: 05/27/2024]
Abstract
Preterm neonates are at risk for neurodevelopmental impairment, especially those with intraventricular hemorrhage (IVH). Cerebral vasospasm (VSP) is a common complication after subarachnoid hemorrhage (SAH) in adult population, but it is unknown if preterm neonates with IVH may develop it. We prospectively enrolled premature newborns < 32 weeks with IVH and without IVH. All patients received serial transcranial sonography through the temporal window of the middle cerebral artery, anterior cerebral artery, posterior cerebral artery, and the internal carotid artery with transcranial Doppler sonography days 2, 4, and 10 of life. Cerebral blood velocities (CBFVs) were measured including median velocity flow (MV), peak systolic velocity (PSV), and maximum end-diastolic velocity (EDV). Resistance index and pulsatility index were calculated. VSP was defined as an increase of 50% in the baseline velocity per day and/or a Lindegaard ratio higher than 3. Fifty subjects were enrolled. None of the patients with IVH showed elevation of MV or a Lindegaard ratio > 3. There were no differences between IVH and without IVH groups regarding resistance index and pulsatility index. Conclusion: Preterm infants with IVH do not present a pattern of VSP analyzed by Doppler transcranial ultrasound in this pilot study. What is Known: • In adult population with subarachnoid hemorrhage the most treatable cause of cerebral ischemia is due cerebral vasospasm but is unknown if premature newborn may have vasospasm due the extravasation of blood in the context of intraventricular hemorrhage What is New: •In this pilot study we did not find in premature newborn with intraventricular hemorrhage signs of vasoespam measured by transcranial color doppler ultrasound.
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Affiliation(s)
- Javier Rodriguez-Fanjul
- Pediatric Intensive Care Unit, Pediatric Service, Hospital Germans Trias I Pujol, Badalona, 08916, Spain.
| | - Iuri Corsini
- Division of Neonatology, Careggi University Hospital of Florence Italy, Florence, Italy
| | - Clara Sorribes Ortí
- Pediatric Intensive Care Unit, Pediatric Service, Hospital Germans Trias I Pujol, Badalona, 08916, Spain
| | - Maite Misis
- Intensive Care Unit Service, Hospital Germans Trias I Pujol, Badalona, Spain
| | - Sara Bobillo-Pérez
- Paediatric Intensive Care Unit, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
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4
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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; 0:revneuro-2024-0028. [PMID: 38581271 DOI: 10.1515/revneuro-2024-0028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [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.
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Affiliation(s)
- Andrew P Carlson
- Department of Neurosurgery, 12288 University of New Mexico School of Medicine , MSC10 5615, 1 UNM, Albuquerque, NM, 87131, USA
- Department of Neurosciences, 12288 University of New Mexico School of Medicine , 915 Camino de Salud NE, Albuquerque, NM, 87106, USA
| | - Andrew R Mayer
- 168528 Mind Research Network , 1101 Yale, Blvd, NE, Albuquerque, NM, 87106, USA
| | - Chad Cole
- Department of Neurosurgery, 12288 University of New Mexico School of Medicine , MSC10 5615, 1 UNM, Albuquerque, NM, 87131, USA
| | - Harm J van der Horn
- 168528 Mind Research Network , 1101 Yale, Blvd, NE, Albuquerque, NM, 87106, USA
| | - Joshua Marquez
- 12288 University of New Mexico School of Medicine , 915 Camino de Salud NE, Albuquerque, NM, 87106, USA
| | - Taylor C Stevenson
- Department of Neurosurgery, 12288 University of New Mexico School of Medicine , MSC10 5615, 1 UNM, Albuquerque, NM, 87131, USA
| | - C William Shuttleworth
- Department of Neurosciences, 12288 University of New Mexico School of Medicine , 915 Camino de Salud NE, Albuquerque, NM, 87106, USA
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5
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Chao H, Acosta S, Rusin C, Rhee C. Comparison of Near-Infrared Spectroscopy-Based Cerebral Autoregulatory Indices in Extremely Low Birth Weight Infants. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1361. [PMID: 37628360 PMCID: PMC10453436 DOI: 10.3390/children10081361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 07/20/2023] [Accepted: 08/08/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND Premature infants are born with immature cerebral autoregulation function and are vulnerable to pressure passive cerebral circulation and subsequent brain injury. Measurements derived from near-infrared spectroscopy (NIRS) have enabled continuous assessment of cerebral vasoreactivity. Although NIRS has enabled a growing field of research, the lack of clear standardization in the field remains problematic. A major limitation of current literature is the absence of a comparative analysis of the different methodologies. OBJECTIVES To determine the relationship between NIRS-derived continuous indices of cerebral autoregulation in a cohort of extremely low birth weight (ELBW) infants. METHODS Premature infants of birth weight 401-1000 g were studied during the first 72 h of life. The cerebral oximetry index (COx), hemoglobin volume index (HVx), and tissue oxygenation heart rate reactivity index (TOHRx) were simultaneously calculated. The relationship between each of the indices was assessed with Pearson correlation. RESULTS Fifty-eight infants with a median gestational age of 25.8 weeks and a median birth weight of 738 g were included. Intraventricular hemorrhage (IVH) was detected in 33% of individuals. COx and HVx demonstrated the highest degree of correlation, although the relationship was moderate at best (r = 0.543, p < 0.001). No correlation was found either between COx and TOHRx (r = 0.318, p < 0.015) or between HVx and TOHRx (r = 0.287, p < 0.029). No significant differences in these relationships were found with respect to IVH and no IVH in subgroup analysis. CONCLUSIONS COx, HVx, and TOHRx are not numerically equivalent. Caution must be applied when interpreting or comparing results based on different methodologies for measuring cerebral autoregulation. Uniformity regarding data acquisition and analytical methodology are needed to firmly establish a gold standard for neonatal cerebral autoregulation monitoring.
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Affiliation(s)
- Howard Chao
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX 77030, USA
| | - Sebastian Acosta
- Department of Pediatrics, Division of Cardiology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX 77030, USA
| | - Craig Rusin
- Department of Pediatrics, Division of Cardiology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX 77030, USA
| | - Christopher Rhee
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX 77030, USA
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6
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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.
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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
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7
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Protective Effects of Early Caffeine Administration in Hyperoxia-Induced Neurotoxicity in the Juvenile Rat. Antioxidants (Basel) 2023; 12:antiox12020295. [PMID: 36829854 PMCID: PMC9952771 DOI: 10.3390/antiox12020295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/12/2023] [Accepted: 01/24/2023] [Indexed: 01/31/2023] Open
Abstract
High-risk preterm infants are affected by a higher incidence of cognitive developmental deficits due to the unavoidable risk factor of oxygen toxicity. Caffeine is known to have a protective effect in preventing bronchopulmonary dysplasia associated with improved neurologic outcomes, although very early initiation of therapy is controversial. In this study, we used newborn rats in an oxygen injury model to test the hypothesis that near-birth caffeine administration modulates neuronal maturation and differentiation in the hippocampus of the developing brain. For this purpose, newborn Wistar rats were exposed to 21% or 80% oxygen on the day of birth for 3 or 5 days and treated with vehicle or caffeine (10 mg/kg/48 h). Postnatal exposure to 80% oxygen resulted in a drastic reduction of associated neuronal mediators for radial glia, mitotic/postmitotic neurons, and impaired cell-cycle regulation, predominantly persistent even after recovery to room air until postnatal day 15. Systemic caffeine administration significantly counteracted the effects of oxygen insult on neuronal maturation in the hippocampus. Interestingly, under normoxia, caffeine inhibited the transcription of neuronal mediators of maturing and mature neurons. The early administration of caffeine modulated hyperoxia-induced decreased neurogenesis in the hippocampus and showed neuroprotective properties in the neonatal rat oxygen toxicity model.
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8
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Bailey SM, Prakash SS, Verma S, Desai P, Kazmi S, Mally PV. Near-infrared spectroscopy in the medical management of infants. Curr Probl Pediatr Adolesc Health Care 2022; 52:101291. [PMID: 36404215 DOI: 10.1016/j.cppeds.2022.101291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Near-infrared spectroscopy (NIRS) is a technology that is easy to use and can provide helpful information about organ oxygenation and perfusion by measuring regional tissue oxygen saturation (rSO2) with near-infrared light. The sensors can be placed in different anatomical locations to monitor rSO2 levels in several organs. While NIRS is not without limitations, this equipment is now becoming increasingly integrated into modern healthcare practice with the goal of achieving better outcomes for patients. It can be particularly applicable in the monitoring of pediatric patients because of their size, and especially so in infant patients. Infants are ideal for NIRS monitoring as nearly all of their vital organs lie near the skin surface which near-infrared light penetrates through. In addition, infants are a difficult population to evaluate with traditional invasive monitoring techniques that normally rely on the use of larger catheters and maintaining vascular access. Pediatric clinicians can observe rSO2 values in order to gain insight about tissue perfusion, oxygenation, and the metabolic status of their patients. In this way, NIRS can be used in a non-invasive manner to either continuously or periodically check rSO2. Because of these attributes and capabilities, NIRS can be used in various pediatric inpatient settings and on a variety of patients who require monitoring. The primary objective of this review is to provide pediatric clinicians with a general understanding of how NIRS works, to discuss how it currently is being studied and employed, and how NIRS could be increasingly used in the near future, all with a focus on infant management.
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Affiliation(s)
- Sean M Bailey
- Division of Neonatology, Department of Pediatrics, New York University Grossman School of Medicine, New York, NY 10016.
| | - Shrawani Soorneela Prakash
- Division of Neonatology, Department of Pediatrics, NYCHHC/Lincoln Medical and Mental Health Center, Bronx, NY 10451
| | - Sourabh Verma
- Division of Neonatology, Department of Pediatrics, New York University Grossman School of Medicine, New York, NY 10016
| | - Purnahamsi Desai
- Division of Neonatology, Department of Pediatrics, New York University Grossman School of Medicine, New York, NY 10016
| | - Sadaf Kazmi
- Division of Neonatology, Department of Pediatrics, New York University Grossman School of Medicine, New York, NY 10016
| | - Pradeep V Mally
- Division of Neonatology, Department of Pediatrics, New York University Grossman School of Medicine, New York, NY 10016
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Dhillon SK, Gunn ER, Lear BA, King VJ, Lear CA, Wassink G, Davidson JO, Bennet L, Gunn AJ. Cerebral Oxygenation and Metabolism After Hypoxia-Ischemia. Front Pediatr 2022; 10:925951. [PMID: 35903161 PMCID: PMC9314655 DOI: 10.3389/fped.2022.925951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 06/15/2022] [Indexed: 11/13/2022] Open
Abstract
Perinatal hypoxia-ischemia (HI) is still a significant contributor to mortality and adverse neurodevelopmental outcomes in term and preterm infants. HI brain injury evolves over hours to days, and involves complex interactions between the endogenous protective and pathological processes. Understanding the timing of evolution of injury is vital to guide treatment. Post-HI recovery is associated with a typical neurophysiological profile, with stereotypic changes in cerebral perfusion and oxygenation. After the initial recovery, there is a delayed, prolonged reduction in cerebral perfusion related to metabolic suppression, followed by secondary deterioration with hyperperfusion and increased cerebral oxygenation, associated with altered neurovascular coupling and impaired cerebral autoregulation. These changes in cerebral perfusion are associated with the stages of evolution of injury and injury severity. Further, iatrogenic factors can also affect cerebral oxygenation during the early period of deranged metabolism, and improving clinical management may improve neuroprotection. We will review recent evidence that changes in cerebral oxygenation and metabolism after HI may be useful biomarkers of prognosis.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Alistair J. Gunn
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
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10
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Martini S, Czosnyka M, Smielewski P, Iommi M, Galletti S, Vitali F, Paoletti V, Camela F, Austin T, Corvaglia L. Clinical determinants of cerebrovascular reactivity in very preterm infants during the transitional period. Pediatr Res 2022; 92:135-141. [PMID: 35513715 DOI: 10.1038/s41390-022-02090-z] [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: 02/25/2022] [Revised: 03/29/2022] [Accepted: 04/10/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Preterm infants are at enhanced risk of brain injury due to altered cerebral haemodynamics during postnatal transition. This observational study aimed to assess the clinical determinants of transitional cerebrovascular reactivity and its association with intraventricular haemorrhage (IVH). METHODS Preterm infants <32 weeks underwent continuous monitoring of cerebral oxygenation and heart rate over the first 72 h after birth. Serial cranial and cardiac ultrasound assessments were performed to evaluate the ductal status and to diagnose IVH onset. The moving correlation coefficient between cerebral oxygenation and heart rate (TOHRx) was calculated. Linear mixed-effect models were used to analyse the impact of relevant clinical variables on TOHRx. The association between TOHRx and IVH development was also assessed. RESULTS Seventy-seven infants were included. A haemodynamically significant patent ductus arteriosus (hsPDA) (β = 0.044, 95% CI: 0.007-0.081) and ongoing dopamine treatment (β = 0.096, 95% CI: 0.032-0.159) were associated with increasing TOHRx, indicating impaired cerebrovascular reactivity. A significant association between TOHRx, mean arterial blood pressure (β = -0.004, 95% CI: -0.007, -0.001) and CRIB-II score (β = 0.007, 95% CI: 0.001-0.015) was also observed. TOHRx was significantly higher in infants developing high-grade IVH compared to those without IVH. CONCLUSIONS Dopamine treatment, low blood pressure, hsPDA and high CRIB-II are associated with impaired cerebrovascular reactivity during postnatal transition, with potential implications on IVH development. IMPACT The correlation coefficient between cerebral oxygenation and heart rate (TOHRx) provides a non-invasive estimation of cerebrovascular reactivity, whose failure has a potential pathogenic role in the development of IVH in preterm infants. This study shows that cerebrovascular reactivity during the transitional period improves over time and is affected by specific clinical and therapeutic factors, whose knowledge could support the development of individualized neuroprotective strategies in at-risk preterm infants. The evidence of increased TOHRx in infants developing high-grade compared to low-grade or no IVH during the transitional period further supports the role of impaired cerebrovascular reactivity in IVH pathophysiology.
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Affiliation(s)
- Silvia Martini
- Neonatal Intensive Care Unit, IRCCS S. Orsola-Malpighi Hospital, Bologna, Italy. .,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrookes Hospital, Cambridge, UK
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrookes Hospital, Cambridge, UK
| | - Marica Iommi
- Department of Biomedical and Neuromotor Sciences, Division of Hygiene and Biostatistics, University of Bologna, Bologna, Italy
| | - Silvia Galletti
- Neonatal Intensive Care Unit, IRCCS S. Orsola-Malpighi Hospital, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Francesca Vitali
- Neonatal Intensive Care Unit, IRCCS S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Vittoria Paoletti
- Neonatal Intensive Care Unit, IRCCS S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Federica Camela
- Neonatal Intensive Care Unit, IRCCS S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Topun Austin
- Neonatal Intensive Care Unit, The Rosie Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Luigi Corvaglia
- Neonatal Intensive Care Unit, IRCCS S. Orsola-Malpighi Hospital, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
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11
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Fan JL, Nogueira RC, Brassard P, Rickards CA, Page M, Nasr N, Tzeng YC. Integrative physiological assessment of cerebral hemodynamics and metabolism in acute ischemic stroke. J Cereb Blood Flow Metab 2022; 42:454-470. [PMID: 34304623 PMCID: PMC8985442 DOI: 10.1177/0271678x211033732] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Restoring perfusion to ischemic tissue is the primary goal of acute ischemic stroke care, yet only a small portion of patients receive reperfusion treatment. Since blood pressure (BP) is an important determinant of cerebral perfusion, effective BP management could facilitate reperfusion. But how BP should be managed in very early phase of ischemic stroke remains a contentious issue, due to the lack of clear evidence. Given the complex relationship between BP and cerebral blood flow (CBF)-termed cerebral autoregulation (CA)-bedside monitoring of cerebral perfusion and oxygenation could help guide BP management, thereby improve stroke patient outcome. The aim of INFOMATAS is to 'identify novel therapeutic targets for treatment and management in acute ischemic stroke'. In this review, we identify novel physiological parameters which could be used to guide BP management in acute stroke, and explore methodologies for monitoring them at the bedside. We outline the challenges in translating these potential prognostic markers into clinical use.
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Affiliation(s)
- Jui-Lin Fan
- Manaaki Mānawa - The Centre for Heart Research, Department of Physiology, Faculty of Medical & Health Sciences, University of Auckland, Auckland, New Zealand
| | - Ricardo C Nogueira
- Neurology Department, School of Medicine, Hospital das Clinicas, University of São Paulo, São Paulo, Brazil.,Neurology Department, Hospital Nove de Julho, São Paulo, Brazil
| | - Patrice Brassard
- Department of Kinesiology, Faculty of Medicine, Université Laval, Québec, Canada.,Research Center of the Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Canada
| | - Caroline A Rickards
- Department of Physiology & Anatomy, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Matthew Page
- Department of Radiology, Wellington Regional Hospital, Wellington, New Zealand
| | - Nathalie Nasr
- Department of Neurology, Toulouse University Hospital, NSERM UMR 1297, Toulouse, France
| | - Yu-Chieh Tzeng
- Wellington Medical Technology Group, Department of Surgery & Anaesthesia, University of Otago, Wellington, New Zealand.,Centre for Translational Physiology, Department of Surgery & Anaesthesia, University of Otago, Wellington, New Zealand
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12
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Schwab AL, Mayer B, Bassler D, Hummler HD, Fuchs HW, Bryant MB. Cerebral Oxygenation in Preterm Infants Developing Cerebral Lesions. Front Pediatr 2022; 10:809248. [PMID: 35498781 PMCID: PMC9039301 DOI: 10.3389/fped.2022.809248] [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: 11/04/2021] [Accepted: 03/10/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND We investigated the association between cerebral tissue oxygen saturation (cStO2) measured by near-infrared spectroscopy (NIRS) and cerebral lesions including intraventricular hemorrhage (IVH) and periventricular leukomalacia (PVL). METHODS Preterm infants <1,500 g received continuous cStO2 monitoring, initiated at the earliest time possible and recorded until 72 h of life. Mean cStO2 over periods of 5, 15, 30 min and 1 h were calculated. To calculate the burden of cerebral hypoxia, we defined a moving threshold based on the 10th percentile of cStO2 of healthy study participants and calculated the area under the threshold (AUT). cStO2 <60% for >5 min was regarded a critical event. The study was registered on clinicaltrials.gov (ID NCT01430728, URL: https://clinicaltrials.gov/ct2/show/NCT01430728?id=NCT01430728&draw=2&rank=1). RESULTS Of 162 infants (gestational age: mean 27.2 weeks, standard deviation 20 days; birth weight: mean 852 g, standard deviation 312 g) recorded, 24/12 (14.8%/7.4) developed any/severe IVH/PVL. Mean cStO2 was significantly lower in infants with IVH/PVL as well as severe IVH/PVL. In addition, we observed critical events defined by mean cStO2 over 5 min <60% in four infants with severe IVH/PVL during NIRS monitoring. AUT showed no statistically significant difference between outcome groups. CONCLUSION These findings suggest that cStO2 is lower in infants developing IVH/PVL. This may be related to lower oxygenation and/or perfusion and implies that cStO2 could potentially serve as an indicator of imminent cerebral lesions.
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Affiliation(s)
- Angelika L Schwab
- Division of Neonatology and Pediatric Intensive Care, Department of Pediatrics and Adolescent Medicine, University Hospital Ulm, Ulm, Germany
| | - Benjamin Mayer
- Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany
| | - Dirk Bassler
- Neonatal Department, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Helmut D Hummler
- Division of Neonatology and Pediatric Intensive Care, Department of Pediatrics and Adolescent Medicine, University Hospital Ulm, Ulm, Germany
| | - Hans W Fuchs
- Division of Neonatology and Pediatric Intensive Care, Department of Pediatrics and Adolescent Medicine, University Hospital Ulm, Ulm, Germany
| | - Manuel B Bryant
- Division of Neonatology and Pediatric Intensive Care, Department of Pediatrics and Adolescent Medicine, University Hospital Ulm, Ulm, Germany.,Neonatal Department, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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13
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Hoffman GM, Scott JP, Stuth EA. Effects of Arterial Carbon Dioxide Tension on Cerebral and Somatic Regional Tissue Oxygenation and Blood Flow in Neonates After the Norwood Procedure With Deep Hypothermic Cardiopulmonary Bypass. Front Pediatr 2022; 10:762739. [PMID: 35223690 PMCID: PMC8873518 DOI: 10.3389/fped.2022.762739] [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: 08/22/2021] [Accepted: 01/04/2022] [Indexed: 11/13/2022] Open
Abstract
Neonates undergoing the Norwood procedure for hypoplastic left heart syndrome are at higher risk of impaired systemic oxygen delivery with resultant brain, kidney, and intestinal ischemic injury, shock, and death. Complex developmental, anatomic, and treatment-related influences on cerebral and renal-somatic circulations make individualized treatment strategies physiologically attractive. Monitoring cerebral and renal circulations with near infrared spectroscopy can help drive rational therapeutic interventions. The primary aim of this study was to describe the differential effects of carbon dioxide tension on cerebral and renal circulations in neonates after the Norwood procedure. Using a prospectively-maintained database of postoperative physiologic and hemodynamic parameters, we analyzed the relationship between postoperative arterial carbon dioxide tension and tissue oxygen saturation and arteriovenous saturation difference in cerebral and renal regions, applying univariate and multivariate multilevel mixed regression techniques. Results were available from 7,644 h of data in 178 patients. Increases in arterial carbon dioxide tension were associated with increased cerebral and decreased renal oxygen saturation. Differential changes in arteriovenous saturation difference explained these effects. The cerebral circulation showed more carbon dioxide sensitivity in the early postoperative period, while sensitivity in the renal circulation increased over time. Multivariate models supported the univariate findings and defined complex time-dependent interactions presented graphically. The cerebral and renal circulations may compete for blood flow with critical limitations of cardiac output. The cerebral and renal-somatic beds have different circulatory control mechanisms that can be manipulated to change the distribution of cardiac output by altering the arterial carbon dioxide tension. Monitoring cerebral and renal circulations with near infrared spectroscopy can provide rational physiologic targets for individualized treatment.
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Affiliation(s)
- George M Hoffman
- Division of Pediatric Cardiac Anesthesia, Children's Hospital of Wisconsin Herma Heart Institute, Milwaukee, WI, United States.,Division of Pediatric Cardiac Critical Care, Children's Hospital of Wisconsin Herma Heart Institute, Milwaukee, WI, United States.,Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, United States.,Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, United States
| | - John P Scott
- Division of Pediatric Cardiac Anesthesia, Children's Hospital of Wisconsin Herma Heart Institute, Milwaukee, WI, United States.,Division of Pediatric Cardiac Critical Care, Children's Hospital of Wisconsin Herma Heart Institute, Milwaukee, WI, United States.,Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, United States.,Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Eckehard A Stuth
- Division of Pediatric Cardiac Anesthesia, Children's Hospital of Wisconsin Herma Heart Institute, Milwaukee, WI, United States.,Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, United States
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14
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Effects of circulatory arrest and cardiopulmonary bypass on cerebral autoregulation in neonatal swine. Pediatr Res 2022; 91:1374-1382. [PMID: 33947997 PMCID: PMC8566324 DOI: 10.1038/s41390-021-01525-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 02/02/2021] [Accepted: 03/18/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Cerebral autoregulation mechanisms help maintain adequate cerebral blood flow (CBF) despite changes in cerebral perfusion pressure. Impairment of cerebral autoregulation, during and after cardiopulmonary bypass (CPB), may increase risk of neurologic injury in neonates undergoing surgery. In this study, alterations of cerebral autoregulation were assessed in a neonatal swine model probing four perfusion strategies. METHODS Neonatal swine (n = 25) were randomized to continuous deep hypothermic cardiopulmonary bypass (DH-CPB, n = 7), deep hypothermic circulatory arrest (DHCA, n = 7), selective cerebral perfusion (SCP, n = 7) at deep hypothermia, or normothermic cardiopulmonary bypass (control, n = 4). The correlation coefficient (LDx) between laser Doppler measurements of CBF and mean arterial blood pressure was computed at initiation and conclusion of CPB. Alterations in cerebral autoregulation were assessed by the change between initial and final LDx measurements. RESULTS Cerebral autoregulation became more impaired (LDx increased) in piglets that underwent DH-CPB (initial LDx: median 0.15, IQR [0.03, 0.26]; final: 0.45, [0.27, 0.74]; p = 0.02). LDx was not altered in those undergoing DHCA (p > 0.99) or SCP (p = 0.13). These differences were not explained by other risk factors. CONCLUSIONS In a validated swine model of cardiac surgery, DH-CPB had a significant effect on cerebral autoregulation, whereas DHCA and SCP did not. IMPACT Approximately half of the patients who survive neonatal heart surgery with cardiopulmonary bypass (CPB) experience neurodevelopmental delays. This preclinical investigation takes steps to elucidate and isolate potential perioperative risk factors of neurologic injury, such as impairment of cerebral autoregulation, associated with cardiac surgical procedures involving CPB. We demonstrate a method to characterize cerebral autoregulation during CPB pump flow changes in a neonatal swine model of cardiac surgery. Cerebral autoregulation was not altered in piglets that underwent deep hypothermic circulatory arrest (DHCA) or selective cerebral perfusion (SCP), but it was altered in piglets that underwent deep hypothermic CBP.
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15
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Suzuki Y, Yamamoto M, Sugiyama K, Akai T, Suzuki K, Kawamura T, Sakata M, Morita Y, Kikuchi H, Hiramatsu Y, Kurachi K, Unno N, Takeuchi H. Usefulness of a finger-mounted tissue oximeter with near-infrared spectroscopy for evaluating the intestinal oxygenation and viability in rats. Surg Today 2021; 51:931-940. [PMID: 33108523 PMCID: PMC8141489 DOI: 10.1007/s00595-020-02171-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 09/26/2020] [Indexed: 12/04/2022]
Abstract
PURPOSE To investigate the utility of the device for evaluating intestinal oxygenation and viability using an animal model. METHODS Sprague-Dawley rats underwent laparotomy under general anesthesia, and the blood vessels in the terminal ileum were clamped to create ischemia. We measured the regional tissue oxygenation saturation (rSO2) using an oximeter after 1, 3, and 6 h of vessel clamping. Ischemic tissue damage was assessed using a histological score. The intestine was reperfused after each clamping period, and intestinal rSO2 and survival rate were evaluated. RESULTS When reperfusion was performed at 1 and 3 h after ischemia, rSO2 increased after 10 min, and it improved to the same level as for normal intestine after 1 h; all rats survived for 1 week. In contrast, after 6 h of ischemia, rSO2 did not increase after reperfusion, and all animals died within 2 days. The histological scores increased after 1 h of reperfusion, with longer clamping periods. CONCLUSION A finger-mounted tissue oximeter could evaluate intestinal ischemia and the viability, which is thus considered to be a promising result for future clinical application.
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Affiliation(s)
- Yuhi Suzuki
- Second Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, Shizuoka, 431-3192, Japan.
| | - Masayoshi Yamamoto
- Second Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Kosuke Sugiyama
- Second Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Toshiya Akai
- Second Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Katsunori Suzuki
- Second Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Takafumi Kawamura
- Second Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Mayu Sakata
- Second Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Yoshifumi Morita
- Second Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Hirotoshi Kikuchi
- Second Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Yoshihiro Hiramatsu
- Second Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Kiyotaka Kurachi
- Second Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Naoki Unno
- Second Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, Shizuoka, 431-3192, Japan
- Division of Vascular Surgery, Hamamatsu Medical Center, 328 Tomitsuka, Hamamatsu, Shizuoka, 432-8580, Japan
| | - Hiroya Takeuchi
- Second Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, Shizuoka, 431-3192, Japan
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16
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Costa FG, Hakimi N, Van Bel F. Neuroprotection of the Perinatal Brain by Early Information of Cerebral Oxygenation and Perfusion Patterns. Int J Mol Sci 2021; 22:ijms22105389. [PMID: 34065460 PMCID: PMC8160954 DOI: 10.3390/ijms22105389] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 05/07/2021] [Accepted: 05/17/2021] [Indexed: 02/01/2023] Open
Abstract
Abnormal patterns of cerebral perfusion/oxygenation are associated with neuronal damage. In preterm neonates, hypoxemia, hypo-/hypercapnia and lack of cerebral autoregulation are related to peri-intraventricular hemorrhages and white matter injury. Reperfusion damage after perinatal hypoxic ischemia in term neonates seems related with cerebral hyperoxygenation. Since biological tissue is transparent for near infrared (NIR) light, NIR-spectroscopy (NIRS) is a noninvasive bedside tool to monitor brain oxygenation and perfusion. This review focuses on early assessment and guiding abnormal cerebral oxygenation/perfusion patterns to possibly reduce brain injury. In term infants, early patterns of brain oxygenation helps to decide whether or not therapy (hypothermia) and add-on therapies should be considered. Further NIRS-related technical advances such as the use of (functional) NIRS allowing simultaneous estimation and integrating of heart rate, respiration rate and monitoring cerebral autoregulation will be discussed.
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Affiliation(s)
- Filipe Gonçalves Costa
- Department of Neonatology, University Medical Center Utrecht, 3584 EA Utrecht, The Netherlands; (F.G.C.); (N.H.)
| | - Naser Hakimi
- Department of Neonatology, University Medical Center Utrecht, 3584 EA Utrecht, The Netherlands; (F.G.C.); (N.H.)
- Artinis Medical Systems, B.V., 6662 PW Elst, The Netherlands
| | - Frank Van Bel
- Department of Neonatology, University Medical Center Utrecht, 3584 EA Utrecht, The Netherlands; (F.G.C.); (N.H.)
- Correspondence: ; Tel.: +31-887-554-545
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17
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Pereira SS, Sinha AK, Shah DK, Kempley ST. Common carotid artery blood flow volume in extremely preterm infants. Acta Paediatr 2021; 110:1157-1165. [PMID: 33145798 DOI: 10.1111/apa.15655] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 10/14/2020] [Accepted: 11/02/2020] [Indexed: 11/28/2022]
Abstract
AIM The aim of this study was to determine carotid blood flow volume, a surrogate for cerebral blood flow, using Doppler ultrasound in extremely preterm infants. METHODS In infants <29 weeks, right common carotid artery flow volume (RCCAF) was calculated from vessel diameter and intensity-weighted mean velocity measured using Doppler ultrasound on days 1 and 3. In addition, left ventricular output (LVO), ductus arteriosus characteristics and invasive mean arterial blood pressure (MABP) were obtained. RESULTS Sixty infants with mean gestation of 25.8 weeks were studied. The median RCCAF increased from 12 (IQR 9-15) mL/kg/min on day 1, to 14 (IQR 12-18) mL/kg/min on day 3 (p = 0.007). RCCAF was positively correlated with invasive MABP on days 1 and 3. RCCAF significantly correlated with LVO in infants with closing or closed ductus arteriosus on day 1. Using multiple regression analysis, RCCAF was significantly associated with invasive MABP on day 1 and to inotropic treatment on day 3. CONCLUSION Doppler ultrasound can be used to measure RCCAF in extremely preterm infants receiving intensive care. RCCAF increased during the first three days and was positively related to invasive MABP on day 1. Values were lower than previously described in more mature infants. CLINICAL TRIAL REGISTRATION ISRCTN 83507686.
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Affiliation(s)
- Sujith S. Pereira
- Centre for Genomics and Child Health Blizard Institute Barts and the London School of Medicine Queen Mary University of London London UK
- Neonatal Unit Homerton University Hospital Foundation NHS Trust London UK
| | - Ajay K. Sinha
- Centre for Genomics and Child Health Blizard Institute Barts and the London School of Medicine Queen Mary University of London London UK
- Neonatal Unit Royal London Hospital, Barts Health NHS Trust London UK
| | - Divyen K. Shah
- Neonatal Unit Royal London Hospital, Barts Health NHS Trust London UK
- Centre for Neuroscience and Trauma Blizard Institute Barts and the London School of Medicine and Dentistry Queen Mary University of London London UK
| | - Stephen T. Kempley
- Centre for Genomics and Child Health Blizard Institute Barts and the London School of Medicine Queen Mary University of London London UK
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18
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Chawla S, Chock VY, Lakshminrusimha S. Intraventricular hemorrhage and white matter injury: is persistent cerebral desaturation a missing link? Pediatr Res 2021; 89:727-729. [PMID: 33247218 DOI: 10.1038/s41390-020-01294-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 10/29/2020] [Accepted: 11/03/2020] [Indexed: 11/09/2022]
Affiliation(s)
- Sanjay Chawla
- Central Michigan University, Children's Hospital of Michigan, 3901 Beaubien, Detroit, MI, 48201, USA.
| | - Valerie Y Chock
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, 750 Welch Road, Suite 315, Palo Alto, CA, 94304, USA
| | - Satyan Lakshminrusimha
- Department of Pediatrics-Neonatology, University of California Davis, 2516 Stockton Blvd, Sacramento, CA, 95817, USA
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19
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Leon RL, Ortigoza EB, Ali N, Angelis D, Wolovits JS, Chalak LF. Cerebral Blood Flow Monitoring in High-Risk Fetal and Neonatal Populations. Front Pediatr 2021; 9:748345. [PMID: 35087771 PMCID: PMC8787287 DOI: 10.3389/fped.2021.748345] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 12/15/2021] [Indexed: 12/18/2022] Open
Abstract
Cerebrovascular pressure autoregulation promotes stable cerebral blood flow (CBF) across a range of arterial blood pressures. Cerebral autoregulation (CA) is a developmental process that reaches maturity around term gestation and can be monitored prenatally with both Doppler ultrasound and magnetic resonance imaging (MRI) techniques. Postnatally, there are key advantages and limitations to assessing CA with Doppler ultrasound, MRI, and near-infrared spectroscopy. Here we review these CBF monitoring techniques as well as their application to both fetal and neonatal populations at risk of perturbations in CBF. Specifically, we discuss CBF monitoring in fetuses with intrauterine growth restriction, anemia, congenital heart disease, neonates born preterm and those with hypoxic-ischemic encephalopathy. We conclude the review with insights into the future directions in this field with an emphasis on collaborative science and precision medicine approaches.
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Affiliation(s)
- Rachel L Leon
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Eric B Ortigoza
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Noorjahan Ali
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Dimitrios Angelis
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Joshua S Wolovits
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Lina F Chalak
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States.,Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, United States
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20
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Hoffman SB, Lakhani A, Viscardi RM. The association between carbon dioxide, cerebral blood flow, and autoregulation in the premature infant. J Perinatol 2021; 41:324-329. [PMID: 33033388 PMCID: PMC7542091 DOI: 10.1038/s41372-020-00835-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 08/24/2020] [Accepted: 09/18/2020] [Indexed: 12/03/2022]
Abstract
OBJECTIVE Evaluate the association between carbon dioxide (pCO2), cerebral blood flow (CBF), and cerebral autoregulation (CA) in preterm infants. STUDY DESIGN Cerebral saturations (rScO2, surrogate for CBF using NIRS) and mean arterial blood pressure (MAP) monitored for 96 h in infants <29 weeks gestation. Relationship between rScO2, the rScO2-MAP correlation (CA analysis) and pCO2 category assessed by mixed effects modeling. RESULTS Median pCO2 differed by postnatal day (p < 0.0001)-pCO2 increased between day 1 and 2, and low variability seen on day 4. A 5% increase in rScO2 was noted when pCO2 was >55 mmHg on each postnatal day (p < 0.001). No association observed between the overall rScO2-MAP correlation and pCO2. On day 1 only, the correlation coefficient decreased from 0.26 to -0.09 as pCO2 category increased (p = 0.02). CONCLUSIONS CBF increased above a pCO2 threshold of 55 mmHg, but overall, no association between pCO2 and CA was noted.
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Affiliation(s)
- Suma Bhat Hoffman
- Department of Pediatrics, University of Maryland Baltimore, School of Medicine, Baltimore, MD, USA.
| | - Anisa Lakhani
- grid.411024.20000 0001 2175 4264Department of Pediatrics, University of Maryland Baltimore, School of Medicine, Baltimore, MD USA
| | - Rose Marie Viscardi
- grid.411024.20000 0001 2175 4264Department of Pediatrics, University of Maryland Baltimore, School of Medicine, Baltimore, MD USA
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21
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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: 44] [Impact Index Per Article: 11.0] [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.
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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
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22
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Renesme L, Dumas de la Roque E, Germain C, Chevrier A, Rebola M, Cramaregeas S, Benard A, Elleau C, Tandonnet O. Nasal high-frequency percussive ventilation vs nasal continuous positive airway pressure in newborn infants respiratory distress: A cross over clinical trial. Pediatr Pulmonol 2020; 55:2617-2623. [PMID: 32609946 DOI: 10.1002/ppul.24935] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 06/26/2020] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To determine if nasal high-frequency percussive ventilation (nHFPV) to manage neonatal respiratory distress decreases the regional cerebral oxygen saturation (rScO2 ) compared to nasal continous positive airway pressure (nCPAP). STUDY DESIGN A prospective, randomized, monocentric, open-label, noninferiority crossover trial. Newborns of gestational age (GA) ≥ 33 weeks exhibiting persistent respiratory distress after 10 minutes of life were treated with nHFPV and nCPAP, in succession and in random order. The primary endpoint was the mean rScO2 , as revealed by near-infrared spectroscopy (NIRS). RESULTS Forty-nine newborns were randomized; the mean GA and birth weight was 36.4 ± 1.9 weeks and 2718 ± 497 g. The mean rScO2 difference during the last 5 minutes of each ventilation mode (nHFPV minus nCPAP) was -0.7 ± 5.4% (95% confidence interval (CI) -2.25; 0.95%). CONCLUSION In our study on newborns of GA ≥33 weeks treated for respiratory distress, cerebral oxygenation via nHFPV was not inferior to nCPAP.
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Affiliation(s)
- Laurent Renesme
- Neonatal Intensive Care Unit, University Hospital of Bordeaux, Bordeaux, France
| | | | - Christine Germain
- Pôle de Santé Publique, Clinical Epidemiology Unit, University Hospital of Bordeaux, Bordeaux, France
| | - Agnès Chevrier
- Neonatal Intensive Care Unit, University Hospital of Bordeaux, Bordeaux, France
| | - Muriel Rebola
- Neonatal Intensive Care Unit, University Hospital of Bordeaux, Bordeaux, France
| | - Sophie Cramaregeas
- Neonatal Intensive Care Unit, University Hospital of Bordeaux, Bordeaux, France
| | - Antoine Benard
- Pôle de Santé Publique, Clinical Epidemiology Unit, University Hospital of Bordeaux, Bordeaux, France
| | - Christophe Elleau
- Neonatal Intensive Care Unit, University Hospital of Bordeaux, Bordeaux, France
| | - Olivier Tandonnet
- Neonatal Intensive Care Unit, University Hospital of Bordeaux, Bordeaux, France
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23
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van Bel F, Naulaers G. Cerebral venous volume changes and pressure autoregulation in critically ill infants: an editorial comment. J Perinatol 2020; 40:693-694. [PMID: 32157218 DOI: 10.1038/s41372-020-0646-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 02/24/2020] [Accepted: 02/26/2020] [Indexed: 11/09/2022]
Affiliation(s)
- Frank van Bel
- Department of Neonatology, Wilhelmina Children's Hospital and Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
| | - Gunnar Naulaers
- Department of Neonatology, University Hospitals Leuven, Leuven, Belgium
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24
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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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25
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Cimatti AG, Martini S, Galletti S, Vitali F, Aceti A, Frabboni G, Faldella G, Corvaglia L. Cerebral Oxygenation and Autoregulation in Very Preterm Infants Developing IVH During the Transitional Period: A Pilot Study. Front Pediatr 2020; 8:381. [PMID: 32760685 PMCID: PMC7373744 DOI: 10.3389/fped.2020.00381] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 06/04/2020] [Indexed: 12/22/2022] Open
Abstract
Background: The transitional period, defined as the first 72 h after preterm birth, is often characterized by a significant hemodynamic instability, which represents an important risk factor for such neurological complications of prematurity as intraventricular hemorrhage (IVH). The impairment of cerebral autoregulation plays a key role in the pathogenesis of IVH, whose incidence is highest during the transitional period. This pilot study aimed to evaluate whether patterns of cerebral autoregulation and oxygenation differ in relation to IVH development in very preterm infants during the transitional period. Methods: Infants <32 weeks' gestation were enrolled within 12 h from birth. A simultaneous monitoring of cerebral oxygenation (CrSO2) by near-infrared spectroscopy and of heart rate and peripheral oxygen saturation by pulse oximetry was performed over the first 72 h. Cerebral fractional oxygen extraction (cFTOE) and tissue oxygenation-heart rate reactivity index (TOHRx), which represents a marker of cerebrovascular reactivity, were calculated. Daily cranial and cardiac ultrasound scans were performed, in order to assess the hemodynamic status and to detect a possible IVH onset. CrSO2 and cFTOE, clustered on 6-hour epochs, were compared between infants who developed IVH during the study period and those who did not. A between-group comparison of TOHRx before and after IVH detection was also performed. Results: Twenty preterm infants with a median gestational age of 27 weeks (interquartile range, IQR: 25-30 weeks) and median birth weight of 895 g (IQR: 822-1208 g) were enrolled. Of these, 8 developed IVH. The median age at IVH detection was 40 h (IQR: 30-48 h). Pre-IVH TOHRx was significantly higher compared to matched control periods (p <0.001). CrSO2 was significantly lower from 12 to 30 h and from 42 h onwards in cases compared to controls; however, a temporary CrSO2 rise preceded IVH detection. Similarly, cFTOE was significantly higher in IVH infants from 12 to 30 h and from 48 to 72 h, with a transient decrease between the two periods. Conclusions: In preterm infants during the transitional period, the development of IVH is preceded by transient changes in cerebral oxygenation and oxygen extraction which, in turn, may underlie an early impairment of cerebral autoregulation. Larger studies are needed to confirm these preliminary findings.
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Affiliation(s)
- Anna Giulia Cimatti
- Neonatal Intensive Care Unit, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Silvia Martini
- Neonatal Intensive Care Unit, S. Orsola-Malpighi University Hospital, Bologna, Italy.,Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Silvia Galletti
- Neonatal Intensive Care Unit, S. Orsola-Malpighi University Hospital, Bologna, Italy.,Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Francesca Vitali
- Neonatal Intensive Care Unit, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Arianna Aceti
- Neonatal Intensive Care Unit, S. Orsola-Malpighi University Hospital, Bologna, Italy.,Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Giulia Frabboni
- Neonatal Intensive Care Unit, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Giacomo Faldella
- Neonatal Intensive Care Unit, S. Orsola-Malpighi University Hospital, Bologna, Italy.,Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Luigi Corvaglia
- Neonatal Intensive Care Unit, S. Orsola-Malpighi University Hospital, Bologna, Italy.,Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
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26
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Solanki NS, Hoffman SB. Association between dopamine and cerebral autoregulation in preterm neonates. Pediatr Res 2020; 88:618-622. [PMID: 32005034 PMCID: PMC7223955 DOI: 10.1038/s41390-020-0790-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 01/21/2020] [Accepted: 01/24/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND To test the hypothesis that dopamine is associated with impaired cerebral autoregulation (ICA) in a dose-dependent fashion. METHODS Non a priori designed secondary analysis of a prospectively enrolled cohort study subjects <12 h of life between 240 and 296 weeks gestation. Cerebral saturations (rScO2) and mean arterial blood pressure (MAP) were continuously monitored every 30 s for 96 h. ICA was defined by a 10 min epoch rScO2-MAP correlation coefficient of >0.5. RESULTS Twenty-three of 61 subjects (38%) required dopamine. Time spent with ICA was 23% in dopamine-exposed subjects vs. 14% in those not exposed (p = 0.0001). On the epoch level, time spent with ICA was 15%, 29%, 34%, 37%, and 23% in epochs with dopamine titration of 0, 1-5, 6-10, 11-15, and 16-20 μg/kg/min, respectively. Using mixed-effect modeling, ICA for each dopamine titration was significantly higher than unexposed times when controlling for gestation, presence of a patent ductus arteriosus, day of life, MAP less than gestational age, and illness severity score (p < 0.02). CONCLUSIONS Dopamine exposure during the first 96 h was associated with ICA. Time periods with ICA increased with dopamine exposure in a dose-dependent fashion peaking at a concentration of 11-15 μg/kg/min.
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Affiliation(s)
- Nina S. Solanki
- grid.411024.20000 0001 2175 4264Department of Pediatrics, School of Medicine, University of Maryland Baltimore, Baltimore, MD USA
| | - Suma B. Hoffman
- grid.411024.20000 0001 2175 4264Department of Pediatrics, School of Medicine, University of Maryland Baltimore, Baltimore, MD USA
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