Evidence-based versus pathophysiology-based approach to diagnosis and treatment of neonatal cardiovascular compromise

Noori, Shahab; Seri, István

doi:10.1016/j.siny.2015.03.005

Cited by 36 publications

(15 citation statements)

References 61 publications

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“…Echocardiography provides an objective assessment of cardiac function and allows assessment of the response to therapeutic interventions. Recent reviews describe a pathophysiology-based approach with functional echo as the primary assessment tool used to define the underlying problem and direct therapeutic interventions [24,25]. However, the exact role functional echocardiography has to play is most likely disease specific and evidence that it improves outcome in preterm infants with low blood pressure in the first days needs to be determined.…”

Section: Has Management Changed?mentioning

confidence: 99%

What Should We Do about Low Blood Pressure in Preterm Infants

Dempsey¹

2017

Neonatology

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The management of preterm infants with low blood pressure soon after birth remains unresolved. The definition of what constitutes low blood pressure is uncertain. At birth, mean blood pressure appears to be gestation specific and increases in the first few days of life. Antenatal steroids, delayed cord clamping, and the avoidance of mechanical ventilation are all associated with higher mean blood pressure and less hypotension after birth. Rates of hypotension of 15-50% have been reported in various studies of extremely preterm infants. However, only about 10% of all extremely preterm infants receive inotropes, suggesting that clinicians take into account other factors such as clinical, biochemical, and echocardiographic findings before deciding to intervene. The exact role of functional echocardiography in assessing the need for treatment of low blood pressure in extremely preterm infants remains to be determined. Near- infrared spectroscopy to assess cerebral perfusion may also have a role to play. Volume expansion (usually 10 mL/kg of saline) remains the most commonly used intervention for low blood pressure but evidence of benefit is lacking and there may be safety concerns. Whilst dopamine is the most commonly used inotropic drug, dobutamine, epinephrine, corticosteroids, milrinone, and vasopressin have also been utilised in preterm infants with low blood pressure. Clinical trials with long-term outcomes are needed to determine the most suitable inotrope and when to use it. Early hypotension differs from late hypotension with regard to cause, treatment, and outcome. A number of recent studies aimed at improving the evidence base for the treatment of early hypotension in extremely preterm infants have been terminated early because of poor recruitment. Currently, the answer to the question of what to do about low blood pressure in preterm infants remains unclear.

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Section: Has Management Changed?mentioning

confidence: 99%

What Should We Do about Low Blood Pressure in Preterm Infants

Dempsey¹

2017

Neonatology

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“…Many neonatal and pediatric pathologies or interventions for their management in the intensive care may affect cardiac function. Clinical examination, routine intensive care monitoring, and biochemical parameters lack sensitivity and specificity to assess cardiac function, which can be easily assessed on echocardiography ( 3 , 4 ). In conjunction with clinical examination and routine cardiovascular monitoring, bedside echocardiography is an invaluable tool allowing for real-time, rapid, and reliable diagnostic information necessary for the clinical decision making in sick neonates and children ( 3 ).…”

Section: Introductionmentioning

confidence: 99%

Echocardiographic Evaluation of Ventricular Function—For the Neonatologist and Pediatric Intensivist

2018

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In the neonatal and pediatric intensive care setting, bedside cardiac ultrasound is often used to assess ventricular dimensions and function. Depending upon the underlying disease process, it is necessary to be able to evaluate the systolic and diastolic function of left and or right ventricles. The systolic function of left ventricle is mostly assessed qualitatively on visual inspection “eye-balling” and quantitatively by measuring circumferential fraction shortening or calculating the ejection fraction by Simpson’s planimetry. The assessment of left ventricular diastolic function relies essentially on the mitral valve and pulmonary venous Doppler tracings or tissue Doppler evaluation. The right ventricular particular shape and anatomical position does not permit to use the same parameters for measuring systolic function as is used for the LV. Tricuspid annular plane systolic excursion (TAPSE) and S′ velocity on tissue Doppler imaging are more often used for quantitative assessment of right ventricle systolic function. Several parameters proposed to assess right ventricle systolic function such as fractional area change, 3D echocardiography, speckle tracking, and strain rate are being researched and normal values for children are being established. Diastolic function of right ventricle is evaluated by tricuspid valve and hepatic venous Doppler tracings or on tissue Doppler evaluation. The normal values for children are pretty similar to adults while normal values for the neonates, especially preterm infants, may differ significantly from adult population. The normal values for most of the parameters used to assess cardiac function in term neonates and children have now been established.

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“…[1][2][3] However, the lower threshold of blood pressure leading to reduced brain perfusion has not yet been established in preterm infants 4,5 and it might very well vary both within and between infants. Consequently, more direct methods of monitoring the sufficiency of oxygen supply to the brain are under investigation.…”

Section: Introductionmentioning

confidence: 99%

Quantifying cerebral hypoxia by near-infrared spectroscopy tissue oximetry: the role of arterial-to-venous blood volume ratio

et al. 2017

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"Quantifying cerebral hypoxia by near-infrared spectroscopy tissue oximetry: the role of arterial-tovenous blood volume ratio," J. Biomed. Opt. 22(2), 025001 (2017), doi: 10.1117/1.JBO.22.2.025001. Abstract. Tissue oxygenation estimated by near-infrared spectroscopy (NIRS) is a volume-weighted mean of the arterial and venous hemoglobin oxygenation. In vivo validation assumes a fixed arterial-tovenous volume-ratio (AV-ratio). Regulatory cerebro-vascular mechanisms may change the AV-ratio. We used hypotension to investigate the influence of blood volume distribution on cerebral NIRS in a newborn piglet model. Hypotension was induced gradually by inflating a balloon-catheter in the inferior vena cava and the regional tissue oxygenation from NIRS (rStO 2;NIRS ) was then compared to a reference (rStO 2;COX ) calculated from superior sagittal sinus and aortic blood sample co-oximetry with a fixed AV-ratio. Apparent changes in the AV-ratio and cerebral blood volume (CBV) were also calculated. The mean arterial blood pressure (MABP) range was 14 to 82 mmHg. PaCO 2 and SaO 2 were stable during measurements. rStO 2;NIRS mirrored only 25% (95% Cl: 21% to 28%, p < 0.001) of changes in rStO 2;COX . Calculated AVratio increased with decreasing MABP (slope: −0.007 · mmHg −1 , p < 0.001). NIRS estimates that CBV decreased with decreasing MABP (slope: 0.008 ml∕100 g∕mmHg, p < 0.001). Thus, cerebral NIRS oximetry responded poorly to changes in tissue oxygenation during hypotension induced by decreased preload. An increase in the AV-ratio during hypotension due to arterial vasodilation and, possibly, cerebral venous collapse may be a part of the explanation.

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Evidence-based versus pathophysiology-based approach to diagnosis and treatment of neonatal cardiovascular compromise

Cited by 36 publications

References 61 publications

What Should We Do about Low Blood Pressure in Preterm Infants

What Should We Do about Low Blood Pressure in Preterm Infants

Echocardiographic Evaluation of Ventricular Function—For the Neonatologist and Pediatric Intensivist

Quantifying cerebral hypoxia by near-infrared spectroscopy tissue oximetry: the role of arterial-to-venous blood volume ratio

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