Cerebral Oximetry Monitoring in Extremely Preterm Infants.

BACKGROUND: The use of cerebral oximetry monitoring in the care of extremely preterm infants is increasing. However, evidence that its use improves clinical outcomes is lacking. METHODS: In this randomized, phase 3 trial conducted at 70 sites in 17 countries, we assigned extremely preterm infants (gestational age, <28 weeks), within 6 hours after birth, to receive treatment guided by cerebral oximetry monitoring for the first 72 hours after birth or to receive usual care. The primary outcome was a composite of death or severe brain injury on cerebral ultrasonography at 36 weeks' postmenstrual age. Serious adverse events that were assessed were death, severe brain injury, bronchopulmonary dysplasia, retinopathy of prematurity, necrotizing enterocolitis, and late-onset sepsis. RESULTS: A total of 1601 infants underwent randomization and 1579 (98.6%) were evaluated for the primary outcome. At 36 weeks' postmenstrual age, death or severe brain injury had occurred in 272 of 772 infants (35.2%) in the cerebral oximetry group, as compared with 274 of 807 infants (34.0%) in the usual-care group (relative risk with cerebral oximetry, 1.03; 95% confidence interval, 0.90 to 1.18; P = 0.64). The incidence of serious adverse events did not differ between the two groups. CONCLUSIONS: In extremely preterm infants, treatment guided by cerebral oximetry monitoring for the first 72 hours after birth was not associated with a lower incidence of death or severe brain injury at 36 weeks' postmenstrual age than usual care. (Funded by the Elsass Foundation and others; SafeBoosC-III ClinicalTrials.gov number, NCT03770741.).

Reference Ranges for Arterial Oxygen Saturation, Heart Rate, and Cerebral Oxygen Saturation during Immediate Postnatal Transition in Neonates Born Extremely or Very Preterm.

OBJECTIVE: To define percentile charts for arterial oxygen saturation (SpO2), heart rate (HR), and cerebral oxygen saturation (crSO2) during the first 15 minutes after birth in neonates born very or extremely preterm and with favorable outcome. STUDY DESIGN: We conducted a secondary-outcome analysis of neonates born preterm included in the Cerebral regional tissue Oxygen Saturation to Guide Oxygen Delivery in preterm neonates during immediate transition after birth III (COSGOD III) trial with visible cerebral oximetry measurements and with favorable outcome, defined as survival without cerebral injuries until term age. We excluded infants with inflammatory morbidities within the first week after birth. SpO2 was obtained by pulse oximetry, and electrocardiogram or pulse oximetry were used for measurement of HR. crSO2 was assessed with near-infrared spectroscopy. Measurements were performed during the first 15 minutes after birth. Percentile charts (10th to 90th centile) were defined for each minute. RESULTS: A total of 207 neonates born preterm with a gestational age of 29.7 (23.9-31.9) weeks and a birth weight of 1200 (378-2320) g were eligible for analyses. The 10th percentile of SpO2 at minute 2, 5, 10, and 15 was 32%, 52%, 83%, and 85%, respectively. The 10th percentile of HR at minute 2, 5, 10, and 15 was 70, 109, 126, and 134 beats/min, respectively. The 10th percentile of crSO2 at minute 2, 5, 20, and 15 was 15%, 27%, 59%, and 63%, respectively. CONCLUSIONS: This study provides new centile charts for SpO2, HR, and crSO2 for neonates born extremely or very preterm with favorable outcome. Implementing these centiles in guiding interventions during the stabilization process after birth might help to more accurately target oxygenation during postnatal transition period.

Neonatal somatic oxygenation and perfusion assessment using near-infrared spectroscopy : Part of the series on near-infrared spectroscopy by the European Society of Paediatric Research Special Interest Group "Near-Infrared Spectroscopy".

In this narrative review, we summarize the current knowledge and applications of somatic near-infrared spectroscopy (NIRS), with a focus on intestinal, renal, limb, and multi-site applications in neonates. Assessing somatic oxygenation at various body locations in neonates may aid in the understanding of underlying pathophysiology of organ injury. Considering cerebral autoregulation may be active to protect the brain during systemic circulatory failure, peripheral somatic oxygenation may potentially provide an early indication of neonatal cardiovascular failure and ultimate hypoxemic injury to vital organs including the brain. Certain intestinal oxygenation patterns appear to be associated with the onset and course of necrotizing enterocolitis, whereas impaired renal oxygenation may indicate the onset of acute kidney injury after various types of hypoxic events. Peripheral muscle oxygenation measured at a limb may be particularly effective in the early prediction of shock in neonates. Using multi-site NIRS may complement current approaches and clinical investigations to alert for neonatal tissue hypoxemia, and potentially even guide management. However, somatic NIRS has its inherent limitations in regard to accuracy. Interpretation of organ-specific values can also be challenging. Last, currently there are limited prospective intervention studies, and clinical benefits need to be examined further, after the clarification of critical threshold-values. IMPACT: The assessment of somatic oxygenation using NIRS may contribute to the prediction of specific diseases in hemodynamically challenged neonates. Furthermore, it may give early warning signs for impending cardiovascular failure, and impaired cerebral circulation and oxygenation. We present a comprehensive overview of the literature on applications of NIRS to various somatic areas, with a focus on its potential clinical applicability, including future research directions. This paper will enable prospective standardized studies, and multicenter collaboration to obtain statistical power, likely to advance the field.

Peripheral arterial catheters in extremely preterm infants born at less than 28 weeks of gestation-a single-center experience.

The aim of this study was to perform a retrospective data analysis of established peripheral artery catheters (pAC) in extremely preterm infants. The primary outcome was the pAC life span and its correlation to gestational age, birth weight, localizations, and pAC removal. Retrospective data analysis of electronic patient records of all extremely preterm infants (born less than 28 weeks gestation) admitted to the neonatal intensive care unit in Graz (Austria) between January 2014 and December 2020. A total of 196 preterm infants with a median (IQR) gestational age of 25.7 (24.6-26.6) weeks and a birth weight of 730 (614-898) g were included. In 155 (79%) of these preterm infants, 286 pAC and six umbilical artery catheters were inserted successfully. The first pAC was inserted 2.5 (1.4-7.4) h after birth, and the median pAC life span was 57.5 (22.-107.2) h. Gestational age, birth weight, and catheter localization did not correlate with the pAC life span. The pAC localizations were the radial artery (63%), tibial posterior artery (21%), ulnar artery (6%), dorsal artery of the foot (6%), others (1%), and not documented (3%). Adverse reactions including temporarily impaired peripheral perfusion, local inflammation, extravasation, or bleeding were reported in 13% of all pAC, but none of these resulted in long-term sequelae. A median (IQR) of 9 (5-18) arterial blood samples were drawn via pAC, resulting in a notable reduction of pain stimuli.Conclusion: The use of pAC in extremely preterm infants is feasible and safe. Neither gestational age, birth weight nor localization did affect the life span of pAC. No long-term sequelae were observed, and pain events were reduced by using pAC for blood drawing. What is Known: • Peripheral artery catheters can be used for continuous blood pressure measurement and blood draw even in extremely preterm infants. • (Severe) adverse reactions such as bleeding, necrosis, or amputation occur between 1 and 4%. • What is New: • The median peripheral arty catheter life span is 58 h and is not affected by gestational age, birth weight, nor localization. • A median of nine blood samples can be taken per each single pAC and, therefore, prevent pain events in extremely preterm infants.

Cerebral fractional tissue oxygen extraction (cFTOE) during immediate fetal-to-neonatal transition: a systematic qualitative review of the literature.

Cerebral monitoring during immediate fetal-to-neonatal transition is of increasing interest. The cerebral fractional tissue oxygen extraction (cFTOE) is a useful parameter to gain insight in the balance between tissue oxygen delivery and consumption during this complex process. The aim of this study was to review the literature on cFTOE during the first 15 min immediately after birth. A systematic qualitative literature research was last performed on 23 November 2023 of PubMed and EMBASE with the following search terms: neonate, infant, newborn, transition, after birth, delivery room, NIRS, near-infrared spectroscopy, spectroscopy, cFTOE, cerebral fractional tissue oxygenation extraction, cerebral oxygenation, and fractional oxygen extraction. Additional published reports were identified through a manual search of references in retrieved articles and in review articles. The methodological quality of the included studies was assessed by predefined quality criteria. Only human studies with data of cFTOE in the first 15 min after birth were included. Accordingly, exclusion criteria were defined as no measurement of cFTOE or no measurement within the first 15 min after birth. Across all studies, a total of 3566 infants (2423 term, 1143 preterm infants) were analysed. Twenty-five studies were identified describing cFTOE within the first 15 min after birth. Four studies established reference ranges for cFTOE and another four studies focused on the effect of pre-/perinatal circumstances on cFTOE in the first 15 min after birth. Six studies investigated the course of cFTOE after transition in infants without complications. Eleven studies analysed different potentially influencing parameters on cFTOE during transition. CONCLUSION: This systematic review provides a comprehensive insight on cFTOE during uncomplicated transition as well as the influence of perinatal circumstances, respiratory, haemodynamic, neurological, and laboratory parameters in preterm and term infants. WHAT IS KNOWN: • The NIRS-measured cerebral fractional tissue oxygen extraction (cFTOE) is a useful parameter to estimate the balance between oxygen delivery and consumption. • During normal transition, the cFTOE decreases in the first minutes after birth and then remains at a stable plateau. WHAT IS NEW: • The cFTOE is a promising parameter that gives additional information on cerebral oxygenation and perfusion in preterm and term infants. • Several hemodynamic, metabolic, respiratory, and perinatal factors are identified, influencing the oxygen extraction of the newborn's brain after birth.

Cardiac output calculation using the Liljestrand and Zander formula: is this method applicable during immediate transition after birth? - A post hoc analysis.

The transition from intrauterine to extrauterine life is a critical period for neonates. Assessing the cardiovascular transition during this period immediately after birth is crucial but challenging. The present study compares adjusted estimated cardiac output values calculated by the Liljestrand and Zander formula (COest/adj LaZ) with non-invasively measured cardiac output values (CO-bioimpedance) during immediate transition after birth. We performed a secondary outcome analysis of a prospective observational study in preterm and term neonates. Ten and 15 min after birth, arterial blood pressure and heart rate were assessed, and CO-bioimpedance was measured using electrical bioimpedance method (Aesculon monitor, Osypka, Germany). We calculated COest/adj LaZ and compared it to CO-bioimpedance. Further, we performed a correlation analysis. Thirty-two neonates with a median (IQR) gestational age of 37.0 (32.0-39.4) weeks were included. Mean ± SD CO-bioimpedance was 0.62 ± 0.15 l/min, and COest/adj LaZ was calculated to be 0.64 ± 0.10 l/min, whereby both correlated significantly (p = 0.025, r = 0.359) with each other.  Conclusion: The present study demonstrates high comparability of COest/adj LaZ and CO-bioimpedance in neonates during immediate transition after birth, suggesting that cardiac output can be derived in a cost-effective and feasible manner if other methods are not available. What is Known: • Echocardiography is considered the gold standard for non-invasive CO evaluation, but its feasibility during the immediate transition period is limited. What is New: • Non-invasive methods such as CO-bioimpedance for cardiac output (CO) measurement and the Liljestrand and Zander (LaZ) formula for estimating CO offer promising alternatives during the immediate transition period.

Cerebral oxygenation during immediate fetal-to-neonatal transition and fidgety movements between six to 20 weeks of corrected age: An ancillary study to the COSGOD III trial.

Fidgety movements provide early information about a potential development of cerebral palsy in preterm neonates. The aim was to assess differences in the combined outcome of mortality and fidgety movements defined as normal or pathological in very preterm neonates according to the group allocation in the randomised-controlled multicentre COSGOD III trial. Preterm neonates of two centres participating in the COSGOD III trial, whose fidgety movements were assessed as normal or pathological at six to 20 weeks of corrected age, were analysed. In the COSGOD III trial cerebral oxygen saturation (crSO2) was measured by near-infrared spectroscopy (NIRS) during postnatal transition and guided resuscitation in preterm neonates randomised to the NIRS-group, whereby medical support was according routine, as it was also in the control group. Fidgety movements were classified in normal or abnormal/absent at six to 20 weeks of corrected age. Mortality and fidgety movements of preterm neonates allocated to the NIRS-group were compared to the control-group. Normal outcome was defined as survival with normal fidgety movements. One-hundred-seventy-one preterm neonates were included (NIRS-group n = 82; control-group n = 89) with a median gestational age of 29.4 (27.4-30.4) and 28.7 (26.7-31.0) weeks in the NIRS-group and the control-group, respectively. There were no differences in the combined outcome between the two groups: 90.2% of the neonates in the NIRS-group and 89.9% in the control-group survived with normal outcome (relative risk [95% CI]; 0.96 [0.31-2.62]).Conclusions: In the present cohort of preterm neonates, monitoring of crSO2 and dedicated interventions in addition to routine care during transition period after birth did not show an impact on mortality and fidgety movements defined as normal or pathological at six to 20 weeks corrected age. What is Known • Fidgety movements display early spontaneous motoric pattern and may provide early information about a potential development of cerebral palsy in preterm neonates.  What is New  â€¢ This retrospective observational study of the randomised-controlled multicentre COSGOD III trial is the first study investigating the potential influence of cerebral oxygenation guided resuscitation during postnatal transition period on combined outcome of mortality and fidgety movements up to 20 weeks of corrected age in very preterm neonates. • This study adds to the growing interest of assessing cerebral oxygenation, that monitoring of cerebral oxygen saturation and dedicated interventions during postnatal transition period according to the COSGOD III trial has no significant influence on mortality and fidgety movements defined as normal or pathological in very preterm neonates.

Impact of in situ simulation training on quality of postnatal stabilization and resuscitation-a before-and-after, non-controlled quality improvement study.

This study aimed to evaluate the impact of in situ simulation-based training on quality indicators of patient care at a level IV neonatal intensive care unit. A before-and-after, non-controlled quality improvement study was performed at the Division of Neonatology, Medical University of Graz. The educational intervention comprised a period of 4 months, with structured in situ simulation training delivered regularly for neonatal providers and nurses in interprofessional teams. The primary study outcome was the quality of non-technical skills and team interaction during actual postnatal stabilization and resuscitation. This was assessed using video recording during two 2-month observational phases before (pre-training) and after the educational intervention (post-training). Delivery room video recordings were assessed by two external, blinded neonatologists using the Anaesthetists' Non-Technical Skills (ANTS) score. Furthermore, we collected clinical patient data from video-recorded neonates during the pre- and post-training periods, and training participants' individual knowledge of neonatal resuscitation guidelines was assessed using a before- and after-questionnaire. A total of 48 healthcare professionals participated in 41 in situ simulation trainings. The level of non-technical skills and team interaction was already high in the pre-training period, and it did not further improve afterwards. Nonetheless, we observed a significant increase in the teamwork event "evaluation of plans" (0.5 [IQR 0.0-1.0] versus 1.0 [1.0-2.0], p = 0.049). Following the educational intervention, training participants' knowledge of neonatal resuscitation guidelines significantly improved, although there were no differences in secondary clinical outcome parameters. CONCLUSION: We have successfully implemented a neonatal in situ simulation training programme. The observed improvement in one teamwork event category in the post-training period demonstrates the effectiveness of the training curriculum, while also showing the potential of in situ simulation training for improving postnatal care and, ultimately, patient outcome. WHAT IS KNOWN: • In situ simulation-based training is conducted in the real healthcare environment, thus promoting experiential learning which is closely aligned with providers' actual work. • In situ simulation-based training may offer an additional benefit for patient outcomes in comparison to other instructional methodologies. WHAT IS NEW: • This observational study investigated translational patient outcomes in preterm neonates before and after delivery of high-frequency in situ simulation-based training at a level IV neonatal intensive care unit. • There was a significant increase in the frequency of one major teamwork event following the delivery of in situ simulation-based training, indicating a notable improvement in the non-technical skills domain, which is closely linked to actual team performance.

Precision and normal values of cerebral blood volume in preterm neonates using time-resolved near-infrared spectroscopy.

AIM: To investigate cerebral blood volume (CBV) in preterm neonates using time-resolved near-infrared spectroscopy. METHODS: In this prospective observational study, time-resolved near-infrared spectroscopy measurements of CBV using tNIRS-1 were performed in 70 preterm neonates. For measurements, a sensor was placed for a duration of 1 min, followed by four further reapplications of the sensor, overall five measurements. RESULTS: In this study, 70 preterm neonates with a mean ± SD gestational age of 33.4 ± 1.7 weeks and a birthweight of 1931 ± 398 g were included with a postnatal age of 4.7 ± 2.0 days. Altogether, 2383 CBV values were obtained with an overall mean of 1.85 ± 0.30 mL/100 g brain. A total of 95% of the measured CBV values varied in a range from -0.31 to 0.33 from the overall individual mean. Taking the deviation of the mean of each single application for each patient, this range reduced from -0.07 to 0.07. The precision of the measurement defined as within-variation in CBV was 0.24 mL/100 g brain. CONCLUSION: The overall mean CBV in stable preterm neonates was 1.85 ± 0.30 mL/100 g brain. The within-variation in CBV was 0.24 mL/100 g brain. Based on the precision obtained by our data, CBV of 1.85 ± 0.30 mL/100 g brain may be assumed as normal value for this cohort.

Physiological-based cord clamping stabilised cardiorespiratory parameters in very low birth weight infants.

AIM: We investigated the influence of physiological-based cord clamping (PBCC) on cardiorespiratory stability in very low birth weight (VLBW) infants during the first 72 h of life. METHODS: This retrospective study comprised VLBW infants born at <32 + 0 weeks of gestation and admitted to the neonatal intensive care unit of the Medical University of Graz, Austria, from December 2014 to April 2021. VLBW infants delivered with PBCC were matched by gestational age and birth weight to delayed cord clamping controls. The PBCC group was stabilised after birth with an intact cord. Routine monitoring parameters were compared between the groups. RESULTS: We included 54 VLBW infants. The mean gestational ages of the PBCC group and controls were 27.4 ± 1.9 versus 27.4 ± 1.8 weeks (p = 0.87), and the mean birth weights were 912 ± 288 versus 915 ± 285 g (p = 0.96), respectively. The mean cord clamping time was 191 ± 78 s in the PBCC group. Heart rate was lower in the PBCC group during the first 3 days after birth, reaching significance by 10 h. Other monitoring parameters did not reveal any differences between the two groups. CONCLUSION: PBCC stabilised cardiorespiratory parameters in VLBW infants. The lower heart rate in the PBCC group suggested higher blood volume following intact cord resuscitation.

Reference ranges of peripheral-muscle oxygenation in term neonates delivered by Caesarean section during immediate transition after birth.

AIM: To establish reference ranges of peripheral-muscle regional oxygen saturation (prSO2) and peripheral fractional tissue oxygen extraction (pFTOE) during the first 15 min after birth in stable term neonates. METHODS: Secondary outcome parameters of prospective observational studies in healthy term neonates delivered by Caesarean section were analysed. prSO2 was measured on the right forearm using the INVOS 5100C monitor. pFTOE was calculated out of prSO2 and arterial oxygen saturation (SpO2). Centile charts (10th-90th) of prSO2 and pFTOE were defined during the first 15 min after birth. RESULTS: Three-hundred-five term neonates with a mean gestational age and birth weight of 39.0 ± 0.9 weeks and 3321 ± 454 g, respectively, were included. The 50th centiles of prSO2 were 39% (minute two), 52% (minute five), 71% (minute 10), and 73% (minute 15). The 50th centiles of pFTOE were 0.529 (minute two), 0.378 (minute five), 0.237 (minute 10), and 0.231 (minute 15). CONCLUSION: Reference ranges of prSO2 and pFTOE were established for term neonates delivered by Caesarean section during the immediate transition after birth. These reference ranges increase knowledge of physiological processes taking place immediately after birth and are necessary for possible future clinical applications.

Cerebral oxygenation immediately after birth and long-term outcome in preterm neonates-a retrospective analysis.

BACKGROUND: Prematurity is associated with increased risk for morbidity and mortality. Aim of this study was to evaluate whether cerebral oxygenation during fetal-to-neonatal transition period was associated with long-term outcome in very preterm neonates. METHODS: Preterm neonates ≤ 32 weeks of gestation and/or ≤ 1500 g with measurements of cerebral regional oxygen saturation (crSO2) and cerebral fractional tissue oxygen extraction (cFTOE) within the first 15 min after birth were analysed retrospectively. Arterial oxygen saturation (SpO2) and heart rate (HR) were measured with pulse oximetry. Long-term outcome was assessed at two years using "Bayley Scales of Infant Development" (BSID-II/III). Included preterm neonates were stratified into two groups: adverse outcome group (BSID-III ≤ 70 or testing not possible due to severe cognitive impairment or mortality) or favorable outcome group (BSID-III > 70). As the association between gestational age and long-term outcome is well known, correction for gestational age might disguise the potential association between crSO2 and neurodevelopmental impairment. Therefore, due to an explorative approach the two groups were compared without correction for gestational age. RESULTS: Forty-two preterm neonates were included: adverse outcome group n = 13; favorable outcome group n = 29. Median(IQR) gestational age and birth weight were 24.8 weeks (24.2-29.8) and 760 g (670-1054) in adverse outcome group and 30.6 weeks (28.1-32.0) (p = 0.009*) and 1250 g (972-1390) (p = 0.001*) in the favorable outcome group, respectively. crSO2 was lower (significant in 10 out of 14 min) and cFTOE higher in adverse outcome group. There were no difference in SpO2, HR and fraction of inspired oxygen (FiO2), except for FiO2 in minute 11, with higher FiO2 in the adverse outcome group. CONCLUSION: Preterm neonates with adverse outcome had beside lower gestational age also a lower crSO2 during immediate fetal-to-neonatal transition when compared to preterm neonates with age appropriate outcome. Lower gestational age in the adverse outcome group would suggest beside lower crSO2 also lower SpO2 and HR in this group, which were however similar in both groups.

Cardiac output and regional-cerebral-oxygen-saturation in preterm neonates during immediate postnatal transition: An observational study.

AIM: To examine potential correlations between cardiac output (CO) with cerebral-regional-oxygen-saturation (crSO2 ) and cerebral-fractional-tissue-oxygen-extraction (cFTOE) during immediate foetal-to-neonatal transition in term and preterm neonates with and without respiratory support. METHODS: Post hoc analyses of secondary outcome parameters of prospective observational studies were performed. We included neonates with cerebral near-infrared-spectroscopy (NIRS) monitoring and an oscillometric blood pressure measurement at minute 15 after birth. Heart rate (HR) and arterial oxygen saturation (SpO2 ) were monitored. CO was calculated with Liljestrand and Zander formula and correlated with crSO2 and cFTOE. RESULTS: Seventy-nine preterm neonates and 207 term neonates with NIRS measurements and calculated CO were included. In 59 preterm neonates (mean gestational age (GA): 29.4 ± 3.7 weeks) with respiratory support, CO correlated significantly positively with crSO2 and significantly negatively with cFTOE. In 20 preterm neonates (GA 34.9 ± 1.3 weeks) without respiratory support and in 207 term neonates with and without respiratory support, CO correlated neither with crSO2 nor with cFTOE. CONCLUSION: In compromised preterm neonates with lower gestational age and in need of respiratory support, CO was associated with crSO2 and cFTOE, whereas in stable preterm neonates with higher gestational age as well as in term neonates with and without respiratory support, no associations were observed.

Fetal to neonatal transition: what additional information can be provided by cerebral near infrared spectroscopy?

This narrative review focuses on the clinical use and relevance of cerebral oxygenation measured by NIRS during fetal to neonatal transition. Cerebral NIRS(cNIRS) offers the possibility of non-invasive, continuous, and objective brain monitoring in addition to the recommended routine monitoring. During the last decade, with growing interest in early and sensitive brain monitoring, many research groups worldwide have been working with cNIRS and verified the feasibility of cNIRS monitoring immediately after birth. Cerebral hypoxia during fetal to neonatal transition, defined as cerebral oxygenation values below10th percentile, seems to have an impact on neurological outcomes. Feasibility to guide clinical support using cNIRS to reduce the burden of cerebral hypoxia has been shown. It is well known that in some cases cerebral oxygenation follows different patterns than SpO2. Cerebral oxygenation does not only depend on systemic oxygenation, hemoglobin content and cerebral blood flow, but also on cardiocirculatory condition, ventilation, and metabolic parameters. Hence, measurement of cerebral oxygenation may uncover problems not detectable by standard monitoring. Therefore, applying NIRS can provide caregivers a more complete clinical overview, especially in critically ill neonates. In this review, we aim to describe the additional information which can be provided by cNIRS during fetal to neonatal transition. IMPACT: This narrative review focuses on the clinical use and relevance of cerebral oxygenation measured by near infrared spectroscopy (NIRS) during fetal to neonatal transition. During the last decade, interest on brain monitoring is growing continuously as the measurement of cerebral oxygenation may uncover problems which are not detectable by routine monitoring. Therefore, it will be crucial to have additional information to get a complete overview, especially in critically ill neonates in need of medical and respiratory support. In this review, we offer additional information which can be provided by cerebral NIRS during fetal to neonatal transition.

Acid base and blood gas analysis in term neonates immediately after birth with uncomplicated neonatal transition.

BACKGROUND: Acid base and blood gas measurements provide essential information, especially in critically ill neonates. After birth, rapidly changing physiology and difficulty to obtain blood samples represent unique challenges. OBJECTIVES: The aim of the present study was to establish normal values of capillary acid base and blood gas analysis immediately after birth in term neonates after uncomplicated neonatal transition. METHOD: This is a post-hoc-analysis of ancillary outcome parameter of a prospective observational study in term neonates immediately after caesarean section. Neonates were included after immediate neonatal transition without need of medical support and a capillary blood sample was taken by a heel-stick within 15-20 minutes after birth. RESULT: One hundred thirty-two term neonates were included with mean (SD) gestational age of 38.7 ± 0.7 weeks. The blood was drawn mean (SD) 16 ± 1.7 minutes after birth. The mean (SD) values of the analyses were: pH 7.30 ± 0.04, pCO2 52.6 ± 6.4, base excess - 0.9 ± 1.7 and bicarbonate 24.8 ± 1.6. CONCLUSION: This is the first study describing acid base and blood gas analyses in term neonates immediately after birth with uncomplicated neonatal transition.

Normal regional tissue oxygen saturation in neonates: a systematic qualitative review.

BACKGROUND: The aim of this systematic qualitative review was to give an overview of reference ranges defined as normal values or centile charts of regional tissue oxygen saturation measured by near-infrared spectroscopy (NIRS) in term and preterm neonates. METHODS: A systematic search of MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials was performed. Additional articles were identified by manual search of cited references. Only human studies in neonates were included. RESULTS: Nineteen studies were identified. Eight described regional tissue oxygen saturation during fetal-to-neonatal transition, six during the first 3 days after birth, four during the first 7 days after birth, and one during the first 8 weeks after birth. Nine described regional tissue oxygen saturation in term, nine in preterm neonates, and one in both. Eight studies published centile charts for cerebral regional tissue oxygen saturation, and only five included large cohorts of infants. Eleven studies described normal values for cerebral, muscle, renal, and abdominal regional tissue oxygen saturation, the majority with small sample sizes. Four studies of good methodological quality were identified describing centile charts of cerebral regional tissue oxygen saturation. CONCLUSIONS: In clinical settings, quality centile charts are available and should be the preferred method when using NIRS monitoring. IMPACT: Near-infrared spectroscopy (NIRS) enables a bed-side non-invasive continuous monitoring of tissue oxygenation. When using NIRS monitoring in a clinical setting, centile charts with good quality are available and should be preferred to normal values. High-quality reference ranges of regional tissue oxygenation in term and preterm born neonates are an important step toward routine clinical application of NIRS.

Comparison of frequency-domain and continuous-wave near-infrared spectroscopy devices during the immediate transition.

BACKGROUND: Non-invasive monitoring of cerebral tissue oxygen saturation (rcSO2) during transition is of growing interest. Different near-infrared spectroscopy (NIRS) techniques have been developed to measure rcSO2. We compared rcSO2 values during the immediate transition in preterm neonates measured with frequency-domain NIRS (FD-NIRS) with those measured with continuous-wave NIRS (CW-NIRS) devices in prospective observational studies. METHODS: We compared rcSO2 values measured with an FD-NIRS device during the first 15 min after birth in neonates with a gestational age ≥ 30 weeks but < 37 weeks born at the Erasmus MC- Sophia Children's Hospital, Rotterdam, the Netherlands, with similar values measured with a CW-NIRS device in neonates born at the Medical University of Graz, Austria. Mixed models were used to adjust for repeated rcSO2 measurements, with fixed effects for time (non-linear), device, respiratory support and the interaction of device and respiratory support with time. Additionally, parameters such as total haemoglobin concentration and oxygenated and deoxygenated haemoglobin concentrations measured by FD-NIRS were analysed. RESULTS: Thirty-eight FD-NIRS measurements were compared with 58 CW-NIRS measurements. The FD-NIRS rcSO2 values were consistently higher than the CW-NIRS rcSO2 values in the first 12 min, irrespective of respiratory support. After adjustment for respiratory support, the time-dependent trend in rcSO2 differed significantly between techniques (p < 0.01). CONCLUSION: As cerebral saturation measured with the FD-NIRS device differed significantly from that measured with the CW-NIRS device, differences in absolute values need to be interpreted with care. Although FD-NIRS devices have technical advantages over CW-NIRS devices, FD-NIRS devices may overestimate true cerebral oxygenation and their benefits might not outweigh the usability of the more clinically viable CW-NIRS devices.

Cerebral and peripheral tissue oxygenation in stable neonates: Absent influence of cardiac function.

AIM: Cardiac function is a major factor for tissue perfusion and therefore may affect the tissue oxygen saturation. Aim was to analyse possible associations between cardiac function parameters and cerebral and peripheral tissue oxygenation in neonates on the first day after birth. METHODS: For the present study, we analysed secondary outcome parameters of a previously performed prospective single centre observational study. The prospective study was conducted at the Medical University of Graz, Austria between September 2011 and June 2013. We included preterm and term neonates who were admitted to the neonatal intensive care unit and in whom simultaneous near-infrared spectroscopy measurements and echocardiography were obtained on the first day after birth. Cardiac function parameters were correlated to cerebral and peripheral tissue oxygen saturation and cerebral and peripheral fractional tissue oxygen extraction at the time of echocardiography. RESULTS: A total of 60 neonates of whom 47 were preterm and 13 were term (median gestational age: 34; IQR 33-35 weeks, mean birth weight: 2276 ± 774 grams) were included. There were no statistically significant correlations between cardiac function parameters and regional tissue oxygenation parameters. CONCLUSION: In the present study, we found no correlation between regional tissue oxygenation and parameters of cardiac function in cardio-circulatory stable neonates on the first day after birth.

No neurodevelopmental benefit of cerebral oximetry in the first randomised trial (SafeBoosC II) in preterm infants during the first days of life.

AIM: Cerebral hypoxia has been associated with neurodevelopmental impairment. We studied whether reducing cerebral hypoxia in extremely preterm infants during the first 72 hours of life affected neurological outcomes at two years of corrected age. METHODS: In 2012-2013, the phase II randomised Safeguarding the Brains of our smallest Children trial compared visible cerebral near-infrared spectroscopy (NIRS) monitoring in an intervention group and blinded NIRS monitoring in a control group. Cerebral hypoxia was significantly reduced in the intervention group. We followed up 115 survivors from eight European centres at two years of corrected age, by conducting a medical examination and assessing their neurodevelopment with the Bayley Scales of Infant and Toddler Development, Second or Third Edition, and the parental Ages and Stages Questionnaire (ASQ). RESULTS: There were no differences between the intervention (n = 65) and control (n = 50) groups with regard to the mean mental developmental index (89.6 ± 19.5 versus 88.4 ± 14.7, p = 0.77), ASQ score (215 ± 58 versus 213 ± 58, p = 0.88) and the number of children with moderate-to-severe neurodevelopmental impairment (10 versus six, p = 0.58). CONCLUSION: Cerebral NIRS monitoring was not associated with long-term benefits or harm with regard to neurodevelopmental outcome at two years of corrected age.

Novel algorithm to screen for heart murmurs using computer-aided auscultation in neonates: a prospective single center pilot observational study.

BACKGROUND: Automated detection of heart murmurs with computer-aided auscultation is not yet in clinical routine use. Aim of this study was to test sensitivity and specificity of a novel prototype algorithm in automated detection of heart murmurs from digitally recorded phonocardiograms in neonates admitted at the Neonatal Intensive Care Unit. METHODS: In a prospective pilot observational study from November 2012 to December 2013 auscultations by pediatricians and computer aided auscultation were performed within 12 hours of neonatal echocardiography. Echocardiography was defined as pathological when resulting in any clinical consequences or causing murmur. Phonocardiograms and auscultation were defined as pathological if a murmur was detected. Phonocardiograms were analyzed offline with a novel algorithm prototype (CSD Labs, Graz, Austria) for detection of murmurs in neonates in a first run and with an optimized algorithm in a second run and were compared with echocardiography. Sensitivity and specificity of auscultation by pediatrician and computer aided auscultation were analyzed. RESULTS: Thirty-six neonates (gestational age: 36±3 weeks) were included. Twenty-three (64%) neonates had pathological or murmur causing findings in echocardiography (positive echocardiography). Sensitivity and specificity of auscultation by pediatrician were 17% and 100%, respectively. In comparison to auscultation by pediatrician sensitivity of first run and second run were significantly higher with 70% and 83%, respectively. Specificity of first run and second run were 77% and 85%, respectively. CONCLUSIONS: Phonocardiogram analysis using the novel algorithm prototype had a higher sensitivity than auscultation by pediatrician in detecting positive echocardiography findings in neonates.