ABSTRACT
OBJECTIVE: To evaluate postprocedural clinical characteristics of preterm infants undergoing transcatheter patent ductus arteriosus (PDA) closure, including oxygenation/ventilation failure and cardiovascular compromise. STUDY DESIGN: Multicenter retrospective cohort study of preterm infants who were ≤2 kg at the time of percutaneous PDA closure between August 2018 and July 2021. Indices of cardiorespiratory stability were collected pre-closure, immediately post-closure, and subsequently averaged every 4 hours for the first 24 hours post-procedure. The primary outcome was incidence of post-transcatheter cardiorespiratory syndrome: composite of hemodynamic instability (defined by systemic hypotension, systemic hypertension, or use of new inotropes/vasopressors in the first 24 hours after catheterization) and at least one of the following: (i) ventilation failure or (ii) oxygenation failure. RESULTS: A total of 197 patients were included with a median [IQR] age and weight at catheterization of 34 [25, 43] days and 1090 [900, 1367] grams, respectively. The primary composite outcome of post-transcatheter cardiorespiratory syndrome was reported in 46 (23.3%). CONCLUSION: Post-transcatheter cardiorespiratory syndrome is characterized primarily by systemic hypertension and oxygenation failure, with a very low incidence of hypotension and need for inotropes.
Subject(s)
Cardiac Catheterization , Ductus Arteriosus, Patent , Infant, Premature , Postoperative Complications , Humans , Ductus Arteriosus, Patent/surgery , Retrospective Studies , Male , Female , Cardiac Catheterization/adverse effects , Cardiac Catheterization/methods , Infant, Newborn , Postoperative Complications/epidemiology , Postoperative Complications/etiology , Infant , Cohort StudiesABSTRACT
Rationale: Increasing survival of extremely preterm infants with a stable rate of severe intraventricular hemorrhage represents a growing health risk for neonates. Objectives: To evaluate the role of early hemodynamic screening (HS) on the risk of death or severe intraventricular hemorrhage. Methods: All eligible patients 22-26+6 weeks' gestation born and/or admitted <24 hours postnatal age were included. As compared with standard neonatal care for control subjects (January 2010-December 2017), patients admitted in the second epoch (October 2018-April 2022) were exposed to HS using targeted neonatal echocardiography at 12-18 hours. Measurements and Main Results: A primary composite outcome of death or severe intraventricular hemorrhage was decided a priori using a 10% reduction in baseline rate to calculate sample size. A total of 423 control subjects and 191 screening patients were recruited with a mean gestation and birth weight of 24.7 ± 1.5 weeks and 699 ± 191 g, respectively. Infants born at 22-23 weeks represented 41% (n = 78) of the HS epoch versus 32% (n = 137) of the control subjects (P = 0.004). An increase in perinatal optimization (e.g., antepartum steroids) but with a decline in maternal health (e.g., increased obesity) was seen in the HS versus control epoch. A reduction in the primary outcome and each of severe intraventricular hemorrhage, death, death in the first postnatal week, necrotizing enterocolitis, and severe bronchopulmonary dysplasia was seen in the screening era. After adjustment for perinatal confounders and time, screening was independently associated with survival free of severe intraventricular hemorrhage (OR 2.09, 95% CI [1.19, 3.66]). Conclusions: Early HS and physiology-guided care may be an avenue to further improve neonatal outcomes; further evaluation is warranted.
Subject(s)
Bronchopulmonary Dysplasia , Infant, Premature, Diseases , Infant , Pregnancy , Female , Infant, Newborn , Humans , Infant, Extremely Premature , Infant, Premature, Diseases/diagnostic imaging , Gestational Age , HemorrhageABSTRACT
PURPOSE: Left atrium to aortic root ratio (LA/Ao) is an echocardiographic marker of hemodynamically significant patent ductus arteriosus (PDA). Since 2-dimensional measurement of the ratio is geometrically limited, left atrial volume (LAV) which has 3-dimensional characteristics was investigated. The aim of this study was to determine a correlation between LA/Ao ratio and LAV as well as holodiastolic flow reversal in preterm neonates with and without a PDA. METHODS: A retrospective evaluation of neonates with and without PDA was performed. Targeted neonatal echocardiography evaluation of LA/Ao and LAV was measured from parasternal long-axis view and the apical 4 and 2-chamber views, respectively. Univariate and linear regression analysis were performed. RESULTS: 200 patients were included of whom 158 (79.0%) had a PDA shunt. The median gestational age at the time of echo was 27.4 weeks (IQR: 25.7-29.4 weeks). The median LA/Ao ratio was 1.51 (IQR: 1.26-1.83) and median LAV indexed to weight was .91 mL/kg (IQR: .65-1.18 mL/kg). There was a significant correlation between LA/Ao and LAV indexed to weight in the PDA group (r2 = .080, p = .0003). LA/Ao ratio and LAV indexed to weight differed significantly between those with diastolic flow reversal versus no-flow reversal (LA/Ao, p = .003; LAV, p = .001). CONCLUSIONS: This study demonstrated a significant correlation between LA/Ao and LAV in preterm infants with PDA, with greater magnitude of discordance for LAV. The power of LAV versus LA/Ao in monitoring hemodynamically significant PDA requires prospective evaluation.
Subject(s)
Ductus Arteriosus, Patent , Echocardiography , Heart Atria , Infant, Premature , Humans , Ductus Arteriosus, Patent/physiopathology , Ductus Arteriosus, Patent/diagnostic imaging , Infant, Newborn , Female , Male , Retrospective Studies , Heart Atria/diagnostic imaging , Heart Atria/physiopathology , Echocardiography/methods , Aorta/diagnostic imaging , Aorta/physiopathologyABSTRACT
OBJECTIVE: An alternative therapy for preterm infants with a hemodynamically significant patent ductus arteriosus (hsPDA) is needed when cyclooxygenase inhibitors fail or where treatment is contraindicated due to coexisting renal failure, necrotizing enterocolitis, and/or intestinal perforation. No studies have evaluated the efficacy of per rectum (PR) acetaminophen. The study aimed to evaluate the efficacy of PR acetaminophen in modulating the risk of PDA ligation. STUDY DESIGN: A retrospective matched case-control study was conducted to compare neonates born <29 weeks' gestation with evidence of hsDA, in an era when rescue rectal acetaminophen was used (January 2014-March 2018) as a treatment strategy, versus historical controls (July 2006-August 2012). All patients underwent comprehensive echocardiography assessment of ductal shunt volume according to a standardized protocol. Acetaminophen treated neonates were matched according to demographics, gestation, preintervention echocardiography features, and comorbidities. Control patients were selected when an echocardiography was performed at an equivalent postnatal age. Infants with a genetic syndrome, severe congenital malformation, or major forms of congenital heart disease excluding small atrial septal defect or ventricular septal defect, PDA, or patent formale ovale were excluded. The primary outcome was surgical ligation of the PDA. Secondary outcomes included echocardiography indices of hemodynamic significance, the composite of death, or severe BPD (defined by ventilator dependence at 36 weeks postmenstrual age). Descriptive statistics and univariate (t-tests, Fisher's exact test, and Mann-Whitney U test) analyses were used to evaluate clinical and echocardiography characteristics of the groups and compare outcomes. RESULTS: Forty infants (20 cases and 20 controls), with similar demographic and echocardiography features, were compared. Cases received 6.8 ± 0.7 days (60 mg/kg/day) of PR acetaminophen. Responders (n = 12, 60%) had echocardiography evidence of reduced ductal diameter (2.2 mm [1.9-2.6] to 1.1 mm [0-1.7], p = 0.002), left ventricular output (363 ± 108-249 ± 61 mL/min/kg; p = 0.002) and left atrium to aortic root ratio (1.7 ± 0.3-1.3 ± 0.2; p = 0.002) following treatment. The rate of PDA ligation was 50% lower (p = 0.02) and composite outcome of death or severe bronchopulmonary dysplasia was reduced (p = 0.04) in the acetaminophen group. CONCLUSION: Rectal acetaminophen was associated with improvement in echocardiography indices of PDA shunt volume, a 50% reduction in PDA ligation rates and a reduction in the composite outcome of death or severe BPD. Pharmacologic and further prospective clinical studies are needed. KEY POINTS: · Many preterm infants encounter the clinical consequences of a hemodynamically significant PDA.. · The merits and optimal timing of PDA ligation remains an area of controversy amongst neonatologists.. · Cyclooxygenase inhibitors are associated with adverse events or are often contraindicated..
Subject(s)
Ductus Arteriosus, Patent , Infant, Extremely Premature , Infant , Infant, Newborn , Humans , Ductus Arteriosus, Patent/diagnostic imaging , Ductus Arteriosus, Patent/drug therapy , Ductus Arteriosus, Patent/surgery , Acetaminophen/therapeutic use , Retrospective Studies , Case-Control Studies , Rectum , Cyclooxygenase Inhibitors/therapeutic use , LigationABSTRACT
Arteriovenous malformations may present with significant haemodynamic compromise in the neonatal period, typically with high output cardiac failure that may be accompanied by hypoxia and right ventricular dysfunction. Targeted neonatal echocardiography performed by trained neonatologists provides an enhanced physiology-based approach that can guide treatment and minimise complications. We present a case of a large hepatic vascular malformation whose therapy was guided by targeted neonatal echocardiography to prevent paradoxical embolisation of procedural glue to the systemic circulation.
Subject(s)
Arteriovenous Malformations , Embolization, Therapeutic , Arteriovenous Malformations/diagnostic imaging , Arteriovenous Malformations/therapy , Echocardiography , Hemodynamics , Humans , Infant, Newborn , Nitric OxideABSTRACT
Evidence suggests that both high and low birth weight children have increased the risk for obesity and the metabolic syndrome in adulthood. Previously we have found altered feeding behaviour and food preferences in pre-school children and adults born with low birth weight. In this study, we investigated if birth weight was associated with different intake of fat, carbohydrate and/or protein at 6-12 years of age. This is a cross-sectional study where 255 guardians answered online and telephone questions including anthropometrics and demographic data, parental family food rules (food control, encouragement and restriction) and a complete web-based FFQ for their children (130 boys and 125 girls). Baseline demographic and parental food rules characteristics did not differ accordingly to sex. Linear regression models were conducted separately for each sex, adjusted for income, age and maternal age. There were no differences in total energy intake, but energy density (ED, energy content/g) was negatively associated with birth weight in boys. Macronutrient analysis showed that ED intake was from a greater intake of fat. Birth weight was not a significant predictor of protein and carbohydrate intake in boys. In girls, we saw a positive correlation between fat intake and cholesterol intake v. birth weight, but no association with ED intake (results did not remain after adjustment). The study shows that low birth weight is associated with altered fat intake in childhood in a sex-specific manner. It is likely that biological factors such as fetal programming of homoeostatic and/or hedonic pathways influencing food preferences are involved in this process.
Subject(s)
Dietary Fats/administration & dosage , Feeding Behavior , Birth Weight , Child , Child Development , Cholesterol, Dietary/administration & dosage , Cross-Sectional Studies , Dietary Carbohydrates/administration & dosage , Dietary Proteins/administration & dosage , Energy Intake , Female , Food Preferences , Humans , Male , Sex FactorsABSTRACT
It is widely accepted that sodium is an essential nutritional electrolyte and its deficiency is associated with neurological sequelae and poor growth. The provision of an adequate sodium intake to preterm neonates is hampered by the technical difficulty in clinically assessing total body sodium content. As addressed in this review, there is a lack of consensus on the definition of hyponatremia early in life, but there is no evidence that it should deviate from the widely accepted normative data for adult subjects. A low urinary sodium content is accepted by many as reflecting total body sodium deficiency, yet spot urinary sodium measurements are of questionable clinical value. The hormonal regulation of sodium homeostasis is here reviewed and the mechanism accounting for sodium deficiency-induced growth impairment in preterm infants addressed. Lastly, we provide evidence-based gestational and postnatal age-dependent recommendations for the provision of adequate sodium intake to preterm neonates.
Subject(s)
Hyponatremia/diagnosis , Infant, Premature/growth & development , Sodium/blood , Animals , Gestational Age , Humans , Hyponatremia/mortality , Hyponatremia/therapy , Infant , Infant, Newborn , Nutritional Requirements/physiology , Sodium/urineABSTRACT
IMPORTANCE: Transcatheter closure of the patent ductus arteriosus (PDA) is being increasingly adopted as an alternative to surgical PDA closure in preterm infants. OBJECTIVE: To develop rigorous clinical practice guideline recommendations on procedural PDA closure in preterm infants. METHODS: The principles of the GRADE (Grading of Recommendations Assessment, Development and Evaluation) Evidence-to-Decision (EtD) framework were used to develop the guideline recommendations. An e-Delphi survey of 45 experts was conducted and recommendations that reached ≥75% agreement were accepted as consensus. MAIN RECOMMENDATIONS: Procedural PDA closure may be considered in extremely preterm infants (<28 weeks gestational age) requiring invasive mechanical ventilation >10 postnatal days and confirmed to have a large hemodynamically significant PDA, at centers with high local rates of death and/or bronchopulmonary dysplasia (conditional recommendation). If sufficient institutional expertise is available and patient characteristics are suitable, transcatheter PDA closure may be considered as the preferred approach over PDA ligation (conditional recommendation).
ABSTRACT
BACKGROUND: The survival of smaller and more immature premature infants has been associated with lifelong cardiorespiratory comorbidities. Infants with bronchopulmonary dysplasia (BPD) undergo routine screening echocardiography to evaluate for development of chronic pulmonary hypertension, a late manifestation of pulmonary vascular disease. METHODS: Our aim was to evaluate left ventricular (LV) performance in infants with BPD and pulmonary vascular disease who developed systemic hypertension. We hypothesized that infants with hypertension were more likely to have impaired LV performance. We present a single-center cross-sectional study of premature infants born at less than 28 0/7 weeks' gestational age with a clinical diagnosis of BPD. Infants were categorized by the systolic arterial pressure (SAP) at time of echocardiography as hypertensive (SAP ≥90 mm Hg) or normotensive (SAP <90 mm Hg). Sixty-four patients were included. RESULTS: Infants with hypertension showed altered LV diastolic function with prolonged tissue Doppler imaging-derived isovolumic relaxation time (54.2 ± 5.1 vs 42.9 ± 8.2, P < .001), lower E:A, and higher E:e'. Indices of left heart volume/pressure loading (left atrium:aorta and LV end-diastolic volume [6.1 ± 2 vs 4.2 ± 1.2, P < .001]) were also higher in the hypertensive group. Finally, infants in the hypertensive group had higher pulmonary vascular resistance index (4.42 ± 1.1 vs 3.69 ± 0.8, P = .004). CONCLUSIONS: We conclude that extremely preterm infants with BPD who develop systemic hypertension are at risk of abnormal LV diastolic dysfunction. Increased pulmonary vascular resistance index in the hypertensive group may relate to pulmonary venous hypertension secondary to LV dysfunction. This is an important consideration in this cohort when selecting the physiologically most appropriate treatment.
Subject(s)
Bronchopulmonary Dysplasia , Hypertension, Pulmonary , Vascular Diseases , Ventricular Dysfunction, Left , Infant , Infant, Newborn , Humans , Pregnancy , Female , Gestational Age , Infant, Extremely Premature , Bronchopulmonary Dysplasia/complications , Bronchopulmonary Dysplasia/diagnosis , Ventricular Function, Left , Cross-Sectional Studies , Echocardiography , Hypertension, Pulmonary/complications , Hypertension, Pulmonary/diagnosis , Ventricular Dysfunction, Left/diagnostic imaging , Ventricular Dysfunction, Left/etiologyABSTRACT
OBJECTIVE: To assess clinical and echocardiography predictors of acetaminophen response for the treatment of patent ductus arteriosus (PDA) in preterm neonates. STUDY DESIGN: Retrospective cohort study of preterm infants born <30 weeks, with a diagnosis of hemodynamically significant PDA, who received 1st line treatment with intravenous acetaminophen during the first 2 postnatal weeks. Response was defined by PDA closure or improvement in PDA score of >50%. RESULTS: A total of 100 infants were included whose median weight and gestational age at birth were 663 grams and 24.6 weeks respectively. In total, 66 infants were classified as responders and were more likely to have intrauterine growth restriction, exposure to maternal hypertension and chorioamnionitis. Non-response was more common among infants with thrombocytopenia and anemia. CONCLUSION: Responders were more likely to be IUGR with echocardiography indices of lower preload. Response to 1st line intravenous acetaminophen therapy is comparable to non-steroidal drugs in preterm infants. Relationship of response to acetaminophen to perinatal characteristics requires further characterization.
Subject(s)
Ductus Arteriosus, Patent , Persistent Fetal Circulation Syndrome , Infant , Infant, Newborn , Humans , Infant, Premature , Acetaminophen/therapeutic use , Ductus Arteriosus, Patent/diagnostic imaging , Ductus Arteriosus, Patent/drug therapy , Retrospective Studies , Persistent Fetal Circulation Syndrome/drug therapy , EchocardiographyABSTRACT
PURPOSE: To investigate whether immediate response to inhaled nitric oxide (iNO) therapy is associated with reduced mortality in preterm infants with hypoxemic respiratory failure (HRF) and pulmonary hypertension (PH). METHODS: A systematic review and meta-analysis of observational studies was conducted to examine the association between immediate response (improved oxygenation ≤6 h) compared to non-response, and all-cause mortality among preterm infants <34 weeks gestational age without congenital anomalies or genetic disorders who received iNO treatment. Adjusted and unadjusted odds ratio, were pooled using a random effects meta-analysis Hartung-Knapp-Sidik-Jonkman approach. Subgroup analyses were planned for infants with preterm premature rupture of membranes (PPROM) and those treated within 72 h after birth. RESULTS: The primary analysis included 5 eligible studies, a total of 400 infants (196 responders; 204 non-responders). The studies were rated as low to moderate risk of bias based on the Quality in Prognostic Studies tool. Immediate iNO responsiveness was associated with reduced odds of mortality [odds ratio (OR) 0.22, 95 % confidence interval (95 % CI) (0.10-0.49)]. Although there was insufficient data for a subgroup analysis of infants with PPROM, infants treated with iNO within 72 h demonstrated consistent findings of reduced mortality [OR 0.21 95 % CI (0.13-0.36)]. Based on the GRADE approach, considering the risk of bias of included studies, the overall strength of evidence was rated as moderate. CONCLUSION: There is evidence to suggest that immediate improvement in oxygenation following iNO therapy is associated with reduced odds of mortality before discharge in preterm infants with HRF and clinically suspected or confirmed PH.
Subject(s)
Hypertension, Pulmonary , Respiratory Insufficiency , Infant , Female , Infant, Newborn , Humans , Infant, Premature , Nitric Oxide/therapeutic use , Hypertension, Pulmonary/drug therapy , Hypoxia , Respiratory Insufficiency/drug therapy , Respiratory Insufficiency/etiology , Administration, InhalationABSTRACT
OBJECTIVE: To determine the clinical/echocardiography (ECHO) phenotype of patients with hypoxic respiratory failure (HRF) and response to late surfactant, according to patent ductus arteriosus (PDA) status. STUDY DESIGN: This retrospective study included infants ≤26+6 weeks gestation who received ≥1 surfactant dose after 6 postnatal days and where PDA status was available by ECHO. Response to surfactant was appraised based on change in respiratory severity score over 48 h. The relationship between PDA status and response to surfactant was evaluated via univariate analysis. RESULT: We studied late surfactant (n = 71 doses) administration in 35 preterm infants born at a mean weight and GA at birth were 595 g (508, 696) and 23.3 (22.7, 25) weeks, respectively of whom 16 (46%) had a diagnosis of PDA. Positive response to late surfactant treatment was independently associated with absence of PDA [OR 26 (2, 334), p = 0.01] whereas presence of PDA was independently associated with negative response [OR 12 (1.1, 126), p = 0.04]. CONCLUSIONS: In neonates ≤26+6 weeks gestation, with HRF, response to surfactant after postnatal day 6 is influenced by PDA status. Future trials should consider PDA status which may enhance diagnostic precision and refine patient selection for late surfactant treatment.
ABSTRACT
OBJECTIVE: Our aim was to determine whether right ventricular (RV) dysfunction at 24-hour postnatal age predicts adverse developmental outcome among patients with hypoxic ischaemic encephalopathy (HIE) undergoing therapeutic hypothermia (TH). DESIGN: Neonates≥35 weeks with HIE/TH were enrolled in a physiological study in the neonatal period (n=46) and either died or underwent neurodevelopmental follow-up at 18 months (n=43). The primary outcome was a composite of death, diagnosis of cerebral palsy or any component of the Bayley Scores of Infant Development III<70. We hypothesised that tricuspid annulus plane systolic excursion (TAPSE) <6 mm and/or RV fractional area change (RV-FAC) <0.29 would predict adverse outcome. RESULTS: Nine patients died and 34 patients were followed up at a mean age of 18.9±1.4 months. Both indices of RV systolic performance were abnormal in 15 (35%) patients, TAPSE <6 mm only was abnormal in 4 (9%) patients and RV-FAC <0.29 only was abnormal in 5 (12%) patients (19 had with normal RV function). Although similar at admission, neonates with RV dysfunction had higher cardiovascular and neurological illness severity by 24 hours than those without and severe MRI abnormalities (70% vs 53%, p=0.01) were more common. On logistic regression, TAPSE <6 mm (OR 3.6, 95% CI 1.2 to 10.1; p=0.017) and abnormal brain MRI [OR 21.7, 95% CI 1.4 to 336; p=0.028) were independently associated with adverse outcome. TAPSE <6 mm predicted outcome with a 91% sensitivity and 81% specificity. CONCLUSIONS: The role of postnatal cardiovascular function on neurological outcomes among patients with HIE who receive TH merits further study. Quantitative measurement of RV function at 24 hours may provide an additional neurological prognostic tool.
Subject(s)
Cerebral Palsy/etiology , Developmental Disabilities/etiology , Hypothermia, Induced , Hypoxia-Ischemia, Brain/physiopathology , Hypoxia-Ischemia, Brain/therapy , Ventricular Dysfunction, Right/physiopathology , Echocardiography , Follow-Up Studies , Gestational Age , Humans , Hypoxia-Ischemia, Brain/diagnostic imaging , Infant , Infant, Newborn , Magnetic Resonance Imaging , Sensitivity and Specificity , Ventricular Dysfunction, Right/diagnostic imagingABSTRACT
OBJECTIVE: Characterize the impact of milrinone on arterial pressure of neonates with persistent hypoxemic respiratory failure (HRF) and hypoxic ischemic encephalopathy (HIE) treated with inhaled nitric oxide and therapeutic hypothermia (TH). STUDY DESIGN: Retrospective cohort study. Arterial pressure was assessed hourly for 24 h. The primary outcome was change in diastolic arterial pressure (DAP). RESULTS: 56 patients were included [(i) cases: HIE/TH who received milrinone (n = 9), (ii) Milrinone controls (n = 17), (iii) HIE controls (n = 30)]. Baseline demographics, severity of HRF and arterial pressure were comparable between groups. Only milrinone treated patients with HIE/TH had a marked drop in DAP in the first hour, which persisted for more than 12 h despite escalation in inotropes (p = 0.008). CONCLUSION: Milrinone treated patients with HRF and HIE/TH develop profound reduction in DAP and require escalation of cardiovascular support. The risk benefit profile of milrinone should be considered and pharmacological studies are warranted to evaluate drug metabolism and clearance in this population.
Subject(s)
Hypothermia, Induced , Hypoxia-Ischemia, Brain , Hemodynamics , Humans , Hypoxia , Hypoxia-Ischemia, Brain/drug therapy , Infant, Newborn , Milrinone/therapeutic use , Retrospective StudiesABSTRACT
Definitive closure of a patent ductus arteriosus (PDA) causes significant changes in loading conditions of the left ventricle (LV) which can lead to cardiorespiratory instability including hypotension, low cardiac output, oxygenation, and ventilation impairment. Physiological insights of the adaptation of the LV can be gained by looking at ventriculo-arterial coupling (VAC) and myocardial work-energetics. We conducted a retrospective cohort study of preterm infants with echocardiographic assessment of VAC parameters, including end-systolic and arterial elastance (EES , EA ), and myocardial work indices derived from longitudinal strain analysis before and 1-h after percutaneous PDA closure. A total of 35 patients were included with mean [±SD] age at intervention of 30.8 ± 9.9 days and median [IQR] weight of 1130 [995, 1318] grams. There was a reduction in preload and stroke volume, an increase in EA (38.6 ± 11.4 vs. 60 ± 15.1 mmHg/ml/kg, p < 0.001) and in EES (72 [61.5, 109.8] vs. 91.6 [72.2, 125.2] mmHg/ml/kg, p = 0.003) post-closure. Myocardial work indices reduced after PDA closure, including global work efficiency (93.9 ± 2.3 vs. 91.1 ± 3.6%, p < 0.001). A total of 17 (48.6%) patients developed post-closure instability which was associated with younger age, lower preload, and higher EA and EES . Percutaneous PDA closure is associated with major short-term changes in VAC and myocardium energetics, which may provide novel insights on the physiology of PDA closure and on the differential vulnerability to changes in loading conditions.
Subject(s)
Ductus Arteriosus, Patent/surgery , Heart Ventricles/physiopathology , Myocardial Contraction/physiology , Myocardium/metabolism , Oxygen Consumption/physiology , Adaptation, Physiological , Blood Pressure/physiology , Cardiac Output/physiology , Ductus Arteriosus, Patent/diagnostic imaging , Ductus Arteriosus, Patent/physiopathology , Echocardiography , Elasticity , Female , Heart Ventricles/diagnostic imaging , Humans , Infant , Infant, Newborn , Infant, Premature , Male , Retrospective StudiesABSTRACT
OBJECTIVE: Postoperative hyperglycemia has been shown to be associated with higher morbidity and mortality in pediatric patients. Data on risk factors for neonatal patients is limited. The objective of this study was to identify pre- and intraoperative risk factors associated with postoperative glucose in neonates. METHODS: We conducted a retrospective cohort study of neonates after surgical procedures between January and December 2016 in a quaternary neonatal intensive care unit. The primary outcome was hyperglycemia defined as serum glucose ≥8.3âmmol/L during the first 4 hours postoperatively. Secondary outcomes included death and length of stay. We assessed the association of risk factors with the postoperative glucose. RESULTS: In total, 206 surgical procedures (171 patients) were evaluated, among which 178 had serum glucose values during the first 4 hours postoperatively available. The incidence of hyperglycemia was 54% (nâ=â96). The median (IQR) glucose during the first 4 hours in NICU was 8.4 (6.52-10.65) mmol/L. Risk factors for postoperative hyperglycemia were intraoperative glucose infusion rate (GIR) and gestational age. There was a non-linear relationship between gestational age and postoperative hyperglycemia. Mortality occurred in 6 (7%) in the no-hyperglycemia group and 3 (3%) in the hyperglycemia group (pâ=â0.31). CONCLUSIONS: Among the risk factors, intraoperative GIR was identified as a modifiable factor that can reduce postoperative hyperglycemia. A non-linear relationship of gestational age with postoperative glucose provides new insights that may help advance our understanding of the complex mechanisms of glucose homeostasis in neonates.
Subject(s)
Hyperglycemia/etiology , Hyperglycemia/therapy , Intensive Care Units, Neonatal , Postoperative Complications/etiology , Blood Glucose/analysis , Female , Humans , Infant, Newborn , Length of Stay , Male , Outcome Assessment, Health Care , Postoperative Period , Retrospective StudiesABSTRACT
Neonatal hypertension has been increasingly recognized in premature infants with bronchopulmonary dysplasia (BPD); of note, a sub-population of these infants may have impaired left ventricular (LV) diastolic function, warranting timely treatment to minimize long term repercussions. In this case series, enalapril, an angiotensin-converting enzyme (ACE) inhibitor, was started in neonates with systemic hypertension and echocardiography signs of LV diastolic dysfunction. A total of 11 patients were included with birth weight of 785 ± 239 grams and gestational age of 25.3 (24, 26.1) weeks. Blood pressure improvement was noticed within 2 weeks of treatment. Improvement in LV diastolic function indices were observed with a reduction in Isovolumic Relaxation Time (IVRT) from 63.1 ± 7.2 to 50.9 ± 7.4 msec and improvement in the left atrium size indexed to aorta (LA:Ao) from1.73 (1.43, 1.88) to 1.23 (1.07, 1.29). Neonatal systemic hypertension is often underappreciated in ex-preterm infants and may be associated with important maladaptive cardiac changes with long term implications. It is biologically plausible that identifying and treating LV diastolic dysfunction in neonates with systemic hypertension may have a positive modulator effect on cardiovascular health in childhood and beyond.
ABSTRACT
Approximately 40% of hypoxemic term/near-term neonates are nonresponders to inhaled nitric oxide (iNO). Phenotypic characterization of patients less likely to respond may improve diagnostic precision and therapeutic decisions. We conducted a retrospective cohort study of neonates born ≥35 weeks gestation with hypoxemia who received iNO in the first 72 h of life and classified them into responders and nonresponders according to changes in the fraction of inspired oxygen, saturations and/or arterial partial pressure of oxygen after 1 h of administration. Comprehensive targeted neonatal echocardiography (TnECHO) data were collected when performed up to 6 h prior or 24 h after iNO initiation. Descriptive statistics, univariate analysis, and binary logistic regression were used to compare the groups. There were 183 patients included (63% responders) and TnECHO was performed in 54 infants. The presence of lung disease, and particularly meconium aspiration syndrome (p = .004), was associated with nonresponse to iNO. Nonresponders were characterized by a higher need for rescue high-frequency ventilation (p < .001), longer duration of mechanical ventilation (p < .001), and need for oxygen support (p = .003). Pulmonary hypertension documented on TnECHO was present in 96.3% of the patients but there was no difference in frequency or severity of pulmonary hypertension, or rates of low cardiac output between the groups. Moderate-to-severe right ventricular systolic dysfunction (p > .05) and lower left ventricular strain (p < .05) were more likely in the nonresponder group. In summary, response to iNO is influenced by lung disease, choice of ventilation strategy, and perhaps underlying cardiovascular physiology. Prospective pre- and post-iNO echocardiography data may provide novel physiologic insights.
Subject(s)
Echocardiography , Administration, Inhalation , Humans , Infant, Newborn , Meconium Aspiration Syndrome/drug therapy , Nitric Oxide/therapeutic use , Retrospective StudiesABSTRACT
Ligation of a hemodynamically significant ductus arteriosus results in significant changes in loading conditions which have predictable consequences. Postligation cardiac syndrome, defined as hypotension requiring inotropic support and failure of oxygenation and ventilation, may occur 6-12 hours following ligation due to left ventricular systolic and diastolic failure, respectively. Afterload is the primary driver of this decompensation. In this review, we describe the pathophysiological changes in loading conditions associated with postligation cardiac syndrome and other contributors to cardiovascular dysfunction following ductal ligation. We present strategies for perioperative optimization and a physiology-based algorithm for postoperative management guided by targeted neonatal echocardiography. The use of these strategies to reduce the frequency of postligation deterioration may be an avenue to improve outcomes for neonates in this vulnerable patient population.