Neonatal Septic Shock and Hemodynamic Monitoring in Preterm Neonates in an NICU: Added Value of Electrical Cardiometry in Real-Time Tailoring of Management and Therapeutic Strategies.

OBJECTIVE: Electrical cardiometry is an impedance-based monitoring technique that provides data on several hemodynamic parameters in a noninvasive way. There is limited information on clinical utility of the application of this technique in neonates. STUDY DESIGN: In this study, we describe the case of a preterm neonate born at 302/7 weeks of gestational age who developed severe systemic infection with fluid refractory septic shock on day 2 of life. DISCUSSION: Electrical cardiometry was used and proved very helpful in real-time guiding the choice and the dosing of the most appropriate inotrope drugs in this patient. In addition, it promptly underlined an abrupt drop of systemic vascular resistances occurring after administration of the first dose of antibiotic, thus warning the attending neonatologist to institute appropriate treatment before the clinical conditions could further worsen. CONCLUSION: This case report suggests that electrical cardiometry could be a useful tool in assessing, monitoring, and guiding care of neonates who develop severe septic shock. We suggest that electrical cardiometry is a promising approach in the management strategies of such patients that warrants informative clinical trials. KEY POINTS: · Electrical cardiometry was helpful in real-time decision-making.. · Electrical cardiometry reported hemodynamic perturbations before worsening of clinical conditions.. · Electrical cardiometry should be included in the management of critical patients..

Noninvasive Cardiac Output Monitoring in Newborn with Hypoplastic Left Heart Syndrome.

OBJECTIVE: This study aimed to describe the first two cases of electrical cardiometry applied to newborn with hypoplastic left heart syndrome for hemodynamical assessment in the first days of life before surgical correction and see if this can help decision making process in these patients. STUDY DESIGN: We describe two case series of two full-term newborn with hypoplastic left heart syndrome in the Neonatal Intensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, between December 2019 and January 2020. RESULTS: Case 1 was persistently hemodynamically stable with prostaglandin E1 infusion at 0.01 mcg/kg/min, showing good capillary refill time, good diuresis, no difference between pre- and postductal values of oxygen saturation or blood pressure. Electrical cardiometry monitoring constantly showed cardiac output values higher than 300 mL/kg/min. Case 2 showed poor clinical condition needing prostaglandin E1 infusion up to 0.05 mcg/kg/min, intubation and septostomy associated with low cardiac output around 190 mL/kg/min. Once cardiac output has begun to rise and reached values constantly over 300 mL/kg/min, clinical condition improved with amelioration in oxygen saturation, diuresis, blood pressure, and blood gas analysis values. She was then extubated and finally clinically stable until surgery with minimal infusion of prostaglandin E1 at 0.01 mcg/kg/min. CONCLUSION: This case highlights how hemodynamic information provided by electrical cardiometry can be used to supplement the combined data from all monitors and the clinical situation to guide therapy in these newborns waiting surgery. KEY POINTS: · This is the first report of electrical cardiometry (EC) use in newborn with hypoplastic left heart syndrome (HLHS).. · In HLHS patients, it is impossible to measure cardiac output without being invasive.. · EC helps in guiding therapy in HLHS patients in a noninvasive way..

Functional cardiac MRI in preterm and term newborns.

OBJECTIVE: To use cardiac MRI techniques to assess ventricular function and systemic perfusion in preterm and term newborns, to compare techniques to echocardiographic methods, and to obtain initial reference data. DESIGN: Observational magnetic resonance and echocardiographic imaging study. SETTING: Neonatal Unit, Queen Charlotte's and Chelsea Hospital, London, UK. Patients 108 newborn infants with median birth weight 1627 (580-4140) g, gestation 32 (25-42) weeks. RESULTS: Mean (SD) flow volumes assessed by phase contrast (PC) imaging in 28 stable infants were left ventricular output (LVO) 222 (46), right ventricular output (RVO) 219 (47), superior vena cava (SVC) 95 (27) and descending aorta (DAo) 126 (32) ml/kg/min, with flow being higher at lower gestational age. Limits of agreement for repeated PC assessment of flow were LVO ±50.2, RVO ±55.5, SVC ±20.9 and DAo ±26.2 ml/kg/min. Mean (SD) LVO in 75 stable infants from three-dimensional models were 245 (47) ml/kg/min, with limits of agreement ±58.3 ml/kg/min. Limits of agreement for repeated echocardiographic assessment of LVO were ±108.9 ml/kg/min. CONCLUSIONS: Detailed magnetic resonance assessments of cardiac function and systemic perfusion are feasible in newborn infants, and provide more complete data with greater reproducibility than existing echocardiographic methods. Functional cardiac MRI could prove to be a useful research technique to study small numbers of newborn infants in specialist centres; providing insights into the pathophysiology of circulatory failure; acting as an outcome measure in clinical trials of inotropic intervention and so guiding clinical practice in the wider neonatal community.

Circulating endothelial progenitor cells in preterm infants with bronchopulmonary dysplasia.

RATIONALE: The new form of bronchopulmonary dysplasia (BPD) is characterized by lung immaturity with disrupted alveolar and capillary development after extremely premature birth, but the mechanism of impaired lung vascular formation is still not completely understood. OBJECTIVES: We tested the hypothesis that reduced numbers of circulating endothelial progenitor cells at birth are associated with the development of BPD. METHODS: We studied ninety-eight preterm infants with gestational age of less than 32 weeks or a birth weight less than 1,500 g. Endothelial colony-forming cells (ECFCs) were assessed by clonogenic analysis in infants for whom cord blood was available. The proportion of circulating endothelial and hematopoietic cells was measured by flow cytometry at birth, at 48 hours, and at 7 days of life. MEASUREMENTS AND MAIN RESULTS: ECFCs in cord blood were lower in infants who later developed BPD (median [range]: 0.00 [0.00-0.48] vs. 2.00 [0.00-21.87]; P = 0.002). ECFCs decreased with decreasing gestational age (r = 0.41; P = 0.02), but even at extremely low gestational ages, infants with higher numbers of ECFCs were protected from BPD. The endothelial and hematopoietic cell subsets studied by flow cytometry were comparable in infants with and without BPD and rapidly decreased after birth. CONCLUSIONS: ECFCs are low at extremely low gestational ages and increase during gestation; extremely preterm infants who display lower numbers at birth have an increased risk of developing BPD. Our findings suggest that decreased ECFCs following extremely preterm birth may be associated with the risk for developing lung vascular immaturity characteristic of new BPD.

Insulin therapy and carbohydrate counting.

Nutritional management is one of the cornerstones of diabetes care. Many studies have been performed on the correlation between nature and amount of carbohydrate in meal intake and insulin delivery by artificial pancreas in Type 1 diabetic patients. In fact consistency in the amount and source of carbohydrate intake from day to day is associated with improved blood glucose control in people with Type 1 diabetes. Many methods of counting carbohydrate have been used and many are still commonly used in paediatric practice (exchange, portion/serving, grams, glycemic index, carbohydrate/insulin ratio). Carbohydrate counting is a meal planning approach with patients with Type 1 diabetes mellitus that focuses on carbohydrate as the primary nutrient affecting postprandial glycemic response. The aim of this paper is to review published data on the significance of carbohydrate counting on meeting outcome goals and allowing flexibility in food choices.

Quality of life and new devices in the management of type 1 diabetes in children and adolescents.

Insulin therapy is the cornerstone in treatment of type 1 diabetes in children and adolescents. In order to prevent long-term complication multiple daily injections (MDI) are required. Quality of life is dearly affected by the administrations of 3-4 daily injections with syringe. Insulin pens are new devices realized with the aim of simplifying insulin administration. More recently continuous blood sugar monitoring has become available for clinical studies and its role for better metabolic control and quality of life is now under investigation. The aim of this paper is to review published data on the significance of insulin pen and continuous blood sugar monitoring on quality of life in diabetic children and adolescents.