Preferential Cephalic Redistribution of Left Ventricular Cardiac Output during Therapeutic Hypothermia for Perinatal Hypoxic-Ischemic Encephalopathy

doi:10.1016/j.jpeds.2014.01.028

The Journal of Pediatrics

Volume 164, Issue 5, May 2014, Pages 999-1004.e1

https://doi.org/10.1016/j.jpeds.2014.01.028 Get rights and content

Objective

To determine the relationship between left ventricular cardiac output (LVCO), superior vena cava (SVC) flow, and brain injury during whole-body therapeutic hypothermia.

Study design

Sixteen newborns with moderate or severe hypoxic-ischemic encephalopathy were studied using echocardiography during and immediately after therapeutic hypothermia. Measures were also compared with 12 healthy newborns of similar postnatal age. Newborns undergoing therapeutic hypothermia also had cerebral magnetic resonance imaging as part of routine clinical care on postnatal day 3-4.

Results

LVCO was markedly reduced (mean ± SD 126 ± 38 mL/kg/min) during therapeutic hypothermia, whereas SVC flow was maintained within expected normal values (88 ± 27 mL/kg/min) such that SVC flow represented 70% of the LVCO. The reduction in LVCO during therapeutic hypothermia was mainly accounted by a reduction in heart rate (99 ± 13 vs 123 ± 17 beats/min; P < .001) compared with immediately postwarming in the context of myocardial dysfunction. Neonates with brain injury on magnetic resonance imaging had higher SVC flow prerewarming, compared with newborns without brain injury (P = .013).

Conclusion

Newborns with perinatal hypoxic-ischemic encephalopathy showed a preferential systemic-to-cerebral redistribution of cardiac blood flow during whole-body therapeutic hypothermia, which may reflect a lack of cerebral vascular adaptation in newborns with more severe brain injury.

Section snippets

Methods

Newborns admitted to the Neonatal Intensive Care Unit of the Children's & Women's Health Centre of British Columbia (Canada) and treated with whole-body therapeutic hypothermia for moderate or severe HIE (based on the Sarnat staging system¹⁴) were prospectively enrolled between January 2009 and June 2010, following parental informed consent. Newborns were started on therapeutic hypothermia within 6 hours of life according to our institutional standards of presentation with moderate or severe

Results

Newborns treated with therapeutic hypothermia were comparable with the healthy term-born newborns with regard to their birth weight (mean ± SD 3.49 ± 0.52 vs 3.54 ± 0.43 kg; P = .78). The clinical markers of severity of the HIE in newborns are detailed in Table I. Moderate (n = 15) or severe HIE (n = 1) was diagnosed in all 16 newborns, of whom 13 had seizures (diagnosed by combination of clinical signs and cerebral function monitor changes). None of the newborns died before the rewarming was

Discussion

Using echocardiography, we document the hemodynamic changes occurring in the systemic and cerebral circulation in newborns with HIE undergoing whole-body therapeutic hypothermia. For comparison, we performed the same measures in a reference group of healthy term newborns without signs of HIE. Our data indicate a significant reduction in LVCO during therapeutic hypothermia, to almost 60% of values observed in healthy newborns. When comparing measures of systemic (LVCO) and cephalic (SVC) blood

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Targeted neonatal echocardiography (TNE) involves the use of comprehensive echocardiography to appraise cardiovascular physiology and neonatal hemodynamics to enhance diagnostic and therapeutic precision in the neonatal intensive care unit. Since the last publication of guidelines for TNE in 2011, the field has matured through the development of formalized neonatal hemodynamics fellowships, clinical programs, and the expansion of scientific knowledge to further enhance clinical care. The most common indications for TNE include adjudication of hemodynamic significance of a patent ductus arteriosus, evaluation of acute and chronic pulmonary hypertension, evaluation of right and left ventricular systolic and/or diastolic function, and screening for pericardial effusions and/or malpositioned central catheters. Neonatal cardiac point-of-care ultrasound (cPOCUS) is a limited cardiovascular evaluation which may include line tip evaluation, identification of pericardial effusion and differentiation of hypovolemia from severe impairment in myocardial contractility in the hemodynamically unstable neonate. This document is the product of an American Society of Echocardiography task force composed of representatives from neonatology-hemodynamics, pediatric cardiology, pediatric cardiac sonography, and neonatology-cPOCUS. This document provides (1) guidance on the purpose and rationale for both TNE and cPOCUS, (2) an overview of the components of a standard TNE and cPOCUS evaluation, (3) disease and/or clinical scenario–based indications for TNE, (4) training and competency-based evaluative requirements for both TNE and cPOCUS, and (5) components of quality assurance.
The writing group would like to acknowledge the contributions of Dr. Regan Giesinger who sadly passed during the final revisions phase of these guidelines. Her contributions to the field of neonatal hemodynamics were immense.
Left Ventricular Function and Dimensions Are Altered Early in Infants Developing Brain Injury in the Setting of Neonatal Encephalopathy
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Cerebral autoregulation (CA) dysfunction is a strong predictor of clinical outcome in patients with acute brain injury (ABI). CA dysfunction is a potential pathologic defect that may lead to secondary injury and worse functional outcomes. Early therapeutic hypothermia (TH) in patients with ABI is controversial. Many factors, including patient selection, timing, treatment depth, duration, and rewarming strategy, impact its clinical efficacy. Therefore, optimizing the benefit of TH is an important issue. This paper reviews the state of current research on the impact of TH on CA function, which may provide the basis and direction for CA-oriented target temperature management.
Neonatal multiple organ failure after perinatal asphyxia
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La asfixia perinatal es un acontecimiento con efectos de gran alcance, pudiendo conducir no solo al desarrollo de encefalopatía neonatal, sino también a un fallo multiorgánico (FMO). Esta afectación posiblemente se deba a la redistribución del flujo sanguíneo, mediante el cual se conserva la irrigación de órganos vitales como el corazón, el cerebro y las glándulas suprarrenales, a expensas de su disminución en otros órganos.
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Se realizó una búsqueda bibliográfica sistemática en las bases de datos Pubmed, Scopus y The Cochrane Library empleando los términos MeSH (ischemia AND hypoxia AND multiorgan dysfunction AND neonat*), (asphyxia AND multiorgan dysfunction AND neonat*) y (liver / kidney / digestive OR gastrointestinal / heart injury AND ischemia AND hypoxia AND neonat*). Se incluyeron trabajos clínicos y preclínicos posteriores al año 2000 y se excluyeron series de casos, cartas al director, cohortes sin grupo comparador y abstracts.
En el presente trabajo describimos que el fallo multiorgánico asociado a la asfixia perinatal es un fenómeno frecuente y relevante en la morbimortalidad del neonato, pudiendo llegar a producir no solo alteraciones en riñón, hígado y tracto gastrointestinal, sino también miocardiopatía si el fenómeno se prolonga o es de elevada gravedad.
Perinatal asphyxia is an event with far-reaching consequences that can lead not only to the development of neonatal encephalopathy, but also to multiple organ failure (MOF). This ailment may result from the redistribution of blood flow, which would preserve the perfusion of vital organs such as the heart, brain and adrenal glands at the expense of other organs.
The objective of the study was to determine the incidence and aetiopathogenesis of failure in the organs most frequently involved in neonatal MOF following perinatal asphyxia.
We conducted a systematic literature search in the PubMed, Scopus and Cochrane Library databases using the MeSH terms (ischemia AND hypoxia AND multiorgan dysfunction AND neonat*), (asphyxia AND multiorgan dysfunction AND neonat*) and (liver/kidney/digestive OR gastrointestinal/heart injury AND ischemia AND hypoxia AND neonat*). We selected clinical and preclinical studies published after 2000 and excluded case series, letters to the editor, cohort studies without comparison groups and abstracts.
In this study, we found that MOF associated with perinatal asphyxia is a frequent phenomenon with a relevant impact on neonatal morbidity and mortality, as it can cause changes not only in the kidney, liver and gastrointestinal tract, but also cardiomyopathy if the ailment is protracted or severe.
Hemodynamic changes and evaluation during hypoxic-ischemic encephalopathy and therapeutic hypothermia
2022, Early Human Development
Multiorgan damage is a hallmark of hypoxic-ischemic encephalopathy and cardiovascular and hemodynamic changes during asphyxia contribute significantly to the brain damage. The main insult to the heart is myocardial damage and associated ventricular dysfunction, which is manifested by reduced preload and afterload. The immature myocardium reacts to asphyxia by bradycardia and reduced contractile capacity. Pulmonary hypertension aggrevates cardiac dysfunction. Hypothermia is the only effective treatment for HIE but it may also affect the heart and peripheral vascular system leading to bradycardia and peripheral vasoconstriction. In fact, these effects might be cardioprotective also. Rewarming after hypothermia may increase the heart rate and cardiac metabolism, augmenting the cardiac output. Monitoring of patient with HIE during and after hypothermia is possible by using near-infrared spectroscopy, echocardiography and electrocardiography. Cerebral effects may be monitored by magnetic resonance imaging also. Management should include the physiological status of the patient and appropriate treatments, including inotropes, vasopressors or rarely fluid boluses. Dopamine should not be used unless absolutely necessary. Drugs like melatonin and magnesium are under investigation. All treatments should be evidence-based and targeted echocardiography should be used more often in these vulnerable infants.

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: P.L. is support by a Clinician-Scientist Award from the Child & Family Research Institute and a Career Investigator Award from the Michael Smith Foundation for Health Research. S.M. is supported by the Bloorview Children's Hospital Chair in Pediatric Neuroscience, with previous support from a Canada Research Chair (Tier 2) and Michael Smith Foundation for Health Research Scholar award. The authors declare no conflicts of interest.

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Original ArticlePreferential Cephalic Redistribution of Left Ventricular Cardiac Output during Therapeutic Hypothermia for Perinatal Hypoxic-Ischemic Encephalopathy

Objective

Study design

Results

Conclusion

Section snippets

Methods

Results

Discussion

J Pediatr

Brain Dev

J Pediatr

J Am Soc Echocardiogr

Lancet Neurol

J Pediatr

Early Hum Dev

Brain Dev

Lancet

No cry at birth: global estimates of intrapartum stillbirths and intrapartum-related neonatal deaths

Bull World Health Organ

Long-term cognitive and behavioral consequences of neonatal encephalopathy following perinatal asphyxia: a review

Eur J Pediatr

Does perinatal asphyxia impair cognitive function without cerebral palsy?

Arch Dis Child Fetal Neonatal Ed

Cardiovascular dysfunction in infants with neonatal encephalopathy

Arch Dis Child

Neurological outcomes at 18 months of age after moderate hypothermia for perinatal hypoxic ischaemic encephalopathy: synthesis and meta-analysis of trial data

BMJ

Original Article
Preferential Cephalic Redistribution of Left Ventricular Cardiac Output during Therapeutic Hypothermia for Perinatal Hypoxic-Ischemic Encephalopathy