Changes in cardiac function and cerebral blood flow in relation to peri/intraventricular hemorrhage in extremely preterm infants. Noori Shahab,McCoy Michael,Anderson Michael P,Ramji Faridali,Seri Istvan The Journal of pediatrics OBJECTIVE:To investigate whether changes in cardiac function and cerebral blood flow (CBF) precede the occurrence of peri/intraventricular hemorrhage (P/IVH) in extremely preterm infants. STUDY DESIGN:In this prospective observational study, 22 preterm infants (gestational age 25.9 ± 1.2 weeks; range 23-27 weeks) were monitored between 4 and 76 hours after birth. Cardiac function and changes in CBF and P/IVH were assessed by ultrasound every 12 hours. Changes in CBF were also followed by continuous monitoring of cerebral regional oxygen saturation (rSO2) and by calculating cerebral fractional oxygen extraction. RESULTS:Five patients developed P/IVH (1 patient grade II and 4 patients grade IV). Whereas measures of cardiac function and CBF remained unchanged in neonates without P/IVH, patients with P/IVH tended to have lower left ventricular output and had lower left ventricle stroke volume and cerebral rSO2 and higher cerebral fractional oxygen extraction during the first 12 hours of the study. By 28 hours, these variables were similar in the 2 groups and myocardial performance index was lower and middle cerebral artery mean flow velocity higher in the P/IVH group. P/IVH was detected after these changes occurred. CONCLUSIONS:Cardiac function and CBF remain stable in very preterm neonates who do not develop P/IVH during the first 3 postnatal days. In very preterm neonates developing P/IVH during this period, lower systemic perfusion and CBF followed by an increase in these variables precede the development of P/IVH. Monitoring cardiac function and cerebral rSO2 may identify infants at higher risk for developing P/IVH before the bleeding occurs. 10.1016/j.jpeds.2013.09.045

Circulatory Management Focusing on Preventing Intraventricular Hemorrhage and Pulmonary Hemorrhage in Preterm Infants. Su Bai-Horng,Lin Hsiang-Yu,Huang Fu-Kuei,Tsai Ming-Luen,Huang Yu-Ting Pediatrics and neonatology The goal of modern neonatal care of extremely preterm infants is to reduce mortality and long-term neurological impairments. Preterm infants frequently experience cerebral intraventricular or pulmonary hemorrhage, which usually occurs within 72 hours after birth and can lead to long-term neurological sequelae and mortality. These serious hemorrhagic complications are closely related to perinatal hemodynamic changes, including an increase in the afterload on the left ventricle of the heart after the infant is separated from the placenta, and an increased preload from a left-to-right shunt caused by a hemodynamically significant patent ductus arteriosus (PDA). The left ventricle of a preterm myocardium has limited ability to respond to such an increase in afterload and preload, and this can result in cardiac dysfunction and hemodynamic deterioration. We suggest that delayed umbilical cord clamping or umbilical cord milking to maintain optimal blood pressure and systemic blood flow (SBF), careful assessment to keep the afterload at an acceptable level, and a strategy of early targeted treatment of significant PDA to improve perfusion during this critical time period may reduce or prevent these serious complications in preterm infants. 10.1016/j.pedneo.2016.01.001

Tailor-made circulatory management based on the stress-velocity relationship in preterm infants. Toyoshima Katsuaki,Kawataki Motoyoshi,Ohyama Makiko,Shibasaki Jun,Yamaguchi Naoto,Hoshino Rikuo,Itani Yasufumi,Nakazawa Makoto Journal of the Formosan Medical Association = Taiwan yi zhi Preterm infants frequently experience pulmonary hemorrhage or cerebral intraventricular hemorrhage after birth. The immature myocardium of the left ventricle faces a high afterload after the baby is separated from the placenta. However, the preterm left ventricle has limited ability to respond to such an increase in afterload. This results in depressed cardiac function and a deterioration in hemodynamics. We speculated that the perinatal deterioration in cardiac performance would be closely related to serious hemorrhages. To prove our hypothesis, we studied the interrelationship between the perinatal changes in cardiac performance and the incidences of intraventricular and pulmonary hemorrhage. We obtained the stress-velocity relationship (rate-corrected mean fiber shortening velocity and end-systolic wall stress relationship) by M-mode echocardiography and arterial blood pressure measurement. We found that the incidences of intraventricular and/or pulmonary hemorrhages were higher in infants with an excessive afterload, which resulted in a decrease in the function of the left ventricle. We suggest that careful attention to keep the afterload at an acceptable level by vasodilator therapy and sedation may reduce or prevent these serious complications. In this review, we will discuss our data along with related literature. 10.1016/j.jfma.2013.02.011

Future perspectives on the use of deformation analysis to identify the underlying pathophysiological basis for cardiovascular compromise in neonates. Bussmann Neidin,El-Khuffash Afif Pediatric research The assessment of the wellbeing of the cardiovascular status in premature infants has come to the forefront in recent years. There is an increasing realisation that myocardial performance, systemic blood flow and end-organ perfusion (particularly during the transitional period) play an important role in determining short and long-term outcomes in this population. The recent open access series on Neonatologist Performed Echocardiography (NPE) published in this journal outline the necessary techniques for image acquisition and analysis and provide a framework for the potential clinical applications of NPE in neonatal, and specifically preterm care. In this "Future Perspectives" review, we describe the important determinants of adequate cellular metabolism and myocardial performance (e.g. loading conditions, intrinsic contractility and morphological change), we discuss the maladaptive state of the preterm cardiovascular system, and highlight the emerging role that non-invasive echocardiography techniques, such as deformation analysis, serve in identifying the underlying physiological basis for cardiovascular instability. 10.1038/s41390-019-0293-z

[Evaluation of volume overload in critical patients by monitoring change of cardiac output under bed head raising combined with passive leg raising]. Zhang Long,Wang Luhao,Luo Weixiong,Mei Meihua,Chen Youjuan,Ouyang Bin Zhonghua wei zhong bing ji jiu yi xue OBJECTIVE:To investigate whether the change of cardiac output (CO) with bed head raising (BHR) combined with passive leg raising (PLR) can be used to assess volume overload in critical patients. METHODS:A prospective observational diagnostic trial was designed. The patients who underwent fluid resuscitation 6 hours or more, and admitted to intensive care unit (ICU) of Meizhou People's Hospital in Guangdong Province from January to December in 2016 were enrolled. Volume overload were identified with the criteria including the increasing of pulmonary rales, the higher levels of N-terminal brain natriuretic peptide (NT-proBNP) and new pulmonary exudates in chest radiograph. CO and heart rate (HR) were monitored with impedance cardiography at supine position and BHR by 30degree angle (BHR), 60degree angle (BHR), and PLR in all patients. The changes of CO (ΔCO, ΔCO, ΔCO) and HR (ΔHR, ΔHR, ΔHR) were calculated at different positions. The receiver operating characteristic curve (ROC) was used to evaluate the predictive values of ΔCO, ΔCO and combination of ΔCO and ΔCO on volume overload. RESULTS:A total of 62 patients were enrolled in this study, with 44 males and 18 females, age of (58.9±15.9) years, a body mass index of (22.7±2.4) kg/m, and an acute physiology and chronic health evaluation II (APACHE II) score of 18.7±4.4. The CO of 32 patients with volume overload was significantly increased at BHR or BHR compared with supine position [ΔCO was (14.5±11.5)%, ΔCO was (26.9±17.5)%, both P < 0.01], and the ΔCO was increased more than the ΔCO (P < 0.01); while CO was slightly decreased after PLR, ΔCO was (-8.4±11.3)% (P > 0.05). There was no consistent change of CO at BHR or BHR compared with supine position in 30 patients without volume overload, ΔCO was (-3.4±9.1)% (P < 0.05), ΔCO was (-2.4±14.0)% (P > 0.05), while CO was significantly increased after PLR, ΔCO was (12.4±11.3)% (P < 0.01). There was no significant change of HR after BHR and PLR in patients with volume overload and non volume overload. ROC curve showed that when the cut-off value of ΔCO≥3.3%, the area under ROC curve (AUC) was 0.903±0.039, the sensitivity was 90.6%, the specificity was 80.0%, and the accuracy was 85.5% for predicting volume overload; when the cut-off value of ΔCO≥5.6%, the AUC was 0.911±0.036, the sensitivity was 96.9%, the specificity was 73.3%, and the accuracy was 85.5% for predicting volume overload. If volume overload was assessed by the increase of ΔCO combining with the decrease of ΔCO, the AUC was 0.928±0.034, the optimal cut-off value for the new combined predictive indicator in predicting volume overload was -0.008, and the sensitivity, specificity, accuracy was 96.9%, 83.3%, 90.3%, respectively, and its evaluation effect is better than the use of ΔCO or ΔCO alone. CONCLUSIONS:The change of CO with BHR combined with PLR can be used to accurately evaluate volume overload in patient with critically illness. 10.3760/cma.j.issn.2095-4352.2017.08.008