Cerebral Oxygenation, Extraction, and Autoregulation in Very Preterm Infants Who Develop Peri-Intraventricular Hemorrhage

doi:10.1016/j.jpeds.2012.09.038

The Journal of Pediatrics

Volume 162, Issue 4, April 2013, Pages 698-704.e2

Portions of this study were presented as a poster at the Pediatric Academic Societies' meeting, April 28-May 1, 2012, Boston, MA.

https://doi.org/10.1016/j.jpeds.2012.09.038 Get rights and content

Objective

To test the hypothesis that near-infrared spectroscopy (NIRS)-determined patterns of regional cerebral oxygen saturation (rScO₂), cerebral fractional tissue oxygen extraction (cFTOE), and autoregulatory ability can identify neonates at risk for developing peri-intraventricular hemorrhage (PIVH).

Study design

This case-control study is a subanalysis of 30 neonates who developed PIVH >12 hours after admission as part of a lager prospective observational cohort study comprising 650 preterm neonates born at ≤32 weeks' gestational age. PIVH was diagnosed by cranial ultrasound, performed at least once daily. Mean arterial blood pressure (MABP), NIRS-determined rScO_2, cFTOE, and MABP–rScO₂ correlation were monitored from birth to 72 hours of age.

Results

Infants with PIVH received more inotropic drugs before being diagnosed with PIVH. Significantly more infants with severe PIVH needed treatment for patent ductus arteriosus. The MABP–rScO₂ correlation was >0.5 significantly more often before mild/moderate PIVH and after severe PIVH compared with controls. rScO₂ was higher and cFTOE lower in infants before severe PIVH.

Conclusion

NIRS-monitored rScO₂ and cFTOE suggest cerebral hyperperfusion in infants with severe PIVH. Moreover, MABP–rScO₂ correlation indicates more blood pressure-passive brain perfusion in infants with PIVH. Continuous assessment of patterns of cerebral oxygenation and arterial blood pressure may identify those preterm infants at risk for severe PIVH and prompt consideration of preventive measures.

Section snippets

Methods

This study is a subanalysis of a prospective observational study of all infants admitted to the neonatal intensive care unit of Wilhelmina Children's Hospital with a gestational age of ≤32 completed weeks. The study was approved by the Medical Ethical Committee of the University Medical Center Utrecht. Parental informed consent was obtained for all infants.

Continuous data on rScO₂ and cFTOE captured by NIRS during the first 72 hours of life were collected prospectively.10, 13, 14 These data

Results

The clinical characteristics of the mild-moderate and severe PIVH groups are summarized in Table I. Analyzing all PIVH cases together showed that only the inotropics score was significantly higher in cases than controls (median, 3 [range, 0-5] vs 0 [0-5]; P < .001). For the 30 cases, the mean interval between the most recent cUS examination without PIVH and the first cUS examination with PIVH was 21 hours (range, 3-36 hours).

Five infants had grade I PIVH, 14 had grade II PIVH, 6 had grade III

Discussion

Higher rScO₂ and lower cFTOE values suggest increased perfusion before the development of severe PIVH.²³ These higher rScO₂ values were not caused by higher SaO₂ values (Table II). This is substantiated by cFTOE values moving in the opposite direction. Moreover, Naulaers et al¹⁴ showed that cerebral oxygenation during the first 3 days of life in very preterm infants had no association with SaO₂ as long as SaO₂ remained stable. Our data on MABP–rScO₂ correlation suggest that (prolonged) blood

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Citation Excerpt :
There have been numerous studies assessing the utility of CrSO2 monitoring to predict those infants that are at higher risk of developing IVH. A trend of lower CrSO2 values and higher cerebral FTOE values have been noted initially, followed by a period of increased CrSO2 in those infants that develop IVH.129-132 Postulating relative early cerebral hypoxia in those infants that develop IVH and cerebral hyper-perfusion prior to bleed.
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: The authors declare no conflicts of interest.

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Original ArticleCerebral Oxygenation, Extraction, and Autoregulation in Very Preterm Infants Who Develop Peri-Intraventricular Hemorrhage

Objective

Study design

Results

Conclusion

Section snippets

Methods

Results

Discussion

J Pediatr

Semin Fetal Neonatal Med

J Pediatr

Lancet

J Pediatr

J Pediatr

Hemodynamic and antecedent risk factors of early and late periventricular/intraventricular hemorrhage in premature infants

Pediatrics

Early ductal shunting and intraventricular haemorrhage in ventilated preterm infants

Arch Dis Child Fetal Neonatal Ed

Low cerebral blood flow is a risk factor for severe intraventricular haemorrhage

Arch Dis Child Fetal Neonatal Ed

Aetiological role of cerebral blood flow alterations in development and extension of peri-intraventricular haemorrhage

Dev Med Child Neurol

Fluctuating cerebral blood-flow velocity in respiratory-distress syndrome: relation to the development of intraventricular hemorrhage

N Engl J Med

Neurodevelopmental and functional outcomes of extremely low birth weight infants in the National Institute of Child Health and Human Development Neonatal Research Network, 1993-1994

Pediatrics

Prophylactic intravenous indomethacin for preventing mortality and morbidity in preterm infants

Cochrane Database Syst Rev

Cerebral tissue oxygenation and regional oxygen saturation can be used to study cerebral autoregulation in prematurely born infants

Pediatr Res

Monitoring neonatal regional cerebral oxygen saturation in clinical practice: value and pitfalls

Neonatology

Original Article
Cerebral Oxygenation, Extraction, and Autoregulation in Very Preterm Infants Who Develop Peri-Intraventricular Hemorrhage