Anie Lapointe

Pulmonary hypertension and the asphyxiated newborn.

Persistent pulmonary hypertension of the newborn may occur with perinatal asphyxia, either because of direct effects of hypoxia/ischemia on pulmonary arterial function or indirectly because both are associated with meconium aspiration syndrome or perinatal sepsis/pneumonia. Therapies for persistent pulmonary hypertension of the newborn have the potential to affect cerebral function and cerebral perfusion in infants with hypoxic ischemic encephalopathy. Our literature review concludes that hyperventilation should be avoided, bicarbonate therapy is unproven, and hypoxia and hyperoxia should both be avoided. Nitric oxide improves pulmonary artery pressure and systemic perfusion. The effects of inotropic agents on cerebral perfusion or outcomes are uncertain.

Targeted neonatal echocardiography (TnECHO) service in a Canadian neonatal intensive care unit: a 4-year experience

Objective:To characterize the effect of a targeted neonatal echocardiography (TnECHO) program on decision making in a tertiary level unit.Study design:Retrospective cohort study of neonates, admitted between September 2007 and April 2011. Details of the TnECHO, and the clinical decisions within 6 h of the consultation were recorded.Result:A total of 199 infants underwent 512 echocardiograms with a median (interquartile range) of 2 (1 to 3) TnECHO studies per infant. The indications included assessment for patent ductus arteriosus (PDA; n=261, 51%), post-PDA ligation assessment (n=101, 19%), pulmonary hemodynamics (n=81, 16%), myocardial performance and systemic blood flow (n=52, 10%), and central venous catheter tip position (n=6, 1%). TnECHO consultation was followed by a change in clinical management in 212 cases (41%) and avoidance of a planned intervention in 112 cases (22%).Conclusion:TnECHO may be a useful tool to guide clinical decisions in the neonatal intensive care unit setting. Well-planned prospective studies are needed to assess the impact of TnECHO on outcomes.

Norepinephrine infusion improves haemodynamics in the preterm infants during septic shock

This study evaluated the clinical and haemodynamic effects of norepinephrine infusion in preterm infants.

Cerebral oxygen saturation and peripheral perfusion in the extremely premature infant with intraventricular and/or pulmonary haemorrhage early in life

Extremely preterm infants are at higher risk of pulmonary (PH) and intraventricular (IVH) haemorrhage during the transitioning physiology due to immature cardiovascular system. Monitoring of haemodynamics can detect early abnormal circulation that may lead to these complications. We described time-frequency relationships between near infrared spectroscopy (NIRS) cerebral regional haemoglobin oxygen saturation (CrSO2) and preductal peripheral perfusion index (PI), capillary oxygen saturation (SpO2) and heart rate (HR) in extremely preterm infants in the first 72 h of life. Patients were sub-grouped in infants with PH and/or IVH (NH = 8) and healthy controls (NC = 11). Data were decomposed in wavelets allowing the analysis of localized variations of power. This approach allowed to quantify the percentage of time of significant cross-correlation, semblance, gain (transfer function) and coherence between signals. Ultra-low frequencies (<0.28 mHz) were analyzed as slow and prolonged periods of impaired circulation are considered more detrimental than transient fluctuations. Cross-correlation between CrSO2 and oximetry (PI, SpO2 and HR) as well as in-phase semblance and gain between CrSO2 and HR were significantly lower while anti-phase semblance between CrSO2 and HR was significantly higher in PH-IVH infants compared to controls. These differences may reflect haemodynamic instability associated with cerebrovascular autoregulation and hemorrhagic complications observed during the transitioning physiology.

Outcomes of extremely premature infants with twin–twin transfusion syndrome treated by laser therapy

ObjectiveTo compare short-term and long-term outcomes of preterm infants born at <29 weeks of gestational age (GA) with twin–twin transfusion syndrome (TTTS) treated with laser therapy to preterm twin infants without TTTS.DesignRetrospective case–control study comparing 33 preterm TTTS twins to 101 preterm diamniotic–dichorionic (di–di) twins born at our institution between 2006 and 2015.ResultsGA at birth were 26.4 ± 1.4 weeks (TTTS) and 26.9 ± 1.6 weeks (di–di) (p = 0.07). TTTS premature newborns were less exposed to antenatal steroids (p = 0.01), more frequently born by C-section (p = 0.005), received more surfactant therapy (p = 0.004, and were smaller for GA (p < 0.001). When adjusted for antenatal steroids and birth weight, TTTS status was not associated with increased mortality (HR 1.66, 95% CI 0.77–3.56, p = 0.20). No differences were found on neurodevelopmental outcomes at 18 months of corrected GA.ConclusionPremature TTTS newborns treated with fetal laser therapy had similar survival and neurodevelopmental outcomes compared to preterm di–di twins without TTTS.

Cardiovascular Associations with Abnormal Brain Magnetic Resonance Imaging in Neonates with Hypoxic Ischemic Encephalopathy Undergoing Therapeutic Hypothermia and Rewarming

Objective This article compares hemodynamic characteristics of neonates with hypoxic ischemic encephalopathy (HIE) receiving therapeutic hypothermia (TH) with normal versus abnormal brain magnetic resonance imaging (MRI). Methods Serial echocardiography (echo) was performed within 24 hours, after 48 to 72 hours of cooling, within 24 hours of normothermia, and after starting feeds. Pulmonary hemodynamics, cardiac output, and ventricular function were evaluated. All neonates underwent brain MRI (day 4‐5), per clinical standard of care. Clinical cardiovascular and echocardiography characteristics were compared between patients with normal versus abnormal MRI. Cardiovascular changes during TH and after rewarming were identified. Results Twenty neonates at median gestation and birth weight of 40 weeks (interquartile range [IQR]: 39, 41) and 3,410 g (IQR: 2,885, 4,093), respectively, were enrolled. Increased median left ventricular output (LVO) (106‐159 mL/kg/min, p < 0.001) and reduced isovolumic relaxation time (IVRT) (48‐42 ms, p < 0.001) were seen after rewarming. Echocardiography evidence of pulmonary hypertension (PH) was identified in five neonates. Eight neonates (40%) had brain injury identified on MRI (watershed [n = 4], basal ganglia [n = 4]); this subgroup were more likely to have echo evidence of PH at 24 hours. Conclusion Longitudinal changes in cardiac output were noted in neonates with HIE during TH and rewarming. Echocardiography evidence of PH, however, was associated with abnormal MRI brain. The prognostic relevance of these physiologic changes requires more comprehensive delineation.

Corticosteroid Therapy in Neonatal Septic Shock—Do We Prevent Death?

Objective The aim was to compare survival of patients with septic shock receiving or not hydrocortisone (HC) and to analyze the hemodynamic response to HC. Study Design It is a retrospective study of 62 premature neonates with septic shock (confirmed bacteremia) and/or necrotizing enterocolitis (NEC) stage 2 and above receiving inotropes with or without HC. We analyzed survival and hemodynamic response to HC. Results Thirty‐nine (63%) premature neonates received HC and were compared with 23 (37%) who only received inotropes. Vasoactive index score (VAI) decreased and blood pressure, urine output, and oxygen requirements improved significantly following HC. Despite receiving more inotropes (VAI of 33 [20‐53] vs 10 [8‐20], p < 0.001), being more premature (26 ± 2 vs 27 ± 2 weeks, p = 0.02) and more frequently having NEC (64 vs 26%, p = 0.004), patients who received HC had similar survival from septic episode (death: 22% vs 41%, p = 0.12). However, patients receiving HC during their sepsis were less likely to survive at their 1‐year postmenstrual age follow‐up when accounted for gestational age (GA) at birth and duration of inotropes (hazard ratio 6.08 p = 0.01). Conclusion HC was used in infants with increased inotropic support. HC during septic shock was associated with similar survival from episode, but with decreased survival at 1‐year postmenstrual age.

Using internal and external reviewers can help to optimise neonatal mortality and morbidity conferences

This study determined whether there was a difference in the conclusions reached by neonatologists in morbidity and mortality conferences based on their level of involvement in a case.

Iatrogenic Oesophageal Perforation in an Extremely Low Birth Weight Newborn

We report a rare case of an extremely low birth weight (ELBW) baby with oesophageal perforation secondary to an oro-gastric tube insertion and concomitant milk pleural effusion diagnosed on chest radiography. Area of perforation was determined with lateral chest radiography. This is the first case described in the literature of a milk pleural effusion in the context of perforation of the inferior third of the oesophagus in an ELBW infant.