Hemodynamic management of congenital diaphragmatic hernia: the role of targeted neonatal echocardiography.

Congenital diaphragmatic hernia (CDH) is a major congenital anomaly, resulting from the herniation of abdominal contents into the thoracic cavity, thereby impeding the proper development of the lungs and pulmonary vasculature. CDH severity correlates with a spectrum of pulmonary hypoplasia, pulmonary hypertension (PHT), and cardiac dysfunction, constituting the pathophysiological triad of this complex condition. The accurate diagnosis and effective management of PHT and cardiac dysfunction is pivotal to optimizing patient outcomes. Targeted neonatal echocardiography is instrumental in delivering real-time data crucial for the bespoke, pathophysiology-targeted hemodynamic management of CDH-associated PHT.

Targeted Neonatal Echocardiography: Basics of Knobology 101.

Targeted neonatal echocardiography (TNE) is essential when approaching hemodynamic instability in neonates. Competency in this field requires standardized training, including robust hands-on experience. Proficiency in understanding the key elements of ultrasound knobology is indispensable for optimal acquisition of imaging. This is a narrative review summarizing the key elements of knobology in TNE. Literature review was mainly done through PubMed. There was no funding allocated for the production of this manuscript. KEY POINTS: · Robust and structured training is essential. · Understanding knobology is required to achieve competency in TNE. · Optimizing knobology is critical for an accurate hemodynamic interpretation report.

Should we "eliminate" PDA shunt in preterm infants? A narrative review.

The patent ductus arteriosus frequently poses a significant morbidity in preterm infants, subjecting their immature pulmonary vascular bed to substantial volume overload. This, in turn, results in concurrent hypoperfusion to post-ductal organs, and subsequently alters cerebral blood flow. In addition, treatment has not demonstrated definitive improvements in patient outcomes. Currently, the optimal approach remains a subject of considerable debate with ongoing research controversy regarding the best approach. This article provides a comprehensive review of existing literature.

Should SVC flow be a routine measure when performing targeted neonatal echocardiography? A narrative review.

Superior vena cava is commonly used in neonatal hemodynamics and is suggested to be the best available non-invasive marker for systemic circulation in preterm infants. Inter- and intra-observer variability remain to be an issue. Its association with neonatal outcomes is has not been established. This is a narrative review about this marker, its use, and its potential pitfalls. OBJECTIVE: This is a narrative review about SVC flow in preterm infants, physiology, techniques of measurement and its potential association with outcomes. SOURCES: Literature revie mainly PubMED. SUMMARY OF THE FINDINGS: SVC flow measurement has some limitations and pitfalls. CONCLUSIONS: SVC flow association with neonatal outcomes, still needs to be established in further research.

Point-of-care ultrasound aided diagnosis and management of peritoneal parenteral nutrition extravasation in a preterm baby: A case report.

POCUS could identify some of UVC complications at the bedside. It complements the clinical picture and helps narrowing the deferential diagnosis when there is a clinical deterioration.

Superior Vena Cava Flow in Preterm Infants and Neonatal Outcomes: A Systematic Review.

Superior vena cava (SVC) flow has been considered a surrogate marker of systemic blood flow in neonates. We conducted a systematic review to evaluate the association between low SVC flow recorded during the early neonatal period and neonatal outcomes. We searched the following databases (until December 9, 2020; updated October 21, 2022): PROSPERO, OVID Medline, OVID EMBASE, Cochrane Library (CDSR and Central), Proquest Dissertations and Theses Global, and SCOPUS using controlled vocabulary and key words representing the concepts "superior vena cava" and "flow" and "neonate." Results were exported to COVIDENCE review management software. The search retrieved 593 records after the removal of duplicates, of which 11 studies (nine cohorts) met the inclusion criteria. The majority of the studies included infants born at <30 weeks of gestation. The included studies were assessed as high risk of bias in terms of the incomparability of the study groups, with infants in the low SVC flow group noted to be more immature than those in the normal SVC flow group or subjected to different cointerventions. We did not conduct meta-analyses in view of the significant clinical heterogeneity noted in the included studies. We found little evidence to suggest that SVC flow in the early neonatal period is an independent predictor for adverse clinical outcomes in preterm infants. Included studies were assessed at high risk of bias. We conclude that SVC flow interpretation for prognostication or for making treatment decisions should be restricted to the research setting for now. We highlight the need for strengthened methods in future research studies. KEY POINTS: · We studied whether low SVC flow in the early neonatal period is a marker for adverse outcomes in preterm infants.. · There is insufficient evidence to conclude that low SVC flow is a valid predictor of adverse outcomes.. · There is insufficient evidence to conclude that SVC flow-directed hemodynamic management improves clinical outcomes..

Predictors of Umbilical Venous Catheter Misalignment.

Introduction: The insertion of an umbilical venous catheter (UVC) is a routine procedure. The success rate of this procedure is about 40−50%, with potential complications arising from misaligned UVC placement. Objectives: To explore potential factors that may aid in the prediction of UVC misalignment. We hypothesized that UVC misalignment is proportionally related with increased chronological age. Methods: Retrospective chart review for newborns who had an UVC procedure followed by an x-ray. All analyses were conducted using standard comparative statistical methods and logistic regression modelling with SPSS v.24 (IBM Corp., Armonk, NY, USA), and p-values < 0.05 were considered statistically significant. Results: The final sample size was 480 patients. There were significant differences between the two groups in terms of gestational age {OR 1.06, 95% CI (1.02−1.10)}, small for gestation (SGA) status {OR 1.07, 95% CI (0.98−1.15)}, and 5-min APGAR scores {OR 0.48, 95% CI (0.23−1.00)}. There were no other significant group differences. Logistic regression modeling identified that chronologic age positively predicted, and SGA negatively predicted, UVC misalignment. Conclusion: A misaligned UVC is more likely to occur in late preterm and term babies, whereas a baby being SGA increases the likelihood of a well-aligned UVC.

What Are the Minimal Feeds Required for Starting Enteral Ibuprofen in Preterm Infants with PDA?

Ibuprofen is commonly used for the treatment of hemodynamically significant patent ductus arteriosus (PDA) in preterm infants. It seems that the oral formulation incurs a higher closure rate and has a better safety profile in preterm infants born > 26 weeks' gestation. There is no consensus across Canadian centers regarding the minimum volume of enteral feeds required prior to starting ibuprofen for the treatment of patent ductus arteriosus, and the current practice is comfort-based depending on the centre and the local prevalence of neonatal morbidities.

Multimodal Assessment of Systemic Blood Flow in Infants.

The assessment of systemic blood flow is a complex and comprehensive process with clinical, laboratory, and technological components. Despite recent advancements in technology, there is no perfect bedside tool to quantify systemic blood flow in infants that can be used for clinical decision making. Each option has its own merits and limitations, and evidence on the reliability of these physiology-based assessment processes is evolving. This article provides an extensive review of the interpretation and limitations of methods to assess systemic blood flow in infants, highlighting the importance of a comprehensive and multimodal approach in this population.

Different approaches for patent ductus arteriosus in premature infants using acetaminophen.

BACKGROUND: Acetaminophen use for pharmacological treatment of hemodynamically significant patent ductus arteriosus (hsPDA) in preterm infants is becoming more popular with emerging evidence that it is effective as well as safe alternative for other agents used to close hsPDA. DATA SOURCES: We performed a narrative review of literature about pharmacological treatment of PDA using acetaminophen. RESULTS: Acetaminophen was used as a prophylaxis, symptomatic, targeted, and a rescue approach. CONCLUSIONS: It appears that acetaminophen could be used in different approaches to close the hsPDA. Long-term outcomes of acetaminophen exposure early in life still lack certainty.

Vasopressin for refractory persistent pulmonary hypertension of the newborn in preterm neonates - a case series.

OBJECTIVE: To describe the clinical outcomes following treatment with vasopressin for a sub-cohort of critically ill preterm neonates who have refractory persistent pulmonary hypertension of the newborn (PPHN). DESIGN: Case series. SETTING: Tertiary neonatal intensive care unit, Toronto, Canada. POPULATION: Neonates born <37 weeks gestational age (GA) who received vasopressin for refractory PPHN (lack of response to inhaled nitric oxide) over a 4-year period. MEASUREMENTS: Changes in physiological indices of cardio-pulmonary stability during vasopressin therapy were analyzed using one-way repeated measures ANOVA, compared to pretreatment values. Data regarding survival to discharge and neurodevelopmental outcomes at 18-24 months were described. MAIN RESULTS: Thirteen neonates with a mean GA of 31.4 ± 3.3 weeks were included. Vasopressin was initiated at 28.5 ± 4.5 h of age. Overall, oxygenation and hemodynamic variables improved significantly following vasopressin therapy (p < .05 at 24 h vs. pretreatment). Oxygenation failure resolved in 8 cases, of which 7 patients survived (6 without disability). Among the 5 cases where oxygenation failure persisted despite vasopressin, 4 died while one survived with disability. CONCLUSIONS: Vasopressin offers promise as a therapy for preterm neonates with refractory PPHN and hemodynamic instability, but prospective investigation is needed.

Use of combination therapy with acetaminophen and ibuprofen for closure of the patent ductus arteriosus in preterm neonates.

OBJECTIVE: To compare effectiveness and safety of combination therapy (acetaminophen and ibuprofen) to monotherapy (ibuprofen, indomethacin, or acetaminophen alone) in treatment of the patent ductus arteriosus (PDA) in premature neonates. METHODS: This was a retrospective cohort study of neonates admitted to a tertiary-level neonatal intensive care unit. Included neonates were born at <32 weeks gestation and received pharmacotherapy for PDA closure. Based on the primary therapy received, our cohort was divided into the following four groups: indomethacin alone, ibuprofen alone, acetaminophen alone, and ibuprofen and acetaminophen (in combination). Baseline characteristics, effectiveness, safety, neonatal mortality, and morbidities rates between these groups were compared. RESULTS: One hundred and forty neonates were analyzed; 17 received combination therapy, and 123 neonates received monotherapy: 22 (17.9%) ibuprofen, 29 (23.6%) acetaminophen, and 72 (58.5%) indomethacin. The PDA closure rates were 41.7% for indomethacin, 41.2% for combination therapy, 37.9% for acetaminophen, and 31.8% for ibuprofen (P=0.100). Rates of adverse effects were comparable between the groups. CONCLUSION: The rate of ductal closure was not different between combination therapy and monotherapy. The study did not demonstrate any increased adverse effects in the combination group. Future well-designed prospective clinical trials are needed to guide clinical practice.

Lower prevalence of aortic dilatation among preemptive pediatric renal transplant recipients - A cross-sectional cohort study.

BACKGROUND: Aortic dilatation is a cardiovascular complication in pediatric renal transplant recipients and may have an increased risk of aortic dissection, aortic rupture, and death. Studies failed to show an association between blood pressure and aortic dilatation; however, 24-hours ambulatory blood pressure monitoring (ABPM) was not performed. There was also no comparison between preemptive transplantation and dialysis. METHODS: After ethics approval, a retrospective cross-sectional study was performed on all prevalent pediatric renal transplant recipients from a single tertiary care center. The presence of aortic dilatation was determined using standard echocardiographic measurements, and those with other risk factors for aortic dilatation were excluded. Associations between 24-hours ABPM, renal function, dialysis history, and aortic dimensions were determined. RESULTS: We enrolled 37 participants with the following characteristics: 46% female, mean age 14.5 ± 3.7 years, 16% preemptive transplantation, and median end-stage renal disease (ESRD) combined vintage (time from ESRD onset to echocardiogram) 597 days (range 289-1290 days). We found 16/37 patients (43%) with aortic dilatation at any level, mostly mild. There was no association between 24-hours ABPM measurements and aortic dilatation. None of the preemptively transplanted children had aortic dilatation. CONCLUSION: This study confirms a high prevalence of aortic dilatation among pediatric renal transplant recipients, which appears to be independent of hypertension on 24-hour ABPM. Patients with preemptive renal transplantation did not have aortic dilatation, suggesting that the effects of dialysis may contribute to the high prevalence of this complication. Pediatric cardiologists need to carefully assess aortic dimensions in these at-risk patients.

An unusual case of pericardial effusion.

We report a case of a 13-year-old male with trisomy 21 in Southwestern Ontario, Canada, who presented with bilateral pneumonia, pericardial effusion, and peripheral oedema. The pericardial effusion did not respond to standard treatment options. Evaluation revealed severe dietary restriction, consistent with kwashiorkor. Hospital course was complicated by severe hypoalbuminaemia, hypocalcaemia, hypomagnesaemia, and hypophosphataemia. The pericardial effusion and other findings resolved gradually upon slow introduction of a well-balanced diet and adequate caloric and protein intake. Kwashiorkor is an unusual cause of pericardial effusion and can be overlooked especially in developed countries. It is a type of protein-calorie malnutrition often seen in children of impoverished countries and famine. It is a result of insufficient protein intake in the context of adequate caloric intake. Pericardial effusion not responding to usual treatment is a challenge, and other aetiologies must be considered. Malnutrition is often underdiagnosed or misdiagnosed in developed countries with devastating outcomes if unrecognised. This makes it imperative to consider this diagnosis, recognise potential risk factors, and be prepared to accurately assess overall nutritional status.