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Abstract
Dr. Richard Polin’s Neonatology Questions and Controversies series highlights the most challenging aspects of neonatal care, offering trustworthy guidance on up-to-date diagnostic and treatment options in the field. In each volume, renowned experts address the clinical problems of greatest concern to today’s practitioners, helping you handle difficult practice issues and provide optimal, evidence-based care to every patient.
- Stay fully up to date in this fast-changing field with Hemodynamics and Cardiology, 3rd Edition.
- A new editorial team and a completely redesigned volume with state-of-the-art chapters on neonatal hemodynamics.
- New chapters on the role of delayed cord clamping/cord milking, the relationship between neonatal transition and brain injury, the hemodynamics of the asphyxiated neonate, the hemodynamic impact of therapeutic hypothermia, and practical physiology-based approaches to the diagnosis and treatment of neonatal hypotension, PPHN and PDA.
- A new section discusses comprehensive real-time monitoring of neonatal hemodynamics, and its role in the establishment of precision medicine in neonatology and the prediction of neonatal sepsis using mathematical modelling of heart rate variability.
- Expanded sections review the clinical application of the tools available for bedside monitoring of systemic and organ blood flow and oxygen delivery and the approaches to the pathophysiology-based treatment of neonatal shock and outcomes.
- Consistent chapter organization to help you find information quickly and easily.
- The most authoritative advice available from world-class neonatologists who share their knowledge of new trends and developments in neonatal care.
Purchase each volume individually, or get the entire 7-volume set! Gastroenterology and Nutrition Hematology, Immunology and Genetics Hemodynamics and Cardiology Infectious Disease and Pharmacology New Volume! Nephrology and Fluid/Electrolyte Physiology Neurology The Newborn Lung
Table of Contents
| Section Title | Page | Action | Price |
|---|---|---|---|
| Front Cover | Cover | ||
| IFC | ES1 | ||
| HEMODYNAMICS AND CARDIOLOGY: Neonatology Questions and Controversies | i | ||
| Series Page | ii | ||
| HEMODYNAMICS AND CARDIOLOGY: Neonatology Questions and Controversies | iii | ||
| Copyright | iv | ||
| Contributors | v | ||
| Preface | xiii | ||
| Series Foreword | xv | ||
| Contents | xvii | ||
| A - Developmental Cardiovascular Physiology and Pathophysiology | 1 | ||
| 1 - Principles of Developmental Cardiovascular Physiology and Pathophysiology | 3 | ||
| Principles of Developmental Physiology | 3 | ||
| Fetal Circulation | 3 | ||
| Transitional Physiology | 4 | ||
| Postnatal Circulation | 5 | ||
| Pressure, Flow, and Resistance | 5 | ||
| Organ Blood Flow Distribution | 5 | ||
| Microcirculatory Physiology (see Chapter 19) | 6 | ||
| Myocardial Function—Developmental Aspects | 7 | ||
| Developmental Cardiovascular Pathophysiology: Etiology and Pathophysiology of Neonatal Shock | 8 | ||
| Definition and Phases of Shock | 10 | ||
| Etiology of Neonatal Shock | 10 | ||
| Hypovolemia | 10 | ||
| Myocardial Dysfunction (see Chapter 26) | 11 | ||
| Vasodilation | 12 | ||
| Adrenal Insufficiency (see Chapter 30) | 18 | ||
| Downregulation of Adrenergic Receptors | 20 | ||
| Summary | 21 | ||
| REFERENCES | 22 | ||
| 2 - Vascular Regulation of Blood Flow to Organs in the Preterm and Term Neonate | 29 | ||
| Regulation of Arterial Tone | 31 | ||
| The Role of Conduit Arteries in Regulating Vascular Resistance | 31 | ||
| Arterial Reaction to Pressure (Autoregulation) | 32 | ||
| Interaction of Autoregulation and Hypoxic Vasodilatation | 33 | ||
| Interaction of Autoregulation and Pco2 | 33 | ||
| Interaction of Autoregulation and Functional Activation (Metabolic Blood Flow Control) | 34 | ||
| Flow-Mediated Vasodilatation | 34 | ||
| Sympathetic Nervous System | 34 | ||
| Humoral Factors in General Circulation | 35 | ||
| Blood Flow to the Brain | 36 | ||
| Autoregulation of Cerebral Blood Flow in the Immature Brain | 36 | ||
| Effect of Carbon Dioxide on Cerebral Blood Flow | 37 | ||
| Metabolic Control of Blood Flow to the Brain | 37 | ||
| Adrenergic Mechanisms Affecting Cerebral Blood Flow | 38 | ||
| Effect of Medications on Cerebral Blood Flow | 38 | ||
| Ischemic Thresholds in the Brain | 38 | ||
| Blood Flow to Other Organs | 39 | ||
| Kidney | 39 | ||
| Liver | 39 | ||
| Stomach and Intestines | 39 | ||
| Distribution of Cardiac Output in the Healthy Human Neonate | 40 | ||
| Blood Flow to the Upper Part of the Body | 40 | ||
| Blood Flow to the Lower Part of the Body | 40 | ||
| Mechanisms Governing the Redistribution of Cardiac Output in the Fetal “Diving” Reflex | 41 | ||
| Aerobic Diving | 41 | ||
| Reactions to Hypoxia | 41 | ||
| Modifying Effects | 41 | ||
| Distribution of Cardiac Output in the Shocked Newborn | 42 | ||
| The Term Neonate With Low Cardiac Output | 42 | ||
| The Very Preterm Neonate During Immediate Postnatal Adaptation | 42 | ||
| Other Scenarios | 42 | ||
| REFERENCES | 43 | ||
| 3 - Definition of Normal Blood Pressure Range: The Elusive Target | 47 | ||
| Measuring Blood Pressure | 48 | ||
| Blood Pressure Standards | 49 | ||
| Clinical Factors Affecting Blood Pressure | 53 | ||
| Antenatal Steroids | 53 | ||
| Placental Transfusion | 53 | ||
| Respiratory Support | 53 | ||
| Blood Pressure and Short- and Long-Term Outcomes | 54 | ||
| Bedside Clinical Assessment and Hemodynamic Monitoring | 56 | ||
| Conclusion | 59 | ||
| REFERENCES | 60 | ||
| B - Hemodynamic Principles of Postnatal Transition | 65 | ||
| 4 - Cardiorespiratory Effects of Delayed Cord Clamping | 67 | ||
| The Transition to Newborn Life | 68 | ||
| Airway Liquid Clearance | 68 | ||
| Increase in Pulmonary Blood Flow at Birth in Response to Lung Aeration | 69 | ||
| The Cardiovascular Transition at Birth: Effect of Umbilical Cord Clamping | 70 | ||
| Neonatal Cardiovascular Responses to Umbilical Cord Clamping | 71 | ||
| Neonatal Cardiovascular Consequences of Umbilical Cord Milking | 72 | ||
| Placental Transfusion During Delayed Umbilical Cord Clamping | 73 | ||
| Potential Mechanisms for Placental Blood Transfusion | 73 | ||
| Gravity and Uterine Contraction | 73 | ||
| Increase in Pulmonary Blood Flow at Birth | 74 | ||
| Vaginal Birth | 74 | ||
| Clinical Effects of Delayed/Deferred Umbilical Cord Clamping | 74 | ||
| Potential Mechanisms of Benefit: Transfusion Versus Timing | 75 | ||
| Determinants of the Placental Transfusion | 76 | ||
| Time | 76 | ||
| Position/Gravity | 76 | ||
| Contractions/Oxytocics | 76 | ||
| Mode of Delivery | 76 | ||
| Umbilical Blood Vessel Patency | 77 | ||
| Breathing/Crying | 77 | ||
| Prevention of Hypotension/Low Systemic Blood Flow | 78 | ||
| Less Intervention at Birth: Resuscitation Versus Transitioning | 79 | ||
| Physiologically Based Cord Clamping | 79 | ||
| Conclusions | 79 | ||
| REFERENCES | 80 | ||
| 5 - Hemodynamic Significance and Clinical Relevance of Delayed Cord Clamping and Umbilical Cord Milking | 83 | ||
| Transitional Physiology and Animal Studies of Delayed Cord Clamping and Umbilical Cord Milking | 84 | ||
| Cardiovascular Effects of Delayed Cord Clamping and Umbilical Cord Milking in the Delivery Room | 86 | ||
| Hemodynamic Measurements in the First Hours After Birth Following Delayed Cord Clamping and Umbilical Cord Milking | 88 | ||
| Neonatal Blood Volume After Delayed Cord Clamping and Umbilical Cord Milking | 89 | ||
| Long-Term Outcomes and Mortality After Delayed Cord Clamping and Umbilical Cord Milking | 89 | ||
| Conclusions and Future Directions | 90 | ||
| REFERENCES | 91 | ||
| 6 - Transitional Hemodynamics and Pathophysiology of Peri/Intraventricular Hemorrhage | 95 | ||
| Fetal and Transitional Circulation | 95 | ||
| Cerebral Blood Flow | 96 | ||
| Normal Changes in Cerebral Blood Flow | 96 | ||
| Cerebral Blood Flow and Peri/Intraventricular Hemorrhage | 97 | ||
| Vulnerabilities of Preterm Infants During Transition | 98 | ||
| Inherent Vulnerability of the Immature Brain | 98 | ||
| Immature Myocardium | 99 | ||
| Hypovolemia and Timing of Cord Clamping | 102 | ||
| Patent Ductus Arteriosus | 102 | ||
| Hypotension | 103 | ||
| Cardiorespiratory Interaction | 104 | ||
| Hypocapnia and Hypercapnia | 104 | ||
| Conclusions | 106 | ||
| REFERENCES | 106 | ||
| 7 - The Immature Autonomic Nervous System, Hemodynamic Regulation, and Brain Injury in the Preterm Neonate | 111 | ||
| Magnitude of the Problem | 112 | ||
| Hemodynamic Vulnerability in Premature Infants | 114 | ||
| The Premature Autonomic Nervous System | 114 | ||
| The Premature Cardiovascular System | 115 | ||
| Cerebral Hemodynamic Control in Premature Infants | 116 | ||
| Evidence for an Association Between Systemic Hemodynamic Disturbances and Prematurity-Related Brain Injury | 116 | ||
| Resolving the Relationship Between Systemic Hemodynamics and Prematurity-Related Brain Injury: Obstacles to Progress | 117 | ||
| Measurement of Relevant Hemodynamic and Metabolic Indices | 117 | ||
| Potential for “Dysmaturation” of the Autonomic Nervous System in Premature Newborns | 119 | ||
| Conclusion | 121 | ||
| REFERENCES | 121 | ||
| 8 - Pathophysiology of Persistent Pulmonary Hypertension of the Newborn—Cellular Basis and Lessons from Animal Studies | 129 | ||
| Physiology of the Fetal Circulation | 130 | ||
| Low Placental Vascular Resistance | 131 | ||
| High Fetal Pulmonary Vascular Resistance | 131 | ||
| Transition at Birth | 134 | ||
| Animal Models of Pulmonary Hypertension in the Newborn | 134 | ||
| Antenatal Ductal Ligation Model in Sheep With Reduced Pulmonary Blood Flow | 134 | ||
| Cellular and Biochemical Changes | 134 | ||
| Aortopulmonary Graft With Pulmonary Overcirculation | 136 | ||
| Cellular and Biochemical Changes | 137 | ||
| Drug Induced Pulmonary Hypertension | 137 | ||
| Meconium Aspiration Model | 137 | ||
| Chronic Hypoxia | 137 | ||
| Monocrotaline-Induced Pulmonary Hypertension in Rats | 138 | ||
| Intrauterine Growth Restriction | 139 | ||
| Congenital Diaphragmatic Hernia | 139 | ||
| Fetal Surgical Model in Lambs | 139 | ||
| Cellular and Biochemical Changes | 139 | ||
| Nitrofen Model in Rats | 140 | ||
| Cellular and Biochemical Abnormalities | 140 | ||
| Medications in Pregnancy and Persistent Pulmonary Hypertension of the Newborn: Cellular Basis | 140 | ||
| Selective Serotonin Reuptake Inhibitors | 140 | ||
| Nonsteroidal Antiinflammatory Drugs | 140 | ||
| Antenatal Betamethasone | 140 | ||
| Free Radicals in Persistent Pulmonary Hypertension of the Newborn | 141 | ||
| Oxidative Stress | 141 | ||
| Reactive Nitrogen Species | 141 | ||
| Pathological Vascular Remodeling in Persistent Pulmonary Hypertension of the Newborn | 142 | ||
| Cellular and Biochemical Basis of Various Persistent Pulmonary Hypertension of the Newborn Therapies | 143 | ||
| Oxygen | 143 | ||
| Human Data on Hypoxic Pulmonary Vasoconstriction | 143 | ||
| Inhaled Nitric Oxide | 145 | ||
| Attenuating Inactivation of Inhaled Nitric Oxide by Superoxide | 145 | ||
| Soluble Guanylate Cyclase Stimulators and Activators (see Fig. 8.9) | 145 | ||
| Inhibition of Phosphodiesterase 5 | 145 | ||
| Hydrocortisone | 146 | ||
| Inhibition of Phosphodiesterase 3 | 146 | ||
| Cellular Basis for Emerging Therapies | 147 | ||
| L-citrulline | 147 | ||
| Rho-kinase inhibitors | 147 | ||
| Stem Cell Therapies | 147 | ||
| Conclusion | 147 | ||
| Founding Sources | 148 | ||
| REFERENCES | 148 | ||
| 9 - Pathophysiologically Based Management of Persistent Pulmonary Hypertension of the Newborn | 155 | ||
| Pathophysiology, Hemodynamics and Treatment Targets | 155 | ||
| Principles of Management of Persistent Pulmonary Hypertension of the Newborn | 157 | ||
| Supportive Care | 157 | ||
| Mechanical Ventilation and Surfactant | 157 | ||
| Vasodilator Therapy in Persistent Pulmonary Hypertension of the Newborn | 158 | ||
| Oxygen and Carbon Dioxide | 158 | ||
| Inhaled Nitric Oxide | 159 | ||
| Role of Inhaled Nitric Oxide in Preterm Oxygenation Failure | 160 | ||
| Weaning Inhaled Nitric Oxide | 161 | ||
| Other Pulmonary/Systemic Vasodilators | 161 | ||
| Phosphodiesterase-5 Inhibitors | 161 | ||
| Phosphodiesterase-3 Inhibitors | 162 | ||
| Prostaglandins | 163 | ||
| Endothelin Receptor Antagonists | 163 | ||
| Magnesium Sulfate | 164 | ||
| Utilizing Pathophysiology to Guide the Use of Vasodilators in Persistent Pulmonary Hypertension of the Newborn | 164 | ||
| Vasopressor Therapy in Persistent Pulmonary Hypertension of the Newborn | 164 | ||
| Using Pathophysiology to Guide Use of Vasopressors in Persistent Pulmonary Hypertension of the Newborn | 167 | ||
| Extracorporeal Membrane Oxygenation | 169 | ||
| Conclusions | 169 | ||
| REFERENCES | 171 | ||
| C - Diagnosis of Neonatal Cardiovascular Compromise: Methods and Their Clinical Applications | 175 | ||
| C1 - Assessment of Systemic Blood Flow and Cardiac Function: Ultrasound | 175 | ||
| 10 - Point of Care Ultrasound in the Assessment of the Neonatal Cardiovascular System | 177 | ||
| Politics of Ultrasound | 178 | ||
| What’s in a Name? | 179 | ||
| Training and Accreditation in Point of Care Ultrasound | 179 | ||
| Using Physiology to Target Treatment | 180 | ||
| Uses of Point of Care Ultrasound in the Neonatal Intensive Care Unit | 184 | ||
| The immediate postnatal period | 184 | ||
| Circulatory transition in the very preterm baby | 185 | ||
| Assessment for PDA | 185 | ||
| The septic baby | 186 | ||
| Suspected PPHN | 186 | ||
| Babies presenting with collapse/shock | 186 | ||
| In newborn transport | 186 | ||
| Avoiding Inappropriate Therapy and Weaning | 187 | ||
| Other uses of neonatal POCU | 187 | ||
| Does Point of Care Ultrasound Make a Difference? | 188 | ||
| Conclusions | 188 | ||
| REFERENCES | 189 | ||
| 11 - Assessment of Systemic Blood Flow and Myocardial Function in the Neonatal Period Using Ultrasound | 191 | ||
| Assessment of Systemic Blood Flow by Ultrasound | 192 | ||
| Left Ventricular Output | 193 | ||
| Right Ventricular Output | 193 | ||
| Superior Vena Cava Flow | 194 | ||
| Cavity Measures | 195 | ||
| Cavity Measures of the Left Ventricle | 196 | ||
| Cavity Measures of the Right Ventricle | 196 | ||
| Use of Cavity Measures | 197 | ||
| Mitral and Tricuspid Annular Plane Systolic Excursion | 197 | ||
| Conclusions | 199 | ||
| Transitional Period in the Very Preterm Baby | 199 | ||
| Suspected PDA Beyond the Early Transitional Period | 200 | ||
| Circulatory Compromise in Neonates | 200 | ||
| Persistent Pulmonary Hypertension in the Neonate | 201 | ||
| REFERENCES | 201 | ||
| 12 - Tissue Doppler Imaging | 205 | ||
| Principles of Cardiac Function | 206 | ||
| Pulsed Wave Tissue Doppler Velocity Measurements | 208 | ||
| Color Tissue Doppler Velocity | 208 | ||
| Measurement of Tissue Doppler Imaging Velocities | 208 | ||
| Clinical Application of Tissue Doppler Imaging Velocity Measurements | 210 | ||
| Tissue Doppler-Derived Deformation Measurements | 212 | ||
| Principles of Deformation Imaging | 212 | ||
| Tissue Doppler Derived Deformation Imaging | 213 | ||
| Clinical Applications in the Neonatal Population | 213 | ||
| Conclusion | 215 | ||
| REFERENCES | 215 | ||
| 13 - Speckle Tracking Echocardiography in Newborns | 219 | ||
| Basic Concepts and Terminology | 220 | ||
| Image Acquisition | 222 | ||
| Sending and Storage of Acquired Images | 223 | ||
| Image Processing | 224 | ||
| Interpretation of the Results | 224 | ||
| Advantages of Two-Dimensional Speckle Tracking Echocardiography | 226 | ||
| Limitations and Pitfalls of Two-Dimensional Speckle Tracking Echocardiography | 226 | ||
| Normal Two-Dimensional Speckle Tracking Echocardiography Values in Newborns | 227 | ||
| Clinical Applications of Two-Dimensional Speckle Tracking Echocardiography | 229 | ||
| Future Directions of Two-Dimensional Speckle Tracking Echocardiography | 230 | ||
| REFERENCES | 230 | ||
| C2 - Assessment of Systemic Blood Flow and Cardiac Function: Other Methods | 235 | ||
| 14 - Assessment of Cardiac Output in Neonates | 237 | ||
| Techniques Using the Fick Principle, Indicator Dilution Technology, Doppler Ultrasound, Thoracic Electrical Impedance, and Arterial Pulse Contour Analysis | 237 | ||
| Fick Principle | 240 | ||
| Oxygen Fick | 240 | ||
| Pulmonary Oxygen Uptake | 244 | ||
| Oxygen Concentration Gradient | 245 | ||
| Cardiac Output (Calculation Examples) | 246 | ||
| Carbon Dioxide Fick | 246 | ||
| Modified Carbon Dioxide Fick Method | 246 | ||
| Carbon Dioxide Rebreathing Technology | 247 | ||
| Indicator Dilution Techniques | 248 | ||
| Pulmonary Artery Thermodilution | 248 | ||
| Transpulmonary Indicator Dilution and Thermodilution | 249 | ||
| Transpulmonary Lithium Dilution | 249 | ||
| Transpulmonary Ultrasound Dilution | 250 | ||
| Pulse Dye Densitometry | 250 | ||
| Doppler Ultrasound | 250 | ||
| Transthoracic Echocardiography | 252 | ||
| Transesophageal Echocardiography | 252 | ||
| Transesophageal Doppler | 253 | ||
| Transcutaneous Doppler | 253 | ||
| Thoracic Electrical Bioimpedance | 254 | ||
| Electrical Cardiometry | 255 | ||
| Bioreactance Method | 258 | ||
| Arterial Pulse Contour Analysis | 258 | ||
| Conclusion | 259 | ||
| REFERENCES | 260 | ||
| 15 - Cardiac Magnetic Resonance Imaging in the Assessment of Systemic and Organ Blood Flow and the Function of the Developing Heart | 265 | ||
| Current Understanding of Neonatal Hemodynamics | 265 | ||
| Circulatory Physiology and Assessment | 266 | ||
| Cardiac Magnetic Resonance in Adults and Newborns | 267 | ||
| Cmr In Adults | 267 | ||
| Cmr In Newborns | 267 | ||
| Current and Emerging Cardiovascular Magnetic Resonance Techniques | 268 | ||
| Cine Cmr | 268 | ||
| PC CMR | 269 | ||
| Three-Dimensional Pc Cmr | 270 | ||
| Assessment of Myocardial Motion | 271 | ||
| “Atlasing” of Cine Cmr Images | 271 | ||
| Validation of Cmr in the Newborn | 271 | ||
| Role of Cardiovascular Magnetic Resonance in the Study of Neonatal Hemodynamics | 271 | ||
| Provision of Normative Data | 271 | ||
| Quantification of Pda Shunt Volume | 272 | ||
| Guiding the Development of Emerging Cardiac Ultrasound Techniques | 272 | ||
| Cardiac Remodeling Following Premature Birth | 274 | ||
| Cardiovascular Magnetic Resonance in the Fetus | 276 | ||
| Advantages and Disadvantages of Functional Cardiovascular Magnetic Resonance Imaging | 276 | ||
| Summary | 277 | ||
| REFERENCES | 277 | ||
| C3 - Assessment of Organ and Peripheral Blood Flow | 281 | ||
| 16 - Methods to Assess Organ Blood Flow in the Neonate | 283 | ||
| Doppler Ultrasound | 284 | ||
| Doppler Principle | 284 | ||
| First Instruments | 284 | ||
| Indices of Pulsatility | 285 | ||
| Blood Flow Velocity | 285 | ||
| Volumetric Measurements | 286 | ||
| Diffuse Optical Methods Using Near-Infrared Light | 286 | ||
| Geometry | 286 | ||
| Algorithms and Wavelengths for Spectroscopy | 286 | ||
| Pathlength | 286 | ||
| Measurement of Cerebral Blood Flow Using Oxyhemoglobin as Tracer | 287 | ||
| Indocyanine Green as an Alternative Tracer | 287 | ||
| Calculating Cerebral Blood Flow from Cerebral Blood Volume | 288 | ||
| Diffuse Correlation Spectroscopy | 288 | ||
| Cerebral Oxygenation as a Surrogate for Blood Flow | 288 | ||
| Quantification | 288 | ||
| Bias of Tissue Oxygen Saturation | 288 | ||
| Precision of the Tissue Oxygen Saturation | 289 | ||
| Importance of the Low Precision of the Tissue Oxygen Saturation | 289 | ||
| Covariance of Cerebral Oxygenation and Arterial Blood Pressure as an Indication of Cerebral Autoregulation | 289 | ||
| Magnetic Resonance Imaging | 289 | ||
| Flow Imaging | 289 | ||
| 133Xe Clearance | 290 | ||
| Single-Photon Emission Computed Tomography | 290 | ||
| Stable Xenon-Enhanced Computed Tomography | 290 | ||
| Positron Emission Tomography | 290 | ||
| Other Methods | 291 | ||
| Flow to Other Organs | 291 | ||
| Conclusion | 292 | ||
| REFERENCES | 292 | ||
| 17 - Near-Infrared Spectroscopy and Its Use for the Assessment of Tissue Perfusion in the Neonate | 295 | ||
| Principles of Near-Infrared Spectroscopy | 296 | ||
| Near-Infrared Spectrophotometers | 296 | ||
| Continuous Wave Instruments | 297 | ||
| Spatially Resolved Spectroscopy | 298 | ||
| Time-of-Flight Instruments | 299 | ||
| Frequency Domain Instruments | 299 | ||
| Measurements of Physiologic Variables | 300 | ||
| Venous Oxygen Saturation | 300 | ||
| Cerebral Venous Oxygen Saturation | 300 | ||
| Peripheral Venous Oxygen Saturation | 301 | ||
| Blood Flow | 302 | ||
| Physiologic Observations Using Near-Infrared Spectroscopy | 303 | ||
| Oxygen Delivery | 303 | ||
| Factors Determining Oxygen Delivery | 303 | ||
| Effect of Anemia | 303 | ||
| Cerebral Oxygen Delivery | 304 | ||
| Cerebral Blood Flow | 304 | ||
| Peripheral Blood Flow | 305 | ||
| Oxygen Consumption | 305 | ||
| Cerebral Venous Oxygen Saturation and Consumption | 306 | ||
| Peripheral Venous Oxygen Saturation and Consumption | 306 | ||
| Fractional Oxygen Extraction | 306 | ||
| Conclusions | 307 | ||
| REFERENCES | 308 | ||
| 18 - Clinical Applications of Near-Infrared Spectroscopy in Neonates | 311 | ||
| Clinical Applications | 315 | ||
| Application of the Sensor and Its Pitfalls | 315 | ||
| Relation to Other Monitoring Devices | 316 | ||
| Clinical Conditions Associated With Low Regional Cerebral Oxygen Saturation | 316 | ||
| Clinical Conditions Associated With High Regional Cerebral Oxygen Saturation Values | 321 | ||
| Conclusion | 322 | ||
| REFERENCES | 323 | ||
| 19 - Assessment of the Microcirculation in the Neonate | 327 | ||
| Why Assess the Microcirculation? | 327 | ||
| Where to Study the Microcirculation in the Human Newborn? | 328 | ||
| Laser Doppler Imaging | 329 | ||
| Laser Doppler Flowmetry | 329 | ||
| Postocclusive Reactive Hyperemia | 330 | ||
| Local Thermal Hyperemia | 330 | ||
| Iontophoresis | 330 | ||
| Videomicroscopy | 331 | ||
| Microvasculature of the Neonate Studied by Laser Doppler Flowmetry and Videomicroscopy | 331 | ||
| Neonatal Peripheral Microvascular Blood Flow and Gestational Age at Birth | 332 | ||
| Neonatal Peripheral Microvascular Blood Flow, Postnatal Age, and Clinical Status | 332 | ||
| Neonatal Peripheral Microvascular Blood Flow and Sex | 334 | ||
| Retinography and Cardiovascular Programming | 335 | ||
| Future Applications in Neonatal Medicine | 336 | ||
| Summary and Conclusions | 336 | ||
| REFERENCES | 336 | ||
| C4 - Comprehensive andPredictive Monitoring | 341 | ||
| 20 - Heart Rate and Cardiorespiratory Analysis for Sepsis and Necrotizing Enterocolitis Prediction | 343 | ||
| Predictable Systemic Inflammatory Crises in the Neonatal Intensive Care Unit | 343 | ||
| Risk Prediction Incorporating Prenatal Heart Rate Data | 344 | ||
| Early Postnatal Predictors of Late Events or Outcomes | 344 | ||
| Risk Prediction for Imminent Clinical Deterioration | 345 | ||
| Heart Rate Regulation by the Autonomic Nervous System | 345 | ||
| Measurement of Heart Rate Variability Using Linear (Time and Frequency Domain) and Nonlinear Mathematical Methods | 347 | ||
| Developmental and Pathologic Factors Impacting Heart Rate Variability and Heart Rate Characteristics | 347 | ||
| Development of the Heart Rate Characteristics Index Monitor | 348 | ||
| Does Heart Rate Characteristics Monitoring Improve Outcomes of Infants in the Neonatal Intensive Care Unit? | 351 | ||
| Can Other Adverse Events Be Predicted by the Heart Rate Characteristics Index? | 351 | ||
| Limitations of the Heart Rate Characteristics Index | 352 | ||
| Would Adding Clinical, Laboratory, or Biomarker Data Improve Predictive Algorithms? | 352 | ||
| Would Adding Respiratory Analysis Improve Predictive Algorithms? | 353 | ||
| Cardiorespiratory Interactions | 354 | ||
| Pulse Oximetry-Based Algorithms: Are “Small Data” as Good as “Big Data”? | 355 | ||
| Other Systems for Predictive Monitoring in Infant and Adult Intensive Care Unit Patients | 355 | ||
| Process of Developing Early Warning Systems | 356 | ||
| Challenges and Future Directions for Predictive Monitoring Research | 357 | ||
| Electronic Medical Record Alerts and Alarms | 357 | ||
| The Importance of Data Sharing | 358 | ||
| Conclusion | 358 | ||
| 21 - Comprehensive, Real-Time Hemodynamic Monitoring and Data Acquisition: An Essential Component of the Development of Individualized Neonatal Intensive Care | 363 | ||
| Limitations of Conventional Monitoring | 364 | ||
| Assessment of Systemic and Regional Blood Flow | 365 | ||
| Systemic Blood Flow | 365 | ||
| Organ Blood Flow | 366 | ||
| Peripheral Perfusion and Microcirculation | 367 | ||
| Comprehensive Monitoring Systems | 367 | ||
| From Research to Individualized Neonatal Intensive Care | 375 | ||
| Conclusion | 377 | ||
| REFERENCES | 380 | ||
| D - Clinical Presentations and Treatment of Cardiovascular Compromise in the Neonate | 385 | ||
| D1 - Patent Ductus Arteriosus | 385 | ||
| 22 - Diagnosis, Evaluation, and Monitoring of Patent Ductus Arteriosus in the Very Preterm Infant | 387 | ||
| Developmental Role of the Ductus Arteriosus | 387 | ||
| Regulation of Ductal Tone and Constriction | 388 | ||
| Resistance to Ductal Closure in Premature Infants | 389 | ||
| Pathophysiologic Continuum of the Ductal Shunt in Preterm Infants | 390 | ||
| Myocardial Adaptation in Preterm Infants to Patent Ductus Arteriosus | 391 | ||
| Effects of Patent Ductus Arteriosus on Blood Pressure | 392 | ||
| Effects of a Hemodynamically Significant Patent Ductus Arteriosus on Organ Perfusion | 392 | ||
| Cerebral Blood Flow | 393 | ||
| Superior Mesenteric and Celiac Artery Blood Flow | 395 | ||
| Pulmonary Blood Flow | 396 | ||
| Clinical and Radiologic Diagnosis of Patent Ductus Arteriosus | 397 | ||
| Echocardiographic Diagnosis and Assessment of a Patent Ductus Arteriosus | 398 | ||
| Ductus Arteriosus Size and Transductal Doppler Flow Pattern | 398 | ||
| Pulmonary Overcirculation and Left Heart Loading | 399 | ||
| Systemic Arterial Diastolic Flow Reversal | 399 | ||
| The Use of Biomarkers in Patent Ductus Arteriosus Assessment: Brain Natriuretic Peptide and N-Terminal Pro–Brain Natriuretic Pep... | 400 | ||
| Brain Natriuretic Peptide/N-Terminal Pro–Brain Natriuretic Peptide and the Diagnosis of Presymptomatic Patent Ductus Arteriosus | 402 | ||
| Near-Infrared Spectroscopy and Patent Ductus Arteriosus Assessment | 402 | ||
| A Comprehensive Appraisal of the Hemodynamic Significance of the Patent Ductus Arteriosus | 403 | ||
| Summary | 405 | ||
| REFERENCES | 406 | ||
| 23 - Pharmacologic Management of Patent Ductus Arteriosus in the Very Preterm Neonate | 411 | ||
| Epidemiology of Patent Ductus Arteriosus Treatment | 412 | ||
| Pharmacologic Interventions | 414 | ||
| Indomethacin | 414 | ||
| Mechanism of Action | 414 | ||
| Route, Dose and Frequency | 415 | ||
| Efficacy | 416 | ||
| Timing of Administration | 416 | ||
| Side Effects | 417 | ||
| Take-Home Message | 417 | ||
| Ibuprofen | 417 | ||
| Mechanism of Action | 417 | ||
| Route, Dose, and Frequency | 418 | ||
| Efficacy | 418 | ||
| Timing of Administration | 419 | ||
| Side Effects | 419 | ||
| Take-Home Message | 419 | ||
| Acetaminophen (Paracetamol) | 419 | ||
| Mechanism of Action | 419 | ||
| Route, Dose, and Frequency | 419 | ||
| Efficacy | 420 | ||
| Timing of Administration | 420 | ||
| Side Effects | 420 | ||
| Take-Home Message | 422 | ||
| Comparison of the Three Pharmacologic Agents | 422 | ||
| Conclusions and Implications for Practice and Research | 422 | ||
| REFERENCES | 423 | ||
| 24 - Surgical Management of Patent Ductus Arteriosus in the Very Preterm Infant and Postligation Cardiac Compromise | 427 | ||
| Patent Ductus Arteriosus Ligation: Evidence of Benefit Versus Harm in Randomized Clinical Trials | 428 | ||
| Patent Ductus Arteriosus Ligation and Outcomes: Associations from Observational Studies | 430 | ||
| Neonatal Morbidity, Neurodevelopmental Impairment, and Patent Ductus Arteriosus Ligation: Residual Bias in Observational Studies... | 432 | ||
| Patent Ductus Arteriosus Ligation Decision: Timing, Patient Selection, and Staging | 433 | ||
| Preoperative and Intraoperative Management | 434 | ||
| Care of the Preterm Infant After Patent Ductus Arteriosus Ligation | 435 | ||
| Physiologic Changes After Surgery | 435 | ||
| Reduction in left ventricle (LV) preload, surge in systemic vascular resistance (SVR), and reduced cardiac output | 435 | ||
| Myocardial dysfunction | 436 | ||
| Hemodynamic changes in mesenteric and cerebral circulations | 436 | ||
| PLCS and Targeted Milrinone Prophylaxis | 437 | ||
| Isolated Postoperative Respiratory Instability | 438 | ||
| Hypothalamic-Pituitary-Adrenal (HPA) Gland Axis and Postligation Cardiovascular Stability | 438 | ||
| Surgical Complications | 438 | ||
| Pneumothorax and Chylothorax | 439 | ||
| Phrenic Nerve Paralysis | 439 | ||
| Injury or Ligation of Adjacent Structures | 439 | ||
| Residual Ductal Shunting | 439 | ||
| Bleeding | 439 | ||
| Vocal Cord Paralysis | 439 | ||
| Early Postoperative Management | 440 | ||
| Transcatheter Closure of Patent Ductus Arteriosus | 441 | ||
| Summary: The Patent Ductus Arteriosus Ligation Decision and Postoperative Management—Present Uncertainty, Practice Variability, ... | 442 | ||
| REFERENCES | 442 | ||
| 25 - Pathophysiology Based Management of the Hemodynamically Significant Ductus Arteriosus in the Very Preterm Neonate | 447 | ||
| Pathophysiology of Patent Ductus Arteriosus Closure | 448 | ||
| Issues to be Considered When Deciding Whether to Treat the Patent Ductus Arteriosus | 448 | ||
| Spontaneous Closure Rates | 448 | ||
| Consequences of a Patent Ductus Arteriosus | 450 | ||
| When to Treat? | 452 | ||
| Prophylactic Treatment | 453 | ||
| Which Patent Ductus Arteriosus to Treat? | 455 | ||
| Candidates for Patient Selection | 457 | ||
| Clinical | 457 | ||
| Ultrasound | 457 | ||
| How to Treat? | 463 | ||
| Conclusion | 464 | ||
| REFERENCES | 464 | ||
| D2 - Pathophysiology andTreatment of Neonatal Shock | 469 | ||
| 26 - Cardiovascular Compromise in the Preterm Infant During the First Postnatal Day | 471 | ||
| Definition of Hypotension and Its Relationship to Low Systemic Perfusion | 472 | ||
| The Transitional Circulation in the Very Low Birth Weight Infant | 474 | ||
| Physiologic Determinants of the Blood Pressure in the Very Low Birth Weight Infant | 475 | ||
| Clinical Determinants of Blood Pressure in the Very Low Birth Weight Infant | 476 | ||
| Gestational Age and Postnatal Age | 476 | ||
| Use of Antenatal Glucocorticoid Therapy | 477 | ||
| Blood Loss | 477 | ||
| Timing of Umbilical Cord Clamp | 477 | ||
| Positive Pressure Ventilation | 477 | ||
| Patent Ductus Arteriosus (see Chapter 22) | 478 | ||
| Calculated Systemic Vascular Resistance | 478 | ||
| Assessment of Cardiovascular Compromise in the Shocked Very Low Birth Weight Infant | 478 | ||
| Capillary Refill Time | 479 | ||
| Urine Output | 479 | ||
| Pulse Rate | 479 | ||
| Metabolic Acidosis/Lactic Acidosis | 479 | ||
| Blood Pressure (see Chapter 3) | 480 | ||
| Cardiac Output (see Chapter 14) | 480 | ||
| Monitoring of Peripheral and Mucosal Blood Flow | 480 | ||
| Pulse Oximeter Derived Perfusion Index | 480 | ||
| Systemic Blood Flow | 481 | ||
| Short- and Long-Term Effects of Cardiovascular Compromise/Shock in the Very Low Birth Weight Infant | 481 | ||
| Peri/Intraventricular Hemorrhage | 482 | ||
| Periventricular Leukomalacia | 482 | ||
| Long-Term Neurodevelopmental Outcome | 482 | ||
| Treatment Options in the Management of Cardiovascular Compromise/Shock in the Very Low Birth Weight Infant | 483 | ||
| Conclusion | 483 | ||
| REFERENCES | 484 | ||
| 27 - Assessment and Management of Septic Shock and Hypovolemia | 489 | ||
| The Hemodynamic Response to Sepsis | 490 | ||
| Adults | 490 | ||
| Children | 490 | ||
| Neonates | 490 | ||
| Approach to the Treatment of Neonates With Septic Shock | 492 | ||
| Catecholamine-Resistant Septic Shock (see Chapter 30) | 496 | ||
| Hypovolemic Shock in Neonates | 497 | ||
| Conclusion | 498 | ||
| REFERENCES | 498 | ||
| 28 - Hemodynamics in the Asphyxiated Neonate and Effects of Therapeutic Hypothermia | 503 | ||
| Pathophysiology of Hypoxic Ischemic Injury | 504 | ||
| Acute Injury | 505 | ||
| Reperfusion Injury (Delayed Brain Damage) | 505 | ||
| Fetal Cardiovascular Adaptation to Hypoxia-Ischemia | 505 | ||
| Cardiovascular Effects of Hypoxia-Ischemia | 506 | ||
| The Cardiovascular System and Central Nervous System injury | 507 | ||
| Autoregulation | 507 | ||
| Cardiovascular Effects of Therapeutic Hypothermia | 508 | ||
| Cardiovascular Effects of Rewarming After Hypothermia | 509 | ||
| Clinical Implications | 509 | ||
| Effect on Heart Rate and Cardiac Output | 509 | ||
| Clinical Implications in Asphyxiated Infants With Sepsis and Persistent Pulmonary Hypertension of the Newborn | 509 | ||
| Clinical Assessment of the Asphyxiated Neonate | 510 | ||
| Immediate Assessment of Perfusion | 510 | ||
| Clinician-Performed Cardiac Ultrasound for Hemodynamic Assessment in Neonates With Hypoxic-Ischemic Encephalopathy | 511 | ||
| Approach to Hemodynamic Management | 511 | ||
| Preload, Pump, and Afterload | 513 | ||
| Clinical Studies of Hemodynamic Management of Asphyxia and Therapeutic Hypothermia | 516 | ||
| Conclusions | 517 | ||
| REFERENCES | 517 | ||
| 29 - Hemodynamically Based Pharmacologic Management of Circulatory Compromise in the Newborn | 521 | ||
| Circulatory Support Interventions | 522 | ||
| Volume Expansion | 522 | ||
| Dopamine | 523 | ||
| Dobutamine | 523 | ||
| Epinephrine (Adrenaline) | 524 | ||
| Norepinephrine (Noradrenaline) | 524 | ||
| Vasopressin | 524 | ||
| Milrinone | 525 | ||
| Hydrocortisone | 525 | ||
| Applying the Evidence in Clinical Practice | 526 | ||
| Conclusion | 533 | ||
| REFERENCES | 533 | ||
| 30 - The Neonate With Relative Adrenal Insufficiency and Vasopressor Resistance | 535 | ||
| Adrenal Insufficiency and Relative Adrenal Insufficiency | 535 | ||
| Incidence of Relative Adrenal Insufficiency | 536 | ||
| Pathophysiology of Relative Adrenal Insufficiency in The Ill Patient | 536 | ||
| Clinical Presentation of Relative Adrenal Insufficiency and Hypotension | 538 | ||
| Relative Adrenal Insufficiency in Preterm Infants | 540 | ||
| Evidence of Relative Adrenal Insufficiency in Sick Late Preterm and Term Infants | 540 | ||
| Duration of Relative Adrenal Insufficiency | 541 | ||
| Late-onset Relative Adrenal Insufficiency-Associated Hypotension | 542 | ||
| Relative Adrenal Insufficiency and Outcomes | 542 | ||
| Diagnosis of Adrenal Insufficiency | 542 | ||
| Corticosteroid Treatment | 544 | ||
| Mechanisms of Action of Corticosteroids | 544 | ||
| Corticosteroid Therapy for Cardiovascular Insufficiency | 545 | ||
| Pharmacokinetics of Hydrocortisone in the Neonate | 546 | ||
| Summary | 547 | ||
| REFERENCES | 548 | ||
| E - Cardiology | 553 | ||
| 31 - Neonates With Critical Congenital Heart Disease: Delivery Room Management and Stabilization Before Transfer to the Cardiac Intensive Care Unit | 555 | ||
| Introduction to Prenatal Evaluation of Congenital Heart Disease and the Definition of Critical Congenital Heart Disease | 555 | ||
| Perinatal Management Strategies to Optimize Postnatal Transition | 556 | ||
| Delivery Room Management and Stabilization | 560 | ||
| Hypoplastic Left Heart Syndrome With Restrictive or Intact Atrial Septum | 562 | ||
| D-Transposition of the Great Artery With Restrictive Atrial Septum | 563 | ||
| Bradyarrhythmias: Complete Heart Block | 567 | ||
| Consideration for Fetal Therapy/Intervention | 568 | ||
| Summary/Conclusions | 569 | ||
| REFERENCES | 569 | ||
| 32 - Catheter-Based Therapy in the Neonate With Congenital Heart Disease | 571 | ||
| Indications for Cardiac Catheterization in the Neonate and Potential Complications | 572 | ||
| Vascular Access | 573 | ||
| Balloon Atrial Septostomy and Septoplasty | 573 | ||
| Atrial Septoplasty | 575 | ||
| Pulmonary Balloon Valvuloplasty for Critical Pulmonary Stenosis | 576 | ||
| Perforation of the Pulmonary Valve in Pulmonary Atresia and Intact Ventricular Septum | 577 | ||
| Balloon Aortic Valvuloplasty in Critical Aortic Stenosis | 580 | ||
| Transcatheter Management of Neonatal Coarctation | 581 | ||
| Ductal Stenting in Ductal-Dependent Pulmonary Circulation | 583 | ||
| Device Closure of the Patent Ductus Arteriosus in the Neonate | 585 | ||
| Future Applications | 587 | ||
| Conclusion | 587 | ||
| REFERENCES | 588 | ||
| Index | 593 | ||
| A | 593 | ||
| B | 594 | ||
| C | 595 | ||
| D | 598 | ||
| E | 599 | ||
| F | 600 | ||
| G | 600 | ||
| H | 600 | ||
| I | 602 | ||
| J | 603 | ||
| K | 603 | ||
| L | 603 | ||
| M | 603 | ||
| N | 604 | ||
| O | 605 | ||
| P | 605 | ||
| Q | 609 | ||
| R | 609 | ||
| S | 609 | ||
| T | 610 | ||
| U | 611 | ||
| V | 611 | ||
| W | 612 | ||
| X | 612 | ||
| Z | 612 | ||
| IBC | ES2 |