Low superior vena cava flow and neurodevelopment at 3 years in very preterm infants

doi:10.1016/j.jpeds.2004.06.056

The Journal of Pediatrics

Volume 145, Issue 5, November 2004, Pages 588-592

https://doi.org/10.1016/j.jpeds.2004.06.056 Get rights and content

Objectives

Low superior vena cava (SVC) flow is common in the first hours after very preterm birth and has a strong association with subsequent periventricular/intraventricular hemorrhage. We report the neurodevelopmental outcome at 3 years of age of very preterm babies who had serial echocardiographic studies, including measures of SVC flow, during the first 48 hours after birth.

Study design

A prospective observational study was performed on a cohort of 126 babies (<30 weeks), 103 of whom survived to discharge. Neurodevelopmental follow-up data, which included abnormal developmental quotient, abnormal motor score, and cerebral palsy, were available for 93% of this cohort at 3 years of age. Relations between 3-year outcome and early hemodynamic measures and clinical parameters were explored.

Results

After controlling for confounding variables, average SVC flow over the first 24 hours of life was significantly associated with the primary outcome of death or survival with any disability (P = .004) and with the secondary outcome of abnormal developmental quotient (P = .006). A greater number of low SVC flow readings during the first 24 hours was significantly related to death and adverse developmental outcome, but the individual lowest SVC flow was not, suggesting the importance of duration of low SVC flow. After adjustment, there was no significant association between average mean blood pressure over the first 24 hours and abnormal developmental outcome, whereas the proportion of mean blood pressure readings less than the gestational age showed a trend toward an association with death and any disability.

Conclusions

Low early postnatal blood flow to the upper body and brain may be one factor in the causal pathway of impaired preterm neurodevelopmental outcome.

Section snippets

Methods

The entry criteria for this study were birth before 30 weeks' gestation and informed parental consent. The 126 babies enrolled between March 1995 and December 1996 represented 85% of eligible babies. Refused consent (n = 5) and investigator not available (n = 19) were the reasons for nonenrolment.4., 5.

Results

The babies had a mean gestation of 27 weeks (range, 23 to 29 weeks) and a mean birth weight of 991 grams (range, 420 to 1630 grams). Fifty-two percent were boys and 91% were inborn. Eighteen percent (n = 23) of the babies died in the neonatal period. Seven babies died from respiratory failure on day 1 or 2. Of the remaining 16 babies who died, 10 had intensive care withdrawn as a result of severe IVH, 5 of late sepsis, and 1 died late of respiratory failure.

Discussion

This study follows a cohort of babies in whom SVC flows were serially measured in the first 48 hours of life and in whom a strong association between SVC flow and subsequent PIVH was previously reported.⁵ The majority of babies (8 of 11) with severe late PIVH died. Despite this, we now report that low SVC flow in the perinatal period is also associated with abnormal neurodevelopment. Specifically, the lower the average SVC flow, or the greater the number of times the SVC flow was <30 mL/kg per

References (17)

H.C. Lou et al.
Low cerebral blood flow: a risk factor in the neonate
J Pediatr
(1979)
L.A. Papile et al.
Incidence and evolution of subependymal and intraventricular haemorrhage: a study of infants with birth weight less than 1500 grams
J Pediatr
(1978)
J.K. Grether et al.
Prenatal and perinatal factors and cerebral palsy in very low birth weight infants
J Pediatr
(1996)
L.J. Graziani et al.
Electroencephalographic, neuroradiologic, and neurodevelopmental studies in infants with subclavian steal during ECMO
Pediatr Neurol
(1994)
D. Osborn et al.
Randomized trial of dobutamine versus dopamine in preterm infants with low systemic blood flow
J Pediatr
(2002)
J.J. Volpe
Neurologic outcome of prematurity
Arch Neurol
(1998)
J.J. Volpe
Neurology of the Newborn
(2001)
M. Kluckow et al.
Superior vena cava flow in newborn infants: a novel marker of systemic blood flow
Arch Dis Child
(2000)

There are more references available in the full text version of this article.

Cited by (209)

Should SVC flow be a routine measure when performing targeted neonatal echocardiography? A narrative review
2024, Pediatrics and Neonatology
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.
This is a narrative review about SVC flow in preterm infants, physiology, techniques of measurement and its potential association with outcomes.
Literature revie mainly PubMED.
SVC flow measurement has some limitations and pitfalls.
SVC flow association with neonatal outcomes, still needs to be established in further research.
Cerebral Blood Flow, Brain Injury, and Aortic-Pulmonary Collateral Flow After the Fontan Operation
2023, American Journal of Cardiology
Patients with a single ventricle develop aortopulmonary collaterals (APCs) whose flow has been shown to be inversely proportional to cerebral blood flow (CBF) in a previous cross-sectional study. Longitudinal CBF and APC flow in patients with Fontan physiology adjusting for brain injury (BI) has never been reported. Decreased CBF and BI may adversely impact neurodevelopment. A prospective longitudinal cohort of 27 patients with Fontan physiology (aged 10 ± 1.9 years, 74% male) underwent cardiac and brain magnetic resonance imaging 3 to 9 months and 6.0 ± 1.86 years after Fontan operation to measure the CBF and APC flow and to reassess the BI (focal BI, generalized insult, and hemorrhage). CBF was measured using jugular venous flow and APC flow was measured by the difference between aortic flow and caval return. Multivariate modeling was used to assess the relation between the change in APC flow and BI. A strong inverse relation was found between CBF/aortic flow change and APC flow/aortic flow and APC flow/body surface area change (R² = 0.70 and 0.72 respectively, p <0.02). Overall, the CBF decreased by 9 ± 11% and the APC flow decreased by 0.73 ± 0.67 l/min/m². The evolution of CBF and APC flow were significantly and inversely related when adjusting for time since Fontan operation, gender, and BI on the multivariate modeling. Every unit increase in APC flow change was associated with an 8% decrease in CBF change. In conclusion, CBF and APC flow change are inversely related across serial imaging, adjusting for time from Fontan operation, gender, and BI. CBF and APC aortic flow decrease over a 6-year period. This may adversely impact neurodevelopment. Because APCs can be embolized, this may be a modifiable risk factor.
Clinical trials numbers: NCT02135081 and NCT02919956.
Effect of sleeping position on cardiac output, pulmonary pressure, and superior vena cava flow in healthy term infants
2023, Pediatrics and Neonatology
Although the mechanism of action in newborns is unknown, sleep positioning is associated with many pathophysiological events. This study aimed to compare the effects of supine and prone sleeping positions on cardiac output (CO), systolic pulmonary arterial pressure (SPAP), and superior vena cava (SVC) flow in healthy newborns.
In the first 24–72 h of life, 40 healthy term newborns born in the same hospital were included in this prospective, cross-sectional, observational study. CO, SVC flow, and SPAP values of newborns in the supine and prone sleeping positions were calculated using echocardiographic examination. The measurements were statistically compared.
In the supine sleeping position, CO, SVC flow, and SPAP were 235.00 (193.07–283.30) ml/kg/min, 92.80 (77.82–121.87) ml/kg/min, and 27.85 (24.70–30.48) mmHg. In the prone sleeping position, CO, SVC flow, and SPAP were measured as 195.35 (166.00–229.40) ml/kg/min, 67.25 (51.82–96.66) ml/kg/min, 31.60 (28.45–37.20) mmHg, respectively. Depending on sleeping position, these variables were significantly different between the groups.
SVC flow and CO decreased in the prone sleeping position compared to the supine sleeping position in healthy newborns, whereas SPAP increased. The different hemodynamic effects of sleeping position on the cardiac, pulmonary, and nervous systems should be considered as flow and pressure changes are important in newborns.
Near-infrared spectroscopy in the medical management of infants
2022, Current Problems in Pediatric and Adolescent Health Care
Near-infrared spectroscopy (NIRS) is a technology that is easy to use and can provide helpful information about organ oxygenation and perfusion by measuring regional tissue oxygen saturation (rSO2) with near-infrared light. The sensors can be placed in different anatomical locations to monitor rSO2 levels in several organs. While NIRS is not without limitations, this equipment is now becoming increasingly integrated into modern healthcare practice with the goal of achieving better outcomes for patients. It can be particularly applicable in the monitoring of pediatric patients because of their size, and especially so in infant patients. Infants are ideal for NIRS monitoring as nearly all of their vital organs lie near the skin surface which near-infrared light penetrates through. In addition, infants are a difficult population to evaluate with traditional invasive monitoring techniques that normally rely on the use of larger catheters and maintaining vascular access. Pediatric clinicians can observe rSO2 values in order to gain insight about tissue perfusion, oxygenation, and the metabolic status of their patients. In this way, NIRS can be used in a non-invasive manner to either continuously or periodically check rSO2. Because of these attributes and capabilities, NIRS can be used in various pediatric inpatient settings and on a variety of patients who require monitoring. The primary objective of this review is to provide pediatric clinicians with a general understanding of how NIRS works, to discuss how it currently is being studied and employed, and how NIRS could be increasingly used in the near future, all with a focus on infant management.
Hemodynamic management of the micropreemie: When inotropes are not enough
2022, Seminars in Fetal and Neonatal Medicine
Managing perfusion in the micropreemie is challenging and should be guided by the patho-physiology, gestational and postnatal age of the baby, perinatal history, and the persistence of fetal shunts. The assessment should incorporate bedside tools such as blood pressure, clinical perfusion markers, and functional echocardiography. The multimodal approach to diagnose and identify the cause of hemodynamic compromise paves the way to a targeted approach to treatment. Characterizing the predominant pathophysiologic cause of low cardiac output and impaired cellular metabolism enables a more accurate use of inotropes, vasopressors, and volume support to suit a particular pathophysiologic situation.
Randomized Trial of Perfusion-Based Circulatory Management in Infants of Very Low Birth Weight
2022, Journal of Pediatrics
To establish the superiority of blood flow (BF)-based circulatory management over conventional blood pressure (BP)-based management strategies used for preventing intraventricular hemorrhage (IVH) in infants of very low birth weight (VLBW).
We conducted a nonblinded, single-centered randomized trial with the aim to prevent IVH by managing BF. Infants with VLBW were assigned randomly to a BF-based group or BP-based (BP group) circulatory management group. The incidence of IVH was the outcome of interest. The IVH also data were compared among healthy patients and patients responsive and unresponsive to the intervention.
A total of 219 and 220 infants with VLBW were assigned to the BF and BP groups, respectively. The IVH incidence rate was lower in the BF group, but the difference was not statistically significant (BF group, 6.8% vs BP group, 10.9%; P = .14). In 21% of patients of the BP group and 20% of the BF group, the intervention failed. In BF group, the IVH incidence rate was significantly greater in infants with unsuccessful intervention when compared with healthy individuals (6% vs 23%, P = .001). Multivariate logistic regression analysis revealed a correlation between low blood flow and IVH (aOR 3.24; 95% CI 1.49-7.08, P = .003) but not between low BP and IVH (P = .73).
The BF management protocol did not significantly decrease the incidence of IVH. However, after further optimization, we speculate the treatment strategy holds promise in decreasing the incidence of IVH.
Trial registration UMIN-CTR: UMIN000013296.

View all citing articles on Scopus

View full text

Original ArticleLow superior vena cava flow and neurodevelopment at 3 years in very preterm infants

Objectives

Study design

Results

Conclusions

Section snippets

Methods

Results

Discussion

J Pediatr

J Pediatr

J Pediatr

Pediatr Neurol

J Pediatr

Neurologic outcome of prematurity

Arch Neurol

Neurology of the Newborn

Superior vena cava flow in newborn infants: a novel marker of systemic blood flow

Arch Dis Child

Original Article
Low superior vena cava flow and neurodevelopment at 3 years in very preterm infants