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Article: Evaluation of the Hypotensive Preterm Infant: Evidence-Based Practice at the Bedside?

Murphy, Elizabeth / Healy, David B / Chioma, Roberto / Dempsey, Eugene M

2023 Volume 10, Issue 3

Abstract: Choosing the appropriate management approach for the preterm infant with low blood pressure during the transition period generally involved intervening when the blood pressure drifted below a certain threshold. It is now clear that this approach is too ... ...

Abstract	Choosing the appropriate management approach for the preterm infant with low blood pressure during the transition period generally involved intervening when the blood pressure drifted below a certain threshold. It is now clear that this approach is too simplistic and does not address the underlying physiology. In this chapter, we explore the many monitoring tools available for evaluation of the hypotensive preterm and assess the evidence base supporting or refuting their use. The key challenge relates to incorporating these outputs with the clinical status of the patient and choosing the appropriate management strategy.
Language	English
Publishing date	2023-03-06
Publishing country	Switzerland
Document type	Journal Article ; Review
ZDB-ID	2732685-8
ISSN	2227-9067
ISSN	2227-9067
DOI	10.3390/children10030519
Database	MEDical Literature Analysis and Retrieval System OnLINE

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Article ; Online: What Should We Do about Low Blood Pressure in Preterm Infants.

Dempsey, Eugene M

Neonatology

2017 Volume 111, Issue 4, Page(s) 402–407

Abstract: The management of preterm infants with low blood pressure soon after birth remains unresolved. The definition of what constitutes low blood pressure is uncertain. At birth, mean blood pressure appears to be gestation specific and increases in the first ... ...

Abstract	The management of preterm infants with low blood pressure soon after birth remains unresolved. The definition of what constitutes low blood pressure is uncertain. At birth, mean blood pressure appears to be gestation specific and increases in the first few days of life. Antenatal steroids, delayed cord clamping, and the avoidance of mechanical ventilation are all associated with higher mean blood pressure and less hypotension after birth. Rates of hypotension of 15-50% have been reported in various studies of extremely preterm infants. However, only about 10% of all extremely preterm infants receive inotropes, suggesting that clinicians take into account other factors such as clinical, biochemical, and echocardiographic findings before deciding to intervene. The exact role of functional echocardiography in assessing the need for treatment of low blood pressure in extremely preterm infants remains to be determined. Near- infrared spectroscopy to assess cerebral perfusion may also have a role to play. Volume expansion (usually 10 mL/kg of saline) remains the most commonly used intervention for low blood pressure but evidence of benefit is lacking and there may be safety concerns. Whilst dopamine is the most commonly used inotropic drug, dobutamine, epinephrine, corticosteroids, milrinone, and vasopressin have also been utilised in preterm infants with low blood pressure. Clinical trials with long-term outcomes are needed to determine the most suitable inotrope and when to use it. Early hypotension differs from late hypotension with regard to cause, treatment, and outcome. A number of recent studies aimed at improving the evidence base for the treatment of early hypotension in extremely preterm infants have been terminated early because of poor recruitment. Currently, the answer to the question of what to do about low blood pressure in preterm infants remains unclear.
Language	English
Publishing date	2017
Publishing country	Switzerland
Document type	Journal Article
ZDB-ID	2266911-5
ISSN	1661-7819 ; 1661-7800
ISSN (online)	1661-7819
ISSN	1661-7800
DOI	10.1159/000460603
Database	MEDical Literature Analysis and Retrieval System OnLINE

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Article: Simulation in Neonatal Resuscitation.

Garvey, Aisling A / Dempsey, Eugene M

Frontiers in pediatrics

2020 Volume 8, Page(s) 59

Abstract: Approximately 1 in 10 newborns will require basic resuscitation interventions at birth. Some infants progress to require more advanced measures including the provision of positive pressure ventilation, chest compressions, intubation and administration of ...

Abstract	Approximately 1 in 10 newborns will require basic resuscitation interventions at birth. Some infants progress to require more advanced measures including the provision of positive pressure ventilation, chest compressions, intubation and administration of volume/cardiac medications. Although advanced resuscitation is infrequent, it is crucial that personnel adequately trained in these techniques are available to provide such resuscitative measures. In 2000, Louis Halmalek et al. called for a "New Paradigm in Pediatric Medical Education: Teaching Neonatal Resuscitation in a Simulated Delivery Room Environment." This was one of the first articles to highlight simulation as a method of teaching newborn resuscitation. The last decades have seen an exponential growth in the area of simulation in newborn care, in particular in newborn resuscitation and stabilization. Simulation is best defined as an instructional strategy "used to replace or amplify real experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner." Simulation training has now become an important point of how we structure training and deliver improved healthcare to patients. Some of the key aspects of simulation training include feedback, deliberate practice, outcome measurement, retention of skills and curriculum integration. The term "Train to win" is often used in sporting parlance to define how great teams succeed. The major difference between sports teams is that generally their game day comes once a week, whereas in newborn resuscitation every day is potentially "game day." In this review we aim to summarize the current evidence on the use of simulation based education and training in neonatal resuscitation, with particular emphasis on the evidence supporting its effectiveness. We will also highlight recent advances in the development of simulation based medical education in the context of newborn resuscitation to ensure we "train to win."
Language	English
Publishing date	2020-02-25
Publishing country	Switzerland
Document type	Journal Article ; Review
ZDB-ID	2711999-3
ISSN	2296-2360
ISSN	2296-2360
DOI	10.3389/fped.2020.00059
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Article ; Online: Management of Neonatal Hypotension and Shock.

Schwarz, Christoph E / Dempsey, Eugene M

Seminars in fetal & neonatal medicine

2020 Volume 25, Issue 5, Page(s) 101121

Abstract: The current standard approach to manage circulatory insufficiency is inappropriately simple and clear: respond to low blood pressure to achieve higher values. However, the evidence for this is limited affecting all steps within the process: assessment, ... ...

Abstract	The current standard approach to manage circulatory insufficiency is inappropriately simple and clear: respond to low blood pressure to achieve higher values. However, the evidence for this is limited affecting all steps within the process: assessment, decision making, therapeutic options, and treatment effects. We have to overcome the 'one size fits all' approach and respect the dynamic physiologic transition from fetal to neonatal life in the context of complex underlying conditions. Caregivers need to individualize their approaches to individual circumstances. This paper will review various clinical scenarios, including managing transitional low blood pressure, to circulatory impairment involving different pathologies such as hypoxia-ischemia and sepsis. We will highlight the current evidence and set potential goals for future development in these areas. We hope to encourage caregivers to question the current standards and to support urgently needed research in this overlooked but crucial field of neonatal intensive care.
MeSH term(s)	Hemodynamics/physiology ; Humans ; Hypotension/physiopathology ; Hypotension/therapy ; Infant, Newborn ; Intensive Care, Neonatal ; Neonatology ; Shock, Septic/physiopathology ; Shock, Septic/therapy
Language	English
Publishing date	2020-05-21
Publishing country	Netherlands
Document type	Journal Article ; Research Support, Non-U.S. Gov't ; Review
ZDB-ID	2174416-6
ISSN	1878-0946 ; 1744-165X
ISSN (online)	1878-0946
ISSN	1744-165X
DOI	10.1016/j.siny.2020.101121
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Article: Challenges in Treating Low Blood Pressure in Preterm Infants.

Dempsey, Eugene M

Children (Basel, Switzerland)

2015 Volume 2, Issue 2, Page(s) 272–288

Abstract: Whilst the prevalence of low blood pressure in preterm infants seems to have fallen over the last number of years, the problem is still frequently encountered in the neonatal intensive care unit and many babies continue to receive intervention. Great ... ...

Abstract	Whilst the prevalence of low blood pressure in preterm infants seems to have fallen over the last number of years, the problem is still frequently encountered in the neonatal intensive care unit and many babies continue to receive intervention. Great variability in practice persists, with a significant number of extremely low gestational age newborns in some institutions receiving some form of intervention, and in other units substantially less. A great degree of this variability relates to the actual criteria used to define hypotension, with some using blood pressure values alone to direct therapy and others using a combination of clinical, biochemical and echocardiography findings. The choice of intervention remains unresolved with the majority of centres continuing to administer volume followed by dopamine as a first line inotrope/vasopressor agent. Despite over 40 years of use there is little evidence that dopamine is of benefit both in the short term and long-term. Long-term follow up is available in only two randomised trials, which included a total of 99 babies. An under recognized problem relates to the administration of inotrope infusions in very preterm infants. There are no pediatric specific inotrope formulations available and so risks of errors in preparation and administration remain. This manuscript outlines these challenges and proposes some potential solutions.
Language	English
Publishing date	2015-06-15
Publishing country	Switzerland
Document type	Journal Article ; Review
ZDB-ID	2732685-8
ISSN	2227-9067
ISSN	2227-9067
DOI	10.3390/children2020272
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Article ; Online: Impact of cord clamping on haemodynamic transition in term newborn infants.

Chioma, Roberto / Finn, Daragh / Healy, David B / Herlihy, Ita / Livingstone, Vicki / Panaviene, Jurate / Dempsey, Eugene M

Archives of disease in childhood. Fetal and neonatal edition

2024 Volume 109, Issue 3, Page(s) 287–293

Abstract: Objective: To assess the haemodynamic consequences of cord clamping (CC) in healthy term infants.: Design: Cohort study.: Setting: Tertiary maternity hospital.: Patients: 46 full-term vigorous infants born by caesarean section.: Interventions! ...

Abstract	Objective: To assess the haemodynamic consequences of cord clamping (CC) in healthy term infants. Design: Cohort study. Setting: Tertiary maternity hospital. Patients: 46 full-term vigorous infants born by caesarean section. Interventions: Echocardiography was performed before CC, immediately after CC and at 5 min after birth. Main outcome measures: Pulsed wave Doppler-derived cardiac output and the pulmonary artery acceleration time indexed to the right ventricle ejection time were obtained. As markers of loading fluctuations, the myocardial performance indexes and the velocities of the tricuspid and mitral valve annuli were determined with tissue Doppler imaging. Heart rate was derived from Doppler imaging throughout the assessments. Results: Left ventricular output increased throughout the first minutes after birth (mean (SD) 222.4 (32.5) mL/kg/min before CC vs 239.7 (33.6) mL/kg/min at 5 min, p=0.01), while right ventricular output decreased (306.5 (48.2) mL/kg/min before vs 272.8 (55.5) mL/kg/min immediately after CC, p=0.001). The loading conditions of both ventricles were transiently impaired by CC, recovering at 5 min. Heart rate progressively decreased after birth, following a linear trend temporarily increased by CC. The variation in left ventricular output across the CC was directly correlated to the fluctuation of left ventricular preload over the same period (p Conclusions: This study illustrates the cardiovascular consequences of CC in term vigorous infants and offers insight into the haemodynamic transition from fetal to neonatal circulation in spontaneously breathing newborns. Strategies that aim to enhance left ventricular preload before CC may prevent complications of perinatal cardiovascular imbalance.
MeSH term(s)	Infant ; Humans ; Infant, Newborn ; Female ; Pregnancy ; Cesarean Section ; Constriction ; Cohort Studies ; Hemodynamics/physiology ; Cardiac Output/physiology
Language	English
Publishing date	2024-04-18
Publishing country	England
Document type	Journal Article
ZDB-ID	2007331-8
ISSN	1468-2052 ; 1359-2998
ISSN (online)	1468-2052
ISSN	1359-2998
DOI	10.1136/archdischild-2023-325652
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Article: What Should We Do about Low Blood Pressure in Preterm Infants

Dempsey, Eugene M.

Neonatology

2017 Volume 111, Issue 4, Page(s) 402–407

Institution	Department of Paediatrics and Child Health, University College Cork, and Irish Centre for Fetal and Neonatal Translational Research (INFANT), Cork, Ireland
Abstract	The management of preterm infants with low blood pressure soon after birth remains unresolved. The definition of what constitutes low blood pressure is uncertain. At birth, mean blood pressure appears to be gestation specific and increases in the first few days of life. Antenatal steroids, delayed cord clamping, and the avoidance of mechanical ventilation are all associated with higher mean blood pressure and less hypotension after birth. Rates of hypotension of 15-50% have been reported in various studies of extremely preterm infants. However, only about 10% of all extremely preterm infants receive inotropes, suggesting that clinicians take into account other factors such as clinical, biochemical, and echocardiographic findings before deciding to intervene. The exact role of functional echocardiography in assessing the need for treatment of low blood pressure in extremely preterm infants remains to be determined. Near- infrared spectroscopy to assess cerebral perfusion may also have a role to play. Volume expansion (usually 10 mL/kg of saline) remains the most commonly used intervention for low blood pressure but evidence of benefit is lacking and there may be safety concerns. Whilst dopamine is the most commonly used inotropic drug, dobutamine, epinephrine, corticosteroids, milrinone, and vasopressin have also been utilised in preterm infants with low blood pressure. Clinical trials with long-term outcomes are needed to determine the most suitable inotrope and when to use it. Early hypotension differs from late hypotension with regard to cause, treatment, and outcome. A number of recent studies aimed at improving the evidence base for the treatment of early hypotension in extremely preterm infants have been terminated early because of poor recruitment. Currently, the answer to the question of what to do about low blood pressure in preterm infants remains unclear.
Keywords	Hypotension ; Blood flow ; Dopamine ; Extremely preterm infant ; Intraventricular haemorrhage
Language	English
Publishing date	2017-05-25
Publisher	S. Karger AG
Publishing place	Basel, Switzerland
Document type	Article
Note	Review
ZDB-ID	2266911-5
ISSN	1661-7819 ; 1661-7800
ISSN (online)	1661-7819
ISSN	1661-7800
DOI	10.1159/000460603
Database	Karger publisher's database

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Zs.A 391: Show issues

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Article ; Online: Applications of near infrared spectroscopy in the neonate.

Garvey, Aisling A / Dempsey, Eugene M

Current opinion in pediatrics

2018 Volume 30, Issue 2, Page(s) 209–215

Abstract: Purpose of review: There has been a significant increase in the utilization of NIRS in neonatal care over the last few years, with some centers now routinely utilizing this monitoring technique for direct intervention at the bedside. In this review, we ... ...

Abstract	Purpose of review: There has been a significant increase in the utilization of NIRS in neonatal care over the last few years, with some centers now routinely utilizing this monitoring technique for direct intervention at the bedside. In this review, we provide a summary of the most up-to-date evidence on near infrared spectroscopy utilization, with particular emphasis on measurement of cerebral oxygenation in preterm infants. Recent findings: There have been significant advances in the technology, leading to an increase in the number of available devices and in the use of this monitoring tool to reduce cerebral injury in preterm infants. The role of NIRS in assessing cerebral autoregulation in preterm and term infants, in evaluating somatic oxygenation, and in the management of newborns with hypoxic ischaemic encephalopathy is discussed. Summary: Two recent pilot randomized controlled trials highlight the potential of cerebral oxygenation monitoring to direct management in the delivery room and the neonatal intensive care unit. However, we urge caution against routine use and await the results of further studies in this area before considering this type of monitoring as standard of care.
MeSH term(s)	Brain/blood supply ; Brain Injuries/prevention & control ; Humans ; Hypoxia-Ischemia, Brain/complications ; Hypoxia-Ischemia, Brain/diagnosis ; Hypoxia-Ischemia, Brain/therapy ; Infant, Newborn ; Infant, Premature ; Infant, Premature, Diseases/diagnosis ; Infant, Premature, Diseases/therapy ; Intensive Care, Neonatal/methods ; Monitoring, Physiologic ; Spectroscopy, Near-Infrared
Language	English
Publishing date	2018-01-25
Publishing country	United States
Document type	Journal Article ; Research Support, Non-U.S. Gov't ; Review
ZDB-ID	1049374-8
ISSN	1531-698X ; 1040-8703
ISSN (online)	1531-698X
ISSN	1040-8703
DOI	10.1097/MOP.0000000000000599
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Article ; Online: Hemodynamic considerations in preterm infants born at less than 25 weeks gestation.

Finn, Bryan P / Bussmann, Neidin / Beechinor, Tom / Dempsey, Eugene M

Seminars in perinatology

2021 Volume 46, Issue 1, Page(s) 151544

Abstract: As survival rates continue to improve for infants born at less than 25 weeks gestation, delineating normal cardiovascular physiology from pathophysiology becomes much more challenging. With a paucity of 'normative' data for such infants, an over-reliance ...

Abstract	As survival rates continue to improve for infants born at less than 25 weeks gestation, delineating normal cardiovascular physiology from pathophysiology becomes much more challenging. With a paucity of 'normative' data for such infants, an over-reliance on studies at older gestations can result in a 'best guess' approach. Here we offer a pragmatic approach to these diagnostic challenges from a cardiovascular viewpoint. An appreciation of the unique physiology, from the immature myocardium and altered vascular tone to an innately large patent ductus arteriosus is essential, as is a thorough history for case specific contributing factors. We explore the additional difficulties in achieving a balance between minimal handling at the bedside and delineating important objective markers of perfusion. Finally, we discuss treatment approaches including inotrope therapy and patent ductus treatment, acknowledging the limited data available to guide these decisions.
MeSH term(s)	Ductus Arteriosus, Patent ; Gestational Age ; Hemodynamics ; Humans ; Infant ; Infant, Newborn ; Infant, Premature ; Infant, Premature, Diseases
Language	English
Publishing date	2021-11-10
Publishing country	United States
Document type	Journal Article
ZDB-ID	752403-1
ISSN	1558-075X ; 0146-0005
ISSN (online)	1558-075X
ISSN	0146-0005
DOI	10.1016/j.semperi.2021.151544
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Article ; Online: First encounters of the microbial kind: perinatal factors direct infant gut microbiome establishment.

Linehan, Kevin / Dempsey, Eugene M / Ryan, C Anthony / Ross, R Paul / Stanton, Catherine

Microbiome research reports

2022 Volume 1, Issue 2, Page(s) 10

Abstract: The human gut microbiome harbors a diverse range of microbes that play a fundamental role in the health and well-being of their host. The early-life microbiome has a major influence on human development and long-term health. Perinatal factors such as ... ...

Abstract	The human gut microbiome harbors a diverse range of microbes that play a fundamental role in the health and well-being of their host. The early-life microbiome has a major influence on human development and long-term health. Perinatal factors such as maternal nutrition, antibiotic use, gestational age and mode of delivery influence the initial colonization, development, and function of the neonatal gut microbiome. The perturbed early-life gut microbiome predisposes infants to diseases in early and later life. Understanding how perinatal factors guide and shape the composition of the early-life microbiome is essential to improving infant health. The following review provides a synopsis of perinatal factors with the most decisive influences on initial microbial colonization of the infant gut.
Language	English
Publishing date	2022-03-01
Publishing country	United States
Document type	Journal Article ; Review
ISSN	2771-5965
ISSN (online)	2771-5965
DOI	10.20517/mrr.2021.09
Database	MEDical Literature Analysis and Retrieval System OnLINE

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