Abstract
Background
Hypotension and hypoxemic respiratory failure are common among neonates with hypoxic–ischemic encephalopathy (HIE) undergoing therapeutic hypothermia (TH). Right ventricular (RV) dysfunction is associated with adverse neurodevelopment. Individualized management utilizing targeted neonatal echocardiography (TnECHO) may enhance care.
Methods
We evaluated the influence of TnECHO programs on cardiovascular practices in HIE/TH patients utilizing a 77-item REDCap survey. Nominated representatives of TnECHO (n = 19) or non-TnECHO (n = 96) sites were approached.
Results
Seventy-one (62%) sites responded. Baseline neonatal intensive care unit characteristics and HIE volume were comparable between groups. Most centers monitor invasive blood pressure; however, we identified 17 unique definitions of hypotension. TnECHO centers were likelier to trend systolic/diastolic blood pressure and request earlier echocardiography. TnECHO responders were less likely to use fluid boluses; TnECHO responders more commonly chose an inotrope first-line, while non-TnECHO centers used a vasopressor. For HRF, TnECHO centers chose vasopressors with a favorable pulmonary vascular profile. Non-TnECHO centers used more dopamine and more extracorporeal membrane oxygen for patients with HRF.
Conclusions
Cardiovascular practices in neonates with HIE differ between centers with and without TnECHO. Consensus regarding the definition of hypotension is lacking and dopamine use is common. The merits of these practices among these patients, who frequently have comorbid pulmonary hypertension and RV dysfunction, need prospective evaluation.
Impact
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Cardiovascular care following HIE while undergoing therapeutic hypothermia varies between centers with access to trained hemodynamics specialists and those without.
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Because cardiovascular dysfunction is associated with brain injury, precision medicine-based care may be an avenue to improving outcomes.
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Therapeutic hypothermia has introduced new physiological considerations and enhanced survival. It is essential that hemodynamic strategies evolve to keep pace; however, little literature exists.
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Lack of consensus regarding fundamental definitions (e.g., hypotension) highlights the importance of collaboration among the scientific community to advance the field.
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The value of enhanced cardiovascular care guided by hemodynamic specialists requires prospective evaluation.
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Acknowledgements
This project utilized REDCap, and therefore the following grant support requires acknowledgment: UL1TR002537 Grant citation notice.
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R.E.G.: study design, data collection, analysis, first draft of the manuscript; P.T.L./J.L.R./M.E.D./K.M./P.J.M.N./P.W.: study design, review of manuscript; P.J.M.N.: study design, analysis, final review of manuscript.
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Giesinger, R.E., Levy, P.T., Ruoss, J.L. et al. Cardiovascular management following hypoxic–ischemic encephalopathy in North America: need for physiologic consideration. Pediatr Res 90, 600–607 (2021). https://doi.org/10.1038/s41390-020-01205-8
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DOI: https://doi.org/10.1038/s41390-020-01205-8
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