Blood Pressure Goals: Is Cerebral Saturation the New Mean Arterial Pressure?

Abstract

Objective The objective of this article was to correlate hypotension and cerebral saturation from near-infrared spectroscopy (cNIRS) in neonates on dopamine.

Study Design Retrospective review of neonates receiving dopamine between August 2018 and 2019 was performed. Hypotension thresholds included mean arterial pressure (MAP) of postmenstrual age (PMA) ± 5 and 30 mm Hg and gestational age (GA) ± 5 mm Hg. Time below threshold MAP was compared with time with cerebral hypoxia (cNIRS <55%).

Results Hypotension occurred 6 to 33% of the time on dopamine in 59 cases. Hypotension did not correlate with abnormal cNIRS overall, within PMA subgroups or by outcomes. Hypotensive periods with MAP < GA had fewer corresponding percent time with abnormal cNIRS events (3.7 ± 1.3%) compared with MAP < PMA (11.9 ± 4.9%, p < 0.003) or 30 mm Hg thresholds (12.2 ± 4.7%, p < 0.0001). In most premature infants, mean cNIRS values during hypotension were still within normal range (57 ± 6%).

Conclusion cNIRS may be a more clinically relevant measure than MAP for the assessment of neonatal hypotension.

Key Points

• Hypotension occurred 6 to 33% of the time on dopamine in 59 cases.

• Hypotension did not correlate with abnormal cNIRS overall, within PMA subgroups or by outcomes.

• MAP

• We found no cNIRS difference between IVH grades, mortality, average Hct, lactates, or urine output.

• cNIRS may be a more clinically relevant measure than MAP for the assessment of neonatal hypotension.

Keywords

Blood pressure - Neonates - Hypotension - NIRS

Publication History

Received: 30 June 2021

Accepted: 17 November 2021

Accepted Manuscript online:
23 November 2021

Article published online:
18 January 2022

• References

• 1 Miall-Allen VM, de Vries LS, Dubowitz LM, Whitelaw AG. Blood pressure fluctuation and intraventricular hemorrhage in the preterm infant of less than 31 weeks' gestation. Pediatrics 1989; 83 (05) 657-661
• 2 Dempsey EM, Barrington KJ. Treating hypotension in the preterm infant: when and with what: a critical and systematic review. J Perinatol 2007; 27 (08) 469-478
• 3 Stranak Z, Semberova J, Barrington K. et al; HIP consortium. International survey on diagnosis and management of hypotension in extremely preterm babies. Eur J Pediatr 2014; 173 (06) 793-798
• 4 Batton B, Li L, Newman NS. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Evolving blood pressure dynamics for extremely preterm infants. J Perinatol 2014; 34 (04) 301-305
• 5 Vesoulis ZA, El Ters NM, Wallendorf M, Mathur AM. Empirical estimation of the normative blood pressure in infants <28 weeks gestation using a massive data approach. J Perinatol 2016; 36 (04) 291-295
• 6 Tran NN, Kumar SR, Hodge FS, Macey PM. Cerebral autoregulation in neonates with and without congenital heart disease. Am J Crit Care 2018; 27 (05) 410-416
• 7 Abdul Aziz AN, Thomas S, Murthy P. et al. Early inotropes use is associated with higher risk of death and/or severe brain injury in extremely premature infants. J Matern Fetal Neonatal Med 2020; 33 (16) 2751-2758
• 8 Seri I, Abbasi S, Wood DC, Gerdes JS. Regional hemodynamic effects of dopamine in the sick preterm neonate. J Pediatr 1998; 133 (06) 728-734
• 9 Dix LM, van Bel F, Baerts W, Lemmers PM. Comparing near-infrared spectroscopy devices and their sensors for monitoring regional cerebral oxygen saturation in the neonate. Pediatr Res 2013; 74 (05) 557-563
• 10 Alderliesten T, Dix L, Baerts W. et al. Reference values of regional cerebral oxygen saturation during the first 3 days of life in preterm neonates. Pediatr Res 2016; 79 (1-1): 55-64
• 11 Karen T, Morren G, Haensse D, Bauschatz AS, Bucher HU, Wolf M. Hemodynamic response to visual stimulation in newborn infants using functional near-infrared spectroscopy. Hum Brain Mapp 2008; 29 (04) 453-460
• 12 “SafeBoosC – a phase II trial (SafeBoosC), ClinicalTrials.gov Identifier: NCT01590316.
• 13 Hyttel-Sorensen S, Pellicer A, Alderliesten T. et al. Cerebral near infrared spectroscopy oximetry in extremely preterm infants: phase II randomised clinical trial. BMJ 2015; 350: g7635
• 14 Miall-Allen VM, de Vries LS, Whitelaw AG. Mean arterial blood pressure and neonatal cerebral lesions. Arch Dis Child 1987; 62 (10) 1068-1069
• 15 Joint Working Party of British Association of Perinatal Medicine and the Research Unit of the Royal College of Physicians. Development of audit measures and guidelines for good practice in the management of neonatal respiratory distress syndrome. Report of a Joint Working Group of the British Association of Perinatal Medicine and the Research Unit of the Royal College of Physicians. Arch Dis Child 1992; 67 (10 Spec No): 1221-1227
• 16 Dempsey EM, Barrington KJ, Marlow N. et al; HIP consortium. Hypotension in preterm infants (HIP) randomised trial. Arch Dis Child Fetal Neonatal Ed 2021; 106 (04) 398-403
• 17 Tyszczuk L, Meek J, Elwell C, Wyatt JS. Cerebral blood flow is independent of mean arterial blood pressure in preterm infants undergoing intensive care. Pediatrics 1998; 102 (2 Pt 1): 337-341
• 18 Hambleton G, Wigglesworth JS. Origin of intraventricular haemorrhage in the preterm infant. Arch Dis Child 1976; 51 (09) 651-659
• 19 Chock VY, Ramamoorthy C, Van Meurs KP. Cerebral autoregulation in neonates with a hemodynamically significant patent ductus arteriosus. J Pediatr 2012; 160 (06) 936-942
• 20 Triplet JJ, Lonetta CM, Levy JC, Everding NG, Moor MA. Cerebral desaturation events in the beach chair position: correlation of noninvasive blood pressure and estimated temporal mean arterial pressure. J Shoulder Elbow Surg 2015; 24 (01) 133-137
• 21 Tax N, Pichler G, Grossauer K. et al. Tilting the head changes cerebral haemodynamics in neonates. Neonatology 2011; 100 (03) 253-259
• 22 Thewissen L, Naulaers G, Hendrikx D. et al. Cerebral oxygen saturation and autoregulation during hypotension in extremely preterm infants. Pediatr Res 2021; 90 (02) 373-380
• 23 Wong FY, Leung TS, Austin T. et al. Impaired autoregulation in preterm infants identified by using spatially resolved spectroscopy. Pediatrics 2008; 121 (03) e604-e611
• 24 Riera J, Cabañas F, Serrano JJ, Madero R, Pellicer A. New developments in cerebral blood flow autoregulation analysis in preterm infants: a mechanistic approach. Pediatr Res 2016; 79 (03) 460-465
• 25 Tsuji M, Saul JP, du Plessis A. et al. Cerebral intravascular oxygenation correlates with mean arterial pressure in critically ill premature infants. Pediatrics 2000; 106 (04) 625-632
• 26 O'Leary H, Gregas MC, Limperopoulos C. et al. Elevated cerebral pressure passivity is associated with prematurity-related intracranial hemorrhage. Pediatrics 2009; 124 (01) 302-309
• 27 Alderliesten T, Lemmers PM, Smarius JJ, van de Vosse RE, Baerts W, van Bel F. Cerebral oxygenation, extraction, and autoregulation in very preterm infants who develop peri-intraventricular hemorrhage. J Pediatr 2013; 162 (04) 698-704.e2
• 28 Solanki NS, Hoffman SB. Association between dopamine and cerebral autoregulation in preterm neonates. Pediatr Res 2020; 88 (04) 618-622
• 29 Garvey AA, Kooi EMW, Dempsey EM. Inotropes for preterm infants: 50 years on are we any wiser?. Front Pediatr 2018; 6: 88
• 30 Hüning BM, Horsch S, Roll C. Blood sampling via umbilical vein catheters decreases cerebral oxygenation and blood volume in preterm infants. Acta Paediatr 2007; 96 (11) 1617-1621
• 31 Rhee CJ, da Costa CS, Austin T, Brady KM, Czosnyka M, Lee JK. Neonatal cerebrovascular autoregulation. Pediatr Res 2018; 84 (05) 602-610
• 32 Chock VY, Kwon SH, Ambalavanan N. et al. Cerebral oxygenation and autoregulation in preterm infants (early NIRS study). J Pediatr 2020; 227: 94-100.e1
• 33 “Avoiding Hypotension in Preterm Neonates (AHIP), ClinicalTrials.gov Identifier: NCT01910467.