Advanced Monitoring of Cardiovascular and Respiratory Systems in Infants Kuwait 2018 Dr. Yasser Elsayed, MD, PhD Director of the Targeted Neonatal

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1 Advanced Monitoring of Cardiovascular and Respiratory Systems in Infants Kuwait 2018 Dr. Yasser Elsayed, MD, PhD Director of the Targeted Neonatal Echocardiography, Point of Care and Hemodynamics Program Staff Neonatologist and echo-cardiologist University of Manitoba - Canada

2 Disclosure No conflict of financial interest to disclose

3 Objective To introduce a stepwise physiologic assessment of respiratory and cardiovascular monitoring parameters in infants Demonstrate the impact of critical assessment of monitoring parameters on daily medical recommendations

4 What is the most important parameter to monitor? a. Blood pressure b. Cardiac output c. Systemic vascular resistance d. Oxygen extraction by tissues and delivery e. All of the above

5 DO2 Blood flow CaO2 HR SV SaO2 Hb

6 Physiology of hypoxia and hypoxemia Blood Elsayed Y, Neonatal Network June 2016 Hypoxemia Ischemic Hypoxia Anemic Hypoxia Resting state 1- General Regulators Nervous- Baroreceptor- Chemoreceptors-Humoral Routine cardiorespiratory monitors Maintaining oxygen delivery With fluctuation of BF or O2 Maintaining aerobic metabolism 2- Autoregulation Organ specific 3-Increase oxygen extraction 4-Low 02 delivery Anaerobic metabolism Coherence of NIRS and blood pressure Coherence of NIRS and pulse oximetry Coherence of NIRS and pulse oximetry And ECHO End organ dysfunction Cell Death

7 First important focused question in any patient care! When was the last time you were fine?

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9 HR histogram General Regulators Nervous- Baroreceptor- Chemoreceptors-Humoral Routine cardiorespiratory monitors Resting state RR histogram PI histogram BP histogram Vital variables are following NDC at any given period It has Narrower base HR, RR, PI, BP histogram look similar in a stable infant

10 Case scenario BB born at 29 wks and PMA is 34 weeks, and was stable on CPAP. Overnight he became irritable and started to require more oxygen and was given multiple doses of chloral hydrate. CPAP increased from 6 to 7 cm.

11 Before intervention After intervention Septic work up revealed Staph Aureus sepsis and pneumonia

12 HIE on cooling, one day old UOP 1 ml/kg no acidosis Dopamine of 5 mic Conclusions : BP trend curve is horizontal (stable ) Pulse pressure is normal= acceptable stroke volume BP histogram is normally distributed (slightly shifted to left due to cooling)

13 Systole 30 %< 5 th about 8 hours With Low BF Target BP Wean CV meds 5 th 50 th 95 th Diastole 6%> 5 th 1h 40 min %< 5 th 5 th 50 th 95 th MBP 6%> 5 th 1h 40 min %< 5 th 5 th 50 th 95 th

14 Before closure of PDA After closure of PDA

15 Physiology of hypoxia and hypoxemia Blood Elsayed Y, Neonatal Network June 2016 Hypoxemia Ischemic Hypoxia Anemic Hypoxia Resting state 1- General Regulators Nervous- Baroreceptor- Chemoreceptors-Humoral Routine cardiorespiratory monitors Maintaining oxygen delivery With fluctuation of BF or O2 Maintaining aerobic metabolism 2- Autoregulation Organ specific 3-Increase oxygen extraction 4-Low 02 delivery Anaerobic metabolism Coherence of NIRS and blood pressure Coherence of NIRS and pulse oximetry Coherence of NIRS and pulse oximetry And ECHO End organ dysfunction Cell Death

16 The Amazing mechanism of autoregulation RBCs are computerized to auto-regulate oxygen delivery Barry W. et al

17 >80% HIGH saturation on the venous side (NIRS) TISSUE IS EXTRACTING LESS OXYGEN 1-Tissue necrosis 2-Sick recovering tissue 3-High arterial saturation Normal fractional extraction: 0.15 to 0.3 <60% Low saturation on the venous side (NIRS) TISSUE IS EXTRACTING MORE OXYGEN i.e. EXHAUSTED AUTOREGULATION 1-Low blood flow 2-Low Hb 3-Low arterial saturation HB

18 Preterm 24 wks 3 days old on HFJV, HRF and PH and RV failure started on pulmonary vasodilator Epinephrine 0.1 mcg/kg/m Compromised Autoregulation

19 Case scenario Baby girl born at 26 weeks, PMA 35 weeks: With VAP, FIO2 :0.9-1 to maintain saturation between % for last 10 days before evaluation HFJV with MAP of 14 on ino PaO2 is 40 mmhg, PCO2 = CXR : Multiple collapses more on right side

20 Gradual oxygen reduction with pulse oximetry and NIRS Time (minutes) FIO2 SpO2 % Cerebral oxygen Saturation (NIRS) Normal 60-80%) Fractional oxygen extraction Normal ( )

21 Hypoxemia RBC release NO Intact Cerebral autoregulation

22 18 preterm infants all on FIO2>40%, with acceptable CO, CO2 and HB Autoregulation by NIRS was acceptable Normal oxygen delivery ml/kg/min

23 Physiology of hypoxia and hypoxemia Blood Elsayed Y, Neonatal Network June 2016 Hypoxemia Ischemic Hypoxia Anemic Hypoxia Resting state 1- General Regulators Nervous- Baroreceptor- Chemoreceptors-Humoral Routine cardiorespiratory monitors Maintaining oxygen delivery With fluctuation of BF or O2 Maintaining aerobic metabolism 2- Autoregulation Organ specific 3-Increase oxygen extraction 4-Low 02 delivery Anaerobic metabolism Coherence of NIRS and blood pressure Coherence of NIRS and pulse oximetry Coherence of NIRS and pulse oximetry And ECHO End organ dysfunction Cell Death

24 Case scenario A preterm female infant, 31 weeks, born with congenital heart block, HR was between 50 to 55 BPM (cardiologist deferred pacemaker) Developed multiple events of bloody stool; at 43 days of age with normal AXR The infant was otherwise stable in level II nursery, Hb was 82mg dl -1, and lactic acid was 2.3 mmol dl -1.

25 Oxygen consumption (VO 2 ): ml O 2 /kg/min >10 Fractional O 2 Extraction Decreasing FOE 60% 50% 40% 30% 20 % 10% Normal Low: CO, SpO2, or HB >25 Oxygen delivery (DO 2 ): ml O 2 /kg/min

26 Lessons Calculating components of oxygen delivery altogether was helpful to detect the mechanism of chronic ischemia in this case The common organs affected by chronic ischemia are intestine and kidneys

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28 Conclusion Integrated Evaluation of Hemodynamics is a physiologic analysis of all respiratory, cardiovascular markers, systemic and tissue oxygen indices aiming to understand the pathophysiologic mechanism of hypoxia and the stage of compensation. This integration should lead to formulating a physiologic based medical recommendation.

29 Thank You