nirs utilizationduringfirsthoursand daysoflife -...

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Medizinische Universität Graz, Universitätsplatz 3, A-8010 Graz, www.medunigraz.at

NIRS utilization during first hours anddays of life

Berndt Urlesberger, MDProfessor of Neonatology

Division of Neonatology, Department of PediatricsMedical University Graz, Austria

Email: [email protected]

B. Urlesberger, Div. Neonatology, Medical University Graz

Definitions

8 Pulse-oximetry– SpO2 – Arterial Oxygen saturation

8 Nearinfrared Spectroscopy (NIRS)– rStO2– Regional tissue oxygen saturation (mixed oxygen saturation)– Venous:arterial = 75:25


Oxygen saturation parameters

8 Peripheral oxygen saturation– SpO2 (peripheral arterial oxygen saturation)– mrStO2 (regional tissue oxygen saturation - muscle)

8 Cerebral oxygen saturation– crStO2 (cerebral regional tissue oxygen saturation) – TOI (cerebral regional tissue oxygen saturation)

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Are there differences between peripheral and cerebral oxygenation ?



Immediate Transition

Cerebral oxygenation may show a different behavior compared to peripheral arterial oxygenation

during immediate transition

J Pediatr 2011

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Cerebral oxygenation may show a different behavior compared to peripheral arterial oxygenation

during respiratory support in NICUJ Pediatr 2015


Why are there differences ?


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Lower cerebral rStO2 levels in infants with respiratory support might not only be due to lower oxygen delivery, but there might be associations with changes in cerebral perfusion!


Immediate Transition

Subjects 109Gender f : m 55 : 54

GA(wks) 38.8 (1.0)BW(g) 3242 (481)

There is a significant decrease in CBV during neonatal transition, theamount of decrease is 25%-50% of total CBV.

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We observed a less pronounced decrease of CBV in infants in needof RS, compared to infants with normal transition .

Changes in CBV of Term and Preterm Infants with and without Respiratory Support after Birth Unpublished data,

Manuscript submitted


How about normal values or target ranges for cerebral oxygen saturation ?


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Normal values for neonates during immediate transition, and preterm infants during first 72h

are established


Are we able to aim for these target ranges ? And does it matter ?


C erebralO xygen S aturation toG uide O xygenD elivery

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Dawson et al, Pediatrics 2010


Pichler et al, J Pediatr 2013


Was it possible to keep crStO2 >10th perc ?Yes !


NIRS visible

NIRS not visible

rStO2, 10th percentile

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Does it matter ?

openNIRS visible

closedNIRS not visible



Spearmans ρ = -0.78, p = 0.02


Infants without IVH

10th Percentile

Infants developed IVH later on

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SafeBoosC: Phase II trial to test the hypothesis that the burden of hypoxia and hyperoxia could be reduced by the combination of cerebral NIRS monitoring and a dedicated treatment guideline – and to demonstrate the feasibility of such an approach.

85%

55%

SafeguardingtheBrainofoursmallestChildren


Treatment Protocol

rStO2 <55%

CRT

Lactate Onvasopressors?

[Hb]low

BloodPressure

Cardiovascularstatus

Considerreducingvasopressor

Clinicalassessment

Considervolumeexpansion,vasopressor/inotropes,decreaseMAP

ConsiderRBCtransfusion

Considertreatment

Urineoutput

Echocardiography

rStO2 >85%

PDA

LowCO/SVCflow Considervolumeexpansion,inotropes,decreaseMAP

Oxygentransport

RespiratorystatusSaO2 low

PCO2 low

ConsiderincreaseFiO2

ConsiderdecreaseMV

ConsiderdecreaseFiO2

ConsiderincreaseMV

Respiratorystatus

SaO2 high

PCO2 high

Bloodglucoselevel

LowConsiderincreaseglucoseintake

SafeBoosC


Treatment Protocol

rStO2 <55%

CRT

Lactate Onvasopressors?

[Hb]low

BloodPressure

Cardiovascularstatus

Considerreducingvasopressor

Clinicalassessment

Considervolumeexpansion,vasopressor/inotropes,decreaseMAP

ConsiderRBCtransfusion

Considertreatment

Urineoutput

Echocardiography

rStO2 >85%

PDA

LowCO/SVCflow Considervolumeexpansion,inotropes,decreaseMAP

Oxygentransport

RespiratorystatusSaO2 low

PCO2 low

ConsiderincreaseFiO2

ConsiderdecreaseMV

ConsiderdecreaseFiO2

ConsiderincreaseMV

Respiratorystatus

SaO2 high

PCO2 high

Bloodglucoselevel

LowConsiderincreaseglucoseintake

SafeBoosC

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Next Step: Phase III Multicenter RCT, that may show improved neonatal outcome.

Results - Does it matter ?


Conclusion I

8 With NIRS it is possible to measure changes in cerebral oxygenation (and perfusion).

8 It has been shown, that peripheral and cerebral oxygenation show differences in behaviour.

8 Autonomous changes in cerebral blood flow may be associated with that different behaviour.

8 Normal ranges / target ranges are established for cerebral oxygen saturation.


Conclusion II - Does it matter ?

8 In two recent Phase II trials it was shown, that interventions based on NIRS were feasible– during resucitation– during first 72h in NICU

8 In the intervention groups it was possible to reduce significantly the primary outcome parameter – burden of cerebral hypoxia.

8 Secondary outcome parameters showed:– Trend to reduce mortality and cerebral injury (SafeBoosC)– Significant reduction in supplemental oxygen (COSGOD)

8 Both trials need Phase III RCT to prove, that neonatal outcome can be improved with such interventions. COSGOD III startet already !

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8 In two recent Phase II trials it was shown, that interventions based on NIRS were feasible.– during resucitation– during first 72h in NICU






8 In two recent Phase II trials it was shown, that interventions based on NIRS were feasible.– during resucitation– during first 72h in NICU




Medizinische Universität Graz, Universitätsplatz 3, A-8010 Graz, www.medunigraz.at

Thank you for your attention !

nirs utilizationduringfirsthoursand daysoflife -...

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