Brain Maturity and Variation of Oxygen Extraction in Premature Infants

Abstract

Objectives The ability of the premature brain to extract and use oxygen has not been studied adequately. This study aimed to determine factors that influence fractional tissue oxygen extraction (FTOE) of the brain in premature infants using near-infrared spectroscopy (NIRS) and pulse oximetry.

Study Design We prospectively studied FTOE in very low birth weight (BW) infants (< 1,500 g and ≤ 34 weeks' gestation). Factors affecting FTOE and its variability were examined using bivariate and linear regression models. FTOE variability was measured on two scales: short scales (3–20 seconds) and long scales (20–150 seconds).

Results We examined 147 simultaneous NIRS and pulse oximetry recordings that were collected from 72 premature infants (gestational age [GA] = 28 weeks and BW = 1,036 g). In regression models, average FTOE correlated negatively with hemoglobin (Hb) and increased significantly in patients with severe intraventricular hemorrhage/periventricular leukomalacia. Both FTOE short- and long-scale variabilities correlated negatively with GA and positively with postnatal age (PNA). Moreover, FTOE long-scale variability was significantly reduced in infants supported with invasive ventilation.

Conclusions In premature infants, cerebral oxygen extraction increased with reduced Hb and severe brain injury. Variability in oxygen extraction showed differential changes with GA and PNAs and was affected by invasive ventilation.

Keywords

NIRS - FTOE - preterm - IVH

• References

• 1 Pichler G, Binder C, Avian A, Beckenbach E, Schmölzer GM, Urlesberger B. Reference ranges for regional cerebral tissue oxygen saturation and fractional oxygen extraction in neonates during immediate transition after birth. J Pediatr 2013; 163 (6) 1558-1563
• 2 Lemmers PMA, Toet M, van Schelven LJ, van Bel F. Cerebral oxygenation and cerebral oxygen extraction in the preterm infant: the impact of respiratory distress syndrome. Exp Brain Res 2006; 173 (3) 458-467
• 3 Wardle SP, Yoxall CW, Weindling AM. Determinants of cerebral fractional oxygen extraction using near infrared spectroscopy in preterm neonates. J Cereb Blood Flow Metab 2000; 20 (2) 272-279
• 4 Lemmers PM, Toet MC, van Bel F. Impact of patent ductus arteriosus and subsequent therapy with indomethacin on cerebral oxygenation in preterm infants. Pediatrics 2008; 121 (1) 142-147
• 5 Takami T, Suganami Y, Sunohara D , et al. Umbilical cord milking stabilizes cerebral oxygenation and perfusion in infants born before 29 weeks of gestation. J Pediatr 2012; 161 (4) 742-747
• 6 Balegar KK, Stark MJ, Briggs N, Andersen CC. Early cerebral oxygen extraction and the risk of death or sonographic brain injury in very preterm infants. J Pediatr 2014; 164 (3) 475-80.e1
• 7 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 (4) 698-704.e2
• 8 Rais-Bahrami K, Rivera O, Short BL. Validation of a noninvasive neonatal optical cerebral oximeter in veno-venous ECMO patients with a cephalad catheter. J Perinatol 2006; 26 (10) 628-635
• 9 Naulaers G, Meyns B, Miserez M , et al. Use of tissue oxygenation index and fractional tissue oxygen extraction as non-invasive parameters for cerebral oxygenation. A validation study in piglets. Neonatology 2007; 92 (2) 120-126
• 10 O'Leary H, Gregas MC, Limperopoulos C , et al. Elevated cerebral pressure passivity is associated with prematurity-related intracranial hemorrhage. Pediatrics 2009; 124 (1) 302-309
• 11 Soul JS, Hammer PE, Tsuji M , et al. Fluctuating pressure-passivity is common in the cerebral circulation of sick premature infants. Pediatr Res 2007; 61 (4) 467-473
• 12 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 (4) 625-632
• 13 Fenton TR, Kim JH. A systematic review and meta-analysis to revise the Fenton growth chart for preterm infants. BMC Pediatr 2013; 13: 59
• 14 Aly S, El-Dib M, Alqahtani S , et al. Transcutaneous pCO2 Monitoring in Very Low Birth Weight Infants Using a Reduced Temperature Probe. In: Pediatric Academic Societies (PAS) Annual Meeting. San Diego, CA; 2015
• 15 Rathinaswamy BG, An NM, Tareq A-S , et al. Detrended fluctuation analysis of non-stationary cardiac beat-to-beat interval of sick infants. EPL (Europhysics Letters) 2014; 108 (4) 40005
• 16 Sandal G, Oguz SS, Erdeve O, Akar M, Uras N, Dilmen U. Assessment of red blood cell transfusion and transfusion duration on cerebral and mesenteric oxygenation using near-infrared spectroscopy in preterm infants with symptomatic anemia. Transfusion 2014; 54 (4) 1100-1105
• 17 Pryds O, Greisen G. Effect of PaCO2 and haemoglobin concentration on day to day variation of CBF in preterm neonates. Acta Paediatr Scand Suppl 1989; 360: 33-36
• 18 Whyte RK, Kirpalani H, Asztalos EV , et al; PINTOS Study Group. Neurodevelopmental outcome of extremely low birth weight infants randomly assigned to restrictive or liberal hemoglobin thresholds for blood transfusion. Pediatrics 2009; 123 (1) 207-213
• 19 Bell EF, Strauss RG, Widness JA , et al. Randomized trial of liberal versus restrictive guidelines for red blood cell transfusion in preterm infants. Pediatrics 2005; 115 (6) 1685-1691
• 20 McCoy TE, Conrad AL, Richman LC, Lindgren SD, Nopoulos PC, Bell EF. Neurocognitive profiles of preterm infants randomly assigned to lower or higher hematocrit thresholds for transfusion. Child Neuropsychol 2011; 17 (4) 347-367
• 21 Nopoulos PC, Conrad AL, Bell EF , et al. Long-term outcome of brain structure in premature infants: effects of liberal vs restricted red blood cell transfusions. Arch Pediatr Adolesc Med 2011; 165 (5) 443-450
• 22 Wardle SP, Garr R, Yoxall CW, Weindling AM. A pilot randomised controlled trial of peripheral fractional oxygen extraction to guide blood transfusions in preterm infants. Arch Dis Child Fetal Neonatal Ed 2002; 86 (1) F22-F27
• 23 El-Dib M, Govindan R, Aly S , et al. EEG maturation and stability of cerebral oxygen extraction in very low birth weight infants (epub ahead of print). J Perinatol 2016; ; Jan 7. doi: 10.1038/jp.2015.200
• 24 Polglase GR, Miller SL, Barton SK , et al. Respiratory support for premature neonates in the delivery room: effects on cardiovascular function and the development of brain injury. Pediatr Res 2014; 75 (6) 682-688
• 25 Albertine KH. Brain injury in chronically ventilated preterm neonates: collateral damage related to ventilation strategy. Clin Perinatol 2012; 39 (3) 727-740
• 26 Vanderhaegen J, Naulaers G, Vanhole C , et al. The effect of changes in tPCO2 on the fractional tissue oxygen extraction—as measured by near-infrared spectroscopy—in neonates during the first days of life. Eur J Paediatr Neurol 2009; 13 (2) 128-134