Premature Birth Clinical Trial
Official title:
The Continuous Monitoring of Cerebral Function, Oxygen Perfusion and Consumption in Extremely Premature Newborns
We are attempting to improve the cerebral monitoring of extremely low gestational age (ELGA)
infants, such that in the future, real-time monitoring will be possible, to aid clinicians in
their management of these infants. We wish to establish a new NIRS device, diffuse
correlation spectroscopy (DCS), as a safe, noninvasive and informative bedside tool for
assessing and monitoring brain health in ELGA infants during the first few days of life. It
is hoped that this method will provide detailed information on changes in oxygen consumption
and metabolism, and cerebral perfusion. This technique will have wide applicability, but for
this research study we wish to focus on the effect of blood flow instabilities, intermittent
hypotension and hypoxic episodes, pressure passive CBF periods, and hypoperfusion on the
preterm brain during the first days of life, and their relationship with incidence of
intraventricular hemorrhage (IVH). We aim to recruit 100 premature infants to obtain data to:
1. Test the feasibility of NIRS-DCS to monitor cerebral activity, perfusion and oxygen
consumption in extremely premature infants during the first week of life.
2. To assess if these baseline values are impacted by intermittent hypoxic episodes.
3. To assess if cerebral blood flow disturbances correlate with incidence of
intraventricular hemorrhage.
4. Correlate the NIRS-DCS findings with clinical outcome at hospital discharge.
Infants born at an extremely low gestational age (<29 weeks GA) (ELGA) are at risk for
developing any grade of intraventricular hemorrhage (IVH). In association with IVH, ELGA
infants may develop associated neuropathology including periventricular hemorrhagic
infarction, post-hemorrhagic hydrocephalus and periventricular leukomalacia. Long-term
neurodevelopmental outcomes depend on the severity of the hemorrhage. High-grade IVH (grade
III or IV) is associated with a 50% risk for cerebral palsy and significant intellectual
disability. Such disabilities have devastating and lifelong impact on affected children,
their families and society. In more than 90% of the cases, IVH in ELGA infants occurs during
the first three postnatal days. The major risk factor for IVH is the gestational age of the
infant with greater immaturity being associated with the highest risk. The degree of
prematurity of the infant relates to the immaturity of the vascular bed within the germinal
matrix as well as challenges in the regulation of the cerebrovascular circulation.
Specifically, increases, decreases and significant fluctuations in cerebral blood flow (CBF)
have been shown to play important pathogenic roles in IVH. These CBF instabilities have been
related to the mechanics of ventilation as well as to the severity of the infant's illness,
with contributing factors of hypercarbia, hypovolemia, hypotension, restlessness, patent
ductus arteriosus, and relatively high inspired oxygen concentrations. Another major
contributing factor to CBF instabilities is the pressure-passive cerebral circulatory state
in the unstable ELGA infants. To prevent such deleterious consequences on the developing
brain of preterm infants, optimal therapeutic strategies that maintain both cardiopulmonary
function and cerebrovascular stability need to be developed. The major obstacle impeding
effective brain-oriented neonatal intensive care is the lack of a relevant bedside continuous
monitor of cerebral blood flow.
Near-infrared spectroscopy (NIRS) is a non-invasive, non-ionizing method for monitoring and
imaging of brain hemodynamics. Commercially available, FDA-approved NIRS systems provide
hemoglobin concentration changes and relative hemoglobin oxygen saturation (rSO2) as a
surrogate for cerebral perfusion and oxygen consumption. However currently there are no
commercially available monitors, which can directly assess cerebral perfusion and oxygen
consumption in preterm infants. We are investigating the possibility of using a novel NIRS
optical method to quantify cerebral perfusion, continuously, at the bedside in the NICU
preterm population. We believe the use of Diffuse Correlation Spectroscopy (DCS) as a
stand-alone and in combination with frequency-domain (FD) or continuous wave (CW) NIRS will
offer more robust diagnostic capabilities by directly quantifying cerebral blood flow (CBF),
and cerebral oxygen metabolism (CMRO2). Our preliminary efforts in animals and humans with
this optical device show the potential of the technique.
Measurement Protocol Summary:
1. Start measurements within 48 hours of life, monitor for up to 72 hrs.
2. Up to 2 optical sensors will be attached with hydrogel, and affixed using either an
infant hat headband or medical grade tapes.
3. Attached optical sensors will be adjusted every few hours to ensure that there is no
disruption to skin integrity. Skin integrity will be assessed every time the optical
sensors are moved and discussed with research nurse or nurse caring for infant
4. When available physiological parameters including heart rate, blood pressure,
transcutaneous CO2 (TcCO2), cerebral oximetry and other systemic parameters from the
bedside monitors will be collected to be compared to the optical data.
5. A research pulse oximeter will be attached to the baby to record arterial saturation
(SpO2).
6. A small accelerometer will be attached to the optical sensor next to the optical sensor
to record baby head motion.
7. In a subgroup of babies we will also monitor enrolled infants with aEEG and FDNIRS. The
aEEG leads are currently used in NICU for clinical care and the FDNIRS handheld probe is
currently used in research. Depending on availability of the FDNIRS device and access to
the infant, every 4 to 12 hrs, we will perform FDNIRS measurements by using a hand-held
optical sensor.
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