Changes in microcirculation have been recognized as central to many disease processes. The aim of this study was to evaluate factors, which influence the microcirculation of the skin during the first month of life in premature infants. Red blood cell (RBC) velocity, vessel diameter, and functional small vessel density (FSVD) were measured daily for the first 30 d on the upper arm in preterm infants with gestational age Ͻ30 wk. Orthogonal polarization spectral (OPS) images were analyzed off-line with the CapiScope-Image program. In 25 infants, FSVD decreased significantly from week 1 (mean Ϯ SD 236 Ϯ 33 cm/cm 2 ) to week 4 (207 Ϯ 30 cm/cm 2 ) and correlated directly with Hb levels and incubator temperature. Vessel diameters and RBC velocity did not change significantly, nor did clinical parameters such as blood pressure, heart rate or body temperature. Microvascular parameters were not dependent on gestational or postnatal age. The microcirculation of the skin might be an easily accessible window to obtain better understanding of circulatory changes in the postnatal period. Our data are essential as basis for further studies in this field. Hb levels and possible incubator temperatures have a substantial influence on functional small vessel density and therefore need to be taken in account. D isturbances of the microcirculation play a key role in many disease states (1-4). The recent development of new technologies has helped to investigate these changes in adult patients with sepsis (5-7). Previous studies have shown that parameters of microcirculation such as microvessel diameter, red blood cell velocity, and functional small vessel density (FSVD) can be measured in the skin of term and preterm infants by Orthogonal Polarization Spectral (OPS) imaging in the first week of life (8) and that FSVD increases after elective blood transfusion in anemic neonates (9). The microcirculation of the skin plays an important role in maintaining a constant body temperature and in regulating the fluid balance (10,11). Adequate function of the microcirculation is a prerequisite for tissue nutrition and oxygen supply (12). The microcirculation of the skin in neonates differs in several aspects from that of an adult. The regular architecture has been found to be poorly developed in the newborn (13). At birth, the skin shows a disorderly capillary network and no papillary loops in almost all areas, except the palms, soles, and nail folds. The skin is richly supplied by a dense subepidermal plexus demonstrating relatively little regional variation (14).Functional capillary density (FCD) is one of the parameters that delineate the microcirculation. FCD is defined as the length of red cell-perfused capillaries per observation area and is given as cm/cm 2 . FCD has been used as an indicator of the quality of tissue perfusion (15). In neonates capillary vessels, arterioles, and venules cannot clearly be differentiated in the OPS images, so that the expression FSVD is used.The aim of the study was to determine whether tissue pe...

ABSTRACT:In adults with severe sepsis, the disturbances of the sublingual microcirculation can be quantified with orthogonal polarization spectral imaging. We investigated the cutaneous microcirculation of preterm infants with proven infection (PosInf) and with suspected but unproven infection (NegInf). In 25 infants, orthogonal polarization spectral images were obtained daily, videos of the images were blinded, and analyzed off-line. Functional small vessel density (FSVD) was prospectively calculated from day 3 to day 30 of life. There were 17 episodes of proven and nine episodes of suspected but unproven nosocomial late onset infection. Four infants remained healthy. The data were analyzed for the 5 d before the start of antibiotics (day Ϫ5 until day Ϫ1). FSVD varied widely, but in the PosInf-group, we found a 10% decline from day Ϫ5 to day Ϫ1 (p ϭ 0.013). There was no significant change over time in the NegInfgroup (p ϭ 0.58). Thus, in infants with proven infection, FSVD decreases already 1 d before changes in laboratory parameters. However, these changes in FSVD during infection are not represented by absolute values, but must be identified by daily intraindividual observation. (Pediatr Res 66: 461-465, 2009) V ery low-birth weight infants are at increased risk for episodes of nosocomial infection, which contributes significantly to mortality and morbidity (1). Early diagnosis and prompt administration of appropriate antibiotics are crucial to improve outcome but clinical signs of infection are very unspecific. White blood cell count has not been shown to improve early diagnosis; C-reactive protein (CRP) is quite specific but not very sensitive for neonatal infection. Cytokines such as interleukine (IL)-6 increase early in neonatal infection before the rise of CRP, and the combination of both increases sensitivity and specificity (2). The need for early treatment in combination with nonspecific clinical signs leads to significant iatrogenic blood loss (3) and an increased exposure to antibiotics.Most clinical signs of infection such as change of skin color, a prolonged capillary filling time, and temperature instability are caused by altered microcirculation. Changes in microcirculation play an important role in the development of septic organ dysfunction (4,5) and the severity of change may even predict outcome (6). Improved technology has made observation and quantification of microcirculatory parameters possible. One of the most promising instrumentation in the regard is the orthogonal polarization spectral (OPS) imaging technique, which allows new insights in the human microcirculation and semiquantified assessment. This method provides high-resolution images of the microvascular architecture to a depth of 1 mm. OPS has been validated by multiple studies in animals and humans (7,8). Using OPS Sakr et al. (6) recently found an association between microcirculatory alterations, organ dysfunction, and death in patients with septic shock. We have previously shown that OPS imaging and measurement of small vess...

Background: Orthogonal polarization spectral (OPS) imaging is a novel method to examine the microcirculation non-invasively.Methods: Red blood cell velocity (RBC vel), vessel diameter (Diam) and functional capillary density (FCD) were measured daily in the first month of life on the upper arm in neonates with gestational age less than 30 weeks. OPS images were recorded on videotape and analysed off-line with the CapiScope program.Results: In 25 preterm infants (median (95% CI): gestational age of 28 (26.18 -27.58) weeks; birth weight 900 (807.9 -992.8) g) Diam ranged from 7 to 24 m, RBC vel from 171.8 to 726.3 m/s with no significant change. RBC vel correlated with hemoglobin levels (r 2 ϭ 0.25, 95% CI (0.14 -0.74), p ϭ 0.0083) and inversely with mean systolic blood pressure (r 2 ϭ 0.36, 95% CI (-0.8 to -0.29), p ϭ 0.0009). FCD decreased significantly from day 7 (mean 236.4 m/s; 95% CI 218.5-254.2) to day 28 (mean 206.9 m/s; 95% CI 190 -223.3; p ϭ 0.0028). FCD correlated directly with hemoglobin levels (r 2 ϭ 0.58, 95% CI (0.54 -0.89), p Ͻ 0.001). There was an inverse correlation between FCD and heart rate (r 2 ϭ 0.39, 95% CI (-0.8 to -0.32), p Ͻ 0.001) and systolic blood pressure (r 2 ϭ 0.32, 95% CI (-0.78 to -0.24), p ϭ 0.0021). Clinical variables, such as blood pressure, heart rate or body temperature did not change significantly. Hemoglobin decreased significantly over time (p Ͻ 0.0001), which explains the concurrent decrease in FCD. Preterm neonates from 23 to 26 and from 28 to 30 weeks did not differ in RBC, Diam and FCD.Conclusion: We have shown that tissue perfusion can be monitored reliably by OPS imaging in premature infants in the first month of life. EARLY QUANTITATIVE ELECTROENCEPHALOGRAPHIC MEASURES OF CONTINUITY ARE ASSOCIATED WITH NEURODEVELOPMENTAL OUT-COME AT 18 MONTHS IN PRETERM INFANTS CHILD DEVELOPMENT UNIT, NATIONAL WOMEN'S HEALTH, AUCKLAND DISTRICT HEALTH BOARD (NEW ZEALAND)Background Early outcome prediction for preterm infants is inadequate. Discontinuity on early conventional electroencephalography (EEG) is associated with poorer outcomes. However, the complexity of EEG interpretation has limited incorporation into routine clinical practice. Cotside EEG monitors are becoming increasingly available and some produce quantitative measures from the EEG to assist interpretation.Aim To examine the ability of quantitative measures of continuity from cotside EEG recordings performed on preterm infants in the first four days after birth to predict neurodevelopmental outcome at 18 months.Methods Preterm infants with birthweights Ͻ1500g had cotside EEG monitoring (research BRM, BrainZ Instruments Ltd, Auckland, New Zealand) within four days of birth. Sixty minute portions of EEG were analysed offline for quantitative continuity measures. Continuity was calculated as the percentage of each minute that the EEG amplitude was above a 10, 25 or 50V threshold and left and right values averaged. Infants had a Bayley-II examination at 18 months chronological age. The relationships between continuity meas...

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Background: Necrotizing enterocolitis (NEC) is a serious complication among pre-term infants. Surfactant replacement therapy can help to prevent respiratory distress syndrome (RDS) among very low birth weight (VLBW) pre-term infants. Currently, there are no pharmacoeconomic analyses that estimate the cost savings in preventing RDS among pre-term infants diagnosed with NEC who receive surfactant therapy.Objectives: To estimate the economic impact of the synthetic protein-containing surfactant lucinactant (Surfaxin) and pooled animal-derived surfactants (beractant [Survanta] and poractant alfa [Curosurf]) in the prevention of RDS among surviving pre-term infants weighing 600 to 1,250 grams who have been diagnosed with NEC.Methods: A decision-analytic model was developed using a hospital perspective to estimate the economic impact of initial length of stay in the neonatal intensive care unit (NICU) for pre-term infants with NEC. Clinical outcomes consist of the average initial NICU length of stay from the combined Phase III randomized, controlled clinical trials of surfactant therapy (SELECT and STAR). The cost input was the average cost of treating surviving pre-term infants with medical NEC, U.S. $2,039, the combined level II and level III NICU cost per day (2002).Results: Pre-term infants with NEC who survived and received lucinactant had 2.27 fewer initial NICU days compared to the pooled animal-derived cohort (73.73 versus 76.00 days, respectively). The estimated average cost of an initial NICU stay per infant was U.S. $150,320 for infants receiving lucinactant compared to U.S. $154,948 for infants receiving animal-derived surfactants. Due to fewer NICU days, lucinactant therapy results in a medical cost savings of U.S. $4,628 per infant.Conclusion: Among surviving pre-term infants diagnosed with NEC who received surfactant therapy, the synthetic protein-containing surfactant lucinactant reduced total initial NICU hospital costs when compared to pooled animal-derived surfactants. Anecdotal evidence, however, suggests that cyanotic episodes are more common in neonates sleeping supine. We wanted to determine whether term neonates do indeed have more episodes of intermittent hypoxia in the supine than in the side position. INTERMITTENT HYPOXIA IN SUPINE VERSUS SIDE POSITION IN 1-5 D OLD TERM NEONATESMethods: We enrolled 1-5 day old term neonates in a controlled 2-phase cross-over study design. They were randomised to sleep, for 6 h each, either in supine followed by side position (right or left) or vice versa. Pulse oximeter saturation (SpO2) values and a signal quality indicator were recorded throughout (VitaGuard VG 300 with Masimo SET, Irvine, CA; 2-4 s averaging). Only recordings lasting at least 3 h in either position were included. Desaturation events to Ͻ85% and Ͻ80% SpO2 were analysed, excluding events with poor signal quality.Results: 477 neonates had recordings of sufficient duration. Mean duration of analyzable signal was 4.93 h for supine and 4.89 h for side position. 38% and 75%, respectively, of in...