Rationale Preterm neonates needing rescue treatments with inotropes and/or inhaled nitric oxide (iNO) (acute critical illnesses, ACIs) in neonatal intensive care units (NICUs) are at high risk of mortality. While targeted neonatal echocardiography consultations (TNE) are increasingly used to guide management, its clinical impact need evaluation. Objectives To investigate clinical outcomes in relation to TNE utilisation during episodes of ACIs among preterm neonates. Methods This retrospective cohort study, conducted at two tertiary NICUs over 10 years, included neonates<37 weeks gestational age (GA) who developed ACIs. Patients receiving TNE-guided care (TNE within 24 hours of treatment initiation) were compared with non-TNE management. Outcomes included predischarge mortality, episode-related mortality (<7 days) and a new diagnosis of intraventricular haemorrhage≥grade 3 (IVH-3). Inverse probability of treatment weighting (IPTW) using propensity score was used to account for confounders, including site, birth years and baseline illness severity. Measurements and main results Of 622 included patients, 297 (48%) had TNE; median (IQR) GA at ACI was 26.4 (25.0–28.4) weeks. TNE group demonstrated higher baseline mean airway pressure, oxygen requirement and heart rate and frequently received both inotrope and iNO during ACI. IPTW analysis revealed TNE was associated with lower mortality (adjusted OR (95% CI) 0.75 (0.59 to 0.95)), episode-related mortality (0.54 (0.40 to 0.72)) and death or IVH-3 (0.78 (0.62 to 0.99)). TNE group received more varied inotropic agents, demonstrated earlier improvements in blood pressures, without increasing overall inotrpoic burden. Conclusions Among preterm neonates requiring rescue treatments with inotropes/iNO, TNE utilisation to guide clinical management may be associated with improved survival.

Background: Characteristic changes in cerebral saturation (CrSO₂), amplitude-integrated electroencephalography (aEEG), and echocardiography (ECHO) may be associated with intraventricular hemorrhage (IVH); however, the feasibility of their combined application is not known. Objective: The aim of this work was to investigate the feasibility and safety of combined multimodal cerebral and hemodynamic monitoring in extremely low gestational age (ELGA) infants in the first 72 h after birth. Methods: In this prospective ­observational study of 50 infants born between 23 + 0 and 27 + 6 weeks gestation, we measured CrSO₂ and aEEG, starting 75% of the subjects satisfying at least 3/4 criteria: (a) CrSO₂ and (b) aEEG monitoring each for >75% of the time, and (c) at least 2 out of 4 ECHO and (d) head ultrasounds (at least one by age 24 h). Adverse reactions to sensors, desaturation, and bradycardia during ultrasound studies were recorded. Results: Fifty infants were enrolled over 14 months. Multimodal monitoring was feasible in 49 (98%) infants. Forty-one (82%) infants fulfilled all 4 criteria. Mild erythema below CrSO₂ sensors lasting 3–8 h without skin breakdown was noted in 8/50 subjects (16%). Desaturation was noted during 17/197 (8.6%) of the ultrasound studies. In total, 26/50 (52%) infants developed IVH (grade I/II, n = 22; grade III/IV, n = 4). Conclusion: Multimodal monitoring is feasible, safe, and well tolerated in ELGA infants in the first 72 h after birth.

Objective: To describe the relationship between cerebral oxygenation, cardiac output, arterial blood pressure (BP), and cerebral blood flow velocity in extremely low gestational age neonates (ELGANs) during transition.Methods: This study comprises secondary analyses from a prospective observational study conducted at a tertiary Neonatal Intensive Care Unit. Recruited ELGANs underwent cerebral saturation (CrSO₂) monitoring and serial echocardiography during 72 h from birth. Correlative analyses of CrSO₂ and cerebral fractional tissue oxygen extraction (CFTOE) with left (LVO) and right ventricular output (RVO), superior vena cava (SVC) flow, middle cerebral artery blood flow mean velocity (MCA.MV), systolic (SBP), diastolic (DBP), and mean (MBP) BP were conducted.Results: Fifty ELGANs with median (range) gestational age of 25.9 (23.1–27.9) weeks were recruited. Echocardiography was performed sequentially at a median (range) age 5.0 (3.8–6.6), 17.3 (15.4–19.4), 31.0 (27.0–34.1), and 53.7 (49.3–58.3) hours. RVO, LVO, CrSO₂, and SBP increased over time but no changes in MBP, DBP, CFTOE, MCA.MV or SVC flow were noted. A weak correlation was identified between CrSO₂ and SBP (r²= 0.11, p = 0.047) and MBP (r² = 0.12, p = 0.04) at 17.3 (15.4–19.4) hours. No correlation of either CrSO₂ or CFTOE with any measures of blood flow was identified.Conclusion: There is a weak correlation between measures of cardiac output, BP, and MCA.MV with both CrSO₂ and CFTOE in ELGANs during transition. Whether this finding suggests intact cerebral autoregulation requires prospective evaluation in a cohort of sick ELGANs.

Background: Phenobarbitone induces suppression of cerebral electrical activity on amplitude-integrated electroencephalography (aEEG) in neonates with hypoxic-ischemic encephalopathy (HIE); however, its effect during therapeutic hypothermia (TH) has not been well characterized. Objective: To evaluate the effect of phenobarbitone on aEEG in neonates with HIE undergoing TH. Methods: Thirty-five neonates born at ≥35⁰ weeks gestational age (GA), who received phenobarbitone as first-line antiepileptic drug during TH for ≥ Sarnat stage II HIE with aEEG recordings were retrospectively studied. Background pattern, upper and lower margin voltages were characterized for a 30-min period before and 30–60 min after phenobarbitone administration. Primary outcome was presence of severely abnormal aEEG pattern after phenobarbitone administration. Results: Mean (±SD) GA and median birth weight were 38.2 ± 1.9 weeks and 3.1 (2.5–3.9) kg, respectively. Phenobarbitone (10–20 mg/kg), administered at median age 16.8 h, was associated with background pattern worsening in 19/29 (65.5%) cases. Severe background patterns were more prevalent in post- versus pre-phenobarbitone tracings (21/29 [72%] vs. 11/29 [38%]; p = 0.01). Presence of severe pattern versus either continuous normal voltage or discontinuous normal voltage pattern post-phenobarbitone, (20/25 [80%] vs. 3/8 [38%]; p = 0.036) was associated with death or moderate-to-severe injury on MRI brain. Median time to trace recovery, when measurable, was 4 h (45 min–72 h). Conclusions: Phenobarbitone induces significant suppression on aEEG in infants with HIE undergoing TH. Development of severe aEEG background patterns after phenobarbitone may unmask a population at greater risk of abnormal outcome.