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Updated: May 5, 2026
Transcutaneous Microcirculatory Imaging in Preterm Neonates
Published on: December 31, 2015
Multimodal Monitoring of Hemodynamics in Neonates With Extremely Low Gestational Age: A Randomized Clinical Trial
Renjini Lalitha1,2, Eyad Bitar2,3, Matthew Hicks2
1Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Western Ontario, London, Canada.
Insights
Multimodal hemodynamic monitoring in extremely low gestational age (ELGA) neonates did not lower cardiorespiratory-kidney scores but reduced severe outcomes and bronchopulmonary dysplasia (BPD). Further research is warranted for this ELGA population.
Area of Science:
- Neonatal Medicine
- Cardiovascular Physiology
- Pediatric Critical Care
Background:
- Transitional circulation management in extremely low gestational age (ELGA) neonates lacks standardized protocols.
- Variability in current practices necessitates research into improved hemodynamic monitoring strategies.
Purpose of the Study:
- To evaluate if multimodal hemodynamic monitoring improves cardiorespiratory-kidney health in ELGA neonates.
- To assess the impact on the vasoactive-ventilation-renal (VVR) score at 7 days of life.
Main Methods:
- A randomized clinical trial involving 132 ELGA neonates (23-28 weeks gestation).
- The multimodal arm used echocardiography and near-infrared spectroscopy (NIRS) with a clinical guideline.
- The standard arm relied on clinical-biochemical data for hemodynamic assessment.
Main Results:
- No significant difference in mean VVR scores at 7 days between groups (16.5 vs 18.9).
- The standard arm showed a higher incidence of severe VVR scores (>53), linked to death or severe intraventricular hemorrhage (11.1% vs 0%).
- The multimodal arm had a lower incidence of bronchopulmonary dysplasia (BPD) (41.3% vs 59.0%).
Conclusions:
- Multimodal hemodynamic monitoring did not reduce the primary VVR score outcome in ELGA neonates.
- This approach was associated with a reduction in severe adverse outcomes and BPD incidence.
- Further investigation is recommended to explore the benefits of multimodal monitoring in this vulnerable population.
Importance:
Evaluation and treatment of transitional circulation in neonates with extremely low gestational age (ELGA) varies greatly across centers.
Objective:
To determine whether multimodal hemodynamic monitoring in neonates with ELGA during the transitional period (first 72 hours of life) will improve cardiorespiratory-kidney health by decreasing vasoactive-ventilation-renal (VVR) score at 7 days.
Design, Setting, And Participants:
This unmasked, 2-arm randomized clinical trial included neonates born at a gestational age of 230 to 286 weeks and admitted to a neonatal unit in Canada. Patients were enrolled from February 15, 2019, to December 31, 2021, with follow-up completed in April 2022.
Interventions:
Neonates in the multimodal arm received early targeted neonatal echocardiography at 18 to 24 and 66 to 72 hours of life and cerebral near-infrared spectroscopy (NIRS) for the first 72 hours. A study guideline incorporating clinical-biochemical and cerebral near-infrared spectroscopy data was used for hemodynamic consultation in the multimodal arm. Neonates in the standard arm received hemodynamic assessment using clinical-biochemical data.
Main Outcome And Measures:
The primary outcome was VVR score at 7 days. The VVR score incorporates measures of inotrope use, ventilation support, and kidney function to reflect cardiorespiratory-kidney health, with possible scores ranging from 0 to 69.62 at 7 days; higher scores indicate worse cardiorespiratory-kidney health.
Results:
Primary analysis included 132 neonates with ELGA (68 in the multimodal arm and 64 in the standard arm) with mean (SD) gestational age of 26.4 (1.5) weeks (75 [56.8%] male). The mean (SD) VVR score at 7 days was 16.5 (15.4) in the multimodal arm and 18.9 (20.2) in the standard arm (P = .45). A day 7 peak VVR score greater than 53 (>95th percentile for VVR in the entire cohort) was seen only in the standard arm (7 of 63 [11.1%] vs 0 in the multimodal arm; P = .005) and was associated with a composite outcome of death or severe intraventricular hemorrhage (odds ratio [OR], 12.37; 95% CI, 1.92-79.63; P = .001) and bronchopulmonary dysplasia (BPD) (6 of 6 [100%] vs 55 of 116 [47.4%]; P = .01). Incidence of BPD was lower in the multimodal arm (26 of 63 [41.3%] vs 36 of 61 [59.0%]; P = .04). Logistic regression showed that VVR score at 7 days in the top quartile (adjusted OR [AOR], 11.40; 95% CI, 2.04-63.67), late sepsis (AOR, 65.24; 95% CI, 5.70-748.18), and patent ductus arteriosus treatment after 72 hours of life vs early or no treatment needed (AOR, 7.20; 95% CI, 1.60-32.41) were associated with BPD.
Conclusions And Relevance:
In this study of neonates with ELGA, multimodal hemodynamic assessment was not associated with decreased VVR scores at 7 days. However, this approach led to lower incidence of VVR associated with severe adverse outcomes and lower BPD incidence, suggesting further investigation is needed.
Trial Registration:
ClinicalTrials.gov Identifier: NCT03841929.
