Abstract
Physiologic-based management of hemodynamic instability is proven to guide the logical selection of cardiovascular support and shorten the time to clinical recovery compared to an empiric approach that ignores the heterogeneity of the hemodynamic instability related mechanisms. In this report, we classified neonatal hemodynamic instability, circulatory shock, and degree of compensation into five physiologic categories, based on different phenotypes of blood pressure (BP), other clinical parameters, echocardiography markers, and oxygen indices. This approach is focused on hemodynamic instability in infants with normal cardiac anatomy.Conclusion: The management of hemodynamic instability is challenging due to the complexity of the pathophysiology; integrating different monitoring techniques is essential to understand the underlying pathophysiologic mechanisms and formulate a physiologic-based medical recommendation and approach. What is Known: • Physiologic-based assessment of hemodynamics leads to targeted and pathophysiologic-based medical recommendations. What is New: • Hemodynamic instability in neonates can be categorized according to the underlying mechanism into five main categories, based on blood pressure phenotypes, systemic vascular resistance, and myocardial performance. • The new classification helps with the targeted management and logical selection of cardiovascular support.
Highlights
The new classification helps to targeted management, and logical selection of cardiovascular support.Stepwise compensatory mechanisms from stability to decompensation: The stable state is a complex process of interaction between diverse body humoral regulators, baroreceptors, and chemoreceptors, and they are all under a balanced control of the autonomic nervous system; all vital functions during the stable state are marinated within an acceptable range within which cellular needs of oxygen and nutrition are maintained.During any temporary period of instability, the first and fast compensatory mechanism that takes place, within a fraction of seconds, is autoregulation, and it happens with any fluctuations or changes of the parameters affecting oxygen delivery, for example; fluctuation of oxygen saturation, carbon dioxide, blood flow or blood pressure
Physiologic based management of hemodynamic instability is proven to guide to logical selection of cardiovascular approach, and shorten time to clinical recovery, compared to empiric approach which is ignoring the heterogeneity of the hemodynamic instability related mechanisms
If the oxygen delivery is less than the demand at any time beyond the capacity of autoregulation, tissue extracts more oxygen than usual to maintain aerobic metabolism; this can be detected in real-time on near infrared spectroscopy (NIRS) as low regional tissue oxygen saturation (StO2) and increased the calculated oxygen extraction, assessment of both trends and histograms are helpful for early detection of the decompensation
Summary
Physiologic assessment of hemodynamics leads to targeted and pathophysiologic based medical recommendation. Hemodynamic instability in neonates can be categorized according to the underlaying mechanism to five main categories, based on blood pressure phenotypes, systemic vascular resistance, and myocardial performance
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