Abstract
BackgroundThe Cushing reflex does not appear to have been described in preterm neonates. This case report shows the presence of an active Cushing reflex in a 32-week preterm neonate with hyaline membrane disease.Case presentationThe 1.94 kg Caucasian infant was delivered by caesarean section following concerns about possible maternal infection and fetal compromise. Chest X-ray showed mild-to-moderate hyaline membrane disease and treatment was initiated with supplemental oxygen and nasal continuous positive airway pressure. It is probable that a pneumothorax occurred at 5–6 hours of age, with progression during the day. Interstitial air, pneumomediastinum, and tension pneumothorax were diagnosed on subsequent X-ray, and ultrasound of the brain showed a grade IV intraventricular hemorrhage. A review of the nurses’ recordings of heart rate, blood pressure, and respiratory rate showed a progressive increase in blood pressure accompanied by slowing of the heart rate and irregular respiration. These are features of the Cushing reflex that is elicited in response to raised intracranial pressure.ConclusionWhile well-described in older children and adults, in neonates the Cushing reflex has mainly been described in animal experiments and infants who have developed hydrocephalus. It is likely that in this case, the reflex was elicited as a result of a progressive increase in intracranial pressure due to the combination of elevated intrathoracic pressure, obstructed venous return from the brain, and concurrent intraventricular hemorrhage.
Highlights
The Cushing reflex does not appear to have been described in preterm neonates
While well-described in older children and adults, in neonates the Cushing reflex has mainly been described in animal experiments and infants who have developed hydrocephalus
It is likely that in this case, the reflex was elicited as a result of a progressive increase in intracranial pressure due to the combination of elevated intrathoracic pressure, obstructed venous return from the brain, and concurrent intraventricular hemorrhage
Summary
It is certainly possible that the Cushing reflex only manifested in this case because the opportunity was missed to treat the infant at ± 6 hours of age, thereby allowing a pathological situation to progress to the point of critically raised ICP. It is important to note that there may be subtle manifestations of the reflex in a critically ill preterm infant such as this, even in the presence of a compliant cranium with open fontanelles and sutures. Abbreviations FiO2: Fractional inspired oxygen; HIE: Hypoxic ischemic encephalopathy; HMD: Hyaline membrane disease; ICP: Intracranial pressure; IVH: Intraventricular hemorrhage; NCPAP: Nasal continuous positive airway pressure; NICU: Neonatal intensive care unit; pO2: Partial pressure of oxygen; SpO2: Oxygen saturation of hemoglobin
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