Original Article

1015

Perfusion Index Variability in Preterm Infants Treated with Two Different Natural Surfactants for Respiratory Distress Syndrome Dilek Dilli, MD1

Aysegul Zenciroglu1

1 Neonatal Intensive Care Unit, Dr. Sami Ulus Maternity and Children

Training and Research Hospital, Ankara, Turkey

Banu Aydin, MD1

Serdar Beken, MD1

Address for correspondence Serdar Beken, MD, Dr. Sami Ulus Hastanesi, Ankara, Turkey (e-mail: [email protected]).

Am J Perinatol 2014;31:1015–1022.

Abstract

Keywords

► surfactant ► respiratory distress syndrome ► perfusion ► pulmonary hemorrhage

Objective The objective of this study was to compare the perfusion index (PI) variability in premature infants with respiratory distress syndrome (RDS) following administration of two different natural surfactant preparations. Study design This was a prospective study on 92 preterm infants with RDS. Patients were randomized into two groups. Group 1 (n ¼ 46) received beractant; Group 2 (n ¼ 46) received poractant alfa. Oxygen saturation, PI, and heart rate were measured by Masimo Rainbow SET Radical-7 pulse oximeter (Masimo Corp., Irvine, CA) before and after surfactant. The effects of the two treatment regimens on PI and oxygenation were compared. Results Repeated doses were more needed in beractant group (p ¼ 0.04). Median oxygenation index (OI) before surfactant were similar, but improvement in OI was more prominent at 6th hour of surfactant in Group 2 (p ¼ 0.001). Both groups had similar preductal PI values before surfactant. PI was higher at 6th hour of surfactant in Group 2 (p ¼ 0.001). Pulmonary hemorrhage, intraventricular hemorrhage, patent ductus arteriosus, necrotizing enterocolitis, and mortality were more frequent in infants whose PI values lower than 0.7 within the first 5 days of life (p ¼ 0.001). Conclusion Poractant alfa resulted in more prominent improvement in PI and OI. Low PI values measured at early postnatal period may predict poor clinical outcome in preterm infants with RDS.

Respiratory distress syndrome (RDS) has been reported to be an important cause of morbidity and mortality in preterm infants before surfactant era. Although both natural and synthetic surfactant preparations reduce the incidence of neonatal mortality in premature infants with RDS, natural surfactants improve oxygenation and lung function more rapidly than synthetic surfactants.1,2 Nowadays, the pulse oximeter has become a vital neonatal intensive care unit (NICU) instrument.3 The perfusion index (PI) derived from the pulse oximeter signal is a noninvasive numerical value of peripheral tissue perfusion obtained from

a new generation pulse oximeter. It reflects real-time changes in peripheral blood flow and may be a predictor for high illness severity in neonates.4 Reference PI values in preterm and term newborns have been recently published.5,6 Peripheral tissues of preterm infants are very sensitive for hypoperfusion. It was hypothesized that surfactant administration might affect hemodynamic parameters and peripheral perfusion. There are different types of surfactants. Within the group of natural surfactants, a differential hemodynamic response has been reported—either as differences in the a: APO2 ratio during the first 24 hours or as a difference in

received October 20, 2013 accepted after revision December 24, 2013 published online February 24, 2014

Copyright © 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.

DOI http://dx.doi.org/ 10.1055/s-0034-1370344. ISSN 0735-1631.

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Nilgun Karadag, MD1 Nurullah Okumus1

Perfusion Index Variability in Surfactant Treatment

Karadağ et al.

ventilatory requirement during the first 24 hours following administration.7,8 However, there are rare data in the literature for peripheral perfusion after surfactant treatment in premature infants with RDS. It is reported that functional residual capacity improves after surfactant treatment and this leads to increased oxygenation.7,8 With the help of new generation pulse oximeter, changes in peripheral perfusion may be demonstrated. Therefore, in this study, we aimed to compare PI variability and oxygenation before and after two different natural surfactant regimens. We also aimed to evaluate whether low PI values were associated with poor clinical outcomes in preterm infants with RDS.

Methods Design: This was a prospective randomized controlled study. Setting and the year of the study: The study was conducted in a level III NICU of Dr. Sami Ulus Maternity and Children Training and Research Hospital, Ankara, Turkey between August 2011 and December 2012. Study population: Inclusion criteria were as follows: • Inborn infants with a gestational age  32 weeks. • Clinical and typical radiological findings of RDS. • Requirement of mechanical ventilation with a fraction of inspired oxygen (FIO2) of > 0.4 and mean airway pressure

(MAP) > 7 cm H2O to obtain arterial pressure of oxygen (PaO2) between 70 and 80 mm Hg. • Age at randomization of 2 hours after delivery. Exclusion criteria were as follows: • • • •

Severe birth asphyxia (Apgar score of 3 at 5 minutes). Structural cyanotic congenital heart disease. Major congenital anomalies. Infants without parental consent.

Intervention Initially a total of 175 inborn infants who were  32 weeks of gestational age were eligible for the study. A total of 92 premature infants with RDS and fulfilled the inclusion criteria were divided into two groups to receive beractant (Survanta, Abbott Laboratories, Chicago, IL) (Group 1) or poractant alfa (Curosurf, Chiesi Pharmaceuticals, Parma, Italy) (Group 2) (►Fig. 1). Envelopes contained cards that were randomly assigned to either Group 1 or Group 2 using a random number generator. These cards were used to choose the type of surfactant to be given to patients. The patients were given the first surfactant dose in the first 2 hours of life as “early surfactant treatment.” In Group 1, for beractant which is from beef lung extract, both initial and subsequent dosing was 100 mg/kg (4 mL/kg), which may be given up to four total doses.9 In Group 2, for poractant alfa, which is from porcine lung extract, initial dosing was 200 mg/ kg (2.5 mL/kg) and repeated dose was given at 100 mg/kg

≤ 32 gestational weeks Assessed for eligibility (n = 175)

Enrollment Excluded (n = 83) n = 61) n = 12) n = 6): perinatal asphyxia, cyanotic congenital heart disease, congenital malformation

Randomized (n = 92)

Allocation Allocated to intervention (n = 46) (Group 1: beractant)

Analyzed Before surfactant (n = 46) At 1st hour (n = 46) At 6th hour (n = 46) On 1st day (n = 46) On 3rd day (n = 46) On 5th day (n = 45): Reason: 1 died

Fig. 1 Flow diagram of the randomized controlled trial.

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Allocated to intervention (n = 46) (Group 2: poractant alfa)

Analysis

Analyzed Before surfactant (n = 46) At 1st hour (n = 46) At 6th hour (n = 46) On 1st day (n = 46) On 3rd day (n = 46) On 5th day (n = 46)

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1016

(1.25 mL/kg) up to maximum of two additional doses when indicated.10 Repeated doses were given if the infants have a MAP > 7 and FIO2 > 0.3. Infants who were administered surfactant treatment were then switched to nasal continuous positive airway pressure (CPAP) as early as possible depending on their respiratory condition. Preductal (right hand) PI, oxygen saturation (SpO2), and heart rate were measured by Masimo Rainbow SET Radical-7 pulse oximeter (Masimo Corp., Irvine, CA). In pulse oximeter, PI is calculated as the ratio of the pulsatile component to the nonpulsatile component of the infrared signal returning from the monitoring site, and it reflects the ratio of the pulsatile to the nonpulsatile component of the bloodstream.4 For Masimo Radical SET, the PI upper and lower limits reported by the manufacturer are 0.02 to 20.00%. The recorded pulse oximeter signals for 5 minutes were stored in a personal computer and analyzed through the VitaWin 3 (Getemed Medizin und Informations Technik AG, Teltow, Germany) software. The median PI for each measurement was obtained from the average of PI values recorded at 6-second intervals. The monitorization was continued for 5 days. Simultaneous systolic arterial pressure (SAP) (Datascope Corporation, Mahwah, NJ) was also recorded. The oxygenation index (OI, in cm H2O/mm Hg) calculated using the formula: OI ¼ (MAP  FIO2  100)/PaO2 was evaluated before surfactant and at the 6th hour of the treatment.

Outcome Measures In the study, analyzed variables were either related to the mother (antenatal corticosteroids and cesarean delivery) or the infant (gestational age, birth weight, Apgar score at 5 minutes and gender). During the first 24 hours after admission, clinical and laboratory evaluations were performed to assess the Score for Neonatal Acute Physiology-Perinatal Extension (SNAPPE-II). Complications such as pneumothorax defined on chest radiographs, pulmonary hemorrhage (bright red blood in endotracheal tube associated with acute respiratory deterioration), patent ductus arteriosus (PDA) (characteristic murmur or echocardiographic confirmation),

Karadağ et al.

intraventricular hemorrhage (IVH) ( grade 2) defined by cranial ultrasound, proven sepsis (bacteria cultured from blood or tracheal aspirate), periventricular leukomalacia defined by cranial ultrasound, necrotizing enterocolitis (NEC) ( grade 2) defined by modified Bell’s classification,11 retinopathy of prematurity (ROP) (requiring laser photocoagulation), and bronchopulmonary dysplasia (BPD) (the need for oxygen at 36 weeks of postmenstrual age) were recorded. Complete duration of mechanical ventilation and nasal CPAP, total need of oxygen support, length of hospital stay, and mortality were also noted. The primary outcome of the study was PI variability before and after surfactant treatment. Secondary outcome was relation of low PI values (< 0.7) at the 1st day of life with clinical outcomes.6

Power and Statistics Analysis According to the results from observational data in a similar group of 40 neonates who were receiving surfactant, the mean PI was 0.79 (0.5). A power calculation indicated that a sample size of 46 in each group would be required to allow 85% probability of detecting a 0.3 difference in PI value with significance at the 5% level. Comparisons of variables in infants who received beractant versus those who received poractant alfa were analyzed. SPSS 16.0 (SPSS, Chicago, IL) was used for statistical analysis. Kolmogorov–Smirnov test was used to analyze the distribution of data. Data were expressed as mean (standard deviation) or median (interquartile range, IQR) as appropriate. Differences between two groups were tested using Student t-test or Mann–Whitney U test. Chi-square tests were performed for categorical variables. Wilcoxon and Friedman tests were used to analyze paired samples. A two-tailed p value of < 0.05 was accepted as significant.

Ethics and Consent Informed consent was obtained from parents before administration of the surfactant. This study was approved by the

Table 1 Demographic and perinatal characteristics of the study infants Group 1 (beractant) (n ¼ 46)

Group 2 (poractant alfa) (n ¼ 46)

p Value

1,086  248

1,098  256

0.91

29.0  1.9

29.6  1.8

0.22

Male, n (%)

27 (58.7)

24 (52.2)

0.53

Cesarean delivery, n (%)

27 (58.7)

26 (56.5)

0.83

Multiple birth, n (%)

9 (19.5)

6 (13.0)

0.62

Premature rupture of membranes, n (%)

8 (17.4)

5 (10.8)

0.55

Birth weight, ga Gestational age, wk

a

Histologic chorioamnionitis, n (%)

7 (15.2)

8 (17.4)

0.77

Preeclampsia, n (%)

7 (15.2)

8 (17.4)

0.77

38 (82.6)

35 (76.0)

0.60

7.1  0.8

7.3  0.8

0.22

Antenatal steroid, n (%) Apgar scores at 5th min a

a

Mean  standard deviation. American Journal of Perinatology

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Perfusion Index Variability in Surfactant Treatment

Perfusion Index Variability in Surfactant Treatment

Karadağ et al.

institutional review board and strictly followed the institution’s ethical guidelines.

Results There were no significant differences between the two groups for demographic and perinatal characteristics (►Table 1). ►Table 2 shows hemodynamic parameters before and after surfactant and clinical outcomes in study infants. Median OI before surfactant were similar, but improvement in OI was more prominent at the 6th hour of surfactant in Group 2 (Group 1: 16 [15–19] vs. Group 2: 13 [12–16], [p ¼ 0.001]). Both groups had similar preductal PI values before surfactant. PI was higher at the 6th hour of surfactant in Group 2 (p ¼ 0.001). Repeated doses were more needed in beractant group. In poractant alfa group, 9 infants (19.6%) needed second dose of surfactant, while 22 (47.8%) in beractant group (p ¼ 0.04). Duration of mechanical ventilation were shorter and rate of pulmonary bleeding were lower in poractant alfa group (p ¼ 0.02). The other clinical outcomes and mortality were similar between the groups. ►Fig. 2 shows PI trend before and after surfactant, during the first 5 days of life. It was found that PI significantly changed in most points within 5 days (p ¼ 0.001). Separate analyses showed that median (IQR) PI value was significantly increased at 1st hour after surfactant treatment (Group 1: 0.50 [0.41–0.63] to 0.80 [0.72–0.87], p ¼ 0.001 and Group 2: 0.50 [0.45–0.60] to 1.20 [1.10–1.20], p ¼ 0.001). At 6th hour, PI values decreased from 6th hour (Group 1: 0.80 [0.74–0.83] and Group 2: 1.17 [1.10–1.20]) to the 1st day (Group 1: 0.80 [0.70–0.82], p ¼ 0.001 and Group 2: 1.10 [1.00–1.17], p ¼ 0.001). No significant changes observed from 3rd to 5th day (Group 1: 0.78 [0.72–0.80] to 0.80 [0.72–0.83], p ¼ 0.10 and Group 2: 1.08 [0.91–1.12] to 1.10 [1.00–1.16], p ¼ 0.09). For 5 days, PI value remained higher in Group 2 compared with Group 1. Preductal PI at 6th hour of surfactant was negatively correlated with SNAPPE-II score (r ¼  0.34, p ¼ 0.001). There was positive correlation between PI at the 6th hour of surfactant and simultaneous SpO2 (r ¼ 0.51, p ¼ 0.001), heart rate (r ¼ 0.43, p ¼ 0.001), and SAP (r ¼ 0.33, p ¼ 0.001). ►Table 3 shows median (IQR) PI values and relation of low PI values (< 0.7) for the first 5 days of life with clinical outcomes. Pulmonary hemorrhage, IVH, PDA, NEC, and mortality were more frequent in infants whose PI values were lower than 0.7 within the 1stday of life (p ¼ 0.001 for all analyses).

Discussion The peripheral PI trend measured by pulse oximeter may reflect the physiological variability of the peripheral microvascular blood flow immediately after preterm birth and it could be related to the intrinsic hemodynamic adaptation which occurs in the 1st day of life. Cresi et al5 showed agerelated differences in peripheral PI recordings with a significant increase in the median PI value between the 1st (0.9) and American Journal of Perinatology

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the 3rd days of life (1.2), whereas there was no significant difference between the 3rd and the 7th days (1.3). In our study, we evaluated PI in infants with RDS. In all patients, it was observed that median PI values were low before surfactant (0.5) and increased at the 1st hour of the treatment (0.9). PI was decreased from the 6th hour to the 1st day and did not change thereafter. Functional residual capacity improves after surfactant treatment and this leads to increased oxygenation.7,8,12 Among studies investigating the effect of type of surfactant on respiratory support, two studies showed significant differences in MAP values, favoring poractant alfa, whereas one study did not find any difference between the two groups with respect to this outcome.7,8,13,14 Faster weaning of oxygen after poractant alfa administration was shown for 6 hours by Ramanathan et al,8 for 24 hours by Speer et al,7 and for 48 hours by Malloy et al.13 In the current study, we observed that reduction in OI and increment in PI were more prominent in poractant alfa group. Duration mechanical ventilation and total need of oxygen support were shorter in the same group. PI remained higher for the first 5 days in poractant alfa group which may be related to improved oxygenation. In a recent Cochrane review, it was reported that in infants with RDS, a policy of multiple doses of natural surfactant extract results in greater improvements regarding oxygenation and ventilatory requirements, a decreased risk of pneumothorax and a trend toward improved survival.15 Retreatment strategies may be associated with the surfactant preparation that is used. A meta-analysis showed that the incidence of redosing was lower in patients receiving poractant alfa, compared with others receiving beractant.16 In our study, we also observed that the infants receiving beractant more needed repeated doses of surfactant than those of receiving poractant alfa. Berg et al17 reported the frequency of pneumothorax in RDS as between 20.7 and 39.7%. The incidence of pneumothorax decreased markedly after the use of surfactant therapy.16 Pulmonary hemorrhage, another complication of surfactant therapy, was reported to be higher with natural surfactant preparations (5–6%) compared with synthetic ones (1–3%).18 However, when compared, the rates of pulmonary air leaks and pulmonary hemorrhage were reported to be similar between the two types of surfactants. It was also reported that there was no difference in the incidence of sepsis, NEC, PDA, severe ROP, and severe IVH between the two types of surfactants.15 In this study, pulmonary hemorrhage after beractant and poractant alfa was at rates 26.1 and 8.7%, respectively. The rate of pneumothorax was similar between the groups. Similarly, we found that the rates of the other disorders did not differ between the groups. The rate of BPD is reported a 23% for infants weighing < 1,500 g in 1995 to 1996.19 The meta-analysis did not show a significant difference in rate of BPD between the infants treated with poractant alfa and those treated with beractant.15 In this study, the rate of BPD was similar between the groups although it is slightly higher in beractant group. Egberts20 and Köksal et al21 reported length of hospital stay as 65 to 71 and 56 days in infants with RDS. It was also

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Table 2 Hemodynamic parameters and clinical outcomes Group 1 (beractant) (n ¼ 46)

Group 2 (poractant alfa) (n ¼ 46)

p Value

0.50 (0.41–0.63)

0.50 (0.45–0.60)

0.35

31 (27–35)

32 (30–35)

0.11

134 (123–142)

134 (124–143)

0.76

84 (80–88)

85 (82–88)

0.25

53 (51–55)

38 (37–39)

0.40

Hemodynamic parameters Before surfactant Preductal PIa OI

a

Heart rate (bpm) SpO2 (%)

a

a

SAP (mm Hg)a Preductal PIa

0.80 (0.74–0.83)

1.17 (1.10–1.20)

0.001

OIa

16 (15–19)

13 (12–16)

0.001

140 (135–145)

144 (136–145)

0.19

92 (89–93)

92 (90–93)

0.50

53 (51.7–55)

53 (52–55)

0.09

28 (24–112)

33 (15–112)

0.30

1 (1–3)

1 (1–2)

0.002

3 (2–5)

2 (1–3)

0.001

8 (7–13)

5 (2–8)

0.001

Heart rate (bpm) SpO2 (%)

a

a

SAP (mm Hg)a Clinical outcomes SNAP-PE-II scoresa Doses of surfactant

a

Need of mechanical ventilation (d)a Need of CPAP (d)

a

Total need of oxygen support (d)

a

23 (17–28)

18 (11–22)

0.005

Pneumothorax, n (%)

6 (13.0)

2 (4.3)

0.26

Pulmonary hemorrhage, n (%)

12 (26.1)

4 (8.7)

0.02

Intraventricular hemorrhage, n (%)

8 (17.4)

6 (13.0)

0.55

Necrotizing enterocolitis, n (%)

8 (17.4)

7 (15.2)

0.57

Patent ductus arteriosus, n (%)

8 (17.4)

6 (13.0)

0.77

Proven sepsis, n (%)

15 (32.6)

12 (26.0)

0.82

Bronchopulmonary dysplasia, n (%)

9 (19.6)

6 (13.0)

0.57

Retinopathy of prematurity, n (%)

7 (15.2)

5 (10.9)

0.75

Periventricular leukomalacia, n (%)

3 (6.5)

1 (2.1)

0.61

63 (40–84)

68 (27–83)

0.84

8 (17.3)

4 (8.7)

0.35

Length of hospital stay Mortality, n (%)

a

Abbreviations: OI, oxygenation index; PI, perfusion index; SAP, systolic arterial pressure; SpO2, oxygen saturation by pulse oximeter. a Median (interquartile range).

Fig. 2 Perfusion index trend before and after surfactant, during the first 5 days of life.

reported that the length of hospital stay was significantly shorter for infants treated with poractant alfa, compared with those treated with beractant.15 In our study, the length of hospital stay did not differ between the groups (63 vs. 68 days). Death due to RDS was reported to be 32% in 1970 but decreased to 11% in 1994 with the development of ventilatory strategies and use of surfactant.22 Speer et al7 and Malloy et al13 found a decreased mortality in the poractant alfa group when compared with beractant: 3% (1 out of 33) versus 12.5% (5 out of 40); and 0 versus 10% (3 out 29), respectively, but this did not reach statistical significance. Moreover, Ramanathan et al8 observed that there was a significant decrease in American Journal of Perinatology

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At the 6th hour of surfactant

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Karadağ et al. mortality at 36 weeks postconceptional age in the poractant alfa group: 3% (3 out of 95) versus 11% (10 out of 90). In the current study, mortality rate was lower in poractant alfa group, although not significantly. In the study by Granelli and Ostman-Smith,6 it was showed that peripheral PI values lower than 0.7 could indicate illness. In another study, Cresi et al5 stated that physiological PI values in preterm newborns could be lower than in term newborns, thus the cutoff values for PI indicating morbidity should be reconsidered in preterms. Bowen et al23 evaluated arterial–alveolar partial pressure differences for oxygen, carbon dioxide, and nitrogen measurements before and after surfactant replacement therapy on preterm infants with RDS. Their results suggested that surfactant replacement therapy produced an improvement in PaO.2 In the current study, we showed that PI value was increased and oxygenation improved after surfactant treatment. PI was increased from 0.50 to 0.80 in beractant group and 0.50 to 1.20 in poractant alfa group. For the first 5 days of life, PI value remained higher in poractant alfa group. We found that neonatal outcome was poor in infants whose PI values were lower than 0.7 at early postnatal period. It was speculated surfactant positively affected perfusion and oxygenation in preterm infants with RDS. Improved perfusion seems to be related with better clinical outcome. There are several limitations of our study. First of all, the number of the cases may not be enough to generalize our results to all premature infants with RDS. On the contrary, PI measurement requires high sensitivity as it can be affected by minor events. This may be impossible in small preterm infants with poor perfusion. In conclusion, the type of surfactant affects oxygenation and perfusion in infants with RDS. Poractant alfa resulted in more rapid and sustained improvement in PI and OI. We speculate that PI may be a noninvasive predictor of early complications in preterm infants with RDS. Further studies are needed to define PI trend in sick premature infants.

Conflict of Interest The authors declare that they have no conflict of interest.

References 1 Jobe AH. Pulmonary surfactant therapy. N Engl J Med 1993;

328(12):861–868 2 Horbar JD, Wright LL, Soll RF, et al; National Institute of Child

Health and Human Development Neonatal Research Network. A multicenter randomized trial comparing two surfactants for the treatment of neonatal respiratory distress syndrome. J Pediatr 1993;123(5):757–766 3 Salyer JW. Neonatal and pediatric pulse oximetry. Respir Care 2003;48(4):386–396, discussion 397–398 4 De Felice C, Latini G, Vacca P, Kopotic RJ. The pulse oximeter perfusion index as a predictor for high illness severity in neonates. Eur J Pediatr 2002;161(10):561–562 5 Cresi F, Pelle E, Calabrese R, Costa L, Farinasso D, Silvestro L. Perfusion index variations in clinically and hemodynamically stable preterm newborns in the first week of life. Ital J Pediatr 2010;36:6

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Abbreviations: BPD, bronchopulmonary dysplasia; IVH, intraventricular hemorrhage; NEC, necrotizing enterocolitis; PDA, patent ductus arteriosus; PI, perfusion index; ROP, retinopathy of prematurity. a Median (interquartile range).

0.001

1.00 1 (6.6)

11 (73.3) 0 (0)

11 (14.4) 1.00

0.001 12 (100)

1 (8.3) 11 (13.8)

0 (0) 0.001

1.00 1 (8.3)

12 (100) 0.001 12 (100) 0 (0)

0 (0)

1.00 1 (8.3) 11 (13.8)

0.001 5 (6) Mortality, n (%)

7 (87.5)

11 (13.1) ROP, n (%)

1 (12.5)

1.00

11 (13.8)

0.68 1 (6.6) 14 (18.4) 0.68 1 (8.3) 14 (17.5) 0.68 1 (8.3) 14 (16.7) BPD, n (%)

1 (12.5)

0.68 1 (8.3) 14 (17.5) 1.00

14 (17.5)

0.001

0.001 10 (66.6)

8 (53.3) 7 (9.2)

3 (3.8) 0.001

0.001 8 (66.7)

11 (91.7) 3 (3.8)

7 (8.8) 0.001

0.001 11 (91.7)

8 (66.7) 7 (8.8)

3 (3.8) 0.001

0.001

11 (91.7)

8 (66.7)

3 (3.8)

7 (8.8)

0.001

0.02 4 (50)

6 (75)

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11 (13.1)

8 (9.5) PDA, n (%)

American Journal of Perinatology

NEC, n (%)

0.001 10 (66.6) 1 (1.3) 0.001 11 (91.7) 1 (1.3) 0.001 11 (91.7) 1 (1.3) 11 (91.7) 1 (125) 6 (7.1) IVH, n (%)

6 (75)

0.001

0.001

0.001 11 (73.3) 4 (5) 0.001 12 (100) 4 (5) 0.001 12 (100) 0.001 12 (100) 8 (9.5) Pulmonary hemorrhage, n (%)

8 (100)

0.001

4 (5)

4 (5)

< 0.7 (n ¼ 15)  0.7 (n ¼ 76) < 0.7 (n ¼ 12)  0.7 (n ¼ 80) < 0.7 (n ¼ 12)  0.7 (n ¼ 80) p < 0.7 (n ¼ 12)  0.7 (n ¼ 80) p < 0.7 (n ¼ 8)  0.7 (n ¼ 84)

At the 1st hour 0.90 (0.8–1.2)a

At the 6th hour 0.90 (0.78–1.18)a

On the 1st day 0.88 (0.75–1.10)a

p

On the 3rd day 0.82 (0.78–1.08)a

p

On the 5th day 0.88 (0.80–1.10)a

p

Perfusion Index Variability in Surfactant Treatment

Table 3 Relation of low PI values (< 0.7) at the first 5 days of life with early and late clinical outcomes

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Karadağ et al.

6 Granelli Ad, Ostman-Smith I. Noninvasive peripheral perfusion

14 Fujii AM, Patel SM, Allen R, Doros G, Guo CY, Testa S. Poractant alfa

index as a possible tool for screening for critical left heart obstruction. Acta Paediatr 2007;96(10):1455–1459 Speer CP, Gefeller O, Groneck P, et al. Randomised clinical trial of two treatment regimens of natural surfactant preparations in neonatal respiratory distress syndrome. Arch Dis Child Fetal Neonatal Ed 1995;72(1):F8–F13 Ramanathan R, Rasmussen MR, Gerstmann DR, Finer N, Sekar K; North American Study Group. A randomized, multicenter masked comparison trial of poractant alfa (Curosurf) versus beractant (Survanta) in the treatment of respiratory distress syndrome in preterm infants. Am J Perinatol 2004;21(3):109–119 Liechty EA, Donovan E, Purohit D, et al. Reduction of neonatal mortality after multiple doses of bovine surfactant in low birth weight neonates with respiratory distress syndrome. Pediatrics 1991;88(1):19–28 Halliday HL, Tarnow-Mordi WO, Corcoran JD, Patterson CC. Multicentre randomised trial comparing high and low dose surfactant regimens for the treatment of respiratory distress syndrome (the Curosurf 4 trial). Arch Dis Child 1993;69(3 Spec No):276–280 Walsh MC, Kliegman RM, Fanaroff AA. Necrotizing enterocolitis: a practitioner’s perspective. Pediatr Rev 1988;9(7):219–226 Fujiwara T, Konishi M, Chida S, et al; The Surfactant-TA Study GroupSurfactant replacement therapy with a single postventilatory dose of a reconstituted bovine surfactant in preterm neonates with respiratory distress syndrome: final analysis of a multicenter, double-blind, randomized trial and comparison with similar trials. Pediatrics 1990;86(5):753–764 Malloy CA, Nicoski P, Muraskas JK. A randomized trial comparing beractant and poractant treatment in neonatal respiratory distress syndrome. Acta Paediatr 2005;94(6):779–784

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American Journal of Perinatology

Vol. 31

No. 11/2014

1021

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Perfusion Index Variability in Surfactant Treatment

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Perfusion index variability in preterm infants treated with two different natural surfactants for respiratory distress syndrome.

The objective of this study was to compare the perfusion index (PI) variability in premature infants with respiratory distress syndrome (RDS) followin...
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