Multimodal Monitoring in Extremely Preterm Neonates: Can We Optimize Transitional Hemodynamics?

A Canadian randomized trial explores whether combining echocardiography and NIRS improves early outcomes in the most vulnerable neonates.

Background

The transitional circulation period in neonates born at extremely low gestational ages (ELGA, <29 weeks) presents unique clinical challenges. Variability in monitoring and managing hemodynamics across neonatal centers often leads to inconsistent outcomes. Current approaches rely heavily on clinical signs and basic biochemical markers, which may not adequately capture complex circulatory dynamics. Could integrating advanced bedside tools like targeted neonatal echocardiography (TnECHO) and near-infrared spectroscopy (NIRS) offer a more precise and protective approach?

Study Objective

This randomized clinical trial investigated whether multimodal hemodynamic monitoring during the first 72 hours of life improves cardiorespiratory-kidney health, measured by a composite vasoactive-ventilation-renal (VVR) score at day 7 in ELGA neonates.

Methods

Conducted across a Canadian NICU from February 2019 to December 2021, this 2-arm, unmasked trial enrolled 132 neonates born between 23+0 and 28+6 weeks’ gestation. Infants were randomized to either:

• Multimodal arm: Received early TnECHO at 18–24h and 66–72h, plus continuous cerebral NIRS for the first 72h. Hemodynamic management followed a structured protocol integrating clinical, biochemical, and cerebral oxygenation data.

• Standard arm: Received routine hemodynamic assessment based only on clinical and biochemical parameters.

The primary outcome was the VVR score at 7 days, an integrated metric incorporating inotrope requirement, respiratory support, and renal function (score range: 0–69.62; higher = worse function).

Key Findings

• Mean VVR score at day 7 was not significantly different between groups (16.5 in the multimodal group vs 18.9 in the standard group; P = .45).

• However, peak VVR scores >95th percentile (indicative of severe dysfunction) occurred only in the standard group (11.1% vs 0%; P = .005).

• These high scores were strongly associated with:

  • Death or severe intraventricular hemorrhage (IVH): OR 12.37, P = .001

  • Bronchopulmonary dysplasia (BPD): 100% in high-VVR vs 47.4% otherwise, P = .01

• Overall BPD incidence was significantly lower in the multimodal group (41.3% vs 59.0%; P = .04).

• Regression analysis identified top-quartile VVR scores, late-onset sepsis, and delayed PDA treatment as independent predictors of BPD.

  
  

Conclusion

Although the average VVR score at 7 days did not differ significantly, the absence of extreme VVR scores and lower BPD incidence in the multimodal group suggest a protective effect from early, integrated hemodynamic assessment. These findings highlight the potential of TnECHO and NIRS-guided management in ELGA neonates and support further research to refine and personalize transitional care.

Implications

This trial demonstrates that multimodal hemodynamic monitoring is safe, feasible, and may reduce severe outcomes in high-risk preterm infants. While not yet definitive, these results lay the groundwork for larger trials and future protocol development focused on individualized circulatory support in the NICU.