Heart Rate Characteristics Index and Extubation Outcome in Neonates - - PowerPoint PPT Presentation

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Heart Rate Characteristics Index and Extubation Outcome in Neonates - - PowerPoint PPT Presentation

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Heart Rate Characteristics Index and Extubation Outcome in Neonates A Retrospective Cohort Study N Goel M Chakraborty WJ Watkins SZ Ansari S Banerjee Heart Rate Characteristics Disease Health Moorman et al .Physiol. Meas 2011; 32: 1821

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SLIDE 1

Heart Rate Characteristics Index and Extubation Outcome in Neonates

A Retrospective Cohort Study

N Goel M Chakraborty WJ Watkins SZ Ansari S Banerjee

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SLIDE 2

Heart Rate Characteristics

Health Disease

Moorman et al .Physiol. Meas 2011; 32:1821–1832

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SLIDE 3

Heart Rate Characteristics index (HRCi)

  • Raw data from routine ECG monitoring
  • Captures characteristics pattern of HR changes
  • Numerical score derived from a mathematical model
  • Signifies the fold rise in the risk of clinical deterioration in the

following 6-24 hours

  • HRCi display to clinicians - reduced mortality in VLBW infants

Moorman et al , J Pediatr. 2011 Dec;159(6):900-6.e1

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SLIDE 4

HRCi Display

5 Days HRC index

Current HRCi

30 minutes heart rate

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SLIDE 5

HRCi Spikes

  • Sepsis / NEC
  • Respiratory deterioration
  • Surgery
  • Drugs
  • Intracranial haemorrhage

Spike

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SLIDE 6

Hypothesis

HRCi can predict the outcome of a clinical decision to extubate a neonate from mechanical ventilation either before or shortly after the extubation

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SLIDE 7

Methods

  • Pilot retrospective single centre cohort study
  • All ventilated infants: June 2014 and January 2015
  • Intubation-extubation episodes identified
  • Cases (reintubation within 72 hours) compared with controls

(successful extubation)

  • Multinomial mixed regression analysis to test for independent

confounding variables

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SLIDE 8

Methods

Extubation

Hourly HRCi scores 6 hours or from intubation , if within 6 hours Hourly HRCi scores 72 hours or until re-intubation Mean pre-extubation epoch

  • BASELINE

Mean Epoch 1 Mean Epoch 2 Mean Epoch 3

6 hrs 6 hrs 6 hrs

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SLIDE 9

Demographics

Variable

Cases

Controls p Total number of episodes 18 79 Gestation (median) 26 29 0.002 Birth weight in grams (median) 950 1330 0.008 Males 10 (56%) 49 (62%) 0.60 Positive blood cultures 6 (33.3%) 3 (3.8%) 0.001 Maximum CRP 7 5 0.521 Maximum WCC 16.5 16 0.993 Antibiotic treatment duration in hours 48 48 0.244 Clinically suspected sepsis 9 (50%) 23 (29%) 0.102 Necrotising enterocolitis 1 (5.6%) 0.186 Grade III-IV intraventricular haemorrhage 2 (2.5%) 1.0 Use of post-natal steroids 3 (3.8%) 1.0 Use of inotropes 1 (5.6%) 5 (6.3%) 1.0 Use of muscle relaxants (not peri-intubation drugs) 1 (5.6% 1 (1.3%) 0.338 Ventilation duration in hours 65.29 38.42 0.046

20/06/2016

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SLIDE 10

HRCi Scores

20/06/2016

HRCi absolute values Fold Changes from baseline

  • 2

2 4 6 8 1 0 1 2 2 4 6 8

C a se s C o n tro ls

**

E p o c h H R C i s c o re s

  • 2

2 4 6 8 1 0 1 2 1 2 3 4 5

C a se s C o n tro ls

** **

E p o c h F o ld C h a n g e s H R C i

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SLIDE 11

Peri-extubation changes

20/06/2016

C o n tro ls C a s e s 2 4 6 8

**

B a s e lin e H R C i

Controls Cases 0.0 0.5 1.0 1.5 2.0 2.5

**

Fold Changes (HeRO)

Baseline HRCi scores Epoch 1 - Fold Changes from baseline

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SLIDE 12

Usefulness

Positive test threshold

Sensitivity Specificity PPV NPV ≥ 1 89 (65 – 99) 53 (41 – 64) 30 (18 – 44) 95 (84 – 99) ≥ 2 39 (17 – 64) 78 (67 – 87) 29 (13 – 51) 85 (74 – 92) ≥ 3 11 (1 – 35) 95 (87 – 99) 33 (4 – 78) 82 (73 – 89)

20/06/2016

Pre-extubation baseline HRCi Post-extubation Epoch 1 Fold Changes from baseline

Sensitivity Specificity PPV NPV ≥ 1 72 (47 – 90) 59 (47 – 70) 29 (16 – 44) 90 (79 – 97) ≥ 2 97 (91 – 99) 81 (71 – 88)

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SLIDE 13

20/06/2016

Regression analysis

Independent risk factors :

  • Baseline HRCi score
  • Post-extubation epoch 1 fold-changes
  • Culture positive sepsis
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SLIDE 14

Limitations

  • Small sample size
  • Single centre
  • Wide gestation range – high extubation success
  • No blinding possible

20/06/2016

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SLIDE 15

Conclusions

  • Baseline and post-extubation HRCi were significantly different

between cases and controls

  • HRCi had poor PPV for extubation failure
  • Low baseline HRCi and minimal changes post-extubation can

add to the confidence of the clinician

  • Culture proven sepsis remains a risk for extubation failure
  • Further studies at different gestation groups required to

establish usefulness

20/06/2016

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SLIDE 16

20/06/2016

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SLIDE 17

Heart Rate Characteristics Index and Extubation Outcome in Neonates

A Retrospective Cohort Study

N Goel M Chakraborty WJ Watkins SZ Ansari S Banerjee