Application of multisite Near-

InfraRed Spectroscopy (NIRS)

in Neonatal Care
Arend Bos
NICU
Beatrix Children’s
Hospital,
University Medical
Center
Groningen
The Netherlands

Bali 2019
Beatrix Children’s Hospital UMCG
 Contents

• Introduction
• What is NIRS?
• How can it help clinical work in the NICU?
• Examples
• Take-home message

Beatrix Children’s Hospital

 Goals of Neonatology

• Improve intact survival -> Brain and organ

protection

• Adequate oxygen supply

• Adequate nutritional supply
• Avoid inflammation / infections

• Circulation – tissue perfusion!

• Heart rate, blood pressure, capillary refill
• Role of NIRS!
Beatrix Children’s Hospital
 Contents

• Introduction
• What is NIRS?
• How can it help clinical work in the NICU?
• Examples
• Take-home message

Beatrix Children’s Hospital

 Near Infrared Spectroscopy

Principle 1

Light goes
through
tissue

Beatrix Children’s Hospital

 Near Infrared Spectroscopy
Principle 2

skin
bone
brain
tissue

Hb HbO2

Absorption, reflection, dispersion

Beatrix Children’s Hospital
 Near Infrared Spectroscopy

Different
absorption
spectra
for Hb and
HbO2

Beatrix Children’s Hospital

 Near Infrared Spectroscopy
Principle 2

skin
bone
brain
tissue

Hb HbO2

Absorption, reflection, dispersion

Beatrix Children’s Hospital
 Near Infrared Spectroscopy

• Regional cerebral tissue oxygen saturation

• Mixed venous (75%), capillary (5%) and
arterial oxygen saturation (20%)
• Estimate of organ perfusion /circulation

Beatrix Children’s Hospital

Various devices
 Various algorithms
CasMedical Fore Sight
NIRO 300-200-100 INVOS 4100-5100
(HAMAMATSU) (COVIDIEN)

rSO2 = HbO2 / HbT

NONIN,
equanox
Various types of Sensors
Multisite NIRS

Beatrix Children’s Hospital

 Contents

• Introduction
• What is NIRS?
• How can it help clinical work in the NICU?
• Examples
• Take-home message

Beatrix Children’s Hospital

 NIRS: balance between oxygen
supply and oxygen consumption

O2
O2

• Regional tissue oxygen saturation (rSO2)

• Cerebral Fractional Tissue Oxygen Extraction (FTOE)
• FTOE = (SpO2 - rSO2)/ SpO2
 Physiology: rcSO2 and FTOE
blood pressure
flow resistance
- BP↓ autoregulation↓, pCO2↓
O2 supply - cardiac output, shunts (PDA)

oxygen content
- concentration hemoglobin
- arterial oxygen saturation

O2 consumption metabolism (CMRO2)

- sedation, necrosis
- inflammation?, luxury perfusion

Beatrix Children’s Hospital

 Blood transfusions in preterm infants (<35
wk)

The lower the Hb, the lower RcSO2 and the higher cFTOE
Transfusion improves
Van Hoften et al. 2010
 Physiology: rcSO2 and FTOE
blood pressure
flow resistance
- BP↓ autoregulation↓, pCO2↓
O2 supply - cardiac output, shunts (PDA)

oxygen content
- concentration hemoglobin
- arterial oxygen saturation

O2 consumption metabolism (CMRO2)

- sedation, necrosis
- inflammation?, luxury perfusion

Beatrix Children’s Hospital

 RcSO2 in preterm infants with GMH
rcSO2 (%) * * * *** *** **

No GMH

GMH

* = <0.05
** = <0.01
*** = <0.001

Day

GMH: lower cerebral RcO2 during first 8 days

Verhagen et al. 2010
 Physiology: rcSO2 and FTOE
blood pressure
flow resistance
- BP↓ autoregulation↓, pCO2↓
O2 supply ? - cardiac output, shunts (PDA)

oxygen content
- concentration hemoglobin
- arterial oxygen saturation

O2 consumption metabolism (CMRO2)

- sedation, necrosis
- inflammation?, luxury perfusion

Beatrix Children’s Hospital

 Term infants on therapeutic hypothermia

Normal outcome

Poor outcome

Term asphyxia: high RcSO2 after 48h / rewarming

in infants with poor outcome /brain death
Niezen et al. 2018
 Physiology: rcSO2 and FTOE
blood pressure
flow resistance
- BP↓ autoregulation↓, pCO2↓
O2 supply - cardiac output, shunts (PDA)

oxygen content
- concentration hemoglobin
- arterial oxygen saturation

O2 consumption metabolism (CMRO2)

- sedation, necrosis
- inflammation?, luxury perfusion

Beatrix Children’s Hospital

 Practical considerations
(keeping the balance in mind):
• Low(er) rcSO2 - high FTOE:
– Supply O2 decreased relative to O2 consumption
• lower cerebral blood flow (auto-regulation ↓:
BP ↓, low PCO2, large ductal le-ri shunt)
• low Hb, low arterial SO2
O2 O2

• High(er) rcSO2 - low FTOE:

– Consumption O2 decreased relative to O2 supply
• higher cerebral blood flow (auto-regulation ↓:
BP ↑), luxury perfusion, ‘compensatory’ after
hypoxia
• Brain cells use less O2 (sedation, †?)
Beatrix Children’s Hospital
Normal values rcSO2 cerebral tissue

• Healthy adults at rest

– Mean rcSO2 69.8 +/- 6.2% (59-79%)
– <50% critical value

• Newborn infants : 72-84% *

– Neonatal sensor (±10% higher than
adult sensor)
– <40% critical value?

* Verhagen et al 2015
Beatrix Children’s Hospital
 Multisite NIRS

• Cerebral
• Renal
• Intestinal

• Less or no autoregulation
• Perhaps better measure of hemodynamics?

Beatrix Kinderkliniek UMCG

 Contents

• Introduction
• What is NIRS?
• How can it help clinical work in the NICU?
• Examples
• Take-home message

Beatrix Children’s Hospital

 0
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19:16:46 15:33:24
15:43:40
15:53:55
rrSO2
rcSO2

rrSO2
SpO2

rcSO2

SpO2
CASE 26 wk /1020g – sepsis, 8h before resuscitation
 PPROM 26 wk, born at 26+6/1070 g
Shortly ventilated, d14 ill, reintubated
100

90

NEC 3B, Coecum

80

70
perforation
60
Cerebraal
50 renaal

abdominaal
40
SpO2
30

20

10

0
0:000:000:000:000:000:000:000:000:000:000:000:000:000:000:000:000:000:000:000:000:000:000:000:000:000:00

Several hours after sepsis suspicion

MABP 28-35 mm Hg
 Take home message

• NIRS provides a continuous recording of

measures of organ / systemic circulation
• Responds well to medical interventions

• Wide ‘normal’ ranges -> interpretation can

be difficult

• If the trend changes: check if something is

emerging

Beatrix Children’s Hospital UMCG

 Acknowledgements

Michelle van der Laan Nynke Schat

Elise Verhagen

Mirthe Mebius Jozien Tanis

Sara Kuik
 Take-Home message

• NIRS may help to guide interventions

regarding circulation /hemodynamics (clinics)

• NIRS may help understand pathofysiology

of various neonatal diseases (research)

• But:
• Wide range of normal values (trend–absolute)
• Different organs – different characteristics
• Many devices, variety of algorithms
Beatrix Children’s Hospital
Influence hypotension / autoregulation
A B

Autoregulation disturbed Autoregulation intact

Beatrix Children’s Hospital Lemmers et al 2006
 Physiology: rcSO2 and FTOE
blood pressure
flow resistance
- BP↓ autoregulation↓, pCO2↓
O2 supply - cardiac output, shunts (PDA)

oxygen content
- concentration hemoglobin
- arterial oxygen saturation

O2 consumption metabolism (CMRO2)

- sedation, necrosis
- inflammation?, luxury perfusion

Beatrix Children’s Hospital

 Consequences for follow-up?

• Limited data

• Both lower and higher cerebral O2 associated with

poorer outcomes

Beatrix Kinderkliniek UMCG

 Third quartile reference
Lowest quartile:
- poorer motor (-8.01 points)
- poorer cognition (-5.8 points)
Duration <50%: poorer gross motor:
(-0.16 points / minute)
Highest quartile:
- poorer cognition (-6.6 points)

Beatrix Children’s Hospital Verhagen et al. 2015