Assessment of Cardiac Functions in Neonatal Sepsis

Hassan, Mohamed Youssef; AbdeL Hakeem, Ahmed Mohsen; Abdelmotalep, Mahmoud Mohammed; Eldahshan, Tarek Abdel-Kareim

doi:10.21608/aimj.2021.100730.1604

Assessment of Cardiac Functions in Neonatal Sepsis

Document Type : Original Article

Authors

¹ Department of Pediatrics, Faculty of Medicine, Al-Azhar University, Egypt

² Department of clinical pathology, Faculty of Medicine, Al-Azhar University, Egypt

10.21608/aimj.2021.100730.1604

Abstract

Background; One of the major organs influenced in neonatal sepsis is the heart. Echocardiogram gives real-time data on the cardiovascular execution instead of reliance on the clinical signs alone.
Aim and objectives; to study the role of transthoracic echocardiogram in the assessment of systolic and diastolic cardiac functions in septic neonates .
Subjects and methods; This cross sectional study was carried out on 80 neonate subdivided into 4 groups (septic full-term, septic preterm, non-septic full-term and non-septic preterm) admitted to the tertiary care NICU of Bab Elsheria Hospital, Al-Azhar University .
Result; Septic patients gather had essentially higher myocardial execution list (MPI) compared to control gather (p < 0.001). Isovolumic compression time(IVCT), Isovolumic unwinding time (IVRT) and A wave were altogether higher in septic patients bunch compared to control bunch (p < 0.01). Agreeing to an examination of the information, the Septic Patients gather had impressively lower E/A and E/E proportions over the tricuspid and mitral valves than the Control bunch (p0.001), and this distinction was measurably critical. whereas septic patients gather had essentially higher A over tricuspid and mitral valves compared to control gather. Tricuspid and mitral annular plane systolic outing (TAPSE and MAPSE) were essentially moo in septic patients . Too e and a wave of both right and cleared out ventricles were altogether moo in septic patients .
Conclusion; The study's discoveries propose that debilitated neonates may involvement significant circulatory modifications, which echocardiography may be a substantial and supportive strategy for evaluating myocardial work amid neonatal sepsis.

Keywords

Full Text

INTRODUCTION

A culture-proven contamination causes sepsis, which is characterised by the nearness of the systemic provocative reaction disorder (SIRS). ¹

It is one of the foremost visit causes of passing in neonatal seriously care units (NICU) worldwide. ²

Sepsis includes a critical affect on the heart, one of the body's most vital organs. Cardiac disability has been reported in a number of creature models of SIRS, with endotoxin infusion being especially risky. ³

Determined pneumonic hypertension of the infant, myocardial brokenness, bacterial myocarditis, or bacterial endocarditis can all be indications of cardiac fondness in neonatal sepsis. Sepsis has a few hazard variables, one of which is myocardial brokenness. Systolic and diastolic brokenness work together to obstruct heart work. ⁴

PATIENTS AND METHODS

It was a cross-sectional study on 40 septic infants (Patients group) admitted to Bab Elsheria University Hospital, Al-Azhar University's tertiary care NICU.

The control group consisted of 40 healthy babies who were not septic (they will be selected from the follow-up neonatology clinic serving the newborns delivered in the bab Elsheria University hospital).

Both patients and controls will divide among 4 groups (septic full-term, septic preterm, non-septic full-term and non-septic preterm).

Inclusion criteria:Preterm and term newborn children less than 28 days of life, nearness of neonatal sepsis risk impacts which incorporate: Little birth weight (less than 2500 gm), pre-maturity (18 hours, delayed labor (whole of 1st and 2nd organize of labor more than 24 hrs.) and neo- natal newborn children have one or more of the taking after criteria of sepsis: Lethargy, an increment within the number or seriousness of apneic periods, nourishment bigotry, temperature insecurity, and a require for more ventilatory help are all signs of apneic spells.

Exclusion criteria: Perinatal asphyxia, newborn child of diabetic mother, intrinsic cyanotic and acyanotic heart illness with hemodynamic noteworthy, clinically clear major inherent inconsistencies, neonates on inotropic back.

The studied patients were subjected to the following:

History: Full history taking: (perinatal, natal, postnatal)andthrough clinical examination including gestational age , APGAR score, Ballard score, general and local examination .

Investigations:

Laboratory tests: Complete bl00d count with differential ,ApG, CrP, Blood culture for septic patients, Liver function test , kidney function test, Chest X-ray,

ECH0 will be done at time of clinical suspicion of sepsis including :

conventional echo study

M-node and 2-dimensional Echocardiography to determine LV systolic function.

M- Mode will be used also for measurement of tricuspid and mitral annular plane systolic excursion ) in apical 4 chamber view.

The presence of valvular incompetence will be determined using colour Doppler. Persistent wave Doppler will be utilized to degree systolic pneumonic course weight from tricuspid spewing forth employing a altered Bernoulli equation. *Tissue Doppler Echo-cardiography: * Beat doppler echo-cardiography will be utilized to decide cleared out and right ventricular diastolic work by measuring the proportion of E esteem (early top stream speed) to A esteem (atrial crest stream speed) (called E/A proportion) with the cursor at the tip of mitral and tricuspid valves pamphlets separately in apical 4-chamber see. * Myocardial execution file (MPI) will be calculated. -All the collecting information will be measurably analyzed, compared and discussed.

Ethical considerations: An informed consent was taken from all parents before getting involved in study. The study was done after approval of ethical committees of Pediatrics department & faculty of medicine for Al-Azhar University.

Statistical analysis: The collected information was arranged, and measurably analyzed utilizing SPSS program (Measurable Bundle for Social Sciences) program form 26.0, Microsoft Exceed expectations 2016. Quantitative factors experienced inferential examinations utilizing autonomous t-tests for bunches with parametric information and Mann Whitney U tests for non-parametric information when there were two autonomous bunches. Subjective information were subjected to inferential examinations utilizing the Chi square test for isolated groups. The level of centrality was taken at P esteem

RESULTS

Table (1) shows comparison between the studied groups in full terms regarding Tricuspid and mitral inflow. Septic patients group had significantly lower E and E/A ratio across tricuspid and mitral valves compared to control group (p<0.001). while septic patients group had significantly higher A across tricuspid and mitral valves compared to control group (p=0.001).

	Septic patients group (n = 27)					Control group (n = 28)					P-value
	m±sd		Median	min.	max.	m±sd		Median	min.	max.	P-value
Tricuspid E (cm/s)	46.48	12.23	43.20	31.50	80.60	53.34	12.85	52.95	12.90	101.0	<0.001
Tricuspid A (cm/s)	64.13	12.44	60.80	44.30	89.70	53.84	11.82	52.50	12.50	90.30	0.001
Tricuspid E/A	.72	.10	.72	.54	.92	.99	.10	.96	.81	1.18	<0.001
Mitral E (cm/s)	51.82	12.16	51.90	29.20	74.30	64.98	9.52	63.90	43.50	101.0	<0.001
Mitral A (cm/s)	71.45	14.83	63.00	49.00	99.20	57.59	9.18	57.00	44.00	82.50	0.001
Mitral E/A	.73	.11	.69	.52	.94	1.14	.11	1.12	.94	1.33	<0.001

Table 1: Comparison between full term septic patients and controls as regard mitral and tricuspid inflow .

Table (2) shows comparison between the preterm groups regarding Mitral and Tricuspid inflow. Septic patients group had significantly lower E and E/A ratio across mitral and tricuspid valves compared to control group (p<0.001). Septic patients group had significantly higher A across mitral and tricuspid valves associated to control group (p<0.001).

	Septic patients Group (n = 13)					Control Group (n = 12)					P-value
	m±sd		Median	min.	max.	m±sd		Median	min.	max.	P-value
Tricuspid E (cm/s)	34.65	8.98	34.00	23.30	54.80	51.06	4.68	50.95	43.00	61.00	<0.001
Tricuspid A (cm/s)	54.43	14.31	54.00	33.50	91.70	52.52	3.76	51.40	48.00	59.00	0.663
tricuspid E/A	.64	.04	.63	.57	.71	.98	.09	.95	.90	1.18	<0.001
Mitral E (cm/s)	47.49	8.10	46.00	39.80	69.40	62.85	4.93	63.00	57.00	71.20	<0.001
Mitral A (cm/s)	68.18	10.28	64.50	58.90	95.70	54.66	5.26	56.95	44.00	62.00	<0.001
Mitral E/A	.70	.08	.68	.59	.82	1.16	.08	1.14	1.04	1.32	<0.001

Table 2: Comparison between patients group and control group in preterm regarding tricuspid and Mitral inflow.

It was noticed that TAPSE and MAPSE were significantly lower in full term septic patients group compared to control group.

	Septic patients (N = 27)					Control patients (N = 28)					P-value
	m±sd		median	Min.	Max.	m±sd		median	Min.	Max.	P-value
TAPSE (mm)	7.08	1.00	7.00	4.76	8.84	8.72	.46	8.65	7.99	9.49	<0.001
MAPSE (mm)	3.38	1.14	3.23	2.05	7.99	5.27	.36	5.28	4.67	5.83	<0.001

Table 3: Evaluation between patients group and control group in full term patients regarding TAPSE & MAPSE

Also TAPSE and MAPSE were significantly lower in preterm septic patients group compared to control group.

	Septic patients group (n = 13)					Control group (n = 12)					P-value
	m±sd		median	Min.	Max.	m±sd		median	Min.	Max.	P-value
TAPSE (mm)	6.58	2.07	5.76	4.99	12.00	9.96	2.52	8.95	7.36	16.80	<0.001
MAPSE (mm)	3.00	.53	2.90	2.57	4.60	5.73	.97	5.49	4.27	7.87	<0.001

Table 4: Evaluation between cases group and control group in preterm regarding TAPSE & MAPSE

Tables (5&6) shows comparison between control and patients group in both full term and preterm; regarding left ventricular IVRT, MPI and a wave were significantly higher in septic patients while e and e/a ratio were significantly lower in septic patients compared to control group (p<0.01) .

	Septic patients group (n = 27)						Control group (n = 28)					P-value
	m±sd		Median	Min.	Max.	m±sd			median	min.	max.	P-value
IVCT	51.74	5.71	51.00	40.00	66.00	47.04		5.37	49.50	32.00	53.00	0.001
IVRT	57.26	9.12	58.00	43.00	74.00	42.21		3.55	41.00	34.00	49.00	<0.001
ET	168.11	14.68	167.0	129.00	195.00	204.11		13.58	201.50	180.00	222.00	<0.001
a (cm/s)	6.64	1.33	6.63	3.90	9.00	5.63		1.75	5.22	4.09	12.00	0.001
e (cm/s)	4.33	1.07	4.00	2.30	7.28	5.75		1.97	5.28	4.12	12.10	<0.001
e/a	.65	.10	.65	.45	.81	1.02		.07	1.02	.85	1.16	<0.001
MPI	.64	.1	.65	.64	.71	.43		.03	.44	.36	.45	<0.001

Table 5: Comparison between patients group and control group in full term patients regarding left ventricle diastolic functions and MPI.

	Septic patients group (n = 13)						Control group (n = 12)					P-value
	m±sd		Median	Min.	Max.	m±sd			median	min.	max.	P-value
IVCT	50.45	5.22	50.00	44.00	61.00	49.92		1.98	50.00	46.00	53.00	0.935
IVRT	66.79	3.40	65.80	63.00	75.00	43.58		4.14	44.00	37.00	49.00	<0.001
ET	154.46	14.45	159.0	132.00	180.00	209.42		12.02	211.00	182.00	222.00	<0.001
e	3.57	.81	3.66	2.50	5.00	4.77		.87	4.46	4.12	7.26	0.001
a	6.24	1.13	5.63	5.25	8.26	4.70		.73	4.54	4.09	6.76	<0.001
e/a	.58	.11	.56	.37	.72	1.01		.05	1.02	.89	1.07	<0.001
MPI	0.76	0.05	0.76	0.70	0.85	0.45		0.02	0.46	0.40	0.48	<0.001

Table 6: Comparison between cases group and control group in preterm regarding left ventricle diastolic functions and MPI of left ventricle.

Tables (7&18) shows comparison between control and patient groups in both full term and preterm; regarding EF and FS there was no statistically significance between both groups .While pulmonary artery pressure was significantly higher in septic patients .

	Septic patients (n = 27)					Control (n = 28)					P-value
	m±sd		Median	Min.	Max	m±sd		median	Min.	Max.	P-value
EF %	67.70	6.13	68.00	56.00	83.00	66.12	3.88	65.90	61.00	79.30	0.095
FS %	32.72	10.19	34.80	32	47.80	33.05	9.92	32.15	31.00	48.70	0.128
Pulmonaryartery Pressure	25.25	2.85	26.50	18.00	29.00	22.40	3.68	22.00	17.00	29.00	0.005

Table 7: Comparison between patients group and control group in full term patients regarding systolic functions

	Septic patients (n = 13)					Control (n = 12)					P-value
	Mean	SD	median	min.	Max.	mean	SD	median	Min.	Max.	P-value
EF %	72.99	.69	69.00	60.00	82.00	71.6	6.15	66.00	66.00	83.00	0.384
FS %	40.57	4.95	33.00	30.00	50.00	39.25	5.09	32.65	35.00	51.00	0.337
Pulmonary artery Pressure	25.3	3.0	26.5	21.0	29.0	22.6	3.0	22.0	18.0	28.0	0.048

Table 8: Comparison between patients group and control group in preterm regarding systolic functions.

DISCUSSION

Amid the course of neonatal sepsis, the discharge of cytokines and the related hypoxia and acidosis may result within the advancement of determined aspiratory hypertension and in this way right ventricular disappointment. Cardiovascular brokenness leads to diminish in oxygen conveyance to tissues and in the long run multiorgan disappointment. In neonates with sepsis, the event of myocardial brokenness is related with destitute result . 5 The reason of this consider was to consider the role of transthoracic echocardiogram within the appraisal of systolic and diastolic cardiac capacities in septic neonates. Regarding Echocardiographic information among our considered bunches; as respect Mitral & Tricuspid influx In term and preterm Septic patients’ bunch had altogether lower E and E/A proportion and essentially higher A over mitral and tricuspid valves compared to control bunch (p<0.001), showing unusual unwinding of both cleared out and right ventricles separately .

Our result were supported by Fahmey et al., 2020 ⁶ as they stated that Septic neonates had a lower E/A ratio of the mitral valve when compared to healthy neonates (p, .048), indicating left ventricular diastolic dysfunction.

It was noticed that TAPSE and MAPSE were significantly lower in both preterm and full term septic patients group compared to control group. This indicated impaired longitudinal myocardial functions of right and left ventricles.

Our results were in agreement with study ofAlzahrani et al, 2017 ⁷ as they reported that MAPSE and TAPSE are considerably affected among septic patients (P<0.05).

Regarding left ventricular IVCT, IVRT and A wave in full term and IVRT and A wave in preterm were significantly higher in septic patients group compared to control group (p<0.01) whereas, e and e/a were significantly lower in septic patients group compared to control group (p<0.001). indicate left ventricular diastolic dysfunction .

Our results were supported byTomerak et al. 2012 ⁸ as they stated that A substantial difference was seen in the prevalence of left ventricular diastolic dysfunction in the babies who had been exposed to bacteria as compared to those who had not.

comparison between the studied groups regarding MPI of left and right ventricles in both preterm and full term Septic patients’ group had significantly higher myocardial performance index (MPI) compared to control group (p<0.001). This indicated impaired systolic and diastolic functions of both left and right ventricles.

Our result was in agreement with Abdel-Hady et al. 2012 ⁹who stated that the TDI (Tissue Doppler Imaging) indexes of global myocardial function (RV and LV Tei indexes "MPI ") were significantly higher.

The right and left ventricular indices (MPI) were considerably greater in septic neonates than non-septic neonates, according to a study done by Abtahi and Jafari in 2014.¹⁰

Our results showed that as regard comparison between the studied groups regarding systolic functions. In both pre term and full term Septic patients’ group There was no statistically significant difference between the two groups regarding EF and FS.

Our results were supported byTomerak et al. 2012 ⁸ as they stated that there was no significant difference noticed in the LV systolic function (EF and FS) between septic and non-septic neonates.

Septic patients’ group (preterm and full term) had significantly higher pulmonary artery pressure compared to control group (p<0.001).

Our result supported by Fahmey et al.,2020 ⁶ revealed that Pulmonary systolic pressure was significantly higher in septic neonates compared to control group (p < .001)

CONCLUSION

The study has concluded that significant cardiovascular changes may occur in the septic neonates; whereas, echocardiography is a reliable and useful tool to evaluate the myocardial function during neonatal sepsis. TDI(Tissue Doppler Imaging) is a promising tool for quantitative assessment of myocardial function and early detection of diastolic dysfunction of the heart which preceding development of systolic dysfunction.

References

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