Journal of Perinatology (2017) 00, 1–7

© 2017 Nature America, Inc., part of Springer Nature. All rights reserved 0743-8346/17
www.nature.com/jp

STATE-OF-THE-ART
How to assess hemodynamic status in very preterm newborns
in the first week of life?
G Escourrou1, L Renesme2, E Zana3, A Rideau4, MO Marcoux5, E Lopez6, G Gascoin7, P Kuhn8, P Tourneux9, I Guellec10 and C Flamant11

BACKGROUND: Assessing hemodynamic status in preterm newborns is an essential task, as many studies have shown increased
morbidity when hemodynamic parameters are abnormal. Although oscillometric monitoring of arterial blood pressure (BP) is widely
used due to its simplicity and lack of side effects, these values are not always correlated with microcirculation and oxygen delivery.
OBJECTIVES: This review focuses on different tools for the assessment of hemodynamic status in preterm newborns. These include
the measurement of clinical (BP, capillary refill time and urinary output (UO)) or biological parameters (lactate analysis), functional
echocardiography, and near-infrared spectroscopy (NIRS). We describe the concepts and techniques involved in these tools in
detail, and examine the interest and limitations of each type of assessment.
CONCLUSIONS: This review highlights the complementarities between the different parameters used to assess hemodynamic
status in preterm newborns during the first week of life. The analysis of arterial BP measured by oscillometric monitoring must take
into account other clinical data, in particular capillary refill time and UO, and biological data such as lactate levels. Echocardiography
improves noninvasive hemodynamic management in newborns but requires specific training. In contrast, NIRS may be useful in
monitoring the clinical course of infants at risk of, or presenting with, hypotension. It holds the potential for early and noninvasive
identification of silent hypoperfusion in critically ill preterm infants. However, more data are needed to confirm the usefulness of
this promising tool in significantly changing the outcome of these infants.
Journal of Perinatology advance online publication, 4 May 2017; doi:10.1038/jp.2017.57

INTRODUCTION
Newborn hemodynamic status results from many physiological
parameters in the first days of life and is closely related to
morbidity.1,2 Physiological transitional hemodynamics results imme-
diately after birth (0 to 1 h), in the loss of low resistance placental
circulation due to cord clamping, increase in the systemic venous
resistance and decrease in the pulmonary vascular resistance.3 A
transitional phase (1 to 48–72 h) will follow with further increase in
systemic venous resistance, and decrease in pulmonary vascular
resistance and closure of the patent ductus arteriosus (PDA).3 Post-
transitional phase (day 3 till discharge) will include further increase in
afterload and further increase in preload.4 Thus, assessing hemody-
namic status in preterm newborns in this transitional period is
challenging. For the last decade, functional echocardiography has
improved noninvasive hemodynamic management in newborns,
allowing for the rapid assessment of cardiac output. It has also
improved our understanding of the pathophysiology of an eventual
shock. However, this technique requires specific training and up-to-
date equipment, and cannot be performed 24 h a day in all neonatal
intensive care units. In contrast, arterial blood pressure (BP) measured
with an oscillometric monitor, a hemodynamic parameter that can
be continuously monitored with little cost and no side effects, is
widely used. However, it is not always correlated with central blood
flow, organ blood flow and oxygen delivery.5
This review describes tools that allow the assessment of the
hemodynamic status in preterm newborns where clinicians often
need multiple tools to assess properly this complex transitional
hemodynamics status (Table 1). It focuses on the interest and
limitations of each technique, highlighting the complementarity
between the continuous monitoring of certain parameters (arterial
BP, tissue oxygenation as measured by near-infrared spectroscopy
or NIRS), clinical evaluation (urinary output (UO), capillary refill
time), biological analysis (serum lactate concentrations) and
specific examinations such as echocardiography performed
periodically.
Arterial BP
The use of arterial BP to assess hemodynamic status remains
widely controversial, even though hypotension is statistically
associated with neonatal morbidity, such as intraventricular
hemorrhage.6 A systematic review has shown that the
incidence of hypotension among the very low birth weight
(VLBW) preterm infant population differs between neonatal
intensive care units, and the frequency of physician inter-
vention varies widely, from 29 to 98%.2 This work underlines the
need for clarification regarding the methods of measurement
and the definition of ‘symptomatic hypotension’ requiring
treatment.

1
Department of Neonatal Medicine, CH Montreuil, Montreuil, France; 2Department of Neonatal Medicine, CHU Bordeaux, France; 3Department of Neonatal Medicine, Port Royal
Maternity, Paris, France; 4Department of Neonatal Medicine, CHU Paris, France; 5Paediatric Intensive Care Unit, CHU Toulouse, France; 6Department of Neonatal Medicine, CHU
Tours, France; 7Department of Neonatal Medicine, CHU Angers, France; 8Department of Neonatal Medicine, CHU Strasbourg, France; 9Department of Neonatal Medicine, CHU
Amiens, France; 10Department of Neonatal Medicine, CHU Paris, France and 11Department of Neonatal Medicine, CHU Nantes, Service de Réanimation néonatale, Nantes, France.
Correspondence: Dr C Flamant, Department of Neonatal Medicine, CHU Nantes, Service de Réanimation Néonatale, 38 Boulevard Jean Monet, Nantes 44093, Cedex 1,
France.
E-mail: cyril.flamant@chu-nantes.fr
Received 16 September 2016; revised 12 February 2017; accepted 28 March 2017
 Hemodynamic status in very preterm newborns
G Escourrou et al
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Table 1.
Comparing advantages of various techniques to assess
hemodynamic status in the preterm neonate
Accuracya Low cost Quick Easy
learning access
curve
Oscillometric arterial BP + +++ +++ +++
Invasive arterial BP +++ +++ +++ + poor neurological outcome with increased intraventricular hemor-
Capillary refill time + +++ +++ +++
Urinary output + +++ +++ ++
Lactates + ++ +++ ++
Echocardiography +++ + + ++
NIRS ++ + ++ ++
Abbreviations: BP, blood pressure; NIRS, near-infrared spectroscopy.
a
Accuracy to reflect HD change.
How to measure arterial BP?
The gold standard for the determination of arterial BP in critically
ill infants is the use of an arterial catheter line, for a maximum
duration of 4 days.7 While this measurement technique is
considered accurate, it is invasive, and has some disadvantages
in very preterm infants: the umbilical artery catheter has a small
diameter, which acts as a filter. This ‘technical issue’ can result in
the loss of higher frequencies, yielding inaccurate systolic arterial
BP measurements. Another source of error is the introduction of
microbubbles of air into the arterial line, resulting in erroneous
arterial BP readings, with a lower systolic and higher diastolic
pressure.8
The most popular method of noninvasive arterial BP measure-
ment uses an automatic oscillometric monitor. There are some
critical aspects such as cuff size and localization of the measure.
Previous studies have shown good correlation between invasive
and noninvasive measurements in a restricted population of 32
neonates.9,10 However, another study in hypotensive VLBW infants
(o 1500 g) has found a frequent overestimation of arterial BP with
a noninvasive monitoring technique.11
Considering these facts and keeping in mind the current
movement toward less invasive neonatal therapies, noninvasive
BP-monitoring methods would be well adapted to most VLBW
infants. Nevertheless, critically ill neonates under consideration for
possible treatment for hypotension may benefit from arterial
access.
What definition of arterial BP?
To define a normal MABP range in the VLBW population requires
stable preterm infants for a control group. This situation is rare
among the high-risk population of VLBW infants in the first weeks
of life. Fanaroff et al.12 determined normal physiologic BP of
extremely low birth weight in the first 72 h of life. The most
commonly accepted ‘rule of thumb’ for low arterial BP is a mean
arterial pressure (MAP) less than or equal to the infant’s
postmenstrual age.13 Another definition of abnormal arterial BP
among premature infants o 31 weeks of gestational age (GA) is a
MAP of o 30 mm Hg.6 Such definitions may lead, in the first days
of life, to the initiation of unnecessary therapy in infants who
manage to maintain good microcirculation at a lower range of
MAP. To the best of our knowledge, there are no randomized
placebo-controlled studies of volume expansion in hypotensive
very preterm infants. A few studies have found that preterm
infants treated for hypotension show no signs of a decrease in
microcirculation or oxygen delivery.4,5 Low MAP is frequently
associated with normal or high left ventricular output (LVO),5 and
volume expansion is potentially associated with complications
such as brain hemorrhage.14 Furthermore, MAP values
Journal of Perinatology (2017), 1 – 7
spontaneously increase within the first 48 h of life even if the
MAP is initially lower than the GA.15
Should we treat low arterial BP?
In regards of the description above, the question remains to
tolerate or not low arterial BP measurements if other hemody-
namic parameters are in the normal range. Studies have shown a
rhage and leukomalacia when antihypotensive therapy was
used.16,17 However, hypotension itself many be responsible for
intraventricular hemorrhage.18 Taken together, these data lead to
the conclusion that a low MAP value in very preterm infants must
be considered in conjunction with other clinical and biological
parameters to consider whether hemodynamic support treatment
should be instituted.
Capillary refill time
Capillary refill time (CRT) is widely used to evaluate hemodynamic
status. A recent survey found CRT on the chest to be used most
often (95%) as a diagnostic method for poor perfusion in
extremely preterm babies.19 CRT has a wide range of normal
values (up to 5 to 7 s) in newborns.20 Even though there is a
significant relationship between cardiac index and CRT in preterm
babies, there appears to be only a weak association between CRT
and systemic blood flow.21 Moreover, BP and CRT are imperfect
bedside tests for detecting low blood flow on the first day after
birth in very premature infants.22 Nevertheless, central CRT values
⩾ 4 s may represent significantly reduced organ blood flow
(likelihood ratio 7.25 in preterm infants at o 30 weeks GA).19
CRT is also one of the most appropriate criteria to stop
resuscitation, being normal in 470% of survivors at 6 h23 and
the first parameter to be significantly normalized in septic shock
management.24 A randomized controlled trial (HIP Trial) to
validate a clinical scoring system for the diagnosis of shock or
failure of systemic perfusion in preterm infants is ongoing, and
CRT will be among the clinical and biochemical parameters
assessed to determine the adequacy of perfusion.25
Urinary output
Physiological arterial pressure can be defined as the arterial
pressure that allows normal organ perfusion.26 Renal hypoperfu-
sion may lead to lower UO as a result of impaired glomerular
filtration. In preterm neonates, UO is assessed by weighing
diapers, as catheters and urine-collection bags may lead to
infection or skin breakdown.27 Oliguria is considered a marker of
acute kidney injury in critically ill patients.28 In the pediatric
population, oliguria, defined as a UO o0.5 ml kg − 1 per h for at
least 16 h, is associated with increased mortality.29 Non-oliguric
acute kidney injury is common in preterm neonates due to their
immature tubular function.30 A large retrospective study found
that a UO o 1.5 ml kg − 1 per h was associated with a significant
increase in in-hospital mortality.31 However, the authors did not
include the first 24 h of life, considered a ‘prediuretic phase’
during which the UO is often o1 ml kg − 1 per h32 and also
depends on renal perfusion.33 For the present, neonatal hypoten-
sion associated with a UO o1.5 ml kg − 1 per h should be a cause
for concern after 24 h of life.
Lactates and hemodynamic evaluation: is there a correlation?
In addition to the clinical parameters, biological parameters
reflecting tissue perfusion, such as metabolic acidosis, should be
considered to reflect the preterm infant hemodynamic status.34 In
case of hypoperfusion and tissue hypoxia, lactic acid is a product
of anaerobic glycolysis. An international survey on the diagnosis of
hypotension in extremely preterm infants has shown that among
© 2017 Nature America, Inc., part of Springer Nature.

laboratory methods used to evaluate tissue perfusion, the most
common was lactate analysis (70%).35
Serum lactate concentrations have been previously used in
preterm infants as a criterion for red blood cell transfusion in
anemia,36 sepsis,37 necrotizing enterocolitis,38 and were strongly
correlated with outcome. Thus, Deshpande and Platt39 found a
57% increase in mortality with two measurements of serum
lactate concentration above 5 mmol l − 1 in a cohort of sick
ventilated newborns ranging from 23 to 40 weeks GA. In a cohort
of preterm babies, Groenendaal et al.40 estimated that the positive
predictive value for an adverse outcome (death or adverse
neurodevelopmental outcome) is 0.47 and the negative predictive
value is 0.97 for a cutoff value of 5.7 mmol l − 1 for arterial lactate
within 3 h after birth.
Only two studies evaluated lactate in the assessment of
perfusion during the first 24 h of life, and the methods used to
assess hemodynamic status were quite different. The first, which
assessed peripheral oxygenation by NIRS in 30 preterm infants at
27 to 29 weeks of GA, found no difference in serum lactate
concentrations between normotensive and hypotensive preterm
infants.41 In this study, hypotension was defined as an invasive
arterial BP measurement below the 10th percentile for birth
weight and post-natal age.42 The second study found a weak
negative correlation between serum lactate concentrations and
superior vena cava blood flow.43 Serum lactate concentrations
were higher in low-flow states when compared to normal flow
states (3.5 vs 2.7 mmol l − 1, P = 0.015).43 It should be noted that
serum lactate concentration does not always correlate with tissue
perfusion. The liver is the major organ that metabolizes increased
lactic acid produced in regional tissues. A rare inborn error of
metabolism in preterm infants with reduced liver metabolism will
have altered lactate levels.44
Echocardiographic assessment
During the first week after birth, very preterm newborns may have
low systemic blood flow that occurs frequently without hypoten-
sion. In such cases, systemic blood flow assessment using targeted
neonatal echocardiography is useful to guide therapeutic strategy
according to the main dysfunction: myocardial dysfunction,
pulmonary hypertension, hypovolemia or vasoplegia.45–47
Central blood flow
LVO and right ventricular output can be used to determine shunt
volume and global cardiovascular function. They are calculated in
preterm infants using similar methods to those in adults or
children, by measuring the internal diameter of the artery, the
velocity time integral and the heart rate, and using the following
formula: ventricular output = 3.14 × (diameter2/4) × velocity time
integral × heart ratio/weight of the baby.48 The baseline LVO in
healthy preterm infants is 150 to 300 ml kg − 1 per min. LVO and
right ventricular output increase during the first days of life and
cannot be used to detect low cardiac output in case of large left-
to-right shunts.48 Right ventricular output is believed to be a
better measure of systemic blood flow in neonates with PDA, if
there is negligible shunting across the patent foramen ovale.49
Superior vena cava flow, which avoids contamination due to left-
to-right shunts, can be used as a surrogate marker for systemic
blood flow.50 It is well correlated with cerebral blood flow, cerebral
NIRS, CRT and lactate concentrations in the preterm
population,43,51 and is one of the criteria associated with impaired
neurodevelopmental outcome in preterm infants.52
Myocardial dysfunction
Myocardial performance in preterm infants increases in the first
48 h of life partly due to changes in loading conditions. In very
preterm infants, maturational changes in diastolic function occur
© 2017 Nature America, Inc., part of Springer Nature.
Hemodynamic status in very preterm newborns
G Escourrou et al
3
relatively independent of the timing of birth (often around 30 to
32 weeks GA). Cardiac contractility does not change much in
preterm infants due to the balanced increase in preload and
afterload.53–56
LV systolic and diastolic function
Although previously used, assessment of LV systolic function
relying on LV dimensions and LV shortening fraction by M-Mode
are no longer recommended. Assessment of cardiac output (right
ventricular output and LVO) by Simpson ejection fraction is better.
Tissue Doppler imaging from the medial mitral and lateral mitral
annuli represent LV function. Peak systolic (S′), early diastolic (E′)
and late diastolic (A′) myocardial velocities are measured.57,58
Myocardial function indices vary with GA at birth, and with post-
natal maturation in healthy term and preterm infants.59 In addition
to tissue Doppler imaging, newer functional techniques, including
deformation imaging (strain and strain-rate imaging), have
recently been studied in neonates, but further validation is
needed before they can be recommended for use in routine
clinical practice. During the first week of life, the impact of LV
diastolic dysfunction on neonatal hemodynamics is difficult to
determine by echocardiography because there is a progressive
increase in E-wave velocities, the E/A ratio, and fused E and A
waves related to high heart rates. PDA also increases left atrial
pressure and E waves.
RV systolic and diastolic function
Right ventricle (RV) functional assessment in neonates has been
reviewed recently.60,61 It first includes linear dimensions and cavity
area measurements with the global RV fractional area change
(FAC global = (FAC − 4C+FAC − 3C)/2). Systolic RV function can be
appreciated by tissue Doppler imaging-derived myocardial velocities
from lateral tricuspid annulus (S′), tricuspid plane excursion and RV
deformation imaging (strain). RV diastolic function in preterm
infants is assessed by transtricuspid flow profile (E, A and E/A ratio)
and tissue Doppler imaging velocities (e′, a′ and e′/a′ and E/e′). RV
function changes significantly during the transitional period in
preterm infants,51 with decreased relaxation of both ventricles. RV
obstructive shock secondary to pulmonary hypertension is noted
in case of dilatation of right cavities, high RV systolic pressure and
high pulmonary arterial pressure, based on measurements of
tricuspid and pulmonary regurgitant jets, and a right-to-left shunt
across a PDA.
In the first week of life, common HD situations in preterm
infants are known. First, immediately after birth (before 1 h), a
situation of pulmonary hypertension or poor cardiac function with
variable afterload occurs. During the transitional phase (1 to 48 h),
hypotension (dysregulation of systemic venous resistance with
low afterload) and/or low systemic blood flow (poor cardiac
function with high afterload) may occur. Third, a post-transitional
phase (day 3 and later) with a risk of PDA volume afterload (high
preload with low afterload) or sepsis (low afterload).62
To conclude, hypotension in preterm infants in the first week of
life may be explored by targeted neonatal echocardiography, by
assessing systemic blood flow (superior vena cava flow in case of
large left-to-right shunts) and its components (global myocardial
function, pulmonary hypertension and intravascular volume
status). Targeted neonatal echocardiography is useful in guiding
therapeutic decisions such as fluid administration, and the use of
inotropic or vasoactive agents.45 Nevertheless, targeted neonatal
echocardiography does not only explore hypotension. Low
systemic blood flow occurs frequently without hypotension, so
systemic assessment is recommended for all infants at risk, usually
selected on GA and post-natal age.
Journal of Perinatology (2017), 1 – 7
 Hemodynamic status in very preterm newborns
G Escourrou et al
4
NIRS in early hypotension in preterm infants: a promising tool to
guide treatment decisions?
NIRS has the potential to assess the circulatory well-being of very
preterm infants in the first few days of life and beyond. The NIRS
technique allows the noninvasive measurement of regional tissue
oxygenation (rSO2) and perfusion by assessing levels of oxyge-
nated (HbO2) and deoxygenated hemoglobin (HHb), measured in
real time from a neonatal transducer fixed to the infant’s body.
This technique is used frequently to assess the cerebral, renal,
splanchnic or peripheral muscular oxygenation. It measures
changes in the concentration of HbO2 and HHb using near-
infrared light of two different wavelengths, 760 and 850 nM that
penetrate the thin tissues and skull of newborns. The absorption
of this light by chromophores, such as circulating hemoglobin,
differs according to their oxygenation status. The levels of HbO2
and HHb permit calculation of rSO2, expressed as the venous-
weighed percentage of oxygenated hemoglobin and of the tissue
oxygenation index. Concomitant measurement of the percentage
of oxygen saturation in arterial blood (SaO2) and rSO2 in the brain
allows estimation of fractional tissue oxygen extraction (FTOE), a
parameter that reflects variations in cerebral oxygenation
independently of systemic oxygenation, using the following
formula (FTOE = (SaO2 − rSO2)/SaO2). FTOE correlates positively
with tissue oxygenation index.63
Concerns exist regarding the external validity of NIRS, among
devices and sensors. Between different NIRS sensors and devices,
in preterm infants, NIRS values may differ as much as 15 (mean
10%).64–66 Therefore, study results that assess NIRS in preterm
infants should be interpreted with caution and taking into account
the device and sensors used. The comparability of measurements
between devices and processes used to reject artifacts using this
technique have been questioned, and recommendations to
increase validity of measurements have been proposed.67
References values for preterm in the first 72 h of life have been
described. In this prospective cohort (n = 999), cerebral rSO2 and
FTOE were influenced by gender, GA, post-natal age, fetal growth
restriction and significant PDA.65 Thus, despite the known pitfalls
of this method, there are arguments in favor of its use to monitor
trends in an individual patient, and it appears to be valuable as a
semiquantitative indicator of changes in cerebral oxygenation and
oxygen extraction.68 A recent systematic review of the literature
concluded that peripheral muscle NIRS measurements alone or in
combination with cerebral or multisite NIRS measurements could
enable the recognition of early states of compensated shock
during the care of critically ill neonates.69 NIRS has been used in
preterm infants mainly to monitor hemodynamic changes related
to PDA, to assess cerebral autoregulation and neurological
outcome, and to examine the potential value of a multisite NIRS
approach for hemodynamic assessment. Although no specific
evaluation of NIRS measurements in the context of isolated
hypotension in very preterm infants has been published, NIRS
could be an additional monitoring tool to assess hemodynamic
status and the need for further intervention or evaluation. NIRS is
beneficial in managing newborns during cardiac surgery and is
widely used for this indication.70
Patent ductus arteriosus
Results to assess the potential of NIRS as a screening tool for PDA
in preterm infants are conflicting.71,72 Chock et al.71 found that low
renal saturation o 66% was associated with the presence of
hemodynamically significant PDAs in o29 weeks gestation
preterm infants. They also showed that cerebral saturation may
be preserved if cerebral autoregulation remained largely intact.
Another recent study in a cohort of preterm infants o 32 weeks
gestation with clinical signs of an hemodynamically significant
PDA within 2 weeks after birth showed that cerebral and renal
oxygen saturation and extraction were not affected.72 In yet
Journal of Perinatology (2017), 1 – 7
another report, NIRS allowed the identification of infants likely to
benefit from early echocardiography and subsequent intervention
to close a PDA.73 In addition, in preterm infants with echocardio-
graphically significant PDA, NIRS may help in the evaluation of
rSO2 levels, which could be decreased at the mesenteric, but not
at the renal or cerebral levels.74 Thus, NIRS may provide
complementary information to echocardiography for PDA evalua-
tion and treatment guidance.
Cerebral autoregulation and neurological outcome
NIRS may be used in preterm infants to noninvasively and
continuously assess dynamic cerebral autoregulation, that is, the
ability of the brain to maintain constant blood flow during normal
variations of arterial pressure. When this system fails, it leads to
pressure-passive circulation, where cerebral blood flow has a
direct linear relationship with mean arterial BP (MABP).75 NIRS
parameters (rSO2, tissue oxygenation index) measured at regional
cerebral levels provide an indirect evaluation of cerebral blood
flow. In association with MABP, assuming that SaO2 remains
constant, they reflect cerebral autoregulation.76 In preterm infants,
cerebral autoregulation is more important than the range of MABP
in maintaining cerebral blood flow, a loss of cerebral autoregula-
tion is more closely associated with adverse neurological out-
comes than the MABP value alone.77 These data provide a
rationale for the continuous monitoring of cerebral oxygenation to
assess cerebral autoregulation in preterm infants to improve long-
term outcome. Regarding the association between cerebral rSO2’s
threshold and neurologic outcome, one study in preterm infants
suggested that cerebral rSO2 below 50% could be associated with
a poorer neurodevelopmental outcome at 18 months’ corrected
age.78
Multisite NIRS approach for hemodynamic assessment
Rhee et al.79 have shown in a model of hemorrhagic shock in
piglets that renal blood flow is impaired before cerebral blood
flow and MABP. They also demonstrated that renal rSO2 measured
by NIRS is a reliable index for the assessment of renal blood flow.
Hoffman et al.70 proposed a two-site NIRS model in infants that
shows good correlation with venous oxygen saturation. Moreover,
this two-site model shows that renal rSO2 is more sensitive to
circulation impairment than cerebral rSO2. In preterm infants, the
abdominal rSO2 signal shows more intra-individual variability than
cerebral or renal rSO2, with additional uncertainty as to which
tissue exactly is being sampled.80 Thus, renal rSO2 should be
preferred to abdominal rSO2 for multisite NIRS. Multisite NIRS
seems to increase the sensitivity of tissue oximetry to detect
systemic hypoperfusion; however, more data are needed.81
Recently, a prospective cohort study of 28 very preterm infants
with clinical sepsis has suggested that multisite NIRS monitoring
(FTOE values at the cerebral, renal and intestinal levels) might help
in the detection of low tissue oxygen delivery that leads to
adverse outcomes, which was not detected by routine clinical
signs of circulatory failure.82
NIRS monitoring of cerebral oxygenation to guide treatment in
preterm infants
The potential clinical value of NIRS measurements in guiding
treatment decisions has been evaluated recently in extremely
preterm infants.83 This multicenter randomized control trial
showed that the combination of continuous NIRS cerebral
monitoring with a prespecified treatment algorithm, as compared
to standard care, was more successful in stabilizing cerebral
oxygenation and maintaining cerebral rSO2 values in a target
range (55 to 85%). While these data are encouraging, for its
implementation in clinical routine, this strategy has to prove its
effectiveness in enhancing the mid- or long-term outcome in
© 2017 Nature America, Inc., part of Springer Nature.

these high-risk preterm infants, as it did not affect significantly
early markers of brain injury and brain imaging assessment at
term equivalent age.84 Moreover, the intervention algorithm used
in that study in case of rSO2 values outside the target range were
multiple, resulting in difficulties to identify the most efficient ones.
Finally, the rSO2 alarms led to clinical interventions only in 25% of
the cases that differed also among sites.85 All together, these data
call for more research in larger multicenter trial. To our knowledge,
three other randomized multicenter interventional trials for
hypotension of prematurity are under way and include NIRS
measurements.86
Future
Further tools such as laser Doppler to assess peripheral micro-
vascular tone87 or electrical velocimetry for noninvasive cardiac
output continuous monitoring88 are promising, but require further
studies to define normal range values and allow routine use of
these new techniques.
CONCLUSION
This review highlights the complementarities between different
parameters used to assess hemodynamic status in preterm
newborns during the first week of life (Table 1). Arterial BP
measured with an oscillometric monitor must be analyzed taking
into account other clinical data, in particular, CRT and UO, and
biological data such as lactate analysis. Cardiac echocardiography
improves noninvasive hemodynamic management in newborns,
but requires specific training. NIRS could be useful in monitoring
the clinical course of infants at risk of, or presenting with,
hypotension, but also needs training before signals can reliably be
interpreted. HD monitoring per se seems to improve outcomes in
some papers,85,89 but it remains unclear what cutoffs should be
used, as treatment of HD compromise does not necessarily
improve long-term outcomes. There is probably no preferred
method as each tool will provide their specific information on HD
at specific pathophysiology. Targeting treatment to a specific
pathophysiology with understanding of central components
(myocardial function, preload and afterload), vascular components
(BP, perfusion and oxygenation) and organ components (oxyge-
nation, urine output and lactate) might improve outcomes.
CONFLICT OF INTEREST
The authors declare no conflict of interest.
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