Predictive monitoring is an exciting new field involving analysis of physiologic data to detect abnormal patterns associated with critical illness. The first example of predictive monitoring being ...taken from inception (proof of concept) to reality (demonstration of improved outcomes) is the use of heart rate characteristics (HRC) monitoring to detect sepsis in infants in the neonatal ICU. The commercially available 'HeRO' monitor analyzes electrocardiogram data from existing bedside monitors for decreased HR variability and transient decelerations associated with sepsis, and converts these changes into a score (the HRC index or HeRO score). This score is the fold increase in probability that a patient will have a clinical deterioration from sepsis within 24 h. This review focuses on HRC monitoring and discusses future directions in predictive monitoring of ICU patients.
In a randomized trial of 3003 very low birthweight infants, display of the HeRO score reduced mortality more than 20%. Ongoing research aims to combine respiratory and HR analysis to optimize care of ICU patients.
Predictive monitoring has recently been shown to save lives. Harnessing and analyzing the vast amounts of physiologic data constantly displayed in ICU patients will lead to improved algorithms for early detection, prognosis, and therapy of critical illnesses.
Neonatal sepsis accounts for significant morbidity and mortality, particularly among premature infants in the Neonatal Intensive Care Unit. Abnormal vital sign patterns serve as physiomarkers of ...sepsis and provide early warning of illness before overt clinical decompensation. The systemic inflammatory response to pathogens signals the autonomic nervous system, leading to changes in temperature, respiratory rate, heart rate, and blood pressure. In infants with comorbidities of prematurity, vital sign abnormalities often occur in the absence of infection, which confounds sepsis diagnosis. This review will cover the mechanisms of vital sign changes in neonatal sepsis, including the cholinergic anti-inflammatory pathway mediated by the vagus nerve, which is critical to the host response to infectious and inflammatory insults. We will also review the clinical implications of vital sign changes in neonatal sepsis, including their use in early warning scores and systems to direct clinicians to the bedside of infants with physiologic changes that might be due to sepsis. IMPACT: This manuscript summarizes and reviews the relevant literature on the physiological manifestations of neonatal sepsis and how we monitor and analyze these through vital signs and advanced analytics.
Artificial intelligence may have a role in the early detection of sepsis in neonates. Machine learning can identify patterns that predict high or increasing risk for clinical deterioration from a ...sepsis-like illness. In developing this potential addition to NICU care, careful consideration should be given to the data and methods used to develop, validate, and evaluate prediction models. When an AI system alerts clinicians to a change in a patient's condition that warrants a bedside evaluation, human intelligence and experience come into play to determine an appropriate course of action: evaluate and treat or wait and watch closely. With intelligently developed, validated, and implemented AI sepsis systems, both clinicians and patients stand to benefit. IMPACT: This narrative review highlights the application of AI in neonatal sepsis prediction. It describes issues in clinical prediction model development specific to this population. This article reviews the methods, considerations, and literature on neonatal sepsis model development and validation. Challenges of AI technology and potential barriers to using sepsis AI systems in the NICU are discussed.
Analysis of subtle vital sign changes could facilitate earlier treatment of acute inflammatory illnesses. We previously showed that high cross-correlation of heart rate and oxygen saturation ...(XCorr-HR-SpO
) occurs in some very low birthweight (VLBW) infants with sepsis, and hypothesized that this corresponds to apnea.
In 629 VLBW infants, we analyzed XCorr-HR-SpO
in relation to central apnea with bradycardia and desaturation (ABD), BD with or without central apnea (BD), and percent time in periodic breathing (PB) throughout the neonatal intensive care unit (NICU) stay (75 infant-years). We reviewed 100 days with extremely high XCorr-HR-SpO
(>0.7) and control days for clinical associations. Next, we identified all cases of late-onset septicemia (LOS) and necrotizing enterocolitis (NEC) and analyzed change in XCorr-HR-SpO
before diagnosis.
Mean XCorr-HR-SpO
was ∼0.10, and increasing XCorr-HR-SpO
was associated with increasing ABD, BD, and PB (correlation coefficients >0.93). Days with maximum XCorr-HR-SpO
>0.7 were more likely to have an adverse event than control days (49% versus 13%). In 93 cases of LOS or NEC, there was a 67% increase in XCorr-HR-SpO
in the 24-hour period prior to diagnosis compared with the previous day (
< 0.01).
High XCorr-HR-SpO
is associated with apnea and adverse events including LOS and NEC.
Objectives To determine whether an early heart rate characteristics (HRC) index (HeRO score), measured in the first day and week after birth predicts death and morbidities compared with established ...illness severity scores. Study design For all very low birth weight infants in a single neonatal intensive care unit from 2004-2014, the average first day HRC index was calculated within 24 hours of birth (aHRC-24h) and the average first week HRC index within 7 days of birth (aHRC-7d). The Score for Neonatal Acute Physiology (SNAP-II) and Clinical Risk Indicator for Babies (CRIB-II) were calculated when data were available. The aHRC was compared with the SNAP-II and CRIB-II for predicting death, late-onset septicemia, necrotizing enterocolitis, bronchopulmonary dysplasia, severe intraventricular hemorrhage, or severe retinopathy of prematurity. Results All 4 scores were associated with death and severe intraventricular hemorrhage ( P < .01). The OR and 95% CI for every 1-point increase in aHRC for predicting mortality, adjusted for gestational age, was 1.59 (1.25-2.00) for aHRC-24h and 2.61 (1.58-4.33) for aHRC-7d. High aHRC-7d, SNAP-II, and CRIB-II were associated with bronchopulmonary dysplasia ( P < .001). High aHRC-7d was associated with late-onset septicemia ( P < .05). None of the scores predicted necrotizing enterocolitis or severe retinopathy of prematurity. Conclusions HRC assessed in the first day or first week after birth compares favorably to established risk scores to predict death and morbidities in very low birth weight infants.
Bradycardia and oxygen desaturation episodes are common among preterm very low birth weight (VLBW) infants in the Neonatal Intensive Care Unit (NICU), and their association with adverse outcomes such ...as bronchopulmonary dysplasia (BPD) is unclear.
For 502 VLBW infants we quantified bradycardias (HR < 100 for ≥ 4 s) and desaturations (SpO
< 80% for ≥ 10 s), combined bradycardia and desaturation (BD) events, and percent time in events in the first 4 weeks after birth (32 infant-years of data). We tested logistic regression models of clinical risks (including a respiratory acuity score incorporating FiO
and level of respiratory support) to estimate the risks of BPD or death and secondary outcomes. We then tested the additive value of the bradycardia and desaturation metrics for outcomes prediction.
BPD occurred in 187 infants (37%). The clinical risk model had ROC area for BPD of 0.874. Measures of desaturation, but not bradycardia, significantly added to the predictive model. Desaturation metrics also added to clinical risks for prediction of severe intraventricular hemorrhage, retinopathy of prematurity and prolonged length of stay in the NICU.
Oxygen desaturations in the first month of the NICU course are associated with risk of BPD and other morbidities in VLBW infants.
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