The effect of oxygen on hemodynamic variables in neonates with single ventricle after the Norwood procedure

BackgroundManagement of neonates with single ventricle physiology after the Norwood procedure relies on optimizing oxygen delivery and achieving an optimal balance between systemic (Qs) and pulmonary blood flow (Qp). The aim of this study was to determine hemodynamic variables and evaluate their response to different fractions of oxygen (FiO2). MethodsWe prospectively determined actively circulating volume (ACV), stroke volume (SV), total cardiac output (CO), shuntfraction (Qp/Qs), and vascular resistances (SVR, PVR) after the Norwood procedure with right ventricle to pulmonary arterial shunt. Measurements were done in 16 neonates by using dilution methodology, where changes in blood velocity due to injection of normal saline were recorded by ultrasound sensors (COstatus, Transonic System Inc). Measurements were performed at stable conditions after sternal closure on sedated and mechanically ventilated neonates at an FiO2 of 0.21, 0.5, and 0.9. ResultsThe Qp/Qs ratio increased from 1.06 (0.7-1.65) (median, (IQR)) to 1.41 (0.93-1.75) (p <0.001) when FiO2 increased from 0.21 to 0.9. This was solely caused by a decrease in Qs, as Qp remained unchanged. Mean arterial pressure (MAP) and central venous pressure (CVP) were stable and at normal levels at different FiO2. SVR increased and PVR remained unchanged when FiO2 increased from 0.21 to 0.9. The indexed ACV (ACVI) was 50 (45-65) ml/kg. ConclusionUnresponsiveness of Qp to changes in FiO2 indicates that Qp is regulated by the size of the RV to PA shunt and not by pulmonary vascular vasomotion. A low ACVI and normal blood pressure indicate that these children have a compensated hypovolemia. These findings suggest that increasing the blood volume and reducing the afterload are appropriate treatment strategies rather than pulmonary vasodilation. Clinical PerspectiveO_ST_ABSWhat Is New?C_ST_ABS# In vivo measurements of hemodynamic parameters after Norwood procedure are possible # Pulmonary blood flow is not amenable for manipulation by increasing oxygen. # Patients that have undergone a Norwood procedure have low intravascular volume What Are the Clinical Implications?# Active circulating volume should be optimized # Systemic cardiac output will benefit from afterload reduction # Oxygen supplementation in the range up to 0.4 fraction of inspired oxygen might be beneficial