Cerebral autoregulation and optimal blood pressure from birth to surgery in neonates with critical congenital heart disease

Objectives Increased time-to-surgery has been correlated with increasing cerebral fractional oxygen extraction without compensatory increase in cerebral blood flow in neonates with critical congenital heart disease (cCHD) suggesting an overwhelmed cerebral autoregulation system. Autoregulation analysis can provide precision targets such as optimal blood pressure but it remains unclear how autoregulation evolves in days preceding surgery. Our hypothesis is that longer wait times between birth and surgery are associated with increasing periods of impaired autoregulation. Methods A retrospective observational study evaluating the time spent within optimal blood pressure (MAP _OPT ) range identified by cerebral autoregulation analysis in full term newborns with cCHD awaiting neonatal surgery. Results Sixty subjects had a median [IQR (interquartile range)] of 5.2 days [3.9–7.9] of recordings from birth to surgery. Subjects spent a median of 7.6%, [5.3–13%] with impaired autoregulation. Time within MAP _OPT decreases slightly within the first ten days of life when controlling for confounders. Subjects spent a mean (+/- standard deviation) of 40.8% (± 15.5%) of each day within MAP _OPT (51.3 ± 6.1 mmHg) and a median of 28.1% [13.6–45.5] time below MAP _OPT . Mixed effects regression showed that subjects spent 1.93% less time each day within MAP _OPT range (p = 0.001) over time but there was no difference in time spent below MAP _OPT . Conclusion Full term neonates with cCHD experience variable periods of impaired autoregulation throughout the preoperative period and spend less time within MAP _OPT over that time. These changes in cerebral hemodynamics may be a physiologic mechanism for previously described association between longer wait time to surgery and increased white matter injury.