Neuroprotection care bundle implementation is associated with improved long-term neurodevelopmental outcomes in extremely premature infants.

OBJECTIVE: To study the impact of an evidence-based neuroprotection care (NPC) bundle on long-term neurodevelopmental impairment (NDI) in infants born extremely premature. STUDY DESIGN: An NPC bundle targeting predefined risk factors for acute brain injury in extremely preterm infants was implemented. We compared the incidence of composite outcome of death or severe neurodevelopmental impairment (sNDI) at 21 months adjusted age pre and post bundle implementation. RESULTS: Adjusting for confounding factors, NPC bundle implementation associated with a significant reduction in death or sNDI (aOR, 0.34; 95% CI 0.17-0.68; P = 0.002), mortality (aOR, 0.31; 95% CI (0.12-0.79); P = 0.015), sNDI (aOR, 0.37; 95% CI: 0.12-0.94; P = 0.039), any motor, language, or cognitive composite score <70 (aOR, 0.48; 95% CI: 0.26-0.90; P = 0.021). CONCLUSION: Implementation of NPC bundle targeting predefined risk factors is associated with a reduction in mortality or sNDI in extremely preterm infants.

A review of different resuscitation platforms during delayed cord clamping.

There is a large body of evidence demonstrating that delaying clamping of the umbilical cord provides benefits for term and preterm infants. These benefits include reductions in mortality in preterm infants and improved developmental scores at 4 years of age in term infants. However, non-breathing or non-vigorous infants at birth are excluded due to the perceived need for immediate resuscitation. Recent studies have demonstrated early physiological benefits in both human and animal models if resuscitation is performed with an intact cord, but this is still an active area of research. Given the large number of ongoing and planned trials, we have brought together an international group that have been intimately involved in the development or use of resuscitation equipment designed to be used while the cord is still intact. In this review, we will present the benefits and limitations of devices that have been developed or are in use. Published trials or ongoing studies using their respective devices will also be reviewed.

Neuroprotection Care Bundle Implementation to Decrease Acute Brain Injury in Preterm Infants.

BACKGROUND: We assessed the impact of an evidence-based neuroprotection care bundle on the risk of brain injury in extremely preterm infants. METHODS: We implemented a neuroprotection care bundle consisting of a combination of neuroprotection interventions such as minimal handling, midline head position, deferred cord clamping, and protocolization of hemodynamic and respiratory managements. These interventions targeted risk factors for acute brain injury in extremely preterm infants (born at gestational age less than 29 weeks) during the first three days of birth. Implementation occurred in a stepwise manner, including care bundle development by a multidisciplinary care team based on previous evidence and experience, standardization of outcome assessment tools, and education. We compared the incidence of the composite outcome of acute preterm brain injury or death preimplementation and postimplementation. RESULTS: Neuroprotection care bundle implementation associated with a significant reduction in acute brain injury risk factors such as the use of inotropes (24% before, 7% after, P value < 0.001) and fluid boluses (37% before, 19% after, P value < 0.001), pneumothorax (5% before, 2% after, P value = 0.002), and opioid use (19% before, 7% after, P value < 0.001). Adjusting for confounding factors, the neuroprotection care bundle significantly reduced death or severe brain injury (adjusted odds ratio, 0.34; 95% confidence interval, 0.20 to 0.59; P value < 0.001) and severe brain injury (adjusted odds ratio, 0.31; 95% confidence interval, 0.17 to 0.58; P < 0.001). CONCLUSIONS: Implementation of neuroprotection care bundle targeting predefined risk factors is feasible and effective in reducing acute brain injury in extremely preterm infants.

Serum calcium derangements in neonates with moderate to severe hypoxic ischemic encephalopathy and the impact of therapeutic hypothermia: a cohort study.

Background: Perinatal hypoxia is a recognized cause of hypocalcemia in neonates in the first 3 days of life. Therapeutic hypothermia (TH) promotes neuroprotection by decreasing calcium influx into the cells during the reperfusion phase thereby increase serum calcium levels. This study examines the trends of serum calcium levels in neonates with hypoxic ischemic encephalopathy (HIE) and the effect of TH.Material and methods: A retrospective cohort study of neonates with moderate to severe HIE admitted to level III neonatal intensive care units (NICU's) in Calgary between September 2011 and October 2015. HIE was staged using modified Sarnat scoring system. Ionized calcium levels were followed in the first 3 days of age.Results: One hundred thirteen neonates admitted with the diagnosis of moderate to severe HIE were included; 89 (79%) underwent TH. Hypercalcemia was significantly higher with TH 57 (64%) compared to 8 (33%) in noncooled group (p = .007). Hypocalcemia was less in TH group; 11 (12%) compared to 5 (21%) in non TH group. Hypo/hypercarbia did not alter the serum calcium levels. Furthermore; there was no increase in the incidence of intracranial hemorrhage, clinical or electrographic seizures, antiepileptic drug use, or hypoxic/ischemic MRI changes with calcium derangements.Conclusion: The incidence of hypocalcemia was reduced by almost half and hypercalcemia was significantly increased with TH in the first 3 days of life. The reduction in hypocalcemia and the increase in hypercalcemia may be attributed to the neuroprotective effect of TH.

Prevalence and Characteristics of Intracranial Hemorrhages in Neonates with Hypoxic Ischemic Encephalopathy.

INTRODUCTION: The risk factors of intracranial hemorrhages (ICH) in the context of neonatal hypoxic ischemic encephalopathy (HIE) and related interventions are unclear. OBJECTIVE: This article examines the prevalence and risk factors associated with ICH in neonates with HIE. STUDY DESIGN: This is a retrospective cohort study of neonates with HIE in Southern Alberta. ICH (subdural [SDH], subarachnoid [SAH], intraventricular [IVH], intraparenchymal [IPH]) were diagnosed by magnetic resonance imaging (MRI). Perinatal and neonatal characteristics were examined. Relation of hemorrhages with hypoxic changes on MRI and HIE stages were assessed. RESULTS: Number of HIE patients, n = 157; brain MRI was done in 138 infants; median gestation, 40 weeks; and cooled = 103 (66%). Prevalence of SDH, IPH, IVH, and SAH were 47, 22, 11, and 10 (34.1%, 15.9%, 7.8%, 7.2%), respectively. There was no significant increase in hemorrhage with mode of delivery, seizures, hypo/hypercarbia, severe thrombocytopenia, or deranged coagulation. All hemorrhages increased with higher HIE stage, regardless of the HIE severity in MRI. Adjusting for HIE staging, cooling, and gestation, IPH was observed more in infants who received inotropes (odds ratio [OR], 3.32; 95% confidence interval [CI], 1.20, 9.20). CONCLUSION: SDH followed by IPH were the most common ICH. Thrombocytopenia and deranged coagulation did not increase risk of hemorrhages in HIE. Our study was not powered to determine the impact of inotrope use on the risk of IPH.

Implementation of a Neurocritical Care Program: Improved Seizure Detection and Decreased Antiseizure Medication at Discharge in Neonates With Hypoxic-Ischemic Encephalopathy.

BACKGROUND: We report the impact of implementing continuous video electroencephalography monitoring for neonates with hypoxic-ischemic encephalopathy via a protocol in the context of neonatal neuro-critical care program. METHODS: Neonates with hypoxic-ischemic encephalopathy were studied retrospectively two years before and after implementing continuous video electroencephalography for 72 hours as a care protocol. Before continuous video electroencephalography, a 60-minute routine electroencephalography was performed at the discretion of the provider. PRIMARY OUTCOME: electrographic seizure detection; secondary outcome: use of maintenance antiseizure medications, discharge antiseizure medications, and cumulative burden for each antiseizure medication defined as total mg/kg during hospital stay. RESULTS: A total of 157 patients with a median gestation of 40 weeks were analyzed; 103 (66%) underwent therapeutic hypothermia. Baseline and clinical characteristics including disease severity and cooling were similar. Before continuous video-electroencephalography (n = 86), 44 (51.2%) had clinical seizures, of those 35 had available routine electroencephalography; 12 of 35 (34%) had electrographic seizures. None of the infants without clinical seizures showed electrographic seizures. After continuous video-electroencephalography (n = 71), 34 (47.9%) had clinical seizures, of those 18 (53%) had electrographic seizures; five of 37 (14%) of infants with no clinical seizures had electrographic seizures. The introduction of continuous video-electroencephalography significantly increased electrographic seizure detection (P = 0.016). Although there was no significant difference in the initiation and maintenance use of antiseizure medications after continuous video-electroencephalography, fewer infants were discharged on any antiseizure medication (P = 0.008). Also, the mean phenobarbital burden reduced (P = 0.04), without increase in other antiseizure medications use or burden. CONCLUSION: Use of continuous video-electroencephalography as part of the neonatal neuro-critical care program was associated with improved electrographic seizure detection, decreased phenobarbital burden, and antiseizure medication use at discharge.