Neonatal Electroencephalogram Electrode-Related Pressure Injury Prevention Quality Improvement Study.

OBJECTIVE: To lengthen the days between electroencephalogram electrode-related pressure injury (EERPI) to 100 EERPI-free days in 6 months of study implementation with a goal to maintain 200 EERPI-free days thereafter (≤1 EERPI event/year). METHODS: This quality improvement study took place in a level IV neonatal ICU over three epochs spanning 2 years: epoch 1 or baseline (January-June 2019), epoch 2 or implementation of intervention (July-December 2019), and epoch 3 or sustainment (January-December 2020). A daily electroencephalogram (EEG) skin assessment tool, introduction in practice of a flexible hydrogel EEG electrode, and successive rapid-cycle staff-education sessions were key interventions of the study. RESULTS: Seventy-six infants were monitored for 214 continuous EEG (cEEG) days, of which six (13.2%) developed EERPI in epoch 1. Eighty infants were monitored for 193 cEEG days, of which two (2.5%) developed EERPI in epoch 2. One hundred thirty-nine infants were monitored for 338 cEEG days, and none developed EERPI in epoch 3. There was no statistical difference with respect to the median cEEG days among study epochs. A G-chart of EERPI-free days showed an increase in EERPI-free days from an average of 34 days in epoch 1 to 182 days in epoch 2 and 365 days (or zero harm) in epoch 3. Skin erythema from EEG electrodes was noted during the study. CONCLUSIONS: The structured study interventions eliminated EERPI events in infants monitored with cEEG. Preventive intervention at the cEEG-electrode level coupled with skin assessment successfully reduced EERPIs in neonates.

Seizures in Children with Cardiac Disease on Extracorporeal Membrane Oxygenation.

BACKGROUND: Children supported with extracorporeal membrane oxygenation (ECMO) have been shown to be at risk for developing seizures. However, previous studies have consisted of heterogeneous patient populations. We aimed to describe the rate of seizures in pediatric patients receiving ECMO for cardiac indications and to identify risk factors for the occurrence of this complication. METHODS: This is a retrospective cohort study of consecutive pediatric patients on ECMO for congenital or acquired cardiac disease between 2014 and 2018 at a tertiary care pediatric hospital. RESULTS: We reviewed 110 children, of whom 104 (95%) received continuous electroencephalogram for at least 48 h after ECMO initiation. Seizures were observed in 20 (18%) children. Seizures were subclinical only in 13 (65%) patients, and 8 (40%) developed status epilepticus. The median time from ECMO initiation to first seizure was 34 h (25%, 75%: 19, 44). Children with seizures were more likely to have suffered pre-ECMO cardiac arrest (odds ratio 5.7, 95% confidence interval 2.0-16.1, p < 0.001), require extracorporeal cardiopulmonary resuscitation (odds ratio 5.2, 95% confidence interval 1.9-14.7, p < 0.001), and have been cannulated via the cervical vessels (p = 0.029). Children with seizures also had lower pH nadir prior to ECMO (p = 0.015) and had higher peak lactate prior to ECMO (p = 0.002). Patients with seizures had significantly a longer median intensive care unit length of stay, (43 versus 32 days, p = 0.02), had a significantly worse pediatric cerebral performance score (2 versus 1, p = 0.03), and tended to have worse survival to hospital discharge (50% versus 71%, p = 0.069). CONCLUSIONS: Seizures in pediatric patients on ECMO for cardiac indications are common, occurring in nearly one in five patients. Seizures are frequently subclinical only and often progress to status epilepticus. Continuous electroencephalogram is therefore warranted for this patient population, especially in the setting of cardiac arrest, extracorporeal cardiopulmonary resuscitation, or severe metabolic acidosis.

A Standardized, 3-Tiered, Seizure Burden-Based Protocol for the Treatment of Neonatal Seizures.

OBJECTIVE: To evaluate use of a standardized, 3-tiered, seizure burden-based protocol for treatment of all electroencephalography (EEG)-confirmed seizures in a level IV neonatal intensive care unit (NICU). STUDY DESIGN: All infants admitted to the NICU with EEG-confirmed seizures over a 25-month period were enrolled in the study. We compared short-term outcomes before and after implementation of a standardized, 3-tiered protocol. RESULTS: A total of 107 infants were enrolled in the study. Use of midazolam infusions was reduced by 53.7% (p = 0.02). Midazolam infusion duration increased from 4 to 7.5 days (p = 0.003); however, when excluding 3 outliers, there was no significant difference between groups (-p = 0.67). Duration of EEG monitoring decreased from 5 to 3 days (p = 0.005). Hospital length of stay was unchanged. CONCLUSION: Implementation of a standardized, 3-tiered protocol for treatment of neonatal seizures improved short-term outcomes. Although not measured directly, reductions in EEG duration and midazolam use are promising indicators of overall seizure burden. More research is needed to evaluate impact on long-term neurodevelopmental outcomes.

Fetal Cerebral Sinovenous Thrombosis and Dural Sinus Malformation.

BACKGROUND: Fetal cerebral sinovenous thrombosis (CSVT) and dural sinus malformation (DSM) are rare types of fetal cerebral venous pathology that are becoming increasingly recognized as fetal imaging advances. Fetal DSMs are a common source of fetal CSVT, although CSVT may occur without a DSM. The literature on these disorders is limited. METHODS: Cases of fetal CSVT and DSM were identified retrospectively through a query of the Indiana University Health fetal imaging archive from 2007 to 2021. RESULTS: Seven cases were identified, all of whom were alive at birth. A DSM was present in six. Treatments after birth included enoxaparin sodium (3), embolization (3), and shunt placements (1). Five cases had documented regression or complete resolution of the thrombus and/or malformation. One was lost to follow-up, one died from complications of hydrocephalus at nine months, one was receiving physical and occupational therapy at last follow-up at three months, one had concern for autism and mild gait abnormality at 21 months, two had concern for speech delay (18 months and 24 months), and one had normal development at most recent follow-up (four years). CONCLUSIONS: Positive short-term outcomes may occur for some cases of fetal CSVT and DSM. However, risk factors and best treatments are not clear, and long-term outcome data are limited. There is a need for further study.