Implementation of amplitude-integrated electroencephalography in tertiary Canadian Neonatal Intensive Care Units-a longitudinal study.

AIM: To investigate the implementation of amplitude-integrated electroencephalography (aEEG) as bedside monitoring tool of cerebral function in tertiary Canadian Neonatal Intensive Care Units (NICU) over the past decade. METHODS: Longitudinal study consisting of online surveys of neonatologists on the use of aEEG in 2009 and 2018. RESULTS: The response rate to the survey was 72 of 149 (49%) in 2009 and 18 of 30 (60%) in 2018, respectively. aEEG has been implemented in almost all (2009: 62.5%; 2018: 94%) tertiary Canadian NICUs. Two-thirds (2009: 67%; 2018: 71%) of the respondents considered information from aEEG tracing helpful in clinical practice. The main indications for aEEG were term neonates with hypoxic ischemic encephalopathy (2009 and 2018: 76%) and seizure detection/surveillance (2009: 88%; 2018: 94%). Teaching on aEEG has been implemented for neonatologists (2018: 100%) and health care providers (2018: 50%) in tertiary Canadian NICUs but there is a lack of standardization of training. Use of aEEG in preterm neonates (2009: 37%, 2018: 33%) and application of aEEG in research (18% reported occasional use) is less common. CONCLUSION: aEEG is well established in tertiary Canadian NICUs to monitor cerebral function and detect seizure activity. There is a need to develop formalized aEEG training programs and methods to assess competence. Further implementation of aEEG in preterm neonates and research is desirable.

Cardiovascular Associations with Abnormal Brain Magnetic Resonance Imaging in Neonates with Hypoxic Ischemic Encephalopathy Undergoing Therapeutic Hypothermia and Rewarming.

OBJECTIVE: This article compares hemodynamic characteristics of neonates with hypoxic ischemic encephalopathy (HIE) receiving therapeutic hypothermia (TH) with normal versus abnormal brain magnetic resonance imaging (MRI). METHODS: Serial echocardiography (echo) was performed within 24 hours, after 48 to 72 hours of cooling, within 24 hours of normothermia, and after starting feeds. Pulmonary hemodynamics, cardiac output, and ventricular function were evaluated. All neonates underwent brain MRI (day 4-5), per clinical standard of care. Clinical cardiovascular and echocardiography characteristics were compared between patients with normal versus abnormal MRI. Cardiovascular changes during TH and after rewarming were identified. RESULTS: Twenty neonates at median gestation and birth weight of 40 weeks (interquartile range [IQR]: 39, 41) and 3,410 g (IQR: 2,885, 4,093), respectively, were enrolled. Increased median left ventricular output (LVO) (106-159 mL/kg/min, p < 0.001) and reduced isovolumic relaxation time (IVRT) (48-42 ms, p < 0.001) were seen after rewarming. Echocardiography evidence of pulmonary hypertension (PH) was identified in five neonates. Eight neonates (40%) had brain injury identified on MRI (watershed [n = 4], basal ganglia [n = 4]); this subgroup were more likely to have echo evidence of PH at 24 hours. CONCLUSION: Longitudinal changes in cardiac output were noted in neonates with HIE during TH and rewarming. Echocardiography evidence of PH, however, was associated with abnormal MRI brain. The prognostic relevance of these physiologic changes requires more comprehensive delineation.

The impact of amplitude-integrated electroencephalography on NICU practice.

OBJECTIVE: To examine how the introduction of amplitude-integrated electroencephalography (aEEG) to our neonatal intensive care unit (NICU) influenced clinical practice. METHODS: This was a retrospective study examining clinical practice three years before and three years after the introduction of aEEG monitors to our NICU. A time series analysis was performed to explore whether aEEG introduction was associated with changes in the rates of conventional EEGs performed, neurology consultations and neonates diagnosed with seizures. RESULTS: Following aEEG introduction, the total number of conventional EEGs performed remained constant; however, there was significant shift in conventional EEG utilization towards neonates receiving fewer multiple EEGs and more single EEGs. There was no change in the rate of neurology consultations or the number of neonates diagnosed with seizures. CONCLUSIONS: Introduction of aEEG monitors to our NICU has led to less reliance on conventional EEG as a tool for the serial evaluation of brain function. Since the number of neonates diagnosed with seizures did not increase, aEEG monitoring did not appear to uncover a significant subgroup of patients with subclinical seizures that would previously have gone undetected. Conventional EEG and aEEG are complementary tools for the assessment of newborn cerebral function.

Role of amplitude-integrated electroencephalography in neonates with cardiovascular compromise.

BACKGROUND: Neonates with congenital heart disease (CHD) and persistent pulmonary hypertension of the newborn (PPHN) represent conditions with increased risk of abnormal neurologic outcome. The role of aEEG in disorders where cerebral perfusion/oxygenation is affected by cardiac or pulmonary disease is unknown. OBJECTIVE: The aim of the study was to characterize amplitude-integrated electroencephalography (aEEG) traces in nonasphyxiated neonates with cardiorespiratory compromise secondary to PPHN or CHD. DESIGN/METHODS: Three hundred sixty-three aEEG records (June 2004-November 2006) were reviewed to identify neonates with a diagnosis of isolated CHD or PPHN. Clinical course, critical interventions, and neurodiagnostic investigation data were collected. The aEEG traces were reviewed by a single blinded expert and classified according to background activity (normal, moderate, or severely abnormal) and presence of seizures. The frequency of abnormal aEEG in both groups and its relationship to recognized markers of abnormal neurologic outcome (electrophysiology [EP] testing and neuroimaging [ultrasound (USS), computerized tomography, and magnetic resonance imaging] was studied. RESULTS: Thirty neonates (PPHN [n = 20], CHD [n = 10]) were reviewed at a mean gestation of 39.2 +/- 1.1 weeks and weight of 3,375 +/- 565 g. Neonates with PPHN had lower Apgar scores at 1-minute (P = .02) and were significantly more likely to require inotropic support (P < .001), inhaled nitric oxide (P = .001), or surfactant (P = .01). An abnormal aEEG was found in 15 (50%) babies, but rates did not differ between CHD (n = 6) and PPHN (n = 9). The rates of abnormal composite neurologic outcome (2/3 of abnormal EP, neuroimaging, or neurologic examination) were significantly higher in neonates with abnormal aEEG. An abnormal magnetic resonance imaging was seen in 4 of 5 neonates with abnormal aEEG. CONCLUSIONS: The risk of abnormal aEEG is high in sick neonates with PPHN or complex CHD. Prospective evaluation of the relationship between aEEG recordings in these disorders and acute cardiorespiratory physiology, comprehensive neuroimaging, and long-term patient outcomes is needed.