6/16/2016. New Approaches for Newborns at Risk for Brain Injury: Creation of the NeuroNICU. Why open a NeuroNICU? EPICure 3-year outcomes: 2006 cohort

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1 Why open a NeuroNICU? New Approaches for Newborns at Risk for Brain Injury: Creation of the NeuroNICU Krisa Van Meurs, MD Rosemarie Hess Professor of Neonatal and Developmental Medicine Stanford University School of Medicine Medical Director, NeuroNICU Lucile Packard Children s Hospital Stanford Evolution in focus of NICU care: Improving neurologic and neurodevelopmental outcomes Bringing new neurodiagnostictechniques and research findings to the bedside Taking advantage of our local expertise in fetal medicine, neonatal intensive care, neonatal neurology, pediatric neuroradiology, pediatric neurosurgery, and high-risk infant follow-up to focus on brain care X Simpósio Internacional de Neonatologia do Rio de Janeiro Hotel Royal Tulip, Rio de Janeiro 23 de Junho2016 Survival to discharge for infants <29 weeks born in 2012 at NICDH Neonatal Research Network Hospitals EPICure 3-year outcomes: 2006 cohort Survival (%) Gestational age (weeks) Stoll BJ et al., JAMA 2015 Moore T et al., BMJ 2012; 345:e7961 Survival has improved, however outcome remains a challenge Extremely low birth weight (ELBW) infant Pre-ECMO and ECMO Hypoxic ischemic encephalopathy (HIE) Seizures Inborn errors of metabolism Meningitis/encephalitis CNS malformations including Spinabifida Congenital heart disease Grade III/IV IVH with hydrocephalus Why open a NeuroNICU? Evolution in focus of NICU care: Improving neurologic and neurodevelopmental outcomes Bringing new neurodiagnostictechniques and research findings to the bedside Taking advantage of our local expertise in fetal medicine, neonatal intensive care, neonatal neurology, pediatric neuroradiology, pediatric neurosurgery, and high-risk infant follow-up to focus on brain care 1

2 What monitoring devices are used for sick neonates in the NICU? What about the brain? Blood pressure Temperature End tidal CO2 Bedside brain monitoring A complimentary tool used at the bedside Used in conjunction with other neuroassessmentsand diagnostics (e.g. neurologic exam, head ultrasound, CT, MRI) Provides bedside, unit-based clinicians with real-time information about neurologic status Heart rate SaO2 Respiratory rate Bedside neuromonitoring devices Continuous video EEG Continuous video EEG (ceeg) Amplitude integrated EEG (aeeg) Near infrared Spectroscopy (NIRS) Continuous, non-invasive, direct measure reflecting CNS function Electrode application and interpretation require expertise Can be viewed and interpreted remotely Demonstrates changes in brain function over time, evolution of EEG pattern can be prognostic Gold standard for seizure detection because: 80-90% of neonatal seizures have no clinical correlate Seizure medications cause uncoupling Neurofax EEG, Nihon Kohden Brainz BRM3, Natus INVOS 5100c, Covidien Amplitude integrated EEG (aeeg) Comparing EEG and aeeg Simplified EEG with small number of electrodes providing an overall impression of cerebral activity. Raw EEG data is filtered, amplified, rectified and displayed in a timecompressed semi-logarithmic fashion. Advantages of ease of use, minimal interference with care, and less training required for interpretation. Conventional EEG, 16 channels aeeg, 2 channels 10 seconds 3.5 hours 2

3 aeeg interpretation by pattern recognition or voltage aeeg and prediction of outcome in HIE Prior to cooling era: Abnormal outcome is seen when aeeg background does not return to normal by 24 hours or sleep wake cycles to not appear by 36 hours. In cooling era: Abnormal outcome is seen when aeeg background does not normalize by 48 hours. Return of SWC is more variable. Thoresen M, et al. Pediatrics (2010) Thoresen M, et al. Pediatrics (2010) Near infrared spectroscopy (NIRS) Use of cerebral oximetry in HIE Continuous, real-time, non-invasive measure of regional tissue oxygenation (rso2) Able monitor cerebral, renal and mesenteric tissues Cerebral rso2 is validated with jugular venous saturation Cerebral saturation (rsco2) is higherand fractional tissue oxygen extraction (FTOE) is lowerby 24 hours and onward in neonates with HIE with adverse outcomes FTOE = SaO2 rsco2/sao2 Reflects secondary energy failure with reduced oxygen consumption by severely injured neuronal cells Solid line = good outcome Dashed line = poor outcome Lemmers P, et al. Ped Res (2013) High rsco2 at 24 hours is associated with poor neurodevelopmental outcome Clinical trials focusing on neurologic outcome in the Packard NICU Trial Name Year PI Funding Whole Body Hypothermia for HIE study 2000 Shankaran NICHD Late Hypothermia study 2008 Laptook NICHD Brain injury in WBH for HIE 2005 Barnes/Shankaran NICHD Childhood outcomes of WBH for HIE 2010 Hintz NICHD SUPPORT Neuroimaging study 2008 Hintz NICHD SUPPORT Neuro School Age FU 2010 Hintz NICHD Pilot Preemie aeeg study 2009 Davis/Van Meurs NICHD Cerebral autoregulation with PDA 2011 Chock Internal Short term ND outcome with CHD 2010 Chock, Heart Center Optimizing Cooling Hypothermia Study 2011 Shankaran NICHD Predicting Outcomes using aeeg 2011 Van Meurs BPCA California Transport Cooling Trial 2012 Akula/Van Meurs Internal 3

4 Clinical research results reach the bedside for babies with hypoxic ischemic encephalopathy (HIE) Therapeutic hypothermia with lowering of body temperature to C within 6 hours after birth in newborns 36 weeks gestation with moderate to severe HIE reduces the risk of death or major neurodevelopmental impairment at 18 months. Why open a NeuroNICU? Evolution in focus of NICU care: Improving neurologic and neurodevelopmental outcomes Bringing new neurodiagnostic techniques and research findings to the bedside Taking advantage of our local expertise in fetal medicine, neonatal intensive care, neonatal neurology, pediatric neuroradiology, pediatric neurosurgery, and high-risk infant follow-up to focus on brain care The Neuro NICU is multi-disciplinary Learning from other Neuro NICUs Neonatology Pediatric Neurosurgery Child Neurology Developmental Behavioral Pediatrics/ High Risk Infant follow-up Clinic Developmental Team Neuroradiology Child Psychiatry UCSF NeuroIntensive Care Nursery 2007 Phoenix Children s NeuroNICU 2009 Johns Hopkins St. Louis Children s Hospital Vanderbilt Medical Center Children s National Medical Center, Washington D.C. Boston Children s - Pediatric Neuro ICU Glass H, et al. Neurocrit Care (2010) Our NeuroNICU Journey Jan 2012 Multidisciplinary meeting to discuss the concept June 2012 Written proposal and budget submitted Oct 2012 Funding approved Dec 2012 Hired NeuroNICU Program Consultant Feb/March 40 RNs trained as NeuroNICU RNs in 3-day training 2013 Hands-on sessions for hypothermia, NIRS and aeeg April 2013 Opening of the NeuroNICU April year anniversary 226 patients cared for Jan 2015 Training course with 130 participants April year anniversary 581 patients 4

5 Medical Director Neurology Director Associate Directors Program Consultant Clinical Nurse Specialist NeuroNICU NNP Leads Fellow liaison NeuroNICU Core Team Members Weekly meeting of core team members Krisa Van Meurs, MD Courtney Wusthoff, MD MS Epi Valerie Chock, MD MS Epi Sonia Bonifacio, MD Kathi Randall, RN NNP CNS Shannon Tinkler, BSN Celia Glennon, NNP RN Rachael Small, NNP RN Anca Pasca, MD Monthly meeting of larger group including OT, PT, social work, parent rep, fellow liaison, nurses, assistant nurse managers, research team Clinical service Specialized care by Neuro NICU trained RN team (n=90) Daily joint rounds with Neurology service On-site NNP or educator 5 days a week Patients with neuro issues or at risk for neurologic injury EPIC enhancements: Neuro NICU tab, dot phrases for neuro exam and aeeginterpretation, order sets for hypothermiaand seizures Neuro NICU database in REDCapfor research, QA/QI, and program planning Top 12 priority diagnoses for Neuro NICU NeuroNICU Education Priority Diagnosis Expected LOS in NNICU (days) Monitoring Neurology consult 1 HIE/cooling 7-10 aeeg/ceeg & NIRS Yes 2 Seizures 7 aeeg/ceeg Yes 3 ECMO/pre-ECMO 7 NIRS + aeeg PRN 4 Critical/unstable 7 NIRS & consider aeeg PRN 5 Preemie <29 weeks 7-10 NIRS PRN 6 Grade III/IV or hydrocephalus 7 aeeg/ceeg Yes 7 Metabolic disease 7 aeeg/ceeg PRN 8 CNS anomalies/primary neurologic disorders 7 aeeg/ceeg Yes 9 Cyanotic CHD 7 NIRS PRN 10 CNS infection 7 aeeg/ceeg Yes 11 Symptomatic PDA 7 NIRS PRN 12 ALTE 3 aeeg PRN Initial education Weekly 2-3 day course 5 minute Friday and Perinatal conference Ongoing Online video lectures, slides, and quizzes to review aeeg and NIRS theory and interpretation Annual skills day (e.g. aeeg, NIRS, neuroexam, positioning, hypothermia equipment and protocol review) NeuroNICU Training Course And extends across the continuum of care 2-3 day course, 25 lectures by 20 speakers and hands-on sessions Topics include: Fetal and neonatal brain development IVH and white matter injuries Neonatal neuroimaging HIE Seizure management NIRS and aeeg Palliative care Follow-up clinic and beyond Parent s perspective Audience includes NeuroNICURNs, NNPs, hospitalists, neonatal fellows, neonatologists, OT, PT, Developmental Care team, and follow-up clinic staff Prior to birth (Fetal Service) From admission to discharge From discharge to home From home to follow-up 5

6 4 Pillars of Neuro-NICU Care A Neuro-Conscious NICU: Connecting Research to Nursing Practice Kathi Randall, RN, MSN, CNS, NNP-BC LPCH NeuroNICU Consultant Assessment Imaging Monitoring Protection The Neuro-Conscious NICU How do we assess the brain? Neuro-Assessment Identification of Risk Clinical/Hands On Metabolic Follow Up Care Neuro-Imaging MRI MRS Ultrasound Neuro-Monitoring EEG aeeg NIRS Hearing Screen Neuro-Protection Developmental Care Cooling Medications Nutrition Adjunctive Neuro-Assessment Training included detailed neonatal neuro exam, Sarnat, and Neonatal Pain, agitation, and sedation Scale (N-PASS) Neuro-Imaging Training included types, timing and indications for neuro-imaging as well as prognostic implications 6

7 Theory and practice Neuro-Monitoring aeeg application techniques and interpretation Near infrared spectroscopy (NIRS) and Vital Sync for autoregulation Conventional EEG interpretation for the non-neurophysiologist Neuro-Protection Initially used to characterize substances or strategies capable of preventing cell death Now, encompasses all interventions that promote normal development and prevent disabilities What A Nurse Ought To Do Florence s Environment of Care (Although) Nursing has been limited to signify little more than the administration of medicines..it ought to signify the proper use of air, light, warmth, cleanliness, quiet, and the administration of diet. Florence Nightingale, 1859 Nightingale, Florence (1859). Notes on Nursing: What it is, and what it is not.. Philadelphia: Edward Stern & Co.. The impact of the environment on a wounded individual s ability to heal is undeniable. A Developmentally Supportive Environment Create a balance of medically intense care with supportive, nurturing, developmentally supportive care Does not replicate the intrauterine environment but simulates it in order to minimize the negative impact of the NICU environment Integrative Model of Developmental Care Safeguarding sleep Optimizing nutrition Minimizing stress and pain Protecting skin Positioning and handling Partnering with families Smell, sound, touch, temperature, light 7

8 Potentially better practices to prevent brain injury in VLBW infants Maintain Midline Head Position x 72 hours 1. Antenatal betamethasone 2. Optimize peripartum management and delivery at a center with a NICU 3. Direct management by Neonatologists/NNPs 4. Minimize pain and stress 1. Avoid early LP 2. Developmental Care 5. Optimal Positioning (Mid-line) 6. Treat hypotension (Keep MAP > 30 not GA) 7. Limit postnatal indomethacin use 8. Optimize respiratory support 9. Limit sodium bicarbonate use 10.Use post-natal dexamethasone judiciously (>42 days & too early) Carteaux P, Pediatrics (2003) Essential elements of positioning Containment with boundaries All 360 degrees Not restrictive The right size for the baby Promote flexion/prevent extension Midline Nose, nipples, knees and toes Infant Positioning Assessment Tool (IPAT) Max Score = 12 Indicator Shoulders Hands Hips Knees, ankles, feet Head Neck Coaghlin M, et al. Newborn and Infant Nursing Reviews (2010) Prevention of Typical Complications Mounting Evidence for Infection and Inflammation and it s impact on brain development Effects of hypocarbia and hypercarbia Multiple studies have associated hypocarbia in VLBW infant with cerebral palsy and PVL. Levene M. Arch Dis (2007) Both minimum PCO2 and cumulative CO2<35 were associated with poor outcome in HIE (p<0.05). Pappas A, et al. J Pediatr (2011) Higher PaCO2 was an independent predictor of severe IVH/death, BPD/death, NDI/death. Ambalavanan N, et al. Arch Dis Child Fetal Neonatal Ed (2015) Rethink other NICU programs as Neuro-protective NEC Prevention Sepsis Prevention Ventilator-Induced Brain Injury Kolan, J of Child Neuro, 2014 Yu, JAMA, week infant with PaCO2 105 then 44 Granot S, Ped Neurol (2012) 8

9 UAC blood sampling practices Rapid withdrawal and flushing of catheters in the aorta can affect cerebral blood flow velocity, volume and oxygenation. Altered cerebral blood flow has been correlated with IVH and PVL. Blood sampling from UAC produces significant changes in cerebral blood flow velocity as measured using doppler in anterior cerebral artery. Withdrawal -19% Infusion +9% change Therapeutic hypothermia for HIE Both body and head cooling have been shown to reduce death and neurodevelopmental impairment (RR % CI ) and NNT = 7 NIRS and tissue oxygen extraction(toi) were measured with 2.3 ml blood withdrawal over 20 and 40 seconds. 20 seconds Significant change 40 seconds No change Lott JW, et al. J Perinatol(1996) Schulz G, et al. Pediatrics (2003) Identification and Treatment of Seizures Seizures can accelerate cell death in HI injuries and adversely affect neurogenesis in animal models. In term newborns with HIE, seizures on EEG are associated with higher mortality and disability at 19 mons. Wyatt JS, et al. Pediatrics (2007) Pretermswith seizures on EEG during the first days of life have worse neurodevelopmental outcomes. Shah DK, et al. PediatrRes (2010), Vesoulis ZA, et al. Pediatr Res (2014) Kangaroo Care improves brain outcomes and more Kangaroo mother care is associated with: Reductionin mortality(rr % CI ) Reduction in nosocomial infection (RR % CI ) Increased weight, lengthand head circumference gain Improved BayleyMDI (p=0.03) and PDI (p=0.06) at 1 year Conde-Agudelo A. et al. Cochrane Database of Systematic Reviews (2011) OhgiS, et al. J Perinatol(2002) Parental Provided Massage PREVENT Pain and Stress in the NICU 9

10 Balance SENSORY Experiences 2 Different Bathing Experiences Create bonds that will last a life-time Why a Neuro-NICU? Brain injury is a reality of many infants in the NICU. The brain is the organ that has the greatest impact on long term quality of life and function. We have the opportunity to improve the quality of life of highrisk infants, and the quality of care provided through the expansion of new technologies, therapies, and practices. Early and more aggressive treatment of neonatal brain pathology will not only result in better survival but better neuro-developmental outcomes. Foster an early and strong relationship between family and child, as well as with teams that will be providing long-term management and care Neuro-conscious care is a new frontier for NICUs We have their futures in our hands Thank you! 10