Monika Olischar

Amplitude-Integrated EEG Pattern Predicts Further Outcome in Preterm Infants

Changes in EEG background activity are powerful but nonspecific markers of brain dysfunction. Early EEG and amplitude-integrated EEG (aEEG) pattern predict further neurodevelopmental outcome in term infants; however, sufficient data for prognostic value of aEEG in preterm infants are not available so far. The aim of the study was to evaluate whether aEEG predicts further outcome and to compare it to cerebral ultrasound assessment. In 143 preterm infants, aEEG within the first 2 wk of life and outcome data at 3 y of age (Bayley Scales) could be obtained.aEEG was classified into a graded score according to background activity, appearance of sleep-wake cycling, and occurrence of seizure activity. In preterm infants, aEEG was significantly associated with further outcome. Specificity was 73% for assessment within the first and increased to 95% in the second week of life, whereas sensitivity stayed nearly the same 87% (first week) to 83% (second week). Cerebral ultrasound showed a specificity of 86% within the first and second week, sensitivity also stayed nearly the same (74 and 75%). aEEG has a predictive value for later outcome in preterm infants and can be used as an early prognostic tool.

Background patterns and sleep-wake cycles on amplitude-integrated electroencephalography in preterms younger than 30 weeks gestational age with peri-/intraventricular haemorrhage

Aim: The objective of this prospective study was to evaluate the influence of peri‐/intraventricular haemorrhage (PIVH) grades I–IV on amplitude‐integrated electroencephalographic (aEEG) activity in preterm infants <30 weeks gestational age (GA).

Intra- and Extrauterine Maturation of Amplitude-Integrated Electroencephalographic Activity in Preterm Infants Younger than 30 Weeks of Gestation

Objective: To prospectively investigate the longitudinal changes of amplitude-integrated electroencephalographic (aEEG) activity in preterm infants <30 weeks gestational age (GA). Methods: Infants (GA <30 weeks) without evidence of neurological abnormalities had weekly aEEG recordings performed. The relative duration of the three aEEG patterns (discontinuous low voltage, discontinuous high voltage and continuous) was determined and the influence of GA and postnatal age (PNA) on the occurrence of each pattern was assessed. Results: Ninety-eight infants (median GA 26 weeks; range 23–29 weeks) were studied. With higher GA (OR 1.68, 95% CI 1.33–2.13) and PNA (OR 1.91, 95% CI 1.53–2.38), the likelihood for the occurrence of continuous activity increased. The discontinuous low-voltage pattern was less likely to occur with increasing GA (OR 0.68, 95% CI 0.55–0.83) and PNA (OR 0.70, 95% CI 0.61–0.81). Conclusion: Maturation of aEEG activity in preterm infants is influenced by both GA and PNA.

Amplitude-Integrated Electroencephalography and Brain Injury in Infants Undergoing Norwood-Type Operations

BACKGROUND Perioperative brain injury is common in infants undergoing cardiac surgery. Amplitude-integrated electroencephalography (aEEG) provides real-time neurologic monitoring and can identify seizures and abnormalities of background cerebral activity. We aimed to determine the incidence of perioperative electrical seizures, and to establish the background pattern of aEEG, in neonates undergoing Norwood-type palliations for complex congenital heart disease in relation to outcome at 2 years. METHODS Thirty-nine full-term neonates undergoing Norwood-type operations underwent aEEG monitoring before and during surgery and for 72 hours postoperatively. The perfusion strategy included full-flow moderately hypothermic cardiopulmonary bypass with antegrade cerebral perfusion. Amplitude-integrated electroencephalography tracings were reviewed for seizure activity and background pattern. Survivors underwent neurodevelopmental outcome assessment using the Bayley Scales of Infant Development (3rd edition) at 2 years of age. RESULTS Thirteen (33%) infants had electrical seizures, including 9 with intraoperative seizures and 7 with postoperative seizures. Seizures were associated with significantly increased mortality, but not with neurodevelopmental impairment in survivors. Delay in recovery of the aEEG background beyond 48 hours was also associated with increased mortality and worse motor development. CONCLUSIONS Perioperative seizures were common in this cohort. Intraoperative seizures predominantly affected the left hemisphere during antegrade cerebral perfusion. Delayed recovery in aEEG background was associated with increased risk of early mortality and worse motor development. Ongoing monitoring is essential to determine the longer-term significance of these findings.

The influence of music on aEEG activity in neurologically healthy newborns ≥32 weeks’ gestational age

Aim:  Music is increasingly being used in neonatal intensive care units to aid neurodevelopmental care. The aim of this pilot study was to examine the possible effects of music on quiet sleep (QS) in neurologically healthy newborns.

The 'Effects of Transfusion Thresholds on Neurocognitive Outcome of Extremely Low Birth-Weight Infants (ETTNO)' Study: Background Aims, and Study Protocol

Background: Infants with extremely low birth weight uniformly develop anemia of prematurity and frequently require red blood cell transfusions (RBCTs). Although RBCT is widely practiced, the indications remain controversial in the absence of conclusive data on the long-term effects of RBCT. Objectives: To summarize the current equipoise and to outline the study protocol of the ‘Effects of Transfusion Thresholds on Neurocognitive Outcome of extremely low birth-weight infants (ETTNO)’ study. Methods: Review of the literature and design of a large pragmatic randomized controlled trial of restrictive versus liberal RBCT guidelines enrolling 920 infants with birth weights of 400–999 g with long-term neurodevelopmental follow-up. Results and Conclusions: The results of ETTNO will provide definite data about the efficacy and safety of restrictive versus liberal RBCT guidelines in very preterm infants.

Cerebrospinal fluid drainage in posthaemorrhagic ventricular dilatation leads to improvement in amplitude-integrated electroencephalographic activity

Aim: Progressive posthaemorrhagic ventricular dilatation (PHVD) may induce abnormal amplitude‐integrated electroencephalographic (aEEG) activity prior to clinical deterioration or significant cerebral ultrasound changes. These abnormalities might be ameliorated with cerebrospinal fluid (CSF) drainage. The aims of this study were to investigate the occurrence of aEEG‐abnormalities with progressive PHVD in relation to clinical and cerebral ultrasound changes and to evaluate whether CSF drainage results in aEEG improvement.

Successful Implementation of a Neonatal Pain and Sedation Protocol at 2 NICUs

OBJECTIVE: To evaluate the implementation of a neonatal pain and sedation protocol at 2 ICUs. METHODS: The intervention started with the evaluation of local practice, problems, and staff satisfaction. We then developed and implemented the Vienna Protocol for Neonatal Pain and Sedation. The protocol included well-defined strategies for both nonpharmacologic and pharmacologic interventions based on regular assessment of a translated version of the Neonatal Pain Agitation and Sedation Scale and titration of analgesic and sedative therapy according to aim scores. Health care staff was trained in the assessment by using a video-based tutorial and bedside teaching. In addition, we performed reevaluation, retraining, and random quality checks. Frequency and quality of assessments, pharmacologic therapy, duration of mechanical ventilation, and outcome were compared between baseline (12 months before implementation) and 12 months after implementation. RESULTS: Cumulative median (interquartile range) opiate dose (baseline dose of 1.4 [0.5–5.9] mg/kg versus intervention group dose of 2.7 [0.4–57] mg/kg morphine equivalents; P = .002), pharmacologic interventions per episode of continuous sedation/analgesia (4 [2–10] vs 6 [2–13]; P = .005), and overall staff satisfaction (physicians: 31% vs 89%; P < .001; nurses: 17% vs 55%; P < .001) increased after implementation. Time on mechanical ventilation, length of stay at the ICU, and adverse outcomes were similar before and after implementation. CONCLUSIONS: Implementation of a neonatal pain and sedation protocol at 2 ICUs resulted in an increase in opiate prescription, pharmacologic interventions, and staff satisfaction without affecting time on mechanical ventilation, length of intensive care stay, and adverse outcomes.

Can neurophysiological assessment improve timing of intervention in posthaemorrhagic ventricular dilatation

Objective Intraventricular haemorrhage is still the most common cause of brain lesion in preterm infants and development of a posthaemorrhagic ventricular dilatation (PHVD) can lead to additional neurological sequelae. Flash visual evoked potentials (fVEP) and amplitude-integrated electroencephalography (aEEG) are non-invasive neurophysiological monitoring tools. The aim of the study was to evaluate fVEPs and aEEGs in preterm infants with progressive PHVD prior to and after neurosurgical intervention for cerebrospinal fluid removal and to correlate the findings with severity of ventricular dilatation. Design fVEPs and aEEGs were performed weekly in infants with developing PHVD. As soon as the ventricular index reached the 97th percentile recordings were performed twice a week. Methods 17 patients admitted to the neonatal intensive care unit of the Medical University of Vienna who developed progressive PHVD were evaluated using fVEP and aEEG until and after reduction of intracranial pressure by placement of an external ventricular drainage. Results In all 17 cases (100%) wave latencies of fVEP increased above normal range and aEEG showed increased suppression in 13 patients (76%) with increasing ventricular dilatation. Both methods showed normalisation of patterns mostly within a week of successful therapeutic intervention (mean 8.5 days). Both changes in fVEP latencies and aEEG background patterns were detected before clinical signs of elevated intracranial pressure occurred. In only 10 patients (58.8%) ventricular width exceeded the 97th percentile+4 mm. Conclusions fVEP and aEEG are useful additional tools for the evaluation of preterm infants with progressive PHVD.

Perinatal Outcome of Preterm Infants <1500 g after IVF pregnancies compared with natural conception

Objective In vitro fertilisation (IVF) pregnancies are at increased risk for adverse perinatal outcome including very low birth weight infants. The purpose of this study was to find out whether the perinatal outcome of preterm infants <1500 g after IVF is different from those in naturally conceived pregnancies. Patients and methods This retrospective cohort study included preterm infants <1500 g born between 1999 and 2007 in a tertiary perinatal referral centre. All analyses were made separately for singletons and multiples, divided into infants <1000 g and 1000–1499 g. The primary study outcomes were infant mortality, short term pulmonary morbidity and cerebral morbidity. The secondary study outcomes were small for gestational age, Apgar score at 5 min, the results of the first venous blood gas analysis of the preterm infant, and the first mean arterial blood pressure after neonatal intensive care unit admission. Logistic regression analysis was done to assess the impact of IVF compared to other maternal and infant factors. Results 1423 patients (195 IVF and 1228 non-IVF patients) were included in this study. The incidence of preterm labour was significantly higher in multiples after IVF than in spontaneously conceived multiples. In the IVF group, there were significantly more multiples. Mortality, pulmonary morbidity and cerebral morbidity did not differ among patients after IVF and naturally conceived patients. Also, there were no significant differences for the secondary outcomes, except for a significantly higher initial pH value in multiples after IVF between 1000–1499 g. Conclusion IVF treatment was not associated with adverse outcome in very low birth weight infants. IVF, preterm birth, VLBW, singletons, multiples, outcome