The added value of simultaneous EEG and amplitude-integrated EEG recordings in three newborn infants

Amplitude-integrated electroencephalograms (aEEGs) recorded by cerebral function monitors (CFMs) are used increasingly to monitor the cerebral activity of newborn infants with encephalopathy. Recently, new CFM devices became available which also reveal the original EEG signals from the same leads. To date it was unclear whether this single-lead EEG provides additional information towards interpreting the aEEG traces more accurately. Our report deals with three cases in which the single-lead EEG from the CFM device did indeed reveal important additional information not provided by the aEEG alone. In cases 1 and 3, the aEEGs showed drifting of the baseline to higher amplitudes. The single-lead EEG revealed that this was due to muscle artefacts, high-frequency oscillation ventilation and the electrocardiogram rather than to cerebral activity. Hence, without knowledge of the EEG, the aEEG trace might have been misinterpreted as being fairly normal. Case 2 showed paroxysmal elevation of the lower margin of the amplitude on the aEEG which looked like epileptic activity. However, additional information from the single-lead EEG revealed that it was due to muscle artefacts. Thus, simultaneously recorded EEG can help to interpret seizure-like episodes on the aEEG. CONCLUSION: Simultaneously recorded single-lead EEGs can help to interpret aEEG traces more accurately.     

Should amplitude-integrated electroencephalography be used to identify infants suitable for hypothermic neuroprotection?

OBJECTIVE: Amplitude-integrated electroencephalography (aEEG) has been used adjunctively to identify infants suitable for hypothermic neuroprotection following severe intrapartum asphyxia. To determine whether an early aEEG predicts short-term adverse outcome in infants with significant hypoxic-ischemic encephalopathy (HIE) evaluated for hypothermic neuroprotection. STUDY DESIGN: The aEEG recordings were obtained within 6 h of birth in infants >or=36 weeks' gestational age during evaluation for possible selective head or whole-body cooling. Recordings were subsequently re-evaluated for both background pattern and voltage abnormalities by a certified reader masked to clinical history and brain-oriented interventions. All infants with moderate or severe HIE evaluated for hypothermic neuroprotection also underwent magnetic resonance imaging (MRI) of the brain at a median postnatal age of 7 days. The predictive value using the aEEG for determining short-term dichotomous outcomes, defined as early death related to HIE, or a characteristic pattern of abnormalities consistent with hypoxic-ischemic injury on the MRI brain scans was assessed. RESULT: Fifty-four infants with moderate or severe HIE were evaluated with aEEG for hypothermic neuroprotection; 34 infants received selective head cooling, 12 infants underwent total body cooling and 8 infants were not cooled. Outcome data, available for 46 of the 54 infants, revealed a poor correlation between the early aEEG and short-term adverse outcomes, with a sensitivity of 54.8% and negative predictive value (NPV) of only 44%. CONCLUSION: Because of the poor NPV of an early aEEG for a short-term adverse outcome, its use as an 'additional selection criterion' for hypothermic neuroprotection may not be appropriate.     

Moderate unconjugated hyperbilirubinemia causes a transient but delayed suppression of amplitude-integrated electroencephalographic activity in preterm infants

Background: Unconjugated hyperbilirubinemia occurs frequently in preterm infants and may result in bilirubin encephalopathy. Amplitude-integrated electroencephalography (aEEG) is used to evaluate brain function in newborns. Objectives: To investigate the influence of total serum bilirubin (TSB) on the aEEG amplitude of preterm infants and to evaluate aEEG as a noninvasive method to identify acute bilirubin encephalopathy. Methods: We performed a prospective observational study of 34 infants with a gestational age (GA) of 26-31 6/7 weeks. Infants had aEEG recordings on the 1st-5th, 8th and 15th day after birth. Infants with asphyxia, intraventricular hemorrhage >grade I or circulatory insufficiency were excluded. aEEG was evaluated by calculating the mean 5th, 50th and 95th centiles of the aEEG amplitudes. Results: TSB peaked on the 4th day after birth. There was no synchronous relationship between TSB and aEEG amplitudes. The 5th, 50th, and 95th aEEG amplitude centiles on the 8th day correlated negatively with the TSB peak value (r = -0.37, p = 0.048; r = -0.60, p = 0.001; r = -0.44, p = 0.017, respectively), irrespective of GA. The 5th and 50th aEEG amplitude centiles increased with increasing GA (r = 0.45, p < 0.001, and r = 0.26, p < 0.001, respectively) and postnatal age (r = 0.25, p < 0.001, and r = 0.16, p = 0.023, respectively). Conclusions: TSB had no direct effect on aEEG amplitudes in preterm infants. There is, however, a delayed effect on electrocerebral activity in the 2nd week after birth.     

振幅整合脑电图预测足月儿缺氧缺血性脑病预后的meta分析

目的 评价振幅整合脑电图(amplitude-integrated EEG,aEEG)判断足月儿缺氧缺血性脑病(hypoxic-ischemic encephalopathy,HIE)预后的价值. 方法 计算机检索EMBASE、Ovid、PubMed、Cochrane图书馆、Springer数据库、中国生物医学文献数据库、中国期刊全文数据库和万方数据库等数据库,检索时间为各数据库建库时间至2010年6月30日.全面检索aEEG判断新生儿HIE预后的文献,提取纳入文献的特征信息,评价纳入文献质量.采用Meta-Disc1.4软件进行meta 分析,对纳入文献予以加权定量合并,计算汇总敏感度、特异度、阳性似然比、阴性似然比及其95％CI. 结果 共有11篇文献符合既定标准纳入分析,共纳入病例717例.aEEG预测足月新生儿HIE神经发育不良的汇总敏感性为86％(95％ CI:81％～89％)、汇总特异性为90％(95％ CI:86％～93％)、汇总阳性似然比为7.70(95％ CI:5.69～10.43)、汇总阴性似然比0.17(95％ CI:0.13～0.22),汇总受试者工作特性曲线的曲线下面积为0.95. 结论 aEEG是有价值的预测足月儿HIE预后的床旁监测工具.     

Lethal lung hypoplasia in infants after prolonged rupture of membranes

A retrospective study to detect the frequency of lethal lung hypoplasia in 48 cases with prolonged rupture of membranes (greater than 7 days) before 34 weeks' gestation was made. Fourteen infants died (29%), but only four deaths (8.3%) were due to lung hypoplasia. Three infants with lung hypoplasia had their membranes ruptured before 20 weeks' gestation and showed echoscopically a persistent oligohydramnios, as did the one with rupture at 26 weeks. Neither the duration of rupture of membranes nor the gestational age at the time of rupture showed any influence on the occurrence of lung hypoplasia. The rupture of membranes before 20 weeks' gestational age with resulting persistent oligohydramnios will certainly lead to lung hypoplasia.     

床旁颅脑超声在早产儿脑损伤诊断中的应用

目的探讨床旁颅脑超声在早产儿脑损伤诊断中的应用价值。方法以2015年1月至2016年6月苏州市立医院NICU收治胎龄≤33周的早产儿529例为研究对象,全部行床旁颅脑超声检查,部分病例辅以头颅MRI或CT对照。结果 529例早产儿中,脑损伤者302例(其中B超检出298例,B超未检出4例,后经MRI或CT检出)。其中颅内出血272例,早产儿脑白质损伤60例(其中38例合并不同程度颅内出血),其他颅脑疾病14例。183例患儿经MRI或CT检出脑损伤56例,除3例蛛网膜下腔出血及1例硬膜下出血B超未探及,其余52例报告与B超相符。颅脑B超异常检出率为56.33%(298/529),显著高于头颅MRI及CT异常检出率30.60%(56/183),差异有统计学意义(P0.05)。颅内出血患儿脑白质损伤发生率为13.97%(38/272),显著高于非颅内出血患儿脑白质损伤发生率8.56%(22/257),差异有统计学意义(P0.05)。结论早产儿脑损伤是动态变化的,床旁颅脑超声在早期筛查及动态监测方面具有优越性,可与头颅MRI及CT结合应用提高诊断准确性。     

Reduction in red blood cell transfusions using a bedside analyzer in extremely low birth weight infants.

BACKGROUND: Preterm infants typically experience heavy phlebotomy losses from frequent laboratory testing in the first few weeks of life. This results in anemia, requiring red blood cell (RBC) transfusions. We recently introduced a bedside point-of-care (POC) blood gas analyzer (iSTAT, Princeton, NJ) that requires a smaller volume of blood to replace conventional Radiometer blood gas and electrolyte analysis used by our neonatal intensive care unit (NICU). The smaller volume of blood required for sampling (100 vs 300-500 microl), provided an opportunity to assess if a decrease in phlebotomy loss occurred and, if so, to determine if this resulted in decreased transfusions administered to extremely low birth weight (ELBW) infants. OBJECTIVE: We hypothesized that the use of the POC iSTAT analyzer that measures pH, PCO(2), PO(2), hemoglobin, hematocrit, serum sodium, serum potassium and ionized calcium would result in a significant decrease in the number and volume of RBC transfusions in the first 2 weeks of life. DESIGN/METHODS: A retrospective chart review was conducted of all inborn premature infants with birth weights less than 1000 g admitted to the NICU that survived for 2 weeks of age during two separate 1-year periods. Blood gas analysis was performed by conventional laboratory methods during the first period (designated Pre-POC testing) and by the iSTAT POC device during the second period (designated post-POC testing). Data collected for individual infants included the number of RBC transfusions, volume of RBCs transfused, and the number and kind of blood testing done. There was no effort to change either the RBC transfusion criteria applied or blood testing practices. RESULTS: The mean (+/-SD) number of RBC transfusions administered in the first 2 weeks after birth was 5.7+/-3.74 (n=46) in the pre-POC testing period to 3.1+/-2.07 (n=34) in the post-POC testing period (p<0.001), a 46% reduction. The mean volume of RBC transfusions decreased by 43% with use of the POC analyzer, that is, from 78.4+/-51.6 ml/kg in the pre-POC testing group to 44.4+/-32.9 ml/kg in the Post-POC testing group (p<0.002). There was no difference between the two periods in the total number of laboratory blood tests done. CONCLUSIONS: Use of a bedside blood gas analyzer is associated with clinically important reductions in RBC transfusions in the ELBW infant during the first two weeks of life.     

同步视频脑电图监测下双导振幅整合脑电图诊断新生儿惊厥的价值

目的 探讨双导振幅整合脑电图(amplitude-integrated electroencephalogram,aEEG)(C3-C4/T3-T4)附加对应的双导原始脑电图(electroencephalogram,EEG)诊断新生儿惊厥的价值及局限性. 方法 2011年1月至7月,对66例入住复旦大学附属儿科医院的临床有惊厥发作或可疑惊厥发作的新生儿,进行床旁视频脑电图(video electroencephalogram,VEEG)监测,时间≥3h.通过Galileo NT PMS软件将原始EEG转化为3种形式aEEG,即单导aEEG(C3-C4)、单导aEEG(C3-C4)附加原始EEG、双导aEEG(C3-C4/T3-T4)附加原始EEG.EEG和aEEG分开判读,VEEG需标记电发作(≥10 s)起始放电灶及放电持续时间,aEEG只进行电发作标记.以VEEG作为标准,采用Spearman相关分析计算aEEG与VEEG识别电发作的相关性.以敏感性、特异性、阳性预测值、阴性预测值评估aEEG诊断新生儿惊厥的价值及局限性. 结果 共62例新生儿的脑电图纳入分析.(1)电发作:VEEG发现39例患儿电发作≥1次,其中8例发生癫痫持续状态,31例非癫痫持续状态惊厥.31例非癫痫持续状态惊厥VEEG发现电发作活动累计352次,其中79.3％(279次)以颞中央区为起始放电灶.(2)电发作次数识别敏感性:8例癫痫持续状态,aEEG与VEEG诊断结果一致;VEEG监测到352次非癫痫持续状态电发作,单导aEEG、单导aEEG附加原始EEG和双导aEEG附加原始EEG识别电发作敏感性分别为49.1％(173/352)、54.5％ (192/352)和81.2％ (286/352),各组识别电发作数和VEEG记录的放电灶记录总数均相关(ρ=0.790、0.907和0.953,P均＜0.01).(3)惊厥患儿识别敏感性(≥1次电发作):单导aEEG、单导aEEG附加原始EEG和双导aEEG附加原始EEG识别惊厥患儿的敏感性分别为66.7％ (26/39,95％ CI:0.62～0.81)、74.4％ (29/39,95％CI:0.78～0.96)和89.7％ (35/39,95％CI:0.89～1.00). 结论 结合VEEG,有助于aEEG诊断新生儿惊厥,aEEG添加T3-T4导联及原始EEG可显著提高其对惊厥电发作及惊厥患儿的识别敏感性.     

Bronchopulmonary dysplasia in very low birth weight infants is associated with prolonged hospital stay.

BACKGROUND: Bronchopulmonary dysplasia (BPD) is associated with prolonged hospital length of stay (LOS) and delayed discharge home. OBJECTIVES: To evaluate the association between BPD and LOS and to assess the contribution of concomitant major morbidities on LOS among infants with BPD. STUDY DESIGN: A population-based observational study of very low birth weight (VLBW) infants born from 1995 through 2003. Multivariate analyses, adjusted for perinatal variables, assessed the association between BPD and concomitant morbidities on LOS. RESULTS: Of 10 134 survivors, 1926 (19.0%) had BPD. The adjusted LOS for infants with and without BPD was 84.1 days (95% CI, 82.8, 85.6) and 58.1 days (95% CI, 57.2, 59.0), respectively. Addition of a single concomitant morbidity increased mean LOS by 4 to 13 days. CONCLUSIONS: BPD is a major cause of increased length of hospitalization among VLBW infants. Preventive or therapeutic modalities are required to reduce the significant burden of this condition.     

Neurodevelopmental status of low birth weight infants with bronchopulmonary dysplasia requiring prolonged oxygen supplementation

Fifty infants weighing 1,500 g or less at birth with a diagnosis of bronchopulmonary dysplasia (BPD) were followed to a mean age of 25 months to determine their clinical course and short-term neurodevelopmental outcome after discharge from the Neonatal Intensive Care Unit, and to identify possible predictive factors for outcome. Because study participation was voluntary, the subjects may not have represented the total population of BPD survivors. Occurrences of abnormalities were high: 11 hearing impaired, 10 legally blind, 14 cerebral palsy, and 23 abnormal development scores. Twenty-one subjects had feeding problems and weight was below the fifth percentile in 26. Home-oxygen therapy was required by 50 per cent of the subjects. Although severity of illness, duration of oxygen therapy and feeding problems were greater among those sent home on oxygen, their neurodevelopmental status did not differ from that of infants breathing room air by discharge. Factors associated with neurodevelopmental outcome were intracranial hemorrhage, pulmonary air leak, and length of hospital stay.     

Tracheal suctioning is associated with prolonged disturbances of cerebral hemodynamics in very low birth weight infants.

OBJECTIVES: Examining the effects of tracheal suctioning on cerebral hemodynamics of normotensive ventilated very low birth weight (VLBW) infants with normal cranial ultrasounds; determining the factor(s) influencing changes in mean cerebral blood flow velocity (CBFv) after suctioning. METHODS: Seventy-three VLBW infants had continuous monitoring of mean arterial blood pressure (MABP), PaCO(2), PaO(2) and mean CBFv before, during, and after 202 suctioning sessions during the first week of life. Peak (or nadir) and relative changes of the four variables for 45 min after suctioning were calculated. Multiple linear regression was used to determine the factor(s) influencing changes in mean CBFv after suctioning. RESULT: Birth weight was 928+/-244 g; gestational age was 27.0+/-2.0 weeks. Mean CBFv increased to 31.0+/-26.4% after suctioning and remained elevated for 25 min. PaCO(2) was highly associated with mean CBFv (P<0.001), whereas MABP and PaO(2) were not. CONCLUSION: We observed prolonged increases of mean CBFv following suctioning in ventilated VLBW infants that were previously unrecognized. This is concerning since disturbances of CBF may be associated with subsequent brain injury.     

Outcome of premature infants delivered after prolonged premature rupture of membranes before 25 weeks of gestation

OBJECTIVE: To identify factors influencing the outcome of premature infants delivered after prolonged premature rupture of membranes before 25 weeks' gestation. DESIGN AND POPULATION: All premature infants with gestational age <34 weeks, either inborn or outborn, with history of rupture of membranes before 25 weeks' gestation, admitted to our NICU between January 1992 and July 1997, were eligible for this retrospective study. Collected information included birth weight, gestational age at rupture of membranes and at delivery, duration between rupture of membranes and delivery (latency period), severity of oligohydramnios, pre- and post-natal managements, and follow-up of survivors. RESULTS: A total of 28 neonates fulfilled the inclusion criteria. Despite new strategies of ventilation and optimal management, the overall mortality rate was 43% (12/28). Nonsurvivors were significantly less mature at rupture of membranes, and had severe oligohydramnios (anamnios). We also noted less antenatal corticosteroids and antibiotic therapy in this group. Nine of eleven infants (82%) following rupture of membranes before 22 weeks' gestation died shortly after birth. The two remaining infants developed severe bronchopulmonary dysplasia. Nine deaths occurred in thirteen cases (69%) of anamnios. The major death causes were refractory respiratory failure and neurologic complications. Half of all survivors (8/16) developed bronchopulmonary dysplasia. CONCLUSION: The outcome of premature infants following prolonged premature rupture of membranes before 25 weeks' gestation is influenced by gestational age at rupture, severity of oligohydramnios, and antenatal antibiotics and corticosteroids. Neonates with rupture of membranes before 22 weeks have a very low chance of survival at the present time.     

Utility of the rapid B-type natriuretic peptide assay for detection of cardiovascular problems in newborn infants with respiratory difficulties

BACKGROUND: Because the major problems of respiratory difficulties in newborn infants are due to cardiopulmonary problems, improving the early detection and referral of newborn infants with cardiovascular problems has been considered one of the primary goals of care in the neonatal intensive care unit. OBJECTIVE: To evaluate whether rapid plasma B-type natriuretic peptide (BNP) assay could be used as a screening test to detect the cardiovascular problems in newborn infants with respiratory difficulties. METHODS: We studied 73 newborn infants >or=34 weeks gestational age presenting with respiratory difficulties during the first few days after birth; they were divided into a cardiovascular problem group (CP group, n = 32) and a noncardiac problem group (NP group, n = 41) according to the presence of cardiovascular problems by clinical and/or echocardiographic studies in newborn infants with respiratory difficulties. RESULTS: On admission, the median (25-75%) BNP concentration of the CP group was significantly higher than that of the NP group [1,038 (578-1,435) vs. 240 (118-388) pg/ml, p < 0.001]. The best cutoff BNP values for differentiating the CP group were 346.0, 421.0, 570.5 and 191.5 pg/ml within 18 h, at 18-36 h, at 36-60 h and after 60 h of life, respectively. Although the plasma BNP measurement was not a single confirmative test, it was found to have a high sensitivity and a high negative predictive value for rapidly ruling out serious cardiovascular problems in neonatal respiratory difficulties. CONCLUSION: A rapid plasma BNP assay may be useful for detection of cardiovascular problems in newborn infants with respiratory difficulties during the first few days after birth.