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Neurocritical Care for Neonates Hannah C. Glass, MDCM, MAS University of California, San Francisco

Neurocritical Care for Neonates Hannah C. Glass, MDCM, MAS University of California, San Francisco Susan Peloquin, RN University of California, San Francisco Renée Shellhaas, MD, MS University of Michigan Steven P. Miller, MDCM, MAS B.C. Children’s Hospital Taeun Chang, MD

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Neurocritical Care for Neonates Hannah C. Glass, MDCM, MAS University of California, San Francisco

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  1. Neurocritical Care for Neonates Hannah C. Glass, MDCM, MAS University of California, San Francisco Susan Peloquin, RN University of California, San Francisco Renée Shellhaas, MD, MS University of Michigan Steven P. Miller, MDCM, MAS B.C. Children’s Hospital Taeun Chang, MD Children’s National Medical Center October 14, 2010

  2. Educational Objectives Highlight the advantages of a coordinated, standardized, and multidisciplinary approach to neurological care in the nursery Describe the specialized nursing and neurology roles at the bedside of newborns with critical illnesses Provide guidance for applying and interpreting advanced technologies in the intensive care nursery

  3. What is Neurocritical Care? • “Distinct multidisciplinary subspecialty • that links neurology, neurosurgery and critical care medicine in the comprehensive management of complex and life-threatening neurological problems” • Rincon and Mayer, Current Opinion in Critical Care 2007 1960 Observation & monitoring after surgery 1970s 1st dedicated units & training programs 1980-90s Broader range of diagnoses 2000s Monitoring Imaging Intervention

  4. Neurocritical Care • - 30 accredited training programs • Guidelines and practice parameters • Growing interest in Pediatric Neurocritical Care (dedicated services, training programs, practice parameters) • Evidence of improved outcomes

  5. Lessons from Adult Neurocritical Care 1. Protocol-driven approach - Higher rates of favorable outcomes

  6. 2. Specialized teams in dedicated units - Reduce mortality & improve resource utilization, especially in hospitals with high patient volumes Diringer MN, et al. Crit Care Med, 2001

  7. 3. Attention to basic physiology - Temperature, glucose, oxygenation, and blood pressure  prevent secondary injury Ntaios, Stroke 2010

  8. 4. Training & Education - Medical and nursing staff

  9. Case • ID • - Term female • Pregnancy • - Unremarkable • Delivery • - Planned home water birth  transition to bed for failure to progress • - Nuchal cord • Resuscitation • - Baby apneic, pale, hypotonic • - PPV by midwife and then paramedics • - APGARS 2/2/4/5

  10. Case • Hospital Course • Intubated & ventilated • 1st gas (45 minutes) 6.90/-29 • Exam  no eye opening, no gag/suck/moro, axial hypotonia and appendicular increased tone • Transfer to a center with a neonatal neurocritical care service for therapeutic hypothermia

  11. What is Neonatal Neurocritical Care? • How can we optimize care for this newborn to maximize neurodevelopmental outcome?

  12. Case - Continued • Therapeutic temp by 2hrs (during transport) • Assigned to a specialized neurology nurse • Monitored using bedside EEG and aEEG  • No EEG seizures • Background very discontinuous  improved <24hr • No complications during cooling • Warmed after 72 hrs

  13. Case - Continued • Imaged on DOL 4  • Minimal reduced diffusion in ventrolateral thalami bilaterally • Multidisciplinary team meeting (parents, nursing, neonatology, neurology) • Follow up arranged with neurology, High Risk Infant Clinic and Early Start state program

  14. Case - Continued • F/U age 12 months • No seizures • Normal developmental milestones • Normal growth (HC 10-25th percentile) • Normal exam • BSID III • Cognitive = 100 • Motor = 100 • Language = 74

  15. What is Neonatal Neurocritical Care? • Emerging as a distinct, multidisciplinary subspecialty • Interdisciplinary care • Specialized bedside nurse, neonatologists & neurologists/neurointesivists, as well as neurophysiologists, neuroradiologists & neurosurgeons • Role for the neurologist in bedside care, developing institutional guidelines, and education • Heavy use of neuromonitoring and neuroimaging • Can be incorporated into guidelines at levels appropriate for each facility Slide courtesy of Dr. Taeun Chang

  16. Conclusions Future directions • Research • Evaluate impact of specialized care • Novel therapies for seizure management and neuroprotection • Develop new diagnostic tools • Guidelines • Neonatal monitoring, seizures, neonatal status, etc • Education • Training programs • Accreditation • Raising awareness

  17. Acknowledgements • Hannah Glass • NIH/NINDS 1K23NS66137 • March of Dimes • Susan Peloquin • Renee Shellhaas • Child Neurology Foundation • Janette Ferrantino Investigator Award • NICHD (NIH 5 K12 HD 028820 18) • Steven Miller • CIHR • Michael Smith Foundation • Hospital for Sick Children Foundation • Canada Foundation for Innovation • BC Children's Hospital Foundation • Taeun Chang • NIH/NHLBI 5R01-HL060922-09 Special thanks to the multidisciplinary teams at our centers, as well as the children and families

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