Neuromonitoring during newborn transition

Background: Newborn infant neurological function can be measured by monitoring electrical activity (electroencephalography) or cerebral oxygenation via NIRS (near infrared spectroscopy). In practice the clinical applications of electroencephalography (EEG) are limited to monitoring infants following moderate to severe hypoxic ischemic injury (HIE), and for the detection of seizures in at risk infants. NIRS monitoring has been the focus of a number of research trials but has no clinical applications in the immediate newborn period to date, and is not routinely performed in neonatal units. Aim: To assess the feasibility of infant neuromonitoring in the immediate period in two important clinical scenarios. Firstly, to assess the feasibility of monitoring brain activity during the first minutes of life in healthy term infants. Secondly, to assess the feasibility and utility of monitoring newborn preterm infants’ brain activity and cerebral oxygenation in the context of an interventional randomized controlled trial. Methods: 1. Healthy term newborn infants had EEG monitoring performed for the first ten minutes of life. EEG was assessed both qualitatively and quantitatively. All infants had respiratory function monitoring performed simultaneously. 2. Forty-five infants (< 32 weeks gestation) were randomly assigned to different methods of newborn infant cord clamping. All infants had EEG and NIRS monitoring for the first 72 hours of life. Quantitative features of EEG and median NIRS values were compared between groups at 6 and 12 hours of life as a primary outcome measure. Results: 1. Forty-nine infants had EEG recordings. Median (IQR) age at time of initial EEG recording was 3.0 (2·5 to 3·8) minutes. End tidal CO2 and tidal volumes increased over the first 3 minutes of life and then stabilized. Good quality EEG, with continuous mixed frequency activity with a range of 25-50μV, was observed in all infants. The majority of EEG spectral power was within the delta band. 2. There were 45 infants included. One infant died in the delivery room. Median time (IQR) from birth until EEG application was 3.05 (1.85 to 5.38) hrs. For primary outcome measures, data was available for 42/44 (95%) at 6 hrs and 44/44 (100%) at 12 hours. There was no significant difference between groups for measures for EEG values or cerebral NIRS. Conclusion: Infant neuromonitoring in the immediate newborn period is feasible in the first minutes of life in healthy term infants and within the first hours of life in preterm infants. Normative quantitative data for electrical activity in healthy newborn term infants during the first minutes of life is described for the first time. Neuromonitoring during the first day of life as an outcome measure for preterm interventional trials is possible and the outcomes from this research is promising for further trials

Lost in transition: a systematic review of neonatal electroencephalography in the delivery room - Are we forgetting an important biomarker for newborn brain health?

Background: Electroencephalography (EEG) monitoring is routine in neonatal intensive care units (NICUs) for detection of seizures, neurological monitoring of infants following perinatal asphyxia, and increasingly, following preterm delivery. EEG monitoring is not routinely commenced in the delivery room (DR). Objectives: To determine the feasibility of recording neonatal EEG in the DR, and to assess its usefulness as a marker of neurological well-being during immediate newborn transition. Methods: We performed a systematic stepwise search of PubMed using the following terms: infant, newborns, neonate, DR, afterbirth, transition, and EEG. Only human studies describing EEG monitoring in the first 15 min following delivery were included. Infants of all gestational ages were included. Results: Two original studies were identified that described EEG monitoring of newborn infants within the DR. Both prospective observational studies used amplitude-integrated EEG (aEEG) monitoring and found it feasible in infants >34 weeks' gestation; however, technical challenges made it difficult to obtain continuous reliable data. Different EEG patterns were identified in uncompromised newborns and those requiring resuscitation. Conclusion: EEG monitoring is possible in the DR and may provide an objective baseline measure of neurological function. Further feasibility studies are required to overcome technical challenges in the DR, but these challenges are not insurmountable with modern technology

Lost in Transition: A Systematic Review of Neonatal Electroencephalography in the Delivery Room—Are We Forgetting an Important Biomarker for Newborn Brain Health?

BackgroundElectroencephalography (EEG) monitoring is routine in neonatal intensive care units (NICUs) for detection of seizures, neurological monitoring of infants following perinatal asphyxia, and increasingly, following preterm delivery. EEG monitoring is not routinely commenced in the delivery room (DR).ObjectivesTo determine the feasibility of recording neonatal EEG in the DR, and to assess its usefulness as a marker of neurological well-being during immediate newborn transition.MethodsWe performed a systematic stepwise search of PubMed using the following terms: infant, newborns, neonate, DR, afterbirth, transition, and EEG. Only human studies describing EEG monitoring in the first 15 min following delivery were included. Infants of all gestational ages were included.ResultsTwo original studies were identified that described EEG monitoring of newborn infants within the DR. Both prospective observational studies used amplitude-integrated EEG (aEEG) monitoring and found it feasible in infants &gt;34 weeks’ gestation; however, technical challenges made it difficult to obtain continuous reliable data. Different EEG patterns were identified in uncompromised newborns and those requiring resuscitation.ConclusionEEG monitoring is possible in the DR and may provide an objective baseline measure of neurological function. Further feasibility studies are required to overcome technical challenges in the DR, but these challenges are not insurmountable with modern technology

Response: Commentary: Enhanced monitoring of the preterm infant during stabilization in the delivery room

A commentary on: Enhanced Monitoring of the Preterm Infant during Stabilization in the Delivery Room by Hutchon DJ. Front Pediatr (2016) 4:64. doi: 10.3389/fped.2016.0006

Enhanced monitoring of the preterm infant during stabilization in the delivery room

Monitoring of preterm infants in the delivery room (DR) remains limited. Current guidelines suggest that pulse oximetry should be available for all preterm infant deliveries, and that if intubated a colorimetric carbon dioxide detector should provide verification of correct endotracheal tube placement. These two methods of assessment represent the extent of objective monitoring of the newborn commonly performed in the DR. Monitoring non-invasive ventilation effectiveness (either by capnography or respiratory function monitoring) and cerebral oxygenation (near-infrared spectroscopy) is becoming more common within research settings. In this article, we will review the different modalities available for cardiorespiratory and neuromonitoring in the DR and assess the current evidence base on their feasibility, strengths, and limitations during preterm stabilization

All Island Congenital Heart Network brings diagnosis closer to home

Aim: The All-Island congenital heart network appointed paediatricians with expertise in cardiology in regional centres. Prior to these appointments children with suspected congenital heart disease were referred to the national children’s heart centre for investigation. The aim of this study is to quantify paediatric cardiology activity in a regional Irish centre over the first year of service provision. Methods: Data was collected retrospectively on all inpatient neonatal referrals over a 12-month period (January 2019 to January 2020). Results: There were 268 neonatal referrals. Premature infants (< 37 weeks gestation) accounted for 26% (n= 69) of total neonatal referrals. Congenital cardiac disease was identified in 58.5% (n= 113) of referrals. Cardiac intervention in the first year of life was required in 24 infants, 12.2% of referrals (5.6% catheter and 6.6% surgery). Discussion: Our report displays how clinical networks of care can reduce hospital transfers from regional neonatal centres for non-invasive cardiology investigations

A Study of the Impacts of Corporate Culture Initiatives – MVV

The purpose of this report is to study the implementation and impacts of Mission, Vision and Values (MVV) initiatives at a Portland based medium-sized technology Company. In 2009 the Company at the core of this case implemented a refreshed MVV initiative to spur innovation, creativity, productivity and improve employee satisfaction within the Company after the recession and a two year down turn. This paper will begin by outlining the case history and problem statements that lead to the conclusion that the MVV required a re-boot. The study will document the implementation strategy and specific identifiable goals for the MVV. We will analyze results of survey data collected both before and after the roll out of the MVV to qualify the impacts to employee satisfaction. Small improvements were observed for Company vision, creativity and inspiration. The survey also showed a reduction in the key talent retention sentiment in the Company. Additional metrics spanning the MVV initiative period will be examined for the following impacts; innovation, creativity, productivity and turnover. A positive trend in innovation and creativity was observed at multiple locations, a productivity increase was not evident from records provided, human resource management (HRM) statistics showed a temporary drop in voluntary turnover during the period, but turnover increased again in the following years. This study has been conducted through the collection of empirical data from the Company and by conducting with interviews with technical staff and HR professionals at the Company. Based on the outcome of this case study, we will be able to conclude to the impacts of the MVV initiative

Production Scheduling and Inventory Optimization: For a High-Tech Company to Manufacture Products Efficiently

Optimizing the production schedule to minimize operating costs and maximize profits is a challenge that a Portland, Oregon, based high-tech Company is facing. The objective of this project was to create a model that could be used as a tool by business analysts to enable informed and educated operational, production, and inventory decisions. An Integer Linear Programming model has been utilized to propose a build schedule and parts order process to meet the forecasted demand and production constraints for which the Company is contending. In addition to minimizing costs, the outputs of the model will allow the procurement team an opportunity to balance the parts necessary for the creation of the products by conforming to a just-in-time manufacturing methodology. Ultimately, this model can produce and will enable the analyst to explore the impacts of new and different constraints involved with creating an optimized production plan, which will improve the inventory, manufacturing, and production costs