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Monitoring the Brain Petra Lemmers neonatologist.

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Presentation on theme: "Monitoring the Brain Petra Lemmers neonatologist."— Presentation transcript:

1 Monitoring the Brain Petra Lemmers neonatologist

2 Introduction Last decades survival of infants needing large surgery in the neonatal period has increased –Prenatal diagnosis/perinatal care –Minimal invasive-more precise procedures –Intensive care More attention for morbidity, but excluded from follow up studies because of congenital malformations. Until now only scarce literature available

3 Introduction Outcome following cardiac surgery Increased risk of neurodevelopmental impairment Brain injury White matter injury and stroke like lesions Outcome following non-cardiac surgery Impairment in motor function Cognitive impairment Kabra et al 2007 Block et al 2010 Andropoulos eat al 2010 Mazer et al Dev Med Child Neurol 2010 Madderom et al Arch Dis Child Fetal Neonatal Ed 2012

4 Outcome following cardiac and non-cardiac surgery –Mental and motor delay Laing et al J Paediatr Child Health 2011 Walker et al J Pediatr % 26% 38% 26% Introduction

5 Long term follow up neonatal surgery non cardiac malformations Ludman et al (London) n= 30 –1 and 3 year: DQ scores significantly lower than controls NL, Rotterdam n= 80 –5 jaar –IQ 36% low normal range –more children with MDI < 85 compared with normal population. –30% emotional /behaviour problems Ludman et al J Pediatr Surg 1990, 1993 Mazer P et al, Developmental medicine and child neurology 2010 Introduction

6 Transition from fetal life Immaturity of organ systems –Hypoxic/ischemic damage –Hyperoxic damage Neurotoxicity anesthetics Monitoring vital parameters: (HR, BP, SaO2, pCO2, Hb, etCO2, SjO2) No direct information Cerebral oxygenation Brain Perfusion Brain activity Risk neonatal brain damage

7 More direct monitoring parameters are needed: Stable and recognizable parameters Bedside monitoring possible for extended periods of time Monitoring the neonatal brain Can we do more?

8 Monitoring the brain Near Infrared Spectroscopy (NIRS) 1 or 2 channel EEG: aEEG

9 Near Infrared Spectroscopy (NIRS) Monitoring technique for cerebral oxygenation and haemodynamics Based on absorption of near-infrared light by oxygenated [O 2 Hb] and deoxygenated Hb [HHb] Absorption-changes in NIR-light (  ODs) can be converted in changes of [  O 2 Hb] and [  HHb] Regional (mixed) cerebral O2-saturation: rScO2

10 Reproducibility is good when used for trend monitoring Menke et al, Biol Neon 2003 Fronto-parietal position Lemmers et al, Pediatr Res, 2009 rScO 2 -Right (%) (r= 0.88, p<0.01) rScO 2 -Left (%)

11 rScO 2 % Expected “normal” values (±2SD) High values (> +2SD) Low values (< -2SD) 1) Hou, Physiol Meas 2007; 2) Kurth, J Cereb Blood Flow Metab 2005; 3) Dent, J Thorac Cardiovasc Surg 2002 Avoid if possible! 1,2,3 Interpretation of rScO 2 values

12 aEEG Filtered (2-15 Hz) Amplification Compressed (6 cm/hr) Semilogarithmic scale 1 channel (2 parietal leads) 1 channel for impedance

13 aEEG signalfiltered

14 signalrectified, smoothed aEEG

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16 signalcompressed in time aEEG

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18 signalcompressed in time aEEG

19 signalcompressed in time aEEG Thanks to M Toet

20 Continuous Burst Suppression Discontinuous Cont. Low Voltage Flat Trace = 10 min Background patterns Thanks to LdeVries/MToet

21 aEEG Seizures

22 Has cerebral monitoring additional value in clinical care in the neonate in the peri- surgical period?

23 No randomised trials Scarse data available (cardiac patients) Conclusions are experience based :

24 non invasive monitoring Preterm infants <32 wks for 72 h Neonates after perinatal asphyxia Brain monitoring in clinical practice Preterm infants <32 wks Term infants after hypoxic ischemic events

25 Arterial saturation (pulse oxymetry) Arterial blood pressure Heart rate Cerebral oxygenation by NIRS (rScO 2 ) aEEG Collected on a PC for offline analysis with Signalbase® Brain monitoring in clinical practice

26 Signalbase/bedbase: collecting and analyzing data

27 aEEG and NIRS in clinical practice Relation with other clinical conditions Blood pressure Patent ductus arteriosus Autoregulatory ability (Mechanical) ventilation Surgery Monitoring the neonatal brain

28 Relation brain monitoring Blood pressure Patent ductus arteriosus Autoregulatory ability (Mechanical) ventilation Surgery

29 Limits of normal blood pressure in neonates Not well defined Mostly used definition MABP (mmHg)

30 $ * Dopamine 5µg/kg/min $ p<0.05 vs controls; * p<0.05 vs before dopa N=38 Bonestroo et al, Pediatrics 2011 $ N=39

31 Surgical closure of PDA

32 Term infant with severe anaemia and hypotension at birth; Bowel perforation of antenatal onset Thanks to Toet/ de Vries

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34 Conclusion aEEG should be continued for at least 48 hrs to be able to detect late onset seizure after HI

35 Extensive watershed injury Ri > Le

36 Suggestion Brain monitoring by NIRS and aEEG could be a useful approach to judge the need of blood pressure support in infants with low blood pressures

37 Relation brain monitoring Blood pressure Patent ductus arteriosus Autoregulatory ability (Mechanical) ventilation Surgery

38 Ductal steal phenomenon in cerebral arteries is a risk factor for cerebral damage in the preterm infant (Perlman 1981) Hemodynamically important PDA

39 * p<0.05 vs pre-clip surgery GA 26.7 ±1.8 wks PNA 7 days [4-39] PDA surgery after failure medication

40 Advanced MRI techniques 8 brain structures cortical gray matter (cGM) central gray matter/basal ganglia (BG) ventricles (VENT) cerebrospinal fluid (CSF) myelinated white matter (MWM) unmyelinated white matter (UWM) brainstem (BS) cerebellum (CB) Cerebellar volume smaller at term equivalent age p<0.05 (Zethof/Lemmers/Benders submitted) PDA surgery

41 Monitoring of rScO2 during surgical ductal closure can prevent surgery-related brain damage Cerebral oxygenation should play a role in the ultimate decision to close of a hemodynamically important ductus arteriosus Suggestions

42 Relation brain monitoring Blood pressure Patent ductus arteriosus Autoregulatory ability (Mechanical) ventilation Surgery

43 Cerebral blood flow Cerebral perfusion pressure (no corr) (corr) rScO 2 MABP Brady, Stroke 2007/2010 Wong, Pediatrics 2008 De Smet Adv Exp Med Biol Aciado Ped Res 2011 Autoregulatory ability

44 ErythrocytesThrombo+FFPDopamine 15Dobutamine and steroidsDopamine 10 ♂, sepsis, † Absence of cerebral autoregulation SaO 2 (%) rScO 2 (%) MABP (mmHg) HR (b/min)

45 Presence cerebral autoregulation SaO 2 (%) rScO 2 (%) MABP (mmHg) ♂, 30 wk 945 g, day 1

46 Monitoring MABP and rScO 2 can, within certain limits, identify infants with absence of autoregulatory ability Identification of absence of autoregulatory ability may help to prevent brain damage Suggestions

47 Relation brain monitoring Blood pressure Patent ductus arteriosus Autoregulatory ability (Mechanical) ventilation Surgery

48 Vanderhaegen et al. Eur J Paediatr Neur 2008 /rScO2 r=0.26 p<0.05 Ventilation: pCO2

49 Victor et al : Pediatr 2005 Ventilation: pCO2

50 pCO2 (mmHg) rScO2 Ventilation: pCO2

51 PV cysts Ventilation: pCO 2 ♀ 26 4/7 wks; 925 g; chorioamnionitis

52 Toet/ de vries Ventilation: pCO2 pCO2 107 mmHg pCO2 68 mmHg

53 rScO 2 (%) fiO Ventilation: pO2

54 Brain monitoring during (artificial) ventilation can help to prevent hypo/hyper perfusion and hyper/hypoxemia and so brain damage Suggestion

55 Relation brain monitoring  Hypotension  Patent ductus arteriosus  Autoregulatory ability  (Mechanical) ventilation  Surgery

56 Neonatal cardiac surgery Toet et al Exp Brain Res 2009 Phelps et al 2009 Sood et al J Thorac Cardiovasc surg 2013 Low cerebral saturations (<35%-45% ) related with adverse outcome

57 Preliminary data 20 infants monitoring data: no analysis 11 infants MRI 4-7 days after surgery 4 normal Cerebellar hemorrhages; infarction basal ganglia; white matter lesions –acute brain damage? or already there prenatally? –due to hypoperfusion? or neurotoxicity? –relation with outcome?

58

59 ADC-MAP T2-W Thanks to M Benders

60 Conclusions The current results of our studies in neonates strongly suggest that SaO2 does not always reflect oxygenation of the neonatal brain. Thus monitoring of cerebral oxygenation by NIRS and brain function by aEEg in addition to SaO2 and blood pressure, can help to prevent brain damage but also prevent unnecessary treatment.

61 Limitations No randomised trials, so scarse proven data are available of benefits in infants undergoing surgical procedures Conclusions are experience based However:

62 The number of infants with (minor) neurodevelopmental problems is high in infants undergoing surgical procedures in neonatal period So Neurodevelopmental delay needs to be investigated in relation to brain injury : brain monitoring (pre-existing) riskfactors brain injury by neuro-imaging longterm follow-up larger cohorts collaboration between disciplines in hospitals and multi-center

63 Study design Antenatally Obstetrics Diagnosis congenital anomaly Post partum Pediatrics and neonatology cUS + aEEG + NIRS Perioperatively Surgery and anesthesiology aEEG + NIRS + vitals + biomarkers Postoperatively Pediatrics and neonatology aEEG + NIRS + biomarkers + cUS + MRI Follow up at 2 and 5 years Psychology and physical therapy Neurodevelopmental outcome

64 Cerebral monitoring during neonatal surgery: a first step to improve outcome

65 Thank you Anesthesiologists: Jurgen de Graaff Desiree vd Werff Ton Schouten Pediatric Surgery: Maud van Herwaarden David van der Zee Psychology Monica Uniken Venema Mijntje van der Linden Pediatric intensive care Koos Jansen Neonatology –Manon Benders –Kristin Keunen –Mona Toet –Floris Groenendaal, –Linda de Vries –Frank van Bel

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67 Interventions A low rStO2 reflects a low oxygen supply to the brain (or a high use of oxygen by the braintissue) If rStO2 < 55%: – Assess cardiovascular status (BP; systemic circulation) – Assess oxygen transport (Hb) – Assess respiratory status (SaO2; pCO2; MAP)

68 Interventions A high rStO2 reflects a high oxygen supply to the brain (or less oxygen use by the brain) If rStO2 > 85%: – Assess respiratory status (SaO2; pCO2)

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70 Recommendations if rScO2 is out of expected range Check sensor Which sensor is used? Position

71 Preterms undergoing surgery Filan et al, J of Pediatr 2011 Introduction

72 Leading to neuro developmental problems Cerebral palsy Behaviour/school problems Neonatal brain damage


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