Innovation in Neonatal Intensive Care Jeanne Mrozek MD

Innovation in Neonatal Intensive Care Jeanne Mrozek, MD Medical Director, NICU, Children’s Hospital MN- Minneapolis Tom George, MD Medical Director, NICU, University of Minnesota Masonic Children's Hospital Associate Director, Pediatric Residency Program, University of Minnesota

A look back…

Surfactant • Ist Trial 1980 • FDA approval

• Respiratory support – – – Conventional High frequency oscillator High frequency Jet Nitric oxide NAVA • ECMO • Incubators • Nutrition – TPN – Milk banks • Family Centered Care • Vermont Oxford Network

Procedural Pain in Neonates • Critical infant may experience > 480 painful procedures during an NICU stay • Negative long-term consequences – Increased morbidity – Increased risk IVH – Increased mortality • 33 week neonates have average of 10 painful procedures/day • Physiological and behavioral instability • Increased oxidative stress • Reduced body and head circumference growth

• Neonatal – Topical anesthesia – Sucrose – Positioning – Distraction

EMLA and Neonates • In neonates, EMLA reduces behavioral pain response to venipuncture but not heel lance. • Effective for neonates > 34 weeks gestation for lumbar puncture

Sucrose Reduces pain and cry during painful procedures • Effective dose (24%) 0, 05 -0. 5 ml • Administer 2 minutes prior to mild=moderately painful procedure • Duration- 4 minutes • Breastfeeding

Integrative Therapies for Neonates Nonpharmacologic, supportive measures: • Breastfeeding (Shah PS, Cochrane Database of Systematic Reviews 2006, Issue 3) • Sucrose (Stevens B, Cochrane Database of Systematic Reviews 2004, Issue 3 • Nesting/Swaddling • Kangaroo care (Gray, Pediatrics 2000; Johnston APAM 2003) • Dimming light & noise Premature 28 -36 wks: For heelstick, Kangaroo care more effective than oral glucose, which is more effective than placebo

Morphine does NOT provide adequate analgesia for acute procedural pain among preterm neonates • Combination of sucrose and radiant warmth effective analgesic in newborns; reduces pain better than sucrose alone

Swaddling, facilitated tucking, kangaroo care

Needle Pain Prevention • Treatment protocol for painful procedures is expected standard of care in 21 st century • Components – Topical anesthesia – Sucrose – Position – Integrative therapies/distraction

Monitoring in the NICU • Critically ill newborns require intense monitoring to make decisions regarding diagnosis and treatment • Advances over the last few years in: – neonatal monitoring of neurologic and cardiopulmonary health – newer uses for old imaging modalities

Neonatal seizures • Several causes for neonatal seizures • Estimated incidence of concern for neonatal seizures 1 in 200 to 500 newborns

Neurologic monitoring • a. EEG – amplitude integrated EEG – allows for continuous neuromonitoring for seizures or abnormal neuroactivity – easy to apply to screen for seizures, available 24/7 if full EEG is not easily accessible

NIRS monitoring • Neonates have a wide variety of cardiopulmonary complications caused by several different diagnoses • Blood pressure is of limited value as a clinical guide to treatment • Echocardiogram can provide data but is not immediately available in all units • Expanding role for Near-infrared spectroscopy monitoring (NIRS)

NIRS monitoring • Uses a beam of light in the near infrared range (700 -1000 mm) that passes through tissue, and measures absorption and scattering of photons • Qualitatively measures cerebral or somatic (renal, splanchnic) oxygenation • Helps determine goals for blood pressure, volume • Reflects real-time changes in regional tissue perfusion adequacy, may precede changes in systemic parameters

NIRS

Monitoring for sepsis • Heart rate characteristics monitoring • Abnormal HRC in neonatal sepsis • UVA generated a HRC index, that is displayed by a He. RO monitor • He. RO renders a score every hour that is the risk of infection in the next 24 hours

HRC monitoring • 22% reduction in mortality Fairchild et al Ped Res 2013

465– 471 Ultrasound use in the NICU • Routinely used to screen for intracranial pathology • Targeted neonatal echocardiography in real time for rapid assessment de Boode et al, Pediatr Res 2016 • Use for diagnosis of neonatal respiratory distrss syndrome and transient tachypnea of the newborn Vergine et al Neonatology, 2014

Ultrasound use in the NICU • Use for diagnosis of neonatal respiratory distrss syndrome and transient tachypnea of the newborn Vergine et al Neonatology. 2014 • For diagnosis of necrotizing enterocolitis Engel et al Ultrasound Q 2012

Ultrasound use in the NICU • For guiding placement of umbilical and other central lines Engel et al Ultrasound Q 2012 • For endotracheal tube placement Sim et al Resuscitation 2016

Thank you!

References Anand KJS (1999) Arch Pediatr Adolesc Med 153: 331 -8 Carbajal, R. , et al. Epidemiology and treatment of painful procedures in neonates in intensive care units. The Journal of the American Medical Association 2008, 157, 1058 -64. Holsti L et al. Specific Newborn Individualized Developmental Care and Assessment Program movements are associated with acute pain in preterm infants in the neonatal intensive care unit. Pediatrics. 2004 Jul; 114(1): 65 -72. Slater L, et al. Procedural pain and oxidative stress in premature neonates. The journal of pain 2012 Jun; 13(6): 590 -7. Vinall, J. S. et al. (2012). "Neonatal pain in relation to postnatal growth in infants born very preterm. " Pain 153(7): 1374 -1381. lance Taddio A, et al: A systematic review of lidocaineprilocaine cream (EMLA) in the treatment of acute pain in neonates. Pediatrics 1998. 101(2): E 1 Kaur G, et al: A randomized trial of eutectic mixture of local anesthetics during lumbar puncture in newborns. Arch Pediatr Adolesc Med 2003, 157(11): 1065 -70 Taddio A, et al. Reducing the pain of childhood vaccination: an evidence-based clinical practice guideline. CMAJ : Canadian Medical Association journal 2010 Dec 14; 182(18): E 843 -55. Freire NB, et al. Evaluation of analgesic effect of skin-to-skin contact compared to oral glucose in preterm neonates. Pain. 2008; 139(1): 28 -33. Epub 2008 Carbajal R, et al. Morphine does not provide adequate analgesia for acute procedural pain among preterm neonates. Pediatrics. 2005 Jun; 115(6): 1494 -500. Gray L, et al. Sucrose and warmth for analgesia in healthy newborns: an RCT. Pediatrics. Mar 2015; 135(3): e 607614.

References • • • Greisen et al Has the time come to use near-infrared spectroscopy as a routine clinical tool inn preterm infants undergoing intensive care? Phil Trans R Soc 2011 369, 4440 -4451 Fairchild et al Septicemia mortality reduction in neonates in a heart rate characteristics monitoring trial Pediatr Res 2013 Nov; 74(5): 570 de Boode et al, Pediatr Res 2016 Recommendations for neonatoligst performed echocardiography in Europe: Consensus statement endorsed by European Society for Paediatric Research (ESPR) and European Societry for Neonatology (ESN) 80: 465 -471 -5 Vergine et al Neonatology. Lung ultrasound accuracy in respiratory distress syndrome and transient tachypnea of he newborn. 2014; 106(2): 87– 93 Engel et al Ultrasound Q 2012 Underutilized ultrasound applications in the neonatal intensive care unit. 28 (4): 299 -304 Sim et al Resuscitation 2016 The utility of ultasonography to confirm proper endotracheal tube placement in neonates Pages e 19–e 20)