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Mohammad K. Standardizing clinician training and patient care in the neonatal neurocritical care: A step-by-step guide. Semin Perinatol 2024; 48:151924. [PMID: 38897827 DOI: 10.1016/j.semperi.2024.151924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
Neonatal neurocritical care (NNCC) has emerged as an important specialty to address neurological conditions affecting newborns including a wide spectrum of brain injuries and developmental impairment. Despite the discipline's growth, variability in NNCC service delivery, patient care, and clinical training poses significant challenges and potentially adversely impacts patient outcomes. Variations in neuroprotective strategies, postnatal care, and training methodologies highlight the urgent need for a unified approach to optimize both short- and long-term neurodevelopmental outcomes for these vulnerable population. This paper presents strategic blueprints for establishing standardized NNCC clinical care and training programs focusing on collaborative effort across medical and allied health professions. By addressing these inconsistencies, the paper proposes that standardizing NNCC practices can significantly enhance the quality of care, streamline healthcare resource utilization, and improve neurodevelopmental outcome, thus paving the way for a new era of neonatal neurological care.
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Affiliation(s)
- Khorshid Mohammad
- Section of Newborn Critical Care, Department of Pediatrics, University of Calgary, Canada.
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Lee KS, Massaro A, Wintermark P, Soul J, Natarajan G, Dizon MLV, Mietzsch U, Mohammad K, Wu TW, Chandel A, Shenberger J, DiGeronimo R, Peeples ES, Hamrick S, Cardona VQ, Rao R. Practice Variations for Therapeutic Hypothermia in Neonates with Hypoxic-ischemic Encephalopathy: An International Survey. J Pediatr 2024; 274:114181. [PMID: 38950817 DOI: 10.1016/j.jpeds.2024.114181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 06/06/2024] [Accepted: 06/25/2024] [Indexed: 07/03/2024]
Abstract
OBJECTIVE To evaluate variations in management of therapeutic hypothermia (TH) for neonatal hypoxic-ischemic encephalopathy (HIE) among international clinical sites and to identify areas for harmonization. STUDY DESIGN An electronic survey was sent to Children's Hospitals Neonatal Consortium site sponsors, Canadian Neonatal Network site investigators, members of the Newborn Brain Society, and American Academy of Pediatrics Neonatology chiefs. RESULTS One hundred five sites responded, with most from high-income regions (n = 95). Groupings were adapted from the United Nations regional groups: US (n = 52 sites); Canada (n = 20); Western Europe and other states excluding Canada and US Group (WEOG, n = 18); and non-WEOG (central and eastern Europe, Asia, Africa, Latin America, and Caribbean, n = 15). Regional variations were seen in the eligibility criteria for TH, such as the minimum gestational age, grading of HIE severity, use of electroencephalography, and the frequency of providing TH for mild HIE. Active TH during transport varied among regions and was less likely in smaller volume sites. Amplitude-integrated electroencephalogram and/or continuous electroencephalogram to determine eligibility for TH was used by most sites in WEOG and non-WEOG but infrequently by the US and Canada Groups. For sedation during TH, morphine was most frequently used as first choice but there was relatively high (33%) use of dexmedetomidine in the US Group. Timing of brain magnetic resonance imaging and neurodevelopmental follow-up were variable. Neurodevelopmental follow occurred earlier and more frequently, although for a shorter duration, in the non-WEOG. CONCLUSIONS We found significant variations in practices for TH for HIE across regions internationally. Future guidelines should incorporate resource availability in a global perspective.
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Affiliation(s)
- Kyong-Soon Lee
- Division of Neonatology, the Hospital for Sick Children, Department of Paediatrics, University of Toronto, Canada.
| | - An Massaro
- Division of Neonatology, Children's National Hospital, Department of Pediatrics, The George Washington School of Medicine, Washington, DC
| | - Pia Wintermark
- Division of Newborn Medicine, Department of Pediatrics, Montreal Children's Hospital, Research Institute of the McGill University Health Centre, McGill University, Montreal, Canada
| | - Janet Soul
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Girija Natarajan
- Children's Hospital of Michigan/Wayne State University, Detroit, MI
| | - Maria L V Dizon
- Division of Neonatology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Ulrike Mietzsch
- Division of Neonatology, Department of Pediatrics, University of Washington/Seattle Children's Hospital, Seattle, WA
| | - Khorshid Mohammad
- Department of Pediatrics, Section of Newborn Critical Care, University of Calgary, Cumming School of Medicine, Alberta Children's Hospital, Calgary, Canada
| | - Tai-Wei Wu
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Amit Chandel
- Atrium Health Wake Forest Baptist, Winston-Salem, NC
| | | | - Robert DiGeronimo
- Division of Neonatology, Seattle Children's Hospital, University of Washington, Seattle, WA
| | - Eric S Peeples
- Division of Neonatology, Department of Pediatrics, Children's Nebraska, University of Nebraska Medical Center, Omaha, NE
| | - Shannon Hamrick
- Emory University and Children's Healthcare of Atlanta, Atlanta GA
| | | | - Rakesh Rao
- Division of Newborn Medicine, Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
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J A, S S, P W, S W, P B, K M. Quality improvement and outcomes for neonates with hypoxic-ischemic encephalopathy: obstetrics and neonatal perspectives. Semin Perinatol 2024; 48:151904. [PMID: 38688744 DOI: 10.1053/j.semperi.2024.151904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
Despite significant improvement in perinatal care and research, hypoxic ischemic encephalopathy (HIE) remains a global healthcare challenge. From both published research and reports of QI initiatives, we have identified a number of distinct opportunities that can serve as targets of quality improvement (QI) initiatives focused on reducing HIE. Specifically, (i) implementation of perinatal interventions to anticipate and timely manage high-risk deliveries; (ii) enhancement of team training and communication; (iii) optimization of early HIE diagnosis and management in referring centers and during transport; (iv) standardization of the approach when managing neonates with HIE during therapeutic hypothermia; (v) and establishment of protocols for family integration and follow-up, have been identified as important in successful QI initiatives. We also provide a framework and examples of tools that can be used to support QI work and discuss some of the perceived challenges and future opportunities for QI targeting HIE.
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Affiliation(s)
- Afifi J
- Department of Pediatrics, Neonatal-Perinatal Medicine, Dalhousie University, 5980 University Avenue, Halifax B3K6R8, Nova Scotia, Canada.
| | - Shivananda S
- Department of Pediatrics, Neonatal-Perinatal Medicine, University of British Columbia, Canada
| | - Wintermark P
- Department of Pediatrics, Neonatal-Perinatal Medicine, McGill University, Canada
| | - Wood S
- Department of Obstetrics and Gynecology, University of Calgary, Canada
| | - Brain P
- Department of Obstetrics and Gynecology, University of Calgary, Canada
| | - Mohammad K
- Department of Pediatrics, Section of Newborn Intensive Care, University of Calgary, Canada
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Cizmeci MN, Wilson D, Singhal M, El Shahed A, Kalish B, Tam E, Chau V, Ly L, Kazazian V, Hahn C, Branson H, Miller SP. Neonatal Hypoxic-Ischemic Encephalopathy Spectrum: Severity-Stratified Analysis of Neuroimaging Modalities and Association with Neurodevelopmental Outcomes. J Pediatr 2024; 266:113866. [PMID: 38061422 DOI: 10.1016/j.jpeds.2023.113866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/26/2023] [Accepted: 12/04/2023] [Indexed: 01/01/2024]
Abstract
OBJECTIVE To compare hypoxic-ischemic injury on early cranial ultrasonography (cUS) and post-rewarming brain magnetic resonance imaging (MRI) in newborn infants with hypoxic-ischemic encephalopathy (HIE) and to correlate that neuroimaging with neurodevelopmental outcomes. STUDY DESIGN This was a retrospective cohort study of infants with mild, moderate, and severe HIE treated with therapeutic hypothermia and evaluated with early cUS and postrewarming MRI. Validated scoring systems were used to compare the severity of brain injury on cUS and MRI. Neurodevelopmental outcomes were assessed at 18 months of age. RESULTS Among the 149 included infants, abnormal white matter (WM) and deep gray matter (DGM) hyperechogenicity on cUS in the first 48 hours after birth were more common in the severe HIE group than the mild HIE group (81% vs 39% and 50% vs 0%, respectively; P < .001). In infants with a normal cUS, 95% had normal or mildly abnormal brain MRIs. In infants with severely abnormal cUS, none had normal and 83% had severely abnormal brain MRIs. Total abnormality scores on cUS were higher in neonates with near-total brain injury on MRI than in neonates with normal MRI or WM-predominant injury pattern (adjusted P < .001 for both). In the multivariable model, a severely abnormal MRI was the only independent risk factor for adverse outcomes (OR: 19.9, 95% CI: 4.0-98.1; P < .001). CONCLUSION The present study shows the complementary utility of cUS in the first 48 hours after birth as a predictive tool for the presence of hypoxic-ischemic injury on brain MRI.
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Affiliation(s)
- Mehmet N Cizmeci
- Division of Neonatology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada.
| | - Diane Wilson
- Division of Neonatology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Maya Singhal
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Amr El Shahed
- Division of Neonatology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Brian Kalish
- Division of Neonatology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Emily Tam
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Vann Chau
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Linh Ly
- Division of Neonatology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Vanna Kazazian
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Cecil Hahn
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Helen Branson
- Division of Radiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Steven P Miller
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada; Department of Pediatrics, BC Children's Hospital, University of British Columbia, Vancouver, Canada
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Amer YS, Anabrees J, Abdelmawla M, Abdalgader A, Almazroei A, Alhifzi I, AlOnazi AH, Sabr Y, Hneiny L, El-Malky A, Alshalawi A, Alayoubi A, Chaudhry IA, Elkhateeb O. Clinical practice guidelines for neonatal hypoxic-ischemic encephalopathy: A systematic review using the appraisal of guidelines for research and evaluation (AGREE) II instrument. Front Pediatr 2023; 11:1092578. [PMID: 37033166 PMCID: PMC10073446 DOI: 10.3389/fped.2023.1092578] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 02/27/2023] [Indexed: 04/11/2023] Open
Abstract
Background and Objective To systematically review, critically appraise the quality of recent clinical practice guidelines (CPGs) for neonatal hypoxic ischemic encephalopathy (HIE), and map their recommendations. Data Sources CPG databases (GIN, ECRI, NICE, SIGN, DynaMed), Bibliographic databases (PubMed, Embase, CINAHL), and related specialized professional societies (e.g., AAP, CPS, BAPM, RCPCH, and SNS). Study Selection Original de-novo developed evidence-based CPGs for HIE, group authorship, Arabic or English languages, and international or national scope. The systematic review was drafted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement and Johnston et al methodological guide. Data Extraction Quality assessment of the included HIE CPGs by the Appraisal of Guidelines for REsearch & Evaluation II (AGREE II) Instrument and report their characteristics, AGREE II ratings, and recommendations. Data Synthesis Our search retrieved 2,489 citations, of which two recent HIE CPGs were eligible and appraised: Canadian Paediatric Society (CPS) and Queensland Maternity and Neonatal Services (QMN). The overall assessment of the QMN CPG was superior (83%). Domain 1 (Scope & Purpose) scored (47%, 63%), Domain 2 (Stakeholder Involvement) (72%, 39%), Domain 3 (Rigour of Development) (48%, 43%), Domain 4 (Clarity & Presentation) (100%, 96%), Domain 5 (Applicability) (59%, 9%), and Domain 6 (Editorial Independence) (67%, 17%) for the QMN and CPS CPGs respectively. All appraisers recommended the QMN CPG for use in practice. Conclusion The methodological quality of the QMN CPG was superior with the relevant recommendations for its use in neonatal practice. Limitations limited to Arabic and English languages. Systematic Review Registration https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=258291, identifier: CRD42021258291.
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Affiliation(s)
- Yasser S. Amer
- Pediatrics Department, King Khalid University Hospital, King Saud University Medical City, Riyadh, Saudi Arabia
- Clinical Practice Guidelines and Quality Research Unit, Quality Management Department, King Saud University Medical City, Riyadh, Saudi Arabia
- Research Chair for Evidence-Based Health Care and Knowledge Translation, King Saud University, Riyadh, Saudi Arabia
- Alexandria Center for Evidence-Based Clinical Practice Guidelines, Alexandria University, Alexandria, Egypt
- Adaptation Working Group, Guidelines International Network, Perth, Scotland
- Correspondence: Yasser S. Amer Jasim Anabrees
| | - Jasim Anabrees
- Pediatrics Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Saudi Neonatology Society (SNS), Riyadh, Saudi Arabia
- Correspondence: Yasser S. Amer Jasim Anabrees
| | - Mohamed Abdelmawla
- Pediatrics Department, King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia
| | - Ayman Abdalgader
- Neonatology Department, Pediatric Hospital, King Saud Medical City, Riyadh, Saudi Arabia
| | - Asmaa Almazroei
- Pediatrics Department, King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia
| | | | - Abdullah Hawash AlOnazi
- Neonatal Intensive Care Unit, Critical Care Services, King Fahad Medical City, MOH, Riyadh, Saudi Arabia
| | - Yasser Sabr
- Obstetrics and Gynecology Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Layal Hneiny
- Wegner Health Sciences Library, University of South Dakota, Sioux Falls, SD, United States
| | - Ahmed El-Malky
- Morbidity and Mortality Unit, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
- Public Health and Community Medicine Department, Theodor Bilharz Research Institute (TBRI), Academy of Scientific Research, Cairo, Egypt
| | - Ayesha Alshalawi
- Nursing Department, King Saud Medical City, Ministry of Health, Riyadh, Saudi Arabia
| | - Ahmed Alayoubi
- Pediatric Department, Umm Al Qura University, Makkah, Saudi Arabia
| | - Iftikhar A. Chaudhry
- Obstetrics and Gynecology Department, Al-Yamamah Hospital, Ministry of Health, Riyadh, Saudi Arabia
| | - Omar Elkhateeb
- Neonatal Intensive Care Unit, Critical Care Services, King Fahad Medical City, MOH, Riyadh, Saudi Arabia
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