Successful Reduction in Electrode-Related Pressure Ulcers During EEG Monitoring in Critically Ill Neonates

Utility and rationale for continuous EEG monitoring: a primer for the general intensivist

This review offers a comprehensive guide for general intensivists on the utility of continuous EEG (cEEG) monitoring for critically ill patients. Beyond the primary role of EEG in detecting seizures, this review explores its utility in neuroprognostication, monitoring neurological deterioration, assessing treatment responses, and aiding rehabilitation in patients with encephalopathy, coma, or other consciousness disorders. Most seizures and status epilepticus (SE) events in the intensive care unit (ICU) setting are nonconvulsive or subtle, making cEEG essential for identifying these otherwise silent events. Imaging and invasive approaches can add to the diagnosis of seizures for specific populations, given that scalp electrodes may fail to identify seizures that may be detected by depth electrodes or electroradiologic findings. When cEEG identifies SE, the risk of secondary neuronal injury related to the time-intensity "burden" often prompts treatment with anti-seizure medications. Similarly, treatment may be administered for seizure-spectrum activity, such as periodic discharges or lateralized rhythmic delta slowing on the ictal-interictal continuum (IIC), even when frank seizures are not evident on the scalp. In this setting, cEEG is utilized empirically to monitor treatment response. Separately, cEEG has other versatile uses for neurotelemetry, including identifying the level of sedation or consciousness. Specific conditions such as sepsis, traumatic brain injury, subarachnoid hemorrhage, and cardiac arrest may each be associated with a unique application of cEEG; for example, predicting impending events of delayed cerebral ischemia, a feared complication in the first two weeks after subarachnoid hemorrhage. After brief training, non-neurophysiologists can learn to interpret quantitative EEG trends that summarize elements of EEG activity, enhancing clinical responsiveness in collaboration with clinical neurophysiologists. Intensivists and other healthcare professionals also play crucial roles in facilitating timely cEEG setup, preventing electrode-related skin injuries, and maintaining patient mobility during monitoring.

Protocols and their effects for medical device-related pressure injury prevention among critically ill patients: a systematic review

BACKGROUND

A pressure injury refers to localized damage to the skin and/or tissue due to prolonged pressure, and it has recently been defined to include pressure injuries related to medical devices. Medical device-related pressure injuries occur in various sites and are difficult to detect. Even if it is detected, medical devices are essential to life for critically ill patients. Thus, it is difficult to remove or change the position of the medical device; therefore, prevention is essential. This study aims to integrate the literature on medical device-related pressure injury prevention protocols among critically ill patients.

METHODS

The literature inclusion criteria were (1) critically ill patients, (2) device-related pressure injury interventions, (3) randomized controlled trials and quasi-experimental designs, and (4) written in Korean or English. The literature search and selection were performed following the Cochrane Handbook for Systematic Reviews of Interventions with the support of the PRISMA Guidelines.

RESULTS

Twelve articles were finally selected. The incidence of medical device-related pressure injury decreased from 8.1-96.7% before intervention to 0.3-53.3% after intervention, respectively. Medical device-related pressure injury prevention was effective in reducing medical device-related pressure injury incidence when applied to patients of all ages, from neonates to adults, in a variety of intensive care units. Medical device-related pressure injury prevention strategies include nurse education, assessment, documentation, and interventions (hygiene, repositioning, emergent therapy such as protective dressing or designed equipment reducing pressure) of pressure injury. Pressure injury dressings primarily included hydrocolloid foam dressings, but transparent hydrocolloid formulations also effectively reduced medical device-related pressure injury incidence rates.

CONCLUSIONS

In the future, it is necessary to increase the level of evidence by applying specialized medical device-related pressure injury prevention methods for different medical devices and areas of pressure injuries, and verifying their effectiveness.

TRIAL REGISTRATION

The review protocol was registered (PROSPERO registration number: CRD42022346450).

Review of Noninvasive Neuromonitoring Modalities in Children II: EEG, qEEG

Critically ill children with acute neurologic dysfunction are at risk for a variety of complications that can be detected by noninvasive bedside neuromonitoring. Continuous electroencephalography (cEEG) is the most widely available and utilized form of neuromonitoring in the pediatric intensive care unit. In this article, we review the role of cEEG and the emerging role of quantitative EEG (qEEG) in this patient population. cEEG has long been established as the gold standard for detecting seizures in critically ill children and assessing treatment response, and its role in background assessment and neuroprognostication after brain injury is also discussed. We explore the emerging utility of both cEEG and qEEG as biomarkers of degree of cerebral dysfunction after specific injuries and their ability to detect both neurologic deterioration and improvement.

Neonatal Electroencephalogram Electrode-Related Pressure Injury Prevention Quality Improvement Study

OBJECTIVE

To lengthen the days between electroencephalogram electrode-related pressure injury (EERPI) to 100 EERPI-free days in 6 months of study implementation with a goal to maintain 200 EERPI-free days thereafter (≤1 EERPI event/year).

METHODS

This quality improvement study took place in a level IV neonatal ICU over three epochs spanning 2 years: epoch 1 or baseline (January-June 2019), epoch 2 or implementation of intervention (July-December 2019), and epoch 3 or sustainment (January-December 2020). A daily electroencephalogram (EEG) skin assessment tool, introduction in practice of a flexible hydrogel EEG electrode, and successive rapid-cycle staff-education sessions were key interventions of the study.

RESULTS

Seventy-six infants were monitored for 214 continuous EEG (cEEG) days, of which six (13.2%) developed EERPI in epoch 1. Eighty infants were monitored for 193 cEEG days, of which two (2.5%) developed EERPI in epoch 2. One hundred thirty-nine infants were monitored for 338 cEEG days, and none developed EERPI in epoch 3. There was no statistical difference with respect to the median cEEG days among study epochs. A G-chart of EERPI-free days showed an increase in EERPI-free days from an average of 34 days in epoch 1 to 182 days in epoch 2 and 365 days (or zero harm) in epoch 3. Skin erythema from EEG electrodes was noted during the study.

CONCLUSIONS

The structured study interventions eliminated EERPI events in infants monitored with cEEG. Preventive intervention at the cEEG-electrode level coupled with skin assessment successfully reduced EERPIs in neonates.

Hospital-acquired skin lesions in the neonatal intensive care unit: A retrospective analysis of temporal trends and quality improvement strategies

PURPOSE

Skin lesions in neonatal population are an emerging problem deserving attention from health care professionals. The purpose of this study is to retrospectively assess the incidence of hospital-acquired skin lesions during a 6-year period and to describe the characteristics of infants who developed them.

DESIGN AND METHODS

This was a retrospective observational study conducted in a university-tertiary care center between 2015 and 2020. A descriptive analysis of the observed skin lesions is presented according to 2 time periods: 1) the implementation phase of a quality improvement program (2015-2019) and 2) the postimplementation phase (2020).

RESULTS

Our findings showed an apparent increase in the incidence of all reported skin lesions throughout the study period. Pressure injuries were the most frequently reported skin lesions showing an increasing incidence over time which, however, was paralleled by a reduction in their severity. Among pressure injuries, device-related injuries were the most commonly observed (56.6% and 62.5% in the two periods, respectively) with nasal continuous positive airway pressure-related injuries accounting for 71.7% and 56.0% of lesions, respectively, and mainly affecting the nose root. The occipital area was the most frequently involved site in cases of conventional pressure injuries.

CONCLUSION

Infants admitted to Neonatal Intensive Care Units may be at high risk of developing skin lesions. The adoption of appropriate preventative as well as treatment interventions could be effective in reducing the severity of pressure injuries.

PRACTICE IMPLICATIONS

The implementation of quality improvement strategies may contribute to prevent skin injuries or lead to their early detection.

Electroencephalogram background and head ultrasound together stratify seizure risk in neonates undergoing hypothermia

The benefits of continuous electroencephalography (cEEG) monitoring in the intensive care unit (ICU) are increasingly appreciated, though expanding indications for cEEG may strain resources. The current standard of care in babies with hypoxic-ischemic encephalopathy (HIE) undergoing therapeutic hypothermia (TH) includes cEEG monitoring throughout the entire TH and rewarming process (at least 72 h). Recent cEEG data demonstrate that most seizures occur within the first 24 h of monitoring. We hypothesized that abnormal head imaging and EEG background could stratify seizure risk in babies with HIE undergoing TH to identify candidates for early cEEG discontinuation. In this retrospective review of 126 neonates undergoing TH and cEEG, we identified seizures in 38 (30%) neonates, 33 (87%) of whom seized within the first 24 h of cEEG monitoring. EEG background was graded and demonstrated that 90% of neonates with seizures had a moderately/markedly abnormal background versus 33% of neonates who did not seize (p < 0.0001). Additionally, while head ultrasound (HUS) obtained before EEG did not stratify seizure risk alone, no neonates with both a normal/mildly abnormal EEG background and a normal HUS (0/25) experienced seizures in contrast to 60% (24/40) neonates with both an abnormal EEG background and an abnormal HUS (p < 0.0001). Our data suggest that neonates with abnormal EEG backgrounds and abnormal HUS should be monitored for seizures throughout TH and rewarming, while neonates with normal/mildly abnormal EEG backgrounds and normal HUS are at low risk of seizures after 24 h of monitoring, and thus would be candidates for early cEEG discontinuation.

Neonatal Seizures: Core Concepts

Seizures are the abnormal, excessive, synchronous discharge of cortical neurons that results in injury to the brain. Seizures presenting in the neonatal period may be the first and only clue to underlying neurological pathology. Despite advances in care, the mortality rate for infants experiencing neonatal seizures is still as high as 20 percent, with up to 65 percent of infants with seizures demonstrating significant morbidity. Early identification and treatment of the seizure or modifiable underlying etiology greatly reduces the extent of morbidity associated with neonatal seizures. Literature, including journal articles and relevant textbooks, was reviewed and condensed into a practical guide to neonatal seizures which includes the pathophysiology of injury associated with neonatal seizures, clinical manifestations, methods of diagnosis, and various options available for treatment.

An Introduction to Neonatal EEG

Newborn care has witnessed significant improvements in survival, but ongoing concerns persist about neurodevelopmental outcome. Protecting the newborn brain is the focus of neurocritical care in the intensive care unit. Brain-focused care places emphasis on clinical practices supporting neurodevelopment in conjunction with early detection, diagnosis, and treatment of brain injury. Technology now facilitates continuous cot-side monitoring of brain function. Neuromonitoring techniques in neonatal intensive care units include the use of electroencephalography (EEG) or amplitude-integrated EEG (aEEG) and near-infrared spectroscopy. This article aims to provide an introduction to EEG, which is appropriate for neonatal healthcare professionals.