Pediatric Critical Care Medicine Fellow Baylor College of Medicine, United States
Abstract:
Introduction: Neonates with congenital heart disease (CHD) are at risk of brain injury from the time they are in utero, through birth, and throughout their admission in the cardiac intensive care unit (CICU). Their anatomy and physiology often exposed these patients to periods of hypoxemia, ischemia and inflammation in the CICU, and they are at risk of neurologic insults with resulting neurodevelopmental sequelae. At our institution we have formulated a comprehensive neuro-monitoring protocol for all infants with critical congenital heart disease requiring intervention.
Methods: All patients who require cardiac intervention in the first 30 days of life are included in the neuromonitoring protocol. Cerebral near infrared spectroscopy (NIRS) is used on all infants upon admission to the CICU. Patients also receive a pre-operative MRI study to screen for intracranial abnormalities. The MRI imaging is non-contrast and is an abbreviated 3D T1 and axial T2,DTI, and SWI sequence developed in collaboration with neuroradiology. Patient is transported and monitored by cardiac anesthesia during study. No sedation is used. If abnormalities are found, neurosurgical and neurology consults are obtained.
Intraoperatively, all neonates are monitored with bilateral cerebral NIRS. For those neonates undergoing complex aortic surgery, transcranial Doppler (TCD) with insonation through anterior fontanelle is utilized to assess cerebral flow during periods of antegrade cerebral perfusion (ACP). If NIRS or CBF drop from the pre-bypass baseline, interventions are implemented to augment cerebral oxygenation and blood flow. This includes, blood transfusion, increasing blood pressure, increasing plasma carbon dioxide and increasing bypass flow.
Post-operatively, all patients are monitored with cerebral NIRS. Those neonates that had complex aortic surgery, open chest, or ECMO support undergo 48 hours of continuous EEG monitoring and neurology consultation. A postoperative, non-sedated MRI – with identical protocol as the pre-operative study – is completed prior to discharge from hospital.
Results: Between 2015 to present, 713 neonates under the 30 days old underwent cardiac intervention in our center. Of those, 445 (62%) had pre-operative brain MRI, and 173 (24%) had both pre-operative and post-operative MRI. The percentage of eligible infants who receive their neuroimaging increase each year as compliancy to the protocol improved.
Conclusion: Given the high risk of neurological insult in this vulnerable patient population, with this protocol, we closely monitor for neurologic insult with a non-invasive neuromonitoring protocol.
