QuickStart Guide Top Takeaway Series - Neuroprotection

Written by Sarah Bakke

In this month’s Neuro-Nurturing NICU Quickstart Guide Top Takeaway Series, we’ll dig in to neuro protection. Missed last month’s blog on neuro-monitoring? You can access it HERE.

In the Quick Start Guide and video series, Kathi introduces us to the 4 Pillars of NeuroNICU care – Neuro-assessment, Neuro-monitoring, Neuro-protection, and Neuro-development.

So let’s talk about the evolution of neuroprotection. When neuroprotection first became part of the NICU dialogue it was typically used to describe those interventions aimed at preventing brain injury and neuronal death. Over the past decade, the term neuroprotection has evolved to describe all therapies and interventions that not just project the newborn brain from injury, but also to support the brain after an injury has occurred.

Here are my top three practical takeaways from the Quick Start Guide video series:

TAKEAWAY 1

What interventions can we implement to prevent injury?

Kathi introduces one of the more popular preventative neuroprotective strategies, midline head positioning. The practice of midline head positioning is typically part of a larger intraventricular hemorrhage (IVH) prevention bundle that includes interventions such as keeping extremely low birthweight (ELBW) neonates positioned with their head midline for the first four days of life in contrast to the more traditional method of positioning supine with the head rotated laterally 90 degrees and simply alternating head position every 3-4 hours. There are a multitude of studies in the literature to support midline head positioning, including a recent study which found that elevated midline head positioning resulted in “lower FiO2 requirement, improved mean blood pressure and potentially improved survival.” (1)

Not sure how to get your midline head positioning quality improvement initiative rolling? Make sure to check out the “Transforming Research into Practice in the Neuro-Nurturing NICU” section of the QuickStart Guide course.

TAKEAWAY 2

What emerging interventions are being studied to help the brain recover from injury?

Although NICU teams around the world have invested much time and effort in implementing quality improvement projects like midline head positioning, we have made little progress in reducing the rate of neonatal brain injury (and other morbidities) for term or preterm infants in decades. Kathi takes us through some emerging therapies aimed at helping the brain to recover from injury through:

increasing neuronal resiliency – e.g. investigational and neuro-protective agents like Magnesium Sulfate (2), Epogen (3), Indomethacin, Xenon (4), and practice changes like delayed cord-clamping (5-6); and/or
enhancing and accelerating recovery and/or salvaging injured neurons – e.g. investigational use of melatonin (7) in premature infants or those with HIE.

TAKEAWAY 3

What emerging research is being done with Therapeutic Hypothermia?

Of course, what discussion of neuroprotective strategies would be complete without discussing Therapeutic Hypothermia? Kathi summarizes the current recommendations that servo regulated whole body cooling be used in the treatment of neonates within 6 hours of sustaining an ischemic brain injury who are at least 36 weeks postmenstrual age (PMA). But she also discussed new studies being done on earlier cooling that shows promise for more motor protection.

Are you sure that you’re unit is using therapeutic hypothermia according to the latest evidence based practice guidelines? Make sure to read the article “Ensuring Quality in the NICU: Translating Research Into Appropriate Clinical Care” available now in the QuickStart Guide.

Want to learn more about Therapeutic Hypothermia? Join our Brain Cooling Club.

REFRENCES

Elevated midline head positioning of extremely low birth weight infants: effects on cardiopulmonary function and the incidence of periventricular-intraventricular hemorrhage. – https://www.ncbi.nlm.nih.gov/pubmed/30348960
Antenatal magnesium sulphate neuroprotection in the preterm infant. – https://www.ncbi.nlm.nih.gov/pubmed?term=17513184
Neuroprotective potential of erythropoietin in neonates; design of a randomized trial – https://mhnpjournal.biomedcentral.com/articles/10.1186/s40748-015-0028-z
Hypothermia and xenon: novel noble guardians in hypoxic-ischemic encephalopathy? – https://www.ncbi.nlm.nih.gov/pubmed/23335252
Delayed Cord Clamping in Very Preterm Infants Reduces the Incidence of Intraventricular Hemorrhage and Late-Onset Sepsis: A Randomized, Controlled Trial – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1564438/
Delayed Umbilical Cord Clamping After Birth – ACOG Committee Opinion 2017 – https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Delayed-Umbilical-Cord-Clamping-After-Birth
Melatonin in the management of perinatal hypoxic-ischemic encephalopathy: light at the end of the tunnel? — https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5045913/