Intraventricular Hemorrhage in the Neonate

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1 Intraventricular Hemorrhage in the Neonate Angela Forbes, RN, MN, ARNP Seattle Children s Hospital Division of Pediatric Neurosurgery Seattle, Washington, U.S.A.

2 Intraventricular Hemorrhage Who Premature infants (less than 32 weeks) Low birth weight (< grams) What IVH is the most frequent and devastating neurological complication of premature birth. Approximately 25-50% of infants with IVH develop post hemorrhagic hydrocephalus (PHH) IVH and PHH are known to have long term neurological sequelae, including cognitive delays, visual impairment, behavioral problems, epilepsy and cerebral palsy.

3 Neuroimaging in Neonate with IVH Grading of IVH based on neuroimaging Ultrasound CT MRI

4 Neuroimaging in the Neonate with IVH Ultrasound Blood in enlarged ventricles

5 Neuroimaging in the Neonate with IVH CT Blood in ventricle

6 Neuroimaging in the Neonate with IVH CT with 3D reconstruction showing splayed sutures Splayed sutures

7 Neuroimaging in the Neonate with IVH MRI Blood in enlarged ventricles

8 IVH Grading IVH grade I Isolated to the germinal matrix Prognosis similar to a neonate without IVH IVH grade II Blood extending into normal sized ventricles (filling less than 50% of the volume of the ventricle Prognosis similar to a neonate without IVH IVH grade III Blood extended into ventricles causing them to be distended (filling >50% of ventricles) ~20% mortality IVH grade IV Grade III but also with parenchymal hemorrhage 90% mortality

9 Case Study Baby K born at 28-3/7 weeks' gestation at 1050 grams Cranial US demonstrated bilateral grade III IVH with resultant PHH Head circumference has increased 2.5 cm in the first 2 weeks Baby K was having apneic events with bradycardia requiring escalating respiratory support Taken to the OR for placement of subgaleal hybrid system

10 Surgical Treatment of IVH/PHH Subgaleal Reservoir

11 Surgical Treatment of IVH/PHH Subgaleal Shunt

12 Large subgaleal pocket Subgaleal Pocket

13 Surgical Treatment of IVH/PHH Hybrid Subgaleal

14 Case Study Baby K was symptomatic with frequent apneic/bradycardic events which would respond well to tapping of the reservoir, but he would become symptomatic again later in the day Reservoir tapping frequency was increased to twice daily and he responded well BUT

15 Case Study A tap occurred when fontanelle was flat, patient was asymptomatic, OFC was stable and patient had no imaging After the tap the fontanelle became extremely sunken Ultrasound demonstrated new parenchymal hemorrhage as well as new subdural hygromas

16 Case Study Why did this happen? We had no policy in place for tapping Who When/Why

17 Clinical Policy Management of Subgaleal Reservoirs and Shunts

18 Clinical Policy Defined Who Will Tap Who Subgaleal reservoir tap can be performed only by a member of the Neurosurgery Team or by a trained NICU Attending Physician. Training for NICU Attendings includes credentialing by Seattle Children s Hospital. Credentialing by Seattle Children's Hospital includes observation and demonstration of competency.

19 Creation of a Subgaleal Simulator

20 Clinical Policy Defined When and Why to Tap When/Why Increased FOR on ultrasound (or other radiographic image) Anterior fontanelle bulging above the bone when the baby is calm and head is elevated Mid-sagittal suture splaying of more than 2 mm Apnea and/or bradycardia Increasing OFC (greater than 1 cm a week) If the ventricles are larger on imaging but the fontanelle is sunken then HOLD tapping until the next assessment

21 FOR (FOR fronto and occipital horn ratio)

22 Clinical Policy Defined Assessment Daily Assessment by the NICU and Twice weekly clinical assessment by Neurosurgery Team to include documentation of: Anterior fontanelle bulging above the bone when the baby is calm and head is elevated Mid-sagittal suture splaying of more than 2 mm Apnea and/or bradycardia out of proportion to that related to prematurity / above baseline for that patient Increasing OFC (greater than 1 cm a week) Twice weekly cranial ultrasound (recommended Monday and Thursday)

23 Clinical Policy Defined Post-Operative Nursing Care Skin Care/Incisions Incisions may be washed with soap and water after 48 hours. Otherwise incision must be kept dry. No ointments or creams should be applied to the incision. No soaking the incisions for 4-6 weeks. Please monitor the incision for erythema, swelling or drainage. Please notify Neurosurgery if there is any leaking, erythema or swelling from incision or around reservoir/valve. Positioning Ensure that infant does not maintain pressure on incision or subgaleal reservoir/shunt secondary to integrity of skin Family Education

24 Brains give rise to our ability to form relationships and make life meaningful sometimes they break. Paul Kalanithi, 2016