Mietzsch Ulrike, Cooper Kristin L, Harris Mandy L
Departments of Pediatrics/Division of Neonatology (Dr Mietzsch) and Neurology, Division of Child Neurology (Dr Harris), Indiana School of Medicine, Indianapolis; Department of Pediatrics, Division of Neonatology, University of Washington School of Medicine, Seattle (Dr Mietzsch); and Department of Neurophysiology, Indiana University Health, Neuroscience Center-Goodman Hall, Indianapolis (Ms Cooper).
Adv Neonatal Care. 2019 Aug;19(4):262-274. doi: 10.1097/ANC.0000000000000641.
Neonates are at a high risk for pressure ulcers (PU) due to skin immaturity and exposure to various medical devices. The prevalence of PU in the neonatal intensive care unit is estimated to be 23%, with 80% of those being related to medical devices, including electroencephalographic (EEG) electrodes. Proposed mechanisms involve prolonged pressure to the electrodes and chemical reactions to conductive agents.
The object of this quality improvement project was to reduce PU in neonates during continuous EEG (cEEG) monitoring by 50% within 12 months and 75% within 18 months. A secondary objective was to eliminate electrode-related infections by 12 months. Balancing measures included gestational age at the time of monitoring, integrity of the EEG setup, and cost effectiveness. The process measure was adherence to the skin-monitoring tool kit.
A multiple Plan-Do-Study-Act cycle method was used. All neonates monitored with cEEG were included. The monitoring tool kit was used to document the condition of scalp and EEG electrodes before, during, and after cEEG.
In the preproject period, 8.5% (9/106) of monitored patients developed PU, and 22.2% (2/9) of those developed infections. During the project period, 3.5% (7/198) of monitored patients developed PU and no infections were observed. During monitoring, 21 patients showed skin irritation, and timely intervention resulted in resolution in more than 90% of the cases and prevented progression into PU. Silver/silver chloride-plated electrodes, when exposed to external heat sources, can cause burns, resembling PU.
Intervention at the electrode level together with skin inspection successfully reduces PU in neonates. Silver/silver chloride-plated electrodes should be avoided in neonates.
Further research is needed to identify the optimal electrode for neonatal EEG.
由于皮肤不成熟以及接触各种医疗设备，新生儿发生压疮（PU）的风险很高。新生儿重症监护病房中PU的患病率估计为23%，其中80%与医疗设备有关，包括脑电图（EEG）电极。推测的机制包括电极的长时间压迫以及对导电剂的化学反应。
本质量改进项目的目标是在12个月内将持续脑电图（cEEG）监测期间新生儿的PU减少50%，在18个月内减少75%。次要目标是在12个月内消除与电极相关的感染。平衡措施包括监测时的胎龄、EEG设置的完整性和成本效益。过程指标是对皮肤监测工具包的依从性。
采用多轮计划-执行-研究-行动循环方法。纳入所有接受cEEG监测的新生儿。使用监测工具包记录cEEG之前、期间和之后头皮及EEG电极的状况。
在项目前期，8.5%（9/106）的受监测患者发生了PU，其中22.2%（2/9）发生了感染。在项目期间，3.5%（7/198）的受监测患者发生了PU，未观察到感染。在监测期间，21例患者出现皮肤刺激，及时干预使90%以上的病例得到解决，并防止进展为PU。镀银/氯化银电极暴露于外部热源时可导致烧伤，类似于PU。
在电极层面进行干预并结合皮肤检查可成功降低新生儿的PU。应避免在新生儿中使用镀银/氯化银电极。
需要进一步研究以确定用于新生儿EEG的最佳电极。
