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Yang ZJ, Hopkins CD, Santos PT, Adams S, Kulikowicz E, Lee JK, Tandri H, Koehler RC. Neuroprotection provided by hypothermia initiated with high transnasal flow with ambient air in a model of pediatric cardiac arrest. Am J Physiol Regul Integr Comp Physiol 2024; 327:R304-R318. [PMID: 38860282 DOI: 10.1152/ajpregu.00078.2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 05/28/2024] [Accepted: 06/05/2024] [Indexed: 06/12/2024]
Abstract
Clinical trials of hypothermia after pediatric cardiac arrest (CA) have not seen robust improvement in functional outcome, possibly because of the long delay in achieving target temperature. Previous work in infant piglets showed that high nasal airflow, which induces evaporative cooling in the nasal mucosa, reduced regional brain temperature uniformly in half the time needed to reduce body temperature. Here, we evaluated whether initiation of hypothermia with high transnasal airflow provides neuroprotection without adverse effects in the setting of asphyxic CA. Anesthetized piglets underwent sham-operated procedures (n = 7) or asphyxic CA with normothermic recovery (38.5°C; n = 9) or hypothermia initiated by surface cooling at 10 (n = 8) or 120 (n = 7) min or transnasal cooling initiated at 10 (n = 7) or 120 (n = 7) min after resuscitation. Hypothermia was sustained at 34°C with surface cooling until 20 h followed by 6 h of rewarming. At 4 days of recovery, significant neuronal loss occurred in putamen and sensorimotor cortex. Transnasal cooling initiated at 10 min significantly rescued the number of viable neurons in putamen, whereas levels in putamen in other hypothermic groups remained less than sham levels. In sensorimotor cortex, neuronal viability in the four hypothermic groups was not significantly different from the sham group. These results demonstrate that early initiation of high transnasal airflow in a pediatric CA model is effective in protecting vulnerable brain regions. Because of its simplicity, portability, and low cost, transnasal cooling potentially could be deployed in the field or emergency room for early initiation of brain cooling after pediatric CA.NEW & NOTEWORTHY The onset of therapeutic hypothermia after cardiac resuscitation is often delayed, leading to incomplete neuroprotection. In an infant swine model of asphyxic cardiac arrest, initiation of high transnasal airflow to maximize nasal evaporative cooling produced hypothermia sufficient to provide neuroprotection that was not inferior to body surface cooling. Because of its simplicity and portability, this technique may be of use in the field or emergency room for rapid brain cooling in pediatric cardiac arrest victims.
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Affiliation(s)
- Zeng-Jin Yang
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, United States
| | - C Danielle Hopkins
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, United States
| | - Polan T Santos
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, United States
| | - Shawn Adams
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, United States
| | - Ewa Kulikowicz
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, United States
| | - Jennifer K Lee
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, United States
| | - Harikrishna Tandri
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland, United States
| | - Raymond C Koehler
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, United States
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Gundersen JK, Chakkarapani E, Menassa DA, Walløe L, Thoresen M. The effects of anaesthesia on cell death in a porcine model of neonatal hypoxic-ischaemic brain injury. BJA OPEN 2024; 10:100283. [PMID: 38741692 PMCID: PMC11089311 DOI: 10.1016/j.bjao.2024.100283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 03/30/2024] [Indexed: 05/16/2024]
Abstract
Background Hypothermia is neuroprotective after neonatal hypoxic-ischaemic brain injury. However, systemic cooling to hypothermic temperatures is a stressor and may reduce neuroprotection in awake pigs. We compared two experiments of global hypoxic-ischaemic injury in newborn pigs, in which one group received propofol-remifentanil and the other remained awake during post-insult hypothermia treatment. Methods In both studies, newborn pigs were anaesthetised using halothane during a 45-min global hypoxic-ischaemic insult induced by reducing Fio2 and graded hypotension until a low-voltage <7 μV electroencephalogram was achieved. On reoxygenation, the pigs were randomly allocated to receive 24 h of normothermia or hypothermia. In the first study (n=18) anaesthesia was discontinued and the pigs' tracheas were extubated. In the second study (n=14) anaesthesia was continued using propofol and remifentanil. Brain injury was assessed after 72 h by classical global histopathology, Purkinje cell count, and apoptotic cell counts in the hippocampus and cerebellum. Results Global injury was nearly 10-fold greater in the awake group compared with the anaesthetised group (P=0.021). Hypothermia was neuroprotective in the anaesthetised pigs but not the awake pigs. In the hippocampus, the density of cleaved caspase-3-positive cells was increased in awake compared with anaesthetised pigs in normothermia. In the cerebellum, Purkinje cell density was reduced in the awake pigs irrespective of treatment, and the number of cleaved caspase-3-positive Purkinje cells was greatly increased in hypothermic awake pigs. We detected no difference in cleaved caspase-3 in the granular cell layer or microglial reactivity across the groups. Conclusions Our study provides novel insights into the significance of anaesthesia/sedation during hypothermia for achieving optimal neuroprotection.
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Affiliation(s)
- Julia K. Gundersen
- Department of Physiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway
| | - Ela Chakkarapani
- Translational Health Sciences, St. Michael's Hospital, Bristol Medical School, University of Bristol, Bristol, UK
| | - David A. Menassa
- Department of Physiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
- Department of Neuropathology and The Queen's College, University of Oxford, Oxford, UK
- Department of Women's & Children's Health, Karolinska Institutet, Solna, Sweden
| | - Lars Walløe
- Department of Physiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Marianne Thoresen
- Department of Physiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
- Translational Health Sciences, St. Michael's Hospital, Bristol Medical School, University of Bristol, Bristol, UK
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Whitelaw A, Thoresen M. Therapeutic Hypothermia for Hypoxic-Ischemic Brain Injury Is More Effective in Newborn Infants than in Older Patients: Review and Hypotheses. Ther Hypothermia Temp Manag 2023; 13:170-174. [PMID: 37638830 DOI: 10.1089/ther.2023.0050] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023] Open
Abstract
Posthypoxic therapeutic hypothermia has been tested in newborn infants, with seven randomized trials showing consistent evidence of reduction in death, cerebral palsy, and cognitive impairment at school age. In contrast, randomized trials of hypothermia after cardiac arrest in adults have not shown consistent evidence of lasting neurological protection. The apparently greater effectiveness of therapeutic hypothermia in newborns may be due to important biological and clinical differences. One such difference is that adults are heavily colonized with microbes, and many have active inflammatory processes at the time of arrest, but few newborns are heavily colonized or infected at the time of birth. Inflammation can interfere with hypothermia's neuroprotection. A second difference is that apoptosis is more commonly the pathway of neuronal death in newborns than in adults. Hypothermia inhibits apoptosis but not necrosis. Newborns have a larger endogenous supply of stem cells (which reduce apoptosis) than adults and this may favor regeneration and protection from hypothermia and regeneration. A third difference is that immature oligodendroglia are more sensitive to free radical attack then mature oligodendroglia. Hypothermia reduces free radical release. In addition, immature brain has increased N-methyl-D-aspartate receptor subunits compared with adults and hypothermia reduces excitotoxic amino acids. Adults suffering cardiac arrest often have comorbidities such as diabetes, hypertension, and atherosclerosis, which complicate recovery, but newborn infants rarely have comorbidities before asphyxia. Adult hypothermia treatment may have been too short as no trial has cooled for longer than 48 hours, some only 24 or 12 hours, but neonatal therapeutic hypothermia has routinely lasted 72 hours. We hypothesize that this combination of differences favors the effectiveness of therapeutic hypothermia in newborn infants compared with adults.
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Affiliation(s)
- Andrew Whitelaw
- Translational Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Marianne Thoresen
- Translational Health Sciences, University of Bristol, Bristol, United Kingdom
- Department of Physiology, Institute of Basic Medical Research, University of Oslo, Oslo, Norway
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Lugli L, Garetti E, Goffredo BM, Candia F, Crestani S, Spada C, Guidotti I, Bedetti L, Miselli F, Della Casa EM, Roversi MF, Simeoli R, Cairoli S, Merazzi D, Lago P, Iughetti L, Berardi A. Continuous Fentanyl Infusion in Newborns with Hypoxic-Ischemic Encephalopathy Treated with Therapeutic Hypothermia: Background, Aims, and Study Protocol for Time-Concentration Profiles. Biomedicines 2023; 11:2395. [PMID: 37760835 PMCID: PMC10525845 DOI: 10.3390/biomedicines11092395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 08/22/2023] [Accepted: 08/24/2023] [Indexed: 09/29/2023] Open
Abstract
Therapeutic hypothermia (TH) is the standard of care for newborns with moderate to severe hypoxic-ischemic encephalopathy (HIE). Discomfort and pain during treatment are common and may affect the therapeutic efficacy of TH. Opioid sedation and analgesia (SA) are generally used in clinical practice, and fentanyl is one of the most frequently administered drugs. However, although fentanyl's pharmacokinetics (PKs) may be altered by hypothermic treatment, the PK behavior of this opioid drug in cooled newborns with HIE has been poorly investigated. The aim of this phase 1 study protocol (Trial ID: FentanylTH; EUDRACT number: 2020-000836-23) is to evaluate the fentanyl time-concentration profiles of full-term newborns with HIE who have been treated with TH. Newborns undergoing TH receive a standard fentanyl regimen (2 mcg/Kg of fentanyl as a loading dose, followed by a continuous infusion-1 mcg/kg/h-during the 72 h of TH and subsequent rewarming). Fentanyl plasma concentrations before bolus administration, at the end of the loading dose, and 24-48-72-96 h after infusion are measured. The median, maximum, and minimum plasma concentrations, together with drug clearance, are determined. This study will explore the fentanyl time-concentration profiles of cooled, full-term newborns with HIE, thereby helping to optimize the fentanyl SA dosing regimen during TH.
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Affiliation(s)
- Licia Lugli
- Neonatal Intensive Care Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (E.G.); (I.G.); (L.B.); (E.M.D.C.); (M.F.R.); (A.B.)
| | - Elisabetta Garetti
- Neonatal Intensive Care Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (E.G.); (I.G.); (L.B.); (E.M.D.C.); (M.F.R.); (A.B.)
| | - Bianca Maria Goffredo
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, Scientific Institute for hospitalization and care (IRCCS), 00100 Rome, Italy; (B.M.G.); (R.S.); (S.C.)
| | - Francesco Candia
- Pediatrics Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (F.C.); (S.C.); (L.I.)
| | - Sara Crestani
- Pediatrics Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (F.C.); (S.C.); (L.I.)
| | - Caterina Spada
- Neonatal Unit, Women’s and Children’s Department, Bufalini Hospital of Cesena, 47521 Cesena, Italy;
| | - Isotta Guidotti
- Neonatal Intensive Care Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (E.G.); (I.G.); (L.B.); (E.M.D.C.); (M.F.R.); (A.B.)
| | - Luca Bedetti
- Neonatal Intensive Care Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (E.G.); (I.G.); (L.B.); (E.M.D.C.); (M.F.R.); (A.B.)
| | - Francesca Miselli
- PhD Program in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, 41100 Modena, Italy;
| | - Elisa Muttini Della Casa
- Neonatal Intensive Care Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (E.G.); (I.G.); (L.B.); (E.M.D.C.); (M.F.R.); (A.B.)
| | - Maria Federica Roversi
- Neonatal Intensive Care Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (E.G.); (I.G.); (L.B.); (E.M.D.C.); (M.F.R.); (A.B.)
| | - Raffaele Simeoli
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, Scientific Institute for hospitalization and care (IRCCS), 00100 Rome, Italy; (B.M.G.); (R.S.); (S.C.)
| | - Sara Cairoli
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, Scientific Institute for hospitalization and care (IRCCS), 00100 Rome, Italy; (B.M.G.); (R.S.); (S.C.)
| | - Daniele Merazzi
- Neonatal Unit, Women’s and Children’s Department, Valduce Hospital, 22100 Como, Italy;
| | - Paola Lago
- Neonatal Intensive Care Unit, Women’s and Children’s Department, Ca’ Foncello Hospital, 31100 Treviso, Italy;
| | - Lorenzo Iughetti
- Pediatrics Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (F.C.); (S.C.); (L.I.)
| | - Alberto Berardi
- Neonatal Intensive Care Unit, Women’s and Children’s Health Department, University Hospital of Modena, 41100 Modena, Italy; (E.G.); (I.G.); (L.B.); (E.M.D.C.); (M.F.R.); (A.B.)
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Hillerson DB, Laine ME, Bissell BD, Mefford B. Contemporary targeted temperature management: Clinical evidence and controversies. Perfusion 2022; 38:666-680. [PMID: 35531914 DOI: 10.1177/02676591221076286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Advancements in cardiac arrest and post-cardiac arrest care have led to improved survival to hospital discharge. While survival to hospital discharge is an important clinical outcome, neurologic recovery is also a priority. With the advancement of targeted temperature management (TTM), the American Heart Association guidelines for post-cardiac arrest care recommend TTM in patients who remain comatose after return of spontaneous circulation (ROSC). Recently, the TTM2 randomized controlled trial found no significant difference in neurologic function and mortality at 6-months between traditional hypothermia to 33°C versus 37.5°C. While TTM has been evaluated for decades, current literature suggests that the use of TTM to 33° when compared to a protocol of targeted normothermia does not result in improved outcomes. Instead, perhaps active avoidance of fever may be most beneficial. Extracorporeal cardiopulmonary resuscitation and membrane oxygenation can provide a means of both hemodynamic support and TTM after ROSC. This review aims to describe the pathophysiology, physiologic aspects, clinical trial evidence, changes in post-cardiac arrest care, potential risks, as well as controversies of TTM.
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Affiliation(s)
- Dustin B Hillerson
- 5232University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Martinello KA, Meehan C, Avdic-Belltheus A, Lingam I, Mutshiya T, Yang Q, Akin MA, Price D, Sokolska M, Bainbridge A, Hristova M, Tachtsidis I, Tann CJ, Peebles D, Hagberg H, Wolfs TGAM, Klein N, Kramer BW, Fleiss B, Gressens P, Golay X, Robertson NJ. Hypothermia is not therapeutic in a neonatal piglet model of inflammation-sensitized hypoxia-ischemia. Pediatr Res 2022; 91:1416-1427. [PMID: 34050269 PMCID: PMC8160560 DOI: 10.1038/s41390-021-01584-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 04/20/2021] [Accepted: 05/10/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Perinatal inflammation combined with hypoxia-ischemia (HI) exacerbates injury in the developing brain. Therapeutic hypothermia (HT) is standard care for neonatal encephalopathy; however, its benefit in inflammation-sensitized HI (IS-HI) is unknown. METHODS Twelve newborn piglets received a 2 µg/kg bolus and 1 µg/kg/h infusion over 52 h of Escherichia coli lipopolysaccharide (LPS). HI was induced 4 h after LPS bolus. After HI, piglets were randomized to HT (33.5 °C 1-25 h after HI, n = 6) or normothermia (NT, n = 6). Amplitude-integrated electroencephalogram (aEEG) was recorded and magnetic resonance spectroscopy (MRS) was acquired at 24 and 48 h. At 48 h, terminal deoxynucleotidyl transferase dUTP nick-end labeling (TUNEL)-positive brain cell death, microglial activation/proliferation, astrogliosis, and cleaved caspase-3 (CC3) were quantified. Hematology and plasma cytokines were serially measured. RESULTS Two HT piglets died. aEEG recovery, thalamic and white matter MRS lactate/N-acetylaspartate, and TUNEL-positive cell death were similar between groups. HT increased microglial activation in the caudate, but had no other effect on glial activation/proliferation. HT reduced CC3 overall. HT suppressed platelet count and attenuated leukocytosis. Cytokine profile was unchanged by HT. CONCLUSIONS We did not observe protection with HT in this piglet IS-HI model based on aEEG, MRS, and immunohistochemistry. Immunosuppressive effects of HT and countering neuroinflammation by LPS may contribute to the observed lack of HT efficacy. Other immunomodulatory strategies may be more effective in IS-HI. IMPACT Acute infection/inflammation is known to exacerbate perinatal brain injury and can worsen the outcomes in neonatal encephalopathy. Therapeutic HT is the current standard of care for all infants with NE, but the benefit in infants with coinfection/inflammation is unknown. In a piglet model of inflammation (LPS)-sensitized HI, we observed no evidence of neuroprotection with cooling for 24 h, based on our primary outcome measures: aEEG, MRS Lac/NAA, and histological brain cell death. Additional neuroprotective agents, with beneficial immunomodulatory effects, require exploration in IS-HI models.
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Affiliation(s)
- Kathryn A Martinello
- Institute for Women's Health, University College London, London, UK
- Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia
| | | | | | - Ingran Lingam
- Institute for Women's Health, University College London, London, UK
| | - Tatenda Mutshiya
- Institute for Women's Health, University College London, London, UK
| | - Qin Yang
- Institute for Women's Health, University College London, London, UK
| | - Mustafa Ali Akin
- Department of Paediatrics, Ondokuz Mayıs University, Samsun, Turkey
| | - David Price
- Medical Physics and Biomedical Engineering, University College London NHS Foundation Trust, London, UK
| | - Magdalena Sokolska
- Medical Physics and Biomedical Engineering, University College London NHS Foundation Trust, London, UK
| | - Alan Bainbridge
- Medical Physics and Biomedical Engineering, University College London NHS Foundation Trust, London, UK
| | - Mariya Hristova
- Institute for Women's Health, University College London, London, UK
| | - Ilias Tachtsidis
- Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Cally J Tann
- Adolescent, Reproductive and Child Health Centre, London School of Hygiene and Tropical Medicine, London, UK
| | - Donald Peebles
- Institute for Women's Health, University College London, London, UK
| | - Henrik Hagberg
- Department of Clinical Sciences, Centre of Perinatal Medicine and Health, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
- Centre for the Developing Brain, Kings College London, London, UK
| | - Tim G A M Wolfs
- Department of Pediatrics, University of Maastricht, Maastricht, The Netherlands
| | - Nigel Klein
- Paediatric Infectious Diseases and Immunology, Institute of Child Health, University College London, London, UK
| | - Boris W Kramer
- Department of Pediatrics, University of Maastricht, Maastricht, The Netherlands
| | - Bobbi Fleiss
- School of Health and Biomedical Sciences, RMIT University, Melbourne, VIC, Australia
- Université de Paris, NeuroDiderot, Inserm, Paris, France
| | | | - Xavier Golay
- Institute of Neurology, University College London, London, UK
| | - Nicola J Robertson
- Institute for Women's Health, University College London, London, UK.
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.
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Lugli L, Spada C, Garetti E, Guidotti I, Roversi MF, Della Casa E, Bedetti L, Lucaccioni L, Pugliese M, Ferrari F, Iughetti L, Lago P, Berardi A. Fentanyl analgesia in asphyxiated newborns treated with therapeutic hypothermia. J Matern Fetal Neonatal Med 2021; 35:7764-7770. [PMID: 34486466 DOI: 10.1080/14767058.2021.1937106] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Therapeutic hypothermia is the standard care for asphyxiated newborns. Discomfort and pain during treatment are common and may affect therapeutic efficacy of hypothermia. Opioid analgosedation is commonly used in the clinical setting, but its effects in the cooled newborns is poorly investigated. OBJECTIVE The aim of this study was to assess the safety of fentanyl analgosedation during therapeutic hypothermia, by evaluating severe adverse effects and possible correlation with the neurodevelopmental outcome. METHODS We analyzed asphyxiated newborns treated with hypothermia receiving fentanyl intravenous infusion (years 2013-2018). Severe neurodevelopmental outcome was defined as cerebral palsy or Griffith's developmental quotient <70 or major sensorineural deficit. Severe brain lesions were defined as cortical or/and basal ganglia extensive involvement. RESULTS Fentanyl cumulative dose was variable (61.7 ± 18.5 µg/kg; range 34.3-120.3 µg/kg) among 45 enrolled patients. Respiratory depression was recorded in 13.3% cases of 30 spontaneously breathing patients. Severe brain lesions and severe neurodevelopmental disability were found in 24.4 and 11.1% of all included cases, respectively. Higher cumulative fentanyl dose was not associated with poor outcome. CONCLUSIONS Fentanyl treatment during therapeutic hypothermia does not negatively affect the neurodevelopmental outcome, thus on the contrary, it may contribute to ameliorate neuroprotection in the asphyxiated cooled newborns.
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Affiliation(s)
- Licia Lugli
- Women's and Children's Health Department, Neonatal Intensive Care Unit, University Hospital of Modena, Modena, Italy
| | - Caterina Spada
- Women's and Children's Health Department, Neonatal Intensive Care Unit, University Hospital of Modena, Modena, Italy
| | - Elisabetta Garetti
- Women's and Children's Health Department, Neonatal Intensive Care Unit, University Hospital of Modena, Modena, Italy
| | - Isotta Guidotti
- Women's and Children's Health Department, Neonatal Intensive Care Unit, University Hospital of Modena, Modena, Italy
| | - Maria Federica Roversi
- Women's and Children's Health Department, Neonatal Intensive Care Unit, University Hospital of Modena, Modena, Italy
| | - Elisa Della Casa
- Women's and Children's Health Department, Neonatal Intensive Care Unit, University Hospital of Modena, Modena, Italy
| | - Luca Bedetti
- Pediatrics, Women's and Children's Health Department, University Hospital of Modena, Modena, Italy
| | - Laura Lucaccioni
- Pediatrics, Women's and Children's Health Department, University Hospital of Modena, Modena, Italy
| | - Marisa Pugliese
- Women's and Children's Health Department, Neonatal Intensive Care Unit, University Hospital of Modena, Modena, Italy
| | - Fabrizio Ferrari
- Women's and Children's Health Department, Neonatal Intensive Care Unit, University Hospital of Modena, Modena, Italy
| | - Lorenzo Iughetti
- Pediatrics, Women's and Children's Health Department, University Hospital of Modena, Modena, Italy
| | - Paola Lago
- Women's and Children's Department, Neonatal Intensive Care Unit, Ca' Foncello Hospital, Treviso, Italy
| | - Alberto Berardi
- Women's and Children's Health Department, Neonatal Intensive Care Unit, University Hospital of Modena, Modena, Italy
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Oleuropein Activates Neonatal Neocortical Proteasomes, but Proteasome Gene Targeting by AAV9 Is Variable in a Clinically Relevant Piglet Model of Brain Hypoxia-Ischemia and Hypothermia. Cells 2021; 10:cells10082120. [PMID: 34440889 PMCID: PMC8391411 DOI: 10.3390/cells10082120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 08/13/2021] [Accepted: 08/16/2021] [Indexed: 10/26/2022] Open
Abstract
Cerebral hypoxia-ischemia (HI) compromises the proteasome in a clinically relevant neonatal piglet model. Protecting and activating proteasomes could be an adjunct therapy to hypothermia. We investigated whether chymotrypsin-like proteasome activity differs regionally and developmentally in the neonatal brain. We also tested whether neonatal brain proteasomes can be modulated by oleuropein, an experimental pleiotropic neuroprotective drug, or by targeting a proteasome subunit gene using recombinant adeno-associated virus-9 (AAV). During post-HI hypothermia, we treated piglets with oleuropein, used AAV-short hairpin RNA (shRNA) to knock down proteasome activator 28γ (PA28γ), or enforced PA28γ using AAV-PA28γ with green fluorescent protein (GFP). Neonatal neocortex and subcortical white matter had greater proteasome activity than did liver and kidney. Neonatal white matter had higher proteasome activity than did juvenile white matter. Lower arterial pH 1 h after HI correlated with greater subsequent cortical proteasome activity. With increasing brain homogenate protein input into the assay, the initial proteasome activity increased only among shams, whereas HI increased total kinetic proteasome activity. OLE increased the initial neocortical proteasome activity after hypothermia. AAV drove GFP expression, and white matter PA28γ levels correlated with proteasome activity and subunit levels. However, AAV proteasome modulation varied. Thus, neonatal neocortical proteasomes can be pharmacologically activated. HI slows the initial proteasome performance, but then augments ongoing catalytic activity. AAV-mediated genetic manipulation in the piglet brain holds promise, though proteasome gene targeting requires further development.
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McPherson C, Frymoyer A, Ortinau CM, Miller SP, Groenendaal F. Management of comfort and sedation in neonates with neonatal encephalopathy treated with therapeutic hypothermia. Semin Fetal Neonatal Med 2021; 26:101264. [PMID: 34215538 PMCID: PMC8900710 DOI: 10.1016/j.siny.2021.101264] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Ensuring comfort for neonates undergoing therapeutic hypothermia (TH) after neonatal encephalopathy (NE) exemplifies a vital facet of neonatal neurocritical care. Physiologic markers of stress are frequently present in these neonates. Non-pharmacologic comfort measures form the foundation of care, benefitting both the neonate and parents. Pharmacological sedatives may also be indicated, yet have the potential to both mitigate and intensify the neurotoxicity of a hypoxic-ischemic insult. Morphine represents current standard of care with a history of utilization and extensive pharmacokinetic data to guide safe and effective dosing. Dexmedetomidine, as an alternative to morphine, has several appealing characteristics, including neuroprotective effects in animal models; robust pharmacokinetic studies in neonates with NE treated with TH are required to ensure a safe and effective standard dosing approach. Future studies in neonates treated with TH must address comfort, adverse events, and long-term outcomes in the context of specific sedation practices.
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Affiliation(s)
- Christopher McPherson
- Department of Pediatrics, Washington University School of Medicine, 660 South Euclid Ave., St. Louis, MO, 63110, USA.
| | - Adam Frymoyer
- Department of Pediatrics, Stanford University, 750 Welch Road, Suite 315, Palo Alto, CA, 94304, USA.
| | - Cynthia M Ortinau
- Department of Pediatrics, Washington University School of Medicine, 660 South Euclid Ave., St. Louis, MO, 63110, USA.
| | - Steven P Miller
- Department of Pediatrics, The Hospital for Sick Children and the University of Toronto, 555 University Avenue, Toronto, ON, Canada.
| | - Floris Groenendaal
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht and Utrecht University, Lundlaan 6, 3584 EA, Utrecht, Netherlands.
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10
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Gundersen JK, Chakkarapani E, Jary S, Menassa DA, Scull-Brown E, Frymoyer A, Walløe L, Thoresen M. Morphine and fentanyl exposure during therapeutic hypothermia does not impair neurodevelopment. EClinicalMedicine 2021; 36:100892. [PMID: 34308308 PMCID: PMC8257990 DOI: 10.1016/j.eclinm.2021.100892] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 04/21/2021] [Accepted: 04/23/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hypothermia-treated and intubated infants with moderate or severe hypoxic-ischemic encephalopathy (HIE) usually receive morphine for sedation and analgesia (SA) during therapeutic hypothermia (TH) and endotracheal ventilation. Altered drug pharmacokinetics in this population increases the risk of drug accumulation. Opioids are neurotoxic in preterm infants. In term infants undergoing TH, the long-term effects of morphine exposure are unknown. We examined the effect of opioid administration during TH on neurodevelopmental outcome and time to extubation after sedation ended. METHODS In this prospectively collected population-based cohort of 282 infants with HIE treated with TH (2007-2017), the cumulative opioid dose of morphine and equipotent fentanyl (10-60 µg/kg/h) administered during the first week of life was calculated. Clinical outcomes and concomitant medications were also collected. Of 258 survivors, 229 underwent Bayley-3 neurodevelopmental assessments of cognition, language and motor function at 18-24 months. Multivariate stepwise linear regression analysis was used to examine the relation between cumulative opioid dose and Bayley-3 scores. Three severity-groups (mild-moderate-severe) were stratified by early (<6 h) amplitude-integrated electroencephalography (aEEG) patterns. FINDINGS The cumulative dose of opioid administered as SA during TH was median (IQR) 2121 µg/kg (1343, 2741). Time to extubation was independent of SA dose (p > 0.2). There was no significant association between cumulative SA dose and any of the Bayley-3 domains when analysing the entire cohort or any of the aEEG severity groups. INTERPRETATION Higher cumulative opioid doses in TH-treated infants with HIE was not associated with worse Bayley-3 scores at 18-24 months of age. FUNDING The Bristol cooling program was funded by the Children's Medical Research Charity SPARKS managing donations for our research from the UK and US, the UK Moulton Foundation, the Lærdal Foundation for Acute Medicine in Norway and the Norwegian Research Council (JKG).
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Affiliation(s)
- Julia K Gundersen
- Division of Physiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
- Translational Health Sciences, St. Michael's Hospital, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Ela Chakkarapani
- Translational Health Sciences, St. Michael's Hospital, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Sally Jary
- Translational Health Sciences, St. Michael's Hospital, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - David A Menassa
- Division of Physiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
- The Queen's College, University of Oxford, Oxford, United Kingdom
| | - Emma Scull-Brown
- Translational Health Sciences, St. Michael's Hospital, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Adam Frymoyer
- Department of Pediatrics, Stanford University, California, United States
| | - Lars Walløe
- Division of Physiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Marianne Thoresen
- Division of Physiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
- Translational Health Sciences, St. Michael's Hospital, Bristol Medical School, University of Bristol, Bristol, United Kingdom
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11
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Kovács V, Remzső G, Körmöczi T, Berkecz R, Tóth-Szűki V, Pénzes A, Vécsei L, Domoki F. The Kynurenic Acid Analog SZR72 Enhances Neuronal Activity after Asphyxia but Is Not Neuroprotective in a Translational Model of Neonatal Hypoxic Ischemic Encephalopathy. Int J Mol Sci 2021; 22:4822. [PMID: 34062911 PMCID: PMC8125407 DOI: 10.3390/ijms22094822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 04/28/2021] [Accepted: 04/29/2021] [Indexed: 11/17/2022] Open
Abstract
Hypoxic-ischemic encephalopathy (HIE) remains to be a major cause of long-term neurodevelopmental deficits in term neonates. Hypothermia offers partial neuroprotection warranting research for additional therapies. Kynurenic acid (KYNA), an endogenous product of tryptophan metabolism, was previously shown to be beneficial in rat HIE models. We sought to determine if the KYNA analog SZR72 would afford neuroprotection in piglets. After severe asphyxia (pHa = 6.83 ± 0.02, ΔBE = -17.6 ± 1.2 mmol/L, mean ± SEM), anesthetized piglets were assigned to vehicle-treated (VEH), SZR72-treated (SZR72), or hypothermia-treated (HT) groups (n = 6, 6, 6; Tcore = 38.5, 38.5, 33.5 °C, respectively). Compared to VEH, serum KYNA levels were elevated, recovery of EEG was faster, and EEG power spectral density values were higher at 24 h in the SZR72 group. However, instantaneous entropy indicating EEG signal complexity, depression of the visual evoked potential (VEP), and the significant neuronal damage observed in the neocortex, the putamen, and the CA1 hippocampal field were similar in these groups. In the caudate nucleus and the CA3 hippocampal field, neuronal damage was even more severe in the SZR72 group. The HT group showed the best preservation of EEG complexity, VEP, and neuronal integrity in all examined brain regions. In summary, SZR72 appears to enhance neuronal activity after asphyxia but does not ameliorate early neuronal damage in this HIE model.
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Affiliation(s)
- Viktória Kovács
- Department of Physiology, Faculty of Medicine, University of Szeged, 6720 Szeged, Hungary; (V.K.); (G.R.); (V.T.-S.); (A.P.)
| | - Gábor Remzső
- Department of Physiology, Faculty of Medicine, University of Szeged, 6720 Szeged, Hungary; (V.K.); (G.R.); (V.T.-S.); (A.P.)
| | - Tímea Körmöczi
- Institute of Pharmaceutical Analysis, Interdisciplinary Excellence Center, University of Szeged, 6720 Szeged, Hungary; (T.K.); (R.B.)
| | - Róbert Berkecz
- Institute of Pharmaceutical Analysis, Interdisciplinary Excellence Center, University of Szeged, 6720 Szeged, Hungary; (T.K.); (R.B.)
| | - Valéria Tóth-Szűki
- Department of Physiology, Faculty of Medicine, University of Szeged, 6720 Szeged, Hungary; (V.K.); (G.R.); (V.T.-S.); (A.P.)
| | - Andrea Pénzes
- Department of Physiology, Faculty of Medicine, University of Szeged, 6720 Szeged, Hungary; (V.K.); (G.R.); (V.T.-S.); (A.P.)
| | - László Vécsei
- Department of Neurology, Interdisciplinary Excellence Center, University of Szeged, 6720 Szeged, Hungary;
- MTA-SZTE Neuroscience Research Group, Hungarian Academy of Sciences, University of Szeged, 6720 Szeged, Hungary
| | - Ferenc Domoki
- Department of Physiology, Faculty of Medicine, University of Szeged, 6720 Szeged, Hungary; (V.K.); (G.R.); (V.T.-S.); (A.P.)
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12
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Htun Y, Nakamura S, Kusaka T. Hydrogen and therapeutic gases for neonatal hypoxic-ischemic encephalopathy: potential neuroprotective adjuncts in translational research. Pediatr Res 2021; 89:753-759. [PMID: 32505123 DOI: 10.1038/s41390-020-0998-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 05/08/2020] [Accepted: 05/12/2020] [Indexed: 11/09/2022]
Abstract
Numerous studies have examined the potential use of therapeutic gases for the treatment of various neurological disorders. Hydrogen gas, a promising neuroprotective agent, has been a focus of study due to its potent antioxidative properties. In translational research into adult diseases, hydrogen has been shown to be neuroprotective in disorders such as cerebral ischemia and traumatic brain injury, and in neurodegenerative diseases such as Alzheimer's disease. Animal and human studies have verified the safety and feasibility of molecular hydrogen. However, despite extensive research on its efficacy in adults, only a few studies have investigated its application in pediatric and neonatal medicine. Neonatal hypoxic-ischemic encephalopathy (HIE) is characterized by damage to neurons and other cells of the nervous system. One of the major contributing factors is excessive exposure to oxidative stress. Current research interest in HIE is shifting toward new neuroprotective agents, as single agents or as adjuncts to therapeutic hypothermia. Here, we review therapeutic gases, particularly hydrogen, and their potentials and limitations in the treatment of HIE in newborns. IMPACT: Translational animal models of neonatal HIE are a current focus of research into the therapeutic usefulness of various gases. Hydrogen ventilation as a single agent or in combination with therapeutic hypothermia shows short- and long-term neuroprotection in neonatal translational HIE models. The optimal target severity for therapeutic interventions should be well established to improve outcomes.
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Affiliation(s)
- Yinmon Htun
- Department of Pediatrics, Faculty of Medicine, Kagawa University, Kagawa, Japan.,Graduate School of Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Shinji Nakamura
- Department of Pediatrics, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Takashi Kusaka
- Department of Pediatrics, Faculty of Medicine, Kagawa University, Kagawa, Japan.
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13
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Shi Z, Qin M, Huang L, Xu T, Chen Y, Hu Q, Peng S, Peng Z, Qu LN, Chen SG, Tuo QH, Liao DF, Wang XP, Wu RR, Yuan TF, Li YH, Liu XM. Human torpor: translating insights from nature into manned deep space expedition. Biol Rev Camb Philos Soc 2020; 96:642-672. [PMID: 33314677 DOI: 10.1111/brv.12671] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 11/09/2020] [Accepted: 11/17/2020] [Indexed: 12/12/2022]
Abstract
During a long-duration manned spaceflight mission, such as flying to Mars and beyond, all crew members will spend a long period in an independent spacecraft with closed-loop bioregenerative life-support systems. Saving resources and reducing medical risks, particularly in mental heath, are key technology gaps hampering human expedition into deep space. In the 1960s, several scientists proposed that an induced state of suppressed metabolism in humans, which mimics 'hibernation', could be an ideal solution to cope with many issues during spaceflight. In recent years, with the introduction of specific methods, it is becoming more feasible to induce an artificial hibernation-like state (synthetic torpor) in non-hibernating species. Natural torpor is a fascinating, yet enigmatic, physiological process in which metabolic rate (MR), body core temperature (Tb ) and behavioural activity are reduced to save energy during harsh seasonal conditions. It employs a complex central neural network to orchestrate a homeostatic state of hypometabolism, hypothermia and hypoactivity in response to environmental challenges. The anatomical and functional connections within the central nervous system (CNS) lie at the heart of controlling synthetic torpor. Although progress has been made, the precise mechanisms underlying the active regulation of the torpor-arousal transition, and their profound influence on neural function and behaviour, which are critical concerns for safe and reversible human torpor, remain poorly understood. In this review, we place particular emphasis on elaborating the central nervous mechanism orchestrating the torpor-arousal transition in both non-flying hibernating mammals and non-hibernating species, and aim to provide translational insights into long-duration manned spaceflight. In addition, identifying difficulties and challenges ahead will underscore important concerns in engineering synthetic torpor in humans. We believe that synthetic torpor may not be the only option for manned long-duration spaceflight, but it is the most achievable solution in the foreseeable future. Translating the available knowledge from natural torpor research will not only benefit manned spaceflight, but also many clinical settings attempting to manipulate energy metabolism and neurobehavioural functions.
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Affiliation(s)
- Zhe Shi
- National Clinical Research Center for Mental Disorders, and Department of Psychaitry, The Second Xiangya Hospital of Central South University, Changsha, Hunan, 410011, China.,Key Laboratory for Quality Evaluation of Bulk Herbs of Hunan Province, Hunan University of Chinese Medicine, Changsha, Hunan, 410208, China.,State Key Laboratory of Space Medicine Fundamentals and Application, China Astronaut Research and Training Center, Beijing, 100094, China.,Shanghai Key Laboratory of Psychotic Disorders, Shanghai Mental Health Center, Shanghai Jiaotong University School of Medicine, Shanghai, 200030, China
| | - Meng Qin
- College of Life Science and Technology, Beijing University of Chemical Technology, Beijing, 100029, China
| | - Lu Huang
- Guangdong-Hongkong-Macau Institute of CNS Regeneration, Ministry of Education CNS Regeneration Collaborative Joint Laboratory, Jinan University, Guangzhou, 510632, China
| | - Tao Xu
- Department of Anesthesiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, 200233, China
| | - Ying Chen
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, 100700, China
| | - Qin Hu
- College of Life Sciences and Bio-Engineering, Beijing University of Technology, Beijing, 100024, China
| | - Sha Peng
- Key Laboratory for Quality Evaluation of Bulk Herbs of Hunan Province, Hunan University of Chinese Medicine, Changsha, Hunan, 410208, China
| | - Zhuang Peng
- Key Laboratory for Quality Evaluation of Bulk Herbs of Hunan Province, Hunan University of Chinese Medicine, Changsha, Hunan, 410208, China
| | - Li-Na Qu
- State Key Laboratory of Space Medicine Fundamentals and Application, China Astronaut Research and Training Center, Beijing, 100094, China
| | - Shan-Guang Chen
- State Key Laboratory of Space Medicine Fundamentals and Application, China Astronaut Research and Training Center, Beijing, 100094, China
| | - Qin-Hui Tuo
- Key Laboratory for Quality Evaluation of Bulk Herbs of Hunan Province, Hunan University of Chinese Medicine, Changsha, Hunan, 410208, China
| | - Duan-Fang Liao
- Key Laboratory for Quality Evaluation of Bulk Herbs of Hunan Province, Hunan University of Chinese Medicine, Changsha, Hunan, 410208, China
| | - Xiao-Ping Wang
- National Clinical Research Center for Mental Disorders, and Department of Psychaitry, The Second Xiangya Hospital of Central South University, Changsha, Hunan, 410011, China
| | - Ren-Rong Wu
- National Clinical Research Center for Mental Disorders, and Department of Psychaitry, The Second Xiangya Hospital of Central South University, Changsha, Hunan, 410011, China
| | - Ti-Fei Yuan
- Shanghai Key Laboratory of Psychotic Disorders, Shanghai Mental Health Center, Shanghai Jiaotong University School of Medicine, Shanghai, 200030, China.,Co-innovation Center of Neuroregeneration, Nantong University, Nantong, 226000, China
| | - Ying-Hui Li
- State Key Laboratory of Space Medicine Fundamentals and Application, China Astronaut Research and Training Center, Beijing, 100094, China
| | - Xin-Min Liu
- Key Laboratory for Quality Evaluation of Bulk Herbs of Hunan Province, Hunan University of Chinese Medicine, Changsha, Hunan, 410208, China.,State Key Laboratory of Space Medicine Fundamentals and Application, China Astronaut Research and Training Center, Beijing, 100094, China.,Research Center for Pharmacology and Toxicology, Institute of Medicinal Plant Development (IMPLAD), Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100193, China
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14
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Variability and sex-dependence of hypothermic neuroprotection in a rat model of neonatal hypoxic-ischaemic brain injury: a single laboratory meta-analysis. Sci Rep 2020; 10:10833. [PMID: 32616806 PMCID: PMC7331720 DOI: 10.1038/s41598-020-67532-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 06/03/2020] [Indexed: 01/19/2023] Open
Abstract
Therapeutic hypothermia (HT) is standard care for term infants with hypoxic–ischaemic (HI) encephalopathy. However, the efficacy of HT in preclinical models, such as the Vannucci model of unilateral HI in the newborn rat, is often greater than that reported from clinical trials. Here, we report a meta-analysis of data from every experiment in a single laboratory, including pilot data, examining the effect of HT in the Vannucci model.
Across 21 experiments using 106 litters, median (95% CI) hemispheric area loss was 50.1% (46.0–51.9%; n = 305) in the normothermia group, and 41.3% (35.1–44.9%; n = 317) in the HT group, with a bimodal injury distribution. Median neuroprotection by HT was 17.6% (6.8–28.3%), including in severe injury, but was highly-variable across experiments. Neuroprotection was significant in females (p < 0.001), with a non-significant benefit in males (p = 0.07). Animals representing the median injury in each group within each litter (n = 277, 44.5%) were also analysed using formal neuropathology, which showed neuroprotection by HT throughout the brain, particularly in females. Our results suggest an inherent variability and sex-dependence of the neuroprotective response to HT, with the majority of studies in the Vannucci model vastly underpowered to detect true treatment effects due to the distribution of injury.
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15
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Benedetti GM, Vartanian RJ, McCaffery H, Shellhaas RA. Early Electroencephalogram Background Could Guide Tailored Duration of Monitoring for Neonatal Encephalopathy Treated with Therapeutic Hypothermia. J Pediatr 2020; 221:81-87.e1. [PMID: 32222256 DOI: 10.1016/j.jpeds.2020.01.066] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 12/05/2019] [Accepted: 01/31/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To evaluate whether features of the early electroencephalographic (EEG) background could guide the optimal duration of continuous video EEG monitoring for seizure detection in newborn infants treated with therapeutic hypothermia for hypoxic ischemic encephalopathy (HIE). STUDY DESIGN Retrospective cohort study of 114 consecutive infants treated with therapeutic hypothermia for moderate to severe HIE at a level IV neonatal intensive care unit (NICU) between 2012 and 2018. All infants were monitored with continuous video EEG through cooling and rewarming. Archived samples from the first 24 hours of these EEG traces were reviewed systematically and classified by background characteristics. RESULTS Electrographic seizures occurred in 56 of the 114 infants (49%). Seizure onset was within the first 24 hours after initiation of continuous video EEG in 49 if these 56 infants (88%), between 24 and 48 hours in 4 infants (7%), and >72 hours in 3 infants (5%). Infants with a normal or mildly abnormal EEG background either had seizure onset within the first 24 hours or never developed seizures. Four patients with seizure onset between 24 and 48 hours had markedly abnormal EEG backgrounds. The 3 patients with seizure onset beyond 72 hours had moderate or severely abnormal early continuous video EEG backgrounds. CONCLUSIONS The use of early continuous video EEG background categorization may be appropriate to guide the duration of continuous video EEG for infants with HIE treated with therapeutic hypothermia. Some infants may reasonably be monitored for 24 hours rather than throughout cooling and rewarming without a significant risk of missed seizures. This could have significant implications for continuous video EEG resource utilization.
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Affiliation(s)
| | - Rebecca J Vartanian
- Division of Neonatology, Department of Pediatrics, CS Mott Children's Hospital, Michigan Medicine, Ann Arbor, MI
| | - Harlan McCaffery
- Center for Human Growth and Development, University of Michigan, Ann Arbor, MI
| | - Renée A Shellhaas
- Division of Pediatric Neurology, Ann Arbor, MI; Center for Human Growth and Development, University of Michigan, Ann Arbor, MI
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16
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Hosseini M, Wilson RH, Crouzet C, Amirhekmat A, Wei KS, Akbari Y. Resuscitating the Globally Ischemic Brain: TTM and Beyond. Neurotherapeutics 2020; 17:539-562. [PMID: 32367476 PMCID: PMC7283450 DOI: 10.1007/s13311-020-00856-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Cardiac arrest (CA) afflicts ~ 550,000 people each year in the USA. A small fraction of CA sufferers survive with a majority of these survivors emerging in a comatose state. Many CA survivors suffer devastating global brain injury with some remaining indefinitely in a comatose state. The pathogenesis of global brain injury secondary to CA is complex. Mechanisms of CA-induced brain injury include ischemia, hypoxia, cytotoxicity, inflammation, and ultimately, irreversible neuronal damage. Due to this complexity, it is critical for clinicians to have access as early as possible to quantitative metrics for diagnosing injury severity, accurately predicting outcome, and informing patient care. Current recommendations involve using multiple modalities including clinical exam, electrophysiology, brain imaging, and molecular biomarkers. This multi-faceted approach is designed to improve prognostication to avoid "self-fulfilling" prophecy and early withdrawal of life-sustaining treatments. Incorporation of emerging dynamic monitoring tools such as diffuse optical technologies may provide improved diagnosis and early prognostication to better inform treatment. Currently, targeted temperature management (TTM) is the leading treatment, with the number of patients needed to treat being ~ 6 in order to improve outcome for one patient. Future avenues of treatment, which may potentially be combined with TTM, include pharmacotherapy, perfusion/oxygenation targets, and pre/postconditioning. In this review, we provide a bench to bedside approach to delineate the pathophysiology, prognostication methods, current targeted therapies, and future directions of research surrounding hypoxic-ischemic brain injury (HIBI) secondary to CA.
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Affiliation(s)
- Melika Hosseini
- Department of Neurology, School of Medicine, University of California, Irvine, USA
| | - Robert H Wilson
- Department of Neurology, School of Medicine, University of California, Irvine, USA
- Beckman Laser Institute, University of California, Irvine, USA
| | - Christian Crouzet
- Department of Neurology, School of Medicine, University of California, Irvine, USA
- Beckman Laser Institute, University of California, Irvine, USA
| | - Arya Amirhekmat
- Department of Neurology, School of Medicine, University of California, Irvine, USA
| | - Kevin S Wei
- Department of Neurology, School of Medicine, University of California, Irvine, USA
| | - Yama Akbari
- Department of Neurology, School of Medicine, University of California, Irvine, USA.
- Beckman Laser Institute, University of California, Irvine, USA.
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17
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Kitase Y, Sato Y, Ueda K, Suzuki T, Mikrogeorgiou A, Sugiyama Y, Matsubara K, Tsukagoshi Okabe Y, Shimizu S, Hirata H, Yukawa H, Baba Y, Tsuji M, Takahashi Y, Yamamoto A, Hayakawa M. A Novel Treatment with Stem Cells from Human Exfoliated Deciduous Teeth for Hypoxic-Ischemic Encephalopathy in Neonatal Rats. Stem Cells Dev 2020; 29:63-74. [DOI: 10.1089/scd.2019.0221] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Yuma Kitase
- Division of Neonatology, Center for Maternal-Neonatal Care, Nagoya University Hospital, Nagoya, Japan
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshiaki Sato
- Division of Neonatology, Center for Maternal-Neonatal Care, Nagoya University Hospital, Nagoya, Japan
| | - Kazuto Ueda
- Division of Neonatology, Center for Maternal-Neonatal Care, Nagoya University Hospital, Nagoya, Japan
| | - Toshihiko Suzuki
- Division of Neonatology, Center for Maternal-Neonatal Care, Nagoya University Hospital, Nagoya, Japan
| | - Alkisti Mikrogeorgiou
- Division of Neonatology, Center for Maternal-Neonatal Care, Nagoya University Hospital, Nagoya, Japan
| | - Yuichiro Sugiyama
- Division of Neonatology, Center for Maternal-Neonatal Care, Nagoya University Hospital, Nagoya, Japan
| | - Kohki Matsubara
- Department of Oral and Maxillofacial Surgery and Nagoya University Hospital, Nagoya, Japan
| | | | - Shinobu Shimizu
- Department of Advanced Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Hitoshi Hirata
- Department of Hand Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroshi Yukawa
- Institute of Nano-Life-Systems, Institutes of Innovation for Future Society, Nagoya University, Nagoya, Japan
- Department of Biomolecular Engineering, Graduate School of Engineering, Nagoya University, Nagoya, Japan
- Institute of Quantum Life Science, National Institutes for Quantum and Radiological Science and Technology, Chiba, Japan
| | - Yoshinobu Baba
- Institute of Nano-Life-Systems, Institutes of Innovation for Future Society, Nagoya University, Nagoya, Japan
- Department of Biomolecular Engineering, Graduate School of Engineering, Nagoya University, Nagoya, Japan
| | - Masahiro Tsuji
- Department of Food and Nutrition, Faculty of Home Economics, Kyoto Women's University, Kyoto, Japan
| | - Yoshiyuki Takahashi
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Akihito Yamamoto
- Department of Tissue Regeneration, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan
| | - Masahiro Hayakawa
- Division of Neonatology, Center for Maternal-Neonatal Care, Nagoya University Hospital, Nagoya, Japan
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18
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O'Brien CE, Santos PT, Kulikowicz E, Reyes M, Koehler RC, Martin LJ, Lee JK. Hypoxia-Ischemia and Hypothermia Independently and Interactively Affect Neuronal Pathology in Neonatal Piglets with Short-Term Recovery. Dev Neurosci 2019; 41:17-33. [PMID: 31108487 DOI: 10.1159/000496602] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 01/06/2019] [Indexed: 12/25/2022] Open
Abstract
Therapeutic hypothermia is the standard of clinical care for moderate neonatal hypoxic-ischemic encephalopathy. We investigated the independent and interactive effects of hypoxia-ischemia (HI) and temperature on neuronal survival and injury in basal ganglia and cerebral cortex in neonatal piglets. Male piglets were randomized to receive HI injury or sham procedure followed by 29 h of normothermia, sustained hypothermia induced at 2 h, or hypothermia with rewarming during fentanyl-nitrous oxide anesthesia. Viable and injured neurons and apoptotic profiles were counted in the anterior putamen, posterior putamen, and motor cortex at 29 h after HI injury or sham procedure. Terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) identified genomic DNA fragmentation to confirm cell death. Though hypothermia after HI preserved viable neurons in the anterior and posterior putamen, hypothermia prevented neuronal injury in only the anterior putamen. Hypothermia initiated 2 h after injury did not protect against apoptotic cell death in either the putamen or motor cortex, and rewarming from hypothermia was associated with increased apoptosis in the motor cortex. In non-HI shams, sustained hypothermia during anesthesia was associated with neuronal injury and corresponding viable neuron loss in the anterior putamen and motor cortex. TUNEL confirmed increased neurodegeneration in the putamen of hypothermic shams. Anesthetized, normothermic shams did not show abnormal neuronal cytopathology in the putamen or motor cortex, thereby demonstrating minimal contribution of the anesthetic regimen to neuronal injury during normothermia. We conclude that the efficacy of hypothermic protection after HI is region specific and that hypothermia during anesthesia in the absence of HI may be associated with neuronal injury in the developing brain. Studies examining the potential interactions between hypothermia and anesthesia, as well as with longer durations of hypothermia, are needed.
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Affiliation(s)
- Caitlin E O'Brien
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA,
| | - Polan T Santos
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ewa Kulikowicz
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Michael Reyes
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Raymond C Koehler
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Lee J Martin
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland, USA.,Pathobiology Graduate Training Program, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jennifer K Lee
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA.,Pathobiology Graduate Training Program, Johns Hopkins University, Baltimore, Maryland, USA
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19
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Ndongson-Dongmo B, Lang GP, Mece O, Hechaichi N, Lajqi T, Hoyer D, Brodhun M, Heller R, Wetzker R, Franz M, Levy FO, Bauer R. Reduced ambient temperature exacerbates SIRS-induced cardiac autonomic dysregulation and myocardial dysfunction in mice. Basic Res Cardiol 2019; 114:26. [DOI: 10.1007/s00395-019-0734-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 04/12/2019] [Indexed: 12/13/2022]
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Gunn AJ, Thoresen M. Neonatal encephalopathy and hypoxic-ischemic encephalopathy. HANDBOOK OF CLINICAL NEUROLOGY 2019; 162:217-237. [PMID: 31324312 DOI: 10.1016/b978-0-444-64029-1.00010-2] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Acute hypoxic-ischemic encephalopathy around the time of birth remains a major cause of death and life-long disability. The key insight that led to the modern revival of studies of neuroprotection was that, after profound asphyxia, many brain cells show initial recovery from the insult during a short "latent" phase, typically lasting approximately 6h, only to die hours to days later after a "secondary" deterioration characterized by seizures, cytotoxic edema, and progressive failure of cerebral oxidative metabolism. Studies designed around this framework showed that mild hypothermia initiated as early as possible before the onset of secondary deterioration and continued for a sufficient duration to allow the secondary deterioration to resolve is associated with potent, long-lasting neuroprotection. There is now compelling evidence from randomized controlled trials that mild to moderate induced hypothermia significantly improves survival and neurodevelopmental outcomes in infancy and mid-childhood.
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Affiliation(s)
- Alistair J Gunn
- Departments of Physiology and Paediatrics, University of Auckland, Auckland, New Zealand.
| | - Marianne Thoresen
- Department of Physiology University of Oslo, Oslo, Norway; Neonatal Neuroscience, Translational Health Sciences, University of Bristol, Bristol, United Kingdom
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Koehler RC, Yang ZJ, Lee JK, Martin LJ. Perinatal hypoxic-ischemic brain injury in large animal models: Relevance to human neonatal encephalopathy. J Cereb Blood Flow Metab 2018; 38:2092-2111. [PMID: 30149778 PMCID: PMC6282216 DOI: 10.1177/0271678x18797328] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Perinatal hypoxia-ischemia resulting in death or lifelong disabilities remains a major clinical disorder. Neonatal models of hypoxia-ischemia in rodents have enhanced our understanding of cellular mechanisms of neural injury in developing brain, but have limitations in simulating the range, accuracy, and physiology of clinical hypoxia-ischemia and the relevant systems neuropathology that contribute to the human brain injury pattern. Large animal models of perinatal hypoxia-ischemia, such as partial or complete asphyxia at the time of delivery of fetal monkeys, umbilical cord occlusion and cerebral hypoperfusion at different stages of gestation in fetal sheep, and severe hypoxia and hypoperfusion in newborn piglets, have largely overcome these limitations. In monkey, complete asphyxia produces preferential injury to cerebellum and primary sensory nuclei in brainstem and thalamus, whereas partial asphyxia produces preferential injury to somatosensory and motor cortex, basal ganglia, and thalamus. Mid-gestational fetal sheep provide a valuable model for studying vulnerability of progenitor oligodendrocytes. Hypoxia followed by asphyxia in newborn piglets replicates the systems injury seen in term newborns. Efficacy of post-insult hypothermia in animal models led to the success of clinical trials in term human neonates. Large animal models are now being used to explore adjunct therapy to augment hypothermic neuroprotection.
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Affiliation(s)
- Raymond C Koehler
- 1 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Zeng-Jin Yang
- 1 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Jennifer K Lee
- 1 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA.,2 The Pathobiology Graduate Training Program, Johns Hopkins University, Baltimore, MD, USA
| | - Lee J Martin
- 2 The Pathobiology Graduate Training Program, Johns Hopkins University, Baltimore, MD, USA.,3 Department of Pathology, Division of Neuropathology, Johns Hopkins University, Baltimore, MD, USA
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Davidson JO, Draghi V, Whitham S, Dhillon SK, Wassink G, Bennet L, Gunn AJ. How long is sufficient for optimal neuroprotection with cerebral cooling after ischemia in fetal sheep? J Cereb Blood Flow Metab 2018; 38:1047-1059. [PMID: 28504050 PMCID: PMC5999002 DOI: 10.1177/0271678x17707671] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The optimal duration of mild "therapeutic" hypothermia for neonates with hypoxic-ischemic encephalopathy is surprisingly unclear. This study assessed the relative efficacy of cooling for 48 h versus 72 h. Fetal sheep (0.85 gestation) received sham ischemia (n = 9) or 30 min global cerebral ischemia followed by normothermia (n = 8) or delayed hypothermia from 3 h to 48 h (n = 8) or 72 h (n = 8). Ischemia was associated with profound loss of electroencephalogram (EEG) power, neurons in the cortex and hippocampus, and oligodendrocytes and myelin basic protein expression in the white matter, with increased Iba-1-positive microglia and proliferation. Hypothermia for 48 h was associated with improved outcomes compared to normothermia, but a progressive deterioration of EEG power after rewarming compared to 72 h of hypothermia, with impaired neuronal survival and myelin basic protein, and more microglia in the white matter and cortex. These findings show that head cooling for 48 h is partially neuroprotective, but is inferior to cooling for 72 h after cerebral ischemia in fetal sheep. The close association between rewarming at 48 h, subsequent deterioration in EEG power and increased cortical inflammation strongly suggests that deleterious inflammation can be reactivated by premature rewarming.
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Affiliation(s)
- Joanne O Davidson
- Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Vittoria Draghi
- Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Sean Whitham
- Department of Physiology, The University of Auckland, Auckland, New Zealand
| | | | - Guido Wassink
- Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Laura Bennet
- Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Alistair J Gunn
- Department of Physiology, The University of Auckland, Auckland, New Zealand
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Yozawitz E, Stacey A, Pressler RM. Pharmacotherapy for Seizures in Neonates with Hypoxic Ischemic Encephalopathy. Paediatr Drugs 2017; 19:553-567. [PMID: 28770451 DOI: 10.1007/s40272-017-0250-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Seizures are common in neonates with moderate and severe hypoxic ischemic encephalopathy (HIE) and are associated with worse outcomes, independent of HIE severity. In contrast to adults and older children, no new drugs have been licensed for treatment of neonatal seizures over the last 50 years, because of a lack of controlled clinical trials. Hence, many antiseizure medications licensed in older children and adults are used off-label for neonatal seizure, which is associated with potential risks of adverse effects during a period when the brain is particularly vulnerable. Phenobarbital is worldwide the first-line drug and is considered standard of care, although there is a limited evidence base for its efficacy. Second-line agents include phenytoin, benzodiazepines, levetiracetam, and lidocaine. These drugs are discussed in more detail along with two emerging drugs (bumetanide and topiramate). More safety, pharmacokinetic, and efficacy data are needed from well-designed clinical trials to develop safe and effective antiseizure regimes for the treatment of neonatal seizures in HIE.
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Affiliation(s)
- Elissa Yozawitz
- Department of Neurology and Pediatrics, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Arthur Stacey
- UCL Institute of Neurology, Queen Square, London, WC1N 3BG, UK
| | - Ronit M Pressler
- Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, Great Ormond Street, London, WC1N 3JH, UK. .,Clinical Neurosciences, UCL- Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK.
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Therapeutic hypothermia translates from ancient history in to practice. Pediatr Res 2017; 81:202-209. [PMID: 27673420 PMCID: PMC5233584 DOI: 10.1038/pr.2016.198] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 08/28/2016] [Indexed: 12/16/2022]
Abstract
Acute postasphyxial encephalopathy around the time of birth remains a major cause of death and disability. The possibility that hypothermia may be able to prevent or lessen asphyxial brain injury is a "dream revisited". In this review, a historical perspective is provided from the first reported use of therapeutic hypothermia for brain injuries in antiquity, to the present day. The first uncontrolled trials of cooling for resuscitation were reported more than 50 y ago. The seminal insight that led to the modern revival of studies of neuroprotection was that after profound asphyxia, many brain cells show initial recovery from the insult during a short "latent" phase, typically lasting ~6 h, only to die hours to days later during a "secondary" deterioration phase characterized by seizures, cytotoxic edema, and progressive failure of cerebral oxidative metabolism. Studies designed around this conceptual framework showed that mild hypothermia initiated as early as possible before the onset of secondary deterioration, and continued for a sufficient duration to allow the secondary deterioration to resolve, is associated with potent, long-lasting neuroprotection. There is now compelling evidence from randomized controlled trials that mild induced hypothermia significantly improves intact survival and neurodevelopmental outcomes to midchildhood.
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Guidotti I, Lugli L, Guerra MP, Ori L, Gallo C, Cavalleri F, Ranzi A, Frassoldati R, Berardi A, Ferrari F. Hypothermia reduces seizure burden and improves neurological outcome in severe hypoxic-ischemic encephalopathy: an observational study. Dev Med Child Neurol 2016; 58:1235-1241. [PMID: 27444888 DOI: 10.1111/dmcn.13195] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/19/2016] [Indexed: 12/01/2022]
Abstract
AIM To evaluate the antiepileptic effect of hypothermia and its association with neurological outcome in infants with moderate and severe hypoxic-ischemic encephalopathy (HIE). METHOD We compared polygraphic electroencephalography monitoring and outcome data in 39 cooled and 33 non-cooled term newborn infants, born between January 2005 and March 2013, and hospitalized because of signs of asphyxia and moderate to severe HIE. RESULTS Cooled newborn infants had fewer seizures (14/39 vs 20/33 p=0.036) and status epilepticus (7/39 vs 13/33, p=0.043), a lower mean duration of seizures (18mins vs 133mins, p=0.026), fewer administered antiepileptic drugs (median 0 vs 1, p=0.045), and more commonly a good outcome at 24 months (normal/mild motor impairment in 32/39 vs 16/33, p=0.003). Seizure burden (accumulated duration of seizures over a defined period) in cooled patients with both moderate (0.0 vs 0.1; p=0.045) and severe HIE (0.3 vs 4.9; p=0.018) was lower than in non-cooled patients. Compared with non-cooled patients, a good outcome was more common in cooled newborn infants with severe HIE (p=0.003). INTERPRETATION Hypothermia has an antiepileptic effect in both moderate and severe neonatal HIE. The lower seizure burden in cooled newborn infants with severe HIE is more commonly associated with normal outcome at 24 months.
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Affiliation(s)
- Isotta Guidotti
- Division of Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy
| | - Licia Lugli
- Division of Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy
| | - Maria Pina Guerra
- Division of Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy
| | - Luca Ori
- Division of Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy
| | - Claudio Gallo
- Division of Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy
| | - Francesca Cavalleri
- Division of Neuroradiology, Department of Neuroscience, Nuovo Ospedale Civile Sant'Agostino Estense, Modena, Italy
| | - Andrea Ranzi
- Regional Agency for Environmental Prevention, Reference Center for Environment and Health, Modena, Italy
| | - Rossella Frassoldati
- Division of Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy
| | - Alberto Berardi
- Division of Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy
| | - Fabrizio Ferrari
- Division of Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy
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Short-term effects of cannabidiol after global hypoxia-ischemia in newborn piglets. Pediatr Res 2016; 80:710-718. [PMID: 27441365 DOI: 10.1038/pr.2016.149] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 05/15/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Cannabidiol (CBD), a nonpsychoactive cannabinoid, has shown neuroprotective actions after neonatal hypoxia-ischemia (HI) in animals. We wanted to further explore the effects of CBD, alone and in conjunction with hypothermia, in a piglet model of global HI. METHODS Fifty-five anesthetized newborn piglets were randomized to either controls (n = 7) or HI (n = 48) by ventilation with 8% O2 until mean arterial blood pressure reached 20 mmHg and/or base excess reached -20 mmol/l. After resuscitation piglets were randomized to either: vehicle (VEH), CBD 1mg/kg, VEH+hypothermia (H) or CBD 1mg/kg+H (each n = 12). Piglets were euthanized 9.5 h after HI and plasma, urine, cerebrospinal fluid, and brain tissue were sampled for analysis. RESULTS HI induced global damage with significantly increased neuropathology score, S100B in cerebrospinal fluid, hippocampal proton magnetic resonance spectroscopy biomarkers, plasma troponin-T, and urinary neutrophil gelatinase-associated lipocalin. CBD alone did not have any significant effects on these parameters while CBD+H reduced urinary neutrophil gelatinase-associated lipocalin compared with VEH+H (P < 0.05). Both hypothermic groups had significantly lower glutamate/N-acetylaspartate ratios (P < 0.01) and plasma troponin-T (P<0.05) levels compared with normothermic groups. CONCLUSION In contrast to previous studies, we do not find significant protective effects of CBD after HI in piglets. Evaluation of CBD in higher doses might be warranted.
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Xenon Combined with Therapeutic Hypothermia Is Not Neuroprotective after Severe Hypoxia-Ischemia in Neonatal Rats. PLoS One 2016; 11:e0156759. [PMID: 27253085 PMCID: PMC4890818 DOI: 10.1371/journal.pone.0156759] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 05/19/2016] [Indexed: 11/21/2022] Open
Abstract
Background Therapeutic hypothermia (TH) is standard treatment following perinatal asphyxia in newborn infants. Experimentally, TH is neuroprotective after moderate hypoxia-ischemia (HI) in seven-day-old (P7) rats. However, TH is not neuroprotective after severe HI. After a moderate HI insult in newborn brain injury models, the anesthetic gas xenon (Xe) doubles TH neuroprotection. The aim of this study was to examine whether combining Xe and TH is neuroprotective as applied in a P7 rat model of severe HI. Design/Methods 120 P7 rat pups underwent a severe HI insult; unilateral carotid artery ligation followed by hypoxia (8% O2 for 150min at experimental normothermia (NT-37: Trectal 37°C). Surviving pups were randomised to immediate NT-37 for 5h (n = 36), immediate TH-32: Trectal 32°C for 5h (n = 25) or immediate TH-32 plus 50% inhaled Xe for 5h (n = 24). Pups were sacrificed after one week of survival. Relative area loss of the ligated hemisphere was measured, and neurons in the subventricular zone of this injured hemisphere were counted, to quantify brain damage. Results Following the HI insult, median (interquartile range, IQR) hemispheric brain area loss was similar in all groups: 63.5% (55.5–75.0) for NT-37 group, 65.0% (57.0–65.0) for TH-32 group, and 66.5% (59.0–72.0) for TH-32+Xe50% group (not significant). Correspondingly, there was no difference in neuronal cell count (NeuN marker) in the subventricular zone across the three treatment groups. Conclusions Immediate therapeutic hypothermia with or without additional 50% inhaled Xe, does not provide neuroprotection one week after severe HI brain injury in the P7 neonatal rat. This model aims to mimic the clinical situation in severely asphyxiated neonates and treatment these newborns remains an ongoing challenge.
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Lynch NE, Stevenson NJ, Livingstone V, Mathieson S, Murphy BP, Rennie JM, Boylan GB. The temporal characteristics of seizures in neonatal hypoxic ischemic encephalopathy treated with hypothermia. Seizure 2015; 33:60-5. [PMID: 26571073 DOI: 10.1016/j.seizure.2015.10.007] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 10/13/2015] [Accepted: 10/15/2015] [Indexed: 12/25/2022] Open
Abstract
PURPOSE The characteristics of electrographic seizures in newborns with hypoxic-ischaemic encephalopathy (HIE) treated with therapeutic hypothermia (TH) are poorly described. This retrospective, observational study provides reference data on the characteristics of seizures and their evolution over time in newborns with HIE receiving whole-body TH. METHOD The cohort under analysis included 23 infants with HIE and seizures defined by multi-channel EEG recordings. Clinical presentation, details of TH and antiepileptic drugs used were recorded. Time from first to last-recorded electrographic seizure (seizure period) was calculated. Temporal characteristics of seizures - total burden, duration, number, burden in minutes per hour, distribution of burden over time (temporal evolution), time from seizure onset to maximum seizure burden (Tmsb), T1, and time from Tmsb to seizure offset, T2 - were analysed. RESULTS The median age at electrographic seizure onset was 13.1h (IQR: 11.4 to 22.0). Tmsb was reached at a median age of 19.4 hours (IQR: 12.2 to 29.7). Median seizure period was 16.5h (IQR: 7.0 to 49.7), median number of seizures per hour was 1.9 (IQR: 1.0 to 3.3). The seizure burden was 4.0 min/h (IQR: 2.0 to 7.0). There was no consistent pattern in the temporal evolution of seizures in neonates treated with TH. The skewness was neither positive nor negative (p-value=0.15), there was no difference between the duration of T1 and T2 (p-value=0.09) and no difference in the seizure burden between T1 and T2 (p=0.09). There was an association between Tmsb and Phenobarbital (PB) administration (r=0.76, p-value<0.001). CONCLUSION There is no consistent temporal evolution of seizure burden in neonates treated with TH. Seizures are diffuse, and their characteristics are variable.
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Affiliation(s)
- Niamh E Lynch
- Department of Paediatrics and Child Health, University College Cork; Neonatal Brain Research Group, Irish Centre for Fetal and Neonatal Translational Research, University College Cork
| | - Nathan J Stevenson
- Neonatal Brain Research Group, Irish Centre for Fetal and Neonatal Translational Research, University College Cork
| | - Vicki Livingstone
- Neonatal Brain Research Group, Irish Centre for Fetal and Neonatal Translational Research, University College Cork
| | - Sean Mathieson
- Elizabeth Garrett Anderson Institute for Women's Health, University College London Hospitals, London
| | - Brendan P Murphy
- Department of Paediatrics and Child Health, University College Cork; Neonatal Brain Research Group, Irish Centre for Fetal and Neonatal Translational Research, University College Cork
| | - Janet M Rennie
- Elizabeth Garrett Anderson Institute for Women's Health, University College London Hospitals, London
| | - Geraldine B Boylan
- Department of Paediatrics and Child Health, University College Cork; Neonatal Brain Research Group, Irish Centre for Fetal and Neonatal Translational Research, University College Cork.
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Rewarming from therapeutic hypothermia induces cortical neuron apoptosis in a swine model of neonatal hypoxic-ischemic encephalopathy. J Cereb Blood Flow Metab 2015; 35:781-93. [PMID: 25564240 PMCID: PMC4420851 DOI: 10.1038/jcbfm.2014.245] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Revised: 12/05/2014] [Accepted: 12/08/2014] [Indexed: 11/08/2022]
Abstract
The consequences of therapeutic hypothermia for neonatal hypoxic-ischemic encephalopathy are poorly understood. Adverse effects from suboptimal rewarming could diminish neuroprotection from hypothermia. Therefore, we tested whether rewarming is associated with apoptosis. Piglets underwent hypoxia-asphyxia followed by normothermic or hypothermic recovery at 2 hours. Hypothermic groups were divided into those with no rewarming, rewarming at 0.5 °C/hour, or rewarming at 4 °C/hour. Neurodegeneration at 29 hours was assessed by hematoxylin and eosin staining, TUNEL assay, and immunoblotting for cleaved caspase-3. Rewarmed piglets had more apoptosis in motor cortex than did those that remained hypothermic after hypoxia-asphyxia. Apoptosis in piriform cortex was greater in hypoxic-asphyxic, rewarmed piglets than in naive/sham piglets. Caspase-3 inhibitor suppressed apoptosis with rewarming. Rapidly rewarmed piglets had more caspase-3 cleavage in cerebral cortex than did piglets that remained hypothermic or piglets that were rewarmed slowly. We conclude that rewarming from therapeutic hypothermia can adversely affect the newborn brain by inducing apoptosis through caspase mechanisms.
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Hoque N, Liu X, Chakkarapani E, Thoresen M. Minimal systemic hypothermia combined with selective head cooling evaluated in a pig model of hypoxia-ischemia. Pediatr Res 2015; 77:674-80. [PMID: 25665052 DOI: 10.1038/pr.2015.31] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 11/03/2014] [Indexed: 11/09/2022]
Abstract
BACKGROUND Selective head cooling (SHC) with moderate hypothermia (HT) and whole-body cooling are beneficial following perinatal asphyxia. SHC with systemic normothermia (NT) or minimal HT is under-investigated, could obviate systemic complications of moderate HT, and be applicable to preterm infants. We hypothesized that minimal systemic HT with SHC following hypoxia-ischemia (HI) would be neuroprotective compared with systemic NT. METHODS Newborn pigs underwent global HI causing permanent brain injury before being randomized to NT (rectal temperature (Trectal) 38.5 °C) or minimal HT (Trectal 37.0 °C) with SHC (cooling cap and body wrap) for 48 h followed by 24-h NT with 72-h survival. RESULTS SHC did not reduce global or regional neuropathology score when correcting for insult severity or compared with a NT group matched for HI severity but increased mortality by 26%. During 48 h, the SHC mean ± SD Trectal was 37.0 ± 0.2 °C, and Tdeep brain and Tsuperficial brain were 35.0 ± 1.1 °C and 31.5 ± 1.6 °C, respectively, with stable Tbrain achieved ≥ 3 h after starting cooling. CONCLUSION This is the first study in newborn pigs of minimal systemic HT with SHC for 48 h and a further 24 h of NT following HI. Mortality was increased in the cooled group with no neuroprotection in survivors.
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Affiliation(s)
- Nicholas Hoque
- Neonatal Neuroscience, School of Clinical Sciences, University of Bristol, Bristol, Avon, UK
| | - Xun Liu
- Neonatal Neuroscience, School of Clinical Sciences, University of Bristol, Bristol, Avon, UK
| | - Ela Chakkarapani
- Neonatal Neuroscience, School of Clinical Sciences, University of Bristol, Bristol, Avon, UK
| | - Marianne Thoresen
- 1] Neonatal Neuroscience, School of Clinical Sciences, University of Bristol, Bristol, Avon, UK [2] Department of Physiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
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Seizures and hypothermia: importance of electroencephalographic monitoring and considerations for treatment. Semin Fetal Neonatal Med 2015; 20:103-8. [PMID: 25683598 DOI: 10.1016/j.siny.2015.01.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Hypoxic-ischemic encephalopathy is a common cause of seizures in neonates. Despite the introduction of therapeutic hypothermia, seizure rates are similar to those reported in the pre-therapeutic hypothermia era. However, the seizure profile has been altered resulting in a lower overall seizure burden, shorter individual seizure durations, and seizures that are harder to detect. Electroencephalographic (EEG) monitoring is the gold standard for detecting all seizures in neonates and this is even more critical in neonates who are cooled, as they are often sedated, making seizures more difficult to detect. Several studies have shown that the majority of seizures in neonates undergoing therapeutic hypothermia remain subclinical, thus requiring EEG monitoring for diagnosis. Amplitude-integrated EEG monitoring is useful but shorter duration seizures are more likely to be missed. Evidence is emerging about the pharmacokinetic profile of routinely used antiepileptic drugs during therapeutic hypothermia and some modifications have been suggested, particularly for lidocaine use.
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Panigrahy A, Schmithorst VJ, Wisnowski JL, Watson CG, Bellinger DC, Newburger JW, Rivkin MJ. Relationship of white matter network topology and cognitive outcome in adolescents with d-transposition of the great arteries. NEUROIMAGE-CLINICAL 2015; 7:438-48. [PMID: 25685710 PMCID: PMC4318874 DOI: 10.1016/j.nicl.2015.01.013] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Revised: 12/25/2014] [Accepted: 01/23/2015] [Indexed: 12/16/2022]
Abstract
Patients with congenital heart disease (CHD) are at risk for neurocognitive impairments. Little is known about the impact of CHD on the organization of large-scale brain networks. We applied graph analysis techniques to diffusion tensor imaging (DTI) data obtained from 49 adolescents with dextro-transposition of the great arteries (d-TGA) repaired with the arterial switch operation in early infancy and 29 healthy referent adolescents. We examined whether differences in neurocognitive functioning were related to white matter network topology. We developed mediation models revealing the respective contributions of peri-operative variables and network topology on cognitive outcome. Adolescents with d-TGA had reduced global efficiency at a trend level (p = 0.061), increased modularity (p = 0.012), and increased small-worldness (p = 0.026) as compared to controls. Moreover, these network properties mediated neurocognitive differences between the d-TGA and referent adolescents across every domain assessed. Finally, structural network topology mediated the neuroprotective effect of longer duration of core cooling during reparative neonatal cardiac surgery, as well as the detrimental effects of prolonged hospitalization. Taken together, worse neurocognitive function in adolescents with d-TGA is mediated by global differences in white matter network topology, suggesting that disruption of this configuration of large-scale networks drives neurocognitive dysfunction. These data provide new insights into the interplay between perioperative factors, brain organization, and cognition in patients with complex CHD. Network topology mediates neurocognitive outcomes in congenital heart disease. Network topology mediates the neuroprotective effect of hypothermia on cognition. Network topology mediates the effect of prolonged hospitalization on cognition.
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Affiliation(s)
- Ashok Panigrahy
- Department of Pediatric Radiology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, CA, USA
- Department of Radiology and Bioinformatics, University of Pittsburgh, Pittsburgh, CA, USA
- Department of Radiology, Children's Hospital Los Angeles, CA, USA
- Brain and Creativity Institute, University of Southern California, CA, USA
- Correspondence to: Department of Pediatric Radiology, Children's Hospital of Pittsburgh of UPMC, 4401 Penn Avenue, Pittsburgh, PA 15224, USA. Tel: +1 412 692 5510; fax: +1 412 864 8622.
| | - Vincent J. Schmithorst
- Department of Pediatric Radiology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, CA, USA
| | - Jessica L. Wisnowski
- Department of Pediatric Radiology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, CA, USA
- Department of Radiology, Children's Hospital Los Angeles, CA, USA
- Brain and Creativity Institute, University of Southern California, CA, USA
| | - Christopher G. Watson
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA
- Graduate Program for Neuroscience, Boston University, Boston, MA, USA
| | | | - Jane W. Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Michael J. Rivkin
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA
- Department of Psychiatry, Boston Children's Hospital, Boston, MA, USA
- Department of Radiology, Boston Children's Hospital, Boston, MA, USA
- Department of Neurology, Harvard Medical School, Boston, MA, USA
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Yang X, Wang X. Potential mechanisms and clinical applications of mild hypothermia and electroconvulsive therapy on refractory status epilepticus. Expert Rev Neurother 2014; 15:135-44. [DOI: 10.1586/14737175.2015.992415] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Schmitt KRL, Tong G, Berger F. Mechanisms of hypothermia-induced cell protection in the brain. Mol Cell Pediatr 2014; 1:7. [PMID: 26567101 PMCID: PMC4530563 DOI: 10.1186/s40348-014-0007-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 08/27/2014] [Indexed: 11/10/2022] Open
Abstract
Therapeutic hypothermia is an effective cytoprotectant and promising intervention shown to improve outcome in patients following cardiac arrest and neonatal hypoxia-ischemia. However, despite our clinical and experimental experiences, the protective molecular mechanisms of therapeutic hypothermia remain to be elucidated. Therefore, in this brief overview we discuss both the clinical evidence and molecular mechanisms of therapeutic hypothermia in order to provide further insights into this promising intervention.
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Affiliation(s)
- Katharina Rose Luise Schmitt
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Institute Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Giang Tong
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Institute Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Felix Berger
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Institute Berlin, Augustenburger Platz 1, 13353, Berlin, Germany. .,Department of Pediatric Cardiology, Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany.
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Orbach SA, Bonifacio SL, Kuzniewicz M, Glass HC. Lower incidence of seizure among neonates treated with therapeutic hypothermia. J Child Neurol 2014; 29:1502-7. [PMID: 24334344 PMCID: PMC4053513 DOI: 10.1177/0883073813507978] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Animal studies suggest that hypothermia decreases seizure burden, whereas limited human data are inconclusive. This retrospective cohort study examines the relationship between therapeutic hypothermia and seizure in neonates with hypoxic-ischemic encephalopathy. Our center admitted 224 neonates from July 2004 to December 2011 who met institutional cooling criteria. Seventy-three neonates were born during the pre-cooling era, prior to November 2007, and 151 were born during the cooling era. Among neonates with moderate encephalopathy, the incidence of seizure in cooled infants was less than half the incidence in those not cooled (26% cooling, 61% pre-cooling era; risk ratio = 0.43, 95% confidence interval = 0.30-0.61). Among neonates with severe encephalopathy, there was no difference in the incidence (83% vs. 87%; risk ratio = 1.05, 95% confidence interval = 0.78-1.39). These results support animal data and suggest a mechanism by which neonates with moderate encephalopathy can benefit more from cooling than neonates with severe encephalopathy.
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Affiliation(s)
- Sharon A Orbach
- School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Sonia L Bonifacio
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Michael Kuzniewicz
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA,Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Hannah C Glass
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA Department of Neurology, University of California San Francisco, San Francisco, CA, USA
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Chalak LF, Tarumi T, Zhang R. The "neurovascular unit approach" to evaluate mechanisms of dysfunctional autoregulation in asphyxiated newborns in the era of hypothermia therapy. Early Hum Dev 2014; 90:687-94. [PMID: 25062804 PMCID: PMC4170014 DOI: 10.1016/j.earlhumdev.2014.06.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 06/27/2014] [Indexed: 10/25/2022]
Abstract
Despite improvements in obstetrical and neonatal care, and introduction of hypothermia as a neuroprotective therapy, perinatal brain injury remains a frequent cause of cerebral palsy, mental retardation and epilepsy. The recognition of dysfunction of cerebral autoregulation is essential for a real time measure of efficacy to identify those who are at highest risk for brain injury. This article will focus on the "neurovascular unit" approach to the care of asphyxiated neonates and will address 1) potential mechanisms of dysfunctional cerebral blood flow (CBF) regulation, 2) optimal monitoring methodology such as NIRS (near infrared spectroscopy), and TCD (transcutaneous Doppler), and 3) clinical implications of monitoring in the neonatal intensive care setting in asphyxiated newborns undergoing hypothermia and rewarming. Critical knowledge of the functional regulation of the neurovascular unit may lead to improved ability to predict outcomes in real time during hypothermia, as well as differentiate non-responders who might benefit from additional therapies.
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Affiliation(s)
- Lina F. Chalak
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX,Correspondence: Lina F. Chalak, MD, MSCS, Associate professor at the University of Texas Southwestern Medical Center at Dallas, Department of Pediatrics, Division of Neonatal-Perinatal Medicine, 5323 Harry Hines Boulevard, Dallas, Texas 75390-9063, Phone: (214) 648-3903, Fax: (214) 648-2481,
| | - Takashi Tarumi
- Department of internal medicine at University of Texas Southwestern Medical Center, Dallas, TX
| | - Rong Zhang
- Department of internal medicine at University of Texas Southwestern Medical Center, Dallas, TX
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Nelson DB, Lucke AM, McIntire DD, Sánchez PJ, Leveno KJ, Chalak LF. Obstetric antecedents to body-cooling treatment of the newborn infant. Am J Obstet Gynecol 2014; 211:155.e1-6. [PMID: 24530976 DOI: 10.1016/j.ajog.2014.02.013] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 12/23/2013] [Accepted: 02/12/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Obstetric antecedents were analyzed in births in which the infant received whole-body cooling for neonatal encephalopathy. STUDY DESIGN This retrospective cohort study included all live-born singleton infants delivered at or beyond 36 weeks' gestation from October 2005 through December 2011. Infants who had received whole-body cooling identified by review of a prospective neonatal registry were compared with a control group comprising the remaining obstetric population delivered at greater than 36 weeks but not cooled. Univariable analysis was followed up by a staged, stepwise selection of variables with the intent to rank significant risk factors for cooling. RESULTS A total of 86,371 women delivered during the study period and 98 infants received whole-body cooling (1.1 per 1000 live births). Of these 98 infants, 80 newborns (88%) had moderate encephalopathy and 10 (12%) had severe encephalopathy prior to cooling. Maternal age of 15 years or younger, low parity, maternal body habitus (body mass index of ≥40 kg/m(2)), diabetes, preeclampsia, induction, epidural analgesia, chorioamnionitis, length of labor, and mode of delivery were associated with significantly increased risk of infant cooling during a univariable analysis. Catastrophic events to include umbilical cord prolapse (odds ratio [OR], 14; 95% confidence interval [CI], 3-72), placental abruption (OR, 17; 95% CI, 7-44), uterine rupture (OR, 130; 95% CI, 11-1477) were the strongest factors associated with infant cooling after staged-stepwise logistic analysis. CONCLUSION A variety of intrapartum characteristics were associated with infant cooling for neonatal encephalopathy, with the most powerful antecedents being umbilical cord prolapse, placental abruption, and uterine rupture.
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Arca G, García-Alix A, Arnáez J, Blanco D. [Sedation in term or near-term newborns with hypoxic-ischemic encephalopathy who require therapeutic hypothermia]. An Pediatr (Barc) 2014; 82:52-3. [PMID: 24907864 DOI: 10.1016/j.anpedi.2014.04.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Revised: 04/23/2014] [Accepted: 04/29/2014] [Indexed: 10/25/2022] Open
Affiliation(s)
- G Arca
- Servicio de Neonatología, Sede Maternidad, Hospital Clínic, Barcelona, España.
| | - A García-Alix
- Servicio de Neonatología, Sede Maternidad, Hospital Clínic, Barcelona, España
| | - J Arnáez
- Servicio de Neonatología, Sede Maternidad, Hospital Clínic, Barcelona, España
| | - D Blanco
- Servicio de Neonatología, Sede Maternidad, Hospital Clínic, Barcelona, España
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Hoque N, Sabir H, Maes E, Bishop S, Thoresen M. Validation of a neuropathology score using quantitative methods to evaluate brain injury in a pig model of hypoxia ischaemia. J Neurosci Methods 2014; 230:30-6. [PMID: 24747875 DOI: 10.1016/j.jneumeth.2014.04.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 03/30/2014] [Accepted: 04/05/2014] [Indexed: 01/20/2023]
Abstract
BACKGROUND Neuropathological examination is the classic outcome measure in experimental studies of newborn brain injury to evaluate novel therapies. We have used a graded neuropathology score in an established global model of perinatal hypoxic-ischaemic (HI) injury. We wished to validate the score using cell counting in our model. NEW METHOD 32 newborn pigs underwent a 45 min global HI insult then maintained at normothermia (NT, rectal temperature, Trectal 38.5 °C) for 72 h or mild total body hypothermia (HT, Trectal 37.0 °C) combined with selective head cooling for 48 h and subsequently maintained at NT for 24h before brain perfusion fixation. A perinatal pathologist scored haematoxylin and eosin stained 6 μm histological sections for injury in the hippocampus and basal ganglia on a 9-step scale (0.0=no injury, 4.0=>75% injury). We counted the number of healthy neurons in the hippocampus CA1 region and putamen using morphological criteria in eight random, non-overlapping fields from representative sections. RESULTS Healthy neuronal cell density correlated with neuropathology score in the hippocampus CA1 (r = -0.74) and in the putamen (r = -0.75) and both measures detected a difference between groups. The correlation coefficients were better for the NT compared to the HT group in both the hippocampus (r = -0.87 vs. -0.53) and putamen (r = -0.77 vs. -0.54). COMPARISON WITH EXISTING METHOD We have validated a histological neuropathological scoring system in our model of perinatal HI by showing correlation between neuronal cell count and estimated injury. CONCLUSIONS Our neuropathology score is a valid method to assess brain injury with good reproducibility and sensitivity.
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Affiliation(s)
- Nicholas Hoque
- Neonatal Neuroscience, School of Clinical Sciences, University of Bristol, St Michael's Hospital, Southwell Street, Bristol, Avon BS2 8EG, United Kingdom
| | - Hemmen Sabir
- Neonatal Neuroscience, School of Clinical Sciences, University of Bristol, St Michael's Hospital, Southwell Street, Bristol, Avon BS2 8EG, United Kingdom
| | - Elke Maes
- Neonatal Neuroscience, School of Clinical Sciences, University of Bristol, St Michael's Hospital, Southwell Street, Bristol, Avon BS2 8EG, United Kingdom; Department of Physiology, Institute of Basic Medical Sciences, University of Oslo, Postboks 1103, Blindern, 0317 Oslo, Norway
| | - Sarah Bishop
- Neonatal Neuroscience, School of Clinical Sciences, University of Bristol, St Michael's Hospital, Southwell Street, Bristol, Avon BS2 8EG, United Kingdom
| | - Marianne Thoresen
- Neonatal Neuroscience, School of Clinical Sciences, University of Bristol, St Michael's Hospital, Southwell Street, Bristol, Avon BS2 8EG, United Kingdom; Department of Physiology, Institute of Basic Medical Sciences, University of Oslo, Postboks 1103, Blindern, 0317 Oslo, Norway.
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Wassink G, Gunn ER, Drury PP, Bennet L, Gunn AJ. The mechanisms and treatment of asphyxial encephalopathy. Front Neurosci 2014; 8:40. [PMID: 24578682 PMCID: PMC3936504 DOI: 10.3389/fnins.2014.00040] [Citation(s) in RCA: 128] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2013] [Accepted: 02/12/2014] [Indexed: 11/13/2022] Open
Abstract
Acute post-asphyxial encephalopathy occurring around the time of birth remains a major cause of death and disability. The recent seminal insight that allows active neuroprotective treatment is that even after profound asphyxia (the “primary” phase), many brain cells show initial recovery from the insult during a short “latent” phase, typically lasting approximately 6 h, only to die hours to days later after a “secondary” deterioration characterized by seizures, cytotoxic edema, and progressive failure of cerebral oxidative metabolism. Although many of these secondary processes are potentially injurious, they appear to be primarily epiphenomena of the “execution” phase of cell death. Animal and human studies designed around this conceptual framework have shown that moderate cerebral hypothermia initiated as early as possible but before the onset of secondary deterioration, and continued for a sufficient duration to allow the secondary deterioration to resolve, has been associated with potent, long-lasting neuroprotection. Recent clinical trials show that while therapeutic hypothermia significantly reduces morbidity and mortality, many babies still die or survive with disabilities. The challenge for the future is to find ways of improving the effectiveness of treatment. In this review, we will dissect the known mechanisms of hypoxic-ischemic brain injury in relation to the known effects of hypothermic neuroprotection.
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Affiliation(s)
- Guido Wassink
- Fetal Physiology and Neuroscience Team, Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland Auckland, New Zealand
| | - Eleanor R Gunn
- Fetal Physiology and Neuroscience Team, Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland Auckland, New Zealand
| | - Paul P Drury
- Fetal Physiology and Neuroscience Team, Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland Auckland, New Zealand
| | - Laura Bennet
- Fetal Physiology and Neuroscience Team, Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland Auckland, New Zealand
| | - Alistair J Gunn
- Fetal Physiology and Neuroscience Team, Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland Auckland, New Zealand
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Gano D, Orbach SA, Bonifacio SL, Glass HC. Neonatal seizures and therapeutic hypothermia for hypoxic-ischemic encephalopathy. MOLECULAR & CELLULAR EPILEPSY 2014; 1:e88. [PMID: 26052538 PMCID: PMC4456026 DOI: 10.14800/mce.88] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Neonatal seizures are associated with morbidity and mortality. Hypoxic-ischemic encephalopathy (HIE) is the most common cause of seizures in newborns. Neonatal animal models suggest that therapeutic hypothermia can reduce seizures and epileptiform activity in the setting of hypoxia-ischemia, however data from human studies have conflicting results. In this research highlight, we will discuss the findings of our recent study that demonstrated a decreased seizure burden in term newborns with moderate HIE treated with hypothermia.
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Affiliation(s)
- Dawn Gano
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Sharon A. Orbach
- School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Sonia L. Bonifacio
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Hannah C. Glass
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
- Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
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Chakkarapani E, Dingley J, Aquilina K, Osredkar D, Liu X, Thoresen M. Effects of xenon and hypothermia on cerebrovascular pressure reactivity in newborn global hypoxic-ischemic pig model. J Cereb Blood Flow Metab 2013; 33:1752-60. [PMID: 23899927 PMCID: PMC3824173 DOI: 10.1038/jcbfm.2013.123] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Revised: 05/22/2013] [Accepted: 07/01/2013] [Indexed: 12/29/2022]
Abstract
Autoregulation of cerebral perfusion is impaired in hypoxic-ischemic encephalopathy. We investigated whether cerebrovascular pressure reactivity (PRx), an element of cerebral autoregulation that is calculated as a moving correlation coefficient between averages of intracranial and mean arterial blood pressure (MABP) with values between -1 and +1, is impaired during and after a hypoxic-ischemic insult (HI) in newborn pigs. Associations between end-tidal CO2, seizures, neuropathology, and PRx were investigated. The effect of hypothermia (HT) and Xenon (Xe) on PRx was studied. Pigs were randomized to Sham, and after HI to normothermia (NT), HT, Xe or xenon hypothermia (XeHT). We defined PRx >0.2 as peak and negative PRx as preserved. Neuropathology scores after 72 hours of survival was grouped as 'severe' or 'mild.' Secondary PRx peak during recovery, predictive of severe neuropathology and associated with insult severity (P=0.05), was delayed in HT (11.5 hours) than in NT (6.5 hours) groups. Seizures were associated with impaired PRx in NT pigs (P=0.0002), but not in the HT/XeHT pigs. PRx was preserved during normocapnia and impaired during hypocapnia. Xenon abolished the secondary PRx peak, increased (mean (95% confidence interval (CI)) MABP (6.5 (3.8, 9.4) mm Hg) and cerebral perfusion pressure (5.9 (2.9, 8.9) mm Hg) and preserved the PRx (regression coefficient, -0.098 (95% CI (-0.18, -0.01)), independent of the insult severity.
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Ferreira Da Silva IR, Frontera JA. Targeted Temperature Management in Survivors of Cardiac Arrest. Cardiol Clin 2013; 31:637-55, ix. [DOI: 10.1016/j.ccl.2013.07.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Abstract
Abstract
Background:
Some inhalation anesthetics increase apoptotic cell death in the developing brain. Xenon, an inhalation anesthetic, increases neuroprotection when combined with therapeutic hypothermia after hypoxic-ischemic brain injury in newborn animals. The authors, therefore, examined whether there was any neuroapoptotic effect of breathing 50% xenon with continuous fentanyl sedation for 24 h at normothermia or hypothermia on newborn pigs.
Methods:
Twenty-six healthy pigs (<24-h old) were randomized into four groups: (1) 24 h of 50% inhaled xenon with fentanyl at hypothermia (Trec = 33.5°C), (2) 24 h of 50% inhaled xenon with fentanyl at normothermia (Trec = 38.5°C), (3) 24 h of fentanyl at normothermia, or (4) nonventilated juvenile controls at normothermia. Five additional nonrandomized pigs inhaled 2% isoflurane at normothermia for 24 h to verify any proapoptotic effect of inhalation anesthetics in our model. Pathological cells were morphologically assessed in cortex, putamen, hippocampus, thalamus, and white matter. To quantify the findings, immunostained cells (caspase-3 and terminal deoxynucleotidyl transferase–mediated deoxyuridine-triphosphate nick-end labeling) were counted in the same brain regions.
Results:
For groups (1) to (4), the total number of apoptotic cells was less than 5 per brain region, representing normal developmental neuroapoptosis. After immunostaining and cell counting, regression analysis showed that neither 50% xenon with fentanyl nor fentanyl alone increased neuroapoptosis. Isoflurane caused on average a 5- to 10-fold increase of immunostained cells.
Conclusion:
At normothermia or hypothermia, neither 24 h of inhaled 50% xenon with fentanyl sedation nor fentanyl alone induces neuroapoptosis in the neonatal pig brain. Breathing 2% isoflurane increases neuroapoptosis in neonatal pigs.
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Srinivasakumar P, Zempel J, Wallendorf M, Lawrence R, Inder T, Mathur A. Therapeutic hypothermia in neonatal hypoxic ischemic encephalopathy: electrographic seizures and magnetic resonance imaging evidence of injury. J Pediatr 2013; 163:465-70. [PMID: 23452588 DOI: 10.1016/j.jpeds.2013.01.041] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Revised: 12/20/2012] [Accepted: 01/22/2013] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To evaluate the electrographic seizure burden in neonates with hypoxic ischemic encephalopathy (HIE) treated with or without therapeutic hypothermia and stratified results by severity of HIE and severity of injury as assessed by magnetic resonance imaging (MRI). STUDY DESIGN Between 2007 and 2011, video-electroencephalography (EEG) monitoring was initiated in neonates with moderate to severe HIE. Seizure burden (in seconds) was calculated, and brain MRI scans were quantitatively scored. Data were analyzed by ANOVA, the Student t test, and the χ(2) test. RESULTS Sixty-nine neonates with moderate or severe HIE were prospectively enrolled, including 51 who received therapeutic hypothermia and 18 who did not. The mean duration of video-EEG monitoring was longer in the therapeutic hypothermia group (72 ± 34 hours vs 48 ± 34 hours; P = .01). The therapeutic hypothermia group had a lower electrographic seizure burden (log units) after controlling for injury, as assessed by MRI (2.9 ± 0.6 vs 6.2 ± 0.9; P = .003). A reduction in seizure burden was seen in neonates with moderate HIE (P = .0001), but not in those with severe HIE (P = .80). Among neonates with injury assessed by MRI, seizure burden was lower in those with mild (P = .0004) and moderate (P = .02) injury, but not in those with severe injury (P = .90). CONCLUSION Therapeutic hypothermia was associated with reduced electrographic seizure burden in neonatal HIE. This effect was detected on video-EEG in infants with moderate HIE, but not in those with severe HIE. When stratified by injury as assessed by MRI, therapeutic hypothermia was associated with a reduced seizure burden in infants with mild and moderate injury, but not in those with severe injury.
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Abstract
Hypoxia-ischemia is a leading cause of morbidity and mortality in the perinatal period with an incidence of 1/4000 live births. Biochemical events such as energy failure, membrane depolarization, brain edema, an increase of neurotransmitter release and inhibition of uptake, an increase of intracellular Ca(2+), production of oxygen-free radicals, lipid peroxidation, and a decrease of blood flow are triggered by hypoxia-ischemia and may lead to brain dysfunction and neuronal death. These abnormalities can result in mental impairments, seizures, and permanent motor deficits, such as cerebral palsy. The physical and emotional strain that is placed on the children affected and their families is enormous. The care that these individuals need is not only confined to childhood, but rather extends throughout their entire life span, so it is very important to understand the pathophysiology that follows a hypoxic-ischemic insult. This review will highlight many of the mechanisms that lead to neuronal death and include the emerging area of white matter injury as well as the role of inflammation and will provide a summary of therapeutic strategies. Hypothermia and oxygen will also be discussed as treatments that currently lack a specific target in the hypoxic/ischemic cascade.
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Affiliation(s)
- John W Calvert
- Departments of Neurosurgery and Molecular and Cellular Physiology, Loma Linda University Medical Center, 11234 Anderson Street, Loma Linda, CA 92354, USA
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LIU X, DINGLEY J, ELSTAD M, SCULL-BROWN E, STEEN PA, THORESEN M. Minimum alveolar concentration (MAC) for sevoflurane and xenon at normothermia and hypothermia in newborn pigs. Acta Anaesthesiol Scand 2013; 57:646-53. [PMID: 23316707 DOI: 10.1111/aas.12055] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2012] [Indexed: 12/21/2022]
Abstract
BACKGROUND Neuroprotection from therapeutic hypothermia increases when combined with the anaesthetic gas xenon in animal studies. A clinical feasibility study of the combined treatment has been successfully undertaken in asphyxiated human term newborns. It is unknown whether xenon alone would be sufficient for sedation during hypothermia eliminating or reducing the need for other sedative or analgesic infusions in ventilated sick infants. Minimum alveolar concentration (MAC) of xenon is unknown in any neonatal species. METHODS Eight newborn pigs were anaesthetised with sevoflurane alone and then sevoflurane plus xenon at two temperatures. Pigs were randomised to start at either 38.5°C or 33.5°C. MAC for sevoflurane was determined using the claw clamp technique at the preset body temperature. For xenon MAC determination, a background of 0.5 MAC sevoflurane was used, and 60% xenon added to the gas mixture. The relationship between sevoflurane and xenon MAC is assumed to be additive. Xenon concentrations were changed in 5% steps until a positive clamp reaction was noted. Pigs' temperature was changed to the second target, and two MAC determinations for sevoflurane and 0.5 MAC sevoflurane plus xenon were repeated. RESULTS MAC for sevoflurane was 4.1% [95% confidence interval (CI): 3.65-4.50] at 38.5°C and 3.05% (CI: 2.63-3.48) at 33.5°C, a significant reduction. MAC for xenon was 120% at 38.5°C and 116% at 33.5°C, not different. CONCLUSION In newborn swine sevoflurane, MAC was temperature dependent, while xenon MAC was independent of temperature. There was large individual variability in xenon MAC, from 60% to 120%.
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Affiliation(s)
- X. LIU
- Neonatal Neuroscience; School of Clinical Sciences; University of Bristol; Bristol; UK
| | - J. DINGLEY
- Anesthetics; Swansea Medical School; University of Swansea; Swansea; UK
| | - M. ELSTAD
- Department of Physiology; Institute of Basic Medical Sciences; University of Oslo; Oslo; Norway
| | - E. SCULL-BROWN
- Neonatal Neuroscience; School of Clinical Sciences; University of Bristol; Bristol; UK
| | - P. A. STEEN
- Clinic for Emergencies and Critical Care; University of Oslo and Oslo University Hospital; Norway
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Marks KA. Hypoxic–ischemic brain injury and neuroprotection in the newborn infant. FUTURE NEUROLOGY 2013. [DOI: 10.2217/fnl.13.5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Recent clinical trials have confirmed that in term infants with moderate-to-severe hypoxic–ischemic encephalopathy, death and severe developmental disability can be reduced by early treatment with hypothermia. However, meta-analysis of these trials has confirmed that two-thirds of the survivors remain seriously impaired. The search for new neuroprotective interventions has therefore continued. Extensive research has identified the important biochemical pathways that result in neuronal loss, and the subsequent repair and regeneration processes. The most promising neuroprotective agents that limit the former, and promote the latter, are being tested in animal models of hypoxic–ischemic brain injury and are awaiting clinical trials. It is likely that a ‘cocktail’ of agents, affecting a number of pathways, will ultimately prove to be the most effective intervention. The latest additions to a long list of proposed substances are various stem cells that promote neurogenesis by releasing trophic substances into the injured brain. Future clinical trials are likely to employ early biomarkers, of which MRI and proton spectroscopy are probably the most predictive of long-term neurodevelopmental outcome. In conclusion, the exponential increase in knowledge in this field can be expected to provide many more neuroprotective agents within the next decade.
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Affiliation(s)
- Kyla-Anna Marks
- Department of Neonatal Medicine, Soroka University Medical Centre, PO Box 151, Beersheva, Israel
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Esencan E, Yuksel S, Tosun YB, Robinot A, Solaroglu I, Zhang JH. XENON in medical area: emphasis on neuroprotection in hypoxia and anesthesia. Med Gas Res 2013; 3:4. [PMID: 23369273 PMCID: PMC3626616 DOI: 10.1186/2045-9912-3-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Accepted: 01/25/2013] [Indexed: 01/03/2023] Open
Abstract
Xenon is a medical gas capable of establishing neuroprotection, inducing anesthesia as well as serving in modern laser technology and nuclear medicine as a contrast agent. In spite of its high cost, its lack of side effects, safe cardiovascular and organoprotective profile and effective neuroprotective role after hypoxic-ischemic injury (HI) favor its applications in clinics. Xenon performs its anesthetic and neuroprotective functions through binding to glycine site of glutamatergic N-methyl-D-aspartate (NMDA) receptor competitively and blocking it. This blockage inhibits the overstimulation of NMDA receptors, thus preventing their following downstream calcium accumulating cascades. Xenon is also used in combination therapies together with hypothermia or sevoflurane. The neuroprotective effects of xenon and hypothermia cooperate synergistically whether they are applied synchronously or asynchronously. Distinguishing properties of Xenon promise for innovations in medical gas field once further studies are fulfilled and Xenon’s high cost is overcome.
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Affiliation(s)
- Ecem Esencan
- Departments of Neurosurgery and Physiology, Loma Linda University, Loma Linda, CA, USA.
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Chang M. Therapeutic Hypothermia for Newborns with Hypoxic Ischemic Encephalopathy. NEONATAL MEDICINE 2013. [DOI: 10.5385/nm.2013.20.1.2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Meayoung Chang
- Department of Pediatrics, Graduate School of Medicine, Chungnam National University, Daejeon, Korea
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