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Garegrat R, Montaldo P, Burgod C, Pant S, Mazlan M, Palanisami B, Chakkarapani E, Woolfall K, Johnson S, Grant PE, Land S, Mahmoud M, Brady T, Cornelius V, Adams E, Dorling J, Aladangadi N, Fleming P, Pressler R, Shennan A, Petrou S, Soe A, Basset P, Shankaran S, Thayyil S. Whole-body hypothermia in mild neonatal encephalopathy: protocol for a multicentre phase III randomised controlled trial. BMC Pediatr 2024; 24:460. [PMID: 39026197 PMCID: PMC11256637 DOI: 10.1186/s12887-024-04935-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Accepted: 07/08/2024] [Indexed: 07/20/2024] Open
Abstract
BACKGROUND Mild hypoxic ischemic encephalopathy is associated with sub optimal cognition and learning difficulties at school age. Although whole-body hypothermia reduces death and disability after moderate or severe encephalopathy in high-income countries, the safety and efficacy of hypothermia in mild encephalopathy is not known. The cooling in mild encephalopathy (COMET) trial will examine if whole-body hypothermia improves cognitive development of neonates with mild encephalopathy. METHODS The COMET trial is a phase III multicentre open label two-arm randomised controlled trial with masked outcome assessments. A total of 426 neonates with mild encephalopathy will be recruited from 50 to 60 NHS hospitals over 2 ½ years following parental consent. The neonates will be randomised to 72 h of whole-body hypothermia (33.5 ± 0.5 C) or normothermia (37.0 ± 0.5 C) within six hours or age. Prior to the recruitment front line clinical staff will be trained and certified on expanded modified Sarnat staging for encephalopathy. The neurological assessment of all screened and recruited cases will be video recorded and centrally assessed for quality assurance. If recruitment occurs at a non-cooling centre, neonates in both arms will be transferred to a cooling centre for continued care, after randomisation. All neonates will have continuous amplitude integrated electroencephalography (aEEG) at least for the first 48 h to monitor for seizures. Predefined safety outcomes will be documented, and data collected to assess resource utilization of health care. A central team masked to trial group allocation will assess neurodevelopmental outcomes at 2 years of age. The primary outcome is mean difference in composite cognitive scores on Bayley scales of Infant and Toddler development 4th Edition. DISCUSSION The COMET trial will establish the safety and efficacy of whole-body hypothermia for mild hypoxic ischaemic encephalopathy and inform national and international guidelines in high income countries. It will also provide an economic assessment of whole-body hypothermia therapy for mild encephalopathy in the NHS on cost-effectiveness grounds. TRIAL REGISTRATION NUMBER NCT05889507 June 5, 2023.
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Affiliation(s)
- Reema Garegrat
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, Du Cane Road, London, W12 0HS, England.
| | - Paolo Montaldo
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, Du Cane Road, London, W12 0HS, England
- Department of Woman, Child, and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Constance Burgod
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, Du Cane Road, London, W12 0HS, England
| | - Stuti Pant
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, Du Cane Road, London, W12 0HS, England
| | - Munirah Mazlan
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, Du Cane Road, London, W12 0HS, England
| | | | - Ela Chakkarapani
- University of Bristol and St Michaels Hospital NHS Trust, Bristol, UK
| | - Kerry Woolfall
- Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | - Samantha Johnson
- Department of Population Health Sciences, University of Leicester, Leicester, UK
| | - Patricia Ellen Grant
- Departments of Radiology and Pediatrics, Boston Children,s Hospital, Harvard Medical School, Boston, USA
| | | | | | | | | | - Eleri Adams
- Neonatal Medicine, John Radcliffe Hospital NHS Trust, London, UK
| | - Jon Dorling
- Neonatal Medicine, University Hospital Southampton NHS Trust, London, UK
| | | | - Paul Fleming
- Neonatal Medicine, Homerton Healthcare NHS Foundation Trust, London, UK
| | - Ronit Pressler
- Department of Neurophysiology, Great Ormond Street Hospital, London, UK
| | - Andrew Shennan
- Department of Obstetrics, Kings College London, London, UK
| | - Stavros Petrou
- Professor of Health Economics, University of Oxford, Oxford, UK
| | - Aung Soe
- Oliver Fisher Neonatal Intensive Care Unit, Medway Maritime Hospital, Medway NHS Foundation Trust, Kent, UK
| | | | - Seetha Shankaran
- Department of Neonatal-Perinatal Medicine, Wayne State University, Detroit, MI, USA
- University of Texas at Austin, Dell Children's Hospital, Austin, USA
| | - Sudhin Thayyil
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, Du Cane Road, London, W12 0HS, England
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Lee KS, Massaro A, Wintermark P, Soul J, Natarajan G, Dizon MLV, Mietzsch U, Mohammad K, Wu TW, Chandel A, Shenberger J, DiGeronimo R, Peeples ES, Hamrick S, Cardona VQ, Rao R. Practice Variations for Therapeutic Hypothermia in Neonates with Hypoxic-ischemic Encephalopathy: An International Survey. J Pediatr 2024; 274:114181. [PMID: 38950817 DOI: 10.1016/j.jpeds.2024.114181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 06/06/2024] [Accepted: 06/25/2024] [Indexed: 07/03/2024]
Abstract
OBJECTIVE To evaluate variations in management of therapeutic hypothermia (TH) for neonatal hypoxic-ischemic encephalopathy (HIE) among international clinical sites and to identify areas for harmonization. STUDY DESIGN An electronic survey was sent to Children's Hospitals Neonatal Consortium site sponsors, Canadian Neonatal Network site investigators, members of the Newborn Brain Society, and American Academy of Pediatrics Neonatology chiefs. RESULTS One hundred five sites responded, with most from high-income regions (n = 95). Groupings were adapted from the United Nations regional groups: US (n = 52 sites); Canada (n = 20); Western Europe and other states excluding Canada and US Group (WEOG, n = 18); and non-WEOG (central and eastern Europe, Asia, Africa, Latin America, and Caribbean, n = 15). Regional variations were seen in the eligibility criteria for TH, such as the minimum gestational age, grading of HIE severity, use of electroencephalography, and the frequency of providing TH for mild HIE. Active TH during transport varied among regions and was less likely in smaller volume sites. Amplitude-integrated electroencephalogram and/or continuous electroencephalogram to determine eligibility for TH was used by most sites in WEOG and non-WEOG but infrequently by the US and Canada Groups. For sedation during TH, morphine was most frequently used as first choice but there was relatively high (33%) use of dexmedetomidine in the US Group. Timing of brain magnetic resonance imaging and neurodevelopmental follow-up were variable. Neurodevelopmental follow occurred earlier and more frequently, although for a shorter duration, in the non-WEOG. CONCLUSIONS We found significant variations in practices for TH for HIE across regions internationally. Future guidelines should incorporate resource availability in a global perspective.
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Affiliation(s)
- Kyong-Soon Lee
- Division of Neonatology, the Hospital for Sick Children, Department of Paediatrics, University of Toronto, Canada.
| | - An Massaro
- Division of Neonatology, Children's National Hospital, Department of Pediatrics, The George Washington School of Medicine, Washington, DC
| | - Pia Wintermark
- Division of Newborn Medicine, Department of Pediatrics, Montreal Children's Hospital, Research Institute of the McGill University Health Centre, McGill University, Montreal, Canada
| | - Janet Soul
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Girija Natarajan
- Children's Hospital of Michigan/Wayne State University, Detroit, MI
| | - Maria L V Dizon
- Division of Neonatology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Ulrike Mietzsch
- Division of Neonatology, Department of Pediatrics, University of Washington/Seattle Children's Hospital, Seattle, WA
| | - Khorshid Mohammad
- Department of Pediatrics, Section of Newborn Critical Care, University of Calgary, Cumming School of Medicine, Alberta Children's Hospital, Calgary, Canada
| | - Tai-Wei Wu
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Amit Chandel
- Atrium Health Wake Forest Baptist, Winston-Salem, NC
| | | | - Robert DiGeronimo
- Division of Neonatology, Seattle Children's Hospital, University of Washington, Seattle, WA
| | - Eric S Peeples
- Division of Neonatology, Department of Pediatrics, Children's Nebraska, University of Nebraska Medical Center, Omaha, NE
| | - Shannon Hamrick
- Emory University and Children's Healthcare of Atlanta, Atlanta GA
| | | | - Rakesh Rao
- Division of Newborn Medicine, Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
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Fribance H, Liang C, Lee CKK, Aziz K, Parkinson C, Gauda EB, Northington FJ, Chalk BS, Chavez-Valdez R. Oral Clonidine-Based Strategy to Reduce Opiate Use During Cooling for Neonatal Encephalopathy: An Observational Study. J Pediatr 2024; 273:114158. [PMID: 38889855 DOI: 10.1016/j.jpeds.2024.114158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Revised: 06/07/2024] [Accepted: 06/11/2024] [Indexed: 06/20/2024]
Abstract
OBJECTIVE To determine whether an enteral, clonidine-based sedation strategy (CLON) during therapeutic hypothermia (TH) for hypoxic-ischemic encephalopathy would decrease opiate use while maintaining similar short-term safety and efficacy profiles to a morphine-based strategy (MOR). STUDY DESIGN This was a single-center, observational study conducted at a level IV neonatal intensive care unit from January 1, 2017, to October 1, 2021. From April 13, 2020, to August 13, 2020, we transitioned from MOR to CLON. Thus, patients receiving TH for hypoxic-ischemic encephalopathy were grouped to MOR (before April 13, 2020) and CLON (after August 13, 2020). We calculated the total and rescue morphine milligram equivalent/kg (primary outcome) and frequency of hemodynamic changes (secondary outcome) for both groups. RESULTS The MOR and CLON groups (74 and 25 neonates, respectively) had similar baseline characteristics and need for rescue sedative intravenous infusion (21.6% MOR and 20% CLON). Both morphine milligram equivalent/kg and need for rescue opiates (combined bolus and infusions) were greater in MOR than CLON (P < .001). As days in TH advanced, a lower percentage of patients receiving CLON needed rescue opiates (92% on day 1 to 68% on day 3). Patients receiving MOR received a greater cumulative dose of dopamine and more frequently required a second inotrope and hydrocortisone for hypotension. MOR had a lower respiratory rate during TH (P = .01 vs CLON). CONCLUSIONS Our CLON protocol is noninferior to MOR, maintaining perceived effectiveness and hemodynamic safety, with an apparently reduced need for opiates and inotropes.
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Affiliation(s)
- Haley Fribance
- Department of Pharmacy, Johns Hopkins Bayview Medical Center, Baltimore, MD
| | - Caroline Liang
- Department of Pharmacy, Johns Hopkins Bayview Medical Center, Baltimore, MD
| | - Carlton K K Lee
- Department of Pediatric Pharmacy, Johns Hopkins Medical Institution, Johns Hopkins Hospital, Baltimore, MD; Department of Pediatrics, Johns Hopkins University - School of Medicine, Baltimore, MD
| | - Khyzer Aziz
- Department of Pediatrics, Johns Hopkins University - School of Medicine, Baltimore, MD; Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Johns Hopkins University, School of Medicine, Baltimore, MD; Department of Pediatrics, Neonatology, Neuroscience Intensive Care Nursery Program, Johns Hopkins University, School of Medicine, Baltimore, MD
| | - Charlamaine Parkinson
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Johns Hopkins University, School of Medicine, Baltimore, MD; Department of Pediatrics, Neonatology, Neuroscience Intensive Care Nursery Program, Johns Hopkins University, School of Medicine, Baltimore, MD
| | - Estelle B Gauda
- Department of Pediatrics, Division of Neonatology, University of Toronto, Toronto, ON, Canada
| | - Frances J Northington
- Department of Pediatrics, Johns Hopkins University - School of Medicine, Baltimore, MD; Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Johns Hopkins University, School of Medicine, Baltimore, MD; Department of Pediatrics, Neonatology, Neuroscience Intensive Care Nursery Program, Johns Hopkins University, School of Medicine, Baltimore, MD
| | - Bethany S Chalk
- Department of Pediatric Pharmacy, Johns Hopkins Medical Institution, Johns Hopkins Hospital, Baltimore, MD
| | - Raul Chavez-Valdez
- Department of Pediatrics, Johns Hopkins University - School of Medicine, Baltimore, MD; Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Johns Hopkins University, School of Medicine, Baltimore, MD; Department of Pediatrics, Neonatology, Neuroscience Intensive Care Nursery Program, Johns Hopkins University, School of Medicine, Baltimore, MD.
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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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Montaldo P, Cirillo M, Burgod C, Caredda E, Ascione S, Carpentieri M, Puzone S, D’Amico A, Garegrat R, Lanza M, Moreno Morales M, Atreja G, Shivamurthappa V, Kariholu U, Aladangady N, Fleming P, Mathews A, Palanisami B, Windrow J, Harvey K, Soe A, Pattnayak S, Sashikumar P, Harigopal S, Pressler R, Wilson M, De Vita E, Shankaran S, Thayyil S. Whole-Body Hypothermia vs Targeted Normothermia for Neonates With Mild Encephalopathy: A Multicenter Pilot Randomized Clinical Trial. JAMA Netw Open 2024; 7:e249119. [PMID: 38709535 PMCID: PMC11074808 DOI: 10.1001/jamanetworkopen.2024.9119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 02/22/2024] [Indexed: 05/07/2024] Open
Abstract
Importance Although whole-body hypothermia is widely used after mild neonatal hypoxic-ischemic encephalopathy (HIE), safety and efficacy have not been evaluated in randomized clinical trials (RCTs), to our knowledge. Objective To examine the effect of 48 and 72 hours of whole-body hypothermia after mild HIE on cerebral magnetic resonance (MR) biomarkers. Design, Setting, and Participants This open-label, 3-arm RCT was conducted between October 31, 2019, and April 28, 2023, with masked outcome analysis. Participants were neonates at 6 tertiary neonatal intensive care units in the UK and Italy born at or after 36 weeks' gestation with severe birth acidosis, requiring continued resuscitation, or with an Apgar score less than 6 at 10 minutes after birth and with evidence of mild HIE on modified Sarnat staging. Statistical analysis was per intention to treat. Interventions Random allocation to 1 of 3 groups (1:1:1) based on age: neonates younger than 6 hours were randomized to normothermia or 72-hour hypothermia (33.5 °C), and those 6 hours or older and already receiving whole-body hypothermia were randomized to rewarming after 48 or 72 hours of hypothermia. Main Outcomes and Measures Thalamic N-acetyl aspartate (NAA) concentration (mmol/kg wet weight), assessed by cerebral MR imaging and thalamic spectroscopy between 4 and 7 days after birth using harmonized sequences. Results Of 225 eligible neonates, 101 were recruited (54 males [53.5%]); 48 (47.5%) were younger than 6 hours and 53 (52.5%) were 6 hours or older at randomization. Mean (SD) gestational age and birth weight were 39.5 (1.1) weeks and 3378 (380) grams in the normothermia group (n = 34), 38.7 (0.5) weeks and 3017 (338) grams in the 48-hour hypothermia group (n = 31), and 39.0 (1.1) weeks and 3293 (252) grams in the 72-hour hypothermia group (n = 36). More neonates in the 48-hour (14 of 31 [45.2%]) and 72-hour (13 of 36 [36.1%]) groups required intubation at birth than in the normothermic group (3 of 34 [8.8%]). Ninety-nine neonates (98.0%) had MR imaging data and 87 (86.1%), NAA data. Injury scores on conventional MR biomarkers were similar across groups. The mean (SD) NAA level in the normothermia group was 10.98 (0.92) mmol/kg wet weight vs 8.36 (1.23) mmol/kg wet weight (mean difference [MD], -2.62 [95% CI, -3.34 to -1.89] mmol/kg wet weight) in the 48-hour and 9.02 (1.79) mmol/kg wet weight (MD, -1.96 [95% CI, -2.66 to -1.26] mmol/kg wet weight) in the 72-hour hypothermia group. Seizures occurred beyond 6 hours after birth in 4 neonates: 1 (2.9%) in the normothermia group, 1 (3.2%) in the 48-hour hypothermia group, and 2 (5.6%) in the 72-hour hypothermia group. Conclusions and Relevance In this pilot RCT, whole-body hypothermia did not improve cerebral MR biomarkers after mild HIE, although neonates in the hypothermia groups were sicker at baseline. Safety and efficacy of whole-body hypothermia should be evaluated in RCTs. Trial Registration ClinicalTrials.gov Identifier: NCT03409770.
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Affiliation(s)
- Paolo Montaldo
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, United Kingdom
- Department of Woman, Child, and General and Specialized Surgery, University of Campania “Luigi Vanvitelli,” Naples, Italy
| | - Mario Cirillo
- Department of Advanced Medical and Surgical Sciences, MRI Research Center, University of Campania “Luigi Vanvitelli,” Naples, Italy
| | - Constance Burgod
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Elisabetta Caredda
- Department of Woman, Child, and General and Specialized Surgery, University of Campania “Luigi Vanvitelli,” Naples, Italy
| | - Serena Ascione
- Department of Woman, Child, and General and Specialized Surgery, University of Campania “Luigi Vanvitelli,” Naples, Italy
| | - Mauro Carpentieri
- Department of Woman, Child, and General and Specialized Surgery, University of Campania “Luigi Vanvitelli,” Naples, Italy
| | - Simona Puzone
- Department of Woman, Child, and General and Specialized Surgery, University of Campania “Luigi Vanvitelli,” Naples, Italy
| | | | - Reema Garegrat
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Marianna Lanza
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Maria Moreno Morales
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Gaurav Atreja
- Neonatal Unit, Imperial Health Care NHS Trust, London, United Kingdom
| | | | - Ujwal Kariholu
- Neonatal Unit, Imperial Health Care NHS Trust, London, United Kingdom
| | - Narendra Aladangady
- Neonatal Unit, Homerton Healthcare NHS Foundation Trust, London, United Kingdom
- Centre for Paediatrics, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Paul Fleming
- Neonatal Unit, Homerton Healthcare NHS Foundation Trust, London, United Kingdom
- Centre for Paediatrics, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Asha Mathews
- Neonatal Unit, Homerton Healthcare NHS Foundation Trust, London, United Kingdom
| | | | - Joanne Windrow
- Liverpool Women’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Karen Harvey
- Liverpool Women’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Aung Soe
- Oliver Fisher Neonatal Intensive Care Unit, Medway Maritime Hospital, Medway NHS Foundation Trust, Kent, United Kingdom
| | - Santosh Pattnayak
- Oliver Fisher Neonatal Intensive Care Unit, Medway Maritime Hospital, Medway NHS Foundation Trust, Kent, United Kingdom
| | - Palaniappan Sashikumar
- Oliver Fisher Neonatal Intensive Care Unit, Medway Maritime Hospital, Medway NHS Foundation Trust, Kent, United Kingdom
| | - Sundeep Harigopal
- Neonatal Medicine, Royal Victoria Infirmary, Newcastle Upon Tyne, United Kingdom
| | - Ronit Pressler
- Department of Neurophysiology, Great Ormond Street Hospital, London, United Kingdom
| | - Martin Wilson
- Centre for Human Brain Health and School of Psychology, University of Birmingham, Birmingham, United Kingdom
| | - Enrico De Vita
- MRI Physics, Radiology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Seetha Shankaran
- Department of Neonatal-Perinatal Medicine, Wayne State University, Detroit, Michigan
- Department of Pediatrics, The University of Texas at Austin, Dell Children’s Hospital, Austin, Texas
| | - Sudhin Thayyil
- Centre for Perinatal Neuroscience, Department of Brain Sciences, Imperial College London, London, United Kingdom
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Joshi M, Muneer J, Mbuagbaw L, Goswami I. Analgesia and sedation strategies in neonates undergoing whole-body therapeutic hypothermia: A scoping review. PLoS One 2023; 18:e0291170. [PMID: 38060481 PMCID: PMC10703341 DOI: 10.1371/journal.pone.0291170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 08/03/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Therapeutic hypothermia (TH) is a widely practiced neuroprotective strategy for neonates with hypoxic-ischemic encephalopathy. Induced hypothermia is associated with shivering, cold pain, agitation, and distress. OBJECTIVE This scoping review determines the breadth of research undertaken for pain and stress management in neonates undergoing hypothermia therapy, the pharmacokinetics of analgesic and sedative medications during hypothermia and the effect of such medication on short- and long-term neurological outcomes. METHODS We searched the following online databases namely, (i) MEDLINE, (ii) Web of Science, (iii) Cochrane Library, (iv) Scopus, (v) CINAHL, and (vi) EMBASE to identify published original articles between January 2005 and December 2022. We included only English full-text articles on neonates treated with TH and reported the sedation/analgesia strategy used. We excluded articles that reported TH on transport or extracorporeal membrane oxygenation, did not report the intervention strategies for sedation/analgesia, and reported hypoxic-ischemic encephalopathy in which hypothermia was not applied. RESULTS The eligible publications (n = 97) included cohort studies (n = 72), non-randomized experimental studies (n = 2), pharmacokinetic studies (n = 4), dose escalation feasibility trial (n = 1), cross-sectional surveys (n = 5), and randomized control trials (n = 13). Neonatal Pain, Agitation, and Sedation Scale (NPASS) is the most frequently used pain assessment tool in this cohort. The most frequently used pharmacological agents are opioids (Morphine, Fentanyl), benzodiazepine (Midazolam) and Alpha2 agonists (Dexmedetomidine). The proportion of neonates receiving routine sedation-analgesia during TH is center-specific and varies from 40-100% worldwide. TH alters most drugs' metabolic rate and clearance, except for Midazolam. Dexmedetomidine has additional benefits of thermal tolerance, neuroprotection, faster recovery, and less likelihood of seizures. There is a wide inter-individual variability in serum drug levels due to the impact of temperature, end-organ dysfunction, postnatal age, and body weight on drug metabolism. CONCLUSIONS No multidimensional pain scale has been tested for reliability and construct validity in hypothermic encephalopathic neonates. There is an increasing trend towards using routine sedation/analgesia during TH worldwide. Wide variability in the type of medication used, administration (bolus versus infusion), and dose ranges used emphasizes the urgent need for standardized practice recommendations and guidelines. There is insufficient data on the long-term neurological outcomes of exposure to these medications, adjusted for underlying brain injury and severity of encephalopathy. Future studies will need to develop framework tools to enable precise control of sedation/analgesia drug exposure customized to individual patient needs.
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Affiliation(s)
- Mahima Joshi
- Faculty of Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Javed Muneer
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Lawrence Mbuagbaw
- Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Ipsita Goswami
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
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7
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Wang Z, Zhang D, Zhang P, Zhou W, Hu L, Wang L, Cheng G. Safety and efficacy of therapeutic hypothermia in neonates with mild hypoxic-ischemic encephalopathy. BMC Pediatr 2023; 23:530. [PMID: 37884911 PMCID: PMC10601291 DOI: 10.1186/s12887-023-04365-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 10/14/2023] [Indexed: 10/28/2023] Open
Abstract
BACKGROUND Though there has been an increase in the number of neonates with hypoxic-ischemic encephalopathy (HIE) treated by therapeutic hypothermia (TH) in recent years, the effect of therapeutic hypothermia on mild HIE neonates is still uncertain. OBJECTIVES This study aims to explore the safety and efficacy of therapeutic hypothermia in neonates with mild HIE. METHODS Retrospectively collected between January 2010 to December 2022 at Children's Hospital of Fudan University, neonates with mild HIE were divided into TH and non-TH groups. Clinical data of the mild HIE neonates and their mothers' general information during pregnancy were collected. SPSS 23.0 was used to compare the general condition, the incidence of adverse events, and efficacy in the two groups. RESULTS A total of 71 neonates with mild HIE were included, including 31 in the TH group and 40 in the non-TH group. Compared with the non-TH group, the TH group had significantly lower 5-minute Apgar scores [6 (5-7) points vs. 7 (5-8) points, p = 0.033 ], but a higher rate of tracheal intubation at birth (68%, 21/31 vs. 40%, 16/40, p = 0.02), a higher rate of chest compressions > 30 s (39%, 12/31 vs. 15%, 6/40, p = 0.023), the later initiation enteral feeding [4 (3-4) days vs. 1 (1-2) days, p < 0.001], a higher usage rate of analgesic and sedative drugs (45%, 14/31 vs. 18%, 7/40, p = 0.011) and the longer hospital stay [12.5 (11-14) days vs. 9 (7-13.9) days, p = 0.003]. There was no death in 71 mild HIE neonates. TH group had lower incidence of brain injury (16%, 5/31 vs. 43%, 17/40, p = 0.017) and encephalopathy progression (10%, 3/31 vs. 45%, 18/40, p = 0.001) than the non-TH group. There was no statistical significance in the incidence of adverse events between the two groups. CONCLUSION Therapeutic hypothermia can reduce the incidence of brain injury in neonates with mild HIE.
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Affiliation(s)
- Zheng Wang
- Department of Neonatology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 201600, China
| | - Dan Zhang
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, 200032, China
| | - Peng Zhang
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, 200032, China
| | - Wenhao Zhou
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, 200032, China
| | - Liyuan Hu
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, 200032, China
| | - Laishuan Wang
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, 200032, China
| | - Guoqiang Cheng
- Department of Fujian Key Laboratory of Neonatal Diseases, Xiamen Key Laboratory of Neonatal Diseases, Fujian, 361000, China.
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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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Bodnar RJ. Endogenous opiates and behavior: 2021. Peptides 2023; 164:171004. [PMID: 36990387 DOI: 10.1016/j.peptides.2023.171004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 03/23/2023] [Accepted: 03/23/2023] [Indexed: 03/29/2023]
Abstract
This paper is the forty-fourth consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2021 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonizts and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, CUNY, 65-30 Kissena Blvd., Flushing, NY 11367, USA.
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10
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Restraint stress during neonatal hypoxia-ischemia alters brain injury following normothermia and hypothermia. Physiol Rep 2023; 11:e15562. [PMID: 36636750 PMCID: PMC9837475 DOI: 10.14814/phy2.15562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 12/19/2022] [Indexed: 01/14/2023] Open
Abstract
Rodent models of neonatal hypoxic-ischemic (HI) injury require a subset of animals to be immobilized for continuous temperature monitoring during the insult and subsequent treatment. Restrained animals are discarded from the analysis due to the effect of restraint on the brain injury as first demonstrated by Thoresen et al 1996. However, the effects of restraint on responses to hypothermic (HT) post-insult therapy are not well described. We examine the effects of restraint associated with different probe placements on HI brain injury. We have conducted a meta-analysis of 23 experiments comparing probe rats (skin n = 42, rectal n = 35) and free-moving matched non-probe controls (n = 80) that underwent HI injury (left common carotid artery ligation and 90 min 8% O2 ) at postnatal day 7 (P7), followed by 5 h of NT (37°C) or HT (32°C). On P14, brain regions were analyzed for injury (by neuropathology and area loss), microglial reactivity and brain-derived neurotrophic factor (BDNF). HI injury was mitigated in NT skin and rectal probe rats, with greater neuroprotection among the rectal probe rats. Following HT, the skin probe rats maintained the restraint-associated neuroprotection, while brain injury was significantly exacerbated among the rectal probe rats. Microglial reactivity strongly correlated with the acquired injury, with no detectable difference between the groups. Likewise, we observed no differences in BDNF signal intensity. Our findings suggest a biphasic neuroprotection from restraint stress, which becomes detrimental in combination with HT and the presumed discomfort from the rectal probe. This finding is useful in highlighting unforeseen effects of common experimental designs or routine clinical management.
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11
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Nakhleh-Philippe P, Zores C, Stern-Delfils A, Escande B, Astruc D, Severac F, Kuhn P. Adequacy of sedation analgesia to support the comfort of neonates undergoing therapeutic hypothermia and its impact on short-term neonatal outcomes. Front Pediatr 2023; 11:1057724. [PMID: 36969279 PMCID: PMC10034099 DOI: 10.3389/fped.2023.1057724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 02/13/2023] [Indexed: 03/29/2023] Open
Abstract
Objectives We aimed to evaluate (1) whether sedation analgesia (SA) used during therapeutic hypothermia (TH) was efficient to support the wellbeing of neonates with hypoxic-ischemic encephalopathy, (2) the SA level and its adjustment to clinical pain scores, and (3) the impact of inadequate SA on short-term neonatal outcomes evaluated at discharge. Methods This was an observational retrospective study performed between 2011 and 2018 in two level III centers in Alsace, France. We analyzed the wellbeing of infants by using the COMFORT-Behavior (COMFORT-B) clinical score and SA level during TH, according to which we classified infants into four groups: those with excess SA, adequate SA, lack of SA, and variability of SA. We analyzed the variations in doses of SA and their justification. We also determined the impact of inadequate SA on neonatal outcomes at discharge by multivariate analyses with multinomial regression, with adequate SA as the reference. Results A total of 110 patients were included, 89 from Strasbourg university hospital and 21 from Mulhouse hospital. The COMFORT-B score was assessed 95.5% of the time. Lack of SA was mainly found on the first day of TH (15/110, 14%). In all, 62 of 110 (57%) infants were in excess of SA over the entire duration of TH. Most dose variations were related to clinical pain scores. Inadequate SA was associated with negative short-term consequences. Infants with excess of SA had a longer duration of mechanical ventilation [mean ratio 1.46, 95% confidence interval (CI), 1.13-1.89, p = 0.005] and higher incidence of abnormal neurological examination at discharge (odds ratio 2.61, 95% CI, 1.10-6.18, p = 0.029) than infants with adequate SA. Discussion Adequate SA was not easy to achieve during TH. Close and regular monitoring of SA level may help achieve adequate SA. Excess of SA can be harmful for newborns with hypoxic-ischemic encephalopathy who are undergoing TH.
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Affiliation(s)
- Pauline Nakhleh-Philippe
- Department of Neonatology, University Hospital of Strasbourg, Strasbourg, France
- Department of Neonatology, Hospital of Mulhouse, Mulhouse, France
| | - Claire Zores
- Department of Neonatology, University Hospital of Strasbourg, Strasbourg, France
- Strasbourg University, Institut des Neurosciences Cellulaires et Intégratives, Strasbourg, France
| | | | - Benoît Escande
- Department of Neonatology, University Hospital of Strasbourg, Strasbourg, France
| | - Dominique Astruc
- Department of Neonatology, University Hospital of Strasbourg, Strasbourg, France
| | - François Severac
- Department of Public Health and Epidemiology, University Hospital of Strasbourg, Strasbourg, France
| | - Pierre Kuhn
- Department of Neonatology, University Hospital of Strasbourg, Strasbourg, France
- Strasbourg University, Institut des Neurosciences Cellulaires et Intégratives, Strasbourg, France
- Neonatal Research Unit, Department of Women’s and Children’s Health, Karolinska Institute, Stockholm, Sweden
- Correspondence: Kuhn Pierre
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Natarajan G, Hamrick SE, Zaniletti I, Lee KS, Mietzsch U, DiGeronimo R, Dizon MLV, Peeples ES, Yanowitz TD, Wu TW, Flibotte J, Joe P, Massaro AN, Rao R. Opioid exposure during therapeutic hypothermia and short-term outcomes in neonatal encephalopathy. J Perinatol 2022; 42:1017-1025. [PMID: 35474129 DOI: 10.1038/s41372-022-01400-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 03/21/2022] [Accepted: 04/08/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To assess the association between opioid exposure during therapeutic hypothermia (TH) for perinatal hypoxic-ischemic encephalopathy (HIE) and in-hospital outcomes. STUDY DESIGN In this retrospective cohort study, linked data were accessed on infants ≥36 weeks gestation, who underwent TH for HIE, born from 2010-2016 in 23 Neonatal Intensive Care Units participating in Children's Hospitals Neonatal Consortium and Pediatric Health Information Systems. We excluded infants who received opioids for >5 days. RESULTS The cohort (n = 1484) was categorized as No opioid [240(16.2%)], Low opioid (1-2 days) [574 (38.7%)] and High opioid group (HOG, 3-5 days) [670 (45.2%)]. After adjusting for HIE severity, opioids were not associated with abnormal MRI, but were associated with decreased likelihood of complete oral feeds at discharge. HOG had increased likelihood of prolonged hospital stay and ventilation. CONCLUSION Opioid exposure during TH was not associated with abnormal MRI; its association with adverse short-term outcomes suggests need for cautious empiric use.
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Affiliation(s)
- Girija Natarajan
- Pediatrics, Central Michigan University, Children's Hospital of Michigan, Detroit, MI, USA.
| | | | | | - Kyong-Soon Lee
- Pediatrics, Hospital for Sick Children, Toronto, ON, Canada
| | - Ulrike Mietzsch
- Pediatrics/Neonatology, Seattle Children's Hospital/University of Washington, Seattle, WA, USA
| | - Robert DiGeronimo
- Pediatrics/Neonatology, Seattle Children's Hospital/University of Washington, Seattle, WA, USA
| | - Maria L V Dizon
- Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago and Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Eric S Peeples
- Pediatrics, University of Nebraska Medical Center, Omaha, NE, USA
| | - Toby D Yanowitz
- Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Tai-Wei Wu
- Neonatology, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - John Flibotte
- Pediatrics/ Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Priscilla Joe
- Neonatology, UCSF Benioff Children's Hospital Oakland, Oakland, CA, USA
| | - An N Massaro
- Neonatology, Children's National Health Systems, Washington, DC, USA
| | - Rakesh Rao
- Pediatrics, Washington University in St. Louis, St. Louis, MO, USA
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Mahdi Z, Marandyuk B, Desnous B, Liet AS, Chowdhury RA, Birca V, Décarie JC, Tremblay S, Lodygensky GA, Birca A, Pinchefsky EF, Dehaes M. Opioid analgesia and temperature regulation are associated with EEG background activity and MRI outcomes in neonates with mild-to-moderate hypoxic-ischemic encephalopathy undergoing therapeutic hypothermia. Eur J Paediatr Neurol 2022; 39:11-18. [PMID: 35598572 DOI: 10.1016/j.ejpn.2022.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 02/23/2022] [Accepted: 04/09/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Therapeutic hypothermia (TH) without sedation may lead to discomfort, which may be associated with adverse consequences in neonates with hypoxic-ischemic encephalopathy (HIE). The aim of this study was to assess the association between level of exposure to opioids and temperature, with electroencephalography (EEG) background activity post-TH and magnetic resonance imaging (MRI) brain injury in neonates with HIE. METHODS Thirty-one neonates with mild-to-moderate HIE who underwent TH were identified. MRIs were reviewed for presence of brain injury. Quantitative EEG background features including EEG discontinuity index and spectral power densities were calculated during rewarming and post-rewarming periods. Dose of opioids administered during TH and temperatures were collected from the medical charts. Multivariable linear and logistic regression analyses were conducted to assess the associations between cumulative dose of opioids and temperature with EEG background and MRI while adjusting for markers of HIE severity. RESULTS Higher opioid doses (β = -0.21, p = 0.02) and reduced skin temperature (β = 0.14, p < 0.01) were associated with lower EEG discontinuity index recorded post-TH. Higher opioid doses (β = 0.75, p = 0.01) and reduced skin temperature (β = -0.39, p = 0.02) were also associated with higher EEG Delta power post-TH. MRI brain injury was observed in 14 patients (45%). In adjusted regression analyses, higher opioid doses (OR = 0.00; 95%CI: 0-0.19; p = 0.01), reduced skin temperature (OR = 41.19; 95%CI: 2.27-747.86; p = 0.01) and reduced cooling device output temperature (OR = 1.91; 95%CI: 1.05-3.48; p = 0.04) showed an association with lower odds of brain injury. CONCLUSIONS Higher level of exposure to opioids and reduced skin temperature during TH in mild-to-moderate HIE were associated with improved EEG background activity post-TH. Moreover, higher exposure to opioids, reduced skin temperature and reduced device output temperature were associated with lower odds of brain injury on MRI.
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Affiliation(s)
- Zamzam Mahdi
- Research Centre, Sainte-Justine University Hospital Center, 3175 Chemin de la Cote-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada
| | - Bohdana Marandyuk
- Research Centre, Sainte-Justine University Hospital Center, 3175 Chemin de la Cote-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada
| | - Beatrice Desnous
- Research Centre, Sainte-Justine University Hospital Center, 3175 Chemin de la Cote-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada; Division of Neurology, Department of Neuroscience, University of Montreal and Sainte-Justine University Hospital Center, 3175 Chemin de la Cote-Sainte-Catherine, Monteal, QC, H3T 1C5, Canada
| | - Anne-Sophie Liet
- Research Centre, Sainte-Justine University Hospital Center, 3175 Chemin de la Cote-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada
| | - Rasheda Arman Chowdhury
- Research Centre, Sainte-Justine University Hospital Center, 3175 Chemin de la Cote-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada; Institute of Biomedical Engineering, University of Montreal, 2900 Edouard Montpetit Blvd, Montreal, QC, H3T 1A4, Canada
| | - Veronica Birca
- Research Centre, Sainte-Justine University Hospital Center, 3175 Chemin de la Cote-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada
| | - Jean-Claude Décarie
- Department of Radiology, Radio-oncology and Nuclear Medicine, University of Montreal, 2900 Edouard Montpetit Blvd, Montreal, QC, H3T 1A4, Canada
| | - Sophie Tremblay
- Research Centre, Sainte-Justine University Hospital Center, 3175 Chemin de la Cote-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada; Division of Neonatology, Department of Pediatrics, University of Montreal and Sainte-Justine University Hospital Center, 3175 Chemin de la Cote-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada
| | - Gregory Anton Lodygensky
- Research Centre, Sainte-Justine University Hospital Center, 3175 Chemin de la Cote-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada; Division of Neonatology, Department of Pediatrics, University of Montreal and Sainte-Justine University Hospital Center, 3175 Chemin de la Cote-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada
| | - Ala Birca
- Research Centre, Sainte-Justine University Hospital Center, 3175 Chemin de la Cote-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada; Division of Neurology, Department of Neuroscience, University of Montreal and Sainte-Justine University Hospital Center, 3175 Chemin de la Cote-Sainte-Catherine, Monteal, QC, H3T 1C5, Canada
| | - Elana F Pinchefsky
- Research Centre, Sainte-Justine University Hospital Center, 3175 Chemin de la Cote-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada; Division of Neurology, Department of Neuroscience, University of Montreal and Sainte-Justine University Hospital Center, 3175 Chemin de la Cote-Sainte-Catherine, Monteal, QC, H3T 1C5, Canada
| | - Mathieu Dehaes
- Research Centre, Sainte-Justine University Hospital Center, 3175 Chemin de la Cote-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada; Institute of Biomedical Engineering, University of Montreal, 2900 Edouard Montpetit Blvd, Montreal, QC, H3T 1A4, Canada; Department of Radiology, Radio-oncology and Nuclear Medicine, University of Montreal, 2900 Edouard Montpetit Blvd, Montreal, QC, H3T 1A4, Canada.
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Dexmedetomidine - An emerging option for sedation in neonatal patients. J Perinatol 2022; 42:845-855. [PMID: 35197548 DOI: 10.1038/s41372-022-01351-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 01/26/2022] [Accepted: 02/08/2022] [Indexed: 11/08/2022]
Abstract
Dexmedetomidine is a sedative agent with limited dosing, safety, and efficacy information in the neonatal population. This comprehensive review describes the available evidence summarizing the use of dexmedetomidine in various neonatal populations. We identified 21 studies and 1 case report supporting the efficacy and short-term safety of DEX in neonates. Reported dosing ranges from 0.5-1.5 mcg/kg/h with or without loading doses. Clinically relevant adverse effects include bradycardia and hypotension. Future studies are needed to determine long-term safety and facilitate clinical applicability.
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Han Y, Cao L, Yuan K, Shi J, Yan W, Lu L. Unique Pharmacology, Brain Dysfunction, and Therapeutic Advancements for Fentanyl Misuse and Abuse. Neurosci Bull 2022; 38:1365-1382. [PMID: 35570233 PMCID: PMC9107910 DOI: 10.1007/s12264-022-00872-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 02/13/2022] [Indexed: 11/20/2022] Open
Abstract
Fentanyl is a fully synthetic opioid with analgesic and anesthetic properties. It has become a primary driver of the deadliest opioid crisis in the United States and elsewhere, consequently imposing devastating social, economic, and health burdens worldwide. However, the neural mechanisms that underlie the behavioral effects of fentanyl and its analogs are largely unknown, and approaches to prevent fentanyl abuse and fentanyl-related overdose deaths are scarce. This review presents the abuse potential and unique pharmacology of fentanyl and elucidates its potential mechanisms of action, including neural circuit dysfunction and neuroinflammation. We discuss recent progress in the development of pharmacological interventions, anti-fentanyl vaccines, anti-fentanyl/heroin conjugate vaccines, and monoclonal antibodies to attenuate fentanyl-seeking and prevent fentanyl-induced respiratory depression. However, translational studies and clinical trials are still lacking. Considering the present opioid crisis, the development of effective pharmacological and immunological strategies to prevent fentanyl abuse and overdose are urgently needed.
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Chalak L. New Horizons in Mild Hypoxic-ischemic Encephalopathy: A Standardized Algorithm to Move past Conundrum of Care. Clin Perinatol 2022; 49:279-294. [PMID: 35210007 DOI: 10.1016/j.clp.2021.11.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Hypoxic-ischemic encephalopathy (HIE) presents clinically with a neonatal encephalopathy (NE) whereby the mild spectrum is difficult to classify immediately after birth. For decades trials have focused exclusively on infants with moderate-severe HIE s, as these infants were easier to identify after birth and had the highest risk of adverse outcomes. Twenty years after those trials, the PRIME study finally solved the first part of the conundrum by providing a definition of mild HIE in the first 6 hours. There is strong biological plausibility and preclinical evidence supporting the efficacy of therapeutic hypothermia (TH) but there is a lack of comparative clinical data to establish the risk-benefit in mild HIE. The fundamental question of how best to manage mild HIE remains unanswered. This review will summarize (1) the evidence that neonates with mild HIE are at significant risk for adverse outcomes, (2) the gaps/controversies in management, and (3) an algorithm of care is proposed to ensure standardized management of mild HIE and the direction of future trials.
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Affiliation(s)
- Lina Chalak
- Neonatal-Perinatal Medicine, University of Texas Southwestern Medical School, 5323 Harry Hines Boulevard, Dallas, TX 75390-9063, USA.
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Abstract
Chronic pain and agitation in neonatal life impact the developing brain. Oral sweet-tasting solutions should be used judiciously to mitigate behavioral responses to mild painful procedures, keeping in mind that the long-term impact is unknown. Rapidly acting opioids should be used as part of premedication cocktails for nonemergent endotracheal intubations. Continuous low-dose morphine or dexmedetomidine may be considered for preterm or term neonates exhibiting signs of stress during mechanical ventilation and therapeutic hypothermia, respectively. Further research is required regarding the pharmacokinetics, pharmacodynamics, safety, and efficacy of pharmacologic agents used to mitigate mild, moderate, and chronic pain and stress in neonates.
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Affiliation(s)
- Christopher McPherson
- Department of Pharmacy, St. Louis Children's Hospital, 1 Children's Place, St. Louis, MO 63110, USA; Department of Pediatrics, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO 63110, USA.
| | - Ruth E Grunau
- Department of Pediatrics, University of British Columbia, F605B, 4480 Oak Street, Vancouver, BC V6H 3V4, Canada; BC Children's Hospital Research Institute, 938 West 28th Avenue, Vancouver BC V5Z 4H4, Canada
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Neural Function Recovery and Safety of Mild Hypothermia Therapy Combined with Monosialotetrahexosylganglioside on Neonatal Asphyxia Complicated by Hypoxic Ischemic Encephalopathy. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2021:6186011. [PMID: 34987600 PMCID: PMC8723842 DOI: 10.1155/2021/6186011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 11/08/2021] [Accepted: 11/20/2021] [Indexed: 11/18/2022]
Abstract
Objective To explore the effect and safety of mild hypothermia therapy combined with monosialotetrahexosylganglioside (GM1) on neural function recovery of neonatal asphyxia complicated by hypoxic ischemic encephalopathy (HIE). Methods The clinical data of 90 neonates with HIE were retrospectively analyzed. According to the treatment methods, the neonates were divided into a routine group, a mild hypothermia group, and a combination group, with 30 cases in each group. The differences in neural function recovery, biochemical indexes, clinical signs recovery, efficacy, and complications were observed in the three groups after treatment. Results After treatment, the score of neonatal behavioral neurological assessment (NBNA) and level of superoxide dismutase (SOD) in the combination group were higher than those of the other two groups (P < 0.05). The levels of neuron-specific enolase (NSE), S-100β protein, and plasma neuropeptide Y (NPY) in the combination group were lower than those in the other two groups, and the recovery time of consciousness, muscle tension, and reflex was shorter (P < 0.05). The combination group showed higher total effective rate and lower incidence of complications as compared with the other two groups (P < 0.05). Conclusion Mild hypothermia therapy combined with GM1 for the treatment of neonatal asphyxia complicated by HIE can promote the recovery of neural function and reduce the incidence of complications in neonates.
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Odd D, Okano S, Ingram J, Blair PS, Billietop A, Fleming PJ, Thoresen M, Chakkarapani E. Physiological responses to cuddling babies with hypoxic-ischaemic encephalopathy during therapeutic hypothermia: an observational study. BMJ Paediatr Open 2021; 5:10.1136/bmjpo-2021-001280. [PMID: 35510511 PMCID: PMC8679081 DOI: 10.1136/bmjpo-2021-001280] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 11/14/2021] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To determine whether parents cuddling infants during therapeutic hypothermia (TH) would affect cooling therapy, cardiorespiratory or neurophysiological measures. The secondary aim was to explore parent-infant bonding, maternal postnatal depression and breastfeeding. DESIGN Prospective observational study. SETTING Two tertiary neonatal intensive care units (NICU). PARTICIPANTS Parents and their term-born infants (n=27) receiving TH and intensive care for neonatal hypoxic-ischaemic encephalopathy. INTERVENTIONS Cuddling up to 2 hours during TH using a standard operating procedure developed in the study (CoolCuddle). MAIN OUTCOME MEASURES Mean difference in temperature, cardiorespiratory and neurophysiological variables before, during and after the cuddle. Secondary outcomes were parental bonding, maternal postnatal depression and breastfeeding. RESULTS During 70 CoolCuddles (115 cumulative hours), there were measurable increases in rectal temperature (0.07°C (0.03 to 0.10)) and upper margin of amplitude-integrated electroencephalogram (1.80 µV (0.83 to 2.72)) and decreases in oxygen saturations (-0.57% (-1.08 to -0.05)) compared with the precuddle period. After the cuddle, there was an increase in end-tidal CO2 (0.25 kPa (95% CI 0.14 to 0.35)) and mean blood pressure (4.09 mm Hg (95% CI 0.96 to 7.21)) compared with the precuddle period. From discharge to 8 weeks postpartum, maternal postnatal depression declined (13 (56.5%) vs 5 (23.8%), p=0.007); breastfeeding rate differed (71% vs 50%, p=0.043), but was higher than national average at discharge (70% vs 54.6%) and mother-infant bonding (median (IQR): 3 (0-6) vs 3 (1-4)) remained stable. CONCLUSION In this small study, CoolCuddle was associated with clinically non-significant, but measurable, changes in temperature, cardiorespiration and neurophysiology. No infant met the criteria to stop the cuddles or had any predefined adverse events. CoolCuddle may improve breastfeeding and requires investigation in different NICU settings.
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Affiliation(s)
- David Odd
- Population Medicine, Cardiff University, School of Medicine, Cardiff, UK
| | - Satomi Okano
- Neonatology, St Michael's Hospital, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK.,Translational Health Sciences, University of Bristol Medical School, Bristol, UK
| | - Jenny Ingram
- Centre for Academic Child Health, University of Bristol Medical School, Bristol, UK
| | - Peter S Blair
- Centre for Child and Adolescent Health, University of Bristol Medical School, Bristol, UK
| | - Amiel Billietop
- Neonatal Intensive Care Unit, North Bristol NHS Trust, Westbury on Trym, Bristol, UK
| | - Peter J Fleming
- Centre for Academic Child Health, University of Bristol Medical School, Bristol, UK
| | - Marianne Thoresen
- Translational Health Sciences, University of Bristol Medical School, Bristol, UK
| | - Ela Chakkarapani
- Neonatology, St Michael's Hospital, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK .,Translational Health Sciences, University of Bristol Medical School, Bristol, UK
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Markus M, Giannakis S, Ruhfus M, Stein A, Heep A, Plagemann T, Jahn P, Hoehn T, Felderhoff-Mueser U, Sabir H. Fluid Supply and Feeding Practices in Cooled Asphyxiated Newborns. CHILDREN (BASEL, SWITZERLAND) 2021; 8:children8100899. [PMID: 34682164 PMCID: PMC8534831 DOI: 10.3390/children8100899] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 09/30/2021] [Accepted: 10/06/2021] [Indexed: 11/16/2022]
Abstract
Therapeutic hypothermia (TH) for 72 h is the standard treatment to reduce neurological deficits in term newborns with hypoxic-ischemic encephalopathy. There is a large variability regarding nutritional supply during TH treatment in asphyxiated newborns. We performed a retrospective multicentre study in four level I (highest level of care in Germany) NICUs, including 135 asphyxiated term newborns undergoing TH. We analyzed enteral and parenteral nutritional supply during and after TH. We correlated nutritional supply with risk factors for encephalopathy, pH, Sarnat score, mechanical ventilation, seizures, and sedation. A total of 120 of 135 neonates received enteral nutritional supply within the first 24 h, and the majority of children were fully enterally fed within the first 10 days. The grade of encephalopathy and mechanical ventilation had a significant influence on the amount of enteral fluids (p = 0.01), whereas the pH and appearance of seizures did not affect the amount of nutritional supply significantly. Furthermore, we did not observe any correlation between enteral intake and abdominal complications such as necrotizing enterocolitis. We observed a large variability of feeding regimes in the four participating NICUs. Early enteral feeding among newborns undergoing TH was performed in each NICU and was well tolerated without increased rates of complications.
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Affiliation(s)
- Mona Markus
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, 40225 Duesseldorf, Germany; (M.M.); (S.G.); (T.H.)
| | - Stamatios Giannakis
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, 40225 Duesseldorf, Germany; (M.M.); (S.G.); (T.H.)
| | - Maria Ruhfus
- Department of Pediatrics I/Neonatology, University Hospital Essen, University Duisburg-Essen, 45147 Essen, Germany; (M.R.); (A.S.); (U.F.-M.)
| | - Anja Stein
- Department of Pediatrics I/Neonatology, University Hospital Essen, University Duisburg-Essen, 45147 Essen, Germany; (M.R.); (A.S.); (U.F.-M.)
| | - Axel Heep
- Department of Paediatrics, Elisabeth Children’s Hospital, University of Oldenburg, 26133 Oldenburg, Germany; (A.H.); (T.P.)
| | - Thorsten Plagemann
- Department of Paediatrics, Elisabeth Children’s Hospital, University of Oldenburg, 26133 Oldenburg, Germany; (A.H.); (T.P.)
| | - Peter Jahn
- Department of Neonatology, Children’s Hospital Leverkusen, 51375 Leverkusen, Germany;
| | - Thomas Hoehn
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, 40225 Duesseldorf, Germany; (M.M.); (S.G.); (T.H.)
| | - Ursula Felderhoff-Mueser
- Department of Pediatrics I/Neonatology, University Hospital Essen, University Duisburg-Essen, 45147 Essen, Germany; (M.R.); (A.S.); (U.F.-M.)
| | - Hemmen Sabir
- Department of Neonatology and Pediatric Intensive Care, Children’s Hospital University of Bonn, 53127 Bonn, Germany
- German Centre for Neurodegenerative Diseases (DZNE), 53175 Bonn, Germany
- Correspondence:
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Sabir H, Bonifacio SL, Gunn AJ, Thoresen M, Chalak LF. Unanswered questions regarding therapeutic hypothermia for neonates with neonatal encephalopathy. Semin Fetal Neonatal Med 2021; 26:101257. [PMID: 34144931 DOI: 10.1016/j.siny.2021.101257] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Therapeutic hypothermia (TH) is now well established to improve intact survival after neonatal encephalopathy (NE). However, many questions could not be addressed by the randomized controlled trials. Should late preterm newborns with NE be cooled? Is cooling beneficial for mild NE? Is the current therapeutic time window optimal, or could it be shortened or prolonged? Will either milder or deeper hypothermia be effective? Does infection/inflammation exposure in the perinatal period in combination with NE offer potentially beneficial preconditioning or might it obviate hypothermic neuroprotection? In the present review, we dissect the evidence, for whom, when and how can TH best be delivered, and highlight areas that need further research.
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Affiliation(s)
- Hemmen Sabir
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital University of Bonn, Bonn, Germany; German Centre for Neurodegenerative Diseases (DZNE), Bonn, Germany.
| | | | - Alistair J Gunn
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand.
| | - Marianne Thoresen
- Division of Physiology, Department of Molecular Medicine, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway; Neonatal Neuroscience, Translational Medicine, University of Bristol, Bristol, United Kingdom.
| | - Lina F Chalak
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, University of Texas Southwestern Medical School, Dallas, TX, USA.
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