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Grzybowski M, Singh M, Shah PS, Lee S, Toye J, Kanungo J, Khurshid F. Determining the Effect of Birth Weight on Therapeutic Hypothermia in Neonates with Hypoxic-Ischemic Encephalopathy. Am J Perinatol 2024; 41:554-560. [PMID: 35158385 DOI: 10.1055/s-0042-1742454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE We examine the effect of birth weight (BW) for gestational age (GA) on the temperatures reached during the treatment of neonatal hypoxic-ischemic encephalopathy (HIE) with therapeutic hypothermia (TH). STUDY DESIGN Retrospective data of 1,736 neonates with HIE who received TH were extracted from the Canadian Neonatal Network database for neonates admitted from 2010 to 2017. Neonates were stratified into three BW groups: small for GA < 10th centile, large for GA > 90th centile, and according to GA 10th to 89th centile at a given gestation using Canadian population data norms. RESULTS There was no significant difference in the lowest temperature reached, the likelihood of overshooting temperatures < 32.5°C during TH, or the change of encephalopathy stages among the three groups. CONCLUSION BW for GA did not appear to influence the temperatures neonates reached during hypothermia or encephalopathy stage following TH. KEY POINT · Therapeutic hypothermia is well tolerated irrespective of weight for age. · SGA infants achieved and maintained target temperature similar to AGA and LGA babies. · Change in the Sarnat stage after hypothermia was similar across all birth weight groups.
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Affiliation(s)
| | - Megan Singh
- Queen's School of Medicine, Kingston, Ontario, Canada
| | - Prakesh S Shah
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Shoo Lee
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer Toye
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Jaideep Kanungo
- Department of Pediatrics, Victoria General Hospital, Victoria, Canada
| | - Faiza Khurshid
- Department of Pediatrics, Kingston Health Science Center, Kingston, Ontario, Canada
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Arnautovic T, Sinha S, Laptook AR. Neonatal Hypoxic-Ischemic Encephalopathy and Hypothermia Treatment. Obstet Gynecol 2024; 143:67-81. [PMID: 37797337 PMCID: PMC10841232 DOI: 10.1097/aog.0000000000005392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 07/27/2023] [Indexed: 10/07/2023]
Abstract
Neonatal hypoxic-ischemic encephalopathy (HIE) is an important clinical entity because it is associated with death and long-term disability, including cognitive impairment, cerebral palsy, seizures, and neurosensory deficits. Over the past 40 years, there has been an intensive search to identify therapies to improve the prognosis of neonates with HIE. Hypothermia treatment represents the culmination of laboratory investigations including small and large animal studies, followed by pilot human studies, and, finally, randomized controlled trials to establish efficacy and safety. Clinical trials have demonstrated that hypothermia treatment reduces mortality and improves early childhood outcome among survivors. Hypoxic-ischemic encephalopathy is a multi-system disease process that requires intensive medical support for brain monitoring and monitoring of non-central nervous system organ dysfunction. Treatment must be conducted in a level III or IV neonatal intensive care unit with infrastructure for an integrated approach to care for critically ill neonates. Hypothermia treatment is the first and currently the only therapy to improve outcomes for neonates with HIE and indicates that HIE is modifiable. However, outcomes likely can be improved further. Hypothermia treatment has accelerated investigation of other therapies to combine with hypothermia. It has also stimulated a more intensive approach to brain monitoring, which allows earlier intervention for complications. Finally, HIE and hypothermia treatment negatively influences the psychological state of affected families, and there is growing recognition of the importance of trauma-informed principles to guide medical professionals.
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Affiliation(s)
- Tamara Arnautovic
- Department of Pediatrics, Women & Infants Hospital of Rhode Island, and Warren Alpert Medical School of Brown University, Providence, Rhode Island
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Troncoso G, Agudelo-Pérez S, Thorin N, Diaz C, Vargas A. Short-term neurological injury in newborns infants with overcooling in passive hypothermia and transferred to reference hospital in Colombia. Acta Paediatr 2023; 112:2346-2351. [PMID: 37485863 DOI: 10.1111/apa.16921] [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: 04/25/2023] [Revised: 07/18/2023] [Accepted: 07/20/2023] [Indexed: 07/25/2023]
Abstract
AIM The aim of the study was to determine whether overcooling (temperature <33°C) during passive hypothermia when transporting neonates with perinatal asphyxia increased the risk of short-term neurological injury. METHODS A retrospective observational study was performed. Newborns transferred to the LaCardio neonatal unit between January 2021 and April 2022 with moderate and severe perinatal asphyxia and who received passive hypothermia during transport were included. A temperature of <33°C was considered overcooling. A composite outcome of neurological injury was defined by the presence of abnormalities on brain magnetic resonance imaging, video telemetry, seizure before discharge or both. RESULTS The study included 101 newborns. A total of 18 neonates had a temperature <33°C after transportation. Neurological injuries were present in 21.8% of the temperature <33°C group and 78.2% of the temperature ≥33°C group. Temperature <33°C at the end of transport (aOR 9.2, 95% CI 1.1-77.3) were associated with neurological injury before discharge from the unit. CONCLUSION During transportation, overcooling in neonates with asphyxia increases the risk of neurological injury before discharge from the neonatal unit. It is important to qualify the transport team with adequate training and equipment for therapeutic hypothermia.
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Affiliation(s)
- Gloria Troncoso
- Neonatal Intensive Care Unit, Fundación Cardioinfantil-LaCardio, Bogota, Colombia
| | - Sergio Agudelo-Pérez
- Neonatal Intensive Care Unit, Fundación Cardioinfantil-LaCardio, Bogota, Colombia
- Department of Pediatrics, School of Medicine, Universidad de La Sabana, Chia, Colombia
| | - Nicole Thorin
- School of Medicine, Universidad de La Sabana, Chia, Colombia
| | - Camila Diaz
- School of Medicine, Universidad de La Sabana, Chia, Colombia
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Bonifacio SL, Chalak LF, Van Meurs KP, Laptook AR, Shankaran S. Neuroprotection for hypoxic-ischemic encephalopathy: Contributions from the neonatal research network. Semin Perinatol 2022; 46:151639. [PMID: 35835616 DOI: 10.1016/j.semperi.2022.151639] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Therapeutic hypothermia (TH) is now well established as the standard of care treatment for moderate to severe neonatal encephalopathy secondary to perinatal hypoxic ischemic encephalopathy (HIE) in infants ≥36 weeks gestation in high income countries. The Neonatal Research Network (NRN) contributed greatly to the study of TH as a neuroprotectant with three trials now completed in infants ≥36 weeks gestation and the only large randomized-controlled trial of TH in preterm infants now in the follow-up phase. Data from the first NRN TH trial combined with data from other large trials of TH affirm the safety and neuroprotective qualities of TH and highlight the importance of providing TH to all infants who qualify. In this review we will highlight the findings of the three NRN trials of TH in the term infant population and the secondary analyses that continue to inform the care of patients with HIE.
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Affiliation(s)
- Sonia Lomeli Bonifacio
- Division of Neonatal & Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA.
| | - Lina F Chalak
- Division of Neonatal-Perinatal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Krisa P Van Meurs
- Division of Neonatal & Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Abbot R Laptook
- Department of Pediatrics, Women and Infants' Hospital of Rhode Island, Providence, RI, USA
| | - Seetha Shankaran
- Department of Pediatrics, Wayne State University, Detroit, MI, USA
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Mathew JL, Kaur N, Dsouza JM. Therapeutic hypothermia in neonatal hypoxic encephalopathy: A systematic review and meta-analysis. J Glob Health 2022; 12:04030. [PMID: 35444799 PMCID: PMC8994481 DOI: 10.7189/jogh.12.04030] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background Therapeutic hypothermia (TH) is regarded as the most efficacious therapy for neonatal hypoxic encephalopathy. However, limitations in previous systematic reviews and the publication of new data necessitate updating the evidence. We conducted this up-to-date systematic review to evaluate the effects of TH in neonatal encephalopathy on clinical outcomes. Methods In this systematic review and meta-analysis, we searched Medline, Cochrane Library, Embase, LIVIVO, Web of Science, Scopus, CINAHL, major trial registries, and grey literature (from inception to October 31, 2021), for randomized controlled trials (RCT) comparing TH vs normothermia in neonatal encephalopathy. We included RCTs enrolling neonates (gestation ≥35 weeks) with perinatal asphyxia and encephalopathy, who received either TH (temperature ≤34°C) initiated within 6 hours of birth for ≥48 hours, vs no cooling. We excluded non-RCTs, those with delayed cooling, or cooling to >34°C. Two authors independently appraised risk-of-bias and extracted data on mortality and neurologic disability at four time points: neonatal (from randomization to discharge/death), infancy (18-24 months), childhood (5-10 years), and long-term (>10 years). Other outcomes included seizures, EEG abnormalities, and MRI findings. Summary data from published RCTs were pooled through fixed-effect meta-analysis. Results We identified 36 863 citations and included 39 publications representing 29 RCTs with 2926 participants. Thirteen studies each had low, moderate, and high risk-of-bias. The pooled risk ratios (95% confidence interval, CI) were as follows: neonatal mortality: 0.87 (95% CI = 0.75, 1.00), n = 2434, I2 = 38%; mortality at 18-24 months: 0.88 (95% CI = 0.78, 1.01), n = 2042, I2 = 51%; mortality at 5-10 years: 0.81 (95% CI = 0.62, 1.04), n = 515, I2 = 59%; disability at 18-24 months: 0.62 (95% CI = 0.52, 0.75), n = 1440, I2 = 26%; disability at 5-10 years: 0.68 (95% CI = 0.52, 0.90), n = 442, I2 = 3%; mortality or disability at 18-24 months: 0.78 (95% CI = 0.72, 0.86), n = 1914, I2 = 54%; cerebral palsy at 18-24 months: 0.63 (95% CI = 0.50, 0.78), n = 1136, I2 = 39%; and childhood cerebral palsy: 0.63 (95% CI = 0.46, 0.85), n = 449, I2 = 0%. Some outcomes showed significant differences by study-setting; the risk ratio (95% CI) for mortality at 18-24 months was 0.79 (95% CI = 0.66,0.93), n = 1212, I2 = 7% in high-income countries, 0.67 (95% CI = 0.41, 1.09), n = 276, I2 = 0% in upper-middle-income countries, and 1.18 (95% CI = 0.94, 1.47), n = 554, I2 = 75% in lower-middle-income countries. The corresponding pooled risk ratios for ‘mortality or disability at 18-24 months’ were 0.77 (95% CI = 0.69, 0.86), n = 1089, I2 = 0%; 0.56 (95% CI = 0.41, 0.78), n = 276, I2 = 30%; and 0.92 (95% CI = 0.77, 1.09), n = 549, I2 = 86% respectively. Trials with low risk of bias showed risk ratio of 0.97 (95% CI = 0.80, 1.16, n = 1475, I2 = 62%) for neonatal mortality, whereas trials with higher risk of bias showed 0.71 (95% CI = 0.55, 0.91), n = 959, I2 = 0%. Likewise, risk ratio for mortality at 18-24 months was 0.96 (95% CI = 0.83, 1.13), n = 1336, I2 = 58% among low risk-of-bias trials, but 0.72 (95% CI = 0.56, 0.92), n = 706, I2 = 0%, among higher risk of bias trials. Conclusions Therapeutic hypothermia for neonatal encephalopathy reduces neurologic disability and cerebral palsy, but its effect on neonatal, infantile and childhood mortality is uncertain. The setting where it is implemented affects the outcomes. Low(er) quality trials overestimated the potential benefit of TH.
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Affiliation(s)
- Joseph L Mathew
- Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research Chandigarh, India
| | - Navneet Kaur
- Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research Chandigarh, India
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Flibotte J, Laptook AR, Shankaran S, McDonald SA, Baserga MC, Bell EF, Cotten CM, Das A, DeMauro SB, DuPont TL, Eichenwald EC, Heyne R, Jensen EA, Van Meurs KP, Dysart K. Blanket temperature during therapeutic hypothermia and outcomes in hypoxic ischemic encephalopathy. J Perinatol 2022; 42:348-353. [PMID: 34999716 PMCID: PMC9121861 DOI: 10.1038/s41372-021-01302-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 11/18/2021] [Accepted: 12/10/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Determine whether blanket temperatures during therapeutic hypothermia (TH) are associated with 18-22 month outcomes for infants with hypoxic ischemic encephalopathy (HIE). STUDY DESIGN Retrospective cohort study of 181 infants with HIE who received TH in two randomized trials within the Neonatal Research Network. We defined summative blanket temperature constructs and evaluated for association with a primary composite outcome of death or moderate/ severe disability at 18-22 months. RESULTS Each 0.5 °C above 33.5 °C in the mean of the highest quartile blanket temperature was associated with a 52% increase in the adjusted odds of death/ disability (aOR 1.52, 95% CI 1.09-2.11). Having >8 consecutive blanket temperatures above 33.5 °C rendered an aOR of death/disability of 5.04 in the first 24 h (95% CI 1.54-16.6) and 6.92 in the first 48 h (95% CI 2.20-21.8) of TH. CONCLUSIONS Higher blanket temperature during TH may be an early, clinically useful biomarker of HIE outcome.
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Affiliation(s)
- John Flibotte
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Abbot R Laptook
- Department of Pediatrics, Alpert Medical School of Brown University, Providence, RI, USA
| | - Seetha Shankaran
- Department of Pediatrics, Wayne State University, Detroit, MI, USA
| | - Scott A McDonald
- Biostatistics and Epidemiology, RTI International, Research Triangle Park, NC, USA
| | - Mariana C Baserga
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Edward F Bell
- Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | | | - Abhik Das
- Biostatistics and Epidemiology, RTI International, Rockville, MD, USA
| | - Sara B DeMauro
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Tara L DuPont
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Eric C Eichenwald
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Roy Heyne
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Erik A Jensen
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Krisa P Van Meurs
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Kevin Dysart
- Division of Neonatal and Perinatal Medicine, Alfred I. duPont Hospital for Children, Wilmington, DE, USA.
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Effectiveness of reaching and maintaining therapeutic hypothermia target temperature using low‐cost devices in newborns with hypoxic–ischemic encephalopathy. Anat Rec (Hoboken) 2021; 304:1217-1223. [DOI: 10.1002/ar.24615] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 02/11/2021] [Accepted: 02/14/2021] [Indexed: 11/07/2022]
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Abate BB, Bimerew M, Gebremichael B, Mengesha Kassie A, Kassaw M, Gebremeskel T, Bayih WA. Effects of therapeutic hypothermia on death among asphyxiated neonates with hypoxic-ischemic encephalopathy: A systematic review and meta-analysis of randomized control trials. PLoS One 2021; 16:e0247229. [PMID: 33630892 PMCID: PMC7906350 DOI: 10.1371/journal.pone.0247229] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 02/04/2021] [Indexed: 11/18/2022] Open
Abstract
Background Hypoxic perinatal brain injury is caused by lack of oxygen to baby’s brain and can lead to death or permanent brain damage. However, the effectiveness of therapeutic hypothermia in birth asphyxiated infants with encephalopathy is uncertain. This systematic review and meta-analysis was aimed to estimate the pooled relative risk of mortality among birth asphyxiated neonates with hypoxic-ischemic encephalopathy in a global context. Methods We used the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines to search randomized control trials from electronic databases (PubMed, Cochrane library, Google Scholar, MEDLINE, Embase, Scopus, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), and meta register of Current Controlled Trials (mCRT)). The authors extracted the author’s name, year of publication, country, method of cooling, the severity of encephalopathy, the sample size in the hypothermic, and non-hypothermic groups, and the number of deaths in the intervention and control groups. A weighted inverse variance fixed-effects model was used to estimate the pooled relative risk of mortality. The subgroup analysis was done by economic classification of countries, methods of cooling, and cooling devices. Publication bias was assessed with a funnel plot and Eggers test. A sensitivity analysis was also done. Results A total of 28 randomized control trials with a total sample of 35, 92 (1832 hypothermic 1760 non-hypothermic) patients with hypoxic-ischemic encephalopathy were used for the analysis. The pooled relative risk of mortality after implementation of therapeutic hypothermia was found to be 0.74 (95%CI; 0.67, 0.80; I2 = 0.0%; p<0.996). The subgroup analysis revealed that the pooled relative risk of mortality in low, low middle, upper-middle and high income countries was 0.32 (95%CI; -0.95, 1.60; I2 = 0.0%; p<0.813), 0.5 (95%CI; 0.14, 0.86; I2 = 0.0%; p<0.998), 0.62 (95%CI; 0.41–0.83; I2 = 0.0%; p<0.634) and 0.76 (95%CI; 0.69–0.83; I2 = 0.0%; p<0.975) respectively. The relative risk of mortality was the same in selective head cooling and whole-body cooling method which was 0.74. Regarding the cooling device, the pooled relative risk of mortality is the same between the cooling cap and cooling blanket (0.74). However, it is slightly lower (0.73) in a cold gel pack. Conclusions Therapeutic hypothermia reduces the risk of death in neonates with moderate to severe hypoxic-ischemic encephalopathy. Both selective head cooling and whole-body cooling method are effective in reducing the mortality of infants with this condition. Moreover, low income countries benefit the most from the therapy. Therefore, health professionals should consider offering therapeutic hypothermia as part of routine clinical care to newborns with hypoxic-ischemic encephalopathy especially in low-income countries.
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Affiliation(s)
- Biruk Beletew Abate
- Department of Nursing, College of Health Sciences, Woldia University, Woldia, Ethiopia
- * E-mail:
| | - Melaku Bimerew
- Department of Nursing, College of Health Sciences, Woldia University, Woldia, Ethiopia
| | | | | | - MesfinWudu Kassaw
- Department of Nursing, College of Health Sciences, Woldia University, Woldia, Ethiopia
| | - Teshome Gebremeskel
- Department of Nursing, College of Health Sciences, Woldia University, Woldia, Ethiopia
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Prashantha YN, Suman Rao PN, Nesargi S, Chandrakala BS, Balla KC, Shashidhar A. Therapeutic hypothermia for moderate and severe hypoxic ischaemic encephalopathy in newborns using low-cost devices - ice packs and phase changing material. Paediatr Int Child Health 2019; 39:234-239. [PMID: 30109814 DOI: 10.1080/20469047.2018.1500805] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Background: Different methods have been used for therapeutic hypothermia for neonates with moderate-to-severe hypoxic ischaemic encephalopathy (HIE). As standard cooling devices are expensive, there is a need to establish the safety and efficacy of low-cost devices such as ice packs (IP) and phase changing material (PCM). Aim: To assess the efficacy and safety of therapeutic hypothermia (TH) and the clinico-laboratory profile of neonates who underwent cooling with IP or PCM. Methods: The study was retrospective. TH for moderate-to-severe HIE was initiated with IP between 2012 and 2014 and with PCM (MiraCradleTM) from September 2014. A standard protocol for inclusion and management during TH was used for all newborns. All data were collected by means of a local cooling registry. Results: Sixty-two cooled newborns (IP 29, PCM 33) were included in the study. Mean gestational age was 38.6 (1.7) weeks and mean birthweight 2920.6 g (450.7); 66.1% were inborn and 91.9% had moderate encephalopathy. Mean (SD) core temperature during cooling was 33.47°C (0.33) for PCM and 33.44°C (0.34) for IP. Adverse events observed during TH were thrombocytopenia (54.8%), coagulopathy (30.6%), shock (30.6%), skin changes (12.9%) and persistent pulmonary hypertension (8.1%). Forty-nine infants were discharged, two died and 11 were discharged against medical advice. TH was prematurely stopped in seven newborns with serious adverse events such as disseminated intravascular coagulation (DIC), gangrene and arrhythmia (IP 5, PCM 2). Conclusion: Low-cost devices are safe and effective alternatives for maintaining TH in low-resource settings with adequate monitoring. Abbreviations: DAMA, discharged against medical advice; DIC, disseminated intravascular coagulation; HELIX, Hypothermia for Encephalopathy in Low- and Middle-Income Countries Trial; HIE, hypoxic ischaemic encephalopathy; IP, ice packs; LMIC, low- and middle-income countries; NICHD, National Institute of Child Health and Human Development; PCM, phase changing; TH, therapeutic hypothermia (TH); TOBY, total body hypothermia for neonatal encephalopathy.
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Affiliation(s)
- Y N Prashantha
- Department of Neonatology, St John's Medical College , Bengaluru , India
| | - P N Suman Rao
- Department of Neonatology, St John's Medical College , Bengaluru , India
| | - Saudamini Nesargi
- Department of Neonatology, St John's Medical College , Bengaluru , India
| | - B S Chandrakala
- Department of Neonatology, St John's Medical College , Bengaluru , India
| | | | - A Shashidhar
- Department of Neonatology, St John's Medical College , Bengaluru , India
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Rosenkrantz TS, Hussain Z, Fitch RH. Sex Differences in Brain Injury and Repair in Newborn Infants: Clinical Evidence and Biological Mechanisms. Front Pediatr 2019; 7:211. [PMID: 31294000 PMCID: PMC6606734 DOI: 10.3389/fped.2019.00211] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 05/09/2019] [Indexed: 12/13/2022] Open
Abstract
Differences in the development of the male and female brain are an evolving area of investigation. We are beginning to understand the underpinnings of male and female advantages due to differences in brain development as well as the consequences following hypoxic-ischemic brain injury in the newborn. The two main factors that appear to affect outcomes are gestation age at the time of injury and sex of the subject. This review starts with a summary of differences in the anatomy and physiology of the developing male and female brain. This is followed by a review of the major factors responsible for the observed differences in the face of normal development and hypoxic injury. The last section reviews the response of male and female subjects to various neuroprotective strategies that are currently being used and where there is a need for additional information for more precise therapy based on the sex of the infant.
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Affiliation(s)
- Ted S Rosenkrantz
- Division of Neonatology, Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT, United States
| | - Zeenat Hussain
- Department of Volunteer Services, UCONN Health, Farmington, CT, United States.,Department of Anthropology, New York University, New York, NY, United States
| | - Roslyn Holly Fitch
- Department of Psychology, University of Connecticut, Storrs, CT, United States
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Natarajan G, Laptook A, Shankaran S. Therapeutic Hypothermia: How Can We Optimize This Therapy to Further Improve Outcomes? Clin Perinatol 2018; 45:241-255. [PMID: 29747886 PMCID: PMC5953210 DOI: 10.1016/j.clp.2018.01.010] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Neonatal hypoxic-ischemic encephalopathy remains associated with considerable death and disability. In multiple randomized controlled trials, therapeutic hypothermia for neonatal moderate or severe hypoxic-ischemic encephalopathy among term infants has been shown to be safe and effective in reducing death and disability in survivors. In this article, the current status of infant and childhood outcomes following this therapy is reviewed. The clinical approaches that may help to optimize this innovative neuroprotective therapy are presented.
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Affiliation(s)
- Girija Natarajan
- Department of Pediatrics, Wayne State University, Children’s Hospital of Michigan and Hutzel Women’s Hospital, Detroit, MI
| | - Abbot Laptook
- Department of Pediatrics, Women and Infants Hospital of Rhode Island, Brown University, Providence, RI
| | - Seetha Shankaran
- Department of Pediatrics, Division of Neonatology, Wayne State University, Children's Hospital of Michigan and Hutzel Women's Hospital, 3901 Beaubien Boulevard, Detroit, MI 48201, USA.
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Thomas N, Abiramalatha T, Bhat V, Varanattu M, Rao S, Wazir S, Lewis L, Balakrishnan U, Murki S, Mittal J, Dongara A, Y. N. P, Nimbalkar S. Phase Changing Material for Therapeutic Hypothermia in Neonates with Hypoxic Ischemic Encephalopathy — A Multi-centric Study. Indian Pediatr 2017. [PMID: 29242417 DOI: 10.1007/s13312-018-1317-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Adstamongkonkul D, Hess DC. Ischemic Conditioning and neonatal hypoxic ischemic encephalopathy: a literature review. CONDITIONING MEDICINE 2017; 1:9-16. [PMID: 30215057 PMCID: PMC6131706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Hypoxic Ischemic Encephalopathy (HIE) is the result of severe anoxic brain injury during the neonatal period and causes life-long morbidity and premature mortality. Currently, therapeutic hypothermia immediately after birth is the standard of care for clinically relevant HIE. However, therapeutic hypothermia alone does not provide complete neuroprotection and there is an urgent need for adjunctive therapies. Ischemic conditioning is an adaptive process of endogenous protection in which small doses of sub-lethal ischemia can provide a protection against a lethal ischemic event. Remote Ischemic Post-conditioning (RIPC), a form of ischemic conditioning, is highly translatable for HIE diagnosed immediately after birth as the conditioned ischemic stimulus is applied at the limb after the lethal ischemic episode. A number of studies in neonatal rats have demonstrated that RIPC is effective at reducing injury in focal cerebral ischemia models and improves neurological outcomes. In this review, we focus on the available data on HIE and its current treatment, models in HIE studies, ischemic conditioning/RIPC and its mechanism. We discuss in particular the effect of RIPC on neonatal brain with HIE. We postulate that combining RIPC with standard therapeutic hypothermia can be an attractive therapeutic approach for HIE.
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Affiliation(s)
- Dusit Adstamongkonkul
- Department of Neurology, Medical College of Georgia, Augusta University, Augusta, GA
| | - David C Hess
- Department of Neurology, Medical College of Georgia, Augusta University, Augusta, GA
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Laptook AR, Shankaran S, Tyson JE, Munoz B, Bell EF, Goldberg RN, Parikh NA, Ambalavanan N, Pedroza C, Pappas A, Das A, Chaudhary AS, Ehrenkranz RA, Hensman AM, Van Meurs KP, Chalak LF, Khan AM, Hamrick SEG, Sokol GM, Walsh MC, Poindexter BB, Faix RG, Watterberg KL, Frantz ID, Guillet R, Devaskar U, Truog WE, Chock VY, Wyckoff MH, McGowan EC, Carlton DP, Harmon HM, Brumbaugh JE, Cotten CM, Sánchez PJ, Hibbs AM, Higgins RD. Effect of Therapeutic Hypothermia Initiated After 6 Hours of Age on Death or Disability Among Newborns With Hypoxic-Ischemic Encephalopathy: A Randomized Clinical Trial. JAMA 2017; 318:1550-1560. [PMID: 29067428 PMCID: PMC5783566 DOI: 10.1001/jama.2017.14972] [Citation(s) in RCA: 182] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Hypothermia initiated at less than 6 hours after birth reduces death or disability for infants with hypoxic-ischemic encephalopathy at 36 weeks' or later gestation. To our knowledge, hypothermia trials have not been performed in infants presenting after 6 hours. Objective To estimate the probability that hypothermia initiated at 6 to 24 hours after birth reduces the risk of death or disability at 18 months among infants with hypoxic-ischemic encephalopathy. Design, Setting, and Participants A randomized clinical trial was conducted between April 2008 and June 2016 among infants at 36 weeks' or later gestation with moderate or severe hypoxic-ischemic encephalopathy enrolled at 6 to 24 hours after birth. Twenty-one US Neonatal Research Network centers participated. Bayesian analyses were prespecified given the anticipated limited sample size. Interventions Targeted esophageal temperature was used in 168 infants. Eighty-three hypothermic infants were maintained at 33.5°C (acceptable range, 33°C-34°C) for 96 hours and then rewarmed. Eighty-five noncooled infants were maintained at 37.0°C (acceptable range, 36.5°C-37.3°C). Main Outcomes and Measures The composite of death or disability (moderate or severe) at 18 to 22 months adjusted for level of encephalopathy and age at randomization. Results Hypothermic and noncooled infants were term (mean [SD], 39 [2] and 39 [1] weeks' gestation, respectively), and 47 of 83 (57%) and 55 of 85 (65%) were male, respectively. Both groups were acidemic at birth, predominantly transferred to the treating center with moderate encephalopathy, and were randomized at a mean (SD) of 16 (5) and 15 (5) hours for hypothermic and noncooled groups, respectively. The primary outcome occurred in 19 of 78 hypothermic infants (24.4%) and 22 of 79 noncooled infants (27.9%) (absolute difference, 3.5%; 95% CI, -1% to 17%). Bayesian analysis using a neutral prior indicated a 76% posterior probability of reduced death or disability with hypothermia relative to the noncooled group (adjusted posterior risk ratio, 0.86; 95% credible interval, 0.58-1.29). The probability that death or disability in cooled infants was at least 1%, 2%, or 3% less than noncooled infants was 71%, 64%, and 56%, respectively. Conclusions and Relevance Among term infants with hypoxic-ischemic encephalopathy, hypothermia initiated at 6 to 24 hours after birth compared with noncooling resulted in a 76% probability of any reduction in death or disability, and a 64% probability of at least 2% less death or disability at 18 to 22 months. Hypothermia initiated at 6 to 24 hours after birth may have benefit but there is uncertainty in its effectiveness. Trial Registration clinicaltrials.gov Identifier: NCT00614744.
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Affiliation(s)
- Abbot R Laptook
- Department of Pediatrics, Women & Infants Hospital, Brown University, Providence, Rhode Island
| | - Seetha Shankaran
- Department of Pediatrics, Wayne State University, Detroit, Michigan
| | - Jon E Tyson
- Department of Pediatrics, McGovern Medical School at the University of Texas Health Science Center at Houston
| | - Breda Munoz
- Social, Statistical, and Environmental Sciences Unit, RTI International, Research Triangle Park, North Carolina
| | - Edward F Bell
- Department of Pediatrics, University of Iowa, Iowa City
| | | | - Nehal A Parikh
- Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Claudia Pedroza
- Department of Pediatrics, McGovern Medical School at the University of Texas Health Science Center at Houston
| | - Athina Pappas
- Department of Pediatrics, Wayne State University, Detroit, Michigan
| | - Abhik Das
- Social, Statistical, and Environmental Sciences Unit, RTI International, Rockville, Maryland
| | | | - Richard A Ehrenkranz
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
| | - Angelita M Hensman
- Department of Pediatrics, Women & Infants Hospital, Brown University, Providence, Rhode Island
| | - Krisa P Van Meurs
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Palo Alto, California
- Lucile Packard Children's Hospital, Palo Alto, California
| | - Lina F Chalak
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas
| | - Amir M Khan
- Department of Pediatrics, McGovern Medical School at the University of Texas Health Science Center at Houston
| | - Shannon E G Hamrick
- Emory University School of Medicine, Department of Pediatrics, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Gregory M Sokol
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis
| | - Michele C Walsh
- Department of Pediatrics, Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, Ohio
| | - Brenda B Poindexter
- Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis
| | - Roger G Faix
- Department of Pediatrics, Division of Neonatology, University of Utah School of Medicine, Salt Lake City
| | | | - Ivan D Frantz
- Division of Newborn Medicine, Department of Pediatrics, Floating Hospital for Children, Tufts Medical Center, Boston, Massachusetts
| | - Ronnie Guillet
- University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Uday Devaskar
- Department of Pediatrics, University of California, Los Angeles
| | - William E Truog
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri
- University of Missouri Kansas City School of Medicine, Kansas City
| | - Valerie Y Chock
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Palo Alto, California
- Lucile Packard Children's Hospital, Palo Alto, California
| | - Myra H Wyckoff
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas
| | - Elisabeth C McGowan
- Department of Pediatrics, Women & Infants Hospital, Brown University, Providence, Rhode Island
| | - David P Carlton
- Emory University School of Medicine, Department of Pediatrics, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Heidi M Harmon
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis
| | | | - C Michael Cotten
- Department of Pediatrics, Duke University, Durham, North Carolina
| | - Pablo J Sánchez
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Anna Maria Hibbs
- Department of Pediatrics, Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, Ohio
| | - Rosemary D Higgins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
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15
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Brotschi B, Gunny R, Rethmann C, Held U, Latal B, Hagmann C. Relationship between temperature variability and brain injury on magnetic resonance imaging in cooled newborn infants after perinatal asphyxia. J Perinatol 2017; 37:1032-1037. [PMID: 28617423 DOI: 10.1038/jp.2017.96] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 04/07/2017] [Accepted: 05/15/2017] [Indexed: 01/15/2023]
Abstract
OBJECTIVE The objective of the study was whether temperature management during therapeutic hypothermia correlates with the severity of brain injury assessed on magnetic resonance imaging in term infants with hypoxic-ischemic encephalopathy. STUDY DESIGN Prospectively collected register data from the National Asphyxia and Cooling Register of Switzerland were analyzed. RESULT Fifty-five newborn infants were cooled for 72 h with a target temperature range of 33 to 34 °C. Individual temperature variability (odds ratio (OR) 40.17 (95% confidence interval (CI) 1.37 to 1037.67)) and percentage of temperatures within the target range (OR 0.95 (95% CI 0.90 to 0.98)) were associated with the severity of brain injury seen on magnetic resonance imaging (MRI). Neither the percentage of measured temperatures above (OR 1.08 (95% CI 0.96 to 1.21)) nor below (OR 0.99 (95% CI 0.92 to 1.07) the target range was associated with the severity of brain injury seen on MRI. CONCLUSION In a national perinatal asphyxia cohort, temperature variability and percentage of temperatures within the target temperature range were associated with the severity of brain injury.
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Affiliation(s)
- B Brotschi
- Department of Pediatric and Neonatal Intensive Care, University Children's Hospital Zurich, Zurich, Switzerland
| | - R Gunny
- Department of Pediatric Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - C Rethmann
- Department of Radiology, University Children's Hospital Zurich, Zurich, Switzerland
| | - U Held
- Horten Centre for Patient Oriented Research and Knowledge Transfer, University Hospital Zurich, Zurich, Switzerland
| | - B Latal
- Child Development Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - C Hagmann
- Department of Neonatology, University Hospital Zurich, Zurich, Switzerland
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Lemyre B, Ly L, Chau V, Chacko A, Barrowman N, Whyte H, Miller SP. Initiation of passive cooling at referring centre is most predictive of achieving early therapeutic hypothermia in asphyxiated newborns. Paediatr Child Health 2017; 22:264-268. [PMID: 29479231 DOI: 10.1093/pch/pxx062] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Objective To identify factors associated with early initiation and achievement of therapeutic hypothermia (TH) in newborns with hypoxic-ischemic encephalopathy (HIE). Methods Retrospective cohort study of newborns who received TH according to National Institute of Child Health and Human Development (NICHD) criteria in two academic level 3 Neonatal Intensive Care Units (NICU) between 2009 and 2013. All infants were transported by a neonatal transport team (NNTT). Multivariate linear regression including who initiated cooling and degree of resuscitation in the model was performed. Results Two hundred and seven infants were included. Waiting for advice from a tertiary care NICU was independently associated with a 50 minute delay in the median time of initiation of TH. The need for extensive resuscitation (cardiopulmonary resuscitation [CPR] or epinephrine) was independently associated with a reduction of 43 minutes in the median time to reach target core temperature. Log-transformed time to initiation of TH was associated with time to reach target core temperature (P<0.001). A doubling of time to initiation of TH corresponds to a 24% (95% CI 18% to 30%) increase in median time to reach target core temperature. Conclusions Initiating passive cooling at the referring centre, before transfer, is critical to faster achievement of target core temperature in asphyxiated infants. Greater outreach education and development of clinical care pathways are needed to improve optimal delivery of TH to enhance outcome.
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Affiliation(s)
- Brigitte Lemyre
- Department of Pediatrics, Children's Hospital of Eastern Ontario and University of Ottawa, Ottawa, Ontario
| | - Linh Ly
- Department of Pediatrics (Neonatology), The Hospital for Sick Children and University of Toronto, Toronto, Ontario
| | - Vann Chau
- Department of Pediatrics (Neurology), The Hospital for Sick Children and University of Toronto, Toronto, Ontario.,Neurosciences & Mental Health Research Institute, Toronto, Ontario
| | - Anil Chacko
- Department of Pediatrics (Neonatology), The Hospital for Sick Children and University of Toronto, Toronto, Ontario
| | - Nicholas Barrowman
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario
| | - Hilary Whyte
- Department of Pediatrics (Neonatology), The Hospital for Sick Children and University of Toronto, Toronto, Ontario.,Neurosciences & Mental Health Research Institute, Toronto, Ontario
| | - Steven P Miller
- Department of Pediatrics (Neurology), The Hospital for Sick Children and University of Toronto, Toronto, Ontario.,Neurosciences & Mental Health Research Institute, Toronto, Ontario
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Rao R, Trivedi S, Vesoulis Z, Liao SM, Smyser CD, Mathur AM. Safety and Short-Term Outcomes of Therapeutic Hypothermia in Preterm Neonates 34-35 Weeks Gestational Age with Hypoxic-Ischemic Encephalopathy. J Pediatr 2017; 183:37-42. [PMID: 27979578 PMCID: PMC5367984 DOI: 10.1016/j.jpeds.2016.11.019] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 10/24/2016] [Accepted: 11/04/2016] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To evaluate the safety and short-term outcomes of preterm neonates born at 34-35 weeks gestation with hypoxic-ischemic encephalopathy (HIE) treated with therapeutic hypothermia. STUDY DESIGN Medical records of preterm neonates born at 34-35 weeks gestational age with HIE treated with therapeutic hypothermia were retrospectively reviewed. Short-term safety outcomes and the presence, severity (mild, moderate, severe), and patterns of brain injury on magnetic resonance imaging were reviewed using a standard scoring system, and compared with a cohort of term neonates with HIE treated with therapeutic hypothermia. RESULTS Thirty-one preterm and 32 term neonates were identified. Therapeutic hypothermia-associated complications were seen in 90% of preterm infants and 81.3% of term infants (P = .30). In the preterm infants, hyperglycemia (58.1% vs31.3%, P = .03) and rewarming before completion of therapeutic hypothermia (19.4% vs 0.0%, P = .009) were more likely compared with term infants. All deaths occurred in the preterm group (12.9% vs 0%, P = .04). Neuroimaging showed the presence of injury in 80.6% of preterm infants and 59.4% of term infants (P = .07), with no differences in injury severity. Injury to the white matter was more prevalent in preterm infants compared with term infants (66.7% vs 25.0%, P = .001). CONCLUSIONS Therapeutic hypothermia in infants born at 34-35 weeks gestational age appears feasible. Risks of mortality and side effects warrant caution with use of therapeutic hypothermia in preterm infants.
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Affiliation(s)
- Rakesh Rao
- Division of Newborn-Medicine, Department of Pediatrics, Washington University School of Medicine, St Louis, MO.
| | - Shamik Trivedi
- Division of Newborn-Medicine, Department of Pediatrics, Washington University School of Medicine
| | - Zachary Vesoulis
- Division of Newborn-Medicine, Department of Pediatrics, Washington University School of Medicine
| | - Steve M. Liao
- Division of Newborn-Medicine, Department of Pediatrics, Washington University School of Medicine
| | - Christopher D. Smyser
- Division of Pediatric Neurology, Departments of Neurology, Pediatrics and Radiology, Washington University School of Medicine
| | - Amit M. Mathur
- Division of Newborn-Medicine, Department of Pediatrics, Washington University School of Medicine
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Radicioni M, Bini V, Chiarini P, Fantauzzi A, Leone F, Scattoni R, Camerini PG. Cerebral Sinovenous Thrombosis in the Asphyxiated Cooled Infants: A Prospective Observational Study. Pediatr Neurol 2017; 66:63-68. [PMID: 27823842 DOI: 10.1016/j.pediatrneurol.2016.09.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 09/07/2016] [Accepted: 09/07/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cerebral sinovenous thrombosis is unusual in the asphyxiated cooled infants, but reliable data regarding the incidence of this comorbidity are lacking. We assessed the incidence of sinovenous thrombosis in a population of asphyxiated cooled infants by performing routine brain magnetic resonance venography. METHODS All asphyxiated infants who underwent therapeutic cooling at our institution completed brain magnetic resonance venography after rewarming. Assessing the incidence of cerebral sinovenous thrombosis was the primary goal. Secondary analyses included group comparisons for laboratory tests and monitored parameters, relationship between variables, logistic regression models, and receiver operating characteristic curve for cerebral sinovenous thrombosis prediction. RESULTS Cerebral sinovenous thrombosis was detected in 10 of 37 infants (27%), most commonly affecting the superior sagittal sinus (eight of ten). These infants manifested higher blanket (P < 0.001) and lower esophageal temperatures (P = 0.006), lower platelet counts (P = 0.045), and received more red blood cell transfusions (P = 0.038) than the cooled infants without thrombosis. Blanket temperature was independently associated with cerebral sinovenous thrombosis (P = 0.049), and 32°C/hour was the optimal cutoff value to predict the event (sensitivity, 90%; specificity, 88.5%). CONCLUSIONS High incidence or cerebral sinovenous thrombosis in neonates treated with therapeutic hypothermia suggests that magnetic resonance venography may be reasonable in many of these children. High blanket temperature may be one variable that helps identify patients at higher risk.
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Affiliation(s)
- Maurizio Radicioni
- Neonatal Intensive Care Unit, S.M. della Misericordia Hospital of Perugia, Perugia, Italy.
| | - Vittorio Bini
- Department of Medicine, University of Perugia, Perugia, Italy
| | - Pietro Chiarini
- Neuroradiology, S.M. della Misericordia Hospital of Perugia, Perugia, Italy
| | - Ambra Fantauzzi
- Neonatal Intensive Care Unit, S.M. della Misericordia Hospital of Perugia, Perugia, Italy
| | - Francesca Leone
- Neuroradiology, S.M. della Misericordia Hospital of Perugia, Perugia, Italy
| | - Raffaella Scattoni
- Neonatal Intensive Care Unit, S.M. della Misericordia Hospital of Perugia, Perugia, Italy
| | - Pier Giorgio Camerini
- Neonatal Intensive Care Unit, S.M. della Misericordia Hospital of Perugia, Perugia, Italy
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Abstract
BACKGROUND Early initiation of therapeutic hypothermia (TH) for the treatment of hypoxic ischemic encephalopathy (HIE) has been shown to improve outcomes. Many of these patients require transport to treatment facilities. At the time of the study, there were no servo-controlled devices approved for flight that allowed for active cooling of the neonate during air transport. PURPOSE To introduce a clinical bundle for safe, active, or passive cooling and to achieve targeted, accurate temperature control with application for air or ground transport. METHODS After meeting criteria, a facsimile is sent to the referring center with instructions for passive cooling. Strict protocols are initiated, guiding the transport team in reaching and maintaining target temperature range of 33°C to 35°C. RESULTS From June 2010 to January 2014, a total of 22 neonates who qualified for TH were transported using the care bundle. Eight were actively cooled, whereas 14 were passively cooled. Of note, 8 infants required warming for temperatures below the acceptable range. The average temperature before turning off the warmer at the referral center was 36.0°C (SD = 1.1). The average temperature upon arrival of the transport team was 34.9°C (SD = 1.4). The average temperature upon arrival to the receiving facility was 33.5°C (SD = 0.7). IMPLICATION FOR PRACTICE By utilizing a care bundle for the initiation of TH on transport, neonates can be safely delivered to a treatment center with an average temperature well within treatment range, all while avoiding extreme fluctuations. IMPLICATIONS FOR RESEARCH The number of qualified participants limited the study. Future research should focus on the effectiveness of the bundle in larger treatment populations, with inclusion of additional transport teams.
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Shankaran S, Natarajan G, Chalak L, Pappas A, McDonald SA, Laptook AR. Hypothermia for neonatal hypoxic-ischemic encephalopathy: NICHD Neonatal Research Network contribution to the field. Semin Perinatol 2016; 40:385-390. [PMID: 27345952 PMCID: PMC5065734 DOI: 10.1053/j.semperi.2016.05.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
In this article, we summarize the NICHD Neonatal Research Network (NRN) trial of whole-body hypothermia for neonates with hypoxic-ischemic encephalopathy in relation to other randomized controlled trials (RCTs) of hypothermia neuroprotection. We describe the NRN secondary studies that have been published in the past 10 years evaluating clinical, genetic, biochemical, and imaging biomarkers of outcome.
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Affiliation(s)
- Seetha Shankaran
- Department of Pediatrics, Children's Hospital of Michigan, Wayne State University School of Medicine, 3901 Beaubien Blvd, Detroit, MI 48201.
| | - Girija Natarajan
- Department of Pediatrics, Wayne State University School of Medicine
| | - Lina Chalak
- Department of Pediatrics, University of Texas Southwestern at Dallas
| | - Athina Pappas
- Department of Pediatrics, Wayne State University School of Medicine
| | - Scott A. McDonald
- Statistics and Epidemiology Unit, RTI International, Research Triangle Park, NC
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Gupta C, Massaro AN, Ray PE. A new approach to define acute kidney injury in term newborns with hypoxic ischemic encephalopathy. Pediatr Nephrol 2016; 31:1167-78. [PMID: 26857710 PMCID: PMC4882244 DOI: 10.1007/s00467-016-3317-5] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 12/14/2015] [Accepted: 12/17/2015] [Indexed: 01/11/2023]
Abstract
BACKGROUND Current definitions of acute kidney injury (AKI) are not sufficiently sensitive to identify all newborns with AKI during the first week of life. METHODS To determine whether the rate of decline of serum creatinine (SCr) during the first week of life can be used to identify newborns with AKI, we reviewed the medical records of 106 term neonates at risk of AKI who were treated with hypothermia for hypoxic ischemic encephalopathy (HIE). RESULTS Of the newborns enrolled in the study, 69 % showed a normal rate of decline of SCr to ≥50 % and/or reached SCr levels of ≤0.6 mg/dl before the 7th day of life, and therefore had an excellent clinical outcome (control group). Thirteen newborns with HIE (12 %) developed AKI according to an established neonatal definition (AKI-KIDGO group), and an additional 20 newborns (19 %) showed a rate of decline of SCr of <33, <40, and <46 % from birth to days 3, 5, or 7 of life, respectively (delayed rise in estimated SCr clearance group). Compared to the control group, newborns in the other two groups required more days of mechanical ventilation and vasopressor drugs and had higher gentamicin levels, more fluid overload, lower urinary epidermal growth factor levels, and a prolonged length of stay. CONCLUSIONS The rate of decline of SCr provides a sensitive approach to identify term newborns with AKI during the first week of life.
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Affiliation(s)
- Charu Gupta
- Division of Nephrology, Children’s National Health System, Washington, DC, USA
| | - An N. Massaro
- Division of Neonatology, Children’s National Health System, Washington, DC, USA,Department of Pediatrics, The George Washington University School of Medicine–Children’s National Medical Center, 111 Michigan Avenue, NW, Washington, DC 20010, USA
| | - Patricio E. Ray
- Division of Nephrology, Children’s National Health System, Washington, DC, USA,Center for Genetic Medicine Research, Children National Health System, Washington, DC, USA,Department of Pediatrics, The George Washington University School of Medicine–Children’s National Medical Center, 111 Michigan Avenue, NW, Washington, DC 20010, USA
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Zhang J, Klufas D, Manalo K, Adjepong K, Davidson JO, Wassink G, Bennet L, Gunn AJ, Stopa EG, Liu K, Nishibori M, Stonestreet BS. HMGB1 Translocation After Ischemia in the Ovine Fetal Brain. J Neuropathol Exp Neurol 2016; 75:527-38. [PMID: 27151753 DOI: 10.1093/jnen/nlw030] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Inflammation contributes to the evolution of hypoxic-ischemic (HI) brain injury. High-mobility group box-1 (HMGB1) is a nuclear protein that is translocated from the nucleus and released after ischemia in adult rodents and thereby initiates inflammatory responses. However, there is very little information regarding the effects of HI on HMGB1 in immature brains. To investigate the effects of HI on HMGB1 in the term-equivalent fetal brain, ovine fetuses at 127 days gestation were studied after 30 minutes of carotid occlusion. Groups were sham-control and ischemia with 48 hours and ischemia with 72 hours of reperfusion. By immunohistochemistry, HMGB1 was found to be localized primarily in cell nuclei and partially in cytoplasmic compartments in the cerebral cortex of controls. Ischemia increased the area fraction of neuronal cells with cytoplasmic HMGB1 staining, and Western immunoblot revealed that cytosolic HMGB1 expression increased after ischemia (p < 0.05) and decreased in nuclei in ischemic versus the sham-control brains (p < 0.05). These data indicate that HMGB1 translocates from the nuclear to cytosolic compartments after ischemic brain injury in fetal sheep. This translocation may enable the action of HMGB1 as a proinflammatory cytokine that contributes to HI injury in the developing brain.
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Affiliation(s)
- Jiyong Zhang
- From the Department of Pediatrics, The Alpert Medical School of Brown University, Women & Infants Hospital of Rhode Island, Providence, Rhode Island (JZ, DK, KM, KA, BSS); Department of Physiology, University of Auckland, Auckland, New Zealand (JOD, GW, LB, AJG); Department of Pathology and Neurosurgery, The Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island (EGS); and Dentistry and Pharmaceutical Sciences, Graduate School of Medicine, Okayama University, Okayama, Japan (KL, MN)
| | - Daniel Klufas
- From the Department of Pediatrics, The Alpert Medical School of Brown University, Women & Infants Hospital of Rhode Island, Providence, Rhode Island (JZ, DK, KM, KA, BSS); Department of Physiology, University of Auckland, Auckland, New Zealand (JOD, GW, LB, AJG); Department of Pathology and Neurosurgery, The Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island (EGS); and Dentistry and Pharmaceutical Sciences, Graduate School of Medicine, Okayama University, Okayama, Japan (KL, MN)
| | - Karina Manalo
- From the Department of Pediatrics, The Alpert Medical School of Brown University, Women & Infants Hospital of Rhode Island, Providence, Rhode Island (JZ, DK, KM, KA, BSS); Department of Physiology, University of Auckland, Auckland, New Zealand (JOD, GW, LB, AJG); Department of Pathology and Neurosurgery, The Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island (EGS); and Dentistry and Pharmaceutical Sciences, Graduate School of Medicine, Okayama University, Okayama, Japan (KL, MN)
| | - Kwame Adjepong
- From the Department of Pediatrics, The Alpert Medical School of Brown University, Women & Infants Hospital of Rhode Island, Providence, Rhode Island (JZ, DK, KM, KA, BSS); Department of Physiology, University of Auckland, Auckland, New Zealand (JOD, GW, LB, AJG); Department of Pathology and Neurosurgery, The Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island (EGS); and Dentistry and Pharmaceutical Sciences, Graduate School of Medicine, Okayama University, Okayama, Japan (KL, MN)
| | - Joanne O Davidson
- From the Department of Pediatrics, The Alpert Medical School of Brown University, Women & Infants Hospital of Rhode Island, Providence, Rhode Island (JZ, DK, KM, KA, BSS); Department of Physiology, University of Auckland, Auckland, New Zealand (JOD, GW, LB, AJG); Department of Pathology and Neurosurgery, The Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island (EGS); and Dentistry and Pharmaceutical Sciences, Graduate School of Medicine, Okayama University, Okayama, Japan (KL, MN)
| | - Guido Wassink
- From the Department of Pediatrics, The Alpert Medical School of Brown University, Women & Infants Hospital of Rhode Island, Providence, Rhode Island (JZ, DK, KM, KA, BSS); Department of Physiology, University of Auckland, Auckland, New Zealand (JOD, GW, LB, AJG); Department of Pathology and Neurosurgery, The Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island (EGS); and Dentistry and Pharmaceutical Sciences, Graduate School of Medicine, Okayama University, Okayama, Japan (KL, MN)
| | - Laura Bennet
- From the Department of Pediatrics, The Alpert Medical School of Brown University, Women & Infants Hospital of Rhode Island, Providence, Rhode Island (JZ, DK, KM, KA, BSS); Department of Physiology, University of Auckland, Auckland, New Zealand (JOD, GW, LB, AJG); Department of Pathology and Neurosurgery, The Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island (EGS); and Dentistry and Pharmaceutical Sciences, Graduate School of Medicine, Okayama University, Okayama, Japan (KL, MN)
| | - Alistair J Gunn
- From the Department of Pediatrics, The Alpert Medical School of Brown University, Women & Infants Hospital of Rhode Island, Providence, Rhode Island (JZ, DK, KM, KA, BSS); Department of Physiology, University of Auckland, Auckland, New Zealand (JOD, GW, LB, AJG); Department of Pathology and Neurosurgery, The Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island (EGS); and Dentistry and Pharmaceutical Sciences, Graduate School of Medicine, Okayama University, Okayama, Japan (KL, MN)
| | - Edward G Stopa
- From the Department of Pediatrics, The Alpert Medical School of Brown University, Women & Infants Hospital of Rhode Island, Providence, Rhode Island (JZ, DK, KM, KA, BSS); Department of Physiology, University of Auckland, Auckland, New Zealand (JOD, GW, LB, AJG); Department of Pathology and Neurosurgery, The Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island (EGS); and Dentistry and Pharmaceutical Sciences, Graduate School of Medicine, Okayama University, Okayama, Japan (KL, MN)
| | - Keyue Liu
- From the Department of Pediatrics, The Alpert Medical School of Brown University, Women & Infants Hospital of Rhode Island, Providence, Rhode Island (JZ, DK, KM, KA, BSS); Department of Physiology, University of Auckland, Auckland, New Zealand (JOD, GW, LB, AJG); Department of Pathology and Neurosurgery, The Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island (EGS); and Dentistry and Pharmaceutical Sciences, Graduate School of Medicine, Okayama University, Okayama, Japan (KL, MN)
| | - Masahiro Nishibori
- From the Department of Pediatrics, The Alpert Medical School of Brown University, Women & Infants Hospital of Rhode Island, Providence, Rhode Island (JZ, DK, KM, KA, BSS); Department of Physiology, University of Auckland, Auckland, New Zealand (JOD, GW, LB, AJG); Department of Pathology and Neurosurgery, The Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island (EGS); and Dentistry and Pharmaceutical Sciences, Graduate School of Medicine, Okayama University, Okayama, Japan (KL, MN)
| | - Barbara S Stonestreet
- From the Department of Pediatrics, The Alpert Medical School of Brown University, Women & Infants Hospital of Rhode Island, Providence, Rhode Island (JZ, DK, KM, KA, BSS); Department of Physiology, University of Auckland, Auckland, New Zealand (JOD, GW, LB, AJG); Department of Pathology and Neurosurgery, The Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island (EGS); and Dentistry and Pharmaceutical Sciences, Graduate School of Medicine, Okayama University, Okayama, Japan (KL, MN).
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23
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Laptook AR, Kilbride H, Shepherd E, McDonald SA, Shankaran S, Truog W, Das A, Higgins RD. Temperature control during therapeutic hypothermia for newborn encephalopathy using different Blanketrol devices. Ther Hypothermia Temp Manag 2015; 4:193-200. [PMID: 25285767 DOI: 10.1089/ther.2014.0009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Therapeutic hypothermia improves the survival and neurodevelopmental outcome of infants with newborn encephalopathy of a hypoxic-ischemic origin. The NICHD Neonatal Research Network (NRN) Whole Body Cooling trial used the Cincinnati Sub-Zero Blanketrol II to achieve therapeutic hypothermia. The Blanketrol III is now available and provides additional cooling modes that may result in better temperature control. This report is a retrospective comparison of infants undergoing hypothermia using two different cooling modes of the Blanketrol device. Infants from the NRN trial were cooled with the Blanketrol II using the Automatic control mode (B2 cohort) and were compared with infants from two new NRN centers that adopted the NRN protocol and used the Blanketrol III in a gradient mode (B3 cohort). The primary outcome was the percent time the esophageal temperature stayed between 33°C and 34°C (target 33.5°C) during maintenance of hypothermia. Cohorts had similar birth weight, gestational age, and level of encephalopathy at the initiation of therapy. Baseline esophageal temperature differed between groups (36.6°C ± 1.0°C for B2 vs. 33.9°C ± 1.2°C for B3, p<0.0001) reflecting the practice of passive cooling during transport prior to initiation of active device cooling in the B3 cohort. This difference prevented comparison of temperatures during induction of hypothermia. During maintenance of hypothermia the mean and standard deviation of the percent time between 33°C and 34°C was similar for B2 compared to B3 cohorts (94.8% ± 0.1% vs. 95.8% ± 0.1%, respectively). Both the automatic and gradient control modes of the Blanketrol devices appear comparable in maintaining esophageal temperature within the target range during maintenance of therapeutic hypothermia.
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Affiliation(s)
- Abbot R Laptook
- 1 Department of Pediatrics, Women & Infants Hospital of Rhode Island, Alpert Medical School of Brown University , Providence, Rhode Island
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24
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Sarkar S, Barks J. Management of neonatal morbidities during hypothermia treatment. Semin Fetal Neonatal Med 2015; 20:97-102. [PMID: 25701292 DOI: 10.1016/j.siny.2015.01.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Although the primary goal of therapeutic hypothermia is to improve the neurodevelopmental outcome in asphyxiated infants, optimal management of the full range of multi-organ system complications typically presented by such infants during cooling treatment is necessary for improvement of the overall outcome. For this reason, adequate knowledge of how cooling affects all organ systems of asphyxiated infants with multi-organ hypoxic-ischemic injury is essential. Adequate diagnostic resources, readily available subspecialty consultant services and trained multidisciplinary staff to monitor and manage multi-organ system complications in asphyxiated infants during therapeutic cooling must be ensured during implementation of a cooling program. As therapeutic hypothermia is being used more widely, centers should consider participation in national or international benchmarking of outcomes and short-term adverse events during cooling to facilitate continuous quality improvement efforts.
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Affiliation(s)
- Subrata Sarkar
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, The University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - John Barks
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, The University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, MI, USA.
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25
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Lee JK, Brady KM, Chung SE, Jennings JM, Whitaker EE, Aganga D, Easley RB, Heitmiller K, Jamrogowicz JL, Larson AC, Lee JH, Jordan LC, Hogue CW, Lehmann CU, Bembea MM, Hunt EA, Koehler RC, Shaffner DH. A pilot study of cerebrovascular reactivity autoregulation after pediatric cardiac arrest. Resuscitation 2014; 85:1387-93. [PMID: 25046743 DOI: 10.1016/j.resuscitation.2014.07.006] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Revised: 06/26/2014] [Accepted: 07/07/2014] [Indexed: 11/17/2022]
Abstract
AIM Improved survival after cardiac arrest has placed greater emphasis on neurologic resuscitation. The purpose of this pilot study was to evaluate the relationship between cerebrovascular autoregulation and neurologic outcomes after pediatric cardiac arrest. METHODS Children resuscitated from cardiac arrest had autoregulation monitoring during the first 72h after return of circulation with an index derived from near-infrared spectroscopy in a pilot study. The range of mean arterial blood pressure (MAP) with optimal vasoreactivity (MAPOPT) was identified. The area under the curve (AUC) of the time spent with MAP below MAPOPT and MAP deviation below MAPOPT was calculated. Neurologic outcome measures included placement of a new tracheostomy or gastrostomy, death from a primary neurologic etiology (brain death or withdrawal of support for neurologic futility), and change in the Pediatric Cerebral Performance Category score (ΔPCPC). RESULTS Thirty-six children were monitored. Among children who did not require extracorporeal membrane oxygenation (ECMO), children who received a tracheostomy/gastrostomy had greater AUC during the second 24h after resuscitation than those who did not (P=0.04; n=19). Children without ECMO who died from a neurologic etiology had greater AUC during the first 48h than did those who lived or died from cardiovascular failure (P=0.04; n=19). AUC below MAPOPT was not associated with ΔPCPC when children with or without ECMO were analyzed separately. CONCLUSIONS Deviation from the blood pressure with optimal autoregulatory vasoreactivity may predict poor neurologic outcomes after pediatric cardiac arrest. This experimental autoregulation monitoring technique may help individualize blood pressure management goals after resuscitation.
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Affiliation(s)
- Jennifer K Lee
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University (JHU), Baltimore, MD, USA.
| | - Ken M Brady
- Department of Anesthesiology, Texas Children's Hospital, Houston, TX, USA
| | - Shang-En Chung
- Department of Pediatrics, Division of General Pediatrics and Adolescent Medicine, JHU, USA; Center for Child and Community Health Research, JHU, USA
| | - Jacky M Jennings
- Department of Pediatrics, Division of General Pediatrics and Adolescent Medicine, JHU, USA; Center for Child and Community Health Research, JHU, USA
| | - Emmett E Whitaker
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University (JHU), Baltimore, MD, USA
| | - Devon Aganga
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University (JHU), Baltimore, MD, USA
| | - Ronald B Easley
- Department of Anesthesiology, Texas Children's Hospital, Houston, TX, USA
| | - Kerry Heitmiller
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University (JHU), Baltimore, MD, USA
| | - Jessica L Jamrogowicz
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University (JHU), Baltimore, MD, USA
| | - Abby C Larson
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University (JHU), Baltimore, MD, USA
| | - Jeong-Hoo Lee
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University (JHU), Baltimore, MD, USA
| | - Lori C Jordan
- Department of Neurology, Vanderbilt University (VU), Nashville, TN, USA
| | - Charles W Hogue
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University (JHU), Baltimore, MD, USA
| | - Christoph U Lehmann
- Department of Pediatrics, VU, USA; Department of Biomedical Informatics, VU, USA
| | - Mela M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University (JHU), Baltimore, MD, USA
| | - Elizabeth A Hunt
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University (JHU), Baltimore, MD, USA
| | - Raymond C Koehler
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University (JHU), Baltimore, MD, USA
| | - Donald H Shaffner
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University (JHU), Baltimore, MD, USA
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26
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Shankaran S. Current status of hypothermia for hypoxemic ischemia of the newborn. Indian J Pediatr 2014; 81:578-84. [PMID: 24820235 DOI: 10.1007/s12098-014-1468-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Accepted: 04/21/2014] [Indexed: 11/27/2022]
Abstract
This article reviews the pathophysiology of hypoxic-ischemic brain injury, and the impact of hypothermia as neuroprotection in the clinical setting. The results of trials performed in well resourced and mid and low resourced countries is presented. Infant and childhood outcome following hypothermia is provided. Biomarkers of outcome that are clinical, electrophysiological and imaging which will be helpful to clinicians are noted. Management of infants with encephalopathy, including safety of hypothermia is reviewed. The article concludes with knowledge gaps in neuroprotection and the future of hypothermia therapy.
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Affiliation(s)
- Seetha Shankaran
- Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI, 48201, USA,
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27
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Shankaran S. Outcomes of hypoxic-ischemic encephalopathy in neonates treated with hypothermia. Clin Perinatol 2014; 41:149-59. [PMID: 24524452 DOI: 10.1016/j.clp.2013.10.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
This article examines the evidence regarding mortality and neurodevelopmental outcomes following hypothermia for neonatal hypoxic-ischemic encephalopathy. Data from randomized controlled trials regarding neurodevelopmental outcome at the end point of the major trials, and from 2 of the trials on childhood outcome following hypothermia for neonatal hypoxic-ischemic encephalopathy are presented. The predictors of outcome that can be evaluated in the neonatal period are also reviewed, as this information may assist in the counseling of families. Most trials of hypothermia have been performed in high-resource countries; published studies from the low- and middle-income countries are also reviewed.
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Affiliation(s)
- Seetha Shankaran
- Division of Neonatal/Perinatal Medicine, Children's Hospital of Michigan, 3901 Beaubien, Detroit, MI, USA.
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28
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Howlett JA, Northington FJ, Gilmore MM, Tekes A, Huisman TA, Parkinson C, Chung SE, Jennings JM, Jamrogowicz JJ, Larson AC, Lehmann CU, Jackson E, Brady KM, Koehler RC, Lee JK. Cerebrovascular autoregulation and neurologic injury in neonatal hypoxic-ischemic encephalopathy. Pediatr Res 2013; 74:525-35. [PMID: 23942555 PMCID: PMC3954983 DOI: 10.1038/pr.2013.132] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2012] [Accepted: 01/31/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Neonates with hypoxic-ischemic encephalopathy (HIE) are at risk of cerebral blood flow dysregulation. Our objective was to describe the relationship between autoregulation and neurologic injury in HIE. METHODS Neonates with HIE had autoregulation monitoring with the hemoglobin volume index (HVx) during therapeutic hypothermia, rewarming, and the first 6 h of normothermia. The 5-mm Hg range of mean arterial blood pressure (MAP) with best vasoreactivity (MAPOPT) was identified. The percentage of time spent with MAP below MAPOPT and deviation in MAP from MAPOPT were measured. Neonates received brain magnetic resonance imaging (MRI) 3-7 d after treatment. MRIs were coded as no, mild, or moderate/severe injury in five regions. RESULTS HVx identified MAPOPT in 79% (19/24), 77% (17/22), and 86% (18/21) of the neonates during hypothermia, rewarming, and normothermia, respectively. Neonates with moderate/severe injury in paracentral gyri, white matter, basal ganglia, and thalamus spent a greater proportion of time with MAP below MAPOPT during rewarming than neonates with no or mild injury. Neonates with moderate/severe injury in paracentral gyri, basal ganglia, and thalamus had greater MAP deviation below MAPOPT during rewarming than neonates without injury. CONCLUSION Maintaining MAP within or above MAPOPT may reduce the risk of neurologic injuries in neonatal HIE.
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Affiliation(s)
- Jessica A. Howlett
- Department of Pediatrics, Division of Neonatology, Johns Hopkins University School of Medicine (JHU), Baltimore, MD,Neurosciences Intensive Care Nursery Program, JHU
| | - Frances J. Northington
- Department of Pediatrics, Division of Neonatology, Johns Hopkins University School of Medicine (JHU), Baltimore, MD,Neurosciences Intensive Care Nursery Program, JHU
| | - Maureen M. Gilmore
- Department of Pediatrics, Division of Neonatology, Johns Hopkins University School of Medicine (JHU), Baltimore, MD,Neurosciences Intensive Care Nursery Program, JHU
| | - Aylin Tekes
- Neurosciences Intensive Care Nursery Program, JHU,Department of Radiology, Division of Pediatric Radiology, JHU
| | - Thierry A.G.M. Huisman
- Neurosciences Intensive Care Nursery Program, JHU,Department of Radiology, Division of Pediatric Radiology, JHU
| | - Charlamaine Parkinson
- Department of Pediatrics, Division of Neonatology, Johns Hopkins University School of Medicine (JHU), Baltimore, MD,Neurosciences Intensive Care Nursery Program, JHU
| | - Shang-En Chung
- Department of Pediatrics, Division of General Pediatrics and Adolescent Medicine, JHU,Center for Child and Community Health Research (CCHR), JHU
| | - Jacky M. Jennings
- Department of Pediatrics, Division of General Pediatrics and Adolescent Medicine, JHU,Center for Child and Community Health Research (CCHR), JHU
| | | | - Abby C. Larson
- Department of Anesthesiology and Critical Care Medicine, JHU
| | - Christoph U. Lehmann
- Department of Pediatrics, Division of Neonatology, Johns Hopkins University School of Medicine (JHU), Baltimore, MD
| | - Eric Jackson
- Department of Anesthesiology and Critical Care Medicine, JHU
| | - Ken M. Brady
- Department of Anesthesiology, Texas Children’s Hospital, Houston, TX
| | | | - Jennifer K. Lee
- Neurosciences Intensive Care Nursery Program, JHU,Department of Anesthesiology and Critical Care Medicine, JHU
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29
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Larson AC, Jamrogowicz JL, Kulikowicz E, Wang B, Yang ZJ, Shaffner DH, Koehler RC, Lee JK. Cerebrovascular autoregulation after rewarming from hypothermia in a neonatal swine model of asphyxic brain injury. J Appl Physiol (1985) 2013; 115:1433-42. [PMID: 24009008 DOI: 10.1152/japplphysiol.00238.2013] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
After hypoxic brain injury, maintaining blood pressure within the limits of cerebral blood flow autoregulation is critical to preventing secondary brain injury. Little is known about the effects of prolonged hypothermia or rewarming on autoregulation after cardiac arrest. We hypothesized that rewarming would shift the lower limit of autoregulation (LLA), that this shift would be detected by indices derived from near-infrared spectroscopy (NIRS), and that rewarming would impair autoregulation during hypertension. Anesthetized neonatal swine underwent sham surgery or hypoxic-asphyxic cardiac arrest, followed by 2 h of normothermia and 20 h of hypothermia, with or without rewarming. Piglets were further divided into cohorts for cortical laser-Doppler flow (LDF) measurements during induced hypotension or hypertension. We also tested whether indices derived from NIRS could identify the LDF-derived LLA. The LLA did not differ significantly among groups with sham surgery and hypothermia (29 ± 8 mmHg), sham surgery and rewarming (34 ± 7 mmHg), arrest and hypothermia (29 ± 10 mmHg), and arrest and rewarming (38 ± 11 mmHg). The LLA was not affected by arrest (P = 0.60), temperature (P = 0.08), or interaction between arrest and temperature (P = 0.73). The NIRS-derived indices detected the LLA accurately, with the area under the receiver-operator characteristic curves of 0.81-0.96 among groups. In groups subjected to arrest and hypothermia, with or without rewarming, the slope of LDF relative to cerebral perfusion pressure during hypertension was not significantly different from zero (P > 0.10). In conclusion, rewarming did not shift the LLA during hypotension or affect autoregulation during hypertension after asphyxic cardiac arrest. The NIRS-derived autoregulation indices identified the LLA accurately.
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Affiliation(s)
- Abby C Larson
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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30
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Jacobs SE, Berg M, Hunt R, Tarnow-Mordi WO, Inder TE, Davis PG. Cooling for newborns with hypoxic ischaemic encephalopathy. Cochrane Database Syst Rev 2013; 2013:CD003311. [PMID: 23440789 PMCID: PMC7003568 DOI: 10.1002/14651858.cd003311.pub3] [Citation(s) in RCA: 769] [Impact Index Per Article: 69.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Newborn animal studies and pilot studies in humans suggest that mild hypothermia following peripartum hypoxia-ischaemia in newborn infants may reduce neurological sequelae without adverse effects. OBJECTIVES To determine the effect of therapeutic hypothermia in encephalopathic asphyxiated newborn infants on mortality, long-term neurodevelopmental disability and clinically important side effects. SEARCH METHODS We used the standard search strategy of the Cochrane Neonatal Review Group as outlined in The Cochrane Library (Issue 2, 2007). Randomised controlled trials evaluating therapeutic hypothermia in term and late preterm newborns with hypoxic ischaemic encephalopathy were identified by searching the Oxford Database of Perinatal Trials, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, 2007, Issue 2), MEDLINE (1966 to June 2007), previous reviews including cross-references, abstracts, conferences, symposia proceedings, expert informants and journal handsearching. We updated this search in May 2012. SELECTION CRITERIA We included randomised controlled trials comparing the use of therapeutic hypothermia with standard care in encephalopathic term or late preterm infants with evidence of peripartum asphyxia and without recognisable major congenital anomalies. The primary outcome measure was death or long-term major neurodevelopmental disability. Other outcomes included adverse effects of cooling and 'early' indicators of neurodevelopmental outcome. DATA COLLECTION AND ANALYSIS Four review authors independently selected, assessed the quality of and extracted data from the included studies. Study authors were contacted for further information. Meta-analyses were performed using risk ratios (RR) and risk differences (RD) for dichotomous data, and weighted mean difference for continuous data with 95% confidence intervals (CI). MAIN RESULTS We included 11 randomised controlled trials in this updated review, comprising 1505 term and late preterm infants with moderate/severe encephalopathy and evidence of intrapartum asphyxia. Therapeutic hypothermia resulted in a statistically significant and clinically important reduction in the combined outcome of mortality or major neurodevelopmental disability to 18 months of age (typical RR 0.75 (95% CI 0.68 to 0.83); typical RD -0.15, 95% CI -0.20 to -0.10); number needed to treat for an additional beneficial outcome (NNTB) 7 (95% CI 5 to 10) (8 studies, 1344 infants). Cooling also resulted in statistically significant reductions in mortality (typical RR 0.75 (95% CI 0.64 to 0.88), typical RD -0.09 (95% CI -0.13 to -0.04); NNTB 11 (95% CI 8 to 25) (11 studies, 1468 infants) and in neurodevelopmental disability in survivors (typical RR 0.77 (95% CI 0.63 to 0.94), typical RD -0.13 (95% CI -0.19 to -0.07); NNTB 8 (95% CI 5 to 14) (8 studies, 917 infants). Some adverse effects of hypothermia included an increase sinus bradycardia and a significant increase in thrombocytopenia. AUTHORS' CONCLUSIONS There is evidence from the 11 randomised controlled trials included in this systematic review (N = 1505 infants) that therapeutic hypothermia is beneficial in term and late preterm newborns with hypoxic ischaemic encephalopathy. Cooling reduces mortality without increasing major disability in survivors. The benefits of cooling on survival and neurodevelopment outweigh the short-term adverse effects. Hypothermia should be instituted in term and late preterm infants with moderate-to-severe hypoxic ischaemic encephalopathy if identified before six hours of age. Further trials to determine the appropriate techniques of cooling, including refinement of patient selection, duration of cooling and method of providing therapeutic hypothermia, will refine our understanding of this intervention.
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Affiliation(s)
- Susan E Jacobs
- Neonatal Services, Royal Women’s Hospital, Parkville, Melbourne, Australia.
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31
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Abstract
OPINION STATEMENT Neonatal Hypoxic-ischemic encephalopathy in full term infants has been associated with a high risk for morbidity and mortality. The patho-physiology of brain injury following hypoxia-ischemia, noted in preclinical models, is a cascade of events resulting from excitotoxic and oxidative injury culminating in cell death. Hypothermia has been noted to be protective by inhibiting various events in the cascade of injury. Major randomized clinical trials in neonatal HIE have demonstrated reduction in death and disability and continued safety and efficacy of neuroprotection in childhood. There is now clinical and imaging evidence for hypothermia as neuroprotection. Hypothermia should be offered to term infants with either severe acidosis at birth or resuscitation needing continued ventilation and evidence of either moderate or severe encephalopathy within 6 hours of birth. The target temperature should be 33° to 34 °C and duration of cooling should be 72 hours, as per the published trials. Rewarming should be slow, at 0.5 °C per hour. Infants should have serial neurological examinations during and at the end of cooling and at discharge. Multiorgan function should be supported and hypocarbia should be avoided during ventilator therapy. If available, the amplitude integrated EEG should be obtained prior to cooling and following rewarming. All infants should have magnetic resonance brain imaging studies within 1 to 2 weeks of age. Information from the neurological examination, aEEG and MRI studies will be helpful in discussing prognosis with parents. All infants should be followed for a minimum of 18 months to evaluate growth parameters and neurodevelopment al outcome.
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Affiliation(s)
- Seetha Shankaran
- Neonatal-Perinatal Medicine, Children's Hospital of Michigan, # 4C19, 3901 Beaubien Boulevard, Detroit, MI, 48201, USA,
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32
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Abstract
This article covers the outcome of full-term infants with encephalopathy due to hypoxic-ischemia and pathophysiology of brain injury following hypoxic-ischemia. Clinical and imaging evidence for hypothermia for neuroprotection is presented. The outcome of infants with hypothermia for encephalopathy due to hypoxic-ischemia from recent trials is summarized. Facts regarding the clinical application of cooling obtained from the randomized trials and knowledge gaps in hypothermic therapy are presented. The review concludes with the future of hypothermia for neuroprotection.
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33
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Kochanek PM, Fink EL, Bell MJ. Politics and hypothermia-what might they have in common? Editorial comment on silasi and colbourne, 2011. Ther Hypothermia Temp Manag 2012; 2:11-3. [PMID: 24717133 DOI: 10.1089/ther.2012.1504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Patrick M Kochanek
- Department of Critical Care Medicine, Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine and Children's Hospital of Pittsburgh , Pittsburgh, Pennsylvania
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34
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Sant’Anna G, Laptook AR, Shankaran S, Bara R, McDonald SA, Higgins RD, Tyson JE, Ehrenkranz RA, Das A, Goldberg RN, Walsh MC. Phenobarbital and temperature profile during hypothermia for hypoxic-ischemic encephalopathy. J Child Neurol 2012; 27:451-7. [PMID: 21960671 PMCID: PMC3530920 DOI: 10.1177/0883073811419317] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Data from the whole-body hypothermia trial was analyzed to examine the effects of phenobarbital administration prior to cooling (+PB) on the esophageal temperature (T (e)) profile, during the induction phase of hypothermia. A total of 98 infants were analyzed. At enrollment, +PB infants had a higher rate of severe hypoxic-ischemic encephalopathy and clinical seizures and lower T (e) and cord pH than infants that have not received phenobarbital (-PB). There was a significant effect of phenobarbital itself and an interaction between phenobarbital and time in the T (e) profile. Mean T (e) in the +PB group was lower than in the -PB group, and the differences decreased over time. In +PB infants, the time to surpass target T (e) of 33.5°C and to reach the minimum T (e) during overshoot were shorter. In conclusion, the administration of phenobarbital before cooling was associated with changes that may reflect a reduced thermogenic response associated with barbiturates.
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Affiliation(s)
| | | | | | | | | | - Rosemary D. Higgins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development
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Higgins RD, Raju T, Edwards AD, Azzopardi DV, Bose CL, Clark RH, Ferriero DM, Guillet R, Gunn AJ, Hagberg H, Hirtz D, Inder TE, Jacobs SE, Jenkins D, Juul S, Laptook AR, Lucey JF, Maze M, Palmer C, Papile L, Pfister RH, Robertson NJ, Rutherford M, Shankaran S, Silverstein FS, Soll RF, Thoresen M, Walsh WF. Hypothermia and other treatment options for neonatal encephalopathy: an executive summary of the Eunice Kennedy Shriver NICHD workshop. J Pediatr 2011; 159:851-858.e1. [PMID: 21875719 PMCID: PMC3263823 DOI: 10.1016/j.jpeds.2011.08.004] [Citation(s) in RCA: 159] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2011] [Revised: 06/16/2011] [Accepted: 08/02/2011] [Indexed: 10/17/2022]
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Jacobs S, Hunt R, Tarnow-Mordi W, Inder T, Davis P. Cooling for newborns with hypoxic ischaemic encephalopathy. Cochrane Database Syst Rev 2003:CD003311. [PMID: 14583966 DOI: 10.1002/14651858.cd003311] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Newborn animal and human pilot studies suggest that mild hypothermia following peripartum hypoxia-ischaemia in newborn infants may reduce neurological sequelae, without adverse effects. OBJECTIVES To determine whether therapeutic hypothermia in encephalopathic asphyxiated newborn infants reduces mortality and long-term neurodevelopmental disability, without clinically important side effects. SEARCH STRATEGY The standard search strategy of the Neonatal Review Group as outlined in the Cochrane Library (Issue 2, 2003) was used. Randomised controlled trials evaluating therapeutic hypothermia in term newborns with hypoxic ischaemic encephalopathy were identified by searching the Oxford Database of Perinatal Trials, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library Issue Issue 2, 2003), MEDLINE (1966 to July 2003), previous reviews including cross-references, abstracts, conferences, symposia proceedings, expert informants and journal hand searching. SELECTION CRITERIA Randomised controlled trials comparing the use of therapeutic hypothermia with normothermia in encephalopathic newborn infants with evidence of peripartum asphyxia and without recognisable major congenital anomalies were included. The primary outcome measure was death or long-term major neurodevelopmental disability. Other outcomes included adverse effects of cooling and 'early' indicators of neurodevelopmental outcome. DATA COLLECTION AND ANALYSIS Three reviewers independently selected, assessed the quality of and extracted data from the included studies. Authors were contacted for further information. Meta-analyses were performed using relative risk and risk difference for dichotomous data, and weighted mean difference for continuous data with 95% confidence intervals. MAIN RESULTS Two randomised controlled trials were included in this review, comprising 50 term infants with moderate/ severe encephalopathy and evidence of intrapartum asphyxia. There was no significant effect of therapeutic hypothermia on the combined outcome of death or major neurodevelopmental disability in survivors followed. No adverse effects of hypothermia on short term medical outcomes or on some 'early' indicators of neurodevelopmental outcome were detected. REVIEWER'S CONCLUSIONS Although two small randomised controlled trials demonstrated neither evidence of benefit or harm, current evidence is inadequate to assess either safety or efficacy of therapeutic hypothermia in newborn infants with hypoxic ischaemic encephalopathy. Therapeutic hypothermia for encephalopathic asphyxiated newborn infants should be further evaluated in well designed randomised controlled trials.
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Affiliation(s)
- S Jacobs
- Division of Paediatrics, Royal Women's Hospital, 132 Grattan Street, Carlton, Melbourne, Victoria, Australia, 3953
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