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Sehgal A, Linduska N, Huynh C. Cardiac adaptation in asphyxiated infants treated with therapeutic hypothermia. J Neonatal Perinatal Med 2020; 12:117-125. [PMID: 30814366 DOI: 10.3233/npm-1853] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Hypoxic ischemic encephalopathy (HIE) affects one to two newborns per 1,000 live births and oftentimes involves multi-organ insult. The objectives were to assess the evolution of cardiac function in infants with HIE treated with therapeutic hypothermia using echocardiography (ECHO). METHODS Archived data during the period 2010-2016 was assessed. Amongst the infants with baseline ECHO assessments, a sub-cohort which had assessments in all the three phases (baseline/pre-active cooling [T1], cooling [T2] and rewarming [T3]) was analyzed separately. RESULTS Thirty three infants formed part of the overall cohort, the gestation and birthweight were 39.6 ± 1.6 weeks and 3306 ± 583 g, respectively. Baseline (T1) information noted impaired cardiac performance (right ventricle stroke volume 1.08 ± 0.04 ml/kg, fractional area change [FAC] 24 ± 0.5% and tricuspid annular peak systolic excursion [TAPSE] 7.46 ± 0.11mm). Serial information was available for 24 of 33 infants. Cardiac function improved significantly between the cooling and the re-warming kphases. This included changes in right ventricular output (127 ± 34 vs 164 ± 47 ml/kg/min, p <0.01) and FAC (20 ± 3 vs 28 ± 2%, p<0.01). Pairwise comparisons for fractional shortening did not show significant changes. From the cooling to the rewarming phase, maximum change was noted in FAC (26.3 ± 9.8%) while minimum change was noted in fractional shortening (median, interquartile range) of 4.6% (1.4, 9.1). Significant correlation between TAPSE and time to peak velocity as a proportion of right ventricular ejection time was noted (r2 = 0.68, p <0.001). CONCLUSIONS In infants with moderate to severe HIE, cardiac function evolves during various phases of therapeutic hypothermia. Low output state during cooling may be due to a combination of the disease state (HIE) and cooling therapy.
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Affiliation(s)
- A Sehgal
- Monash Newborn, Monash Children's Hospital, Clayton, Australia.,Department of Pediatrics, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - N Linduska
- Monash Newborn, Monash Children's Hospital, Clayton, Australia
| | - C Huynh
- Monash Newborn, Monash Children's Hospital, Clayton, Australia
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2
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Xue LL, Wang F, Xiong LL, Du RL, Zhou HL, Zou Y, Wu MX, Yang MA, Dai J, He MX, Wang TH. A single-nucleotide polymorphism induced alternative splicing in Tacr3 involves in hypoxic-ischemic brain damage. Brain Res Bull 2020; 154:106-115. [PMID: 31722250 DOI: 10.1016/j.brainresbull.2019.11.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 09/28/2019] [Accepted: 11/04/2019] [Indexed: 02/05/2023]
Abstract
Single-nucleotide polymorphism (SNP) and Alternative splicing (AS) were found to be implicated in certain diseases, nevertheless, the contributions of mRNA SNPs and AS to pathogenesis in developing rat brains with hypoxic-ischemic encephalopathy (HIE) remained largely vague. Additionally, the disease associated with Tacr3 was normosmic congenital hypogonadotropic hypogonadism, while the relationship between HIE and Tacr3 remained largely elusive. The current study was designed to investigate the differentially expressed mRNAs and related SNPs as well as AS in neonatal rats subjected to HIE to identify if the exhibition of AS was associated with SNPs under pathological condition. Firstly, we used postnatal day 7 Sprague-Dawley rats to construct neonatal HIE model, and analyzed the expression profiles of SNP mRNA in hypoxic-ischemic (HI) and sham brains by using RNA sequencing. Then four genes, including Mdfic, Lpp, Bag3 and Tacr3, connecting with HIE and exhibiting SNPs and AS were identified by bioinformatics analysis. Moreover, combined with exonic splicing enhancer (ESE) and alternative splice site predictor (ASSP) analysis, we found that Tacr3 is associated specifically with HIE through 258547789 G > A SNP in inside the Alt First Exon and 258548573 G > A SNP in outside the Alt First Exon. Taken together, our study provides new evidence to understand the role of Tacr3 in HIE and it is possibly a potential target for the treatment of HIE in future clinic trial.
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MESH Headings
- Animals
- Humans
- Male
- Rats
- Alternative Splicing/genetics
- Animals, Newborn
- Brain/metabolism
- Disease Models, Animal
- Hypoxia-Ischemia, Brain/genetics
- Hypoxia-Ischemia, Brain/metabolism
- Neurons/metabolism
- Polymorphism, Single Nucleotide/genetics
- Rats, Sprague-Dawley
- Receptors, Neurokinin-3/genetics
- Receptors, Neurokinin-3/metabolism
- Receptors, Tachykinin/genetics
- Receptors, Tachykinin/metabolism
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Affiliation(s)
- Lu-Lu Xue
- Institute of Neurological Disease, Department of Anesthesiology, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, 610041, China; Institute of Neuroscience, Animal Zoology Department, Kunming Medical University, Kunming 650031, China
| | - Fang Wang
- Department of Science and Technology, Kunming Medical University, Kunming 650031, China
| | - Liu-Lin Xiong
- Department of Anesthesiology, The Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, P. R. 563000, China
| | - Ruo-Lan Du
- Institute of Neuroscience, Animal Zoology Department, Kunming Medical University, Kunming 650031, China
| | - Hao-Li Zhou
- The Clinical Hospital of Chengdu Brain Science Institute, MOE Key Lab for Neuroinformation, University of Electronic Science and Technology of China, Chengdu, China
| | - Yu Zou
- The Clinical Hospital of Chengdu Brain Science Institute, MOE Key Lab for Neuroinformation, University of Electronic Science and Technology of China, Chengdu, China
| | - Ma-Xiu Wu
- The Clinical Hospital of Chengdu Brain Science Institute, MOE Key Lab for Neuroinformation, University of Electronic Science and Technology of China, Chengdu, China
| | - Ming-An Yang
- Division of Biostatistics and Epidemiology, School of Public Health, San Diego State University, USA
| | - Jing Dai
- The Clinical Hospital of Chengdu Brain Science Institute, MOE Key Lab for Neuroinformation, University of Electronic Science and Technology of China, Chengdu, China
| | - Man-Xi He
- The Clinical Hospital of Chengdu Brain Science Institute, MOE Key Lab for Neuroinformation, University of Electronic Science and Technology of China, Chengdu, China.
| | - Ting-Hua Wang
- Institute of Neurological Disease, Department of Anesthesiology, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, 610041, China; Institute of Neuroscience, Animal Zoology Department, Kunming Medical University, Kunming 650031, China.
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Nitzan I, Goldberg S, Hammerman C, Bin-Nun A, Bromiker R. Effect of rewarming in oxygenation and respiratory condition after neonatal exposure to moderate therapeutic hypothermia. Pediatr Neonatol 2019; 60:423-427. [PMID: 30459100 DOI: 10.1016/j.pedneo.2018.10.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 08/28/2018] [Accepted: 10/25/2018] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND To assess changes in clinical condition and oxygenation in neonates after rewarming following moderate therapeutic hypothermia (MTH) for neonatal encephalopathy. METHODS Retrospective study of 28 neonates receiving MTH in a tertiary neonatal intensive care unit in Israel. We compared pre-and 24 h post-rewarming arterial oxygen saturation (SaO2) as measured by the blood gases analyzer, pulse-oximetry saturation (SpO2), and cardio-respiratory condition. RESULTS The SpO2 declined from 96.9% (±2.9) before rewarming to 95.2% (±2.6) after rewarming (p < 0.001). Twelve neonates (42.9%) had clinical respiratory impairment (needing higher respiratory support or had new onset desaturations). In 16 neonates (57.1%) with no change in respiratory support after rewarming, SpO2 decreased from 98.3 ± 1.9% to 95.6 ± 3.0% (p < 0.001) and SaO2 decreased from 97.1 ± 1.7% to 96.0 ± 2.3% (p = 0.002). The mean SpO2 decrease was greater than mean SaO2 decrease (2.63 ± 1.8 and 1.1 ± 1.3 respectively, p = 0.021). CONCLUSION Neonates who underwent MTH showed reduction in oxygenation after rewarming either by decreasing SpO2 or increasing FiO2 requirements. The SpO2 decline was larger than the SaO2 decline. We suggest careful monitoring of neonates after rewarming.
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Affiliation(s)
- Itamar Nitzan
- Neonatology Department, Shaare Zedek Medical Center, Jerusalem, Israel.
| | - Shmuel Goldberg
- Pediatric Pulmonology, Shaare Zedek Medical Center, Jerusalem, Israel; Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - Cathy Hammerman
- Neonatology Department, Shaare Zedek Medical Center, Jerusalem, Israel; Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - Alona Bin-Nun
- Neonatology Department, Shaare Zedek Medical Center, Jerusalem, Israel; Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - Ruben Bromiker
- Neonatology Department, Shaare Zedek Medical Center, Jerusalem, Israel; Hebrew University Faculty of Medicine, Jerusalem, Israel
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Eriksen VR, Trautner S, Hahn GH, Greisen G. Lactate acidosis and cardiac output during initial therapeutic cooling in asphyxiated newborn infants. PLoS One 2019; 14:e0213537. [PMID: 30870445 PMCID: PMC6417718 DOI: 10.1371/journal.pone.0213537] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 02/21/2019] [Indexed: 11/19/2022] Open
Abstract
Aim We hypothesized that compromised cardiac output in asphyxiated infants may influence on the rate of disappearance of lactate due to insufficient perfusion. Methods The study was a prospective, observational study, where infants with perinatal asphyxia who met the criteria for therapeutic hypothermia were included. Cardiac output, stroke volume and heart rate were measured by electrical velocimetry in 15 newborn infants with perinatal asphyxia during the first six hours of active therapeutic hypothermia. Results from routine blood samples were collected retrospectively. Cardiac parameters were also measured in 10 healthy, term infants after caesarian section. Cardiac parameters were compared between the asphyxiated group and the control group prior to and during hypothermia. Rate of disappearance of lactate was correlated to cardiac output in the asphyxiated infants. Results Cardiac output was stable in the healthy infants from 0.5 to 6 hours postnatally. The infants with perinatal asphyxia had lower cardiac output prior to and during therapeutic hypothermia compared to the control group. Rate of disappearance of lactate was not related to cardiac output. Conclusion An association between disappearance of lactate acidosis and low cardiac output was not confirmed. A low rate of disappearance of lactate may rather be an indicator of organ injury due to asphyxia.
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Affiliation(s)
- Vibeke Ramsgaard Eriksen
- Department of Neonatology, Copenhagen University Hospital–Rigshospitalet, Copenhagen, Denmark
- * E-mail:
| | - Simon Trautner
- Department of Neonatology, Copenhagen University Hospital–Rigshospitalet, Copenhagen, Denmark
| | - Gitte Holst Hahn
- Department of Neonatology, Copenhagen University Hospital–Rigshospitalet, Copenhagen, Denmark
| | - Gorm Greisen
- Department of Neonatology, Copenhagen University Hospital–Rigshospitalet, Copenhagen, Denmark
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5
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Salas J, Reddy N, Orru E, Carson KA, Chavez-Valdez R, Burton VJ, Stafstrom CE, Northington FJ, Huisman TAGM. The Role of Diffusion Tensor Imaging in Detecting Hippocampal Injury Following Neonatal Hypoxic-Ischemic Encephalopathy. J Neuroimaging 2018; 29:252-259. [PMID: 30325083 DOI: 10.1111/jon.12572] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Revised: 09/12/2018] [Accepted: 10/03/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND AND PURPOSE Neonatal hypoxic-ischemic injury of the brain and resultant encephalopathy (HIE) leads to major developmental impairments by school age. Conventional/anatomical MRI often fails to detect hippocampal injury in mild cases. We hypothesize that diffusion tensor imaging (DTI) has greater sensitivity for identifying subtle hippocampal injury. METHODS We retrospectively analyzed DTI data collected from a cohort of neonates with HIE and controls. Conventional MRI sequences were classified qualitatively according to severity using a modified Barkovich scale. Using multivariate linear regression, we compared hippocampal DTI scalars of HIE patients and controls. Spearman correlation was used to test the association of DTI scalars in the hippocampal and thalamic regions. A multiple regression analysis tested the association of the DTI scalars with short-term outcomes. RESULTS Fifty-five neonates with HIE (42% males) and 13 controls (54% males) were included. Hippocampal DTI scalars were similar between HIE and control groups, even when restricting the HIE group to those with moderate-to-severe injury (8 subjects). DTI scalars of the thalamus were significantly lower in the moderate-to-severely affected patients compared to controls (right fractional anisotropy [FA] .148 vs. .182, P = .01; left FA .147 vs. .181, P = .03). Hippocampal and thalamic DTI scalars were correlated (P < .001). Hippocampal DTI scalars were not associated with short-term outcomes. CONCLUSIONS Quantitative DTI analysis of the hippocampus in neonates following HIE is a feasible technique to examine neuronal injury. Although DTI scalars were useful in identifying thalamic injury in our cohort, hippocampal DTI analysis did not provide additional information regarding hippocampal injury following HIE.
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Affiliation(s)
- Jacqueline Salas
- Division of Neonatology, Department of Pediatrics, The Johns Hopkins University School of Medicine, The Charlotte R. Bloomberg Children's Center, Baltimore, MD.,Neuro-Intensive Care Nursery Group, The Johns Hopkins School of Medicine, Baltimore, MD
| | - Nihaal Reddy
- Division of Pediatric Radiology and Pediatric Neuroradiology, Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Emanuele Orru
- Division of Pediatric Radiology and Pediatric Neuroradiology, Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kathryn A Carson
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Raul Chavez-Valdez
- Division of Neonatology, Department of Pediatrics, The Johns Hopkins University School of Medicine, The Charlotte R. Bloomberg Children's Center, Baltimore, MD.,Neuro-Intensive Care Nursery Group, The Johns Hopkins School of Medicine, Baltimore, MD
| | - Vera Joanna Burton
- Neuro-Intensive Care Nursery Group, The Johns Hopkins School of Medicine, Baltimore, MD.,Department of Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, MD
| | - Carl E Stafstrom
- Neuro-Intensive Care Nursery Group, The Johns Hopkins School of Medicine, Baltimore, MD.,Division of Pediatric Neurology, Department of Neurology, The Johns Hopkins School of Medicine, Baltimore, MD
| | - Frances J Northington
- Division of Neonatology, Department of Pediatrics, The Johns Hopkins University School of Medicine, The Charlotte R. Bloomberg Children's Center, Baltimore, MD.,Neuro-Intensive Care Nursery Group, The Johns Hopkins School of Medicine, Baltimore, MD
| | - Thierry A G M Huisman
- Division of Pediatric Radiology and Pediatric Neuroradiology, Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, MD.,Neuro-Intensive Care Nursery Group, The Johns Hopkins School of Medicine, Baltimore, MD
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6
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Aggarwal S, Natarajan G. Biventricular function on early echocardiograms in neonatal hypoxic-ischaemic encephalopathy. Acta Paediatr 2017; 106:1085-1090. [PMID: 28374415 DOI: 10.1111/apa.13866] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 01/30/2017] [Accepted: 03/30/2017] [Indexed: 11/30/2022]
Abstract
AIM To compare early (<24 hours) echocardiograms (ECHOs) in infants with perinatal hypoxic-ischaemic encephalopathy (HIE) undergoing (i) therapeutic hypothermia (TH), (ii) normothermia and (iii) normal controls. METHODS This was a single-centre retrospective review of clinical early ECHOs of term infants with moderate or severe HIE and controls (with a normal ECHO <72 hours of age). Right (RVO) and left ventricular output (LVO), RV and LV myocardial performance index (MPI), systolic to diastolic duration ratio (S/D) and eccentricity indices (EI) in systole and diastole were compared using ANOVA. RESULTS Among infants with HIE (n = 56, 38 in the TH and 18 in normothermia groups), 14 (25%) infants died and 42 survived. Significantly elevated biventricular MPI, lower RVO and LVO and pulmonary hypertension (abnormal EI, higher RV S/D and bidirectional or right-to-left ductal shunt) were found in groups with HIE, compared to controls (n = 35). LV MPI was lower in HIE-TH, compared to the HIE-normothermia group. Infants with HIE who died (n = 14) had a significantly lower EId [0.77 (0.09) vs. 0.83 (0.08), p = 0.021] compared to survivors (n = 42). CONCLUSION Infants with perinatal HIE have ventricular dysfunction; those who died had significantly lower EId than survivors; this association needs to be further validated.
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Affiliation(s)
- Sanjeev Aggarwal
- Department of Pediatrics; Wayne State University, Children's Hospital of Michigan; Detroit MI USA
| | - Girija Natarajan
- Department of Pediatrics; Wayne State University, Children's Hospital of Michigan; Detroit MI USA
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7
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Heart rate response to therapeutic hypothermia in infants with hypoxic-ischaemic encephalopathy. Resuscitation 2016; 106:53-7. [PMID: 27368430 DOI: 10.1016/j.resuscitation.2016.06.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Revised: 05/20/2016] [Accepted: 06/17/2016] [Indexed: 01/15/2023]
Abstract
AIM OF THE STUDY Neonatal encephalopathy (NE) of hypoxic-ischaemic origin may cause death or life-long disability which is reduced by therapeutic hypothermia (TH). Our objective was to assess HR response in infants undergoing TH after perinatal asphyxia. METHODS We performed a retrospective case series, from a single-centre tertiary care NICU. We included ninety-two infants with NE of likely hypoxic-ischaemic origin, moderate or severe, treated with TH (n=60) or normothermia (n=32) who had 18 month outcome data and at least 12 HR recordings the first 24h after birth (1998-2010) Bristol, UK. Poor outcome was defined as death or severe disability. Data are reported as medians and 95% confidence intervals (CI). RESULTS TH to 33.5°C decreased HR by 30bpm to 92bpm (95% CI: 88, 96) 12h after birth in infants with NE and good outcome as compared to infants treated at normothermia 118bpm (95% CI: 110, 130). Despite constant low rectal temperature, HR increased gradually during cooling from 36 to 72h to 97bpm (89, 106) approaching the normothermia group, 117bpm (96, 133). During TH, infants with poor outcome had higher HR at 12h after birth (112bpm, 95% CI: 92, 115) as compared to infants with good outcome (p=0.004). Inotropic support increased HR by 17bpm in infants with good outcome and by 22bpm in infants with poor outcome. CONCLUSIONS In NE, TH decreases HR the first day of life. HR remained lower during TH, but increased during the last day of TH. Infants with poor outcome have higher HR.
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8
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Elbahtiti A, Aly NY, Abo-Lila R, Al-Sawan R. Therapeutic hypothermia for infants with hypoxic ischemic encephalopathy: A five years' single center experience in Kuwait. J Neonatal Perinatal Med 2016; 9:179-185. [PMID: 27197929 DOI: 10.3233/npm-16915090] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
OBJECTIVE We aimed to evaluate the effect of therapeutic hypothermia (TH) on brain MRI findings, neurological outcome, and mortality in patients with perinatal hypoxic ischemic encephalopathy (HIE) and compare between two modalities of TH: whole body cooling (WBC) and selective head cooling (SHC). PATIENTS AND METHODS Sixty-two inborn babies with HIE admitted to the NICU of a Kuwaiti teaching hospital between 2006 and 2013 were retrospectively reviewed. Patients were divided into two groups: group 1 (2006-2008, n = 30) never received hypothermia, and group 2 (2009-2013, n = 32) treated with hypothermia. Group 2 patients were chronologically divided into two subgroups: 2a, the SHC, (2009-2010, n = 15) and 2b, the WBC, (2011-2013, n = 17). Brain MRI taken 7-10 days after birth, neurological status and mortality at time of hospital discharge were evaluated. RESULTS Patients who received TH showed significantly fewer MRI hypoxic changes (P = 0.04) and had better neurological outcome. Their need for anticonvulsants diminished (P = 0.04). However, their need for inotropes and duration of mechanical ventilation were increased (P = 0.001 & 0.02 respectively). No significant difference in mortality was found between the two groups (P = 0.6). In regression analysis, only MRI hypoxic changes predicted the occurrence of neurological abnormalities (P = 0.001). No difference in brain MRI findings, neurological outcome and mortality was observed between subgroups 2a and 2b (P > 0.05). CONCLUSION TH improved the neurological outcome of HIE patients but had no effect on mortality. There was no difference between the two modalities of TH on patients' outcome.
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Affiliation(s)
- A Elbahtiti
- Department of Neonatology, Farwaniya Hospital, Ministry of Health, Kuwait city, Kuwait
| | - N Yehia Aly
- Department of Infection Control, Farwaniya Hospital, Ministry of Health, Kuwait city, Kuwait
- Department of Tropical Medicine and Hygiene, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
| | - R Abo-Lila
- Department of Neonatology, Farwaniya Hospital, Ministry of Health, Kuwait city, Kuwait
| | - R Al-Sawan
- Department of Neonatology, Farwaniya Hospital, Ministry of Health, Kuwait city, Kuwait
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9
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Hoque N, Liu X, Chakkarapani E, Thoresen M. Minimal systemic hypothermia combined with selective head cooling evaluated in a pig model of hypoxia-ischemia. Pediatr Res 2015; 77:674-80. [PMID: 25665052 DOI: 10.1038/pr.2015.31] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 11/03/2014] [Indexed: 11/09/2022]
Abstract
BACKGROUND Selective head cooling (SHC) with moderate hypothermia (HT) and whole-body cooling are beneficial following perinatal asphyxia. SHC with systemic normothermia (NT) or minimal HT is under-investigated, could obviate systemic complications of moderate HT, and be applicable to preterm infants. We hypothesized that minimal systemic HT with SHC following hypoxia-ischemia (HI) would be neuroprotective compared with systemic NT. METHODS Newborn pigs underwent global HI causing permanent brain injury before being randomized to NT (rectal temperature (Trectal) 38.5 °C) or minimal HT (Trectal 37.0 °C) with SHC (cooling cap and body wrap) for 48 h followed by 24-h NT with 72-h survival. RESULTS SHC did not reduce global or regional neuropathology score when correcting for insult severity or compared with a NT group matched for HI severity but increased mortality by 26%. During 48 h, the SHC mean ± SD Trectal was 37.0 ± 0.2 °C, and Tdeep brain and Tsuperficial brain were 35.0 ± 1.1 °C and 31.5 ± 1.6 °C, respectively, with stable Tbrain achieved ≥ 3 h after starting cooling. CONCLUSION This is the first study in newborn pigs of minimal systemic HT with SHC for 48 h and a further 24 h of NT following HI. Mortality was increased in the cooled group with no neuroprotection in survivors.
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Affiliation(s)
- Nicholas Hoque
- Neonatal Neuroscience, School of Clinical Sciences, University of Bristol, Bristol, Avon, UK
| | - Xun Liu
- Neonatal Neuroscience, School of Clinical Sciences, University of Bristol, Bristol, Avon, UK
| | - Ela Chakkarapani
- Neonatal Neuroscience, School of Clinical Sciences, University of Bristol, Bristol, Avon, UK
| | - Marianne Thoresen
- 1] Neonatal Neuroscience, School of Clinical Sciences, University of Bristol, Bristol, Avon, UK [2] Department of Physiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
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Abstract
Therapeutic hypothermia is the only treatment currently recommended for moderate or severe encephalopathy of hypoxic‒ischaemic origin in term neonates. Though the effects of hypothermia on human physiology have been explored for many decades, much of the data comes from animal or adult studies; the latter originally after accidental hypothermia, followed by application of controlled hypothermia after cardiac arrest or trauma, or during cardiopulmonary bypass. Though this work is informative, the effects of hypothermia on neonatal physiology after perinatal asphyxia must be considered in the context of a prolonged hypoxic insult that has already induced a number of significant physiological sequelae. This article reviews the effects of therapeutic hypothermia on respiratory, cardiovascular, and metabolic parameters, including glycaemic control and feeding requirements. The potential pitfalls of blood‒gas analysis and overtreatment of physiological changes in cardiovascular parameters are also discussed. Finally, the effects of hypothermia on drug metabolism are covered, focusing on how the pharmacokinetics, pharmacodynamics, and dosing requirements of drugs frequently used in neonatal intensive care may change during therapeutic hypothermia.
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van den Broek MPH, Rademaker CMA, van Straaten HLM, Huitema ADR, Toet MC, de Vries LS, Egberts ACG, Groenendaal F. Anticonvulsant treatment of asphyxiated newborns under hypothermia with lidocaine: efficacy, safety and dosing. Arch Dis Child Fetal Neonatal Ed 2013; 98:F341-5. [PMID: 23303304 DOI: 10.1136/archdischild-2012-302678] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Lidocaine is an antiarrythmicum used as an anticonvulsant for neonatal seizures, also during therapeutic hypothermia following (perinatal) asphyxia. Hypothermia may affect the efficacy, safety and dosing of lidocaine in these patients. OBJECTIVE To study the efficacy and safety of lidocaine in newborns with perinatal asphyxia during moderate hypothermia, and to develop an effective and safe dosing regimen. METHODS Hypothermic newborns with perinatal asphyxia and lidocaine for seizure control were included. Efficacy was studied using continuous amplitude-integrated electroencephalography. Safety was assessed using continuous cardiac monitoring. An optimal dosing regimen was developed with simulations using data from a pharmacokinetic model. Plasma samples were collected during hypothermia on consecutive mornings. RESULTS A total of 22 hypothermic and 26 historical normothermic asphyxiated newborns with lidocaine were included. A response of 91% on epileptiform activity on the amplitude-integrated EEG was observed for lidocaine add-on therapy. No relationship between lidocaine or MEGX plasma concentrations and heart frequency could be identified. None of the newborns experienced cardiac arrythmias. Hypothermia reduced lidocaine clearance by 24% compared with normothermia. A novel dosing regimen was developed an initial bolus loading dose of 2 mg/kg, for patients with body weight 2.0-2.5 kg followed by consecutive continuous infusions of 6 mg/kg/h (for 3.5 h), 3 mg/kg/h (for 12 h), 1.5 mg/kg/h (for 12 h), or for patients with body weights 2.5-4.5 kg 7 mg/kg/h (for 3.5 h), 3.5 mg/kg/h (for 12 h), 1.75 mg/kg/h (for 12 h), before stopping. CONCLUSIONS Lidocaine can be assumed to be an effective antiepileptic drug during hypothermia in asphyxiated neonates.
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12
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Heart Rate and Arterial Pressure Changes during Whole-Body Deep Hypothermia. ISRN PEDIATRICS 2013; 2013:140213. [PMID: 23691350 PMCID: PMC3649319 DOI: 10.1155/2013/140213] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Accepted: 03/18/2013] [Indexed: 11/17/2022]
Abstract
Whole-body deep hypothermia (DH) could be a new therapeutic strategy for asphyxiated newborn. This retrospective study describes how DH modified the heart rate and arterial blood pressure if compared to mild hypothermia (MH). Fourteen in DH and 17 in MH were cooled within the first six hours of life and for the following 72 hours. Hypothermia criteria were gestational age ≥36 weeks; birth weight ≥1800 g; clinical signs of moderate/severe hypoxic-ischemic encephalopathy. Rewarming was obtained in the following 6-12 hours (0.5°C/h) after cooling. Heart rates were the same between the two groups; there was statistically significant difference at the beginning of hypothermia and during rewarming. Three babies in the DH group and 2 in the MH group showed HR < 80 bpm and QTc > 520 ms. Infant submitted to deep hypothermia had not bradycardia or Qtc elongation before cooling and after rewarming. Blood pressure was significantly lower in DH compared to MH during the cooling, and peculiar was the hypotension during rewarming in DH group. Conclusion. The deeper hypothermia is a safe and feasible, only if it is performed by a well-trained team. DH should only be associated with a clinical trial and prospective randomized trials to validate its use.
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Bader EBMK. Clinical q & a: translating therapeutic temperature management from theory to practice. Ther Hypothermia Temp Manag 2013; 3:28-38. [PMID: 24837637 DOI: 10.1089/ther.2013.1503] [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
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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: 801] [Impact Index Per Article: 72.8] [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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15
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Drury PP, Booth LC, Bennet L, Davidson JO, Wibbens B, Gunn AJ. Dopamine infusion for postresuscitation blood pressure support after profound asphyxia in near-term fetal sheep. Exp Physiol 2012; 98:699-709. [DOI: 10.1113/expphysiol.2012.069989] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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16
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Robertson NJ, Faulkner S, Fleiss B, Bainbridge A, Andorka C, Price D, Powell E, Lecky-Thompson L, Thei L, Chandrasekaran M, Hristova M, Cady EB, Gressens P, Golay X, Raivich G. Melatonin augments hypothermic neuroprotection in a perinatal asphyxia model. Brain 2012. [PMID: 23183236 DOI: 10.1093/brain/aws285] [Citation(s) in RCA: 184] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Despite treatment with therapeutic hypothermia, almost 50% of infants with neonatal encephalopathy still have adverse outcomes. Additional treatments are required to maximize neuroprotection. Melatonin is a naturally occurring hormone involved in physiological processes that also has neuroprotective actions against hypoxic-ischaemic brain injury in animal models. The objective of this study was to assess neuroprotective effects of combining melatonin with therapeutic hypothermia after transient hypoxia-ischaemia in a piglet model of perinatal asphyxia using clinically relevant magnetic resonance spectroscopy biomarkers supported by immunohistochemistry. After a quantified global hypoxic-ischaemic insult, 17 newborn piglets were randomized to the following: (i) therapeutic hypothermia (33.5°C from 2 to 26 h after resuscitation, n = 8) and (ii) therapeutic hypothermia plus intravenous melatonin (5 mg/kg/h over 6 h started at 10 min after resuscitation and repeated at 24 h, n = 9). Cortical white matter and deep grey matter voxel proton and whole brain (31)P magnetic resonance spectroscopy were acquired before and during hypoxia-ischaemia, at 24 and 48 h after resuscitation. There was no difference in baseline variables, insult severity or any physiological or biochemical measure, including mean arterial blood pressure and inotrope use during the 48 h after hypoxia-ischaemia. Plasma levels of melatonin were 10 000 times higher in the hypothermia plus melatonin than hypothermia alone group. Melatonin-augmented hypothermia significantly reduced the hypoxic-ischaemic-induced increase in the area under the curve for proton magnetic resonance spectroscopy lactate/N-acetyl aspartate and lactate/total creatine ratios in the deep grey matter. Melatonin-augmented hypothermia increased levels of whole brain (31)P magnetic resonance spectroscopy nucleotide triphosphate/exchangeable phosphate pool. Correlating with improved cerebral energy metabolism, TUNEL-positive nuclei were reduced in the hypothermia plus melatonin group compared with hypothermia alone in the thalamus, internal capsule, putamen and caudate, and there was reduced cleaved caspase 3 in the thalamus. Although total numbers of microglia were not decreased in grey or white matter, expression of the prototypical cytotoxic microglial activation marker CD86 was decreased in the cortex at 48 h after hypoxia-ischaemia. The safety and improved neuroprotection with a combination of melatonin with cooling support phase II clinical trials in infants with moderate and severe neonatal encephalopathy.
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Affiliation(s)
- Nicola J Robertson
- Institute for Women's Health, University College London, 74 Huntley Street, London WC1E 6AU, UK.
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17
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Filippi L, Catarzi S, Padrini L, Fiorini P, la Marca G, Guerrini R, Donzelli GP. Strategies for reducing the incidence of skin complications in newborns treated with whole-body hypothermia. J Matern Fetal Neonatal Med 2012; 25:2115-21. [PMID: 22524246 DOI: 10.3109/14767058.2012.683898] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To present the results of a strategy designed to reduce the incidence of skin complications in newborns with hypoxic-ischemic encephalopathy treated with moderate whole-body hypothermia. DESIGN Retrospective study. SETTING Neonatal Intensive Care Unit (NICU). PATIENTS Thirty-nine neonates cooled in the considered period. INTERVENTION Starting from January 2008, for neonates treated with moderate whole-body hypothermia (33.5 °C), the cooling system was set in "automatic servo-controlled mode (ACM)", where the temperature of the circulating water could vary between 4 °C and 42 °C. Starting from January 2009, cooling blankets were used in another type of automatic mode, the "gradient variable mode (GVM)", where the circulating water was maintained at a specific pre-set gradient towards the patient's body temperature, and a specific nursing protocol (NP) was adopted. MEASUREMENTS AND MAIN RESULTS Two of the eleven newborns treated with the "ACM" exhibited skin complications compatible with subcutaneous fat necrosis (SFN). None of the twenty-eight newborns treated with the "GVM" exhibited skin complications. A comparison of the biochemical and hematological data between these two groups revealed that newborns treated after the adopting of a NP and the "GVM" showed lower serum protein C and calcium levels, and higher platelet levels. CONCLUSIONS Our data suggest that newborns undergoing therapeutic cooling may benefit from a specific NP and correct cooling unit setting. Should further studies confirm our data, this nursing approach could be easily adopted.
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Affiliation(s)
- Luca Filippi
- Neonatal Intensive Care Unit, Medical Surgical Feto-Neonatal Department, A. Meyer University Children's Hospital, Florence, Italy.
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18
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Kerenyi A, Kelen D, Faulkner SD, Bainbridge A, Chandrasekaran M, Cady EB, Golay X, Robertson NJ. Systemic effects of whole-body cooling to 35 °C, 33.5 °C, and 30 °C in a piglet model of perinatal asphyxia: implications for therapeutic hypothermia. Pediatr Res 2012; 71:573-82. [PMID: 22314664 PMCID: PMC4241373 DOI: 10.1038/pr.2012.8] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
INTRODUCTION The precise temperature for optimal neuroprotection in infants with neonatal encephalopathy is unclear. Our aim was to assess systemic effects of whole-body cooling to 35 °C, 33.5 °C, and 30 °C in a piglet model of perinatal asphyxia. METHODS Twenty-eight anesthetized male piglets aged <24 h underwent hypoxia-ischemia (HI) and were randomized to normothermia or cooling to rectal temperature (Trec) 35 °C, 33.5 °C, or 30 °C during 2-26 h after insult (n = 7 in each group). HR, MABP, and Trec were recorded continuously. RESULTS Five animals cooled to 30 °C had fatal cardiac arrests. During 30 °C cooling, heart rate (HR) was lower vs. normothermia (P < 0.001). Although mean arterial blood pressure (MABP) did not vary between groups, more fluid boluses were needed at 30 °C than at normothermia (P < 0.02); dopamine use was higher at 30 °C than at normothermia or 35 °C (P = 0.005 and P = 0.02, respectively). Base deficit was increased at 30 °C at 12, 24, and 36 h vs. all other groups (P < 0.05), pH was acidotic at 36 h vs. normothermia (P = 0.04), and blood glucose was higher for the 30 °C group at 12 h vs. the normothermia and 35 °C groups (P < 0.05). Potassium was lower at 12 h in the 30 °C group vs. the 33.5 °C and 35 °C groups. There was no difference in cortisol level between groups. DISCUSSION Cooling to 30 °C led to metabolic derangement and more cardiac arrests and deaths than cooling to 33.5 °C or 35 °C. Inadvertent overcooling should be avoided.
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Affiliation(s)
- Aron Kerenyi
- Institute for Women’s Health (AK, DK, SDF, MC, NJR), University College London, London WCIE 6AU, UK
| | - Dorottya Kelen
- Institute for Women’s Health (AK, DK, SDF, MC, NJR), University College London, London WCIE 6AU, UK
| | - Stuart D Faulkner
- Institute for Women’s Health (AK, DK, SDF, MC, NJR), University College London, London WCIE 6AU, UK
| | - Alan Bainbridge
- Medical Physics and Bio-engineering (AB, EBC), University College London, London WC1E 6DB, UK
| | | | - Ernest B Cady
- Medical Physics and Bio-engineering (AB, EBC), University College London, London WC1E 6DB, UK
| | - Xavier Golay
- Institute of Neurology (XG), University College London, London WC1N 3BG, UK
| | - Nicola J Robertson
- Institute for Women’s Health (AK, DK, SDF, MC, NJR), University College London, London WCIE 6AU, UK
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Choi KE, Hall CL, Sun JM, Wei L, Mohamad O, Dix TA, Yu SP. A novel stroke therapy of pharmacologically induced hypothermia after focal cerebral ischemia in mice. FASEB J 2012; 26:2799-810. [PMID: 22459147 DOI: 10.1096/fj.11-201822] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Compelling evidence from preclinical and clinical studies has shown that mild to moderate hypothermia is neuroprotective against ischemic stroke. Clinical applications of hypothermia therapy, however, have been hindered by current methods of physical cooling, which is generally inefficient and impractical in clinical situations. In this report, we demonstrate the potential of pharmacologically induced hypothermia (PIH) by the novel neurotensin receptor 1 (NTR1) agonist ABS-201 in a focal ischemic model of adult mice. ABS-201 (1.5-2.5 mg/kg, i.p.) reduces body and brain temperature by 2-5°C in 15-30 min in a dose-dependent manner without causing shivering or altering physiological parameters. Infarct volumes at 24 h after stroke are reduced by ∼30-40% when PIH therapy is initiated either immediately after stroke induction or after 30-60 min delay. ABS-201 treatment increases bcl-2 expression, decreases caspase-3 activation, and TUNEL-positive cells in the peri-infarct region, and suppresses autophagic cell death compared to stroke controls. The PIH therapy using ABS-201 improves recovery of sensorimotor function as tested 21 d after stroke. These results suggest that PIH induced by neurotensin analogs represented by ABS-201 are promising candidates for treatment of ischemic stroke and possibly for other ischemic or traumatic injuries.
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Affiliation(s)
- Ko-Eun Choi
- Department of Anesthesiology, Emory University School ofMedicine, Atlanta, Georgia 30322, USA
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20
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Mertens L, Seri I, Marek J, Arlettaz R, Barker P, McNamara P, Moon-Grady AJ, Coon PD, Noori S, Simpson J, Lai WW. Targeted Neonatal Echocardiography in the Neonatal Intensive Care Unit: practice guidelines and recommendations for training. Writing Group of the American Society of Echocardiography (ASE) in collaboration with the European Association of Echocardiography (EAE) and the Association for European Pediatric Cardiologists (AEPC). J Am Soc Echocardiogr 2012; 24:1057-78. [PMID: 21933743 DOI: 10.1016/j.echo.2011.07.014] [Citation(s) in RCA: 236] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Luc Mertens
- The Labatt Family Heart Center, The Hospital for Sick Children, Toronto, Ontario, Canada
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Chakkarapani E, Thoresen M, Liu X, Walloe L, Dingley J. Xenon offers stable haemodynamics independent of induced hypothermia after hypoxia-ischaemia in newborn pigs. Intensive Care Med 2011; 38:316-23. [PMID: 22160201 DOI: 10.1007/s00134-011-2442-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2011] [Accepted: 11/17/2011] [Indexed: 10/14/2022]
Abstract
PURPOSE To assess the effect of 18 hour (h) 50% xenon (Xe) inhalation at normothermia (NT, 38.5°C) or hypothermia (HT, 33.5°C) on mean arterial blood pressure (MABP), inotropic support and heart rate (HR) following an induced perinatal global hypoxic-ischaemic insult (HI) in newborn pigs. METHODS Newborn pigs ventilated under inhalational anaesthesia, following a 45 min HI (inhaled oxygen fraction reduced until amplitude integrated electroencephalogram was less than 7 μV), were randomised to three Xe (n = 45) (50% Xe 18 h with NT, HT 12 h or HT 24 h) or three non-Xe groups (n = 53) (0% Xe with NT, HT 12 h or HT 24 h) under otherwise identical conditions. We measured MABP and HR every minute. Hypotension (MABP <40 mmHg) was treated sequentially with 2 × 10 mL/kg saline, dopamine, norepinephrine and hydrocortisone if required. RESULTS Xe maintained higher MABP during HT (5.1 mmHg, 95% CI 2.34, 7.89), rewarming (10.1 mmHg, 95% CI 6.26, 13.95) and after cessation (4.1 mmHg, 95% CI 0.37, 7.84) independent of HT, inotropic support and acidosis. Xe reduced the duration of inotropic support by 12.6 h (95% CI 5.5, 19.73). Inotropic support decreased the HR reduction induced by HT from 9 to 5 bpm/°C during cooling and from 10-7 to 4-3 bpm/°C during rewarming. There was no interaction between Xe, HT, inotropic support and acidosis. Xe during HT cleared lactate faster; 3 h post-HI median (IQR) values of (Xe HT) 2.8 mmol/L (0.9, 3.1) vs. (HT) 5.9 mmol/L (2.5, 7.9), p = 0.0004. CONCLUSION Xe maintained stable blood pressure, thereby reducing the inotropic support requirements during and after administration independently of induced HT-current neonatal encephalopathy treatment. Xe may offer haemodynamic benefits in clinical neuroprotection studies.
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Affiliation(s)
- Elavazhagan Chakkarapani
- Department of Child Health, School of Clinical Sciences, St Michael's Hospital, Level D, University of Bristol, Southwell Street, BS2 8EG Bristol, UK
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Mulkey SB, Fontenot EE, Imamura M, Yap VL. Therapeutic Hypothermia in a Neonate with Perinatal Asphyxia and Transposition of the Great Arteries. Ther Hypothermia Temp Manag 2011; 1:205-8. [DOI: 10.1089/ther.2011.0016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Sarah B. Mulkey
- Section of Pediatric Neurology, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Eudice E. Fontenot
- Section of Cardiology, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Michiaki Imamura
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Vivien L. Yap
- Section of Neonatology, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
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23
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Mertens L, Seri I, Marek J, Arlettaz R, Barker P, McNamara P, Moon-Grady AJ, Coon PD, Noori S, Simpson J, Lai WW. Targeted Neonatal Echocardiography in the Neonatal Intensive Care Unit: Practice Guidelines and Recommendations for Training: Writing group of the American Society of Echocardiography (ASE) in collaboration with the European Association of Echocardiography (EAE) and the Association for European Pediatric Cardiologists (AEPC). EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2011; 12:715-36. [PMID: 21998460 DOI: 10.1093/ejechocard/jer181] [Citation(s) in RCA: 133] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Luc Mertens
- The Labatt Family Heart Center, The Hospital for Sick Children, Toronto, Ontario, Canada
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Blanco D, García-Alix A, Valverde E, Tenorio V, Vento M, Cabañas F. [Neuroprotection with hypothermia in the newborn with hypoxic-ischaemic encephalopathy. Standard guidelines for its clinical application]. An Pediatr (Barc) 2011; 75:341.e1-20. [PMID: 21925984 DOI: 10.1016/j.anpedi.2011.07.012] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Revised: 07/18/2011] [Accepted: 07/18/2011] [Indexed: 01/24/2023] Open
Abstract
Standardisation of hypothermia as a treatment for perinatal hypoxic-ischaemic encephalopathy is supported by current scientific evidence. The following document was prepared by the authors on request of the Spanish Society of Neonatology and is intended to be a guide for the proper implementation of this therapy. We discuss the difficulties that may arise when moving from the strict framework of clinical trials to clinical daily care: early recognition of clinical encephalopathy, inclusion and exclusion criteria, hypothermia during transport, type of hypothermia (selective head or systemic cooling) and side effects of therapy. The availability of hypothermia therapy has changed the prognosis of children with hypoxic-ischaemic encephalopathy and our choices of therapeutic support. In this sense, it is especially important to be aware of the changes in the predictive value of the neurological examination and the electroencephalographic recording in cooled infants. In order to improve neuroprotection with hypothermia we need earlier recognition of to recognise earlier the infants that may benefit from cooling. Biomarkers of brain injury could help us in the selection of these patients. Every single infant treated with hypothermia must be included in a follow up program in order to assess neurodevelopmental outcome.
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Affiliation(s)
- D Blanco
- Servicio de Neonatología, Hospital Universitario Gregorio Marañón, Madrid, España.
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Albers GW, Goldstein LB, Hess DC, Wechsler LR, Furie KL, Gorelick PB, Hurn P, Liebeskind DS, Nogueira RG, Saver JL. Stroke Treatment Academic Industry Roundtable (STAIR) Recommendations for Maximizing the Use of Intravenous Thrombolytics and Expanding Treatment Options With Intra-arterial and Neuroprotective Therapies. Stroke 2011; 42:2645-50. [DOI: 10.1161/strokeaha.111.618850] [Citation(s) in RCA: 156] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Gregory W. Albers
- From the Stanford Stroke Center (G.W.A.), Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA; Duke University Medical Center (L.B.G.), Durham, NC; the Medical College of Georgia (D.C.H.), Augusta, GA; the University of Pittsburgh Medical Center (L.R.W.), Pittsburgh, PA; Massachusetts General Hospital (K.L.F.), Boston, MA; the University of Illinois College of Medicine (P.B.G.), Chicago, IL; University of Texas System (P.H.), Austin, TX; UCLA Medical Center (D.S.L.,
| | - Larry B. Goldstein
- From the Stanford Stroke Center (G.W.A.), Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA; Duke University Medical Center (L.B.G.), Durham, NC; the Medical College of Georgia (D.C.H.), Augusta, GA; the University of Pittsburgh Medical Center (L.R.W.), Pittsburgh, PA; Massachusetts General Hospital (K.L.F.), Boston, MA; the University of Illinois College of Medicine (P.B.G.), Chicago, IL; University of Texas System (P.H.), Austin, TX; UCLA Medical Center (D.S.L.,
| | - David C. Hess
- From the Stanford Stroke Center (G.W.A.), Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA; Duke University Medical Center (L.B.G.), Durham, NC; the Medical College of Georgia (D.C.H.), Augusta, GA; the University of Pittsburgh Medical Center (L.R.W.), Pittsburgh, PA; Massachusetts General Hospital (K.L.F.), Boston, MA; the University of Illinois College of Medicine (P.B.G.), Chicago, IL; University of Texas System (P.H.), Austin, TX; UCLA Medical Center (D.S.L.,
| | - Lawrence R. Wechsler
- From the Stanford Stroke Center (G.W.A.), Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA; Duke University Medical Center (L.B.G.), Durham, NC; the Medical College of Georgia (D.C.H.), Augusta, GA; the University of Pittsburgh Medical Center (L.R.W.), Pittsburgh, PA; Massachusetts General Hospital (K.L.F.), Boston, MA; the University of Illinois College of Medicine (P.B.G.), Chicago, IL; University of Texas System (P.H.), Austin, TX; UCLA Medical Center (D.S.L.,
| | - Karen L. Furie
- From the Stanford Stroke Center (G.W.A.), Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA; Duke University Medical Center (L.B.G.), Durham, NC; the Medical College of Georgia (D.C.H.), Augusta, GA; the University of Pittsburgh Medical Center (L.R.W.), Pittsburgh, PA; Massachusetts General Hospital (K.L.F.), Boston, MA; the University of Illinois College of Medicine (P.B.G.), Chicago, IL; University of Texas System (P.H.), Austin, TX; UCLA Medical Center (D.S.L.,
| | - Philip B. Gorelick
- From the Stanford Stroke Center (G.W.A.), Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA; Duke University Medical Center (L.B.G.), Durham, NC; the Medical College of Georgia (D.C.H.), Augusta, GA; the University of Pittsburgh Medical Center (L.R.W.), Pittsburgh, PA; Massachusetts General Hospital (K.L.F.), Boston, MA; the University of Illinois College of Medicine (P.B.G.), Chicago, IL; University of Texas System (P.H.), Austin, TX; UCLA Medical Center (D.S.L.,
| | - Patty Hurn
- From the Stanford Stroke Center (G.W.A.), Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA; Duke University Medical Center (L.B.G.), Durham, NC; the Medical College of Georgia (D.C.H.), Augusta, GA; the University of Pittsburgh Medical Center (L.R.W.), Pittsburgh, PA; Massachusetts General Hospital (K.L.F.), Boston, MA; the University of Illinois College of Medicine (P.B.G.), Chicago, IL; University of Texas System (P.H.), Austin, TX; UCLA Medical Center (D.S.L.,
| | - David S. Liebeskind
- From the Stanford Stroke Center (G.W.A.), Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA; Duke University Medical Center (L.B.G.), Durham, NC; the Medical College of Georgia (D.C.H.), Augusta, GA; the University of Pittsburgh Medical Center (L.R.W.), Pittsburgh, PA; Massachusetts General Hospital (K.L.F.), Boston, MA; the University of Illinois College of Medicine (P.B.G.), Chicago, IL; University of Texas System (P.H.), Austin, TX; UCLA Medical Center (D.S.L.,
| | - Raul G. Nogueira
- From the Stanford Stroke Center (G.W.A.), Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA; Duke University Medical Center (L.B.G.), Durham, NC; the Medical College of Georgia (D.C.H.), Augusta, GA; the University of Pittsburgh Medical Center (L.R.W.), Pittsburgh, PA; Massachusetts General Hospital (K.L.F.), Boston, MA; the University of Illinois College of Medicine (P.B.G.), Chicago, IL; University of Texas System (P.H.), Austin, TX; UCLA Medical Center (D.S.L.,
| | - Jeffrey L. Saver
- From the Stanford Stroke Center (G.W.A.), Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA; Duke University Medical Center (L.B.G.), Durham, NC; the Medical College of Georgia (D.C.H.), Augusta, GA; the University of Pittsburgh Medical Center (L.R.W.), Pittsburgh, PA; Massachusetts General Hospital (K.L.F.), Boston, MA; the University of Illinois College of Medicine (P.B.G.), Chicago, IL; University of Texas System (P.H.), Austin, TX; UCLA Medical Center (D.S.L.,
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Faulkner S, Bainbridge A, Kato T, Chandrasekaran M, Kapetanakis AB, Hristova M, Liu M, Evans S, De Vita E, Kelen D, Sanders RD, Edwards AD, Maze M, Cady EB, Raivich G, Robertson NJ. Xenon augmented hypothermia reduces early lactate/N-acetylaspartate and cell death in perinatal asphyxia. Ann Neurol 2011; 70:133-50. [PMID: 21674582 DOI: 10.1002/ana.22387] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2010] [Revised: 12/03/2010] [Accepted: 01/19/2011] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Additional treatments for therapeutic hypothermia are required to maximize neuroprotection for perinatal asphyxial encephalopathy. We assessed neuroprotective effects of combining inhaled xenon with therapeutic hypothermia after transient cerebral hypoxia-ischemia in a piglet model of perinatal asphyxia using magnetic resonance spectroscopy (MRS) biomarkers supported by immunohistochemistry. METHODS Thirty-six newborn piglets were randomized (all groups n = 9), with intervention from 2 to 26 hours, to: (1) normothermia; (2) normothermia + 24 hours 50% inhaled xenon; (3) 24 hours hypothermia (33.5°C); or (4) 24 hours hypothermia (33.5°C) + 24 hours 50% inhaled xenon. Serial MRS was acquired before, during, and up to 48 hours after hypoxia-ischemia. RESULTS Mean arterial blood pressure was lower in all treatment groups compared with normothermia (p < 0.01) (although >40mmHg); the combined therapy group required more fluid boluses (p < 0.05) and inotropes (p < 0.001). Compared with no intervention, both hypothermia and xenon-augmented hypothermia reduced the temporal regression slope magnitudes for phosphorus-MRS inorganic phosphate/exchangeable phosphate pool (EPP) and phosphocreatine/EPP (both p < 0.05); for lactate/N-acetylaspartate (NAA), only xenon-augmented hypothermia reduced the slope (p < 0.01). Xenon-augmented hypothermia also reduced transferase-mediated deoxyuridine triphosphate nick-end labeling (TUNEL)(+) nuclei and caspase 3 immunoreactive cells in parasagittal cortex and putamen and increased microglial ramification in midtemporal cortex compared with the no treatment group (p < 0.05). Compared with hypothermia, however, combination treatment did not reach statistical significance for any measure. Lactate/NAA showed a strong positive correlation with TUNEL; nucleotide triphosphate/EPP showed a strong negative correlation with microglial ramification (both p < 0.01). INTERPRETATION Compared with no treatment, xenon-augmented hypothermia reduced cerebral MRS abnormalities and cell death markers in some brain regions. Compared with hypothermia, xenon-augmented hypothermia did not reach statistical significance for any measure. The safety and possible improved efficacy support phase II trials.
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Affiliation(s)
- Stuart Faulkner
- Institute for Women's Health, University College London, London, UK
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Zanelli S, Buck M, Fairchild K. Physiologic and pharmacologic considerations for hypothermia therapy in neonates. J Perinatol 2011; 31:377-86. [PMID: 21183927 PMCID: PMC3552186 DOI: 10.1038/jp.2010.146] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
With mounting evidence that hypothermia is neuroprotective in newborns with hypoxic-ischemic encephalopathy (HIE), an increasing number of centers are offering this therapy. Hypothermia is associated with a wide range of physiologic changes affecting every organ system, and awareness of these effects is essential for optimum patient management. Lowering the core temperature also alters pharmacokinetic and pharmacodynamic properties of medications commonly used in asphyxiated neonates, necessitating close attention to drug efficacy and side effects. Rewarming introduces additional risks and challenges as the hypothermia-associated physiologic and pharmacologic changes are reversed. In this review we provide an organ system-based assessment of physiologic changes associated with hypothermia. We also summarize evidence from randomized controlled trials showing lack of serious adverse effects of moderate hypothermia therapy in term and near-term newborns with moderate-to-severe HIE. Finally, we review the effects of hypothermia on drug metabolism and clearance based on studies in animal models and human adults, and limited data from neonates.
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Affiliation(s)
- S Zanelli
- Department of Pediatrics, University of Virginia, Charlottesville, USA.
| | - M Buck
- Department of Pediatrics, University of Virginia, Charlottesville, VA, USA,Department of Pharmacy, University of Virginia, Charlottesville, VA, USA
| | - K Fairchild
- Department of Pediatrics, University of Virginia, Charlottesville, VA, USA
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Abstract
Neonatal asphyxia is associated with multi-organ hypoxia-ischemia and subsequent dysfunction. The cardiovascular system is frequently affected, causing signs of shock and complicating the neonatal circulatory transition. Hypothermia therapy can improve outcome from neonatal asphyxia without adversely affecting cardiovascular stability. Therapy directed at the cardiovascular system can improve short-term measures of systemic blood flow, but to date has not been demonstrated to improve long-term outcome.
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Affiliation(s)
- Tina A Leone
- Department of Pediatrics, University of California, San Diego, CA 92103, USA.
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29
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Abstract
Cooling for neonatal hypoxic-ischemic encephalopathy is a novel and promising neuroprotective therapy that requires significant understanding of how cooling affects all organ systems and interventions used to treat systemic complications of cooling in an intensive care setting. As cooling is used more widely and has been newly introduced in neonatal units, continued surveillance of its use in clinical practice is mandatory. Units offering cooling should strongly consider joining a registry (e.g. the Vermont-Oxford Neonatal Encephalopathy Registry in the USA or the TOBY Register in the UK) that facilitates benchmarking of short-term adverse effects and long-term outcomes of cooling and that supports local quality improvement efforts.
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Affiliation(s)
- Subrata Sarkar
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, University of Michigan Health System, C.S. Mott Children's Hospital, Ann Arbor, Michigan 48109-0254, USA.
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30
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Therapeutic hypothermia for neonatal hypoxic ischaemic encephalopathy. Early Hum Dev 2010; 86:361-7. [PMID: 20570448 DOI: 10.1016/j.earlhumdev.2010.05.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2010] [Accepted: 05/07/2010] [Indexed: 01/17/2023]
Abstract
There is now a strong evidence base supporting therapeutic hypothermia for infants with moderate or severe neonatal hypoxic ischaemic encephalopathy. Experimental and clinical data indicate that induced hypothermia reduces cerebral hypoxic ischaemic injury and randomized clinical trials in newborns with hypoxic ischaemic encephalopathy confirm improved neurological outcomes and survival at 18 months of age with therapeutic hypothermia. Studies are on-going to confirm whether these benefits are maintained in later childhood. Efforts are now focused on optimal implementation of therapeutic hypothermia in clinical practice: training in the assessment of severity of encephalopathy; initiation and maintenance of hypothermia before admission to a cooling facility; care of the infant during cooling; and appropriate investigation and follow-up are crucial for optimizing neurological outcomes. The establishment of registries of infants with hypoxic ischaemic encephalopathy and audit are important for guiding clinical practice.
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Abstract
Neonatal brain injury is an important cause of death and disability, with pathways of oxidant stress, inflammation, and excitotoxicity that lead to damage that progresses over a long period of time. Therapies have classically targeted individual pathways during early phases of injury, but more recent therapies such as growth factors may also enhance cell proliferation, differentiation, and migration over time. More recent evidence suggests combined therapy may optimize repair, decreasing cell injury while increasing newly born cells.
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Affiliation(s)
| | - Donna M. Ferriero
- Department of Pediatrics; University of California, San Francisco (FFG, DMF)
- Department of Neurology; University of California, San Francisco (DMF)
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Abstract
Hypoxic ischemic encephalopathy is a serious condition affecting infants which can result in death and disability. This is a summary of pathogenesis of HIE, animal studies of cooling for hypoxic and ischemic models, human hypothermia trials, and the American Academy of Pediatrics publication on hypothermia for HIE. Hypothermia for neonatal HIE is continuing to evolve as a therapy. Studies, gaps in knowledge and opportunities for research are presented herein.
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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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