Asphyxiated Neonates Treated with Hypothermia: Birth Place Matters

Abstract

Objective This study aimed to assess whether the hospital level of care where asphyxiated neonates treated with hypothermia were originally born influences their outcome. Study Design We conducted a retrospective cohort study of all asphyxiated neonates treated with hypothermia in a large metropolitan area. Birth hospitals were categorized based on provincially predefined levels of care. Primary outcome was defined as death and/or brain injury on brain magnetic resonance imaging (adverse outcome) and was compared according to the hospital level of care. Results The overall incidence of asphyxiated neonates treated with hypothermia significantly decreased as hospital level of care increased: 1 per 1,000 live births (109/114,627) in level I units; 0.9 per 1,000 live births (73/84,890) in level II units; and 0.7 per 1,000 live births (51/71,093) in level III units (p < 0.001). The rate of emergent cesarean sections and the initial pH within the first hour of life were significantly lower in level I and level II units compared with level III units (respectively, p < 0.001 and p = 0.002). In a multivariable analysis adjusting for the rates of emergent cesarean sections and initial pH within the first hour of life, being born in level I units was confirmed as an independent predictor of adverse outcome (adjusted odds ratio [OR] level I vs. level III 95% confidence interval [CI]: 2.13 [1.02–4.43], p = 0.04) and brain injury (adjusted OR level I vs. level III 95% CI: 2.41 [1.12–5.22], p = 0.02). Conclusion Asphyxiated neonates born in level I units and transferred for hypothermia treatment were less often born by emergent cesarean sections, had worse pH values within the first hour of life, and had a higher incidence of adverse outcome and brain injury compared with neonates born in level III units. Further work is needed to optimize the initial management of these neonates to improve outcomes, regardless of the location of their hospital of birth. Key Points

Hipotermia terapéutica para tratamiento de encefalopatía hipóxico-isquémica del recién nacido asfixiado: Características clínicas, radiológicas y electrográficas de los neonatos atendidos en el Instituto Nacional Materno Perinatal

“…Este resultado puede deberse a que, a diferencia de nuestra población, los pacientes de dicha serie son en su mayoría referidos en otros centros y/o partos domiciliarios (69 %), la frecuencia de eventos centinela es de apenas 8 %, lo que se traduce que en pocos casos se conoce el momento exacto de ocurrencia de la injuria hipóxico-isquémica. En esta serie la mayoría de los nacimientos ocurrieron fuera del hospital donde se aplicó la HT, esto puede llevar a grandes diferencias en el manejo prehospitalario de los bebés [19] . Si buscamos el perfil del paciente atendido en nuestro centro con el mejor resultado, encontramos que se trata del bebé nacido en nuestra institución, con un antecedente de evento centinela identificado, que clínicamente sólo expresa compromiso neurológico moderado, sin compromiso de otros órganos y sistemas, y que logra ingresar a hipotermia en las tres primeras horas de vida.…”