Earlier Initiation of Therapeutic Hypothermia by Non-Tertiary Neonatal Units in Victoria, Australia

Abstract

Background: Therapeutic hypothermia is an effective treatment for moderate or severe hypoxic-ischaemic encephalopathy (HIE), with maximal neuroprotective benefit when initiated soon after birth.Early initiation of therapeutic hypothermia in infants with HIE born in geographically distant settings is challenging. Objective: To audit temperature control in infants with HIE treated with hypothermia during neonatal transport in Victoria, Australia. Methods: A retrospective database review from September 1, 2008 to August 31, 2012 compared temperatures of transported outborn infants with HIE treated with hypothermia initiated by the referring non-tertiary neonatal unit, with hypothermia initiated by the transport team. Results: 123 infants received therapeutic hypothermia during the study period. Hypothermia treatment commenced significantly earlier [median (interquartile range [IQR]) 1.1 h (0.6-1.7) vs. 3.3 h (2.1-4.5); p < 0.01] with the target temperature (33-34°C) achieved sooner [median (IQR) 3.4 h (2.4-4.6) vs. 4.5 h (3.6-5.5)] when initiated by the referring hospital (n = 71) than by the transport team (n = 52). There was no statistically significant difference in achieving the target temperature before admission to the tertiary neonatal intensive care unit when hypothermia was initiated by the referring unit, compared with by the transport team [51/71 (71.8%) vs. 28/52 (53.9%), odds ratio (95% CI) 2.19 (0.96, 4.96)]. Infants in whom hypothermia was initiated by the referring hospital were more likely to have a recorded temperature below 33°C [22/71 (31.0%) vs. 4/52 (7.7%), odds ratio (95% CI) 5.39 (1.64, 22.83)]. Conclusions: The target temperature is achieved sooner in infants with moderate or severe HIE when therapeutic hypothermia is initiated by referring non-tertiary neonatal units under guidance from the regional transport service. This practice may enhance neuroprotection for infants with HIE born in non-tertiary units, particularly in remote locations.

Therapeutic Hypothermia on Transport: The Quest for Efficiency: Results of a Quality Improvement Project

“…Initiating passive cooling at referral centers before the transfer is essential to achieve target core temperature faster. 15 , 16 , 23 …”

“…2 Delays identified were found to be the cumulative result of varying regional hospital clinical expertise and resources, a limited ability to monitor rectal or esophageal temperatures appropriately, 4,6 distances involved, and our neonatologists perceived risk of overcooling. Roberts et al 23 describe similar clinical care challenges in Australia based on vast geography and referral hospital capabilities. Initiating passive cooling at referral centers before the transfer is essential to achieve target core temperature faster.…”

“…Initiating passive cooling at referral centers before the transfer is essential to achieve target core temperature faster. 15,16,23 Although correlated, axillary temperatures in newborns do not accurately reflect rectal or core temperatures based on systematic reviews, 24 precluding the use of axillary monitoring as a proxy for rectal temperature measurement in TH protocols. 6,25 Unfortunately, most of our regional referral centers have neither rectal temperature monitoring experience nor resource capabilities.…”

Cooling strategies during neonatal transport for hypoxic‐ischaemic encephalopathy

“…While outcomes may be influenced by local neonatal transport resources, several studies demonstrated that education and training can improve neonatal outcomes. 49,50 Bellini et al 51 suggested that an experienced transport team can successfully start passive cooling before admission to a referral centre. In contrast, Reaney et al 52 stated that passive cooling does not consistently achieve adequate control of body temperature for outborn infants.…”

Impact of Education on Hypothermia Delivery during Neonatal Transport

“…Passive cooling, by removing external heat sources, or active cooling using cool packs have been shown to effectively reduce infants’ core temperature [11-14]. Continuous rectal temperature monitoring and adherence to a strict cooling guideline are recommended for the safe administration of TH without a servo-controlled cooling device.…”