While Waiting

Abstract

Hypoxic-ischemic encephalopathy (HIE) occurring during the perinatal period is one of the primary causes of severe, long-term neurological deficits in children. Initial systemic supportive therapy remains a critical aspect of HIE management. In addition to support therapy, the widespread use of hypothermia has demonstrated a reduction in death and neurodevelopmental disability in infants with moderate to severe HIE. Neonates with HIE born outside of tertiary care centers must be rapidly identified as hypothermia candidates and have emergent transport arranged. While waiting for the transport team to arrive, these neonates often require intensive stabilization, including meticulous temperature management. This article examines the need for HIE outreach teaching programs, assists in the identification of a neonate for hypothermia therapy, and supplies evidence-based recommendations for the initial stabilization and care of neonates delivered at nontertiary care facilities. The guidelines and materials supplied represent the outreach model used by our regional hypothermia center and disseminated to the surrounding referral hospitals.

Incidence of encephalopathy and comorbidity in infants with perinatal asphyxia: a comparative prospective cohort study

“…Identifying the newborn with HIE and establishing the severity of this is crucial to controlling comorbid factors during the first hours of life, in order to delineate management strategies, including TH, but also to plan the services involved in long-term follow-up. In fact, early identification of neonates with moderate or severe HIE is one of the strategies to optimize early initiation of HT and maximize its neuroprotective effect, improving outcomes ( 2 , 5 , 6 , 38 , 39 ). There are many studies that have analyzed the relationship between perinatal acidosis and neonatal encephalopathy, as well as other clinical morbidities and long-term adverse outcomes.…”

“…Since the introduction of TH as the standard of treatment for moderate or severe HIE has narrowed the time frame for establishing the diagnosis, these golden hours are crucial to initiate the hypothermia code that includes stabilization and close monitoring that includes gas analysis, surveillance of comorbid factors such as temperature, glucose, cardiovascular and respiratory function, and obviously determination of the presence and severity of HIE in order to start TH ( 33 , 39 , 49 , 50 ). Due to the need to diagnose and establish the severity of HIE and monitor the associated multiorgan dysfunction, we agree with other authors that recommend close monitoring of infants with severe acidemia who appear clinically well immediately after delivery for up to 24 h, ideally with concomitant aEEG ( 51 ).…”

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

“…6,25 Unfortunately, most of our regional referral centers have neither rectal temperature monitoring experience nor resource capabilities. Sussman and Weiss 19 recommended that centers not accustomed to caring for critically ill newborns consider maintaining the axillary temperature between 33.5 °C and 35 °C as an alternative to avoid unnecessary injury from incorrect techniques. Faced with this limitation within our region and aware of the need to consider adapting to meet the ongoing challenge of highly variable community resources, 1 we created a passive cooling guideline ( see Appendix 1, Supplemental Digital Content 1, http://links.lww.com/PQ9/A373).…”

“…2 ). Given the majority of our regional referral centers do not have continuous rectal temperature monitoring experience or capabilities, we also created a passive hypothermia guideline with an adaptation, as per Sussman and Weiss, 19 allowing for axillary temperature monitoring pending arrival of the TT. This guideline is faxed (or emailed) to the regional referral center as a support reference to promote safe and effective early initiation of TH using passive cooling when advised by a neonatologist ( see Appendix 1, Supplemental Digital Content 1, http://links.lww.com/PQ9/A373 ).…”

“…We acknowledge the following limitations: this study is a QI initiative in a single-center institution without formal evaluation of the different modes of cooling during transport, specifically given standardized recommendations and studies that already exist in this domain. [7][8][9][10]12,17,19 Although we collected developmental outcome data on all our TH patients, we did not link cases to developmental outcomes for this study. The earlier neonates eligible for TH have passive cooling safely initiated, the lower the risk of missing an opportunity to reach better outcomes.…”