Hypothermia for neonates, india , ppt - Dr Karthik Nagesh

5. ACCUMULATION OF K,
EXCITATORY A A, e.g.-
GLUTAMATE
DELAYED NEURONAL
DEATH(NMDA Channel)
CELL NECROSIS
APOPTOSIS
ACTIVATION OF
LIPASES,
CYTOKINES
FREE RADICALS –
O, OH-
, HO,
SUPEROXIDE
REPERFUSION
HYPOXIC ISCHEMIC BRAIN INJURY
PATHOPHYSIOLOGY
HYPOXIA
ATP  GLUCOSE
DELIVERY
ISCHEMIA
FAILURE OF ION
PUMPS
(Na, K, ATPase)
INTRACELLULAR
ACCUMULATION OF
Na,Ca,Mg,Cl.
+
IMMEDIATE
NEUORONAL DEATH
ANAEROBIC
GLYCOSIS
LACTIC ACIDOSIS
 ACIDOSIS

8. Perinatal Insults
Decreased ATP
Failure of ATP dependent Na-
K Channel
Membrane depolarisation
Increased Glutamate
Increased Calcium
Cell Death
Late Apotosis>necrosis
Increased
Na Infux
Cell swelling
Early Cellular
Necrosis
Cooling……….
What we know?

9. Hypoxic Ischaemic Encephalopathy
Intervene within 6 hours of
Insult
For better Outcome.
Transient recovery(Reperfusion)
Secondary energy failure Hours-days(6-72hours)
INSULT(Perinatal Events)
Primary Energy failure Within minutes(<6hours)
THERAPEU
TIC
WINDOW
Immediate
Necrotic
death
Delayed
Apototic
cell death
COOLING COOLING
Cool before secondary
Brain Injury Occurs

10. 38°C
37°C
36°C
35°C
34°C
33°C
32°C
31°C
30°C
Brain Injury
Brain Protection
Australian Trial
NICHD Trial
Whole body cooling is better
than selective head cooling
Jacob et al. Cochrane review, 2007
Davidovich et al. , 2012
Grade A

11. NNT = 6 (95% CI, 3 to 22) for HT therapy to prevent one death
or severe disability
Shankaran S, et al. NEJM 2005; 353:1574-84.

19. Strictly adhere to the temperature of
33.5c during the maintainence phase

20. • Metabolic
Increase in oxygen consumption; elevated levels
catecholamines; hypoglycaemia
• Cardiovascular
Arrhythmias; decreased left ventricular output;
increased pulmonary vascular resistance
• Hematological
Hyperviscosity; platelet dysfunction
Adverse Effects of Hypothermia

21. What needs to be monitored How frequently
Blood sugar 2,6,12,24,28, 72hrly
2, 6, 12, 24, then every 8hrly
Unit protocol
PCV 24hrly first few days
Serum Sodium, potassium, calcium 24hrly first few days
Urea, creatinine As required, one baseline on day2-3
Liver/Cardiac enzymes HIE injury, once

22. What needs to be monitored How frequently
ECG HR<100/min
PT, APTT 24hrly for 3days-24, 48, 72hrs
Blood gas 8-12hrly on day 1
Once a day for next 2days
Blood counts Once a day for 3 days or
At least One baseline, repeat if
bleeding +
Glucose, RFT, LFT As mentioned above

23. Respiratory Indications for ventilation- frequent apnea, PaCO2>50mm Hg,
Hypoventilation secondary to anticonvulsants, meconium aspiration
syndrome/pulmonary hypertension
Maintain PaCO2 35-45 mmHg
Blood
Pressure
Maintain mean arterial pressure >40mm Hg in term infants
Cautious use of volume expansion (10m/kg colloid)
Use dopamine (2-5 microg/kg./min) dobutamine (5-15 microg/kg/min) if no
response within 30 minutes
Fluids and
electroly
tes
Restrict to 20% less than maintenance for first 48 hours (anticipating SIADH or renal
failure)
Aim for neutral fluid balance (i.e. replacement of losses)
Mannitol (1g/Kg can be used if clinical signs of raised intracranial pressure (renally
excreted)
Treat hypocalcemia if Ca < 1.7 mmol
Seizures Treat if frequent (> 1 per hour), prolonged (I or more minutes), or interfering with
respiration or ventilation
Glucose Treat hypoglycemia (<40 mg %) and maintain glucose levels between 70 to 100 mg %.

24. Infection Blood cultures, consider lumbar puncture
Antibiotics if clinically indicated
Hematology Check clotting ,give parenteral vitamin K
Treat DIC with plasma, clotting factors, platelet transfusions, as necessary
Nutrition Observe for Necrotizing Enterocolitis ,Aspirate gastric contents
Caution and patience with enteral feeds
Temperature If pyrexial (>37
0
C) lower environmental temperature, use antipyretics
Maintain environmental temperature in thermo neutral range.
No indications
for
Hyperventilation
Corticosteroids
Prophylactic anticonvulsants

28. There is a wide gap
in the efficacy and
the outcome

31. Cool cap

32. FEATURES BLANKETROL TECOTHERM
MANUAL
COOL CAP TECOTHERM
SERVO
CRITIC-COOL
DESIGN MATTRESS
AND WRAPS
MATTRESS CAP MATTRESS COOLING
WRAP
COOLANT WATER ALCOHOL WATER ALCOHOL WATER
SITE OF
temp
MONTORING
ESOPHAGEAL RECTAL RECTAL RECTAL RECTAL
NURSING
INPUT
LOW HIGH HIGH LOW LOW
ECT LOW LOW LOW HIGH HIGH
RECURRENT
EXPENSES
COOLING
WRAPS
NIL COOLING
CAP
COOLINNG
MATRESS
COOLING
WRAP
N.J. Robertson et al. / Seminars in Fetal & Neonatal Medicine (2010)

35. Whole body cooling in term infants with perinatal asphyxia is achievable, safe and inexpensive in a low-resource se
Thomas N, Ind Pediatr,2011, Grade C

37. FEATURES NATURAL
COOLING
WATER
BOTTLES
FANS GELS PCM**
DESIGN WITHOUT
WARMER
BOTTLES
FILLED WITH
TAP WATER
SERVO
CONTROLLE
D FAN
SOFT COLD
GEL KEPT AT
THE HEAD(7-
10c)
NAKED BABY
LAID ON PCM
MAINTAINEN
CE
LASTS UPTO
15hours
CORE/RECT
t-33-34
RECTAL t
33-34
RECTA t
33-34
RECTAL t
33-34
AMBIENT
TEMPERAT
URE
<26 25-26 24 24 <30
SHIVERING NO NO YES YES NO
TEMPERAT
URE
STABILITY
POOR ACCEPTABLE ACCEPTABLE VARIABLE ACCEPTABLE*
N.J. Robertson et al. / Seminars in Fetal & Neonatal Medicine (2010)

40. Whole Body Cooling…Manipal Hospital,Blore
Criticool
Whole Body Cooling…Bijapur District
Some Tertiary Care Centres have Adapted
High Cost Devices
CFM-aEEG

44. STUDIES TYPE OF
STUDY
SAMPLE
SIZE
TYPE OF
COOLING
DEVICE
USED
MORTALITY
Thomas et
al,2011
CASE SERIES 20H WHOLE
BODY
FROZEN GEL
PACK
5
Bhatt et
al,2006
RCT 35 WBC NO
DESCRIPTIO
N
15
Rajhans et
al,2012
CASE SERIES 5 WBC BLANKETER
OL-II
NO REPORT
Bharadwaj et
al,2012
RCT 124(62H,62S) WBC GEL PACKS 4.8/9.7
Thayill et al,
2013
RCT 33(17H,16S) WBC PCM 23.5 /12.5
Joy et al,2013 RCT 116(58H. 58S) WBC GEL PACKS 1.7/6.9
Gane et
al,2014
RCT 120(60H,60S) WBC GEL PACKS 8/16

46. Arch Dis Child Fetal Neonatal Ed
2014;99:A74 doi:10.1136/archdischild-2014-
306576.211
SS Pauliah, E Narayanan, K Kumutha, M
Vijaykumar, M Nair, S Shankaran, S Thayyil
+