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Mira cradle TH guide
- 1. Mira cradle applications Dr. SACHIN SAKHARKAR Surya hospital NICU 7/29/2022
- 2. Objectives • Therapeutic hypothermia (TH) • Selection criteria for TH • Contraindication • Monitoring of the infant • Systemic care of patients during TH • Mira Cradle • Re-warming • TH prior to and during transport 7/29/2022
- 3. Introduction • Neonatal hypoxic encephalopathy is a neurological emergency • Peripartum asphyxia affects 3 to 5 newborns per 1000 live births with subsequent hypoxic ischemic encephalopathy (HIE) in 0.5 to 1 per 1000 live births (Levene 1986) • N Gunn (1997): 60% LTND if: HIE Seizures
- 4. • Biphasic nature of cell death Gluckman PD, et al 1992 • Primary neuronal death (cell hypoxia/primary energy failure) • Latent period – 6 hours • Secondary phase – delayed neuronal death begins
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- 9. History • 1803 “Russian Method of Resuscitation” consisted of burying the victim of a cardiac arrest in snow hoping for ROSC 7/29/2022
- 10. • James Miller and Bjorn Westin in the 1950s developed a scientific rationale for the use of hypothermia in "asphyxia neonatorum” in first case series • In 1959, Benson et al, case series of 19 patient post cardiac arrest
- 11. • Animal Studies • Preservation of architecture in cortex of cooled fetal sheep (Gunn et al J of ClinInv 1997) • Control Cooled
- 12. • Mariane Thorensen - Intrigued by stories of children who fell through Norwegian ice and suffered prolonged drowning in iced water emerged with preserved cerebral function
- 13. • Infants ≥ 36 weeks gestational age with moderate to severe neonatal encephalopathy • Intervention- Brain cooling vs conventional treatment • Outcome: Death Neurodevelopmental disability Combined outcome
- 14. • TH is defined as moderate hypothermia when where the core body temperature measured by esophageal or rectal probe is cooled down to 33.0–35°C for 72 h followed by slow re-warming (0.2–0.5°C/h)
- 16. Total body hypothermia for neonatal encephalopathy TOBY-n= 325 • Cooled to 33C - 34C for 72 hours or usual care. • Primary outcome: death or severe neurodevelopmental disability at 18 months occurred in 53% of the usual care group and 45% of the cooled group ([RR] 0.86 [0.68–1.07], P = .17). • Predefined secondary outcomes: survival without disabilities significantly higher in the cooled vs. the usual care group. The rate of CP was low, improved mental and psychomotor indices were noted in the cooled vs. the usual care group (P<.05) 7/29/2022
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- 23. Inclusion Criteria Infant > 36 weeks gestation and least one • Apgar score of ≤5 at 10 minutes • Continued need for assisted ventilation at 10 mins • Acidosis (umbilical cord ph or arterial ph <7.00) • Base deficit ≥16 mmol/L • Moderate to severe encephalopathy with or without seizures or the presence of one or more signs in 3 of 6 categories on the chart (modified Sarnat score)
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- 26. Exclusion Criteria for Therapeutic Hypothermia: • Severe IUGR <1750grams • Severe congenital anomalies/genetic syndromes/ metabolic disorders • Major intracranial hemorrhage • Overwhelming sepsis • Uncorrectable, clinically relevant coagulopathy 7/29/2022
- 28. MIRA CRADLE
- 29. • It has been developed in collaboration with CMC, Vellore • Components Cradle Phase change material Conduction mattress • Associated equipments 7/29/2022
- 30. • Cradle Exoskeleton of the device Provides insulation to the PCM mattress from ambient temperature 7/29/2022
- 31. • Phase Change Materials (PCMs) are special thermal energy storage materials • It uses chemical bonds to store and release heat • Properties- Consistency Constant Temperature High Latent heat energy storage capacity • Two PCMs FS21 FS29
- 33. FS29 • Nominal freezing and melting temperature of 29° c • It retains its form and shape • Six units are provided • Charging time 8-10 hours when stored in bottom part of the refrigerator
- 34. 7/29/2022 • Used in maintaining and sustaining hypothermia • Three units to be used • Not required to be replaced during 72 hours process • Other three units should be kept on standby
- 35. FS21 • Nominal freezing and melting temperature of 21°c • It retains its form and shape • Two units are provided • Charging time 6-8 hours when stored in bottom part of the refrigerator
- 36. • Used in conjunction with FS29 • Used to induce hypothermia • Used to control temperature ( when newborn temperature starts drifting above 33.8 c)
- 37. Conduction mattress • Gel based, wt-1.2kg • Enhances heat transfer • Provides smooth surface for newborn to lie • Store- room temperature • Flat and uniform before use
- 38. Use Before use • Clean components with hospital approved disinfectant • Remove cloth bag and ensure PCMs are hard and rigid • Ensure that PCMs and conduction mattress are not leaking • Ensure the temperature of FS29
- 39. Checking FS29 • Should feel hard and rigid • Temperature indicator • Three units to be placed at the bottom 7/29/2022
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- 42. Preparing associated equipments • Thin clean bed shit • Warmer- switch of the warmer and later to be used in manual mode • Rectal probe- insert 3-5cm within the rectum to monitor core temperature • Multiparameter- set temperature alarm limits of 33.2- 33.8 c • NICU temperature 24-30 C
- 46. Re-warming phase • Target re-warming rate -0.2°C/hour • Target re-warming temperature- 36.5°C • During re-warming phase, do not remove infant from Mira cradle • Use warmer in manual mode only
- 47. Steps • Cover newborn with sheet • Turn on warmer with 10-30% output • Record temperature every hour • If rate is higher- switch of the warmer • Once the temperature is 36.5°C remove infant from Mira cradle • Monitor temperature for next 8 hours
- 48. Monitoring Heart rate Hourly Respiratory rate Hourly Blood pressure Hourly Spo2 Hourly Rectal temperature Skin temperature Continuous Urine output 6 hourly Skin redness/breaks 4 hourly
- 49. Respiratory management • Hypocarbia and hyperoxia have shown to increase neuronal injury in asphyxiated newborns • Thoresen et al. suggest to aim for PaCO2 levels of 41–50 mmHg • Effects of whole body hypothermia on lung mechanics • hypothermia causes a leftward shift in the hemoglobin- oxygen dissociation curve
- 50. Circulatory management • Effects of TH on heart are bradycardia and decreased cardiac output • Sinus bradycardia -slower activity of atrial pacemaker and intracardiac conduction • Cardioprotective effect 7/29/2022
- 51. • Effect of TH on mesenteric circulation is unclear • Enteral nutrition is generally delayed until rewarming • HIE itself cause renal failure or SIADH resulting in oligo-anuria which may necessitate fluid restriction to avoid volume overload and brain edema • TH may be associated with “cold diuresis” in the adult
- 52. Hematological aspects • TH is also known to cause platelet dysfunction, and thrombocytopenia and Electrolyte monitoring • Dilutional hyponatremia • Intracellular potassium shift Glucose management • Hyperglycemia due to stress hormones followed by • Hypoglycemia due to depleted liver glycogen
- 53. Subcutaneous fat necrosis • TH has association with SCFN • Self-limited condition • SCFN usually appears within 1st week of life, hypercalcemia may even occur months later • May cause refractory hypercalcemia sometimes resulting in nephrocalcinosis
- 54. Drug metabolism • TH causes delayed metabolism of drugs - phenobarbital, morphine, and vecuronium • Gentamicin metabolism has been studied during TH and 36 h dosing interval has been found to result in acceptable trough levels with desired efficacy
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- 56. Stop cooling before 72 hours if • Persistent hypoxemia with 100% Fio2 • Life threatening coagulopathy • Arrhythmia requiring medical treatment • Decision on withdrawal of care 7/29/2022
- 57. Maintenance Storage • Store in refrigerator • Charge for 8-10 hours • Do not fold/bend/distort • Store on flat surface • Do not stack one above other • When not in use, should be kept in cloth bag provided
- 58. Periodic calibration check • Once a month, cross check indicator temperature manually • Temperature difference of 1C is acceptable • If difference is >1c, then contact company for replacement 7/29/2022
- 59. Periodic replacement • To be replaced 3 years from 1st use or when found damaged 7/29/2022
- 60. Cooling during transport • passive cooling allows safe controlled cooling to begin prior to the arrival of the baby in the cooling centre 7/29/2022
- 61. 7/29/2022
- 63. Thank you
Editor's Notes
- After a latent period of at least six hours, the secondary phase of ’delayed neuronal death’ begins (Williams 1991).
- Perinatal acidemia itself has been found to be associated with abnormal outcome in 20% of the otherwise mild HIE appearing newborns. [16] Profound postnatal acidosis (pH < 7.00) within 1st h afte birth has also been found to be predictive of bad outcome and early indication for potential TH.
- sinus bradycardia secondary to the slower activity of atrial pacemaker and intracardiac conduction. Biomarkers such as cardiac troponin I, CPK‑myocardium bound (CPK‑MB), B type natriuretic peptide (BNP)[38] are additional parameters that can be followed during the course of treatment. Both troponin and CPK‑MB increase in HIE depending on the extent of injury to the heart and then decrease gradually. TH has been shown to prevent the excessive increase in troponin which can be interpreted as
- 1.Azzopardi suggests feeding cautiously after 24 h even during TH. 2. It is most likely due to nonosmotic suppression of vasopressin during cold exposure.