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Filchak Symposium 1.pdf
- 1. Sarah Filchak, MSNCPNP-PC November 3, 2017
- 2. Review theresuscitation and NICU admission/stay of Baby Girl M Discuss criteria for therapeutic hypothermia Review hypoxic-ischemic encephalopathy (HIE) Discuss goals of treatment for infants with HIE
- 3. Maternal history ◦Evaluated in triage x 2 on 5/21 for bleeding but discharged home undelivered ◦ Seen in OB office on 5/22 for routine visit decreased heart tones ◦ Admitted to MHSB ◦ C-section for non-reassuring fetal status ◦ 23 minutes from arrival to OB floor to delivery of infant
- 4. C-section fornon-reassuring fetal status Complete abruption Apgars 1 – 2- 5 ◦ Occasional gasps at delivery ◦ Initial heart rate ~20 ◦ Given PPV to improve heart rate but gasping respirations continue ◦ Intubated at 7 minutes of age ◦ At 10 minutes of age was having more spontaneous respirations but apgar score was 5 so passive cooling initiated
- 5. Occurs inapproximately 1.5/1000 live births
- 8. Neuroprotective Currenttreatment of choice to reduce brain injury and improve long-term outcomes for neonates with HIE
- 9. Current criteriafor cooling does not capture all infants with brain injury Close and repetitive clinical assessment required
- 10. ◦ Fetal bradycardia ◦Complete placental abruption ◦ Cord pH of 6.54 and base deficit of -25 ◦ Apgar of 5 at 10 minutes of age ◦ Required intubation in delivery room
- 11. Passive coolingcontinues CPAP per ETT Placement of umbilical venous catheter VBG: pH 7.13 and base deficit -20 Started on aEEG Clinical presentation Total body cooling began at ~90 minutes of age
- 12. Respiratory management ◦Attempt to maintain normal blood gas values Circulatory ◦ Decreased cardiac output ◦ Maintain arterial blood pressure 40-60 mmHg Fluid/Electrolyte/Nutrition ◦ Fluid restriction ◦ Monitor electrolytes every 8-12 hr ◦ Glucose ◦ Delayed feedings Renal ◦ Follow serum creatinine rather than urinary output
- 13. Hematologic ◦ Increasein nucleated RBCs ◦ Prolonged coagulation/DIC ◦ Low platelet counts Infection Control Stress/Pain management ◦ Provide optimal sedation and analgesia during cooling Skin ◦ Skin lesions ◦ Subcutanous fat necrosis
- 14. Treat seizures ◦aEEG ◦ Phenobarbital is first line of treatment ◦ Can be difficult to treat ◦ May need to consult neurology Neuroimaging ◦ MRI Educate/support family
- 15. Continuous patternon aEEG at 4 hours of age Metabolic acidosis normalized Day 1: mild abnormalities in liver functions, good renal function and extubated Day 2: improved liver functions, off CPAP Day 3: sleep-wake cycling on aEEG Day 4: rewarmed Day 10: MRI and discharge to home
- 16. Ahearne, C.,Boylan, G., & Murray, D. Short and long term prognosis in perinatal asphyxia: an update. (2013) World Journal of Clinical Pediatrics 5 (1), 67-74. Natarajan, G., et al. (2013). Apgar scores at 10 minutes and outcomes at 6-7 years following hypoxic-ischaemic encephalopathy. Archives of Disease in Childhood: Fetal and Neonatal edition 98(6), F473-479. Pappas, A., et al. (2014). Cognitive outcomes after neonatal encephalopathy. Pediatrics 135 3), e624-634.
- 17. Robertson, C.& Perlman, M. (2006). Follow-up of the term infant after hypoxic-ischemic encephalopathy. Paediatrics & Child Health 11 (5), 278-282. Shankaran, S., et al. (2012). Childhood outcomes after hypothermia for neonatal encephalopathy. New England Journal of Medicine 366 (22), 2085- 2092. van Laerhoven, H., de Haan, T., Offringa, M., Post, B., & van der Lee, J. (2013). Pediatrics 131 (1), 88-98. Verklan, M.T., & Walden, M. (2010). Core curriculum for Neonatal Intensive Care Nursing (4th ed). St. Louis: Saunders.