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Hypoxic Ischemic Encephalopathy
The document presents a case of a 14-day-old male neonate with severe hypoxic-ischemic encephalopathy (HIE) requiring intensive care due to respiratory distress and convulsions. It outlines the definition, causes, prevalence, diagnosis, and treatment options for HIE, along with a detailed medical history and treatment plan for the patient during his NICU stay. The treatment involved mechanical ventilation, various medications, and monitoring for complications, with a focus on addressing seizures and lung infections.
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Hypoxic Ischemic Encephalopathy
- 1. NEONATAL HYPOXIC ISCHEMIC ENCEPHALOPATHY Case presentationof Neonate ICU rotation Presented by : Walaa Fahad Aljuaid . Supervised by : Dr.Daniah Rifqi
- 2. OUTLINES : • Historyof the case • What is the HIE : • Definition • Causes • Incidence and Prevalence • Diagnosis • Complication • Treatment • Intervention
- 3. The Case : M.Ais 14 days old male came to NICU from another hospital very sick , severe HIE , Respiratory distress He was presented there ( another hospital ) with : failure to thrive , hypotonic , flacid , Apgar score was 1 , he was on the mechanical ventilator as a case of sever HIE stage 3 , the baby developed convulsion on the first day controlled on phenobarbitone , hypertension controlled with Lasix and Captopril
- 4. HISTORY OF PRESENTILLNESS: • Medical history : FTT , SVD , Prolonged Labore , HIE , CHD . Broncholitis • Family history : Mother has one abortion in the past . • Allergy : +ve consanguinity • Medication history : Captoril ,Phenoparbetone , Lasix
- 5. REVIEW OF SYSTEMS: • Head and nick : normal • Eyes : restricted pinpoint • Nose : normal • CVS : S1 + S2 , HTN • Chest : RD , low air entry . • Abdomen : Soft , no organomegally . • Spine and Genitalia : normal • Hips : normal • CNS : AF at level , Tone : hyper Reflexes : Weak .
- 6. • Respiration :tachypnea • Color : normal • Cry : weak • Movement : abnormal • Birth trauma : no • Apparent Congenital Anomalies : no
- 7. WHAT IS THESEVER HIE ? References : Kenneth A. stem , Stern Law 2017 , cerebralpalsy , Hypoxic-Ischemic Encephalopathy .
- 8. Definition: • Hypoxic-ischemic encephalopathy,or HIE, is the brain injury caused by oxygen deprivation to the brain References : Kenneth A. stem , Stern Law 2017 , cerebralpalsy , Hypoxic-Ischemic Encephalopathy .
- 9. Causes of HIE Asnoted HIE may result from any event that restricted the flow of oxygenated blood to the brain The case was due to prolonged delivery . References : Kenneth A. stem , Stern Law 2017 , cerebralpalsy , Hypoxic-Ischemic Encephalopathy .
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- 11. Incidence and Prevalenceof HIE in KSA : A total of 70 cases of HIE were recorded in the study period giving an incidence of 5.5 cases per 1000 term births. This incidence is lower compared to many developing countries and comparable to other centers. References : Itoo BA1, Al- Hawsawi ZM, Khan AH, February 2003,Hypoxic ischemic encephalopathy. Incidence and risk factors in North Western Saudi Arabia. References : Adnan Amin Alsulaimani , Abdelaziz SA Abuelsaad and Nader M Mohamed , January 27, 2015 , Inflammatory Cytokines in Neonatal Hypoxic Ischemic Encephalopathy and their Correlation with Brain Marker S100 Protein: A Case Control Study in Saudi Arabia 2003 2015 mention
- 12. Diagnosis : • diagnosedclinical by the combination of evidence of fetal distress • heart rate abnormalities • Meconium stained fluid • Birth depression • Low Apgars Normal Abnormal References : Kenneth A. stem , Stern Law 2017 , cerebralpalsy , Hypoxic-Ischemic Encephalopathy .
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- 14. Complications To the Mother: • Maternal diabetes with vascular disease • Problems with blood circulation to the placenta • Preeclampsia • Cardiac disease • Congenital infections of the fetus • Drug and alcohol abuse • Severe fetal anemia • Lung malformations References : Kenneth A. stem , Stern Law 2017 , cerebralpalsy , Hypoxic-Ischemic Encephalopathy .
- 15. Complications To the infants: Intrapartum period : • Excessive bleeding from the placenta • Very low maternal blood pressure • Umbilical cord accidents • Prolonged late stages of labor • Abnormal fetal position • Rupture of the placenta or the uterus Postpartum HIE : • Severe cardiac or pulmonary disease • Infections, including sepsis and meningitis • Severe prematurity • Low neonatal blood pressure • Brain or skull trauma • Congenital brain malformations
- 16. Treatment : The basicgoal of HIE treatment is to support the baby’s affected organs , treatment options include: • Mechanical ventilation to help a baby who can’t breathe • Cooling the baby’s brain or body to reverse brain hypoxia caused by high temperatures • Hyperbaric oxygen treatment in cases where HIE is caused by carbon monoxide intoxication • Treatments to assist the baby’s heart function and control blood pressure • Maintain normal blood glucose • Prevent or control seizures • Prevent or minimize cerebral edema References : Kenneth A. stem , Stern Law 2017 , cerebralpalsy , Hypoxic-Ischemic Encephalopathy .
- 17. BACK TO THECASE
- 18. VITALS AT ADMISSION •Weight : 2.5 Kg • Temperature : 36 Cْ • pulses : 147 • Respiratory Rate : 54 • Blood pressure : 82 / 46 • Pain score : 1 . • SPO2 : 100 . • Level of consciousness: low • Respons : 2 . • Pupil size : 3 .
- 19. • The patientMove directly to NICU , he received nothing in ER . • At the NICU First Day : • medication : DATE OF ADMISSION : 29-2-1438 Drug name Dose frequency Route of administration IV fluid ( Ca , Kcl , AA10% , D5, D10 NS) . 150 ml/kg/ day OD IV Tamiflu 63 mg BID IV Amikacin 38 mg OD IV Phenobarbitone 10 mg OD Slow IV Empiric
- 20. WBC 10^3/uL RBC 10^6/uL Hb g/dL Platelet 10^3/uL 11.26 4.215.3 363 CBC and Differential : glucose mg/dl K mmol/L Na mmol/L Cl mmol/L Ca mg/dL PO4 mg/dL Mg mg/dL 34 3.9 148 108 9.7 4.6 1.7 Chemistry: Abnormal slightly normal
- 21. ASSESSMENT : • Measureserum level Amikacin Peak should not exceed 30 mg / liter . • Do Blood culture ( To know reason of respiratory distress ) . • keep using phenoparbiton to control seizures . • vital signs were stable . • keep patient on mechanical ventilator
- 22. SECOND DAY -SEVENTH DAY • The blood culture -ve viral infection so stopped Tamiflu . • OGT feeding start 3ml / 3 hrs on the fifth day . • intubation at fourth day • medication : Drug name Dose frequency Route of administration IV fluid 150 ml/kg/day OD IV meropnem 63 mg BID IV Amikacin 38 mg OD IV Phenobarbitone 10 mg OD Slow IV fentanyl 5 mcg/kg PNR slow IV . fentanyl 2 mcg/kg/h OD IV Midazolam 40 mcg/kg/h OD IV mgso4 80mg TID slow IV due to low mg
- 23. WBC 10^3/uL RBC 10^6/uL Hb g/dL Platelet 10^3/uL 12.5 3.411.7 363 CBC and Differential : glucose mg/dl K mmol/L Na mmol/L Cl mmol/L Ca mg/dL PO4 mg/dL Mg mg/dL 80 4.2 132 106 9.5 4.3 1.27 Chemistry: Abnormal slightly normal At 4th day Vital sign : TEMP BP HR RR O2 sat. 37 88/56 154 48 90%
- 24. ASSESSMENT : • Measureserum level Amikacin Peak should not exceed 30 mg / liter . • keep using Phenoparbiton to control seizures . • vital signs were stable . • addition midazolam and fentanyl to do intubation surgery . < on the fourth day . • OGT feeding start 3ml / 3 hrs on the fifth day . • X-ray for chest at fourth day • keep mechanical ventilation • vital sign were stable
- 25. EIGHTH DAY ANDNINTH DAY • patient developed peritonitis - sepsis • tolerating Extubation • medication : Drug name Dose frequency Route of administration IV fluid 150 ml/kg/day OD IV Meteclopromide 0.25 mg TID OGT tube Vancomycin 25 TID IV Phenobarbitone 15 mg OD Slow IV fentanyl 2 mcg/kg/h OD IV Tazocin 200 mg TID IV Instead of meropenem and Amikacin Midazolam 2 mcg/kg/h OD IV
- 26. WBC 10^3/uL RBC 10^6/uL Hb g/dL Platelet 10^3/uL 23 2.310.2 347 CBC and Differential : glucose mg/dl K mmol/L Na mmol/L Cl mmol/L Ca mg/dL PO4 mg/dL Mg mg/dL 67 5.4 132 103 9.5 5 1.6 Chemistry: Abnormal slightly normal Vital sign : TEMP BP HR RR O2 sat. 37.9 82/47 131 48 97%
- 27. ASSESSMENT : • CNSlethargic , weak , grade 2 encephalopathy • change Antibiotic to ( Pepracillin Tazopactam , Meteclopromide , Vancomycin ) • EEG , MRT • chest physiotherapy • Chest :good air entry • Increase the dose of phenobarbetone into 15 mg . • Measure Vancomycin Trough after 3rd dose ( <40 µg/ml and <10 µg/ml, respectively ) • Vital sign were stable .
- 28. TENTH DAY -EIGHTEENTHDAY • patient developed Seizures Bronchopneumonia then left lung collapse < on tenth day , • on 13th day patient develop convulsions and on the 14th RD again and tachypnea . • medication : Drug name Dose frequency Route of administration IV fluid 150 ml/kg/day OD IV Meteclopromide 0.25 mg TID OGT tube Vancomycin 25 TID IV Phenobarbitone 15 mg OD Slow IV fentanyl 2 mcg/kg/h OD IV Tazocin 200 mg TID IV Atrovent + normalS ( 3ml) 0.5 ml TID Nebulizer 10% N-Acetyl cysteine 2 ml TID Nebulizer Ranitidine 3.7mg TID IV Omeprazole 2.5mg OD IV discontinue on 11th day add on 14th day add on 15th day Midazolam 40 mcg/kg/h OD IV
- 29. WBC 10^3/uL RBC 10^6/uL Hb g/dL Platelet 10^3/uL 15 3.310.2 347 CBC and Differential : glucose mg/dl K mmol/L Na mmol/L Cl mmol/L Ca mg/dL PO4 mg/dL Mg mg/dL 73.1 5.4 139 104 9.5 5 1.6 Chemistry: Abnormal slightly normal on 13th day CRP 7.11mg/dl TEMP BP HR RR O2 sat. 37 88/47 139 48 98% INFECTION
- 30. ASSESSMENT : • CNS: poor response , hypotonic , poor acting • Chest : SC I.C retractile Coarse • CVS: S1+S2+O • convulsions on day 13th then controlled until the day 16th then appear again on the day 17th then controlled again . • continue Antibiotics until 10 days . • on the 14th day Sepsis disappear • OGT increase into 5 ml BID • Cardiopulmonary monitor . • Change position every 4 h . • on eighteenth day they discontinued Vancomycin and Tazocin but still on Meteclopromide .
- 31. 19 DAY -25DAY • patient still with left lung collapse developed RD again . • medication : Drug name Dose frequency Route of administration Meteclopromide 0.25 mg TID OGT tube Vancomycin 36.5 TID IV meropenem 98 mg BID IV Phenobarbitone 15 mg OD Slow IV Atrovent + normalS ( 3ml) 0.5 ml TID Nebulizer 10% N-Acetyl cysteine 2 ml TID Nebulizer Ranitidine 3.7mg TID IV Omeprazole 2.5mg OD IV lasix 2.4 mg OD IV add on 20 day discontinue on 24 discontinue on 25 add on 25
- 32. WBC 10^3/uL RBC 10^6/uL Hb g/dL Platelet 10^3/uL 18 2.912.5 347 CBC and Differential : glucose mg/dl K mmol/L Na mmol/L Cl mmol/L Ca mg/dL PO4 mg/dL Mg mg/dL 80 4.3 132 103 9.5 4.2 1.6 Chemistry: Abnormal slightly normal LAP result : PSUDOMONAS on 23 on day 21 Vital sign : TEMP BP HR RR O2 sat. 37 110/80 167 49 98% HOSPITAL ACQUIRED
- 33. ASSESSMENT : • continuethe antibiotic until 10 days . • Measure Vancomycin Trough after 3rd dose ( <40 µg/ml and <10 µg/ml, respectively ) • seizures were controlled • on day 22 add multivitamins 0.5 mg + vit D 4 drops • tachypnea on and off • vital signs are stable .
- 34. 26 DAY -31DAY • patient still with left lung collapse , seizures is control . • medication : Drug name Dose frequency Route of administration Vancomycin 36.5 TID IV meropenem 98 mg BID IV Phenobarbitone 15 mg OD Slow IV 10% N-Acetyl cysteine 2 ml TID Nebulizer Ranitidine 3.7mg TID IV Omeprazole 2.5mg OD IV IV Fluid Midazolam 60 mcg/kg/h OD IV lasix 2.4 mg OD IV ventoline 0.2 ml OD IVadd on 26 150 ml/kg/day OD IVadd on 26
- 35. WBC 10^3/uL RBC 10^6/uL Hb g/dL Platelet 10^3/uL 13 3.4810.1 415 CBC and Differential : glucose mg/dl K mmol/L Na mmol/L Cl mmol/L Ca mg/dL PO4 mg/dL Mg mg/dL 70.8 4.5 139 102 9.3 6 1.8 Chemistry: Abnormal slightly normal Vital sign : TEMP BP HR RR O2 sat. 37 78/40 188 58 99%
- 36. ASSESSMENT : • extendduration of the antibiotic until 14 days . • Measure Vancomycin Trough ( <40 µg/ml and <10 µg/ml, respectively ) • seizures were controlled • increase OGT 45 ml ( to maximum ) on day 31 . • on day 32 re-add the Midazolam dose in to 60 mcg . • tachypnea on and off . • vital signs are stable .
- 37. PATIENT STILL IN THE HOSPITALat NICU .
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- 39. 1- INTUBATION PROPHYLAXIS •1- THERE IS NO GIT Bleeding after intubation, or Vomiting or any kind of gastric problems or esophagitis WHY USE RANITIDINE for 5 days ? < there is no reason ! • 2- If there is suspected to bleeding only give high dose OMEPRAZOLE , according to study on MARS 2016 , DOSE ALSO WAS WRONG according TO BNF , 2014 -2015 . Maurice A Cerulli, MD, Mars 2016 , Upper Gastrointestinal Bleeding Treatment &Management ,
- 40. 2- MANAGEMENT OF SEIZURES •MIDAZOLAM DOSE NOT WORK , why keep use it ? • That is right the Benzodiazepines increase the activity of GABA, BUT GABA is Immature yet in the neonate ! • when the GABA is Immature the CL Already inside the cell and +ve Ions Out ! < NO MORE ENTRY of CL inside the cell .
- 42. SO USE WHATAS A SOCEND LINE TREATMENT? • According to Survey of 55 child neurologists • Contemporary choice of second, add-on drug if initial drug fails: • – Topiramate is “anti-epileptogenic” and neuroprotective 55% (30/55) among those recommending TPM, 70% (21/30) perceived treatment beneficial and 63% (19/30) saw no apparent ADRs
- 43. Levetiracetam: the anti-seizure medication(no hepatic metabolism, limited drug-drug interactions, low protein binding, renal elimination) and iv formulation . 47% (26/55) treatment beneficial and 92% (24/25) saw no apparent ADR SO USE WHAT AS A SOCEND LINE TREATMENT?
- 44. 3- ANTIBIOTICS • AccordingTO BNF to treatment Pseudomonal lung infection:
- 45. Swami Sivananda “Put yourheart, mind, and soul into even your smallest acts. This is the secret of success. ”
- 46.