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cB23

Cooling off-protocol

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Have a case:

Stat CS for maternal abruption and decels

Term baby. Poor tone and resp effort. Suspected blood aspiration. Needed PPV and 100% FiO2 for hypoxia. Intubated in DR.

Cord gases pH 7.22 BE -8

Baby H/H: 18/50

Baby gas 7.18 / -8 at ~50 min of life

Started having clinical seizures at 12 HOL. Electrical seizures on EEG. Normal HUS. 

Would you start late therapeutic hypothermia? Did not meet mod/severe sarnat encephalopathy on exam but was hypotonic, was intubated, and required prolonged resuscitation. TH is often fairly well tolerated and there's not much else to do.

2017 Laptook paper suggests potential benefit with late cooling. The baby had a perinatal event and clinical signs of possible HIE but no acidosis. Could be stroke or other. Some papers looking retrospectively at cooled infants who went on to have perinatal stroke had seizure reduction with TH.

So far has received phenobarb, keppra, fospheny for refractory seizures. 

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Thanks for sharing this (not uncommon!) clinical scenario. Will be interesting to follow the discussion.

Actually, this topic will be one of the interactive lecture sessions on the #99nicuMeetup in Vienna next year :) , one of the real experts in this field has semi-confirmed.

I find this tricky myself, I like to stick to our guidelines. In practise, we typically handle a case like this with an inter-collegial discussion (sometimes also involving our neighbouring level-3 NICU) and reach consensus how to act that way. In this case, I think the jury would be out for some time before deciding. What we'd decide in this case, an open question in my view.

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Just for the purpose of recall.(Cochrane 2013, Jacobs)

Evidence of peripartum asphyxia, with each enrolled infant satisfying at least one of the following criteria:
i) Apgar score of 5 or less at 10 minutes;
ii) mechanical ventilation or resuscitation at 10 minutes;
iii) cord pH < 7.1, or an arterial pH < 7.1 or base deficit of 12 or more within 60 minutes of birth.
AND

Evidence of encephalopathy according to Sarnat staging (Sarnat 1976; Finer 1981):
i) Stage 1 (mild): hyperalertness, hyper-reflexia, dilated pupils, tachycardia, absence of seizures;
ii) Stage 2 (moderate): lethargy, hyper-reflexia, miosis, bradycardia, seizures, hypotonia with weak suck and Moro;
iii) Stage 3 (severe): stupor, flaccidity, small to mid position pupils that react poorly to light, decreased stretch reflexes, hypothermia and absent Moro.

AND abnormal standard EEG or aEEG findings(this in addition to above as in NeoNeuro Network RCT by Simburner, Germany).

Evidence

Laptook etal. Effect of therapeutic hypothermia initiated after 6hours of age on death or disability among newborns with Hypoxic-ischemic encephalopathy, Jama 2017 October 24;318(16): 1550-1560.

•Randomized clinical trial

•April 2008 –june 2016

•Moderate or severe HIE enrolled at 6-24 hours after birth.

•Twenty one US neonatal research network centers

•There were 168 participants and 83 were randomly assigned to hypothermia and 85 to noncooling.

Results

76% probability of any reduction in death or disability.(Biasian Statistics and analysis)
64% probability of at least 2% less death or disability at 18 to 22 months. 
Hypothermia initiated at 6 to 24 hours after birth may have benefit but there is uncertainty in its effectiveness.

Gist: TH can be tried for its benefit though not greater than that of starting early but with due consideration of parents participation and Consultant in decision making.
 

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This is not an uncommon dilemma. We have developed a one paged trigger/ assessment tool for babies who meet criteria for monitoring for moderate or severe encephalopathy. It seems to work most times and one of our fellows is conducting an audit to see if we miss any babies with this tool. 

Based on this case, it sounds like the baby would have met criteria for clinical monitoring for moderate or severe HIE i.e. prolonged resuscitation and possibly Apgar scores? but not pH or BE related values and we would have then assessed this baby hourly for the first 6 hours of life for clinical signs of moderate or severe encephalopathy. TH would have been started as per the trigger tool thresholds.

The problem comes when these babies don't meet clinical criteria for moderate or severe HIE and clinical monitoring is ceased and then go on to have seizures some time later - as is seen in this case. The current trend in our unit would be to not cool them at the 12hr mark but I have personally cooled a baby who did not meet criteria for moderate or severe encephalopathy in the 1st 6hrs but then went on to have seizures at ~8hrs of life. We would just optimise other medical intervention and use anti-convulsants (levetiracetam, topiramate and midazolam or lignocaine) to treat seizure burden.

I'm not sure if that helps!

Cheers

Richard

HIE trigger tool.pdf

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There has been a recent narrative review of cooling outside of "standard" criteria here: https://www.sciencedirect.com/science/article/abs/pii/S1355184118301595

I agree with above comments- I think given need for resuscitation at 10 mins (ventilated) and evidence of encephalopathy on clinical assessment (+/1 aEEG/CFAM) then we would have cooled on admission. 

We generally do not cool > 6 hrs but have on occasions, including late preterms. We had an interesting situation a few years ago where a baby ended up being resuscitated after an unplanned extubation (ex-preterm, difficult to get chest movement, difficult to intubate, long period of bradycardia and poor oxygenation) and there was a decision made to cool. 

What happened in your case?

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