Careers, Unable to load your collection due to an error. Although the evaluation of the overall guideline quality and the usage of the recommendation are essential sections of AGREE II, it's likely that they are not clearly communicated in the published CPGs' methodology. Therapeutic hypothermia should last 72 hours, followed by rewarming at a rate of 0.5 degrees celsius /hour. Design: Retrospective cohort study using the National Neonatal Research Database. [4] This latent phase or therapeutic window of opportunity exists in the interval following resuscitation of the asphyxiated newborn before the second phase of delayed neuronal death starts. They might have absent primitive reflexes, dilated pupils, and apnea. American journal of perinatology. The consistency of ratings or the capacity for datasets that were gathered as clusters or sorted into clusters using intra-class correlation were also assessed in the second overall assessment (OA2) in addition to the percent agreement in the first overall evaluation (OA1). Neonatal therapeutic hypothermia at Nationwide Children's is intended to improve long-term neurological outcome for patients who would otherwise have no available options beyond life-supportive care. Conclusions Three members of the GRG attended capacity building training in AGREE II appraisal of CPGs. Cold stress is quite painful, so the neonates need adequate sedation. Lancet (London, England). Archives of pediatrics & adolescent medicine. Typically, start the total fluid rate at 50-60 mL/kg/day and adjust based on the input-output chart. Impact of therapeutic hypothermia on MRI diffusion changes in neonatal encephalopathy. Assess the baseline clinical and neurological status and record in chart. If the neonatal 5-minute Apgar score is 5 or less, or if requestedby the delivering or newborn provider, umbilical artery blood should be sent for analysis whenever possible. Significant hypotension may need a saline bolus, vasopressors, and steroids. Most neonates are fluid restricted to avoid cerebral edema and fluid overload. PROSPERO 2021 CRD42021258291. Quality assessment of clinical practice guidelines for neonatal sepsis using the appraisal of guidelines for research and evaluation (AGREE) II instrument: a systematic review of neonatal guidelines. Therapeutic hypothermia in neonates has a neuroprotective effect by modifying the cells programmed for apoptosis and reducing cerebral metabolic rate.
Variations in care of neonates during therapeutic hypothermia - Nature Sedation:Infants may require a low dose morphine infusion to optimise comfort and efficacy of the cooling process. To systematically review, critically appraise the quality of recent clinical practice guidelines (CPGs) for neonatal hypoxic ischemic encephalopathy (HIE), and map their recommendations. The latent period between primary and delayed neuronal death is approximately 6 hours, as per the experimental study. 50 Flemington Road Parkville Victoria 3052 Australia, Site Map | Copyright | Terms and Conditions, A great children's hospital, leading the way. If an eligible neonate is born in a setup without the cooling facility, the transport team has to transport the neonate as soon as possible to the neonatal intensive care unit with the cooling facility. Avoid overcooling the patient. Therapeutic hypothermia (TH) has become standard of care for neonates with hypoxic-ischemic encephalopathy, but is associated with significant physiologic stress to the neonate, as evidenced by . Neuroprotection in babies 35 weeks gestation with moderate to severe hypoxic ischaemic encephalopathy (HIE) is optimised by commencing therapeutic hypothermia treatment as soon as possible after resuscitation, between 1-6 hours of life. Neonates on therapeutic hypothermia need interprofessional intervention, including neonatologists, neurologists, cardiologists, and nutritionists. Conclusions Therapeutic hypothermia reduces the risk of death in neonates with moderate to severe hypoxic-ischemic encephalopathy. Infants usually need ventilator support to maintain adequate oxygenation and ventilation. The baby's temperature is measured throughout to . Radiant warmer should remain off until the end of the rewarming period to avoid any possible adverse effects of rapid rewarming. Pediatr Res. Cool Cap trial enrolled and randomly assigned 234 term neonates with moderate or severeHIE and abnormalamplitude-integrated EEG to either head cooling (n=116) or conventional management (n=118). Moreover, we are looking forward to having new evidence-based recommendations in the next editions of these CPGs based on the mounting evidence addressing the new options of care like the use of conventional electroencephalography (EEG) or Amplitude-integrated Electroencephalogram (aEEG) monitoring in neonatal HIE (30, 31). Archives of neurology. Babies with moderate to severe HIE or who received TH require a neurodevelopmental review by early intervention specialists. Moreover, low income countries benefit the most from the therapy. While the core focus of these guidelines is infant screening and eligibility, the guidelinesalsoaddress several other areas critical to the treatment of suspected neonatal encephalopathy, including: exclusion criteria stabilization & management transport 2011 Aug:165(8):692-700. doi: 10.1001/archpediatrics.2011.43. The development of this nursing guideline was coordinated by Alison Kendrick, Clinical Nurse Educator, Butterfly Ward, and approved by the Nursing Clinical Effectiveness Committee. At 33.5C, the average HR is approximately 80-100 beats per minute (bpm). The number of observed agreements is six (77.16% of the observations). It is evident from many systematic reviews that therapeutic hypothermia is beneficial in neonates with moderate to severe hypoxic-ischemic encephalopathy. Cooling the baby's body and brain temperature in a controlled environment alters chemical processes in the brain, thus reducing the risk of permanent brain damage. To avoid impairment to cerebral blood flow return, keep head in alignment with spine (nose in body midline), Monitor skin for colour, perfusion, skin breakdown and for signs of subcutaneous fat necrosis, Although rare, subcutaneous fat necrosis is characterised by induration erythemateous nodules and plaques over bony prominences such as back, arms, buttocks, thighs and chest. The TOBY trial suggested that induction of therapeutic hypothermia in infants with perinatal asphyxia did not significantly reduce the combined rate of mortality or severe disability but improved neurologic outcomes among survivors.
Clinical practice guidelines for neonatal hypoxic-ischemic 2005 Feb 19-25:365(9460):663-70 [PubMed PMID: 15721471], Azzopardi DV, Strohm B, Edwards AD, Dyet L, Halliday HL, Juszczak E, Kapellou O, Levene M, Marlow N, Porter E, Thoresen M, Whitelaw A, Brocklehurst P, TOBY Study Group. The exclusion criteria for therapeutic hypothermia in neonates is as follow: Before initiating therapeutic hypothermia, the neonate should have a secure airway and vascular access. The systematic review (SR) and quality appraisal of CPGs using the Appraisal of Guidelines for REsearch & Evaluation II (AGREE II) Instrument is a critical step in the KSU-Modified-ADAPTE CPG adaptation process (12, 13). FOIA Document programmed temperature and actual temperature on EMR. The benefits of survival and neurodevelopmental outcomes outweigh the short-term adverse effects.[3].
Also, side effects are similar in both methods. Document the discussion and rationale for the decision to offer or not to offer therapeutic hypothermia. Follow-up of infants who received hypothermia to a minimum of 2 years, but ideally until school age, in a neonatal follow-up clinic, is recommended. Frequent monitoring is crucial for the early detection and management of complications. The requirement for positive pressure ventilation, at ten minutes, Umbilical cord pH or any arterial pH less than 7, within 1 hour of life, Base Deficit more than 16 mmol/L in cord blood or arterial blood within 1 hour of life. Pressure Injury Prevention and Management Nursing Guideline, Assisted Thermoregulation Nursing Guideline, Seizure Management in the NICU Departmental Guideline, Neonatal Pain Assessment Nursing Guideline, Neonatal Pain Management in the NICU Nursing Guideline, Constricted Bradycardic Periodic breathing. 2020 Apr:120(2):277-288. doi: 10.1007/s13760-020-01308-3. 2012 Apr:1(2):101-6. doi: 10.4103/2249-4847.96777. We continue to recommend compiling the findings of this study with similar quality appraisals of neonatology CPGs to set up a CPGs hub or Recommendation map that would be of the utmost value for healthcare providers caring for newborn babies in selecting and implementing high-quality evidence-based CPGs and recommending them to their colleagues (11, 2529). Selective Head Cooling vs. Whole-body Cooling, If the neonatal unit is not equipped with a cooling facility, consider passive cooling for eligible neonates. Hypothermia can cause immune dysfunctions so cooled infants are often covered prophylactically with IV antibiotics, Strict infection control - care of CVADs, and indwelling catheter care, Daily review for evidence of infection (see bloods and monitoring above and observe abdomen for distension), Need frequent inspections of skin and repositioning as per Pressure Injury guideline, Infant can be nursed supine and 30 tilt to right or left. Serum Lactate, Brain Magnetic Resonance Imaging and Outcome of Neonatal Hypoxic Ischemic Encephalopathy after Therapeutic Hypothermia. What is therapeutic hypothermia? The evidence table for this guideline can be found here. Therapeutic Hypothermia for Hypoxic Ischemic Encephalopathy: initiation in special care nurseries, Safer Care Victoria, Updated 17. However, 30-50% of infants with moderate . We decided on linear weights because the difference between the first and second categories was similar to the difference between the second and third categories, and so on. A recently published network meta-analysis compared the effectiveness and safety of different neuroprotective interventions for neonates with HIE (23). Cooling for newborns with hypoxic ischaemic encephalopathy. Many experimental animal models and systematic reviews of randomised controlled trials have shown that both whole-body hypothermia and selective head cooling has a neuroprotective effect. Neurology. Six large randomized clinical trials of induced hypothermia for neonatal encephalopathy were published from 2005 to 2011. Inclusion in an NLM database does not imply endorsement of, or agreement with, sharing sensitive information, make sure youre on a federal Criteria 1: Infants > 36 weeks gestation with one out of the following four criteria: The target temperature in SHC is 34 to 35 degrees C. Remove the cooling cap every 12 hours to look for irritative injury of the scalp due to the cap. Table2 shows a map of the recommendations from both HIE CPGs (21, 22). Apgar score 5 at 10 minutes or at least 10 minutes of positive-pressure ventilation. official website and that any information you provide is encrypted shows the intraclass correlation coefficient (Kappa value) among raters for the two CPGs for the second Overall Assessment. Variations in care of neonates during therapeutic hypothermia: call for care practice bundle implementation. moribund or in extremis (e.g. A systematic review of clinical practice guidelines for acute procedural pain on neonates, A quality appraisal using the AGREE II instrument of endotracheal tube suction guidelines in neonatal intensive care units, valuation de la qualit dlaboration dune recommandation pour la pratique clinique avec la grille AGREE II: exemple de lictre nonatal [how to assess clinical practice guidelines with AGREE II: the example of neonatal jaundice]. Monitor the pain scale using the validated pain assessment tool. [3]As per current guidelines, it is mandatory to offer therapeutic hypothermia to all term neonates with evolving moderate or severe hypoxic-ischemic encephalopathy. As newer evidence and CPGs were published overtime, SNS decided to update this CPG and launch a national HIE CPG project. After a latent period (6-100 hrs) neuronal death may be initiated by a cascade of pathologic processes and is associated with marked encephalopathy.
PDF Therapeutic Hypothermia for Neonatal Encephalopathy - Amazon Web Services PDF Appendix 5- Transfusion Guidelines for infants with NE receiving TH YA and AE analyzed and interpreted the data. (2022 version available). Available from: Login - AGREE Enterprise website.
2013 Jan 31:2013(1):CD003311. How to use Medi-Therm III hyper/hypothermia system. Both CPGs have not reported using the GRADE (Grading of Recommendations; Assessment; Development and Evaluations) Method. dioxide production. Maintain glucose and electrolytes within normal limits. Explain to family that their baby will feel cold for the duration of the treatment and reassure them that their baby will be kept comfortable during the treatment. Most infants have mild coagulopathy from the combined effects of asphyxia and cooling, and many have an increased rate of mild clinical bleeding but still benefit from therapeutic hypothermia. The kappa (K) statistic is used to measure agreement (18, 19): When categorization systems agree completely, K=1 when there is no agreement greater than chance, and K is negative when there is agreement worse than chance. Epub 2010 Jun 16 [PubMed PMID: 20554402], Jacobs SE, Berg M, Hunt R, Tarnow-Mordi WO, Inder TE, Davis PG. Monitor comfort using modified pain assessment tool (mPAT). abruption placenta, cord prolapse, severe foetal heart rate abnormality.). Available at: Amer YS, Wahabi HA, Abou Elkheir MM, Bawazeer GA, Iqbal SM, Titi MA, et al. Hypothermia for neonatal hypoxic ischemic encephalopathy: an updated systematic review and meta-analysis. The partial pressure of gases depends on the temperature. Refer to Neonatal pain assessment and Neonatal Pain Management Guidelines. The delayed phase accounts for a significant proportion of the final cell loss even after severe insults. This study was supported by King Saud University, Deanship of Scientific Research, Research Chair for Evidence-Based Health Care and Knowledge Translation, Riyadh, Saudi Arabia. Increased incidence of sepsis due to inhibition of pro-inflammatory response, Delayed gastric emptying causing intolerance of enteral feeds, Altered pharmacokinetics and pharmacodynamics of medications like sedatives and analgesics during hypothermia, Higher risk of seizures due to an increase in cerebral metabolic rate. The AGREE II standardized domain scores for the first overall assessment was higher for the QMN CPG (83%) than the CPS CPG (63%). Sakr. Passive cooling can be an early adjunct to therapeutic hypothermia.[11]. Death or disability occurred in 66 % conventional care and 55 % cooled group (OR 0.61; 95% CI 0.34-1.09, p=0.1).The frequency of clinically important complications was not different. The full inclusion and exclusion criteria were reported in the PROSPERO protocol (16). The entire treatment takes approximately 72 hours. [1], Infant Cooling Evaluation (ICE) trial (n=221) is the most recent randomized control trial published. GIR needs to be calculated to ensure adequate sugar in continuous infusions as they are at risk of hypoglycaemia. The adapted ADAPTE: an approach to improve utilization of the ADAPTE guideline adaptation resource toolkit in the Alexandria Center for Evidence-Based Clinical Practice Guidelines, The advantages and limitations of guideline adaptation frameworks. Scale for Hypoxic Ischemic Encephalopathy, Table adapted from Sarnat el al Pediatric Neurology 113 (2020) 75-79, 6. 10.1136 . Watch for oversedation due to possible accumulation because of altered pharmacokinetics, especially if the neonate is on phenobarbitone, as this might mask neurological examination. Whole-body hypothermia for neonates with hypoxic-ischemic encephalopathy. The infant will be assessed sequentially by three criteria as listed below. Term and late preterm infants 36 weeks GA with HIE who are 6 hours old and who meet either treatment criteria A or treatment criteria B, and also meet criteria C: B.pH 7.01 to 7.15 or base deficit 10 to 15.9 on cord gas or blood gas within 1 h AND, 1. Bradycardia - Heart rate decreases 15 /min per 1degree C change in temperature. This study aimed to report the systematic review and quality assessment of HIE CPGs as a part of the HIE CPG adaptation process.
Neonatal Therapeutic Hypothermia Article - StatPearls Passive cooling to initiate hypothermia for transported encephalopathic newborns. This guideline provides recommendations regarding transport, assessment, and treatment of neonatal encephalopathy. Total fluid intake is usually 40-60ml/kg/day. Commence aEEG monitoring - Seizures can occur in approximately 50% of neonates with hypoxic-ischemic encephalopathy getting therapeutic hypothermia. Therapeutic hypothermia should not be offered as treatment for neonatal encephalopathy in low-income and middle-income countries, even when tertiary neonatal intensive care facilities are available. During prenatal care, the clinician and patient will discuss common events and procedures in labor, including methods of assessing fetal well-being. Br Med J. 25. . Chen Y, Guyatt GH, Munn Z, Florez ID, Marui A, Norris SL, et al. Check pupils, evaluate level of consciousness and for signs of raised intracranial pressure.
Advances in the Prevention and Treatment of Neonatal Hypothermia in Infants in the hypothermia group had an increased rate of survival without neurologic deficit ( P=0.003). Long-term neuropsychological and behavioral outcome of mild and moderate hypoxic ischemic encephalopathy. Queensland Health. The primary outcome measured was death or severe neurodevelopmental disability at 18 months. 2012 Jun 1:166(6):558-66. doi: 10.1001/archpediatrics.2011.1772. As per current guidelines, it is mandatory to offer therapeutic hypothermia to all term neonates with evolving moderate or severe hypoxic-ischemic encephalopathy. The first stage is the primary neuronal death. Risk-benefit assessment should take into account relevant data from laboratory models of asphyxial arrest, 8,30-32 results from trials of adult cardiac arrest, 18,19 and reports on the use of hypothermia in treatment of neonatal asphyxia. At 33.5 degrees C, the average heart rate is approximately 80 to 100 beats per minute (bpm). When there are more than two raters, we use this. (Supplementary information) demonstrates possible interpretations of the K value (20). The mortality rate was significantly low, and survival free of disability was higher in the cooling group than the control group. Treatment of term and near-term infants with neonatal encephalopathy and clinical findings suggestive of hypoxic-ischemic injury (hypoxic-ischemic encephalopathy, HIE) with hypothermia for 72 h reduces risk of death or survival with neurodevelopmental impairment in high resource settings. electrical seizure activity with normal background, Moderate abnormal background activity (<5uV and >10uV), Suppressed background activity (<5uV and <10uV), Birth weight less than 1800 gram (some units consider less than 2000 gram), More than 6 hours of age at the time of initiatingtherapeutic hypothermia, Life-threatening abnormalities of the respiratory or cardiovascular system, E.g., diaphragmatic hernia requiring ventilation or complex congenital heart disease, Significant chromosomal anomaly such as trisomy 13, 18. This study was funded by the Saudi Neonatology Society (SNS). Introduction. Do not nurse in an incubator. [9] Passive rewarming will continue for four hours in SHC or six hours in WBC. 2023 THE RISK MANAGEMENT FOUNDATION OF THE HARVARD MEDICAL INSTITUTIONS INCORPORATED, CRICO, AND AFFILIATES. Watch for arrhythmias - sinus bradycardia is the most common arrhythmia. Table1 highlights the characteristics of all eligible CPGs. Clinically defined moderate or severe HIE (stage 2 or 3 based on modified Sarnat Classification). If urine output drops below 1ml/kg/hr medical team will need to be notified. 2010 Jun:86(6):329-38. doi: 10.1016/j.earlhumdev.2010.05.010. Hypothermia is not without risk and thus it is important to manage the patient safely during induction and maintenance of hypothermia and during the rewarming process. This activity reviews the indications, preparation, technique, and complications of therapeutic hypothermia. Agreetrust.org. BMJ Paediatrics Open. 3401 Civic Center Blvd. The widespread use of therapeutic hypothermia (TH) in the treatment of neonatal encephalopathy (NE) has reduced the associated morbidity and mortality. Amer Y, Shaiba L, Hadid A, Anabrees J, Almehery A, AAssiri M, et al. What to do with all the AGREEs? The aim of this guideline is to describe the management of a patient undergoing therapeutic hypothermia in the NICU. If the baby shows any signs of distress or there is excessive shivering causing difficulties maintaining the desired baby temperature, consider: There is insufficient evidence to recommend their use at this time, Selective head cooling can be achieved with cooling caps fitted around an infants head, with the aim of maintaining fontanelle temperature below 30C.