Clinical Identification Of Neonates

Eligible For Therapeutic Hypothermia:

Can We Do Better?

Dr Prashanth Murthy

Alberta

■ 661,848 km²

■ Population : 4.146 million

■ 58000 births per year

■ Southern Alberta Neonatal Transport Service (SANTS):

serves a catchment area of 1.8 million people and more than 20,000 births/year

TH was introduced as standard of care in June 2008

Approximately 40 neonates eligible for TH get admitted to Calgary centers per year

1.67 per 1000 births in 2005 to a high of 2.89 per 1000 births in 2013. overall rate 2.30 per

1000 births.

Since Introduction Of TH

• Standard of care

• Need for early identification of infants with HIE

• Urgency soon after birth…panic

OUTBORN NEONATES WITH HIE

outborn 66%

inborn 34%

HIE birth location (157)

OUTBORN HIE AND SHORT-TERM OUTCOMES

9%

50% 49%

13%

59% 60%

0%

10%

20%

30%

40%

50%

60%

70%

Death Acute Brain injury Ab EEG

Inborn Outborn

A Significant Proportion Of Outborn Infants Who Qualified For Cooling Were Not Cooled

PASSIVE COOLING AND TEMPERATURE CONTROL

How can we improve?

Cooling

eligibility app

Targeted

neuro exam

Improve

Documentation

Neuroprotection

during stabilization

and transportation

Improve Identification, Documentation and Implementation

IdentificationConfusion: Criteria For Cooling

Cooling Criteria

• Qualifying Criteria

• Criteria A (Signs Of Intrapartum Hypoxia)

• Criteria B (Signs Of Encephalopathy)

Eligibility Criteria - Criteria A

CoolCap( any )

NICHD ( only 1)

TOBY(any)

Neo.nEURO(any)

ICE ( 2 of)

CPS (any)

Calgary (any)

Apgar ≤ 5 @ 10 PH < 7.00 Apgar ≤ 5 @ 10

Apgar < 5 @ 10 Apgar ≤ 5 @ 10

Apgar < 5 @ 10

Apgar ≤ 5 @ 10

PH < 7.00 BD≥16 PH < 7.00 PH < 7.00 PH < 7.00 PH < 7.00 PH ≤ 7.00

BD≥16 If 7.01 - 7.15, a BD 10 and 15.9 then add:

BD≥16 BD ≥ 16 BD ≥ 12 BD > 16 BD≥16

IPPV ≥ 10 min Acute perinatal event and :

IPPV ≥ 10 min

IPPV ≥ 10 min IPPV ≥ 10 min

IPPV ≥ 10 min

IPPV ≥ 10 min

Apgar ≤ 5 @ 10OR

IPPV ≥ 10 min

Solution:Cooling Application

TO COOL OR NOT TO COOL APP

Cooling App

• Free!

• Easy To Use

• Took away guessing and made it easy for end users

Confusion: Criteria For Cooling

Solution: Cooling App

Identification of

Encephalopathy

Criteria B

Criteria B - Problem

• Inexperienced end users

• Inconsistency

• Neurological exam often incomplete and badly performed

• Need for repeat exams

Sarnat Staging

Criteria B – Identification Of Encephalopathy

Identification of Encephalopathy

Solution: Targeted Neurological Exam

Step By Step Guide For End User On How To Conduct A Quick And

Targeted Neuro Exam

SHOW CLIP

Certain Aspects Of Neurological Examination Were

Particularly Inconsistent:

Tone

Message Made to Stick

Three Or More Cool The Core

and

If Baby Seizes She Freezes

Documentation

Bringing This All Together:Outreach Education

Feb 2016

THERAPEUTIC HYPOTHERMIA IN STAGE II AND III HIES

Before After

28%

9%

% of mod to severe HIE not cooled

P=0.001

Outreach Program And Short Term Outcomes

Outreach Education

Before After P value

Eligible and not cooled (%) 25 6 0.015

Time to passive by referral Team (minutes),

mean (SD)154.27(82.733) 92.14(105.948) 0.063

Time to initiation of active cooling, (minutes),

mean (SD)264.15(109.440)

226.17(124.802

)0.329

Time to referral(minutes), mean (SD) 106.7(73.8) 89.5(64.2) 0.32

Summary

• Hypothermia standard of therapy

• Challenge In prompt identification and initiation of cooling

• Screening Infants For Cooling – Cooling App

• Identify Encephalopathy – Targeted Neurological Exam

• Improve Compliance – Documentation

• Outreach education

• aEEG – We did not embark on utilizing aEEGg because of local resources

• Improvement in identification and initiation of cooling is achievable with

very little resource utilization

CASE 1

History

• 35 Weeks

• 2.2 Kg

• Late Decelerations

• Cord Ph 7.1

• IPPV For 10 Minutes

• Apgar At 10 Minutes 7

Clinical Exam

Please Vote

1. Cool

2. No Cooling

CASE 2

History

• 36 Weeks

• 1900 Gm

• Cord Ph 7.1

• Apgar 0, 1 and 3 at 1, 5 and 10 Minutes

• PPV for 5 mins

EXAM

Please Vote

1. Cool

2. No Cooling

CASE 3

History

• 40 Weeks

• 4 Kg

• Uterine Rupture

• Breech presentation

• Apgar 3 At 10 Minutes

• Cord Ph 7

Please Vote

1. Cool

2. No Cooling

DON'T POKE ME, I AM HIBERNATING!

NEUROPROTECTION PACKAGE FOR NEONATAL HIE

ACKNOWLEDGEMENTS

NICU-NCC◦ ALIXE HOWLETT

◦ HUSSEIN ZEIN

◦ PRASHANTH MURTHY

◦ THIERRY LACAZE

◦ LEONORA HENDSON

◦ ELSA FIEDRICH

◦ AYMAN ABOU MEHREM

◦ IPSITA GOSWAMI

◦ JAN LIND

◦ CATHY METCALF

◦ LEIGH IRVINE

◦ NORMA OLIVER

◦ SHAUNA LANGENBERGER

SANTS OUTREACH PROGRAM TEAM◦ SUMESH THOMAS

◦ RENEE PAUL

◦ NTNS AND TRTS

PEDIATRIC-NCC

◦ MICHAEL ESSER

◦ LUIS BELLO-ESPINOZA

◦ JEFFREY BUCHHALTER

◦ JP APPENDINO

◦ ALEKSANDRA MINEYKO

◦ JONG RHO

◦ ADAM KIRTON

◦ HARVEY SARNAT

◦ ALICE HO

◦ KIM SMYTH

◦ XING-CHANG WEI

◦ JAMES SCOTT

◦ MEGAN CRONE