Upload
vudang
View
217
Download
0
Embed Size (px)
Citation preview
Overview What is known?
- studies
- outcomes at 18 months and 6-7 years
What is new?
- adjuvant therapies with hypothermia
Where are we now?
- Chris Hani Baragwanath experience
8 randomised trials were included
638 term infants with moderate to severe encephalopathy and evidence of intrapartum asphyxia
Hypothermia resulted in statistically significant and clinically important reduction in the combined outcome of mortality and major neurodevelopmental disability to 18 months of age
NNT =7
Borderline increase in the need for inotropic support and significant increase in thrombocytopaenia
Cochrane review
Long term Outcomes (6-7 years) NICHD – death or disability was decreased (41% vs 60% P=0.03)
- survivors – IQ < 70 ( 27% vs 33%) and CP in 17% vs 29% (P=NS)
Toby – 52% hypothermia patients vs 39% control groupchildren survived with an IQ>85 (RR>1.31, P=0.04)
- number of children that died were 29% vs 30% - 45% vs 28 % survived without neurological abnormalities (RR 1.61, CI - 1.15-2.22)- a decrease in the rate of CP and moderate to severe disability
CoolCap – status at 18 months was associated with status at 6-7 years (p<0.001)
- CP diagnosed at 18 months was highly associated with WeeFim mobility scores at 7-8 years
Asphyxiated babies would not qualify for ventilation
Some studies include
Passive cooling/accidental cooling
Gel packs
Servocontrolled cooling fan
use of water bottles
These studies demonstrate that a cost effective feasible method of cooling can be achieved
Efficacy still needs to be demonstrated
Cooling in resource poor settings
AEDS – Phenobarbital, Topiramate and Levetiracetam Xenon N-acetylcysteine (NAC) EPO Melatonin Cannabinoids Pomegranate juice Trapidil Morphine Allopurinol VEGF/HIF Magnesium sulphate
Synergistic therapies with hypothermia
RESULTS
Demographics Mean (SD)
n=98
Mom’s Age (years) 24.3 (5.6)
Parity 1 (0-4)*
Mode Of Delivery - NVD- Caesarian Section
56 (57)27 (28)
HIV positive 18 (18)
* Median (IQ Ranges)
98 patients were cooled
Demographics of infants that were cooled
Demographics Mean (SD)
n=98
Gestational Age (wks) 39.1 (1.5)
Birth weight (g) 3182.7 (440.8)
Gender - Males- Females
55 (56) 43 (44)
98 patients were cooled
Criteria Number (%)
Sentinel event 48 (49)
Apgars <5 at 10 min 25 (26)
Resuscitation at 10 min 59(60)
Ph <7.0Base Deficit >16 mmol/l
65 (66)81 (83)
Encephalopathy - HIE 1- HIE 2- HIE 3
2 (2)81 (83)15 (15)
aEEG pattern
Continuous normal voltage
Discontinuous normal voltage
Burst Suppression
Continuous Low Voltage
Flat Trace
58
4 (7)
26 (45)
10 (17)
16 (28)
2 (3)
Number of patients who fulfilled criteria for cooling
Platelet and Coagulation Abnormalities During Cooling
Characteristic Mean (SD)
Platelets before hypothermia (X109/l)- <150 X109/l (n=85)
220.4 (172.7)19 (22)*
Platelets during cooling (X109/l) - <150 X 109/l (n=54)
167.8 (69.9)22 (41)*
INR- >1.5 IU/l (n=35)
1.6 (1.3)3 (9)*
Ventilated during hypothermia 7 (7)*
*n(%)
Outcomes
Number (%)
Died 15 (15)
Griffiths Score at 12- 18 months (n=20)- <85- 85-100- >100
5 (25)12 (60)3 (15)
Conclusion
Therapeutic Hypothermia is feasible within a South African setting outside of an NICU setting.
Resources remain a major factor in managing these patients according to the protocol
Long-term follow-up is important to fully assess the effectiveness of induced hypothermia
Exciting times for neuroprotection
Questions as to
When is the optimal time and at what dosage to administer some of the synergistic therapies?
Need to consider risk / benefit ratio?
Cost may be prohibitive!
Consider effects long term ?
In Summary