Implementation of a ‘Hypothermia for HIE’ program: 2-year experience in a single NICU

Abstract

Hypothermia has been shown to be neuroprotective in some newborns with moderate-to-severe perinatal hypoxic-ischemic encephalopathy (HIE). In 2006, the American Academy of Pediatrics recommended that institutions that choose to use therapeutic hypothermia do so in the context of a rigorous protocol, with systematic collection of patient data including neurodevelopmental follow-up. In this report, we describe our experience with implementation of a 'Hypothermia for HIE' program in a single tertiary care Neonatal Intensive Care Unit (NICU). Important components of the program include detailed protocols, staff and outreach education, early initiation of cooling in both inborn and outborn patients, maintaining stable hypothermia during neonatal transport, and comprehensive neurologic evaluation including serial EEGs, brain MRI and neurodevelopmental follow-up. In the first 2 years of the program, we have used hypothermia therapy in 21 patients, 18 with perinatal and 3 with early postnatal events leading to HIE. Eleven of fifteen outborn patients were cooled prior to and during transport, resulting in initiation of therapy 3 h sooner than if therapy had been delayed until arrival at our center. While lowering the body temperature of encephalopathic newborns is not difficult, addressing the complex medical problems of this vulnerable group of patients requires an experienced multidisciplinary team in regional referral centers.

Safety and Effectiveness of Whole Body Cooling Therapy for Neonatal Encephalopathy on Transport

“…To date, induced hypothermia by either selective head or whole body cooling within 6 hours of birth 1-3 is the only effective treatment for HIE shown to decrease the combined outcome of death or severe neurodisability at 18 months. 4-10 Several randomized clinical trials 5,7,9 and other single-institution studies [11][12][13][14][15][16] have included protocols that have initiated and/or continued cooling therapy during interfacility transport of "outborn" neonates delivered far from a cooling center or referred several hours after delivery. Although these studies have shown that cooling on transport is feasible and provide guidelines for protocol development, 17 efficacy and safety concerns such as potential overcooling 13 remain in question.…”

Passive cooling for initiation of therapeutic hypothermia in neonatal encephalopathy

“…If cooling is delayed until the arrival of an infant at a cooling centre, this is likely to reduce its efficacy. A number of passive cooling12 13 and combined passive and active cooling14 15 strategies have been used during transport. In the largest series of babies undergoing passive cooling, a significant proportion of infants were overcooled,13 suggesting the need for clear and validated passive cooling protocols.…”

Programa multicéntrico para la atención integral del recién nacido con agresión hipóxico-isquémica perinatal (ARAHIP)

“…Aunque existen recomendaciones y programas específi-camente en el tratamiento con hipotermia 5,[16][17][18][19] , no resulta fácil encontrar protocolos o vías clínicas que ordenen todo el proceso asistencial del RN en riesgo de presentar EHI antes del inicio de la hipotermia terapéutica 10,20 . Si en la práctica clínica el tratamiento con hipotermia exige rigor para optimizar su éxito fuera de ensayos clínicos 21 , este rigor también es necesario en la vigilancia previa y en la selección adecuada de los candidatos a recibir dicho tratamiento 10,22 .…”

“…En nuestro país, comunidades como Madrid o Cataluña disponen de equipos entrenados y con protocolos de manejo del RN con EHI durante el transporte. El programa ARAHIP, a través de la vigilancia sistemática de todo RN con riesgo de EHI y la aplicación de recomendaciones protocolizadas para el traslado, ha permitido una alta tasa de tratamiento con hipotermia en el periodo ventana, iniciándose en el hospital emisor y manteniéndose durante el traslado 17,18 . La excelente comunicación entre los centros emisores y receptores, con apoyo a los equipos de transporte, ha sido clave para estos resultados.…”