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Hipotermia Terapêutica

A Hipotermia Terapêutica melhora a sobrevivência e o neurodesenvolvimento em recém-nascidos com EHI moderada ou grave. Utilizar-se da evidência científica e de protocolos previamente estabelecidos é passo fundamental.

Therapeutic Hypothermia for Neonatal Encephalopathy

Neonatal Hypoxic-ischemic encephalopathy in full term infants has been associated with a high risk for morbidity and mortality. The patho-physiology of brain injury following hypoxia-ischemia, noted in preclinical models, is a cascade of events resulting from excitotoxic and oxidative injury culminating in cell death. Hypothermia has been noted to be protective by inhibiting various events in the cascade of injury. Major randomized clinical trials in neonatal HIE have demonstrated reduction in death and disability and continued safety and efficacy of neuroprotection in childhood. There is now clinical and imaging evidence for hypothermia as neuroprotection. Hypothermia should be offered to term infants with either severe acidosis at birth or resuscitation needing continued ventilation and evidence of either moderate or severe encephalopathy within 6 hours of birth. The target temperature should be 33° to 34 °C and duration of cooling should be 72 hours, as per the published trials. Rewarming should be slow, at 0.5 °C per hour. Infants should have serial neurological examinations during and at the end of cooling and at discharge. Multiorgan function should be supported and hypocarbia should be avoided during ventilator therapy. If available, the amplitude integrated EEG should be obtained prior to cooling and following rewarming. All infants should have magnetic resonance brain imaging studies within 1 to 2 weeks of age. Information from the neurological examination, aEEG and MRI studies will be helpful in discussing prognosis with parents. All infants should be followed for a minimum of 18 months to evaluate growth parameters and neurodevelopment al outcome.

Risk factors for EEG seizures in neonates treated with hypothermia…

OBJECTIVE: To assess the risk factors for electrographic seizures among neonates treated with therapeutic hypothermia for hypoxic-ischemic encephalopathy (HIE). CONCLUSIONS: Electrographic seizures are common among neonates with HIE undergoing hypothermia and are difficult to predict based on clinical features. These results justify the recommendation for cEEG monitoring in neonates treated with hypothermia.

Rewarming: facts and myths from the systemic perspective

It is a pleasure to announce the 2nd Innsbruck Hypothermia Symposium. We are very happy that Critical Care has agreed to publish extended abstracts submitted by invited renowned scientists from all over the world; that is, Europe, the Americas, Asia. Neuroprotection - potentially achieved by targeted temperature management (that is, therapeutic hypothermia or prophylactic controlled normothermia) - is essential in emergency and acute care management of various severe neurologic and cardiologic diseases. Beyond neuroprotection - for this aim, therapeutic hypothermia has been established after resuscitation of patients with cardiac arrest due to a shockable arrhythmia and in neonatal asphyxic encephalopathy - therapeutic hypothermia and prophylactic controlled normothermia have been published in single case reports, retrospective, open, but also in prospective randomised controlled trials in many other emergency disciplines in which both neuroprotection and protection of other organs and tissues are the target of our therapeutic endeavours. The Medical University Innsbruck, Austria, is happy to organise this conference on temperature management, therapeutic hypothermia and prophylactic normothermia respectively, to be held in Portoroz, Slovenia. In accordance with the first Meeting on Hypothermia, which was held in Miami, Florida, USA (CHilling At the Beach), we are proud to suggest the acronym CHAB standing for take Care for Heart And Brain, characterising the major target organs of therapeutic and, possibly also, prophylactic temperature management. Again, we have been able to gather most renowned scientists, neurointensivists and intensivists, emergency physicians, cardiologists and other specialists to cover the entire scientific and clinical spectrum of emergency temperature management, technical aspects of cooling and management of potential complications including shivering, but also temperature management in neurology, neurosurgery, intensive care medicine, in the operation theatre, cardiology, infectious diseases, and so forth. Beyond that we cross borders and discuss hypothermia and intracranial pressure, pharmacodynamics in hypothermic patients and the influence of hypothermia onto pharmacokinetics/pharmacodynamics, hypothermia in refractory status epilepticus or heat stroke, hypothermia and advanced neuromonitoring, hypothermia and nutrition, shivering and the critical issue of rewarming, amongst other topics.The aim of this symposium is to enhance the knowledge on temperature management, increase the readiness and stimulate the preparedness to institute therapeutic hypothermia and/or prophylactic controlled normothermia, respectively, in patients in need of tissue and organ protection, uncontrolled body temperatures possibly adding - per se - to neuronal damage. Knowing the medical literature and knowing the issue of potentially life-threatening side effects and complications incurred by this invasive therapeutic manoeuvre, it is the foremost aim of this symposium and this supplementary issue of Critical Care to discuss all these aspects of targeted temperature management in emergency, critical care and, in particular, neurocritical patients and conditions. For this reason the organisers have agreed that the discussion of these various issues, being so important for general critical care, neurocritical care and emergency medicine, must be distributed as widely as possible, making it available to critical care and neurocritical care specialists all over the world. Therefore we are extremely grateful to the Editors of Critical Care for providing a forum for all of the extended abstracts of all invited speakers, covering the entire field of adult emergency and critical care medicine. We do hope and we are convinced that this supplementary issue will be a source of inspiration and knowledge, hopefully becoming a work of reference for intensivists, neurologists, neurointensivists, cardiologists and all emergency physicians alike. It is the aim of the organisers to establish a series of such symposia within the next years in order to keep up with all the developments in this field and to maintain the highest possible level of knowledge of targeted temperature management in the community of emergency and intensive care physicians.

Supportive care during neuroprotective hypothermia in the term newborn…

Hypothermia as neuroprotective treatment requires significant knowledge of how temperature affects all organ systems and interventions used in intensive care. Education and training in resuscitation, including avoidance of hyperthermia, early diagnosis of eligible infants, and initiation of early cooling followed by safe transport of cooled infants to the cooling center seems to be an optimal approach. This article suggests clinical management and shows examples of potential adverse effects of clinical hypothermia. The practical cooling recommendations suggested herein are therefore likely to develop and change over time as more experience is gained.

Clinical management of the baby with hypoxic ischaemic encephalopathy

The results of randomized clinical trials indicate that the optimal management for infants with hypoxic ischaemic encephalopathy is therapeutic hypothermia combined with high quality standard neonatal intensive care. In addition to therapeutic hypothermia clinical management of the infant with hypoxic ischaemic encephalopathy should include the management of multiorgan dysfunction, obtaining and documenting detailed clinical information and performing appropriate investigations and assessment to confirm the diagnosis and to help direct care, and providing counseling and support to the family. This article is a summary of the in hospital clinical management of infants with hypoxic ischaemic encephalopathy.

Whole-body hypothermia for neonates with hypoxic–ischemic encephalopathy

Hypothermia is protective against brain injury after asphyxiation in animal models. However, the safety and effectiveness of hypothermia in term infants with encephalopathy is uncertain. CONCLUSIONS: Whole-body hypothermia reduces the risk of death or disability in infants with moderate or severe hypoxic-ischemic encephalopathy.

Part 13: Neonatal Resuscitation

The following guidelines are a summary of the evidence presented in the 2015 International Consensus on Cardiopulmo nary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR). Throughout the online version of this publication, live links are provided so the reader can connect directly to systematic reviews on the International Liaison Committee on Resuscitation (ILCOR) Scientific Evidence Evaluation and Review System (SEERS) website. These links are indicated by a combination of letters and numbers (eg, NRP 787). We encourage readers to use the links and review the evidence and appendices.These guidelines apply primarily to newly born infants transitioning from intrauterine to extrauterine life. The recommendations are also applicable to neonates who have completed newborn transition and require resuscitation during the first weeks after birth. Practitioners who resuscitate infants at birth or at any time during the initial hospitalization should consider following these guidelines. For purposes of these guidelines, the terms newborn and neonateapply to any infant during the initial hospitalization. The term newly born applies specifically to an infant at the time of birth.Immediately after birth, infants who are breathing and crying may undergo delayed cord clamping (see Umbilical Cord Management section). However, until more evidence is available, infants who are not breathing or crying should have the cord clamped (unless part of a delayed cord clamping research protocol), so that resuscitation measures can commence promptly.Approximately 10% of newborns require some assistance to begin breathing at birth. Less than 1% require extensive resuscitation measures, such as cardiac compressions and medications. Although most newly born infants successfully transition from intrauterine to extrauterine life without special help, because of the large total number of births, a significant number will require some degree of resuscitation.

Hypothermia and Neonatal Encephalopathy

Data from large randomized clinical trials indicate that therapeutic hypothermia, using either selective head cooling or systemic cooling, is an effective therapy for neonatal encephalopathy. Infants selected for cooling must meet the criteria outlined in published clinical trials. The implementation of cooling needs to be performed at centers that have the capability to manage medically complex infants. Because the majority of infants who have neonatal encephalopathy are born at community hospitals, centers that perform cooling should work with their referring hospitals to implement education programs focused on increasing the awareness and identification of infants at risk for encephalopathy, and the initial clinical management of affected infants.

Hypothermia for newborns with hypoxic ischemic encephalopathy

Hypoxic ischemic encephalopathy (HIE) remains a significant cause of mortality and long-term disability in late preterm and term infants. Mild therapeutic hypothermia to a rectal temperature of 34±0.5°C initiated as soon as possible within the first 6 h of life decreases mortality and severe long-term neurodevelopmental disabilities in infants with moderate HIE who are ≥36 weeks’ gestational age. There are minimal side effects, and the incidence of disability in survivors is not increased. Infants with severe encephalopathy are less likely to benefit from treatment. Cooling may be achieved by either total body or selective head cooling. As cooling is now considered a standard of care, infants ≥36 weeks’ gestational age who are depressed at birth should be assessed to determine whether they meet the criteria for cooling. There is currently no evidence that therapeutic hypothermia offers any benefit to infants <36 weeks’ gestational age. Keywords: Asphyxia, Cooling, Hypothermia, Hypoxic ischemic encephalopathy, Outcome

Prospective research on infants with mild encephalopathy: the PRIME study

Objective: To determine short-term outcomes of infants with evidence of hypoxia–ischemia at birth and classified as mild neonatal encephalopathy (NE) at <6 h of age. Study Design: Prospective multicenter study. Mild NE was defined as 1 abnormal category in modified Sarnat score. Primary outcome was any abnormality on early amplitude integrated electroencephalogram (aEEG) or seizures, abnormal brain magnetic resonance imaging (MRI) or neurological exam at discharge. Results:  A total of 54/63 (86%) of enrolled infants had data on components of the primary outcome, which was abnormal in 28/54 (52%): discontinuous aEEG (n=4), MRI (n=9) and discharge exam (n=22). Abnormal tone and/or incomplete Moro were the most common findings. MRI abnormalities were confined to cerebral cortex but two infants had basal ganglia and/or thalamus involvement. The 18 to 24 months follow-up is ongoing. Conclusions: A larger than expected proportion of mild NE infants with abnormal outcomes was observed. Future research should evaluate safety and efficacy of neuroprotection for mild NE.

Principais Questões sobre a Classificação de Robson em Obstetrícia

A Classificação de Robson ajuda instituições e gestores a responderem quem são as mulheres submetidas à cesariana e se há excessos de cesárea em algum grupo específico.