Dr Peter Reynolds Neonatal Consultant, St. Peter’s Hospital Clinical Lead, Surrey and Sussex Neonatal ODN Time = Brain Effective Diagnosis and Therapeutic Hypothermia in babies with HIE Time = Brain Effective Diagnosis and Therapeutic Hypothermia in babies with HIE

Cooling is Clinically and Cost Effective Application of therapeutic hypothermia ("cooling") for 72 hours in babies who are suffering hypoxic ischaemic encephalopathy (HIE) is a recognised standard of care approved by NICE and ILCOR Meta-analysis by Jacobs et al confirmed the improvement in clinical outcomes associated with cooling NNT=7 Regier et al from the NPEU demonstrated that it is a cost- effective treatment. Current estimate ?£150 million saved to UK to date

Passive cooling can be unreliable Kendall et al: 39 babies that only 15% were cooled to the target range successfully Akula et al: passive cooling in 223 babies transported achieved the target temperatures in only 44% of babies, with admission temperatures after transfer as low as 29.2°C and as high as 37.1°C Hallberg et al: 22% temperature in the desired range (33– 34 °C), 33% too cold and 45% too warm

KSS Cooling 2012 and 2013

Iwata O et al: - ‘Therapeutic time window’ duration decreases with increasing severity of cerebral hypoxia- ischaemia under normothermia and delayed hypothermia in newborn piglets. Brain Res 2007; 1154: 173–180. Time = Brain

Azzopardi et al UK data showed the average time to start cooling for HIE was 3.3 hours (range hrs) It took a further 1-3 hours to achieve target temperature *FVGIT INREPARABILE TEMPVS: "it escapes, irretrievable time". Vergilius Maro, Publius. Georgicon, Line 284, Book III. c. 29 BC Tempus Fugit*

Network Data

Not routinely available at network level Local transport teams may have data Prediction? – suboptimal Time to reach 33-34°C

Aim of Time=Brain 1.Improve clinical assessment of babies suspected of HIE 2.Improve documentation 3.Ensure prompt cooling within timeframe available

Making the Decision to Cool

Network website has all documentation, presentations, training manuals and background information Best way to submit data is using the form

Patient Code – use excel form (see next slide) Time of birth is critical information!

All units encouraged to phone NICU / transport neonatal Consultant early prior to starting cooling Document discussions – who with and when? Decision –Start cooling? Postnatal collapse should ALWAYS be discussed prior to decision to cool and only applies to babies who are still in hospital and less than 48 hours old

A baby who is hyperalert, hyperexcitable (e.g. hyperreflexic) without other abnormal signs (e.g. normal tone and respiration) has mild HIE and does not require cooling, as their outcome is expected to be normal. Document examination and repeat examination – HIE can worsen over time but repeated examinations in the first few hours are good practice and will help to ensure worsening HIE is not missed A baby who is subsequently improving is unlikely to have moderate / severe HIE Clinical diagnosis of Encephalopathy

A baby with these signs is likely to be encephalopathic: Reduced response to stimulation e.g. lethargic, or obtunded AND Abnormal neurology e.g. reduced tone, abnormal posturing and reduced/absent primitive reflexes AND Abnormal state of consciousness e.g. low Apgar scores, reduced spontaneous movements, respiratory difficulties, weak, absent or irritable cry OR Seizures Clinical diagnosis of Encephalopathy

Decision to cool? Stuporous Flaccid Abnormal posture Reduced or absent reflexes Yes – this may be severe encephalopathy and ongoing medical treatment may or may not be appropriate. However the decision to discontinue further active treatment should be made after detailed neurological evaluation in NICU Clinical diagnosis of Encephalopathy

Clinical Assessment of Neonatal Encephalopathy: Print out this sheet and use it to guide a structured examination of the baby.

Aim to bring baby to neonatal unit for examination, and don’t start cooling until neurological examination is completed. Active servo-cooling means you have plenty of time to make the diagnosis. 6 hours after birth remains the key timepoint for target temperature to be achieved. Once active cooling has started, it will normally take ≤30 mins to reach target temperatures Festina lente – “hasten slowly”

What about the babies who are in between “mild to moderate” Irritable Tone either normal or decreased – difficult to know Hyperflexia Requiring CPAP / nasal High Flow Possibly abnormal posture Use the grading sheet to help Answer: Difficult to predict clinical progression Plan: Wait an hour, re-examine. Talk to a neonatal consultant. Repeat examination is the key to good decision making Clinical diagnosis of Encephalopathy

Post Decision Management

First scoring is done after the decision to cool but before cooling commenced The scoring is the same as the Badger scoring to make data entry simple Second scoring is done at 6 hours or at handover to transport team (if applicable) We are aiming for target temperature to be reached within 6 hours of delivery (or hypoxic event)

Clinical teams should use the prompts to ensure optimal clinical management. Neonatal consultants at NICU and/or transport team consultants are available 24/7 for advice

Simultaneously: Risk factors / concerns? => Clinical examination Cooling unit set up by nurses Decision to cool Document yes/no If yes – Ensure all fields on Time=Brain pathway completed Make copy Transfer baby to NICU (as per current network pathways) for neurointensive care Send paperwork to Dr. Reynolds by Pathway Completion

Clinical Scenario

Term baby, concerns about pathological CTG Trial of ventouse in theatre by obs. registrar 3 pulls unsuccessful, consultant advises episotomy + forceps Baby delivered, thick meconium noted Heart rate <60bpm, no resp effort, pale and floppy Inflation breaths poor chest wall movement, CPR started Intubated at 4 minutes, HR increased after 2 min and then gasped at 7 minutes and regular resps at 10 minutes White secretions from ET tube Cord gas pH 7.1, pCO kPa, BE -16 mmol/L ACTIONS? Clinical Scenario 1.

AT RISK - admit – bloods, i.v. 10% dextrose at 40ml/kg/d Neurological examination Breathing spontaneously in air with ETT in situ Normal tone, deep tendon reflexes and posture Extubate Continue monitoring Check gases – BE and lactate improving Re-examine hourly over next 3-4 hours NOT ENCEPHALOPATHIC. NOT FOR COOLING Clinical Scenario 1.

Baby has started cooling after decision made on Time=Brain pathway CFM is applied at 6 hours and appears to be normal Should cooling be discontinued? Clinical Scenario 2. The answer should normally be “no” because: There should have been a neurological assessment and documentation of encephalopathy The predictive value of CFM is reduced in a cooled baby However this is predictive of a good outcome (PPV 91%)

Thank you Time = Brain Effective Diagnosis and Therapeutic Hypothermia in babies with HIE Thank you Time = Brain Effective Diagnosis and Therapeutic Hypothermia in babies with HIE