Don’t Get Left Out in the Cold

Don’t Get Left Out in the Cold
Brandi Vandivier, NNP-BC Onsite Neonatal Partners Union Hospital, Terre Haute

Learning Objectives Define Hypothermia
Identify Neonates most at risk for hypothermia Identify complications of hypothermia Identify ways to prevent hypothermia in the delivery room Identify challenges to implementing change to improve temperatures in your hospital Hypothermia is Preventable!

Thermoregulation Body temperature is one of the primary vital signs.
A - Airway B - Breathing C - Circulation D - Degrees Hypothermia in infants is an independent risk factor for morbidity and mortality

Goal of Thermoregulation
Maintain correct body temperature range in order to: maximize metabolic efficiency reduce oxygen use protect enzyme function reduce calorie expenditure Neutral thermal environment: ambient temperature within which the baby can maintain normal body temperature with minimum metabolic rate and oxygen consumption

Challenges of thermoregulation in Neonatal care
Prior to delivery infants do not maintain temperature independently Infant’s in-utero temp is generally 0.5˚C higher than mother’s temp Rapid cooling occurs after delivery -Fetal mechanisms for cold stress responses are not active in-utero as the mother is a massive heat reservoir. Therefore, the fetus does not thermoregulate -infant is characteristically born into a wet, cold and hostile environment

Neurologic adaptation: Thermoregulation
Maintenance of body temp is a major task Term Infants have 3x the surface to body mass of an adult Preterm infants and SGA infants have 4x the surface mass to body mass of an adult Preterm infants are especially susceptible to heat loss due to poor tone,  fat and thinner skin than term infants The first 6-10 hours of life is the critical period of transition for the preterm baby. Some may exhibit distress at delivery; others may develop signs and symptoms over the first few hours. *Infant must produce 5x heat per kilo as an adult faced with the same stress

Thermoregulation Risk Factors
Premature SGA Neuro problems Endocrine Cardiac / respiratory problems Large open areas in the skin Sedated Infants Drug exposure Hypothermia is usually iatrogenic and increases the metabolic demands on an already stressed baby

Cold Stress Response in Term Infants
Vasoconstriction Prevents blood from reaching the skin surface where heat loss occurs If prolonged, blood flow and oxygen delivery to the tissues is reduced and increases the risk of organ and tissue damage from anaerobic metabolism and lactic acidosis Increased Muscle Activity & Flexion Poor capacity to shiver instead they increase their activity level by crying and flexing arms and legs Norepinephrine release from hypothalamus causes pulmonary and peripheral vasoconstriction, increased metabolic rate, and increased oxygen and glucose consumption. Right to left shunting secondary to pulmonary vasoconstriction leads to hypoxemia, increased oxygen consumption and poor tissue oxygenation secondary to prolonged peripheral vasoconstriction can lead to hypoxia *a term healthy newborn can maintain an increased metabolic rate of heat production from minutes to a few hours depending on their environmental conditions. After that, energy stores become depleted and hypothermia rapidly progresses

Metabolic Processes Brain, heart, and liver produce the most metabolic energy by oxidative metabolism of glucose, fat and protein Nonshivering Thermogenesis Heat is produced by the metabolism of brown fat

Accumulated in increasing amounts especially in the last part of the 3rd trimester At term, accounts for 2-7% of infant’s total body weight The distribution of brown adipose tissue (brown fat) in the newborn. p. 490 Nonshivering theromgenesis. Primary method of heat production in infants Found only in newborns Found in back of neck, axillae, around the kidney, adrenals and sternum, between the scapula and along the abdominal aorta. C. Non shivering thermogenesis 1. Newborns rarely shiver Cold stress -> norepinephrine released into nerve endings of brown fat->signals brown fat to start burning -> when signaled to burn the brown fat cells generate more energy than any other tissue n the body. It’s a highly metabolic activity that produces heat in the core regions of the body and warms the blood as it circulates past Nonshivering thermogenesis The distribution of brown adipose tissue (brown fat)

Risk factors for Preterm Infants
less brown fat and glycogen stores decreased ability to maintain flexion increased body surface area compared to weight thinner immature skin- increased evaporation loss poor ability to vasoconstrict in the first few days of life The smaller or more premature the newborn is, the greater the risk of heat loss. When heat loss exceeds the newborn’s ability to produce heat, its body temperature drops below the normal range and the newborn becomes hypothermic.

Servo on radiant warmer and do not place over areas of brown fat
Servo on radiant warmer and do not place over areas of brown fat. If probe is placed over a brown fat area the probe will not be reading a core temp not skin temp. The core temp will be higher than the skin and the warming device will cool environment

Adverse Consequences of Hypothermia
Cold Stress Increased metabolic rate Increased oxygen consumption and glucose use Worsening respiratory distress and unable to meet increase tissue demand for oxygen Worsening hypoxemia and worsening pulmonary vasoconstriction *Cold stress imposes metabolic and physiologic demands on all infants, regardless of gestational age or condition. In the cold stressed infant oxygen consumption and energy are diverted from maintaining normal brain and cardiac function and growth to thermogenesis for survival. *oxygen consumption increases, and pulm and peripheral vasoconstriction occur, which decreases oxygen uptake by the lungs and tissues, anaerobic glycolysis increases; and a decrease in Po2 and pH, leading to metabolic acidosis (Excessive fatty acids can displace albumin binding sites and exacerbate hyperbilirubinemia) The end result of hypothermia is similar for both term and preterm infants. During anaerobic metabolism, lactic acid accumulates rapidly and the pH of the blood drops quickly. If not reversed, there is significant risk of cell damage and death. Norepinephrine release from hypothalamus causes metabolic rate to increase ->increases oxygen consumption and glucose utilization. Peripheral vasoconstriction is limited in VLBW in the first 48 hrs thus increasing loss at the skin level. Effect of norephinephrine on pulm vasoconstriction in preterm baby is not well described. In preterm infants, heat loss occurs at a faster rate than their ability to produce or conserve heat. If left unprotected from heat loss, the preterm infant will decrease their body temperature to the same as the surrounding environment.

Signs/Symptoms of Hypothermia
Hypoglycemia Respiratory Distress, Apnea, Tachypnea Poor Feeding or Tolerance Lethargy Irritability Poor Muscle Tone Cool Skin Temperature Mottled Skin A baby can have a normal axillary temperature and still be cold stressed as indicated by a low skin temperature. Both skin and axillary temps should be monitored with a goal to maintain as close of a differential between core and peripheral as possible to reduce energy expenditure *All of these signs are non-specific and can indicate other significant conditions such as bacterial infection in the newborn *A slight decrease in temperature may produce a profound metabolic change; however a significant decrease must occur before any clinical features are present*

Hypoglycemia Lethargy, bradycardia, irritability, apnea, seizures Increased metabolic rate to produce heat Increase glucose needs at a time when stores are diminished and glucose delivery is delayed

Hypoxia Tachypnea, grunting, flaring, retracting, central cyanosis Increased demand for oxygen for thermogenesis may decrease oxygen delivery to tissues and other vital organs, worsening respiratory distress and desaturation Hypoxia can lead to anaerobic metabolism and pulmonary vasoconstriction

Respiratory & Metabolic Acidosis Apnea, seizures, pulmonary hemorrhage Anaerobic metabolism with ongoing hypoxia leads to decreased cardiac output and acid-base abnormalities Fatty acids and lactic acid from incomplete glucose breakdown and lower pH

Cardiovascular Compromise Tachycardia followed by bradycardia, hypotension Decreased baseline heart rate, blood pressure and perfusion Impaired contractility and function

Neurologic Compromise Irritability, lethargy, unresponsiveness Decreased circulation and increased permeability of blood-brain barrier May increase the risk of IVH in the first 3 days of life with alterations in SVC flow and hypoperfusion-reperfusion injury directly related to cost stress and inadequate vasomotor tone

High O2 consumption  hypoxia, bradycardia High glucose usage  hypoglycemia / decreased glycogen stores High energy expenditure  reduced growth rate, lethargy, hypotonia, poor suck/cry Low surfactant production  RDS Vasoconstriction  poor perfusion  metabolic acidosis Delayed transition from fetal to newborn circulation Thermal shock  DIC  death *Twice as much oxygen is needed if infant’s temp is 35 degrees rather than 97 degrees Especially profound in the preterm infant because babies at <28 weeks in particular do not have mature alveoli, have the structurally underdeveloped lung known as RDS due to inadequate surfactant

Neonatal Energy Triangle
In response to cold stress a series of reactions are activated for the purpose of decreasing heat loss and increasing heat production. To mount these responses, the metabolic rate must increase which increases utilization of both oxygen and glucose

If a baby is hypothermic, the risk of dying is increased If a baby’s temperature is below 36.5 (97.7) the risk of dying is 12x higher For every degree below 36.5 (97.7) the risk of a preterm baby dying is 23x higher During literature review for NRP, recent studies were reviewed and included over 50,000 babies. Studies were all inclusive, resource rich, resource poor, term and preterm around the world, the effect of hypothermia is the same.

If a baby is not protected from heat loss, the infant’s body temperature may drop as fast as 0.2 to 1 degree C per minute! Remember baby’s temp is 0.5 degree higher than mom’s

Convection and Radiation
Occurs when air flow carries heat to or away from the body Radiation Radiant energy exchange occurs between two objects that are not in direct contact with each other.

Conduction and Evaporation
Occurs when liquid is turned to vapor, as with amniotic fluid on a newly delivered infant. Conduction Heat exchange that occurs between objects that are in direct contact with one another

Conduction Transfer of heat between two solid objects that are in contact with each other Examples: infant’s body against a mattress, scale, x-ray plate, stethoscope, temperature probe, hands, blankets Prevention: Pre-warm objects Provide insulation between baby and the cooler surface Place warm blanket on scale and re-zero and then weigh baby

Convection Occurs when baby’s body heat is swept by air currents
Examples: drafts from air vents, open doors, fans, heaters, open incubator portholes, traffic around the bed Prevention: Keep warmer sides up and portholes closed Increase delivery room temperature Cover preterm infant with food grade plastic Transport in a closed pre-warm incubator Use heated, humidified gases The cooler the environment the more rapid the heat loss

Evaporation Prevention Dry infant with pre-warmed towels (term) and immediately remove damp or wet linens Dry head before applying hat Cover neck to feet in plastic wrap Increase room temperature Heat and humidify oxygen ASAP Occurs when moisture on the skin surface or respiratory tract is converted into vapor Evaporation is always accompanied by a cooling effect. The cooler the environment the more rapid the heat loss.

Radiation Occurs with the transfer of heat between solid surfaces that are not in contact with each other Prevention: Move away from cold windows/walls Use thermal shades over windows Cover incubator to insulate it from cold walls Use double-walled incubator to provide a warmer internal surface closest to baby The infant’s skin temp is usually warmer than surrounding surfaces so the direction of heat transfer will be from the exposed parts of infant’s body to adjacent solid surfaces. The cooler the surfaces, the greater the heat loss. The cooler surfaces are due to decreased room temperature. *Radiant heat gain occurs when surrounding surfaces are warmer than infant’s skin temp. When baby is under radiant warmer, the temp under the heating element and projected over infants body is higher than temp a few feet away. Remember that during resuscitation, caregeivers are working over an infant and the radiant warmer heat is obstructed *Use temp probe on servo and place temp sensor over the right upper quadrant of abdomen, liver location – make sure it is well secured for a good reading and the infant isn’t lying on it

Prevention of Hypothermia
Hypothermia can be prevented by maintaining a neutral thermal environment and reducing heat loss. A neonate is in a neutral thermal environment when the axillary temperature remains at 36.5° ° (97.7° ° F) with minimal oxygen and calorie consumption

Reduction of heat loss Consider the four ways by which the neonate experiences heat loss and intervene appropriately.

An Ounce of Prevention is worth a pound of cure
Prevention of hypothermia is the best treatment but if it occurs, the following is a list of what you can do to relieve the cold stress. Increase ambient air temperature Apply external heat sources Warm hat Warm blankets or diapers Chemical mattress Radiant warmer or isolette *radiant warmers alone cannot deliver enough heat to maintain normothermia in ELBW infants *stockingnet hats are ineffective, wool hats or hats lined with plastic wrap are more effective

Management in the delivery room
OR temperature degrees (WHO); NRP degrees for a preterm delivery WHO, American Society of Heating, Refrigeration, and Air Conditioning Engineers (ASHRAE) recommend that OR temperatures are never < or = to 68 degrees Use of forced air warming systems or radiant heater Insulate infant during transport Minimize area of exposure – a naked baby exposed to a room temperature of 73.4 degrees at birth has the same heat loss as a naked adult at 0 degrees

Management in the delivery room
Estimated Post-Menstrual Age (weeks) Estimated Birth Weight (grams) Delivery Room /Stabilization Area Temperature < or = 26 < or = 750 27C (80F) 27-28 751-1,000 29-32 1,001-1,500 > or = 22C (72F); Goal 24C (75F) 33-36 1,501-2,500 37-42 > or = 2,500 > or = 21C (70F); Goal 24C (75F) This table is more specific based on gestational age and weight and is based off of the ASHRAE and WHO recommendations

Avoid stressing the baby Monitor skin temperature carefully and when it normalizes remove the external heat sources one at a time to prevent rebound hypothermia Do not remove plastic wrap until NTE achieved. May need to place lines with plastic bag intact.

Warm chain system System of keeping the baby warm immediately after birth,in delivery room,post partum ward, transportation and while nursing the baby at home. Components are: -warm delivery room -immediate drying -skin to skin contact with the mother -immediate initiation of breast feeding -bathing and weighing post pond -appropriate clothing and bedding -warm transportation. Following the transition period (6-8 hrs), the baby can be assessed for bathing readiness. Must have stable vitals.

Treatment of Hypothermia
Mild Hypothermia ( ) Skin to skin contact, in a warm room Cap on newborn head Cover mother and newborn with warm blankets

Moderate Hypothermia ( ) Place under radiant warmer on servo Warm, heated incubator

Use a warm incubator set at least 1 to 1.5 degrees C above the baby’s body temperature and should be adjusted as the baby’s temperature increases Eliminate potential heat loss Monitor temperature q min Warm IV fluids if possible Increase humidity Monitor infant for apnea and hypotension Avoid hyperthermia Be ready to resuscitate during rewarming; increased risk of apnea and hypotension with rapid rewarming

Hypothermia QI Project
We identified that our NICU patients were admitted in the hypothermia range when entering our data into the Vermont Oxford Database and we needed to improve admission temperatures

What was our next step?

Goal: Improve the admission temperatures of our patients
Goal: Improve the admission temperatures of our patients. It was not just a preterm problem Make Plan: Formed a multidisciplinary committee to identify the contributing factors and help implement change Get To Work: We began by reviewing VON data and team members giving feedback about where we could improve Stick to It: The committee continues to meet Reach Goal: Our goal is 100% admissions in normothermic range. This will be a work in progress and we anticipate will need to review thermoregulation and strategies for preventing

Goal - Increase knowledge of thermoregulation methods among staff
We formed a multidisciplinary committee, developed and implemented an evidence-based thermoregulation protocol Goal - Increase knowledge of thermoregulation methods among staff Aim – To reduce the incidence of neonatal hypothermia Prior to creating the committee I met with the Unit director and manager about our admission temperatures. We decided that a committee approach would be best. Anyone is always invited to attend but we do have a core group of team members who meet. Mutidisciplinary Team included: neonatologists, NP’s, RTs, L&D nurses, NICU nurses, scrub techs, OBs, anesthesia. Need multidisciplinary group for buy in. Goal: varying practices in delivery room (ie weigh before NICU admission, use of temp probe, accessing umbilical cord via plastic bag)

Hypothermia Bundle Checklist(< or = 32 weeks) Delivery Bundle:
__ Increase Room Temperature to 74 degrees (initiated by NICU charge RN as soon as we are aware of the delivery by calling powerplant x 7656 and asking them turn turn off the override and increase temperature to 74 degrees) __ Thermal Mattress __ Plastic Bag __ Apply radiant warmer temperature probe __ Triple layer hat (2 blue/pink hats with plastic in the middle) __ OR door to remain closed __ Weight/Length/OFC postponed until NICU admission Transfer Bundle: __ Large warm blanket over the top of baby __ Weight done without taking baby out of bag/snugglie/hat __ Stay in plastic bag until neutral thermal environment is achieved __ Length/OFC after neutral thermal environment achieved Room Temperature when NICU arrives to delivery: ______ Baby’s Initial Temperature in delivery room:______ Temperature on admission to NICU:______ There are several things that would be done for term baby as well. We are trying to make it part of our practice so that it becomes habit. Making sure temp in room is increased, using temp probe, OR door remain closed, prewarm equipment, postpone measurements if needed (it’s just paperwork)

Hypothermia Bundle Checklist(< or = 32 weeks) Delivery Bundle:
__ Increase Room Temperature to 74 degrees (initiated by NICU charge RN as soon as we are aware of the delivery by calling powerplant x 7656 and asking them turn turn off the override and increase temperature to 74 degrees) __ Baby delivered on to warm sterile towel on mom __ Wait with sterile sheet under radiant warmer until baby is out __ Catch baby with warm blanket under the sterile sheet __ Sterile sheet and blanket wrapped around baby on transfer from OB to radiant warmer __ Thermal Mattress __ Plastic Bag __ Apply radiant warmer temperature probe __ Triple layer hat (2 blue/pink hats with plastic in the middle) __ OR door to remain closed __ Weight/Length/OFC postponed until NICU admission Transfer Bundle: __ Large warm blanket over the top of baby __ Weight done without taking baby out of bag/snugglie/hat __ Stay in plastic bag until neutral thermal environment is achieved __ Length/OFC after neutral thermal environment achieved Time Powerplant notified to increase delivery room temperature: _____ Room Temperature when NICU arrives to delivery: ______ Delivery: Vaginal C-Section Was C-section Stat? Yes No Delivery Time: _____ Baby’s Initial Temperature in delivery room:______ Temperature on admission to NICU:______ We decided we needed more data to determine where to focus our attention. Where could we get the most bang for our buck? We are in the process of getting a transport isolette ready for moving from delivery room to NICU for all patients

Challenges to the project
There was a knowledge deficit identified Change was difficult to implement. Continued education and follow-up is warranted to increase compliance with this protocol. Schedule challenges for meetings Buy in from staff – we’ve never done it that way and my babies are not cold, they aren’t under the warmer that long anyway (ref probe attachment), equipment availability (transport isolette vs radiant warmer), OR temp is the biggest challenge because the staff get hot under the lights with gowns/hats on OR in older part of building, typically use the larger OR

Project In Progress… Our focus remains quality patient care with changes implemented based on evidence We our off to a good start with a focused goal and team members who are invested in improving the care we deliver to our most fragile patients

Don’t Just Let It Go If hypothermia is an issue in your hospital, don’t just let it go. Find you data, make a plan and make the necessary changes to improve patient care.

I would like to thank AWHONN for inviting me to speak
I would like to thank AWHONN for inviting me to speak. Thank you to each and every one of you that make sacrifices to care for others. Nurses truly are and thank you for your attention this morning. Questions?

References American Academy of Pediatrics & American College of Obstetricians and Gynecologists. (1997). Guidelines for perinatal care. (4th ed.). ElkGrove Village, IL/Washington. Aylott, M The neonatal energy triangle. Part 1: Metabolic adaptation. Paediatric Nursing. 18, 6, Bissinger, R & Annibale, D Golden hours: care of the very low birth weight infant. Chicago, IL. Brodsky, D Neonatology Review. 2nd edition.. Fanaroff, A Care of the high-risk neonate. 6th edition. Philadelphia, PA. Mullany, LC Neonatal Hypothermia in low-resource settings. Seminars in Perinatology. 34 (6); World Health Organization. (1997). Safe Motherhood: Thermal Protection of the Newborn: A Practical Guide. Geneva: Author.

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