Brandau Peds conference Flashcards
baby born with pH 6.6 and base excess > 16. Dx?
Hypoxic Ischemic Encephalopathy
Diagnosis - Hypoxic Ischemic Encephalopathy(HIE)
Diagnosis based on:
APGAR under 5 at 10 minutes
Continued need for resuscitation at 10 minutes
Acidotic cord gas (pH under 7 base deficit >16 mmol/L within the first hour following delivery
Generalized hypotonia
Incidence 1-8 per thousand births
Sentinel Events Associated with HIE
Prolapsed cord Uterine rupture Amniotic fluid embolus Acute maternal hemorrhage Acute neonatal hemorrhage Any cause of sudden decrease in maternal cardiac output
Management of HIE
Whole Body Therapeutic Hypothermia
cost effective
Aim of cooling is to reduce cerebral metabolism AND neuronal cell apoptosis that can occur with reperfusion
needs to be begin before 6 hours of age
Goal: 33-34° C for 72 hours
After 72 hours warming should be no faster than 0.5°C/hour (Faster rates are likely to produce peripheral vasodilation leading to hypotension and/or seizures
rest of the management of HIE (besides the cooling)
Infants with HIE frequently show signs of multi-system failure requiring supportive therapy
IV fluids restricted to two thirds of maintenance (40 mL/kg/day)
Hyper- and hypoglycemia need to be avoided
Antibiotics for possible sepsis
Treat symptomatic for frequent seizures (> 3/hour)
Cooling is contraindicated if the infant will need surgery or has other serious life threatening conditions
Clinical staging of HIE: mild encephalopathy
alert or hyperalert spontaneous movement posture may be normal normal or hypertonia weak suck reflex exaggerated Moro relfex dilated pupils tachycardia normal respiration irritable, jitteriness no seizures normal EEG background normal outcome
Clinical staging of HIE: moderate encephalopathy
moderate encephalopathy lethargic decreased sponatneous activity distal flexion, complete extension focal/generalised hypotonia weak suck reflex incomplete moro reflex constricted pupils bradycardia periodic breathing brainstem dysfunction may have seizures (in the first 24 hours) normal EEG background 20-40% abnormal
Clinical staging of HIE: severe encephalopathy
coma or stupor no spontaneous movement decerebrate flaccid absent suck reflex absent moro reflex deviated, dilated, or non-reactive pupils variable heart rate apnea may have raised intracranial pressure frequent seizures (often refractory to anticonvulsants) EEG periodic, isoelectric Death or 100% abnormal
How our case turned out
Therapeutic cooling was carried out for 72 hours
Antibiotics were given for possible sepsis
Fluids were restricted and she required dobutamine infusion for 4 days
CRP was as high as 62 mg/L
Lactate normalized at 3 hours
She was treated with phenobarbital for seizure activity
At 72 hours cranial ultrasound was normal
MRI at 14 days was normal
By day 9 she was totally bottle fed with good suck
At discharge her neurological exam normal
At 3 and 6 months she was meeting her developmental milestones
Long Term Outcomes
Long term outcomes vary depending on extent of brain damage
Observed outcomes include:
Lower scores on mental development index and psychomotor development index
Disabling CP (less than 10% of CP is associated with intrapartum hypxia
Epilepsy
Blindness
Hearing loss
Severe learning disabilities
MRI of the Brain Can Help Predict Outcomes
Basal ganglia involvement sometimes associated with CP, feeding problems, speech and language problems
Seizure disorders associated with cerebral cortical injury
Global patterns in severe HIE are frequently fatal
randomised controlled trial found, Bottom Line:
The accuracy of prediction by MRI of death or disability to 18 months of age was 0.84 (0.74-0.94) in the cooled group and 0.81 (0.71-0.91) in the non-cooled group. Therapeutic hypothermia decreases brain tissue injury in infants with hypoxic-ischaemic encephalopathy.
what do we use PET scan for?
image of glucose with 18F on it so that it is stuck in the neuron and can’t go into the TCA cycle
bright shows normal uptake and metabolism of glucose
can see asymmetry or global decrease in intensity in babies with HIE
