Brandau Peds conference Flashcards

1
Q

baby born with pH 6.6 and base excess > 16. Dx?

A

Hypoxic Ischemic Encephalopathy

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2
Q

Diagnosis - Hypoxic Ischemic Encephalopathy(HIE)

A

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

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3
Q

Sentinel Events Associated with HIE

A
Prolapsed cord
Uterine rupture
Amniotic fluid embolus
Acute maternal hemorrhage
Acute neonatal hemorrhage
Any cause of sudden decrease in maternal cardiac output
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4
Q

Management of HIE

A

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

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5
Q

rest of the management of HIE (besides the cooling)

A

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

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6
Q

Clinical staging of HIE: mild encephalopathy

A
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
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7
Q

Clinical staging of HIE: moderate encephalopathy

A
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
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8
Q

Clinical staging of HIE: severe encephalopathy

A
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
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9
Q

How our case turned out

A

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

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10
Q

Long Term Outcomes

A

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

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11
Q

MRI of the Brain Can Help Predict Outcomes

A

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

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12
Q

randomised controlled trial found, Bottom Line:

A

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.

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13
Q

what do we use PET scan for?

A

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

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