Hypothermia Therapy for Neonatal Hypoxic Ischemic Encephalopathy in the State of California

doi:10.1016/j.jpeds.2014.04.052

The Journal of Pediatrics

Volume 165, Issue 2, August 2014, Pages 267-273

https://doi.org/10.1016/j.jpeds.2014.04.052 Get rights and content

Objective

To characterize the implementation of hypothermia for neonatal hypoxic ischemic encephalopathy (HIE) in a population-based cohort.

Study design

Using the California Perinatal Quality Care Collaborative and California Perinatal Transport System linked 2010-2012 datasets, we categorized infants ≥36 weeks' gestation with HIE as receiving hypothermia or normothermia. Sociodemographic and clinical factors were compared, and multivariable logistic regression was used to determine factors associated with hypothermia therapy.

Results

There were 238 reported encephalopathy cases in 2010, 280 in 2011, and 311 in 2012. Hypothermia therapy use in newborns with HIE increased from 59% to 73% across the study period, mainly occurring in newborns with mild or moderate encephalopathy. A total of 36 centers provided hypothermia and cared for 94% of infants, with the remaining 6% being cared for at one of 25 other centers. Of the centers providing hypothermia, 12 centers performed hypothermia therapy to more than 20 patients during the 3-year study period, and 24 centers cared for <20 patients receiving hypothermia. In-hospital mortality was 13%, which primarily was associated with the severity of encephalopathy.

Conclusions

Our findings highlight an opportunity to explore practice-site variation and to develop quality improvement interventions to assure consistent evidence-based care of term infants with HIE and appropriate application of hypothermia therapy for eligible newborns.

Section snippets

Methods

We linked the California Perinatal Transport System and the California Perinatal Quality Care Collaborative (CPQCC) datasets. These quality improvement organizations provide benchmarks, site-specific data reports, and conduct performance improvement activities in perinatal care.¹⁵ The California Perinatal Transport System collects information from 53 transport systems in California and completes a neonatal data transport form for each transported infant. CPQCC collects maternal and neonatal

Hypothermia Treatment

During the study period, there were 829 infants with HIE diagnosis and without congenital anomalies, with 238 (29%) neonatal HIE cases in 2010, 280 (34%) cases in 2011, and 311 (37%) cases in 2012. We observed an increase in the number of HIE cases, as well as hypothermia treatment during the study period, that occurred primarily in infants with mild or moderate HIE, with an 17% absolute rate increase in infants with mild HIE, 15% increase in infants with moderate HIE, and 12% increase in

Discussion

In this analysis of 829 infants with HIE admitted to NICUs in California during 2010-2012, more than two-thirds (68%) of infants with HIE of any severity received hypothermia therapy, with an increase in hypothermia use from 2010 to 2012. In comparison with the reported UK TOBY Cooling Register, in which more than 80% of infants had Thompson encephalopathy scores in the moderate-to-severe range,13, 14 our observed increase in HIE treated cases mainly consisted of infants with mild or moderate

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Cited by (67)

Perinatal Hypoxic-Ischemic Encephalopathy: Incidence Over Time Within a Modern US Birth Cohort
2023, Pediatric Neurology
Recent studies suggest that the incidence of perinatal hypoxic-ischemic encephalopathy (HIE) may be increasing in developed countries. However, this observed increase may be due to increased ascertainment and increased treatment with therapeutic hypothermia rather than an increase in disease burden. In a US population-based cross-sectional study, we determined the incidence of perinatal HIE over time.
The study population included all 289,793 live-born infants ≥35 weeks gestational age born at 15 Kaiser Permanente Northern California hospitals between 2012 and 2019. Perinatal HIE was defined as the presence of both neonatal acidosis (i.e., cord blood pH < 7 or base deficit ≥10, or base deficit ≥10 on first infant gas) and neonatal encephalopathy confirmed by medical record review. Hospital discharge diagnoses of HIE were determined by extracting International Classification of Disease diagnostic codes for HIE assigned upon hospital discharge.
The population incidence of perinatal HIE was 1.7 per 1000. Although the incidence of perinatal HIE did not change significantly, both hospital discharge diagnoses of HIE and treatment with therapeutic hypothermia increased significantly during the study period. The sensitivity and positive predictive value of a hospital discharge diagnosis of HIE for identifying perinatal HIE confirmed by chart review were 72% and 79%, respectively.
During the study years, the incidence of perinatal HIE remained stable despite increases in hospital discharge diagnoses of HIE and in the use of therapeutic hypothermia. Our findings underscore the importance of applying stringent diagnostic criteria when diagnosing this complex condition.
Adherence to hypothermia guidelines in newborns with hypoxic-ischemic encephalopathy
2022, Anales de Pediatria
No disponemos de datos poblacionales en España sobre la aplicación de la hipotermia terapéutica (HT). El objetivo fue examinar la adherencia a los estándares de manejo durante la HT de los recién nacidos (RN) con encefalopatía hipóxico-isquémica (EHI).
Estudio observacional de cohortes, multicéntrico desde el inicio de la HT (2010) en una región extensa española, hasta el año 2019.
Se incluyeron 133 pacientes, el 72% con EHI moderada y el resto con EHI grave. En el 84% se inició hipotermia pasiva en paritorio. La HT activa comenzó a las 5 h de vida (RIC: 3,3-6,3), si bien, la temperatura diana central (33-34 °C) se alcanzó a una edad de 3,5 h (1;6). Los nacidos extramuros iniciaron la HT activa 3,3 h de media más tarde que los intramuros, pero sin diferencias en la edad a la que se alcanzó la temperatura diana.
El 96% recibió sedoanalgesia. El 100% fue monitorizado con electroencefalografía integrada por amplitud y el 59% con oximetría cerebral. La RM se realizó en el 94% con EHI moderada vs. el 65% con grave; p < 0,001. Se determinó enolasa neuronal-específica en LCR en el 42% de los pacientes. La duración media del recalentamiento fue de 10 h (RIC: 8-12), sin diferencias según el grado de EHI (p = 0,57).
La aplicación de la HT cumplió satisfactoriamente con los estándares. No obstante, se detectaron aspectos de la atención mejorables. Auditar la atención al recién nacido con EHI es crucial para conseguir programas con una alta calidad asistencial en cada región.
We do not have population data in Spain on the application of therapeutic hypothermia (TH). The objective was to examine adherence to management standards during TH of infants with hypoxic-ischemic encephalopathy (HIE).
Multicenter observational cohort study from the beginning of TH (year 2010) in 5 hospitals in a Spanish region, until year 2019.
133 patients were recruited, 72% diagnosed with moderate HIE and the rest of them with severe HIE. In 84% of infants, passive hypothermia was started at birth. Active TH was started at a median age of 5 hours of life (IQR: 3.3-6.3), although the central targeted temperature (33-34 °C) was reached at a median age of 3.5 hours (IQR: 1-6). Those born extramural, initiated active TH 3.3 hours on average later than those born intramural, but without differences in the age at which the targeted temperature was reached.
Sedoanalgesia was used in 97%. The 100% were monitored with amplitude-integrated EEG and 59% with cerebral oxymetry. MRI was performed in 94% with moderate HIE vs. 65% with severe; P<.001. Neuron-specific enolase in cerebrospinal fluid was determined in 42%. The average duration of rewarming was median 10 hours (IQR: 8-12), with no differences depending on the degree of HIE (P=.57).
The implementation of TH successfully met the standards. However, aspects of care that could be improved were detected. Auditing newborn care with HIE is crucial to achieving programs with a high quality of care in each region.
New Horizons in Mild Hypoxic-ischemic Encephalopathy: A Standardized Algorithm to Move past Conundrum of Care
2022, Clinics in Perinatology
Citation Excerpt :
Data from the Vermont Oxford Network (VON) Neonatal Encephalopathy Registry from 99 centers reveals that 40% of infants receiving TH have mild HIE.45 The state of California reported the use of TH in 50% of mild HIE using the California Perinatal Quality Care Collaborative datasets.46 The Children’s Hospital Neonatal Consortium registry from 27 NICUs in the United States reports abnormal short-term outcomes in mild HIE with TH but provides no comparison to noncooled infants.47
Is It Time for a Randomized Controlled Trial of Hypothermia for Mild Hypoxic-Ischemic Encephalopathy?
2020, Journal of Pediatrics
Neonatal Neurocritical Care: Providing Brain-Focused Care for All at Risk Neonates
2019, Seminars in Pediatric Neurology
Citation Excerpt :
Furthermore, the infants were noted to be safely and appropriately treated according to the criteria and management guidelines used in clinical trials. Data from the state of California using California Perinatal Quality Care Collaborative (CPQCC) database do not demonstrate a similar picture.40 Kracer found that there was an increase in the number of HIE cases treated with hypothermia between 2010 and 2012, but the increase occurred primarily in infants with mild or moderate HIE.
Neonatal neurocritical care is an evolving subsubspecialty whose goal is to implement neuroprotective care strategies, continuous bedside monitoring of neurologic function, and therapies in order to reduce the risk of neurologic injury and improve long-term neurodevelopmental outcomes in neonates who require intensive care. The provision of neonatal neurocritical care requires a culture change across a Neonatal Intensive Care Unit (NICU) in which equal importance is placed on the neurologic care and the cardiorespiratory care of a given patient. It is a multidisciplinary framework of care in which neonatologist and pediatric neurologist come together to address the unique needs of NICU patients whose brains are still developing and are vulnerable to injury. Advances in bedside brain monitoring techniques and the use of therapeutic hypothermia for Hupoxic-Ischemic Encephalopathy have accelerated the development of NeuroNICUs across the United States and abroad. Neonatologists, neurologists, neurophysiologists, nurses, and other ancillary members of the team work together to develop guidelines for commonly encountered neurological conditions in the NICU. The use of these guidelines helps provide standardized care across a unit and can reduce morbidity and length of hospital stay.
Growth and developmental outcomes of infants with hypoxic ischemic encephalopathy
2023, Scientific Reports

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: Supported by the Department of Health and Human Services Health Resources and Services Administration Centers of Excellence (D34HP16047), from the National Institute of Health Developmental & Neonatal Biology Training Program (HD07249), the Cooperative Multicenter Neonatal Research Network Research Supplement (U10HD027880S1) to promote Diversity in Health-Related Research from the Eunice Kennedy Shriver National Institute of Child Health & Human Development (3U10HD02788019S1), and the Eunice Kennedy Shriver National Institute of Child Health & Human Development grant Number K23HD068400. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Eunice Kennedy Shriver National Institute of Child Health & Human Development. The authors declare no conflicts of interest.

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Original ArticleHypothermia Therapy for Neonatal Hypoxic Ischemic Encephalopathy in the State of California

Objective

Study design

Results

Conclusions

Section snippets

Methods

Hypothermia Treatment

Discussion

Clin Perinatol

Early Hum Dev

Lancet

Semin Fetal Neonatal Med

Clin Perinatol

J Pediatr

J Pediatr

J Pediatr

Whole-body hypothermia for neonates with hypoxic-ischemic encephalopathy

N Engl J Med

Systemic hypothermia after neonatal encephalopathy: outcomes of neo.nEURO.network RCT

Pediatrics

Original Article
Hypothermia Therapy for Neonatal Hypoxic Ischemic Encephalopathy in the State of California