Therapeutic Hypothermia during Neonatal Transport: Current Practices in California

Abstract

Therapeutic hypothermia initiated at <6 hours of age reduces death and disability in newborns ≥36 weeks’ gestation with moderate to severe hypoxic ischemic encephalopathy. Given the limited therapeutic window, cooling during transport becomes a necessity. Our goal was to describe the current practice of therapeutic hypothermia during transport used in the state of California. All level III neonatal intensive care units (NICUs) were contacted to identify those units providing therapeutic hypothermia. An electronic questionnaire was sent to obtain basic information. Responses were received from 28 (100%) NICUs performing therapeutic hypothermia; 26 NICUs were cooling newborns and two were in the process of program development. Eighteen (64%) centers had cooled a patient in transport, six had not yet cooled in transport, and two do not plan to cool in transport. All 18 centers use passive cooling, except for two that perform both passive and active cooling, and 17 of 18 centers recommend initiation of cooling at the referral hospital. Reported difficulties include overcooling, undercooling, and bradycardia. Cooling on transport is being performed by majority of NICUs providing therapeutic hypothermia. Clinical protocols and devices for cooling in transport are essential to ensure safety and efficacy.

Keywords

hypoxic ischemic encephalopathy (HIE) - therapeutic hypothermia - passive cooling

• References

• 1 Gunn AJ, Gunn TR, de Haan HH, Williams CE, Gluckman PD. Dramatic neuronal rescue with prolonged selective head cooling after ischemia in fetal lambs. J Clin Invest 1997; 99: 248-256
• 2 Busto R, Dietrich WD, Globus MYT, Valdés I, Scheinberg P, Ginsberg MD. Small differences in intraischemic brain temperature critically determine the extent of ischemic neuronal injury. J Cereb Blood Flow Metab 1987; 7: 729-738
• 3 Vannucci RC, Perlman JM. Interventions for perinatal hypoxic-ischemic encephalopathy. Pediatrics 1997; 100: 1004-1014
• 4 Gluckman PD, Williams CE. When and why do brain cells die?. Dev Med Child Neurol 1992; 34: 1010-1014
• 5 Iwata O, Iwata S, Thornton JS , 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
• 6 Gluckman PD, Wyatt JS, Azzopardi D , et al. Selective head cooling with mild systemic hypothermia after neonatal encephalopathy: multicentre randomised trial. Lancet 2005; 365: 663-670
• 7 Eicher DJ, Wagner CL, Katikaneni LP , et al. Moderate hypothermia in neonatal encephalopathy: efficacy outcomes. Pediatr Neurol 2005; 32: 11-17
• 8 Shankaran S, Laptook AR, Ehrenkranz RA , et al; National Institute of Child Health and Human Development Neonatal Research Network. Whole-body hypothermia for neonates with hypoxic-ischemic encephalopathy. N Engl J Med 2005; 353: 1574-1584
• 9 Azzopardi DV, Strohm B, Edwards AD , et al; TOBY Study Group. Moderate hypothermia to treat perinatal asphyxial encephalopathy. N Engl J Med 2009; 361: 1349-1358
• 10 Simbruner G, Mittal RA, Rohlmann F, Muche R ; neo.nEURO.network Trial Participants. Systemic hypothermia after neonatal encephalopathy: outcomes of neo.nEURO.network RCT. Pediatrics 2010; 126: e771-e778
• 11 Jacobs SE, Morley CJ, Inder TE , et al; for the Infant Cooling Evaluation Collaboration. Whole body hypothermia for term and near-term newborns with hypoxic ischemic encephalopathy. Arch Pediatr Adolesc Med 2011; 165: 692-700
• 12 Gunn AJ, Gunn TR. The “pharmacology” of neuronal rescue with cerebral hypothermia. Early Hum Dev 1998; 53: 19-35
• 13 Fairchild K, Sokora D, Scott J, Zanelli S. Therapeutic hypothermia on neonatal transport: 4-year experience in a single NICU. J Perinatol 2010; 30: 324-329
• 14 Hallberg B, Olson L, Bartocci M, Edqvist I, Blennow M. Passive induction of hypothermia during transport of asphyxiated infants: a risk of excessive cooling. Acta Paediatr 2009; 98: 942-946
• 15 Historical and Projected State and County Births, 1980–2019, with Actual and Projected Fertility Rates by Mother's Age and Race/Ethnicity, 2000–2019 State of California, Department of Finance, Demographic Research Unit. September 2010
• 16 Kendall GS, Kapetanakis A, Ratnavel N, Azzopardi D, Robertson NJ ; Cooling on Retrieval Study Group. Passive cooling for initiation of therapeutic hypothermia in neonatal encephalopathy. Arch Dis Child Fetal Neonatal Ed 2010; 95: F408-F412
• 17 O’Reilly K, Winterbottom S, Tooley J. Therapeutic hypothermia during transport: which method is the most effective and reliable?. Acta Paediatr 2011; 100: 1084-1086
• 18 Johnston ED, Becher J-C, Mitchell AP, Stenson BJ. Provision of servo-controlled cooling during neonatal transport. Arch Dis Child Fetal Neonatal Ed 2011; ; March 6 (Epub ahead of print)
• 19 Rabenstein E, Tyree M, Dimberger D, DiGeronimo R. Whole body hypothermia using a portable cooling unit in a neonatal pig model: implications for transport. J Neonatal Perinatal Med 2010; 3: 15-20