Safety and Effectiveness of Whole Body Cooling Therapy for Neonatal Encephalopathy on Transport.

OBJECTIVE: The purpose of this study was to evaluate the safety and effectiveness of a transport protocol using active and passive methods for therapeutic whole body cooling of the neonate with hypoxic-ischemic encephalopathy. METHODS: A retrospective study of neonates who received whole body cooling during transport by our pediatric/neonatal transport team between December 2008 and April 2012 was conducted. RESULTS: Sixty-three of 66 (95%) neonates arrived within a safety temperature range of 33.0°C-37°C, and 3 (5%) were hypothermic (31.9°C-32.8°C). No clinical complications of cooling during transport were identified. Twenty-five (38%) and 57(86%) achieved therapeutic cooling upon admission and ≤ 6 hours after birth, respectively. Factors associated with cooling > 6 hours included a later time of initial referral (2.44 vs. 1.07 hours, P = .01), a later rendezvous time (4.17 vs. 1.92 hours, P = .002), and a later admission time (6.46 vs. 3.99 hours, P = .001). CONCLUSION: Whole body cooling of neonates with hypoxic-ischemic encephalopathy can be effectively and safely performed during interfacility transport.

Improving Thermal Support in Very and Extremely Low Birth Weight Infants during Interfacility Transport.

INTRODUCTION: Review of very low birth weight (VLBW) and extremely low birth weight (ELBW) neonates transported by our specialized pediatric/neonatal transport team revealed hypothermia in up to 52% of admissions. This project aimed to decrease the incidence of hypothermia in VLBW and ELBW neonates requiring transport between facilities from 52% to <20% over 1 year. METHODS: In response to gaps in knowledge and barriers to care revealed by a survey administered to transport personnel, we used a standard quality improvement plan-do-study-act model to introduce new equipment and a comprehensive thermoregulation protocol via standardized education. The primary outcome measure was the incidence of hypothermia (axillary temperature < 36.5°C) in transported VLBW and ELBW neonates. The process measure was compliance with the protocol. The balancing measures were unintended hyperthermia and transport team ground time. Transport personnel were updated on progress via meetings and run charts. RESULTS: We reduced the incidence of hypothermia to 17% in 1 year. Compliance with the protocol improved from 60% to 76%. There was no increase in unintended hyperthermia (5% preintervention, 4% intervention, 7% surveillance, P = 0.76) or transport team ground time (in hours) (1.2 ± 0.9 preintervention versus 1.3 ± 0.8 intervention versus 1.2 ± 0.7 surveillance, P = 0.2). CONCLUSIONS: Quality improvement methods were used to develop an evidence-based, standardized approach to thermal support in VLBW and ELBW neonates undergoing transport between facilities. Following the implementation of this approach, we achieved the desired percent decrease in the incidence of hypothermia.

Term Neonate with Atypical Hypoxic-Ischemic Encephalopathy Presentation: A Case Report.

We describe a case of atypical hypoxic-ischemic encephalopathy (HIE) in a neonate following a normal pregnancy and delivery who was found to have an umbilical vein thrombosis. The infant arrived to our center with continuous bicycling movement of her lower extremities. She had a continuous electroencephalogram that showed burst suppression and magnetic resonance imaging of the brain showed diffusely abnormal cerebral cortical/subcortical diffusion restriction which may be secondary hypoxic-ischemic injury. Interestingly, a pathology report noted a focal umbilical vein thrombosis appearing to have compressed an umbilical artery with associated arterial dissection and hematoma. Our case illustrates how umbilical venous or arterial thrombosis may be associated with HIE and refractory seizures.

Altered pulmonary lymphatic development in infants with chronic lung disease.

Pulmonary lymphatic development in chronic lung disease (CLD) has not been investigated, and anatomy of lymphatics in human infant lungs is not well defined. Hypothesis. Pulmonary lymphatic hypoplasia is present in CLD. Method. Autopsy lung tissues of eighteen subjects gestational ages 22 to 40 weeks with and without history of respiratory morbidity were stained with monoclonal antipodoplanin and reviewed under light microscopy. Percentage of parenchyma podoplanin stained at the acinar level was determined using computerized image analysis; 9 CLD and 4 control subjects gestational ages 27 to 36 weeks were suitable for the analysis. Results. Distinct, lymphatic-specific staining with respect to other vascular structures was appreciated in all gestations. Infants with and without respiratory morbidity had comparable lymphatic distribution which extended to the alveolar ductal level. Podoplanin staining per parenchyma was increased and statistically significant in the CLD group versus controls at the alveolar ductal level (0.06% ± 0.02% versus 0.04% ± 0.01%, 95% CI -0.04% to -0.002%, P < 0.03). Conclusion. Contrary to our hypothesis, the findings show that there is an increase in alveolar lymphatics in CLD. It is suggested that the findings, by expanding current knowledge of CLD pathology, may offer insight into the development of more effective therapies to tackle CLD.