Organ donor management: Eight common recommendations and actions that deserve reflection.

Despite major advances in our understanding of the physiopathology of brain death (BD), there are important controversies as to which protocol is the most appropriate for organ donor management. Many recent reviews on this subject offer recommendations that are sometimes contradictory and in some cases are not applied to other critically ill patients. This article offers a review of the publications (many of them recent) with an impact upon these controversial measures and which can help to confirm, refute or open new areas of research into the most appropriate measures for the management of organ donors in BD, and which should contribute to discard certain established recommendations based on preconceived ideas, that lead to actions lacking a physiopathological basis. Aspects such as catecholamine storm management, use of vasoactive drugs, hemodynamic objectives and monitoring, assessment of the heart for donation, and general care of the donor in BD are reviewed.

[Survival and neurological outcome in out-of-hospital cardiac arrests due to shockable rhythms treated with mild therapeutic hypothermia]. / Supervivencia y pronóstico neurológico en paradas cardiorrespiratorias extrahospitalarias por ritmos desfibrilables tratadas con hipotermia terapéutica moderada.

OBJECTIVE: To analyze survival and neurological outcome at short and medium term in patients treated with mild therapeutic hypothermia (HTM) in our hospital after suffering an out-of-hospital cardiac arrest (CA) secondary to a shockable rhythm. DESIGN: Prospective, observational study from September 1, 2010 to December 31, 2012, with a follow up of 6 months. SETTING: Tertiary hospital. PATIENTS: All patients who suffer an out-of-hospital CA due to shockable rhythms. EXCLUSION CRITERIA: non-shockable rhythms, resuscitation >45 minutes without pulse recovery, septic shock, previous coagulopathy, terminal illness or order for withholding treatment. INTERVENTION: Mild hypothermia (33°C) and postresuscitation care on the basis of standardized protocols. MAIN VARIABLES: Demographic and epidemiological data, CA data and survival and neurological outcome at hospital discharge and after 6 months. To assess the patients' neurological status, Cerebral Performance Categories (CPC) scale was used. RESULTS: A total of 54 patients were analyzed. 37 patients were discharged to hospital, representing a survival at discharge of 68.5%, which remains 6 months later because no discharged patient died during the follow up period. Regarding neurological outcome, 44.4% of patients were alive and with CPC 1-2 at discharge and up to 54.71% at 6 months. CONCLUSIONS: The results of survival and neurological functional status obtained in our center after implementation of HTM are comparable to those published in the literature.

Motor, cognitive and behavioural outcomes after neonatal hypoxic-ischaemic encephalopathy.

INTRODUCTION: The current neurodevelopmental status of patients with neonatal hypoxic-ischaemic encephalopathy (HIE) in Spain is unknown. Recent European studies highlight a shift of severe pathology towards mild motor disorders and emotional problems. The aim of this study was to analyse neurodevelopmental outcomes in a cohort of neonates with HIE at age 3 years. PATIENTS AND METHOD: Multicentre observational study of neonates born at 35 or more weeks of gestation with moderate to severe HIE in 2011-2013 in 12 hospitals in a large Spanish region (91 217 m2), with the recruitment extended through 2017 in the coordinating hospital. We analysed the findings of neonatal neuroimaging and neurodevelopmental test scores at 3 years (Bayley-III, Peabody Picture Vocabulary Test and Child Behavior Checklist). The sample included 79 controls with no history of perinatal asphyxia. RESULTS: Sixty-three patients were recruited, of whom 5 (7.9%) were excluded due to other pathology and 14 (24%) died. Of the 44 survivors, 42 (95.5%) were evaluated. Of these 42, 10 (24%) had adverse outcomes (visual or hearing impairment, epilepsy, cerebral palsy or developmental delay). Other detected problems were minor neurological signs in 6 of the 42 (14%) and a higher incidence of emotional problems compared to controls: introversion (10.5% vs. 1.3%), anxiety (34.2% vs. 11.7%) and depression (28.9% vs. 7.8%) (P < .05). The severity of the lesions on neuroimaging was significantly higher in patients with motor impairment (P = .004) or who died or had an adverse outcome (P = .027). CONCLUSION: In addition to classical sequelae, the followup of patients with neonatal HIE should include the diagnosis and treatment of minor motor disorders and social and emotional problems.

Temperature management in acute brain injury: A narrative review.

Temperature management has been used in patients with acute brain injury resulting from different conditions, such as post-cardiac arrest hypoxic-ischaemic insult, acute ischaemic stroke, and severe traumatic brain injury. However, current evidence offers inconsistent and often contradictory results regarding the clinical benefit of this therapeutic strategy on mortality and functional outcomes. Current guidelines have focused mainly on active prevention and treatment of fever, while therapeutic hypothermia (TH) has fallen into disuse, although doubts persist as to its effectiveness according to the method of application and appropriate patient selection. This narrative review presents the most relevant clinical evidence on the effects of TH in patients with acute neurological damage, and the pathophysiological concepts supporting its use.

Hypoxic-ischaemic encephalopathy code: A systematic review for resource-limited settings.

It is estimated that 96% of infants with hypoxic-ischaemic encephalopathy (HIE) are born in resource-limited settings with no capacity to provide the standard of care that has been established for nearly 15 years in high-resource countries, which includes therapeutic hypothermia (TH), continuous electroencephalographic monitoring and magnetic resonance imaging (MRI) in addition to close vital signs and haemodynamic monitoring. This situation does not seem to be changing; however, even with these limitations, currently available knowledge can help improve the care of HIE patients in resource-limited settings. The purpose of this systematic review was to provide, under the term "HIE Code", evidence-based recommendations for feasible care practices to optimise the care of infants with HIE and potentially help reduce the risks associated with comorbidity and improve neurodevelopmental outcomes. The content of the HIE code was grouped under 9 headings: (1) prevention of HIE, (2) resuscitation, (3) first 6h post birth, (4) identification and grading of encephalopathy, (5) seizure management, (6) other therapeutic interventions, (7) multiple organ dysfunction, (8) diagnostic tests and (9) family care.

Repair of a gigantic ascending aortic pseudoaneurysm - A challenging approach.

Aortic pseudoaneurysms can be a potentially fatal, yet rare, complication of heart surgery. Surgery is indicated but is high risk during sternotomy. Therefore, careful planning is required. We report the case of a 57-year-old patient who underwent heart surgery twice in the past and who presented with an ascending aortic pseudoaneurysm. A successful repair of the pseudoaneurysm was performed under deep hypothermia, left ventricular apical venting, periods of circulatory arrest and endoaortic balloon occlusion.

Current status and outlook for the management of intracranial hypertension after traumatic brain injury: decompressive craniectomy, therapeutic hypothermia, and barbiturates.

INTRODUCTION: Increased intracranial pressure (ICP) has been associated with poor neurological outcomes and increased mortality in patients with severe traumatic brain injury (TBI). Traditionally, ICP-lowering therapies are administered using an escalating approach, with more aggressive options reserved for patients showing no response to first-tier interventions, or with refractory intracranial hypertension. DEVELOPMENT: The therapeutic value and the appropriate timing for the use of rescue treatments for intracranial hypertension have been a subject of constant debate in literature. In this review, we discuss the main management options for refractory intracranial hypertension after severe TBI in adults. We intend to conduct an in-depth revision of the most representative randomised controlled trials on the different rescue treatments, including decompressive craniectomy, therapeutic hypothermia, and barbiturates. We also discuss future perspectives for these management options. CONCLUSIONS: The available evidence appears to show that mortality can be reduced when rescue interventions are used as last-tier therapy; however, this benefit comes at the cost of severe disability. The decision of whether to perform these interventions should always be patient-centred and made on an individual basis. The development and integration of different physiological variables through multimodality monitoring is of the utmost importance to provide more robust prognostic information to patients facing these challenging decisions.

Ten years since the introduction of therapeutic hypothermia in neonates with perinatal hypoxic-ischaemic encephalopathy in Spain.

INTRODUCTION: More than a decade has passed since therapeutic hypothermia (TH) was introduced in Spain; this is the only neuroprotective intervention that has become standard practice in the treatment of perinatal hypoxic-ischaemic encephalopathy (HIE). This article aims to provide a current picture of the technique and to address the controversies surrounding its use. DEVELOPMENT: In the last 10 years, TH has been successfully implemented in the vast majority of tertiary hospitals in Spain, and more than 85% of newborns with moderate or severe HIE currently receive the treatment. The factors that can improve the efficacy of TH include early treatment onset (first 6 h of life) and the control of comorbid factors associated with perinatal asphyxia. In patients with moderate HIE, treatment onset after 6 h seems to have some neuroprotective efficacy. TH duration longer than 72 h or deeper hypothermia do not offer greater neuroprotective efficacy, but instead increase the risk of adverse effects. Controversy persists around the sedation of patients during TH, the application of the treatment in infants with mild HIE, and its application in other scenarios. Prognostic information and time frame are one of the most challenging aspects. CONCLUSIONS: TH is universal in countries with sufficient economic resources, although certain unresolved controversies remain. While the treatment is widespread in Spain, there is a need for devices for the transfer of these patients and their centralisation.

Adherence to hypothermia guidelines in newborns with hypoxic-ischemic encephalopathy.

INTRODUCTION: 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). METHOD: Multicenter observational cohort study from the beginning of TH (year 2010) in 5 hospitals in a Spanish region, until year 2019. RESULTS: 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 h of life (IQR 3.3; 6.3), although the central targeted temperature (33-34 °C) was reached at a median age of 3.5 h (IQR 1; 6). Those born extramural, initiated active TH 3.3 h 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%. 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 h (IQR 8; 12), with no differences depending on the degree of HIE (P = .57). CONCLUSIONS: 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.

Bispectral index and suppression ratio after cardiac arrest: are they useful as bedside tools for rational treatment escalation plans?

INTRODUCTION AND OBJECTIVES: Myocardial dysfunction contributes to early mortality (24-72 hours) among survivors of a cardiac arrest (CA). The benefits of mechanical support in refractory shock should be balanced against the patient's potential for neurological recovery. To date, these early treatment decisions have been taken based on limited information leading mainly to undertreatment. Therefore, there is a need for early, reliable, accessible, and simple tools that offer information on the possibilities of neurological improvement. METHODS: We collected data from bispectral index (BIS) and suppression ratio (SR) monitoring of adult comatose survivors of CA managed with targeted temperature management (TTM). Neurological status was assessed according to the Cerebral Performance Category (CPC) scale. RESULTS: We included 340 patients. At the first full neurological evaluation, 211 patients (62.1%) achieved good outcome or CPC 1-2. Mean BIS values were significantly higher and median SR lower in patients with CPC 1-2. An average BIS> 26 during first 12 hours of TTM predicted good outcome with 89.5% sensitivity and 75.8% specificity (AUC of 0.869), while average SR values> 24 during the first 12 hours of TTM predicted poor outcome (CPC 3-5) with 91.5% sensitivity and 81.8% specificity (AUC, 0.906). Hourly BIS and SR values exhibited good predictive performance (AUC> 0.85), as soon as hour 2 for SR and hour 4 for BIS. CONCLUSIONS: BIS/SR are associated with patients' potential for neurological recovery after CA. This finding could help to create awareness of the possibility of a better outcome in patients who might otherwise be wrongly considered as nonviable and to establish personalized treatment escalation plans.

[Challenges in the application of non-servocontrolled therapeutic hypothermia during neonatal transport in Catalonia]. / Retos en la aplicación de la hipotermia terapéutica no servo-controlada durante el transporte neonatal en Cataluña.

INTRODUCTION: Therapeutic hypothermia (TH) improves survival and neurological prognosis in hypoxic-ischemic encephalopathic (HIE) babies, being better the sooner TH is implemented. HIE babies are born more frequently in a non-cooling centre and need to be referred. METHODS: Prospective-observational study (April 18-November 19). Newborns (≥34 weeks of gestational age (GA) and >1800g) with moderate/severe HIE on non-servocontrolled therapeutic hypothermia by the two neonatal transport teams in Catalonia. RESULTS: 51 newborns. The median stabilisation and transport time were 68min (p25-75, 45-85min) and 30min (p25-75, 15-45min), respectively. The mean age at arrival at the receiving unit was 4h and 18min (SD 96.6). The incubator was set off in 43 (84%), iced-packs 11 (21.5%) and both (11, 21.5%). Target temperature was reached in 19 (37.3%) babies. There was no differences in the overcooling in relation to the measures applied. The transport duration was not related with temperature stabilisation or target temperature reachiness. CONCLUSIONS: Rectal temperature monitorisation is compulsory for the stabilisation and the application of non-servocontrolled hypothermia during transport. There is still time for improving in the administration of this treatment during transport. Servo-controlled hypothermia would be a better alternative to improve the management of HIE babies.

Challenges in the application of non-servocontrolled therapeutic hypothermia during neonatal transport in Catalonia.

INTRODUCTION: Therapeutic hypothermia (TH) improves survival and neurological prognosis in hypoxic-ischemic encephalopathic (HIE) babies, being better the sooner TH is implemented. HIE babies are born more frequently in a non-cooling centre and need to be referred. METHODS: Prospective-observational study (April 18 2018 - November 19 2019). Newborns (≥34 weeks of gestational age (GA) and >1800 g) with moderate/severe HIE on non-servocontrolled therapeutic hypothermia by the two neonatal transport teams in Catalonia. RESULTS: 51 newborns. The median stabilisation and transport time were 68 min (p25-75, 45-85 min) and 30 min (p25-75, 15-45 min), respectively. The mean age at arrival at the receiving unit was 4 h and 18 min (SD 96.6). The incubator was set off in 43 (84%), iced-packs 11 (21.5%) and both (11, 21.5%). Target temperature was reached in 19 (37.3%) babies. There were no differences in the overcooling in relation to the measures applied. The transport duration was not related with temperature stabilisation or target temperature reachiness. CONCLUSIONS: Rectal temperature monitorisation is compulsory for the stabilisation and the application of non-servocontrolled hypothermia during transport. There is still time for improving in the administration of this treatment during transport. Servo-controlled hypothermia would be a better alternative to improve the management of HIE babies.

Management of temperature control in post-cardiac arrest care: an expert report. / Manejo con control de temperatura en los cuidados posparada cardiaca: documento de expertos.

Targeted temperature management (TTM) through induced hypothermia (between 32-36 oC) is currently regarded as a first-line treatment during the management of post-cardiac arrest patients admitted to the Intensive Care Unit (ICU). The aim of TTM is to afford neuroprotection and reduce secondary neurological damage caused by anoxia. Despite the large body of evidence on its benefits, the TTM is still little used in Spain. There are controversial issues referred to its implementation, such as the optimal target body temperature, timing, duration and the rewarming process. The present study reviews the best available scientific evidence and the current recommendations contained in the international guidelines. In addition, the study focuses on the practical implementation of TTM in post-cardiac arrest patients in general and cardiological ICUs, with a discussion of the implementation strategies, protocols, management of complications and assessment of the neurological prognosis.

Nursing care in therapeutic hypothermia in neonates with hypoxic-ischaemic encephalopathy. Review of the literature. / Cuidados enfermeros a neonatos con encefalopatía hipóxico-isquémica en hipotermia terapéutica. Revisión bibliográfica.

INTRODUCTION: Hypoxic-ischaemic encephalopathy is one of the main causes of neurological damage in the new-born. Therapeutic hypothermia is the current treatment to reduce mortality and disability in new-borns with this condition. OBJECTIVE: To identify nursing care in new-borns with severe to moderate hypoxic-ischaemic encephalopathy, treated with active therapeutic hypothermia. MATERIALS AND METHODS: A review of the scientific literature was carried out in different databases (PubMed, Lilacs, IBECS, Cinhal, OvidSP, Cuiden, Embase and Cochrane Plus) over the last five years. The documentary assessment was carried out by peers and the quality was evaluated using the CEBM and GRADE scales. RESULTS: Of the 22 articles selected and reviewed, it is evident that therapeutic hypothermia is effective in reducing the mobility and mortality of neo-nates with hypoxic-ischaemic encephalopathy. Nursing care during hypothermia treatment focuses on four basic pillars: general care for stabilisation of the new-born, preparation of the material, administration of medical treatment in all its phases and emotional support of the family. CONCLUSIONS: Therapeutic hypothermia is effective in reducing the sequelae and mortality of neonates with hypoxic-ischaemic encephalopathy. Nursing care is essential throughout the treatment, in the early detection of complications in the infant and psychological support for parents. It is essential for nurses to receive training in this care.

Nursing care in therapeutic hypothermia in neonates with hypoxic-ischaemic encephalopathy. Review of the literature.

INTRODUCTION: Hypoxic-ischaemic encephalopathy is one of the main causes of neurological damage in the new-born. Therapeutic hypothermia is the current treatment to reduce mortality and disability in new-borns with this condition. OBJECTIVE: To identify nursing care in new-borns with severe to moderate EHI, treated with active therapeutic hypothermia. MATERIALS AND METHODS: A review of the scientific literature was carried out in different databases (PubMed, Lilacs, IBECS, Cinhal, OvidSP, Cuiden, Embase and Cochrane Plus) over the last five years. The documentary assessment was carried out by peers and the quality was evaluated using the CEBM and GRADE scales. RESULTS: Of the 22 articles selected and reviewed, it is evident that therapeutic hypothermia is effective in reducing the mobility and mortality of neo-nates with hypoxic-ischaemic encephalopathy. Nursing care during hypothermia treatment focuses on four basic pillars: general care for stabilisation of the new-born, preparation of the material, administration of medical treatment in all its phases and emotional support of the family. CONCLUSIONS: Therapeutic hypothermia is effective in reducing the sequelae and mortality of neonates with hypoxic-ischaemic encephalopathy. Nursing care is essential throughout the treatment, in the early detection of complications in the infant and psychological support for parents. It is essential for nurses to receive training in this care.

[Adherence to hypothermia guidelines in newborns with hypoxic-ischemic encephalopathy]. / Adherencia a los estándares en el tratamiento con hipotermia del recién nacido con encefalopatía hipóxico-isquémica.

INTRODUCTION: 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). METHOD: Multicenter observational cohort study from the beginning of TH (year 2010) in 5 hospitals in a Spanish region, until year 2019. RESULTS: 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 5hours of life (IQR: 3.3-6.3), although the central targeted temperature (33-34°C) was reached at a median age of 3.5hours (IQR: 1-6). Those born extramural, initiated active TH 3.3hours 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 10hours (IQR: 8-12), with no differences depending on the degree of HIE (P=.57). CONCLUSIONS: 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.

Current status and outlook for the management of intracranial hypertension after traumatic brain injury: decompressive craniectomy, therapeutic hypothermia, and barbiturates. / Estado actual y perspectivas futuras en el manejo de la hipertensión intracraneal posterior a traumatismo craneoencefálico: craniectomía descompresiva, hipotermia terapéutica y barbitúricos.

INTRODUCTION: Increased intracranial pressure has been associated with poor neurological outcomes and increased mortality in patients with severe traumatic brain injury. Traditionally, intracranial pressure-lowering therapies are administered using an escalating approach, with more aggressive options reserved for patients showing no response to first-tier interventions, or with refractory intracranial hypertension. DEVELOPMENT: The therapeutic value and the appropriate timing for the use of rescue treatments for intracranial hypertension have been a subject of constant debate in literature. In this review, we discuss the main management options for refractory intracranial hypertension after severe traumatic brain injury in adults. We intend to conduct an in-depth revision of the most representative randomised controlled trials on the different rescue treatments, including decompressive craniectomy, therapeutic hypothermia, and barbiturates. We also discuss future perspectives for these management options. CONCLUSIONS: The available evidence appears to show that mortality can be reduced when rescue interventions are used as last-tier therapy; however, this benefit comes at the cost of severe disability. The decision of whether to perform these interventions should always be patient-centred and made on an individual basis. The development and integration of different physiological variables through multimodality monitoring is of the utmost importance to provide more robust prognostic information to patients facing these challenging decisions.

[Holistic approach of the care of the infant with hypoxic-ischaemic encephalopathy in Spain]. / Atención integral del neonato con encefalopatía hipóxico-isquémica en España.

INTRODUCTION: There is not much information about the care of infants with hypoxic-ischaemic encephalopathy (HIE) treated with therapeutic hypothermia (TH) in Spain. This includes whether protocols are routinely used, the type of neuro-monitoring performed, and how information on the neurological prognosis is presented to families. The answers to these would allow to detect and implement areas of improvement. METHOD: A cross-sectional analysis was performed on the responses to structured questionnaires sent to all the Spanish neonatal units that were performing TH in June 2015. Questions were divided into 5sections: 1) the availability of protocols and technological resources, 2) the use of neuro-monitoring tools, 3) the knowledge and training of the professionals; 4) the prognostic information given to the parents; and 5) the discharge report and the follow-up plan. RESULTS: Most centres (95%) use servo controlled whole-body cooling methods and have specific management protocols. Sedation is used in 70% of centres, and in 68% of them the onset of enteral feeding is delayed until the end of the cooling period. Amplitude-integrated electroencephalography monitoring is used in more than 80% of the centres, although only in 50% are nurses able to interpret it. Cerebral oxygen saturation is not often monitored (16%). As regards diagnostic-prognostic studies, neuroimaging is universal, but brain damage biomarkers are hardly used (29%). Prognostic information is offered within the first 72 posnatal hours in 21% of the centres, and is given without the presence of the nurse in 70% of the centres. Follow-up is performed by a neuro-paediatrician (84%), with an uneven duration between centres. CONCLUSIONS: The care of infants with HIE treated with TH in Spain is generally adequate, although there are areas for improvement in neuromonitoring, sedation, prognostic information, teamwork, and duration of follow-up.

Analysis of hypothermia through the acute phase in major burns patients: Nursing care. / Análisis de la hipotermia durante la fase aguda del paciente gran quemado: cuidados enfermeros.

Major burns patients usually present hypothermia after suffering a thermal burn, due to exposure during the accident, cooling of the burn and transfer. There are methods of reheating to avoid this heat loss, where nursing care is key. OBJECTIVE: To analyse the constant temperature presented by large burns patients on admission to the Burns Unit and their progression over the first 72hours. METHOD: Retrospective cross-sectional descriptive observational study of patients with thermal burns affecting more than 15% of body surface area, from December 2010 to May 2018. By reviewing databases and clinical records, demographic data, qualitative variables (origin of burn, previous pathologies, mechanical ventilation and ABSI and BOBI scales) and quantitative variables (burn depth and extension, temperature at admission and taken every 8hours for 72hours). Absolute, relative frequencies and the statistics of the quantitative variables were analysed. The study was verified by statistical tests according to the variables and contingency tables. A logistic regression model was developed expressed in a ROC curve. RESULTS: Of the 57 patients included, 79.2% developed hypothermia on admission. They presented burns over 34.56%±16.64 of their body surface, with 28.04%±17.49 being deep burns. Mortality during the stay was 29.8%. The presence of hypothermia during the acute phase was statistically related to death during stay in the unit (p=.033). It was observed that hypothermia is directly related to the extent of the burn (p=.003). CONCLUSIONS: Due to the presence of hypothermia on admission, and to the fact that the average temperature does not exceed 36°C until at least 16hours after the burn, nurses must know and promptly administer adequate reheating measures to improve chances of survival in major burns.

Ten years since the introduction of therapeutic hypothermia in neonates with perinatal hypoxic-ischaemic encephalopathy in Spain. / Una década después de la implantación en España de la hipotermia terapéutica en el recién nacido con encefalopatía hipóxico-isquémica perinatal.

INTRODUCTION: More than a decade has passed since therapeutic hypothermia (TH) was introduced in Spain; this is the only neuroprotective intervention that has become standard practice in the treatment of perinatal hypoxic-ischaemic encephalopathy (HIE). This article aims to provide a current picture of the technique and to address the controversies surrounding its use. DEVELOPMENT: In the last 10 years, TH has been successfully implemented in the vast majority of tertiary hospitals in Spain, and more than 85% of newborns with moderate or severe HIE currently receive the treatment. The factors that can improve the efficacy of TH include early treatment onset (first 6hours of life) and the control of comorbid factors associated with perinatal asphyxia. In patients with moderate HIE, treatment onset after 6hours seems to have some neuroprotective efficacy. TH duration longer than 72hours or deeper hypothermia do not offer greater neuroprotective efficacy, but instead increase the risk of adverse effects. Unclarified aspects are the sedation of patients during TH, the application of the treatment in infants with mild HIE, and its application in other scenarios. Prognostic information and time frame are one of the most challenging aspects. CONCLUSIONS: TH is universal in countries with sufficient economic resources, although certain unresolved controversies remain. While the treatment is widespread in Spain, there is a need for cooling devices for the transfer of these patients and their centralisation.