Knowledge and practices of neonatal intensive care unit nurses concerning hypothermia in preterm infants: A descriptive cross-sectional study.

AIM: To investigate the knowledge level and clinical practice of neonatal intensive care unit nurses on the whole process of hypothermia prevention in preterm infants. DESIGN: A polycentric descriptive cross-sectional study was conducted in 23 hospitals in Shandong province involving 254 neonatal intensive care unit nurses. METHODS: An evidence-based knowledge and clinical practice questionnaire on hypothermia prevention in preterm infants and a general information questionnaire were used to collect data. SPSS and EXCEL 24.0 database were used for data statistics and analysis. RESULTS: Nearly one-third of nurses were unclear about the definition of mild hypothermia and heat preservation measures during labour management and resuscitation. Knowledge about the correct rate of amniotic fluid evaporation was low. The higher the hospital level and nurses' education level, professional title, work experience, and position, the higher the knowledge level. The clinical practice of nurses differed in terms of body temperature assessment tools, measurement sites, and measurement frequency for premature infants. CONCLUSIONS: Nurses in neonatal intensive care units need to apply evidence-based knowledge and carry out practice interventions to ensure preterm infants' safe transition from the delivery room to the neonatal intensive care unit. IMPACT: There have been few studies evaluating neonatal nurses' knowledge and practices with regards to the preventing hypothermia of premature infants from delivery room to neonatal intensive care unit. The study identifies the deficiencies and problems in temperature management that can be attributed to the knowledge level of nurses. The findings will help improve the current curriculum, teaching strategies, and the nurses' knowledge levels, preventing premature hypothermia in infants. REPORTING METHOD: This study adhered to the STROBE statement for observational studies and obtained approval (KYLL-2023LW045) from the ethics committee of The Second Hospital of Shandong University. The other 22 third- and second-level hospitals, as our alliance members, recognized our chairperson status within the alliance and were willing to join our academic activities. Mutual responsibility for ethical filing between alliance units. PUBLIC CONTRIBUTION: 254 nurses were recruited from 23 tertiary and secondary public hospitals in Shandong province. No public or patient involvement. Members of the research group used the Questionnaire Star platform to prepare the electronic questionnaire, including obtaining informed consent, taking precautions for questionnaire completion, and using the aforementioned measurement tools. The project research team contacted the head nurses of 23 neonatal intensive care units in Shandong Province. After obtaining consent from the head nurses, they were asked to send the requirements and link of the electronic questionnaire to their WeChat management group. The nurses go through each question and make a choice which has two options of 'agree' or 'disagree.' Based on their answers, nurses were evaluated as having 'mastered' or 'not mastered' each item. Each 'mastered' item (correct answer) was given a score of 4; an item 'not mastered' (incorrect answer) was given a score of 0. The total score ranged from 0 to 100.

Parent-infant closeness and care practices during therapeutic hypothermia in Swedish neonatal intensive care units.

OBJECTIVES: The aim of this study was to investigate care practices among Neonatal Intensive Care Units (NICU) providing Therapeutic hypothermia (TH), and more specific to investigate staff's experiences of parental participation, presence, and possibilities of being close with their infant during TH. METHODS: A descriptive, qualitative, and quantitative study. All Swedish NICUs providing TH (n = 10) participated. Data were collected during January-April 2021 via a questionnaire followed by a semi-structured interview with the registered nurse and the neonatologist responsible for TH at each unit. Descriptive statistics were calculated, and a qualitative content analysis was performed. RESULTS: All NICUs allowed parents unlimited stay with their infants and were keen to support parental presence, which was a prerequisite for promoting parent-infant closeness. Standardized routines regarding the infants' care space and course of action were described as time-efficient and staff-saving, which freed up time to focus on the families. CONCLUSION: Standardized routines regarding the care space setup and the medical and caring approach, as well as the NICU environment and practices around the families, can promote or curb the possibilities of parent-infant closeness. Well-established care practices and good environmental conditions with flexibility regarding the family's needs are therefore required.

Reverse Therapy: Impact of Hyperthermia and Rewarming on Newborn Outcomes.

Therapeutic hypothermia is now well established to improve neurodevelopmental outcomes after hypoxic-ischemic encephalopathy (HIE). Although the overall principles of treatment are now well established, many smaller questions are unclear. The potential impact of reversal of hypothermia therapy and the effect of high temperatures on recovery of the neurovascular unit after therapeutic hypothermia for HIE has received relatively little attention. This article will address the effects of hypoxia-ischemia and rewarming and increased temperatures on the neurovascular unit in preclinical and clinical models.

Long-Term Outcomes Following Hypoxic Ischemic Encephalopathy.

Hypoxic ischemic encephalopathy (HIE) is the most common cause of neonatal encephalopathy and results in significant morbidity and mortality. Long-term outcomes of the condition encompass impairments across all developmental domains. While therapeutic hypothermia (TH) has improved outcomes for term and late preterm infants with moderate to severe HIE, trials are ongoing to investigate the use of TH for infants with mild or preterm HIE. There is no evidence that adjuvant therapies in combination with TH improve long-term outcomes. Numerous trials of various adjuvant therapies are underway in the quest to further improve outcomes for infants with HIE.

Communicating with Parents About Therapeutic Hypothermia and Hypoxic Ischemic Encephalopathy: Integrating a Palliative Care Approach into Practice.

Parents of newborns with hypoxic ischemic encephalopathy (HIE) can face communication challenges in the neonatal intensive care unit. Both specialty palliative care and primary palliative care trained clinicians can assist parents as they navigate traumatic experiences and uncertain prognoses. Using evidence-based frameworks, the authors provide samples of how to communicate with parents and promote parent well-being across the care trajectory. The authors demonstrate how to involve parents in a shared decision-making process and give special consideration to the complexities of hospital discharge and the transition home. Sustained investment to guide the development of effective communication skills is crucial to support families of infants with HIE.

A New Horizon for Understanding the Comparative Effectiveness for Cooling Prospectively Infants with Mild Encephalopathy.

The authors summarize the methodology for a new pragmatic comparative effectiveness research investigation, Cooling Prospectively Infants with Mild Encephalopathy (COOLPRIME), which uses sites' existing mild hypoxic-ischemic encephalopathy (HIE) treatment preference (hypothermia or normothermia) to assess hypothermia effectiveness and safety. COOLPRIME's primary aim is to determine the safety and effectiveness of hypothermia compared to normothermia in mild HIE. Engagement of Families and Community Affected by Hypoxic-Ischemic Encephalopathy strongly favored Effectiveness over Efficacy Trials leading to COOL PRIME design.

Key Inflammatory Biomarkers in Perinatal Asphyxia: A Comprehensive Review.

This article summarizes the current evidence regarding inflammatory biomarkers (placental and postnatal) and provides a comprehensive understanding of their roles: (1) diagnostic accuracy to predict the severity of hypoxic-ischemia encephalopathy (HIE), (2) value in assessing treatment responses, and (3) prediction of both short- and long-term neurodevelopmental outcomes. In the early critical stages of perinatal asphyxia, inflammatory biomarkers may guide clinical decision-making. Additional research is required to increase our understanding of the optimal utility of biomarkers to predict the severity, evolution, and developmental outcomes after exposure to HIE.

Pipeline to Neonatal Clinical Transformation: The Importance of Preclinical Data.

Historically, neonatal neuroscience boasted a robust and successful preclinical pipeline for therapeutic interventions, in particular for the treatment of hypoxic-ischemic encephalopathy (HIE). However, since the successful translation of therapeutic hypothermia (TH), several high-profile failures of promising adjunctive therapies, in addition to the lack of benefit of TH in lower resource settings, have brought to light critical issues in that same pipeline. Using recent data from clinical trials of erythropoietin as an example, the authors highlight several key challenges facing preclinical neonatal neuroscience for HIE therapeutic development and propose key areas where model development and collaboration across the field in general can ensure ongoing success in treatment development for HIE worldwide.

Moving the Needle in Low-Resource Settings: Is Hypothermia a Friend or a Foe?

Hypoxic-ischemic encephalopathy in low resource settings is associated with low occurrence of perinatal sentinel events, growth restriction, short birth depression, early seizure onset, white matter injury, and non-acute hypoxia on whole genome expression profile suggesting that intra-partum hypoxia might be occurring from a normal or augmented labor process in an already compromised fetus. Induced hypothermia increases mortality and does not reduce brain injury. Strict adherence to the updated National Neonatology forum guidelines is essential to prevent harm from induced hypothermia in low resource settings.

Ethical and Legal Perspectives on the Treatment of Hypoxic Ischemic Encephalopathy in the Newborn.

Hypoxic ischemic encephalopathy (HIE) in neonates can cause severe, life-long functional impairments or death. Treatment of these neonates can involve ethically challenging questions about if, when, and how it may be appropriate to limit life-sustaining medical therapy. Further, parents whose infants suffer severe neurologic damage may seek recourse in the form of a medical malpractice lawsuit. This study uses several hypothetical cases to highlight important ethical and legal considerations in the care of infants with HIE.

An unusual cause of neonatal hypothermia and shock in the emergency department: Diamond Blackfan Anemia.

Diamond Blackfan Anemia (DBA) is a rare disease characterized by anemia secondary to impaired red blood cell production from bone marrow failure. We present a case of infantile hypothermia and shock caused by this clinical pathology. A seven-week-old infant was brought to the emergency department by the father with the chief complaint of abnormal breathing and low activity level throughout the day. Medical history was unremarkable for both the patient and the family. On examination, the infant was breathing 30 breaths per minutes, had a heart rate of 116, and a core temperature of 33 degrees Celsius. The infant was ashen in color, limp, with grunted breathing and minimal movement. Numerous abnormal laboratory readings were reported, with the most significant being a hemoglobin of 1.7 and a hematocrit of 7.4. Emergent blood transfusion was initiated, and the patient was eventually air-lifted to a pediatric hospital two hours away. This case highlights the imperative of a thorough history and examination and consideration of a broad differential for neonatal hypothermia and shock, especially in the setting of no obvious bleeding.

Prevalence of Pulmonary Hypertension During Therapeutic Hypothermia for Hypoxic Ischemic Encephalopathy and Evaluation of Short-Term Outcomes.

Infants with perinatal asphyxia and moderate-to-severe hypoxic ischemic encephalopathy (HIE) are currently treated with therapeutic hypothermia (TH) as part of a brain protective strategy. However, perinatal asphyxia is a risk factor for development of persistent pulmonary hypertension (PPHN). As such, the aim of this study was to quantify the risk of PPHN in infants undergoing TH and assess short-term outcomes in infants developing PPHN. All N = 59 infants undergoing TH for moderate-to-severe HIE over a period of 3 years (January 2020-December 2022) at a single center were included. PPHN was diagnosed in N = 10 (17%), with this deemed to have been exacerbated by TH in n = 6 (10%). Only 50% (5/10) with PPHN required inhaled nitric oxide, and none of the infants received extracorporeal membrane oxygenation. PPHN was not found to be significantly associated with short-term outcomes, including the extent of HIE on brain magnetic resonance imagings, in-hospital mortality or requirement for nasogastric feeding at discharge. In conclusion, TH appears to be a safe and effective treatment for moderate-to-severe HIE with or without PPHN.

Intermittent hemodialysis as a rewarming strategy for severe hypothermia in patients without renal failure: a case report.

This case report highlights the effective use of intermittent hemodialysis (IHD) in warming a 71-year-old female patient with severe hypothermia who presented with a rectal temperature of 25 °C and signs of hemodynamic instability. The patient, found unconscious after prolonged exposure to cold exacerbated by alcohol consumption, initially showed some improvement in core temperature through active external rewarming methods. However, soon, her temperature plateaued at 27 °C. Patient was deemed unsuitable for extracorporeal membrane oxygenation (ECMO) or cardiopulmonary bypass (CPB) due to her age, and urgent IHD was initiated. This approach resulted in a stable increase in core temperature at approximately 2.0 °C/hr, along with normalization of lactic acidosis, creatinine phosphokinase, and correction of electrolyte imbalances, culminating in her full recovery and discharge after seven days in the hospital.After reviewing this case alongside similar ones from before, this case report highlights the efficacy and safety of IHD as an efficient, readily available, and less invasive method for rewarming moderate to severe hypothermic patients who are hemodynamically unstable patients but do not have cardiac arrest or renal dysfunction. IHD is especially useful when less invasive cooling devices (Artic Sun/ CoolGard) are not available or more invasive extracorporeal life support options (ECMO/ CPB) are either not indicated or unavailable. IHD can also help improve concurrent electrolyte imbalances and/or toxin buildup. The report further emphasizes the necessity of monitoring for potential complications, such as post-dialysis hypophosphatemia and rebound hyperkalemia, following successful rewarming.

The Effect of Therapeutic Hypothermia on Ischemic Brain Injury in a Rat Model of Cardiac Arrest: An Assessment Using 18F-FDG PET.

PURPOSE: Therapeutic hypothermia (TH) is widely acknowledged as one of the interventions for preventing hypoxic ischemic brain injury in comatose patients following cardiac arrest (CA). Despite its recognized efficacy, recent debates have questioned its effectiveness. This preclinical study evaluated the impact of TH on brain glucose metabolism, utilizing fluorine-18-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) in a rat model of CA. METHODS: Asphyxia CA was induced in Sprague-Dawley rats using vecuronium. Brain PET images using 18F-FDG were obtained from 21 CA rats, who were randomized to receive either TH or no intervention. Of these, 9 rats in the TH group received hypothermia under general anesthesia and mechanical ventilation for eight hours, while the remaining 12 rats in the non-TH group were observed without intervention. We conducted regional and voxel-based analyses of standardized uptake values relative to the pons (SUVRpons) to compare the two groups. RESULTS: Survival rates were identical in both the TH and non-TH groups (67%). There was no discernible difference in the SUVRpons across the brain cortical regions between the groups. However, in a subgroup analysis of the rats that did not survive (n = 7), those in the TH group (n = 3) displayed significantly higher SUVRpons values across most cortical regions compared to those in the non-TH group (n = 4), with statistical significance after false-discovery rate correction (p < 0.05). CONCLUSIONS: The enhancement in SUVRpons due to TH intervention was only observed in the cortical regions of rats with severe encephalopathy that subsequently died. These findings suggest that the beneficial effects of TH on brain glucose metabolism in this asphyxia CA model may be confined to cases of severe ischemic encephalopathy.

Severe Hypothermia Induces Ferroptosis in Cerebral Cortical Nerve Cells.

Abnormal shifts in global climate, leading to extreme weather, significantly threaten the safety of individuals involved in outdoor activities. Hypothermia-induced coma or death frequently occurs in clinical and forensic settings. Despite this, the precise mechanism of central nervous system injury due to hypothermia remains unclear, hindering the development of targeted clinical treatments and specific forensic diagnostic indicators. The GEO database was searched to identify datasets related to hypothermia. Post-bioinformatics analyses, DEGs, and ferroptosis-related DEGs (FerrDEGs) were intersected. GSEA was then conducted to elucidate the functions of the Ferr-related genes. Animal experiments conducted in this study demonstrated that hypothermia, compared to the control treatment, can induce significant alterations in iron death-related genes such as PPARG, SCD, ADIPOQ, SAT1, EGR1, and HMOX1 in cerebral cortex nerve cells. These changes lead to iron ion accumulation, lipid peroxidation, and marked expression of iron death-related proteins. The application of the iron death inhibitor Ferrostatin-1 (Fer-1) effectively modulates the expression of these genes, reduces lipid peroxidation, and improves the expression of iron death-related proteins. Severe hypothermia disrupts the metabolism of cerebral cortex nerve cells, causing significant alterations in ferroptosis-related genes. These genetic changes promote ferroptosis through multiple pathways.

Intraoperative zero-heat-flux thermometry overestimates nasopharyngeal temperature by 0.39 °C: an observational study in patients undergoing congenital heart surgery.

During surgery for congenital heart disease (CHD) temperature management is crucial. Vesical (Tves) and nasopharyngeal (TNPH) temperature are usually measured. Whereas Tves slowly responds to temperature changes, TNPH carries the risk of bleeding. The zero-heat-flux (ZHF) temperature monitoring systems SpotOn™ (TSpotOn), and Tcore™ (Tcore) measure temperature non-invasively. We evaluated accuracy and precision of the non-invasive devices, and of Tves compared to TNPH for estimating temperature. In this prospective observational study in pediatric and adult patients accuracy and precision of TSpotOn, Tcore, and Tves were analyzed using the Bland-Altman method. Proportion of differences (PoD) and Lin´s concordance correlation coefficient (LCC) were calculated. Data of 47 patients resulted in sets of matched measurements: 1073 for TSpotOn vs. TNPH, 874 for Tcore vs. TNPH, and 1102 for Tves vs. TNPH. Accuracy was - 0.39 °C for TSpotOn, -0.09 °C for Tcore, and 0.07 °C for Tves. Precisison was between - 1.12 and 0.35 °C for TSpotOn, -0.88 to 0.71 °C for Tcore, and - 1.90 to 2.05 °C for Tves. PoD ≤ 0.5 °C were 71% for TSpotOn, 71% for Tcore, and 60% for Tves. LCC was 0.9455 for TSpotOn, 0.9510 for Tcore, and 0.9322 for Tves. Temperatures below 25.2 °C (TSpotOn) or 27.1 (Tcore) could not be recorded non-invasively, but only with Tves. Trial registration German Clinical Trials Register, DRKS00010720.

STudy to ActivelY WARM trauma patients (STAY WARM): a pilot study assessing feasibility of self-warming blankets in patients requiring a massive hemorrhage protocol activation.

PURPOSE: Massively bleeding trauma patients often arrive to intensive care units hypothermic. Active warming blankets have shown promise in reducing hypothermia in the pre-hospital setting, but less is known about their in-hospital use. The aim of this pilot evaluation was to understand the feasibility of the Ready-Heat® blanket in a level 1 trauma centre to improve the management of hypothermia in massively bleeding trauma patients. METHODS: This was a prospective, observational, feasibility study of 15 patients performed at a single level 1 trauma centre. Patients were eligible for enrollment if they presented to the trauma bay and a massive hemorrhage protocol was activated. Primary outcome measures (feasibility) included: blanket applied to the patient; temperature recording in the trauma bay, and next phase or final phase of care; and blanket remaining on patient upon arrival to the subsequent phase of care.Secondary outcome measures (safety) included skin irritation and cold discomfort. Use of the Ready-Heat® blanket was considered feasible if 10 of 15 patients met all four criteria for feasibility. RESULTS: The Ready-Heat® blanket was placed on all patients with mean time to blanket application of 24 (± 13.4) minutes. Thirteen patients (86.7%) met all four criteria for feasibility. Initial challenges were identified in the first five patients including proper blanket application, keeping the blanket on the patient through subsequent phases of care, and failure to obtain temperature recordings. CONCLUSION: The Ready-Heat® blanket proves feasible for this patient population. A larger study focusing on hypothermia prevention and treatment is warranted. TRIAL REGISTRATION NUMBER: NCT04399902. DATE OF REGISTRATION: May 22, 2020.

Hypothermia for Hypoxic-ischemic Encephalopathy: Second-generation Trials to Address Gaps in Knowledge.

Multiple randomized controlled trials of hypothermia for moderate or severe neonatal hypoxic-ischemic encephalopathy (HIE) have uniformly demonstrated a reduction in death or disability at early childhood evaluation. These initial trials along with other smaller studies established hypothermia as a standard of care in the neonatal community for moderate or severe HIE. The results of the initial trials have identified gaps in knowledge. This article describes 3 randomized controlled trials of hypothermia (second-generation trials) to address refinement of hypothermia therapy (longer and/or deeper cooling), late initiation of hypothermia (after 6 hours following birth), and use of hypothermia in preterm newborns.

A clinical comparison of glycol and water-based heater-cooler systems for cardiopulmonary bypass.

INTRODUCTION: While newer heater-cooler technologies using ethylene glycol-based (GB) solutions during cardiothoracic surgery have become commercially available, there is a paucity of clinical data describing their effectiveness during cardiopulmonary bypass (CPB) support. This analysis aimed to compare clinical characteristics and procedural outcomes using water-based (WB) and GB heater-cooler systems. METHODS: A retrospective analysis was performed on consecutive adult patients undergoing CPB from June to October 2022 comparing WB or GB groups. The primary outcome was a composite of operative death or major morbidity. Secondary endpoints included transfusion requirements on CPB, patient cooling and warming rates, and vasoactive-inotropic scores (VIS) at case completion. P-control charts were used to monitor the weekly incidence of the composite outcome. A sub-analysis was performed to evaluate the primary outcome for cardiac surgery cases indexed by the Society of Thoracic Surgeons (STS). RESULTS: There were 167 patients included for analysis; 87 (52.1%) underwent CPB with a WB system and 80 (47.9%) with a GB system. GB procedure subjects were younger (p = .01), experienced longer CPB times (p = .034), and were more likely to receive thoracic transplant or aortic surgery (p = 0.015). The composite outcome of operative mortality or major morbidity occurred in 29.9% and 24% of the WB and GB groups, respectively (p = .372). P-control charts indicated a weekly mean incidence of 30% during WB practice, which decreased to 24% with GB practice. Among 106 STS-indexed cardiac surgery cases, mean composite outcome incidence decreased from 19% to 6% following our GB transition. Additionally, cooling, and warming rates indexed to patient BSA and VIS at case completion were not significantly different. CONCLUSION: Our analysis demonstrated a safe transition from WB to GB heater-cooler technologies in our practice. This early analysis suggests that GB heater coolers may be safely adopted to mitigate the risks of nontuberculous mycobacterium infections for cardiac surgical patients.

An Implementation Science Study of a Heat-Producing Wrap to Complement KMC in Rwanda.

Background: Neonatal hypothermia is a major cause of preventable morbidity and mortality, especially among the world's poorest newborns. A heat-producing wrap is necessary when kangaroo mother care (KMC) is insufficient or unavailable, yet there is little published research on such wraps. The Dream Warmer is a wrap designed to complement KMC and has been extensively studied in formal research settings but not in real-world conditions. Objectives: We used implementation science methodology to understand the safety, effectiveness, and functionality of the Dream Warmer (hereafter, "Warmer"); its effect on clinical workflows; its interaction with other aspects of care such as KMC; and the Warmer's reception by healthcare providers (HCPs) and parents. Methods: We conducted a prospective, interventional, one-arm, open-label, mixed-methods study in 6 district hospitals and 84 associated health centers in rural Rwanda. Our intervention was the provision of the Warmer and an educational curriculum on thermoregulation. We compared pre and post intervention data using medical records, audits, and surveys. Findings: The Warmer raised no safety concerns. It was used correctly in the vast majority of cases. The mean admission temperature rose from slightly hypothermic (36.41 °C) pre, to euthermic (36.53 °C) post intervention (p = 0.002). Patients achieved a temperature ≥36.5 °C in 86% of uses. In 1% of audits, patients were hyperthermic (37.6-37.9 °C). Both HCPs and parents reported a generally positive experience with the Warmer. HCPs were challenged to prepare it in advance of need. Conclusions: The Warmer functions similarly well in research and real-world conditions. Ongoing education directed toward both HCPs and parents is critical to ensuring the provision of a continuous heat chain. Engaging families in thermoregulation could ease the burden of overtaxed HCPs and improve the skill set of parents. Hypothermia is a preventable condition that must be addressed to optimize neonatal survival and outcome.