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

Introducción: Se cumple ahora más de una década del inicio de la hipotermia terapéutica (HT)en Espa ̃na, la única intervención neuroprotectora que ha venido a ser práctica estándar en eltratamiento de la encefalopatía hipóxico-isquémica perinatal (EHI). El objetivo de este artículoes ofrecer un panorama actual y presentar las controversias surgidas alrededor de la aplicaciónde esta terapia. Desarrollo: En esta década se ha implantado con éxito la HT en la gran mayoría de los hospitalesterciarios de Espa ̃na y más del 85% de los recién nacidos con EHI moderada-grave reciben estaterapia. Entre los aspectos que pueden mejorar la eficacia de la HT están su inicio precoz dentrode las primeras 6 h de vida y el control de factores comórbidos asociados a la asfixia perinatal. En los pacientes con EHI moderada el inicio después de las 6 h parece mantener cierta eficacianeuroprotectora. Una duración de la HT mayor de 72 horas o un enfriamiento más profundo noofrecen mayor eficacia neuroprotectora y aumentan el riesgo de efectos adversos. Aspectosno bien aclarados aún son la sedación durante la HT y la aplicación de esta intervención a losneonatos con EHI leve y en otros escenarios. La información pronóstica y su marco temporal esuno de los aspectos más desafiantes. Conclusiones: La HT es universal en países con recursos económicos, aunque existen puntos de controversia no resueltos. Si bien es un tratamiento generalizado en nuestro país, falta disponerde dispositivos para el traslado de estos pacientes y su centralización.(AU)

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 inthe treatment of perinatal hypoxic-ischaemic encephalopathy (HIE). This article aims to providea 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 severeHIE currently receive the treatment. The factors that can improve the efficacy of TH includeearly treatment onset (first 6 hours of life) and the control of comorbid factors associated withperinatal asphyxia. In patients with moderate HIE, treatment onset after 6 hours seems to havesome neuroprotective efficacy. TH duration longer than 72 hours or deeper hypothermia do notoffer 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 infantswith mild HIE, and its application in other scenarios. Prognostic information and time frame areone of the most challenging aspects. Conclusions: TH is universal in countries with sufficient economic resources, although certainunresolved controversies remain. While the treatment is widespread in Spain, there is a needfor cooling devices for the transfer of these patients and their centralisation.(AU)

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.

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.

Sedación en los recién nacidos a término o casi a término con encefalopatía hipóxico-isquémica que requieren hipotermia terapéutica / Sedation in term or near-term newborns with hypoxic-ischemic encephalopathy who require therapeutic hypothermia

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Hipotermia cerebral moderada en la encefalopatía hipóxico-isquémica. Experiencia en el primer año de su puesta en marcha / Moderate cerebral hypothermia in hypoxic-ischaemic encephalopathy: Experience after one year

Introducción: La hipotermia cerebral moderada ha probado ser una intervención eficaz para reducir la mortalidad y la discapacidad mayor en los neonatos con encefalopatía hipóxico-isquémica (EHI) moderada-grave. Objetivos: Describir la experiencia en el primer año de su utilización y valorar la factibilidad y seguridad de esta intervención. Métodos: Revisión de los 20 pacientes con EHI moderada-grave tratados con hipotermia corporal total en la Agrupación Sanitaria Hospital Sant Joan de Déu-Hospital Clínic, entre enero de 2009 y junio de 2010. Resultados: Durante este periodo ingresaron 50 neonatos con EHI perinatal, en 26 de ellos moderada-grave. Un total de 20 neonatos recibieron hipotermia (13 con EHI grave y 7 moderada). En todos ellos se encontró un antecedente de riesgo de hipoxia-isquemia perinatal y algún signo clínico de EHI. Quince neonatos presentaron convulsiones clínicas y/o en el registro electroencefalográfico. La temperatura rectal se mantuvo en 33,5±0,5°C en el 76,5% de las determinaciones para los neonatos con control manual de la temperatura y en el 93,6% para los manejados con servocontrol (p<0,0001). El recalentamiento se realizó en una mediana de 10,5 horas. No se produjo ninguna complicación potencialmente grave relacionada con la hipotermia. Fallecieron 7 neonatos (35%), todos ellos con EHI grave. Conclusiones: No se han apreciado dificultades en ninguna de las fases de esta intervención terapéutica ni se ha registrado ninguna complicación potencialmente grave relacionada con ella. Tanto el control manual de la temperatura como su servocontrol son eficaces para mantener la temperatura diana, pero esta muestra una menor variabilidad con el equipo servocontrolado(AU)

Introduction: Moderate cerebral hypothermia has been shown to be an effective intervention in decreasing mortality and major disabilities in infants with moderate-severe hypoxic-ischaemic encephalopathy (HIE). Objectives: To describe our experience within the first year of implementation, and to evaluate the feasibility and safety of this intervention. Methods: Retrospective study of 20 patients with moderate-severe HIE treated with whole body hypothermia in the Agrupación Sanitaria Hospital Sant Joan de Déu-Hospital Clínic, between January 2009 and June 2010.ResultsDuring this period, 50 patients with perinatal HIE, 26 of them moderate- severe, were admitted to our units. Twenty patients received hypothermia (13 with severe and 7 with moderate HIE). All of them had at least one risk factor for perinatal hypoxia-ischaemia, and clinical signs of HIE. Fifteen had clinical and/or EEG seizures. Core temperature was maintained at 33.5±0.5°C in 76.5% of determinations for infants cooled with a manual control device, and in 93.6% for those cooled with a servo-controlled device (P<0,0001). Re-warming took a median time of 10.5hours. No potentially severe complications related to hypothermia were observed. Seven patients (35%) died, all of them with severe HIE. Conclusions: There were no difficulties in any of the steps of this intervention, and no potentially severe complications related to it were recorded. Both manual and servo-control methods are equally effective on maintaining the target temperature, although temperature shows less variability using the servo-controlled equipment(AU)

[Moderate cerebral hypothermia in hypoxic-ischaemic encephalopathy: Experience after one year]. / Hipotermia cerebral moderada en la encefalopatía hipóxico-isquémica. Experiencia en el primer año de su puesta en marcha.

INTRODUCTION: Moderate cerebral hypothermia has been shown to be an effective intervention in decreasing mortality and major disabilities in infants with moderate-severe hypoxic-ischaemic encephalopathy (HIE). OBJECTIVES: To describe our experience within the first year of implementation, and to evaluate the feasibility and safety of this intervention. METHODS: Retrospective study of 20 patients with moderate-severe HIE treated with whole body hypothermia in the Agrupación Sanitaria Hospital Sant Joan de Déu-Hospital Clínic, between January 2009 and June 2010. RESULTS: During this period, 50 patients with perinatal HIE, 26 of them moderate- severe, were admitted to our units. Twenty patients received hypothermia (13 with severe and 7 with moderate HIE). All of them had at least one risk factor for perinatal hypoxia-ischaemia, and clinical signs of HIE. Fifteen had clinical and/or EEG seizures. Core temperature was maintained at 33.5 ± 0.5°C in 76.5% of determinations for infants cooled with a manual control device, and in 93.6% for those cooled with a servo-controlled device (P<.0001). Re-warming took a median time of 10.5 hours. No potentially severe complications related to hypothermia were observed. Seven patients (35%) died, all of them with severe HIE. CONCLUSIONS: There were no difficulties in any of the steps of this intervention, and no potentially severe complications related to it were recorded. Both manual and servo-control methods are equally effective on maintaining the target temperature, although temperature shows less variability using the servo-controlled equipment.

[Cerebrovascular accidents in full-term newborn infants]. / Accidentes vasculares encefálicos en neonatos a término.

INTRODUCTION: The purpose of this paper is to review the role of the neurologist in the management of cerebrovascular accidents (CVA) (insults resulting from a sudden obstruction or rupture of an intracranial vessel). This was accomplished by reviewing the literature (PubMed) under the heading of stroke and term neonate. DEVELOPMENT: CVA in full-term neonates are classified as hematomas and infarcts. Hematomas are classified according to: location, structure (arterial, venous, or sinus), type of malformation (aneurysm, venous malformation, and telangiectasia), and cause of the bleed (vessel wall rupture or hypo-coagulation). Classification according to location is based on compartment supra or infratentorial; space -extra-axial (epidural, subdural, or subarachnoid) or intra-axial (parenchymal or ventricular)-; and region -parietal, temporal, thalamic, etc.-. Infarcts are classified according to vascular and parenchymal factors. The vascular factors are the structure, the cause of the obstruction -extramural, mural or intramural (thrombus or embolus)-. The parenchymal factors are type of damage (pale vs hemorrhagic) and location. Patients with suspected embolism should have ultrasound neck. Coagulation studies should be done in patients with hematomas and infracts. Multiple causes may be present in each case. Anticoagulation is only used in small pale infarcts of cardiac embolic origin. CONCLUSION: The neurologist roles in the management of CVA are to classify the event, select the appropriate investigation, and implement treatment.

Accidentes vasculares encefálicos en neonatos a término / Cerebrovascular accidents in full-term newborn infants

Introducción. El propósito de este artículo es revisar elpapel del neurólogo en el manejo de los recién nacidos a términocon accidentes vasculares encefálicos (AVE) (lesiones debidas auna súbita obstrucción o ruptura de un vaso intracraneal). Coneste fin se revisaron las fuentes bibliográficas (PubMed) mediantela búsqueda de los términos ‘stroke’ y ‘term neonate’. Desarrollo.Los AVE se dividen en hematomas e infartos. Los hematomas debenclasificarse de acuerdo con su localización; estructura vascularenvuelta (arteria, vena o seno), el tipo de anomalía vascular (aneurisma,malformaciones venosas, telangiectasia) y la causa de laextravasación de la sangre (ruptura de la pared vascular o hipocoagulación).La clasificación de acuerdo con la localización incluye:compartimentos (supra e infratentoriales), espacios –extraaxial(epidural, subdural o aracnoideo) o intraaxial (parénquima oventrículos)– y regiones –parietal, temporal, talámica, etc.–. Losinfartos se clasifican de acuerdo con factores vasculares y parenquimatosos;los factores vasculares son el tipo de estructura vascularenvuelta, causa de la obstrucción –extramural, mural o intramural(émbolo o trombo)–; los factores parenquimatosos son el tipode infarto –pálido o hemorrágico– y la localización de éste. Lospacientes con procesos embólicos requieren ecografía del corazóny del cuello. La posibilidad de causas múltiples debe sospecharse.Se deben realizar estudios de coagulación. La cirugía puede sernecesaria en determinados casos. En pacientes con cardioembolismose sugiere la anticoagulación en infartos pálidos y pequeños.Conclusión. La función del neurólogo en estos pacientes consisteen clasificar el evento, guiar las investigaciones y decidir el tratamiento

Introduction. The purpose of this paper is to review the role of the neurologist in the management of cerebrovascularaccidents (CVA) (insults resulting from a sudden obstruction or rupture of an intracranial vessel). This was accomplished byreviewing the literature (PubMed) under the heading of stroke and term neonate. Development. CVA in full-term neonates areclassified as hematomas and infarcts. Hematomas are classified according to: location, structure (arterial, venous, or sinus), typeof malformation (aneurysm, venous malformation, and telangiectasia), and cause of the bleed (vessel wall rupture or hypocoagulation).Classification according to location is based on compartment supra or infratentorial; space –extra-axial (epidural,subdural, or subarachnoid) or intra-axial (parenchymal or ventricular)–; and region –parietal, temporal, thalamic, etc.–.Infarcts are classified according to vascular and parenchymal factors. The vascular factors are the structure, the cause of theobstruction –extramural, mural or intramural (thrombus or embolus)–. The parenchymal factors are type of damage (pale vshemorrhagic) and location. Patients with suspected embolism should have ultrasound neck. Coagulation studies should be donein patients with hematomas and infracts. Multiple causes may be present in each case. Anticoagulation is only used in small paleinfarcts of cardiac embolic origin. Conclusion. The neurologist roles in the management of CVA are to classify the event, selectthe appropriate investigation, and implement treatment

A case of hyperglycemic hyperosmolar non-ketotic coma during anesthesia: a possible cause of failed re-awakening.

The case of a non diabetic 6-year-old boy affected by Down's syndrome, who developed hyperosmolar hyperglycemic non-ketotic coma following the infusion of hypertonic dextrose solution during general anesthesia for a surgical procedure for cryptorchidism is reported. Following surgery, the patient remained deeply comatose and generalized seizures occurred. Hyperosmolarity due to hyperglycemia and acidosis were reduced by administration of insulin at low rate, hypotonic saline and sodium-bicarbonate solutions. The patient's clinical conditions promptly improved following normalization of blood glucose levels. An oral glucose tolerance test performed three months later was normal. The authors emphasize the potential risk of hyperosmolar hyperglycemic non-ketotic coma also in non diabetic patients treated with hypertonic dextrose solutions, during surgery events.