Efficacy of passive hypothermia and adverse events during transport of asphyxiated newborns according to the severity of hypoxic-ischemic encephalopathy / Eficácia da hipotermia passiva e eventos adversos durante o transporte de recém-nascidos asfixiados de acordo com a gravidade da encefalopatia hipóxico-isquêmica

Abstract Objective To determine if the efficacy of passive hypothermia and adverse events during transport are related to the severity of neonatal hypoxic-ischemic encephalopathy. Methods This was a retrospective study of 67 infants with hypoxic-ischemic encephalopathy, born between April 2009 and December 2013, who were transferred for therapeutic hypothermia and cooled during transport. Results Fifty-six newborns (84%) were transferred without external sources of heat and 11 (16%) needed an external heat source. The mean temperature at departure was 34.4 ± 1.4 °C and mean transfer time was 3.3 ± 2.0 h. Mean age at arrival was 5.6 ± 2.5 h. Temperature at arrival was between 33 and 35 °C in 41 (61%) infants, between 35 °C and 36.5 °C in 15 (22%) and <33 °C in 11 (16%). Infants with severe hypoxic-ischemic encephalopathy had greater risk of having an admission temperature < 33 °C (OR: 4.5; 95% CI: 1.1-19.3). The severity of hypoxic-ischemic encephalopathy and the umbilical artery pH were independent risk factors for a low temperature on admission (p < 0.05). Adverse events during transfer, mainly hypotension and bleeding from the endotracheal tube, occurred in 14 infants (21%), with no differences between infants with moderate or severe hypoxic-ischemic encephalopathy. Conclusion The risk of overcooling during transport is greater in newborns with severe hypoxic-ischemic encephalopathy and those with more severe acidosis at birth. The most common adverse events during transport are related to physiological deterioration and bleeding from the endotracheal tube. This observation provides useful information to identify those asphyxiated infants who require closer clinical surveillance during transport.

Resumo Objetivo Determinar se a eficácia da hipotermia passiva e eventos adversos durante o transporte estão relacionados à gravidade da encefalopatia hipóxico-isquêmica neonatal. Métodos Estudo retrospectivo de 67 neonatos com encefalopatia hipóxico-isquêmica (nascidos entre abril de 2009 e dezembro de 2013) transferidos para hipotermia terapêutica e resfriados durante o transporte. Resultados Foram transportados 56 recém-nascidos (84%) sem fontes externas de calor e 11 (16%) precisaram de uma fonte externa de calor. A temperatura média na saída foi de 34,4 ± 1,4 °C e o tempo médio de transporte foi de 3,3 ± 2,0 horas. A idade média na chegada foi de 5,6 ± 2,5 horas. A temperatura na chegada ficou entre 33-35 °C em 41 (61%) neonatos, entre 35°-36,5 °C em 15 (22%) e < 33 °C em 11 (16%). Neonatos com encefalopatia hipóxico-isquêmica grave apresentaram maior risco de temperatura < 33 °C na internação (RC 4,5; IC de 95% 1,1-19,3). A gravidade da encefalopatia hipóxico-isquêmica e o pH da artéria umbilical foram fatores de risco independentes para uma baixa temperatura na internação (p < 0,05). Eventos adversos durante o transporte, principalmente hipotensão e sangramento do tubo endotraqueal, ocorreram em 14 neonatos (21%), sem diferenças entre neonatos com encefalopatia hipóxico-isquêmica moderada ou grave. Conclusão O risco de super-resfriamento durante o transporte é maior em recém-nascidos com encefalopatia hipóxico-isquêmica grave e naqueles com acidose mais grave no nascimento. Os eventos adversos mais comuns durante o transporte estão relacionados a deterioração fisiológica e sangramento do tubo endotraqueal. Essa observação fornece informações úteis para identificar neonatos asfixiados que exigem maior vigilância clínica durante o transporte.

Efficacy of passive hypothermia and adverse events during transport of asphyxiated newborns according to the severity of hypoxic-ischemic encephalopathy.

OBJECTIVE: To determine if the efficacy of passive hypothermia and adverse events during transport are related to the severity of neonatal hypoxic-ischemic encephalopathy. METHODS: This was a retrospective study of 67 infants with hypoxic-ischemic encephalopathy, born between April 2009 and December 2013, who were transferred for therapeutic hypothermia and cooled during transport. RESULTS: Fifty-six newborns (84%) were transferred without external sources of heat and 11 (16%) needed an external heat source. The mean temperature at departure was 34.4±1.4°C and mean transfer time was 3.3±2.0h. Mean age at arrival was 5.6±2.5h. Temperature at arrival was between 33 and 35°C in 41 (61%) infants, between 35°C and 36.5°C in 15 (22%) and <33°C in 11 (16%). Infants with severe hypoxic-ischemic encephalopathy had greater risk of having an admission temperature<33°C (OR: 4.5; 95% CI: 1.1-19.3). The severity of hypoxic-ischemic encephalopathy and the umbilical artery pH were independent risk factors for a low temperature on admission (p<0.05). Adverse events during transfer, mainly hypotension and bleeding from the endotracheal tube, occurred in 14 infants (21%), with no differences between infants with moderate or severe hypoxic-ischemic encephalopathy. CONCLUSION: The risk of overcooling during transport is greater in newborns with severe hypoxic-ischemic encephalopathy and those with more severe acidosis at birth. The most common adverse events during transport are related to physiological deterioration and bleeding from the endotracheal tube. This observation provides useful information to identify those asphyxiated infants who require closer clinical surveillance during transport.

Transporte neonatal seguro en la población abierta del estado de Jalisco: impacto del programa S.T.A.B.L.E. en la morbilidad y mortalidad / Safe neonatal transport in Jalisco state: impact of S.T.A.B.L.E. program on morbidity and mortality

Introducción. El transporte neonatal desde las unidades médicas hasta las unidades de tercer nivel en muchos casos es desorganizado y arriesgado, situación que compromete aún más el estado de salud del neonato enfermo. El objetivo del estudio fue analizar el impacto del programa S.T.A.B.L.E. (de las siglas en inglés: Sugar and Safe care, Temperature, Airway, Blood, Lab work, Emotional support) en la morbimortalidad de los neonatos trasladados del interior del estado de Jalisco y de la zona metropolitana de Guadalajara, a la Unidad de Cuidados Intensivos Neonatales Externos (UCIN-EX) del Hospital Civil de Guadalajara. Métodos. Se diseñó un estudio prospectivo de 2005 a 2009. El proceso de intervención se basó en la aplicación del programa S.T.A.B.L.E. a todo neonato que requirió ser trasladado. Esto se logró con la intervención de los médicos reguladores del Sistema de Atención Médica de Urgencias (SAMU) del estado de Jalisco. Se implementó un curso de capacitación para el personal médico y paramédico de los centros de atención que refieren pacientes a nuestra unidad, con el fin darles a conocer el programa S.T.A.B.L.E. y su forma de aplicación. Resultados. Un total de 3,277 neonatos fueron incluidos en el estudio, 384 antes de implementar el programa y 2,893 con la aplicación del programa S.T.A.B.L.E. En el grupo con intervención se observó una frecuencia mayor de pacientes con temperatura corporal normal a su ingreso a la unidad receptora [516 (87%) vs. 227 (59%) p < 0.01 ], así como cifras de glicemia en rangos normales [690 (93%) vs. 173 (45%) p < 0.001]. La mortalidad durante el periodo de hospitalización en la unidad receptora fue menor en el grupo con intervención [405 (14%) vs. 84 (22%) p < 0.05]. Después del proceso de intervención, más pacientes fueron trasladados en incubadora [2,806 (97%) vs. 200 (52%) p < 0.001]; de igual forma, en más pacientes se aplicaron métodos de monitoreo de oximetría de pulso [2,575 (89%) vs. 235 (61 %) p < 0.01 ]. En cuanto al número de transportes neonatales regulados y autorizados por el sistema SAMU, se observó un incremento a favor del grupo con intervención [2,806 (97%) vs. 234(61%) p < 0.001]. La frecuencia de defunciones durante el transporte neonatal no presentó diferencias [30 (1 %) vs. 10 (2.6%) p = NS]. Conclusiones. El traslado de neonatos enfermos al tercer nivel de atención médica en el estado de Jalisco se realizó de forma segura, con una mejoría importante en la morbilidad. El programa S.T.A.B.L.E. fue altamente eficiente y de fácil aplicación. La disminución de la mortalidad de los pacientes con intervención del programa durante el periodo de hospitalización requiere estudios especialmente diseñados para establecer posibles asociaciones.

Background. Transporting newborn infants to third-level units is often disorganized, thus entailing several risks that may further compromise the health of newborn patients. Methods. A prospective study was designed in orderto assess the impact ofthe S.T.A.B.L.E. program (Sugarand Safe Care, Temperature, Airway, Blood, Lab work, Emotional support) from 2005 to 2009 in regard to morbidity and mortality rates of newborn patients who had to be transferred from other regions within Jalisco state or within Guadalajara's metropolitan area to the Neonatal Intensive Care Unit ofthe Civil Hospital in Guadalajara. The intervention process was based on applying the S.T.A.B.L.E. program to all newborns who needed to be transferred and was achieved with the intervention ofthe physicians regulating the Emergency Medical Assistance System (SAMU) of the state of Jalisco. A training course, as well as an educational brochure, was given to medical and paramedical staff from the medical assistance centers referring patients to our unit in orderto provide them with information on the S.T.A.B.L.E. program and its implementation. Results. A total of 3,277 newborn infants were included in the study, 384 before the intervention program and 2,893 once the S.T.A.B.L.E. program was implemented. Within the group transferred after the program's implementation, we observed a greater incidence of patients with normal body temperature upon admission to the receiving unit [516 (87%) vs. 227 (59%); p < 0.01 ] as well as with blood glucose figures within the normal range [690 (93%) vs. 173 (45%); p < 0.001]. Mortality during the hospitalization period in the receiving unit was lower in the group treated after the program's implementation [405 (14%) vs. 84 (22%); p < 0.05]. After the intervention process, more patients were transported in incubators [2,806 (97%) vs. 200 (52%); p < 0.001] and equally, pulse oximetry monitoring methods were applied in a greater number of patients [2,575 (89%) vs. 235 (61 %); p < 0.01 ]. With regard to the number of transfers of newborns that were regulated and authorized by the SAMU system, we also observed an increase in such numbers for the group treated after the intervention program [2,806 (97%) vs. 234 (61 %); p < 0.001]. There was no difference in the incidence of death during the newborns' transport [30 (1%) vs. 10 (2.6%); p = NS]. Conclusions. Transfer of ill newborns to third-level medical care units in the state of Jalisco was safely undertaken with a significant improvement in morbidity rates. The S.T.A.B.L.E. program was highly effective and easy to implement. The decrease in mortality during the hospitalization period of patients treated after the intervention program merits further studies especially designed to establish possible associations.