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.

Código encefalopatía hipóxico-isquémica: revisión sistematizada para entornos con recursos limitados / Hypoxic-ischaemic encephalopathy code: a systematic review for resource-limited settings

Se estima que el 96% de los recién nacidos (RN) con encefalopatía hipóxico-isquémica (EHI) nacen en entornos con recursos limitados (ERL) sin capacidad para ofrecer el estándar asistencial vigente desde hace cerca de 15 años en los países con altos recursos y que incluye hipotermia terapéutica, neuromonitorización continua electroencefalográfica y resonancia magnética, además de un control intensivo de las constantes vitales y del equilibrio homeostático. Esta situación no parece estar cambiando; sin embargo y aún con estas limitaciones, el conocimiento actualmente disponible permite mejorar la asistencia de los pacientes con EHI atendidos en ERL. El propósito de esta revisión sistematizada es ofrecer, bajo el término «código EHI», recomendaciones de prácticas asistenciales basadas en evidencia científica y factibles en ERL, que permitan optimizar la atención del RN con EHI y ayuden potencialmente a reducir los riesgos asociados a la comorbilidad y a mejorar los resultados neuroevolutivos. El contenido del código EHI se agrupó en nueve epígrafes: 1) prevención de la EHI, 2) reanimación, 3) primeras seis horas de vida, 4) identificación y graduación de la EHI, 5) manejo de las convulsiones, 6) otras intervenciones terapéuticas, 7) disfunción multiorgánica, 8) estudios complementarios, y 9) atención a la familia. (AU)

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, continuous electroencephalographic monitoring and magnetic resonance imaging 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 6hours 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. (AU)

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.

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.

Desarrollo motor, cognitivo y conductual tras encefalopatía hipóxico-isquémica neonatal / Motor, cognitive and behavioural outcomes after neonatal hypoxic-ischaemic encephalopathy

Introducción: El neurodesarrollo actual de pacientes con encefalopatía hipóxico-isquémica (EHI) neonatal en España se desconoce. Recientes estudios europeos destacan el desplazamiento de la patología grave hacia trastornos motores leves y problemas emocionales. El objetivo de este estudio fue analizar el estado neuroevolutivo integral a los 3años de una cohorte de neonatos con EHI. Pacientes y métodos: Estudio observacional multicéntrico de neonatos ≥35 semanas de edad gestacional con EHI moderada-grave nacidos entre 2011 y 2013 en 12 hospitales de una extensa región española (91.217m2) y ampliado hasta 2017 en el hospital coordinador. Se evaluaron los estudios de neuroimagen neonatal y del neurodesarrollo a los 3años mediante Bayley-III, Peabody Picture Vocabulary Test y Child Behaviour Checklist. Se incluyeron 79 controles sin asfixia perinatal. Resultados: Se reclutaron 63 pacientes, de los cuales 5/63 (7,9%) se excluyeron por presentar otra patología, y 14/58 (24%) fallecieron. De los 44 supervivientes, 42/44 (95,5%) fueron evaluados. De ellos, 10/42 (24%) presentaron evolución adversa (alteraciones visuales o auditivas, epilepsia, parálisis cerebral [PC] o retraso del desarrollo). Adicionalmente se detectaron otras alteraciones: trastorno motor mínimo (TMM) en 6/42 (14%) y más problemas de introversión (10,5% vs 1,3%), ansiedad (34,2% vs 11,7%) y depresión (28,9% vs 7,8%) que los controles (p<0,05). La gravedad de las lesiones en neuroimagen fue significativamente mayor en pacientes con trastorno motor (PC o TMM) (p=0,004) y muerte o evolución adversa (p=0,027). Conclusiones: Además de las secuelas clásicas, el seguimiento de los pacientes con EHI neonatal debería incluir el diagnóstico y el manejo de trastornos motores mínimos y problemas emocionales.(AU)

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 3years. 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 (91,217m2), with the recruitment extended through 2017 in the coordinating hospital. We analysed the findings of neonatal neuroimaging and neurodevelopmental test scores at 3years (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 follow-up of patients with neonatal HIE should include the diagnosis and treatment of minor motor disorders and social and emotional problems.(AU)

Bundle para regulação da temperatura corporal de recém-nascidos maiores de 34 semanas: construção e validação / Bundle for regulating the body temperature of newborns over 34 weeks: Construction and validation / Paquete para regular la temperatura corporal de recién nacidos de más de 34 semanas: construcción y validación

Objetivo: Descrever o processo de construção e validação de um bundle para promoção da regulação da temperatura corporal de recém-nascidos maiores de 34 semanas. Métodos: Pesquisa metodológica executada em três etapas: revisão de escopo, construção da primeira versão do bundle e validação de conteúdo realizada por 15 experts, sendo nove enfermeiros e seis médicos, selecionados conforme critérios adaptados de referencial na área. O índice de validade de conteúdo acima de 0,80 foi considerado aceitável para a concordância entre os experts sobre cada cuidado. Foram necessárias duas rodadas de avaliação para a confecção da versão final. Resultados: O bundle foi estruturado em cuidados: na sala de parto, no transporte e no alojamento conjunto, com total de 15 itens, todos com concordância acima de 0,90 após a segunda rodada de avaliação. Conclusão: O bundle elaborado foi considerado válido quanto ao conteúdo e estabelece cuidados baseados em evidências científicas de maneira padronizada e segura para a equipe de assistência ao parto.

Objective: Describe the process of building and validating a bundle to promote body temperature regulation in newborns over 34 weeks of age. Methods: This methodological research was carried out in three stages: a scoping review, construction of the first version of the bundle, and content validation by 15 experts, nine nurses and six physicians, selected according to criteria adapted from references in the field. A content validity index above 0.80 was considered acceptable for the agreement among the experts on each type of care. Two rounds of evaluation were required to produce the final version. Results: The bundle was structured into care in the delivery room, during transportation, and in the rooming- in unit, with a total of 15 items, all with agreement above 0.90 after the second round of evaluation. Conclusion: The bundle developed was considered valid in terms of content and establishes care based on scientific evidence in a standardized and safe way for the childbirth care team.

Objetivo: Describir el proceso de creación y validación de un paquete para promover la regulación de la temperatura corporal en recién nacidos de más de 34 semanas de edad. Métodos: Investigación metodológica realizada en tres etapas: una revisión del alcance, la construcción de la primera versión del paquete y la validación del contenido llevada a cabo por 15 expertos, nueve enfermeras y seis médicos, seleccionados según criterios adaptados a partir de referencias en la materia. Se consideró aceptable un índice de validez de contenido superior a 0,80 para el acuerdo entre los expertos sobre cada tipo de atención. Fueron necesarias dos rondas de evaluación para elaborar la versión final. Resultados: El paquete se estructuró en cuidados: en la sala de partos, durante el transporte y en la unidad de alojamiento, con un total de 15 ítems, todos ellos con una concordancia superior a 0,90 tras la segunda ronda de evaluación. Conclusión: El paquete se consideró válido en cuanto a su contenido y establece una atención basada en pruebas científicas de forma estandarizada y segura para el equipo de atención al parto.

Necesidades de cuidados en recién nacidos con encefalopatía hipóxico-isquémica tratados con hipotermia terapéutica / Care needs in newborns with hypoxic-ischemic encephalopathy treated with therapeutic hypothermia

Objetivo: describir las necesidades de cuidados de Enfermería derivadas de las principales secuelas en recién nacidos (RN) diagnosticados de encefalopatía hipóxico-isquémica (EHI) y tratados con hipotermia terapéutica en el Hospital Universitario Miguel Servet de Zaragoza (España).Método: estudio descriptivo transversal con datos retrospectivos sobre 32 pacientes, mediante revisión de historias clínicas. Variables de estudio: variables sociodemográficas, clínicas (para establecer la gravedad de la EHI se utilizó la escala de García-Alix) y necesidades de cuidados enfermeros.Resultados: se estudiaron 32 pacientes. El 68,8% fue diagnosticado de EHI moderada y el 31,2% de EHI severa, con resultado de fallecimiento tras el tratamiento del 21,9%. El 31,3% sufrió aspiración de líquido meconial en el momento del parto. Un 32% tuvo alteraciones visuales, un 20% alteraciones en la integridad de la piel, un 16% problemas de eliminación y crisis epilépticas, y un 12% microcefalia. El 100% estaba escolarizado, el 12% tenía apoyo en el colegio y solamente el 4% necesitó acudir a un centro de educación especial. El 68% de las familias recibió apoyo tras el alta hospitalaria. El 56% fue incluido en un programa de atención temprana.Conclusión: la población infantil con EHI tratados con hipotermia presentan secuelas a medio-largo plazo, siendo las más relevantes las alteraciones visuales, las de la integridad de la piel, problemas de eliminación, crisis epilépticas y microcefalia. Se han de potenciar los programas de seguimiento y apoyo tras el alta para poder detectar de forma precoz los signos de alarma, así como para el acompañamiento de sus familias. (AU)

Objective: to describe the Nursing care needs derived of the main consequences in newborns (NBs) diagnosed with hypoxic-ischemic encephalopathy (HIE) and treated with therapeutic hypothermia at the Hospital Universitario Miguel Servet in Zaragoza (Spain).Method: a descriptive cross-sectional study with retrospective data about 32 patients, through clinical record review. The study variables were sociodemographic, clinical (the scale by García-Alix was used to determine the severity of GIE), and Nursing care needs.Results: thirty-two (32) patients were studied; 68.8% were diagnosed with moderate HIE and 31.2% with severe HIE, with 21.9% of death outcomes after treatment. Out of these patients, 31.3% suffered meconium fluid aspiration at the time of delivery; 32% had visual alterations, 20% had alterations in their skin integrity, 16% had elimination problems and epileptic seizures, and 12% presented microcephalia. 100% of them were enrolled in school, 12% had support at school, and only 4% needed to attend a special education centre. Regarding their families, 68% received support after discharge from hospital, and 56% were included in an early care program.Conclusion: the paediatric population with HIE treated with hypothermia presented sequels at medium-long term; the most relevant were visual and skin integrity alterations, elimination problems, epileptic seizures and microcephalia. Programs for follow-up and support after discharge from hospital must be promoted, for an early detection of warning signs, as well as for accompanying their families. (AU)

Estratégias de termorregulação em recém-nascidos prematuros: uma revisão de escopo / Thermoregulation strategies in premature newborns: a scoping review / Estrategias de termorregulación en recién nacidos prematuros: una revisión de alcance

Objetivo: mapear as estratégias para o controle e regulação da temperatura corporal em recém-nascidos prematuros. Método: revisão de escopo sobre termorregulação do prematuro, orientada pelas recomendações do Instituto Joanna Briggs, desenvolvida em oito bases de informações eletrônica. A busca, síntese e análise dos resultados ocorreu em dezembro de 2022. Resultados: compuseram a revisão 15 estudos que foram agrupados em duas categorias: Fontes de calor e Uso de pacotes de medidas/bundle. Como estratégias para a manutenção da temperatura corporal do prematuro, destacam-se: temperatura adequada materna e do ambiente; envoltório plástico; touca dupla; panos aquecidos; aquecimento do ar no suporte respiratório; contato pele a pele; berços aquecidos e incubadoras. Evidenciou-se que os recursos conjugados foram mais efetivos do que quando usados isoladamente. Conclusão: os resultados da revisão de escopo apontaram para estratégias que podem ser utilizadas para mitigar os riscos de hipotermia em recém-nascidos prematuros.

Objective: to map strategies for controlling and regulating body temperature in premature newborns. Method: scope review on premature thermoregulation, guided by the recommendations of the Joanna Briggs Institute, developed in eight electronic databases. The search, synthesis and analysis of the results took place in December 2022. Results: the review was made up of 15 studies, which were grouped into two categories: Heat sources and use of measurement packages/bundle. As strategies for maintaining the body temperature of preterm infants, the following stand out: adequate maternal and environmental temperature; plastic wrap; double bonnet; heated cloths; air heating in respiratory support; skin-to-skin contact; heated cribs and incubators. It was evident that the combined resources were more effective than when used separately. Conclusion: the scoping review results pointed to strategies that can be used to mitigate the risks of hypothermia in premature newborns.

Objetivo: mapear estrategias para el control y regulación de la temperatura corporal en recién nacidos prematuros. Método: revisión de alcance sobre la termorregulación prematura, siguiendo las recomendaciones del Instituto Joanna Briggs, desarrollada en ocho bases de datos electrónicas. La búsqueda, la síntesis y el análisis de los resultados se llevaron a cabo en diciembre de 2022. Resultados: la revisión fue conformada de 15 estudios, agrupados en dos categorías: fuentes de calor y uso de paquetes de medidas/bundle. Como estrategias para mantener la temperatura corporal del prematuro se destacan: temperatura adecuada materna y ambiental; envoltura de plástico; gorro doble; paños tibios; calentamiento del aire en soporte respiratorio; contacto piel a piel; cunas calefaccionadas e incubadoras. Se evidenció que los recursos combinados fueron más efectivos que si usados de forma individual. Conclusión: los resultados de la revisión de alcance señalaron estrategias que pueden usarse para mitigar los riesgos de hipotermia en recién nacidos prematuros.

Precalentamiento quirúrgico, ¿mito o realidad? / Surgical Prewarming, ¿myth or reality?

A pesar de la disponibilidad de soluciones de calentamiento de los pacientes en los quirófanos, la tasa de hipotermia al ingreso en unidades de reanimación (REA, URPA) continúa siendo mayor del 50% en pacientes sometidos a una cirugía. Se ha demostrado que aplicar un precalentamiento por aire convectivo de 10 minutos previo a la cirugía es efectivo en la reducción de la tasa de hipotermia perioperatoria del paciente. Las guías clínicas de las sociedades científicas recomiendan un precalentamiento entre 10-30 minutos. El mantenimiento de la normotermia del paciente ha reducido un 63% la tasa de infecciones de sitio quirúrgico, un 77,5% los eventos cardiacos mayores en 24 horas y un 68,2% los escalofríos postoperatorios entre otros. El Observatorio de Infección Quirúrgica (PRIQ-O), sitúa el mantenimiento de la normotermia en una de las medidas más importantes y más factibles de llevar a cabo en el perioperatorio para prevenir la infección de sitio quirúrgico (SSI). El uso de una bata de calentamiento activo con aislamiento evita la pérdida de calor por radiación del paciente en los traslados y facilita el precalentamiento del paciente al venir con ella colocada desde la planta. Esto impactaría en la temperatura del paciente en el momento de la inducción de la anestesia, siendo esta temperatura uno de los factores clave que decidirán la facilidad del manejo de la normotermia intraoperatoria. (AU)

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

Introducción: El aumento de la presión intracraneal se ha asociado a un pronóstico neurológicodesfavorable y a un incremento en la mortalidad en pacientes con traumatismo craneoencefálico grave. Tradicionalmente, las terapias para disminuir la presión intracraneal se administranutilizando un enfoque progresivo, reservando el uso de opciones más agresivas para los casossin respuesta a intervenciones de primer nivel, o de hipertensión intracraneal refractaria. Desarrollo: El valor terapéutico de las intervenciones de rescate para la hipertensión intracraneal, así como el momento adecuado para su uso ha sido debatido constantemente en laliteratura. En esta revisión, discutiremos las principales opciones de tratamiento para la hipertensión intracraneal refractaria posterior a un traumatismo craneoencefálico grave en adultos.Tenemos la intención de llevar a cabo una revisión en profundidad de los ensayos controladosaleatorios más representativos sobre las diferentes intervenciones terapéuticas de rescate,incluyendo la craniectomía descompresiva, hipotermia terapéutica y barbitúricos. Además,discutiremos las perspectivas futuras de estas opciones de tratamiento. Conclusiones: La evidencia parece mostrar que se puede reducir la mortalidad al utilizar estasintervenciones de rescate como terapia de último nivel, sin embargo, este beneficio vieneacompanado de una discapacidad severa. La decisión de realizar o no estas intervencionesdebe ser individualizada y centrada en el paciente. El desarrollo e integración de diferentesvariables fisiológicas a través de monitorización multimodal es de suma importancia para poderproporcionar información pronóstica más sólida a los pacientes que enfrentan este tipo dedecisiones.(AU)

Introduction: Increased intracranial pressure has been associated with poor neurological out-comes and increased mortality in patients with severe traumatic brain injury. Traditionally,intracranial pressure-lowering therapies are administered using an escalating approach, withmore 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 treat-ments for intracranial hypertension have been a subject of constant debate in literature. Inthis review, we discuss the main management options for refractory intracranial hypertensionafter severe traumatic brain injury in adults. We intend to conduct an in-depth revision of themost representative randomised controlled trials on the different rescue treatments, includingdecompressive craniectomy, therapeutic hypothermia, and barbiturates. We also discuss futureperspectives for these management options. Conclusions: The available evidence appears to show that mortality can be reduced whenrescue interventions are used as last-tier therapy; however, this benefit comes at the cost ofsevere disability. The decision of whether to perform these interventions should always bepatient-centred and made on an individual basis. The development and integration of differentphysiological variables through multimodality monitoring is of the utmost importance to providemore robust prognostic information to patients facing these challenging decisions.(AU)

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)

Gestão de hipotermia associada ao trauma no extra-hospitalar / Management of hypothermia associated with out-of-hospital trauma

No âmbito do XII Curso de Mestrado em Enfermagem Médico-Cirúrgica, da Escola Superior de Enfermagem de Coimbra, foi-nos proposta a realização de um Relatório Final de Estágio, que se encontra dividido em duas partes: a primeira relativa ao desenvolvimento das competências gerais e específicas do enfermeiro especialista em Enfermagem Médico-Cirúrgica e a segunda constituída por uma scoping review. A primeira parte, onde se incluem os estágios de urgência, cuidados intensivos e em contexto extra-hospitalar, tem como objetivos principais descrever as atividades realizadas e analisar criticamente situações pertinentes, com base nas competências descritas e que se consideram atingidas, preconizando-se agora o seu desenvolvimento na prática clínica diária. A segunda parte é constituída pela componente de investigação que partiu da seguinte questão de revisão: ?Quais as estratégias de gestão de hipotermia utilizadas nas vítimas de trauma em contexto extra-hospitalar??. Para tal foi desenvolvida uma scoping review com o objetivo de mapear as estratégias de gestão de hipotermia em vítimas de trauma em contexto extra-hospitalar. A pesquisa foi realizada nas bases de dados Medline (via PubMed) e Cinahl Complete (via EBSCOhost), assim como no Repositório Comum de Acesso Aberto de Portugal (RCAAP), na língua portuguesa, inglesa e espanhola, nos anos de 2019 a 2023. Selecionaram-se sete estudos nesta revisão, verificando-se que as estratégias de gestão de temperatura podem-se dividir em dois grandes grupos: medidas de aquecimento passivo e medidas de aquecimento ativo. É primordial o desenvolvimento de estratégias de gestão de hipotermia pelos profissionais do extra-hospitalar e, em especial por parte dos enfermeiros, nos cuidados prestados, e pela relação existente entre a hipotermia, morbilidade e mortalidade das vítimas de trauma.

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.

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.

Sistema de monitorización de Temperatura 3MTM Bair HuggerTM / 3MTM Bair HuggerTM Temperature Monitoring System

La hipotermia perioperatoria inadvertida sigue siendo un problema clínico de alta incidencia asociado a graves complicaciones. La monitorización de la temperatura central en el proceso perioperatorio es recomendada por las guías clínicas nacionales e internacionales con un nivel de evidencia elevado. El sistema de monitorización de temperatura 3M™ Bair Hugger™ surge como respuesta a una necesidad clínica, innovando al medir de manera directa, precisa y no invasiva la evolución de la temperatura central del paciente. Las características de este dispositivo lo sitúan como una gran opción para monitorizar la hipotermia perioperatoria de una manera sencilla y cómoda para el paciente, evitando las complicaciones y sus costes hospitalarios derivados. (AU)

Inadvertent perioperative hypothermia remains a clinical problem of high incidence associated with serious complications. The core temperature monitoring in the perioperative process is recommended by national and international clinical guidelines with a high level of evidence. The 3M™ Bair Hugger™ Temperature Monitoring System arises in response to a clinical need, innovating by measuring in a direct, precise and non-invasive way the evolution of the patient’s core temperature. This device characteristics place it as a great option to control perioperative hypothermia in a simple and comfortable way for the patient, avoiding complications and it´s hospital costs. (AU)

Comparison between selective head cooling and whole-body cooling in neonatal therapeutic hypothermia / Comparação entre resfriamento seletivo da cabeça e resfriamento de corpo inteiro na hipotermia terapêutica neonatal

INTRODUCTION: Experimental evidence, as well as improved clinical studies of the reduction of brain injury and, improves the neurological outcome, in newborns with hypoxic-ischemic encephalopathy (HIE) occurring in therapeutic hypothermia (TH). OBJECTIVE: To verify the potential of hypothermic hypoxic-ischemic encephalopathy (HIE) therapy in neonatal asphyxia, based on literature data, comparing the benefits between selective head cooling (SHC) and whole-body cooling (WBC), see that the use of TH as a standard treatment in newborns with moderate or severe HIE has been adopted. METHODS: A search was performed in the PubMed and SciELO databases of human studies, using the keywords "Therapeutic Hypothermia", "Induced Hypothermia", and "Hypoxic-Ischemic Encephalopathy", "Selective cooling of the head", "Total body cooling" and its variables. RESULTS: Eleven articles were selected to compose the review, after detailed reading. There is a consensus, that the reduction of the risk of death or disability at 18 months of life in neonates with moderate to severe HIE, occurs to TH through the techniques of WBC or SHC. It was found in the studies that there is no difference in terms of adverse effects between the two methods. As for radiological changes, such as hypoxic-ischemic injuries and the incidence of seizures after cooling, they are more frequent with SHC. CONCLUSION: Both WBC and SHC demonstrated neuroprotective properties, although WBC provides a broader area of brain protection. However, no significant differences were found between the methods in terms of adverse effects and beneficial short or long-term results.

INTRODUÇÃO: Evidências experimentais, assim como estudos clínicos, sugerem a redução da lesão cerebral e melhora do desfecho neurológico, em recém-nascidos com encefalopatia isquêmica hipóxica (EHI) submetidos à hipotermia terapêutica (HT). OBJETIVO: Verificar a potencialidade da terapia hipotérmica de encefalopatia hipóxico-isquêmica (EHI) na asfixia neonatal, com base em dados da literatura, comparando os benefícios entre o resfriamento seletivo da cabeça (RSC) e o resfriamento de corpo inteiro (RCI), visto que o uso de hipotermia terapêutica (HT) como tratamento padrão em recém-nascidos com EHI moderada ou grave tem sido amplamente adotada. MÉTODOS: Foi realizada uma busca nas bases de dados PubMed e SciELO de estudos em humanos, utilizando-se as palavras-chave "Therapeutic Hypothermia", "Induced Hypothermia", "Hypoxic-Ischemic Encephalopathy", "selective head cooling", "whole body cooling" e suas respectivas variáveis. RESULTADOS: Foram selecionados 11 artigos para compor a revisão, após leitura detalhada. É consenso, a redução do risco de morte ou incapacidade aos 18 meses de vida nos neonatos com EHI moderado a grave, submetidos à HT através das técnicas de RCI ou RSC. Constatou-se diante dos estudos que não há diferença em termos de efeitos adversos entre os dois métodos. Quanto às alterações radiológicas, as lesões hipóxico-isquêmicas e incidência de convulsões após o resfriamento são mais frequentes com o RSC. CONCLUSÃO: Tanto RCI quanto o RSC demonstraram propriedades neuroprotetoras, embora o RCI proporcione uma área de proteção cerebral mais ampla. No entanto, não foram constatadas diferenças significativas entre os métodos quanto a efeitos adversos e a resultados benéficos em curto e longo prazo.

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.

Cuidado de la temperatura en personas sometidas a procedimientos quirúrgicos electivos en una institución de salud / Temperature care in persons undergo-ing elective surgical procedures in a health institution

Objetivo: Analizar la adherencia a las actividades para el control de la termorregulación en procedimientos quirúrgicos por parte de técnicos y profesionales de cirugía para el año 2021 en una institución de salud de tercer nivel en la ciudad de Medellín, Colombia. Metodología: Investigación descriptiva transversal. Se revisaron registros clínicos de pacientes sometidos a cirugía electiva mayor a una hora, también se realizó encuesta autoaplicada a personal que labora en el área quirúrgica, indagando por variables demográficas, del servicio y de adherencia al protocolo de termorregulación. Resultados: Se evidencia baja adherencia a la toma de temperatura. En el servicio de recuperación hay mejor adherencia por medio del calentamiento activo. Conclusión: La temperatura es un signo vital al que no se le da la importancia suficiente, constituyéndose así como una constante vital olvidada.(AU)

Objective: To analyze adherence to activities for the control of thermoregulation in surgical procedures by surgical technicians and professionals for the year 2021, in a tertiary health institution in the city of Medellín, Colombia. Methods: Cross-sectional descriptive research. Clinical records of patients undergoing elective surgery greater than one hour were reviewed, a self-applied survey was also carried out on personnel working in the surgical area, inquiring for demographic variables, service and adherence to the thermoregulation protocol. Results: Low adherence to temperature measurement is evident. In the recovery service there are better adherence through active heating. Conclusions: Temperature is a vital sign that is not given enough importance, thus becoming a forgotten vital sign.Objective: To analyze adherence to activities for the control of thermoregulation in surgical procedures by surgical technicians and professionals for the year 2021, in a tertiary health institution in the city of Medellín, Colombia. Methods: Cross-sectional descriptive research. Clinical records of patients undergoing elective surgery greater than one hour were reviewed, a self-applied survey was also carried out on personnel working in the surgical area, inquiring for demographic variables, service and adherence to the thermoregulation protocol. Results: Low adherence to temperature measurement is evident. In the recovery service there are better adherence through active heating. Conclusions: Temperature is a vital sign that is not given enough importance, thus becoming a forgotten vital sign.(AU)

Hypothermia among premature newborns on admission to a neonatal intensive care unit / Hipotermia entre los recién nacidos prematuros que ingresan en una unidad de cuidados intensivos neonatales / Hipotermia entre recém-nascidos prematuros na admissão em uma unidade de terapia intensiva neonatal

ABSTRACT Objective: To assess prevalence and factors associated with hypothermia in preterm infants admitted to a neonatal intensive care unit. Methods: It is a cross-sectional retrospective study, with 154 premature newborns admitted between 2017 and 2019 in a neonatal intensive care unit. Logistic regression was used to evaluate the association to hypothermia. Results: There was a predominance of males (55.8%), coming from the operating room (55.8%), gestational age > 32 weeks (71.4%), weight > 1500g (59.1%), Apgar in the 1st minute of life less than seven (51.9%) and in the 5th minute of life greater than or equal to seven (94.2%). The prevalence of hypothermia at admission was 68.2%. It was found that the lower the weight, the greater the chances of hypothermia, being three times higher in low weight (OR 3.480), five times higher in very low weight (OR5.845) and up to 47 times higher in extremely low weight (OR47.211). Conclusion: Hypothermia was 68.2% and it was associated with lower birth weight.

RESUMEN Objetivo: Evaluar prevalencia y factores asociados a la hipotermia entre los recién nacidos prematuros ingresados en una unidad de cuidados intensivos neonatales. Métodos: Estudio transversal retrospectivo, con 154 recién nacidos prematuros ingresados entre 2017 y 2019 en una unidad de cuidados intensivos neonatales. Se utilizó la regresión logística para evaluar la asociación a la hipotermia. Resultados: Hubo un predominio de varones (55,8%), procedentes del centro quirúrgico (55,8%), edad gestacional > 32 semanas (71,4%), peso > 1500g (59,1%), puntuación de Apgar en el primer minuto de vida inferior a siete (51,9%) y en el quinto minuto superior o igual a siete (94,2%). La prevalencia de hipotermia al ingreso fue del 68,2%. Se comprobó que cuanto menor es el peso, mayores son las posibilidades de hipotermia, tres veces más para el peso bajo (R.O. 3,480), cinco veces más para el peso muy bajo (R.O.5,845) y hasta 47 veces más para el peso extremadamente bajo (R.O.47,211). Conclusión: La hipotermia fue del 68,2% y se asoció a un menor peso al nacer.

RESUMO Objetivo: Avaliar prevalência de hipotermia e fatores associados entre recém-nascidos prematuros admitidos em uma unidade de terapia intensiva neonatal. Métodos: Estudo transversal retrospectivo, com 154 recém-nascidos prematuros admitidos entre 2017 e 2019 em uma unidade de terapia intensiva neonatal. Utilizou-se regressão logística para avaliar associação à hipotermia. Resultados: Houve predomínio do sexo masculino (55,8%), procedência de centro cirúrgico (55,8%), idade gestacional > 32 semanas (71,4%), peso > 1.500g (59,1%), Apgar no 1º minuto de vida menor que sete (51,9%) e no 5º maior ou igual a sete (94,2%). A prevalência de hipotermia à admissão foi de 68,2%. Verificou-se que quanto menor o peso, maiores as chances de hipotermia, sendo três vezes maior no baixo peso (O.R. 3,480), cinco vezes maior no muito baixo peso (O.R. 5,845) e 47 vezes maior no extremo baixo peso (O.R. 47,211). Conclusão: A hipotermia foi de 68,2% e esteve associada ao menor peso ao nascer.

Hipotermia episódica postraumática

Introducción: La regulación de temperatura es uno de los mecanismos de control vital de mayor importancia en el ser humano. Entre las causas de hipotermia se describe varias de origen neurológico y no neurológicas. En la mayoría de los casos de hipotermia que se desarrolla secundaria a trauma craneal, se trata de pacientes con daño neurológico severo mantenido pero se encuentran escasas descripciones relacionadas con trauma craneoencefálico leve o en pacientes sin otras secuelas importantes. Objetivo: Examinar un caso de hipotermia episódica postraumática sin afectaciones neurológicas asociadas y sin lesiones orgánicas demostradas. Presentación del caso: Paciente masculino, 14 años, antecedentes de salud. Sufre trauma de cráneo sin repercusión clínica aparente en ese momento. Una semana posterior al trauma comienza a presentar episodios de hipotermia nocturna de duración variable, autolimitados, siempre durante el sueño del paciente. Entre los episodios el paciente se mantiene asintomático. Examen físico normal. Estudios de neuroimagen sin alteración. Se indica reposo y tratamiento médico, primero con carbamazepina y luego con valproato de sodio. Actualmente el paciente muestra mejoría del cuadro, aunque no remisión completa de los episodios. Conclusiones: La hipotermia se relaciona con un elevado número de afecciones. La mayoría de los pacientes con trauma de cráneo que presentan hipotermia tienen asociados otros daños y presentan la afección de forma mantenida. Existen otros pacientes, como el caso presentado, sin lesiones orgánicas demostrables en estudios de imágenes que exteriorizan los trastornos de la termorregulación de forma recurrente con periodos de normalidad entre ellos.

Introduction: Temperature regulation corresponds to one of the most important vital control mechanisms in humans. Among the causes of hypothermia are described several of neurological and non-neurological origin. In most cases of hypothermia that develops secondary to cranial trauma described in literature, these are patients with sustained severe neurological damage but there are few descriptions related to mild cranioencephalic trauma or in patients without other important sequelae. Objective: To examine a case of post-traumatic episodic hypothermia without associated neurological affectations and without demonstrated organic lesions. Case presentation: Male patient, 14 years old, health history. He suffered from a cranial trauma with no apparent clinical repercussion at the time. A week after the trauma, episodes of nocturnal hypothermia of variable duration, self-limiting, always during the patient's sleep, begin to occur. Between episodes the patient remains asymptomatic. Normal physical exam. Neuroimaging studies without alteration. Rest and medical treatment are indicated first with carbamazepine and then with sodium valproate. Currently, the patient shows improvements but not complete remission of the episodes. Conclusions: Hypothermia is associated with a high number of conditions. Most patients with cranial trauma who present hypothermia have other associated damages and present hypothermia in a frequent manner, but there are other patients, such as the case presented, without comprobable organic lesions in imaging studies that present thermoregulation disorders on a recurrent basis with periods of normality between them.