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Signa Vitae

Journal of Anaesthesia, Intensive Care and Emergency Medicine

Early instrumental predictors of long term neurodevelopmental impairment in newborns with perinatal asphyxia treated with therapeutic hypothermia


Background. Hypoxic-ischemic encephalopathy (HIE) is a leading cause of disability in full-term newborns. Long-term consequences of HIE, even when treated by hypothermia, are not easily predictable.

Aims. To assess the potential role of electroencephalography and neuroimaging parameters as early predictors of neurodevelopmental outcome in HIE newborns treated with hypothermia.

Methods. We retrospectively evaluated 13 HIE patients treated with hypothermia in January 2012-September 2014. We reviewed their amplitude-integrated electroencephalography (a-EEG) at 6, 12 and 24 hours (h), cranial ultrasonography (US) at 12, 72 h and >7 days of life (DOL) and brain magnetic resonance (MRI) performed at 7-28 DOL, according to validated scores. aEEG, US and MRI patterns were correlated to neurodevelopmental outcome at 18-24 months, considered as negative if one of the following was present: Mental Development Index (MDI)<85, motor, visual or hearing impairment.

Results. The severity of a-EEG, US and MRI alterations at each time point was not different according to the outcome. MDI was negatively correlated with aEEG score at 12h (R= -0.571, p=0.04) and with US score at 72h (R= -0.630, p=0.02). A positive correlation was found between aEEG score at 6h and US score at >7DOL (R=0.690, p=0.013). US alterations of the cortical matter at 72h were directly correlated with a-EEG score at 12h (R = 0.606, p=0.028) and 24h (R=0.605, p=0.029).

Conclusions. Early instrumental evaluations, in particular aEEG and US, seem to predict neurodevelopmental outcome at 18-24 months in HIE newborns treated with hypothermia.

Key words: asphyxia, hypoxic-ischemic encephalopathy, hypothermia, newborn

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Inadvertent hypothermia during the perioperative period


Inadvertent hypothermia, which is defined as temperature below 36°C, is common in the perioperative setting. Patients under general or regional anaesthesia have impaired temperature regulation/homeostasis. Temperature monitoring should be an established standard for all procedures that last more than 30 minutes. Unfortunately, study shows that it is not a common practice in European hospitals. Passive and active patient warming should be used to prevent and treat hypothermia. Warming should start in the preoperative period and last throughout all perioperative phases. In that way, well-known complication of hypothermia should be prevented. Cardiac event, coagulopathy and wound infection are the leading causes of delayed discharge and more adverse outcomes related to hypothermia. It is especially important to undertake all necessary intervention procedures to prevent hypothermia in a group of patients with known high number of risk factors for hypothermia. Ambient temperature, an important risk factor, should be monitored and maintained at about 21°C. According to reviewed evidence, the protocol to prevent, monitor and treat hypothermia should be established. Further studies about the implementation of temperature monitoring and regulation are needed in order to raise awareness about this issue.

Key words: hypothermia, core temperature, anaesthesia, warming devices, prevention, treatment

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Induced mild hypothermia in children


The objective of this study was to measure outcomes and to determine the safety and effectiveness of mild induced hypothermia in children after traumatic and posthypoxic brain injury.
Methods. Forty patients, following traumatic or posthypoxic brain injury, were involved in the study. Mean age was 10.7 ± 0.8 years. Median GCS (Glasgow Coma Scale) was  6.0 (4-7) and mean PIM2 (Pediatric Index of Mortality) 14.6 ± 3.8 %.
Results. GOS (Glasgow Outcome Scale) of 5 was assigned for 15 (37.5%) patients, GOS 4 for 14 (35.0%), GOS 3 for 7 (17.5%) and GOS 2 for 4 (10%) patients. The average GOS in patients after severe head trauma was 3.6 ± 0.9 points and in patients with posthypoxic brain injury 5 points, (p < 0.05). No life threatening complications occurred.
Conclusion. Mild induced hypothermia can be safely used in pediatric patents after severe traumatic or posthypoxic brain injury. This method may be of benefit while improving outcomes in children.


Key words: traumatic brain injury, posthypoxic brain injury, children, hypothermia, outcome, Pediatric Index of Mortality

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Temperature to heart rate relationship in the neonate

Key words: neonate, fever, hypothermia, heart rate, neonatal sepsis

In neonatal intensive care, measurement of heart rate is part of every clinical examination and it is used for monitoring hemodynamic status. However, it is influenced by some exogenous and endogenous factors, such as medication, pain, and stress. (1) Similarly, an increased heart rate is a normal physiological response to fever. Heart rate is known to increase by 10 beats per minute (bpm) per degree centigrade increase in body temperature in children. (2) In order to allow physicians to identify patients who have a higher heart rate than would be expected for a given level of temperature, Thompson et al. (3) created temperature specific heart rate centile charts adaptable to children from three months to ten years. Very few data exist on the relationship of temperature and heart rate in younger infants. The only study on this topic so far was performed in an emergency department that included infants up to the age of 12 months, where they found no linear correlation between fever and heart rate in the group of infants younger than two months. (4) To our knowledge no studies have ever addressed this issue in newborns.

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Establishing Coronary Patency: A Key to Optimal Post Resuscitation Care


The formalizing post resuscitation care to include therapeutic hypothermia and cardiac angiography with percutaneous coronary intervention when needed could significantly improve survival following cardiac arrest. Any sudden death patient suspected to have a cardiac origin for their cardiac arrest should be considered for early catheterization and subsequent percutaneous coronary intervention (PCI) if a culprit lesion can be identified. Successful PCI improves survival to hospital discharge and cerebral performance category in patients with or without ST elevation. Current ‘report carding’ methodology needs to be changed regarding those resuscitated from cardiac arrest (patients with cardiac arrest not including them in any statistical reporting on PCI mortality report cards).

Key words: percutaneous coronary intervention, hypothermia, cardiac arrest, survival to hospital discharge, cerebral performance category, PCI report carding

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