Implementation of a Hypothermia Treatment Program for

Hypoxic Ischemic Encephalopathy- SCVMC NICU Experience

Implementation of this program would not have been possible without extreme dedication of SCVMC NICU staff and families, and support from Santa Clara County First Five and Valley Medical Center Foundation.

HI

Primary cell death

Cytotoxic mechanisms

Delayed neuronal death

6 hours Days

Repair mechanisms

Hypothermia Hypothermia 72 hrs72 hrs

Brain injury evolves over time Brain injury evolves over time following hypoxic-ischemic insultfollowing hypoxic-ischemic insult

Epo and other Epo and other interventionintervention

-

+

INCLUSION: ≥36wks GA and ≥ 1800gms AND meet both Physiologic and Neurological CriteriaEXCLUSION: 1) Lethal Chromosomal or Congenital anomalies, 2) Active bleeding, 3) Severely injured - comfort care

Physiological Criteria Neurological Criteria

Cord or Baby’s ABG < 1 hour

No gas <1hrOR

pH 7.01-7.15 and BD 10-15.9

Moderate Encephalopathy3 of 6 findings below

1. Lethargic2. Inactive/decreased activity3. Distal flexion4. Hypotonia- focal or general5. Weak suck/incomplete moro6. Pupil constricted/ Bradycardia/periodic breathing

pH ≤7.0OR

BD ≥ 16

SeizureOn Clinical Exam or BrainZ

A Major Perinatal Event1. FHR decals, cord prolapse, abruption, uterine rapture, 2. Maternal trauma, hemorrhage3. Infant CPR in DR ANDApgar ≤ 5 at 10 min or PPV ≥ 10 min

PlusOR

Severe Encephalopathy3 of 6 findings below

1. Stupor/coma2. No activity3. Decerebrate4. Flaccid tone5. Absent suck/moro6. Pupils dilated /unreactive, variable HR, apnea

OR

SCVMC Total Body Cooling (TBC)

Active Cooling

ANDNeurologicalCriteria

Physiological Criteria

Lit. ReviewProgram Set Up

Train aEEG “Super Users”

First infant

Nursing P and P

2008 2010

Cooling Equipment Changed

Skills LabHands-on Staff Ed.

Staff In-serviceHIE and TBC

NursingMedical P and P Revised

2007

Start Data Submission to VON - NER

Feb 08

2009

Epo study

VON NICQEncephalopathycollaborative

2011

Completion of Epo study

Supper User Skills day

2012

Cooling duringtransport Trial

Bay Area3rd CoolingSummit

47 infant

SCVMC Regional NICU TBC

Institution(Birth Rate/y)

2008 2009 2010 2011 20121st Q

Total

VMC(~5000)

5 6 6 11 (1KSC)

7(1KSC)

34

OCH(~4000)

0 5 1 2 1 9

SRH(~1000)

0 1 1 1 0 4

Total(~10,000)

5 12 8 14 8 47

QI paper – Pediatrics in press

Optimizing Therapeutic Hypothermia for Neonatal Encephalopathy: A Quality Improvement Collaborative Using Potentially Better Practices

¹Steven L. Olsen, MD, ²Mitchell DeJonge, MD, ³Alex Kline, MD, 4Ellina Liptsen, MD, 5Dongli Song, MD, PhD, ¹Betsi Anderson, RN, BSN, CPHQ, 6Amit Mathur, MBBS, MD

Long-Term Neurodevelopmental Outcomes?

Evaluation of Brain Injury and Prognosis?