whitelaw prevention of ivh.pptx [somente leitura] · 2016. 6. 27. · vitamin e and ivh in preterm...
TRANSCRIPT
Prevention of Intraventricular Hemorrhage
in preterm infants
Andrew Whitelaw MD FRCPCH
Emeritus Professor of Neonatal Medicine
University of Bristol
Bristol, UK
Rio de Janeiro, 29th August 2014
Highly vascular germinal matrix Unstable cerebral blood f
0
5
10
15
20
25
30
35
<750 751-1000 1001-
1250
1251-
1500
1551-
2250
Birth weight (g)
Pe
rce
nt w
ith
IV
H
Incidence of Intraventricular haemorrhage (IVH
in premature newborn infants
Sheth RD. Trends in incidence and severity of intraventricular hemorrhage. J Child Neurol. 1998 Jun;13(6):261-4.
Vermont-Oxford Network
Infants 500-1500g
Grade 3 or 4 IVH 6.2% in 2000-1
Grade 3 or 4 IVH 6.2% in 2008-9
Corresponds to 4,000 to 5,000 annually in US
Risk factors for IVH
Very short gestationMale gender
Labour and vaginal delivery v elective CaesareanRespiratory distress syndrome
PneumothoraxEarly hypothermia (marker of prolonged resuscitatiFluctuating blood pressure/cerebral blood flow
Early hypotension and rapid correctionCoagulopathy and thrombocytopenia
IVH in term infants is different from IVH in prematuresWu YW, et al . Intraventricular hemorrhage in term neonates
caused by sinovenous thrombosis. Ann Neurol. 2003 ;54:123-6.
29 term infants with IVH in 5 yr UCSF
Perinatal asphyxia
Congenital heart disease
ECMO
9 cerebral sinovenous thrombosis:
Presented with seizures, apnoea or temperatu
3 Thrombophilia
Voutsinas L, et al.. Clin Imaging. 1991;15:273-
Protein C deficiency.
Kita H, et al. No To Shinkei. 1990;42:297-302.
Homocystinuria
Interventions shown to prevent IVH in
randomised clinical trials
Antenatal corticosteroids
Postnatal
Muscle relaxation
Ethamsylate
Vitamin E
Indomethacin
Delayed cord clamping
Volume targeted ventilation
Antenatal steroid and IVH
Antenatal steroid and neurodevelopmental delay
Antenatal dexamethazone is associated with more PVL than isbetamethazone
Corticosteroids target
Very short gestationMale gender
Labour and vaginal delivery v elective CaesareanRespiratory distress syndrome
PneumothoraxEarly hypothermia (marker of prolonged resuscitatiFluctuating blood pressure/cerebral blood flowEarly hypotension and rapid correctionCoagulopathy and thrombocytopenia
Indomethacin and death/disability at 1+yr
Indomethacin reduces IVH
No reduction in disability or death
Not recommended as routine
Ethamsylate and IVH
Ethamsylate and severe IVH
No reduction in disability or death.
Not recommended as routine
Vitamin E and IVH
in preterm infants
Reduced IVH
IV vit E increased Sepsis
IV vit E increased parenchymal infarction
No effect on mortality
Not recommended routinely
Brion LP et al. Cochrane Library 2003.
imination of fluctuating blood flow velocity in preterm infants with respiratory distress syndrome. NEJM 1985; 312: 1353-7
IVH
Panc 5/14
No Panc 10/10
Severe IVH
Panc 0/14
No Panc 7/10
Neuromuscular paralysis and IVH
Reduction in IVH in one small trial
Modern ventilators can synchronize with the
infant’s breathing
Uncertainty over effects of long periods of
neuro-muscular paralysis
Not recommended as routine
Delayed cord clamping (30-45 seconds): and IVH
Delayed cord clamping (30-45 sec)and severe IVH
ercer JS et al. Seven month developmental outcomes
very low birth weight infants enrolled in a randomized
trial of delayed versus immediate cord clamping. J
Perinitalogy 2010; 30: 11-16
Infants 24-31 weeks
Higher motor scores in male infants at 7 months
The umbilical cord should NOT be clamped EARLY
ut resuscitation has to be possible while cord intact.
without coagulopathy screening
Beverley (1985)
IVH
Plasma 7/38
No plasma 14/42
Fresh frozen plasma 10 ml/kg after abnormal coagulatio
INR > 1.4 or APTT >50 sec on screening at 2 h
(infants 23-26 w).
Dani (2009)
IVH
Early screen 34.5%
Factor XIII infusion at 6 hr reduced IVH
from 75% to 15%
in preterm infants at high risk if IVH
Shirata A. Thrombosis Research 1990;57: 755-6
Tranexamic acid did not reduce IVH in
a randomised trial.
Hensey O. Arch Dis Child 1984; 59: 719-21.
Recombinant Factor VII did not
Prevent IVH. Veldman A.
Ped Crit Care Med 2006; 7: 34-9
Recommendations to reduce IVH based
n epidemiology and pathophysiology but n
supported by randomised trials
Carteaux P et al.
Evaluation and development of potentially
better practices for prevention of brain
emorrhage and ischemic brain injury in ve
low birth weight infants.
Pediatrics 2003; 111: e489-496.
Practices which may prevent IVH
1. Delivery in tertiary center with NICU
irect clinical management and delivery by mater
fetal medicine specialists
Antibiotics for preterm rupture of membranes
. Delivery room resuscitation by neonatologists a
an experienced team
Maintain baby’s temperature at 36.0 or above
Maintain cardiorespiratory stability during surfacta
administration
Practices which may prevent IVH
1. Delivery in tertiary center with NICU
irect clinical management and delivery by mater
fetal medicine specialists
Antibiotics for preterm rupture of membranes
. Delivery room resuscitation by neonatologists a
an experienced team
Maintain baby’s temperature at 36.0 or above
Maintain cardiorespiratory stability during surfacta
administration
Reduce environmental noiseMinimize handlingMinimize lighting
Judicious use of narcotic sedation
4. Neutral head position and elevate head (Cowan F & Thoresen M. Pediatrics 1985; 75: 1038-47).
5. Avoid rapid correction of hypotension
6. Optimize respiratory managementAvoid hypocapnia/severe hypercapnia
Avoid routine chest physiotherapyAvoid routine suctioning
7. Limit sodium bicarbonate
Reduce environmental noiseMinimize handlingMinimize lighting
Judicious use of narcotic sedation
4. Neutral head position and elevate head (Cowan F & Thoresen M. Pediatrics 1985; 75: 1038-47).
5. Avoid rapid correction of hypotension
6. Optimize respiratory managementAvoid hypocapnia/severe hypercapnia
Avoid routine chest physiotherapyAvoid routine suctioning
7. Limit sodium bicarbonate
Reduce environmental noiseMinimize handlingMinimize lighting
Judicious use of narcotic sedation
4. Neutral head position and elevate head (Cowan F & Thoresen M. Pediatrics 1985; 75: 1038-47).
5. Avoid rapid correction of hypotension
6. Optimize respiratory managementAvoid hypocapnia/severe hypercapnia
Avoid routine chest physiotherapyAvoid routine suctioning
7. Limit sodium bicarbonate
Reduce environmental noiseMinimize handlingMinimize lighting
Judicious use of narcotic sedation
4. Neutral head position and elevate head (Cowan F & Thoresen M. Pediatrics 1985; 75: 1038-47).
5. Avoid rapid correction of hypotension
6. Optimize respiratory managementAvoid hypocapnia/severe hypercapnia
Avoid routine chest physiotherapyAvoid routine suctioning
7. Limit sodium bicarbonate
Reduce environmental noiseMinimize handlingMinimize lighting
Judicious use of narcotic sedation
4. Neutral head position and elevate head (Cowan F & Thoresen M. Pediatrics 1985; 75: 1038-47).
5. Avoid rapid correction of hypotension
6. Optimize respiratory managementAvoid hypocapnia/severe hypercapnia
Avoid routine chest physiotherapyAvoid routine suctioning
7. Limit sodium bicarbonate
Take home message: Prevention of IVH
Antenatal betamethazone 24 mg 24 hr before delivery
Antibiotics for preterm rupture of membranes
Delayed cord clamping
Maintain temperature >36.0.
Minimize pain and stress/handling/noise/light
Judicious opiate sedation, rarely pancuronium.
Neutral head position with head up tilt.
Avoid rapid swings in blood pressure and CO2
Minimize chest physio and tube suction