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Hipoxic Ischaemic Encephalopaty
PRESENTAN:
DANIEL E. R. MALAU
LECTURER:
PROF. DR. M. I. WIDIASTUTI, PAK, SP.S(K), M.SC
Definitions
Hypoxia or Anoxia: A partial (hypoxia) or complete (anoxia) lack of oxygen in the brain or blood
Asphyxia: The state in which placental or pulmonary gas exchange is compromised or ceases altogether
Ischemia: The reduction or cessation of bloodflow to an organ which compromises both oxygen and substrate delivery to the tissue
Hypoxic-Ischemic Encephalopathy: Abnormal neurologic behavior in the neonatal period arising as a result of a hypoxic-ischemic event.
Incidence of HIE
Occurs in 2-9 per 1000 live term births in developed countries
WHO : 0.5 – 1 per 1000 live term birth
Surabya (dr Soetomo Hospital ) : 12.25 % fro,m 3405 live term birth
Etiology of HIE
Maternal:
HYPERTENSION
Vascular Diseases
Diabetes
Uterine Ruptur
Uteroplacental:
Placental abruption
Cord prolapse
Uterine rupture
Fetal:
Anemia
Infectio
Severe isoimmune hemolytic disease
Cardiac arrhythmia
Patophysiology Hipoxic Ischemic Encephalopaty
PATHOPHYSIOLOGYPotential pathways for brain injury after hypoxia-ischemia.
Perlman J M Pediatrics 2006;117:S28-S33
©2006 by American Academy of Pediatrics
Clinical Staging of HIE (Sarnat and Sarnat, 1976)
Diagnosis
There is no clear diagnostic test for HIE Abnormal findings on the neurologic exam in the first few days
after birth is the single most useful predictor that brain insult has occurred in the perinatal period
Essential Criteria for Diagnosis of HIE: Metabolic acidosis (cord pH <7 or base deficit of >12)
APGAR SCORE 0-3 un first 5 minutes
Early onset of encephalopathy
Multisystem organ dysfunction
Assessment Tools in HIE
Amplitude-integrated EEG (aEEG)
When performed early, it may reflect dysfunction rather than permanent injury
Most useful in infants who have moderate to severe encephalopathy
Marginally abnormal or normal aEEG is very reassuring of good outcome
Severely abnormal aEEG in infants with moderate HIE raises the probability of death or severe disability from 25% to 75%
Assessment Tools in HIE
Evoked Potentials Brainstem auditory evoked potentials,
visual evoked potentials and somatosensory evoked potentials can be used in full-term infants with HIE
More sensitive and specific than aEEG alone
However, not as available as aEEG and there is a lack of experience among pediatric neurologists
Therefore aEEG is preferred because of easy access, application, and interpretation
Assessment Tools in HIE
Neuroimaging Cranial ultrasound: Not the best in assessing
abnormalities in term infants. Echogenicity develops gradually over days
CT: Less sensitive than MRI for detecting changes in the central gray nuclei
MRI: Most appropriate technique and is able to show different patterns of injury. Presence of signal abnormality in the internal capsule later in the first week has a very high predictive value for neurodevelopmental outcome
Differential Diagnosis
1. Analgesia during delivery
2. Viral, Sepsis, Meningitis
3. Kongenital Anomaly in central nervous system, heart and lung
4. Neuromuscular diseases
5. Trauma during delivery
THERAPY
1. Adequate Ventilation
2. Adequate Oxygenation,
3. Temperature Controlled : Head Cooling and Whole Body Cooling
4. Acidosis Metabolic Correction
5. Blood Glucose Controlled ( between 75-100 mg/dl)
6. Prevent Seizures
Management - Hypothermia
Has become standard of care
Whole-body and head-cooling available
Unclear if one regimen is superior to the other -
currently either one is utilized, based on availability
Aim to get core (rectal) temperature to 33-35º C for 72 hours
Hypothermia - Mechanism of Action
Reduces cerebral metabolism, prevents edema Decreases energy utilization Reduces/suppresses cytotoxic amino acid
accumulation and nitric oxide Inhibits platelet-activating factor, inflammatory
cascade Suppresses free radical activity Attenuates secondary neuronal damage Inhibits cell death Reduces extent of brain damage
DEATH OR SEVERE DISABILITY AT 18 MONTHS OF AGE SIGNIFICANTLY REDUCED!!
Criteria for Hypothermia
Hypothermia is not effective for every baby
Currently only used in infants > 35 weeks Time interval between birth and initiation of
treatment important
Treatment must be started within 6 hours of birth to be effective
HYPOTHERMIA
1. HEAD COOLING 2. WHOLE BODY COOLING
HEAD COOLING WHOLE BODY COOLING
Pharmacologic Management
Allopurinol
Some trials have shown a decrease in mortality and a beneficial effect on free radical formation, cerebral blood flow and electrical brain activity
Meta-analysis concluded that more trials need to be done using allopurinol as an adjunct to hypothermia to make a conclusion on its effectiveness in treating HIE
Pharmacologic Management
Opioids
A few studies have demonstrated that morphine and fentanyl may have a neuroprotective effect after HIE with less severe signs of brain damage on MRI at 7 days of life and better neurologic outcomes at 13 months of age
However, long term effects of these medications are not known and more prospective randomized trials are warranted.
Prognosis
It is variated , from mild to severe :
1. Severa asphyxia
2. Seizures that cant controlled for 12 hours or more
3. Multi Organ Failure
4. Neurological problem that persisten
5. Persisten Oliguria
Microcephaly
Severe Abnormality in EEG
Ct Scan Severe Haemmorhage, periventrikel leukomalasi (PVL) atau nekrosis.
MRI 24-72 hours after birth.
THANK YOU
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