Clinics in perinatology
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There is strong evidence that prolonged, moderate cerebral hypothermia initiated within a few hours after severe hypoxia-ischemia and continued until resolution of the acute phase of delayed cell death can reduce neuronal loss and improve behavioral recovery in term infants and adults after cardiac arrest. This review examines the evidence that mild to moderate hypothermia is protective after hypoxia-ischemia in models of preterm brain injury and evaluates the potential risks. Induced hypothermia likely has potential to significantly reduce disability. Cautious, systematic trials are essential before hypothermia can be used in these vulnerable infants.
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Neonatal hypoxic-ischemic encephalopathy, prematurity, sepsis-meningitis, and serious forms of complex congenital heart disease requiring infant heart surgery are just a few examples of disorders that share high mortality and morbidity rates. Newborn heart surgery represents a period of planned and deliberate ischemia-reperfusion injury, which is obliged to occur to cure or palliate complex forms of congenital heart disease. Advances in cardiothoracic surgical and anesthetic techniques, including cardiopulmonary bypass and deep hypothermic circulatory arrest, have substantially decreased mortality, expanding the horizon to address functional neurologic and cardiac outcomes in long-term survivors. Interest in the functional status of survivors now stretches beyond the newborn period to childhood, adolescence, and adulthood.
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Clinics in perinatology · Dec 2008
ReviewSupportive care during neuroprotective hypothermia in the term newborn: adverse effects and their prevention.
Hypothermia as neuroprotective treatment requires significant knowledge of how temperature affects all organ systems and interventions used in intensive care. Education and training in resuscitation, including avoidance of hyperthermia, early diagnosis of eligible infants, and initiation of early cooling followed by safe transport of cooled infants to the cooling center seems to be an optimal approach. This article suggests clinical management and shows examples of potential adverse effects of clinical hypothermia. The practical cooling recommendations suggested herein are therefore likely to develop and change over time as more experience is gained.
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We are entering an era in which hypothermia will be used in combination with other novel neuroprotective interventions. The targeting of multiple sites in the cascade leading to brain injury may prove to be a more effective treatment strategy after hypoxic-ischemic encephalopathy in newborn infants than hypothermia alone.
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Clinicians who are convinced by the available evidence that cooling is a safe and effective treatment of hypoxic-ischemic encephalopathy in the term or near-term infant are now faced with a series of decisions around implementation of therapeutic hypothermia in their neonatal ICU or region. There is currently uncertainty about the efficacy of cooling or at least the magnitude of the effect, and precise estimates of the benefit of cooling must await the publication of the results of the several pending trials. This article assumes that clinicians are sufficiently convinced by the available evidence of safety and efficacy to proceed to the implementation step and offers guidelines for starting a neonatal cooling program.