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Encefalopata Hipxico-
Isqumica
hipotermia
Temas a desarrollar
Asfixia perinatal
Encefalopata hipxico-isqumica
Estados
Fisiopatologa
Exmenes complementarios
Outcome
Hipotermia:
Fisiopatologa
Seguridad
Estudios
Manejo: Medidas generales
Conclusiones
Introduccin
Per (INEI):
En el ao 2012 se inscribieron 698 954
nacimientos
2656 pacientes con EHI en el 2012!
Asfixia Perinatal
Falta de oxgeno o de perfusin en los tejidos del feto
Signos Neonatales:
Apgar < 5 a los 5 min
Neuroimagen
Encefalopata
Neonatal Encephalopathy and Neurologic Outcome, Second Edition Report of the American College of
Obstetricians and Gynecologists Task Force on Neonatal Encephalopathy. Pediatrics 2014; 133: e1482-e1488
Encefalopata Hipxico-
Isqumica
Sntomas/signos neurolgicos
inmediatamente despus del parto
Escala de Sarnat
Escala de Amiel-Tison
Amiel-Tison C. Update of the Amiel-Tison neurological assessment for the term neonate or at
40 weeks corrected age. Pediatr Neurol 2002;27:196-212.
Encefalopata Hipxico-Isqumica: Escala
de Sarnat
EHI: Fisiopatologa
Fase inicial:
Reduccin en flujo cerebral y distribucin de
oxgeno
Metabolismo anaerbico
citotxico
Liberacin de neurotransmisores excitatorios
Radicales libres
Muerte celular
Brote-supresin
Convulsiones
EHI: Estudios
Complementarios: aEEG
Roelfsema V, Bennet L, et al. J Cereb Blood Flow Metab 2004; 24: 877-86.
Gunn AJ, Bennet L. NeoReviews 2002; 3: e116-e122.
Azzopardi D, Edwards AD. Semin Fetal Neonatal Med 2007; 12: 303-310.
Hipotermia
Tiempo: Primeras 6 horas de vida
Estudios en fetos de ovejas:
Hipotermia entre 90min-3h: mejora importante
5.5h: slo mejora parcial
8.5h: no mejora
Gunn AJ, Gunn TR, et al. J Clin Invest 1997; 99: 248-56.
Thoresen M, et al. Pediatr Res 1995; 37:667-70.
Hipotermia
Mtodos:
Hipotermia cerebral selectiva (Cool Cap)
con hipotermia sistmica leve (34-35C)
Hipotermia
Mtodos:
Hipotermia corporal total (Blanketroll,
Tecotherm, CritiCool)
Hipotermia: Seguridad
Seguridad: Cochrane Review 2013
No hay diferencia significativa en:
Arritmias RR 0.55 (0.12-2.56)
Hipotensin que requiera inotropos RR 1.09 (0.96-1.24)
Anemia con necesidad de transfusin RR 1.01 (0.71-
1.43)
Coagulopata RR 1.10 (0.93-1.29)
Fallo renal RR 0.87 (0.74-1.02)
Sepsis RR 0.87 (0.60-1.26)
Hipertensin pulmonar RR 1.36 (0.94-1.97)
Disfuncin heptica RR 0.84 (0.74-1.05)
Jacobs SE, Berg M, Hunt R, et al. Cooling for newborns with hypoxic ischaemic encephalopathy.
Cochrane Database of Systematic Reviews 2013, Issue 1. Art. No.: CD003311. DOI:
Hipotermia: Seguridad
Seguridad: Cochrane Review 2013
S hay diferencia significativa en:
Bradicardiasinusal RR 11.6 (4.9-27.17)
Trombocitopenia RR 1.21 (1.05-1.40)
Jacobs SE, Berg M, Hunt R, et al. Cooling for newborns with hypoxic ischaemic encephalopathy.
Cochrane Database of Systematic Reviews 2013, Issue 1. Art. No.: CD003311. DOI:
Hipotermia: Cool Cap Trial
RCT multicntrico: 234 px
Muerte o discapacidad severa: 66% control vs.
55% hipotermia OR 061(034109)
Ajustado segn severidad de aEEG OR 057 (032
10)
Conclusin: podra mejorar sobrevida sin
discapacidad severa en los RN con cambios menos
severos en aEEG
Gluckman PD, Wyatt JS, et al. Selective head cooling with mild systemic hypothermia after
neonatal encephalopathy: multicentre randomised trial. Lancet 2005; 365: 663-70.
Hipotermia: Corporal total
RCT: 239 px
Muerte o discapacidad severa: 44%
hipotermia vs 62% control RR 0.72
(0.54-0.95)
NNT 6
Conclusin: Hipotermia corporal total
reduce el riesgo de muerte o
disabilidad en RN con EHI moderada o
severa
Azzopardi D, Strohm B, et al for the TOBY study group. Moderate hypothermia to treat
perinatal asphyxia encephalopathy. N Engl J Med 2009; 361: 1349-58.
Hipotermia:
Neo.nEURO.Network
RCT multicntrico: 239 px
Muerte o discapacidad severa: 51% en
hipotermia vs 83% en normotermia OR 0.21
(0.09-0.54)
NNT 4
Conclusin: Hipotermia corporal total mostr un
efecto neuroprotector efectivo en EHI severa
Jacobs SE, Morley CJ, Inder TE, Stewart MJ, Smith KR, McNamara PJ, et al. Whole-body
hypothermia for term and near-term newborns with hypoxic-ischemic encephalopathy: a RCT.
Hipotermia: Cochrane
11 estudios :1505 pacientes
Hipotermia: cerebral selectiva y corporal
total
Conclusin: Hipotermia reduce la muerte
y discapacidad neurolgica en EHI
Recomiendan ms estudios para
comparar los mtodos de hipotermia y la
duracin ideal
Jacobs SE, Berg M, Hunt R, et al. Cooling for newborns with hypoxic ischaemic encephalopathy.
Cochrane Database of Systematic Reviews 2013, Issue 1. Art. No.: CD003311. DOI:
Analysis 1.1. Comparison 1 Therapeutic hypothermia versus standard care: subgroup analysis by method of
cooling, Outcome 1 Death or major disability in survivors assessed, by method of cooling.
Studyor subgroup Hypothermia Standard care Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95%CI M-H,Fixed,95%CI
Subtota
Cooling l (95%
for CI)with hypoxic ischaemic
newborns 452 encephalopathy 449(Review) 69.7 % 0.75 [ 0.66, 0.84 ]63
Total events:2013
Copyright 215 (Hypothermia),
The Cochrane 286 (Standard care) Published by John Wiley & Sons, Ltd.
Collaboration.
Heterogeneity:Chi2 = 4.25, df = 4 (P =0.37); I2 =6%
Test for overall efect: Z =4.80 (P < 0.00001)
Total (95% CI) 678 666 100.0 % 0.75 [ 0.68, 0.83 ]
Total events: 312 (Hypothermia), 409 (Standard care)
Heterogeneity:Chi2 = 6.89, df = 7 (P =0.44); I2 =0.0%
Test for overall efect: Z =5.53 (P < 0.00001)
Test for subgroup diferences: Chi2 =0.06, df =1 (P = 0.81), I2 =0.0%
0.2 0.5 1 2 5
Favours hypothermia Favours standard care
Jacobs SE, Berg M, Hunt R, et al. Cooling for newborns with hypoxic ischaemic
encephalopathy. Cochrane Database of Systematic Reviews 2013, Issue 1. Art. No.:
Hipotermia a largo plazo
TOBY: seguimiento a 6-7 aos
Sobrevida sin anormalidades neurolgicas:
45% vs 28% (RR 1.60, CI 1.15-2.22)
Parlisis cerebral: 21% vs 36% p=0.03