Prehľad. III. Riadená hypotermia (RH) I. Hypoxia ischémia (HI) II. Patofyziológia HI
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1 Prehľad I. Hypoxia ischémia (HI) II. Patofyziológia HI III. Riadená hypotermia (RH) 1. účinky a metódy 2. metaanalýzy 3. podmienky a prístroje 4. indikácie 5. aeeg 6. kontraindikácie a prerušenie 7. PRINCÍPY 8. PRAKTICKÁ REALIZÁCIA 9. komplikácie
2 Riadená hypotermia - indikačné kritériá 1. všeobecné 2. ťažká asfyxia klinicky laboratórne 3. HIE klinicky elektrofyziologicky (aeeg)!!!???
3 Riadená hypotermia - indikačné kritériá 1. všeobecné 2. ťažká asfyxia klinicky laboratórne 3. HIE klinicky elektrofyziologicky (aeeg)!!!??? 36 t.g. (term, near term) 2000 g. (AGA, bez mikrocefalie) < 6 h (optimálne prvé 3 h)
4 Riadená hypotermia - indikačné kritériá - vplyv začiatku chladenia na efektivitu liečby 6 hod hod. Gunn AJ, Curr Opinion in Pediatrics 2000
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9 Riadená hypotermia - indikačné kritériá 1. všeobecné 2. ťažká asfyxia 3. HIE klinicky stačí 1 kritérium klinické (v 10. min.života) Apgar < 6 ventilácia maskou / ETK laboratórne (do 60.min.života) ph < 7.00 BE 16 mmol/l laktát > 10 mmol/l* elektrofyziologicky (aeeg)!!!???
10 Klinická validita metabolickej acidózy The BD in the great majority of infants with severe intrapartum asphyxia normalizes within 4 h of birth. The BD recovery rate of infants with adverse outcomes was similar to those with relatively good outcome. S da Silva, Acta Paediatr 89: Shah PS, Acta Paediatr 92: , 2003
11 Riadená hypotermia - indikačné kritériá 1. všeobecné 2. ťažká asfyxia klinicky laboratórne 3. HIE klinické (stačí splnenie podmienok jedného z uvedených: A,B,C,D) A. Sarnat / Fenichel (II. / III. št.) B. TOBY C. Thompson skóre (> 7 bodov) D. Gluckman ELEKTROFYZIOLOGICKÉ (aeeg)!!?? Horn A.R. BMC Pediatrics 2013, 13:52
12 Riadená hypotermia: indikačné kritériá Stupne HIE modifikované podľa SARNAT-FENICHELA: I.štádium II.štádium III.štádium stav vedomia Hyperaktivita, letargia kóma autonómne funkcie pupily; FR; nystagmus dýchanie, sekréty* 3 pulzy GIT motilita, sekréty* 3 Sympatické mydriáza pravidelné N - N - Parasympatické mióza periodické,, apnoe / hnačka, Paralýza dilat/fix/anizok.; ; + apnoe/pphn/ TI* 2 / variabilné variabilná kŕče ( h) myoklónus (III. chýba) - + časté/fokálne/multifok + (včasné)/časté/ general./ ťažko kontrolovateľné trvalý tonus normo/m. / mark.abnorm.*1 atonia posturálne držanie reflexy: sací Morov úchop tonické šijové okulokefalický šlachové ľahká distálna flexia,fisting hlad+slabo pije prehnaný N / nepatrné normálny silná distálna flexia tot. extenzia nemá hlad inkompletný prehnaný/ silné zvýšený / intermit.decerebrá cia (časté kŕče) chýba chýba chýba chýbajú znížený-chýba Chýbajú trvanie*3 < 3-4 dni!!! 1-2 týždne hodiny - týždne
13 Klinická validita kŕčov 1/3 HIE II a III má kŕče Prítomnosť kŕčov horšia prognóza Glass HC et al, J Peds 2011 Wusthoff et al, J Child Neurol 2011 Low E et al, Arch Dis Child Fetal Neonatal Ed 2012 Srinivasakumar P et al, J Pediatr 2013
14 RH holandská štúdia -kŕče Groenendaal F., Neonatology; 2013;104:15-21, Dresden,
15 NE: Kŕče v plyv na rozvoj CP
16 Riadená hypotermia: indikačné kritériá TOBY 2010 KŔČE (clinical / aeeg) cerebr. metab. demand hypoxia excitation injury BRAIN INJURY SUBSEQUENT EPILEPSY Treat seizures early alebo HIE II. III. stp. a. porucha vedomia v zmysle útlmu ( až žiadna reakcia na stimuly) a b. hypotonia až atonia (fokálne alebo generalizované) a b. slabé až chýbajúce primit. reflexy (sací a Morov)
17 Riadená hypotermia - indikačné kritériá THOMPSON skóre 9 príznakov body vedomie N fixovaný pohľad, široké oči, iritovanosť letargia kóma 2. fontanela N plná, nie napätá napätá - 3. respirácia N hyperventilácia krátkodobé apnoe UPV 4. kŕče - < 3 / deň 3 / deň - 5. tonus N atonia 6. postura N ľahká distálna flexia fisting- zaťaté päste, bicyklovanie silná distálna flexia intermit.decerebrácia 7. reflexy: úchop Morov sanie N N N slabý čiastočný slabé chýba chýba chýba - - -
18 Thomson skóre Horn A.R. BMC Pediatrics 2013, 13:52
19 ? Horn AR. Acta Paediatr 2013, 102(8):378
20 Horn A.R. BMC Pediatrics 2013, 13:52 Interpretácia a využitie Thompson scóre Thompson score 5 v hodine identifikovalo všetkých novorodencov s abnormálnym aeeg v 3. a/alebo 6. hodine toto môže byť dostatočnou indikáciou na to, aby sa volalo centrum s chladením pre rozhodnutie o ďalšom postupe Thompson score 7 v hodine bolo viac senzitívnym prediktorom strednej až závažnej HIE v 72. hodine ako aeeg v 6. hodine kritérium pre riadenú hypotermiu Thompson score 17 v hodine by mohlo byť vylučovacím kritériom???
21 Riadená hypotermia: indikačné kritériá Gluckman - prítomnosť strednej / závažnej HIE: KŔČE alebo 3 príznaky zo 6 kategórií kategória Stredná encephalopathia Závažná encephalopathia 1. vedomie letargia stupor / kóma 2. autonómny systém oči AS respirácia mióza bradykardia periodické dýchanie variabilné / nereaktívne variabilná apnoe 3. tonus / atonia 4. spontánna hybnosť žiadna 5. postura distálna flexia decerebrácia 6. reflexy: Morov sanie inkompletný slabé - -
22 Horn A.R. BMC Pediatrics 2013, 13:52 Riadená hypotermia: indikačné kritériá 1. všeobecné 2. ťažká asfyxia klinicky laboratórne 3. HIE klinické (stačí splnenie podmienok jedného z uvedených: A,B,C,D) A. Sarnat / Fenichel (II. / III. št.) B. TOBY C. Thompson skóre (> 7 bodov) D. Gluckman ELEKTROFYZIOLOGICKÉ (aeeg)!!??
23 Podmienky a interpretácia aeeg aeeg podmienky záznamu: 1. medzi 1. a 5. hod života 2. dĺžka záznamu 30 min 3. podľa možnosti pred antikonvulzívami 4. odstup po podaní antikonvulzív 30 min (nie diazepam a midazolam) 5. maximálna dávka fenobarbitalu 20 mg/kg pred aeeg 6. realizácia v PC aspoň 1 z uvedených príznakov: závažný podľa vzoru krivky burnst - suppression low voltage flat trace kŕče Je možno zahájiť RH aj bez aeeg
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