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Temperature During Resuscitation: Emerging Evidence for Best Management

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Background About 10% of babies require some resuscitation at ... 25 C delivery room as recommended by WHO 2. 31-38 C for preterm 1 kg unclothed newborn ... – PowerPoint PPT presentation

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Title: Temperature During Resuscitation: Emerging Evidence for Best Management


1
Temperature During Resuscitation Emerging
Evidence for Best Management
  • NRP, NCE, New Orleans October 19,2012

Marilyn B Escobedo MD FAAP Reba McEntire Endowed
Chair in Neonatology University of Oklahoma
2
University of Oklahoma, Childrens Hospital
3
I have nothing to disclose
4
Learning Objectives
  • Recall the transitional physiology of thermal
    regulation in the neonate
  • Review the vulnerability of the ELGAN to
    excessive morbidity and mortality of hypothermia
  • Update knowledge of the multiple factors that may
    threaten thermal integrity
  • Learn multiple methods to affect better thermal
    outcomes in the vulnerable group.

5
Background
  • About 10 of babies require some resuscitation
    at birth
  • 1 need extensive resuscitation
  • ALL need attention to thermal integrity
  • ELGANs are the MOST vulnerable.

6
QUESTION 1
  • Human babies have thermoregulatory systems that
    are similar to
  • Frogs
  • Toucans
  • Lambs
  • Hibernating bears

7
A few words
  • On the physiology
  • of thermoregulation

8
The relationship between frogs and humans has
long been debated
9
How is a baby not a frog?
This was an evolutionary LEAP
10
How is a baby not a frog?
  • Homeotherms increase their metabolic rate in
    response to cooling.
  • Poikilotherms decrease their metabolic rate in
    response to cooling

11
Poikiolotherms vs homeotherms
  • Homeotherms have 2-3 times metabolic rate
  • Homeothermy demands that heat production
    precisely compensates losses to the environment

12
The human baby maintains his body temperature
with energy
13
The human baby maintains his body temperature
with energy
14
The human baby maintains his body temperature
with energy
15
QUESTION 2
  • The thermoneutral zone
  • 1. 25 C delivery room as recommended by WHO
  • 2. 31-38 C for preterm 1 kg unclothed
    newborn
  • 3. 23-28 C for unclothed adult human
  • 4. 35-37 C for tem 3 kg unclothed newborn.

16
What is the thermoneutral zone for humans?
  • Unclothed resting adult23-28 C (73 F)
  • Unclothed full term neonate32-35 C (90 F)
  • Unclothed 1 Kg preterm neonate 35 C (95 F)

17
PHYSICS OF HEAT TRANSFER
WHO, 1997, Safe Motherhood Thermal Protection of
the Newborn, a Practical Guide
18
How does this apply to the DR?
LOSSES
  • Radiation Cold walls, all solid furnishings of
    the theatre, poor muscle tone increasing surface
    area exposed
  • Conduction cold blankets, instruments,
    mattresses
  • Convection-Vents from HVAC system, Movement of
    personnel, Doors, Gases
  • Evaporation- Amniotic fluid, no clothing

19
How does this apply to the DR?
INTERVENTIONS
  • Radiation Increase room temperature in advance,
    use radiant warmer for care
  • Conduction warm blankets, exothermic mattresses
  • Convection-Design appropriate HVAC system, Be
    aware of movement of personnel, doors, gases, use
    transport incubator
  • Evaporation- Dry or place barriers to evaporation
    on body and head

20
WHEN do we need to intervene?
21
Is it just theoretically important?
  • How do we intervene?
  • When do we intervene?
  • To whom to we apply these techniques?
  • Do they change outcome?

22
Reduction in Mortality by Reducing Hypothermia
  • Budin, Pierre in The Nursling
  • Comparison of Mortality in the Maternite( the
    Usual standard of care) with
  • The Tarnier ( the preventive approach to
    Hypothermia)

23
Silverman to Costeloe
  • Survival significantly higher in incubators kept
    at 32 C. vs 29 C ( Silverman1958)
  • Survival significantly higher in radiantly heated
    incubators vs convectively heated due to
    stability of the environmental temp (
    Silverman1963)
  • Survival improved in computer controlled SKIN
    temperature environment (1976 Ahlgren)
  • Hypothermia remains an independent risk factor
    for mortality in very small preterm babies
    (Costeloe 2000) Admission temps lt35 C in 40 of
    infants lt26 wks

24
Question 3
  • At birth the body temperature of the newborn is
  • 1. Dependent on gestational age
  • 2. Always 0.5 degree C above the maternal temp
  • 3. Higher is LGA and lower in SGA babies
    secondary to the conductive properties of fat
  • 4. 36- 37 degrees C as a species specific
    feature

25
How do we best defend the tiny babys thermal
integrity?

McCall, Alderdice, Halliday Jenkins Vohra 2010
Cochrane Review
26
Barrier Methods to prevent evaporative heat loss
  • Polyethylene occlusive wrapping of ELGANs
    immediately upon delivery (Vohra, et al J Pediatr
    2004, HeLP study

Decreases the incidence of hypothermia Increases
the NICU admission temperature Fewer deaths (all
hypothermic) but NS
27
Prevention of Evap Heat Loss
  • ALL the RCTs of occlusive wrapping of the very
    preterm baby with food grade plastic wrap
  • Showed improved temperatures on admission to
    NICU of almost 1degree C
  • Reduced the incidence of hypothermia
  • Some have studied effects on
  • Acid base balance
  • RDS
  • IVH
  • NEC
  • O2 need
  • LOS
  • None have shown an effect on Mortality

28
Second barrier to reduction of evap loss of heat
HATS

29
Second barrier to reduction of evap loss of heat
HATS
  • Stockinette Hat studies by Roberts ( gt31 wks)
  • Plastic hat study by Trevisunuto
  • Plastic hat study by Wyckoff
  • Woolen hats studied in terms ( Coles 1979
    Stothers 1981 and Chaput de Saintonge 1979)
  • NEEDS STUDY

30
Conductive heat transfer
  • Exothermic warming mattressess

31
THERMAL MATTRESS vs PLASTIC WRAP RCT lt 28 week
  • Thermal warming mattresses
  • Compared to plastic wrap
  • Reduced hypothermia ( lt0.01)
  • Raised NICU adm temp
  • Allowed more direct access
  • Improved visualization
  • Less cumbersome to apply

Thermal defense of extremely low gestational age
newborns during resuscitation exothermic
mattresses vs polyethylene wrap Simon Dannaway
Escobedo et al J Perinatology 2010
32
Various Studies of warming mattressesall positive
  • Brennan 1996 RCT
  • Singh 2009 Cohort, historical
  • Almeida 2009 RCT
  • Ibrahim 2010 Retrospective Review

33
Caveat!!
34
Positive transfer of radiant heat
  • Manuel radiant warmer
  • International Standard requires power cut and
    alarm if total output has been gt 10mW/cm2 for gt15
    minutes
  • Most warmers will have shut off before the usual
    20- 30 minute resuscitation of VLBW
  • Servo-controlled radiant warmer should probably
    be used or team member should be assigned to
    monitor temp to avoid highs and lows (Rich,
    Leone, Finer in Clinics in Perinatology Mar
    2010)

35
Question 4
  • What should the DR Temp Be?
  • 1. 64 degrees F to keep the OBs cool
  • 2. 73 degrees F, thermoneutral environment for
    unclothed adults
  • 3. 25 degrees C as recommended by the WHO
  • 4. 37 degrees C, the thermoneutral zone for term
    babies

36
Reducing radiant heat losses beyond the warmer
  • Delivery room temperature needs to be kept at the
    WHO standard of 25 degrees C or higher (mid 70s
    F)

37
Environmental Temps Birthing and Surgical
Suite
  • WHO recommendation for 25 C or greater
  • No references
  • Knobel (2005) post hoc analysis
  • Subjects born in room temps gt 26 had higher mean
    admission temps than those in lt26
  • Cramer (2005) Positive relationship between DR
    temp and NICU admission temp
  • Kent (2008) changed environmental temp from 20 to
    25-28 C along with other interventions and showed
    a positive effect on T.

38
Humidified and Heated Air during Resuscitation
te Pas AB. Lopriore E. Dito I. Morley CJ. Walther
FJ. Pediatrics. 125(6)e1427-32, 2010 Jun.
  • Prospective study of lt33 wks
  • "heated" cohort used heated and humidified gas
    during resuscitation vs cold cohort
  • Temperature at admission in the NICU 35.9 vs 36.4
    ( P lt .0001).
  • Normothermia (36.5 degrees C-37.5 degrees C)
    occurred less often in the cold cohort than in
    the heated cohort (12 vs 43 P lt .0001).
  • The use of heated and humidified air during
    respiratory support in very preterm infants just
    after birth reduced the postnatal decrease in
    temperature

39
What about hyperthermia?
  • As core temperatures increase O2 consumption
    rises again.
  • This is stressful for any neonate with ELGANs
    more susceptible
  • If preterms also have CNS injury, the possibility
    of hyperthemia exacerbating the injury may exist.

40
Question 5
  • What is the national rate (VON 2010) of
    hypothermia (lt 36.5 C) on admission to NICU for
    inborn VLBWs?
  • 1. 10
  • 2. 25
  • 3. 50
  • 4 75

41
The evidence shows we should be preventing
hypothermia. The VON report for 2010 shows a
rate of about ½ of VLBWs with admission temps
lt36.5 C and about ¼ lt 36 C Why arent we doing
better?
42
TIPQC- Tennessee Initiative
43
Incidence of Hypothermia (lt 36 C) on Admission
to NICU MUSC
2010 Robin L. Kissinger, PhD, APRN, NNP-BC David
J. Annabale, MD
44
Learning Objectives
  • Recall the transitional physiology of thermal
    regulation in the neonate
  • Review the vulnerability of the ELGAN to
    excessive morbidity and mortality of hypothermia
  • Update knowledge of the multiple factors that may
    threaten thermal integrity
  • Learn multiple methods to affect better thermal
    outcomes in the vulnerable group.

45
Thermal Defense for Preterms
  • Reasonable Evidence
  • Plastic bag with hats
  • Thermal mattresses
  • Emerging considerations
  • Hats
  • Heated gases
  • Radiant warmer
  • The role of the delivery room temperature
  • Avoid hyperthermia especially in depressed
  • Effective and consistent application

46

HOME DELIVERY IS FOR PIZZA!!!!!!!
47

UNDERWATER BIRTH IS FOR WHALES!!!
48

questions?
49
(No Transcript)
50
Heat Loss Prevention for Preterm Infants in the
Delivery Room Robin B Knobel, John E Wimmer Jr
and Don Holbert
51
Reponses to Cool Environment
  • Change in posture
  • Vasoconstriction
  • Crying and activity
  • Chemical thermogenesis
  • Norepinephrine
  • Thyroid hormones
  • Lipolysis (brown fat)
  • Glycolysis (glycogen)

52
Thermal defense of low gestational age newborns
during resuscitation exothermic mattresses vs.
polyethylene wrap Simon, Escobedo et al J
Perinatolgy 2010
  • PRCT of 38 infants lt 28 weeks gestation
  • Placed on Na acetate thermal mattress, Pinfeather
    or wrapped in plastic, Enwrap
  • Wrap group (n18, GA 25.8 1.29 wks)
  • Mattress group (n20, GA 26.05 1.19 wks)
  • Significant difference in NICU admission temp
    between groups ( P value 0.0153)
  • Wrap group (36.1 0.65)
  • Mattress group (36.7 0.75)
  • CONCLUSIONS
  • Thermal mattresses improved the admission
    temperature for extremely low gestational age
    neonates over plastic wrap

53
The human baby maintains his body temperature
with energy
54
Response of oxygen need to core body temperature
55
After many millennia, Caesar invented the
sectionwhat did this experiment do to the finely
tuned thermal response to birth?
  • Full term C/S babies have lower temps at birth
  • Sympathetic activity, catecholamine's, thyroid
    all lower in the C/S
  • Brown fat activation and uncoupling proteins are
    low in C/S lambs
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