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Temperature During Resuscitation: Emerging Evidence for Best Management NRP, NCE, New Orleans October 19,2012 Marilyn B Escobedo MD FAAP Reba McEntire.

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Presentation on theme: "Temperature During Resuscitation: Emerging Evidence for Best Management NRP, NCE, New Orleans October 19,2012 Marilyn B Escobedo MD FAAP Reba McEntire."— Presentation transcript:

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, Children ’ s 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 1. Frogs 2. Toucans 3. Lambs 4. 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

14

15 QUESTION #2 The thermoneutral zone C delivery room as recommended by WHO C for preterm 1 kg unclothed newborn C for unclothed adult human C for tem 3 kg unclothed newborn.

16 What is the thermoneutral zone for humans? Unclothed resting adult — C (73 F) Unclothed full term neonate — 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? 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 LOSSES

19 How does this apply to the DR? 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 INTERVENTIONS

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 <35 C in 40% of infants <26 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 degrees C as a species specific feature

25 How do we best defend the tiny baby ’ s 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 Stockinette Hat studies by Roberts ( >31 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 warming mattresses Compared to plastic wrap Reduced hypothermia ( <0.01) 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 THERMAL MATTRESS vs PLASTIC WRAP RCT < 28 week

32 Various Studies of warming mattresses — all 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 > 10mW/cm2 for >15 minutes Most warmers will have shut off before the usual 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? degrees F to keep the OBs cool degrees F, thermoneutral environment for unclothed adults degrees C as recommended by the WHO 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 > 26 had higher mean admission temps than those in =<26 Cramer (2005) Positive relationship between DR temp and NICU admission temp Kent (2008) changed environmental temp from 20 to C along with other interventions and showed a positive effect on T.

38 Humidified and Heated Air during Resuscitation Prospective study of <33 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 <.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 <.0001). The use of heated and humidified air during respiratory support in very preterm infants just after birth reduced the postnatal decrease in temperature te Pas AB. Lopriore E. Dito I. Morley CJ. Walther FJ. Pediatrics. 125(6):e , 2010 Jun.

39 What about hyper thermia? 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 (< 36.5 C) on admission to NICU for inborn VLBWs? 1. 10% 2. 25% % 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 <36.5 C and about ¼ < 36 C Why aren ’ t we doing better?

42 TIPQC- Tennessee Initiative

43 Incidence of Hypothermia (< 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

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 < 28 weeks gestation Placed on Na acetate thermal mattress, Pinfeather or wrapped in plastic, Enwrap Wrap group (n=18, GA wks) Mattress group (n=20, GA wks) Significant difference in NICU admission temp between groups ( P value = ) Wrap group ( ) Mattress group ( ) 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 section — what 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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