NEONATAL HYPOXIC

ISCHEMIC
ENCEPHALOPATHY
Case presentation of Neonate ICU rotation

Presented by : Walaa Fahad Aljuaid .

Supervised by : Dr.Daniah Rifqi
OUTLINES :

• History of the case

• What is the HIE :
• Definition
• Causes
• Incidence and Prevalence
• Diagnosis
• Complication
• Treatment
• Intervention
 The Case :

M.A is 14 days old male came to NICU from another

hospital very sick , severe HIE , Respiratory distress

He was presented there ( another hospital ) with :

failure to thrive , hypotonic , flacid , Apgar score was
1 , he was on the mechanical ventilator as a case of
sever HIE stage 3 , the baby developed convulsion on
the first day controlled on phenobarbitone ,
hypertension controlled with Lasix and Captopril
HISTORY OF PRESENT ILLNESS:

• Medical history :
FTT , SVD , Prolonged Labore , HIE , CHD .
Broncholitis
• Family history :
Mother has one abortion in the past .
• Allergy :
+ve consanguinity
• Medication history :
Captoril ,Phenoparbetone , Lasix
 REVIEW OF SYSTEMS :

• Head and nick : normal

• Eyes : restricted pinpoint
• Nose : normal
• CVS : S1 + S2 , HTN
• Chest : RD , low air entry .
• Abdomen : Soft , no organomegally .
• Spine and Genitalia : normal
• Hips : normal
• CNS : AF at level , Tone : hyper Reflexes : Weak .
• Respiration : tachypnea
• Color : normal
• Cry : weak
• Movement : abnormal
• Birth trauma : no
• Apparent Congenital Anomalies : no
 WHAT IS THE SEVER HIE ?

References : Kenneth A. stem ,

Stern Law 2017 , cerebralpalsy ,
Hypoxic-Ischemic
Encephalopathy .
 Definition:
• Hypoxic-ischemic encephalopathy, or HIE, is
the brain injury caused by oxygen deprivation
to the brain

References : Kenneth A. stem ,

Stern Law 2017 , cerebralpalsy ,
Hypoxic-Ischemic
Encephalopathy .
 Causes of HIE

As noted HIE may result from any event that restricted the flow
of oxygenated blood to the brain

The case was

due
to prolonged
delivery .

References : Kenneth A. stem ,

Stern Law 2017 , cerebralpalsy ,
Hypoxic-Ischemic
Encephalopathy .
CLASSIFICATION OF HIE

The case
 Incidence and Prevalence of HIE in
KSA :
A total of 70 cases of HIE were recorded in the
study period giving an incidence of 5.5 cases
per 1000 term births.

This incidence is lower compared to many

developing countries and comparable to other
centers.
2003 2015
References : Itoo BA1, Al-
Hawsawi ZM, Khan AH, mention References : Adnan Amin Alsulaimani , Abdelaziz SA
Abuelsaad and Nader M Mohamed , January 27, 2015 ,
February 2003,Hypoxic ischemic
Inflammatory Cytokines in Neonatal Hypoxic Ischemic
encephalopathy. Incidence and
Encephalopathy and their Correlation with Brain Marker
risk factors in North Western
S100 Protein: A Case Control Study in Saudi Arabia
Saudi Arabia.
 Diagnosis : References : Kenneth A. stem ,
Stern Law 2017 , cerebralpalsy ,
Hypoxic-Ischemic
Encephalopathy .

• diagnosed clinical by
the combination of
evidence of fetal
distress Normal Abnormal

• heart rate
abnormalities

• Meconium stained fluid

• Birth depression

• Low Apgars
The Case
 References : Kenneth A. stem ,
Stern Law 2017 , cerebralpalsy ,
Hypoxic-Ischemic

Complications Encephalopathy .

To the Mother :
• Maternal diabetes with vascular disease
• Problems with blood circulation to the placenta
• Preeclampsia
• Cardiac disease
• Congenital infections of the fetus
• Drug and alcohol abuse
• Severe fetal anemia
• Lung malformations
 Complications

To the infants :
Intrapartum period : Postpartum HIE :
• Excessive bleeding from • Severe cardiac or
the placenta pulmonary disease
• Very low maternal • Infections, including
blood pressure sepsis and meningitis
• Umbilical cord • Severe prematurity
accidents • Low neonatal blood
• Prolonged late stages of pressure
labor • Brain or skull trauma
• Abnormal fetal position • Congenital brain
• Rupture of the placenta malformations
or the uterus
 References : Kenneth A. stem ,
Stern Law 2017 , cerebralpalsy ,
Hypoxic-Ischemic
Treatment : Encephalopathy .

The basic goal of HIE treatment is to support the baby’s affected

organs , treatment options include:

• Mechanical ventilation to help a baby who can’t breathe

• Cooling the baby’s brain or body to reverse brain hypoxia
caused by high temperatures
• Hyperbaric oxygen treatment in cases where HIE is caused by
carbon monoxide intoxication

• Treatments to assist the baby’s heart function and control

blood pressure
• Maintain normal blood glucose
• Prevent or control seizures
• Prevent or minimize cerebral edema
BACK TO THE CASE
 VITALS AT ADMISSION

• Weight : 2.5 Kg
• Temperature : 36 Cْ
• pulses : 147
• Respiratory Rate : 54
• Blood pressure : 82 / 46
• Pain score : 1 .
• SPO2 : 100 .
• Level of consciousness: low
• Respons : 2 .
• Pupil size : 3 .
 DATE OF ADMISSION : 29-2-1438
• The patient Move directly to NICU , he
received nothing in ER .
• At the NICU First Day :
• medication :

Route of
Drug name Dose frequency administration
IV fluid ( Ca , Kcl , 150 ml/kg/
AA10% , D5, D10 NS) . day OD IV
Tamiflu 63 mg BID IV
Empiric
Amikacin 38 mg OD IV
Phenobarbitone 10 mg OD Slow IV
 Abnormal
slightly
CBC and Differential :
normal
WBC RBC Platelet
Hb g/dL 10^3/uL
10^3/uL 10^6/uL

11.26 4.2 15.3 363

Chemistry:
K Na Cl Ca PO4 Mg
glucose mg/dl
mmol/L mmol/L mmol/L mg/dL mg/dL mg/dL

34 3.9 148 108 9.7 4.6 1.7

ASSESSMENT :

• Measure serum level Amikacin Peak should

not exceed 30 mg / liter .
• Do Blood culture ( To know reason of
respiratory distress ) .
• keep using phenoparbiton to control
seizures .
• vital signs were stable .
• keep patient on mechanical ventilator
SECOND DAY - SEVENTH DAY
• The blood culture -ve viral infection so
stopped Tamiflu .
• OGT feeding start 3ml / 3 hrs on the fifth
day .
• intubation at fourth day
• medication :
Route of
Drug name Dose frequency
administration
IV fluid 150 ml/kg/day OD IV
meropnem 63 mg BID IV
Amikacin 38 mg OD IV
Phenobarbitone 10 mg OD Slow IV
fentanyl 5 mcg/kg PNR slow IV .
fentanyl 2 mcg/kg/h OD IV
due to
Midazolam 40 mcg/kg/h OD IV
low mg mgso4 80mg TID slow IV
CBC and Differential : Abnormal
slightly
normal
WBC RBC Platelet
Hb g/dL 10^3/uL
10^3/uL 10^6/uL

12.5 3.4 11.7 363

Chemistry:
K Na Cl Ca PO4 Mg
glucose mg/dl
mmol/L mmol/L mmol/L mg/dL mg/dL mg/dL

80 4.2 132 106 9.5 4.3 1.27

At 4th day
Vital sign :
TEMP BP HR RR O2 sat.
37 88/56 154 48 90%
ASSESSMENT :

• Measure serum level Amikacin Peak should not

exceed 30 mg / liter .
• keep using Phenoparbiton to control seizures .
• vital signs were stable .
• addition midazolam and fentanyl to do
intubation surgery . < on the fourth day .
• OGT feeding start 3ml / 3 hrs on the fifth day .
• X-ray for chest at fourth day
• keep mechanical ventilation
• vital sign were stable
 EIGHTH DAY AND NINTH
DAY
• patient developed peritonitis - sepsis
• tolerating Extubation
• medication :
Route of
Drug name Dose frequency
administration
IV fluid 150 ml/kg/day OD IV
Meteclopromide 0.25 mg TID OGT tube
Instead of
meropenem Vancomycin 25 TID IV
and
Amikacin Phenobarbitone 15 mg OD Slow IV
fentanyl 2 mcg/kg/h OD IV
Tazocin 200 mg TID IV

Midazolam 2 mcg/kg/h OD IV
 Abnormal
slightly
CBC and Differential :
normal
WBC RBC Platelet
Hb g/dL 10^3/uL
10^3/uL 10^6/uL
23 2.3 10.2 347

Chemistry:
K Na Cl Ca PO4 Mg
glucose mg/dl
mmol/L mmol/L mmol/L mg/dL mg/dL mg/dL

67 5.4 132 103 9.5 5 1.6

Vital sign :
TEMP BP HR RR O2 sat.
37.9 82/47 131 48 97%
ASSESSMENT :

• CNS lethargic , weak , grade 2 encephalopathy

• change Antibiotic to ( Pepracillin Tazopactam ,
Meteclopromide , Vancomycin )
• EEG , MRT
• chest physiotherapy
• Chest :good air entry
• Increase the dose of phenobarbetone into 15 mg .
• Measure Vancomycin Trough after 3rd dose
( <40 µg/ml and <10 µg/ml, respectively )
• Vital sign were stable .
 TENTH DAY -EIGHTEENTH DAY
• patient developed Seizures Bronchopneumonia then left lung
collapse < on tenth day ,
• on 13th day patient develop convulsions and on the 14th RD
again and tachypnea .
• medication :
Drug name Dose frequency Route of
administration
IV fluid 150 ml/kg/day OD IV
Meteclopromide 0.25 mg TID OGT tube
Vancomycin 25 TID IV
Phenobarbitone 15 mg OD Slow IV
discontinue
on 11th day fentanyl 2 mcg/kg/h OD IV
Tazocin 200 mg TID IV
Atrovent + 0.5 ml TID Nebulizer
add on 14th normalS ( 3ml)
day 10% N-Acetyl 2 ml TID Nebulizer
cysteine
Ranitidine 3.7mg TID IV
add on 15th day
Omeprazole 2.5mg OD IV

Midazolam 40 mcg/kg/h OD IV
 Abnormal
slightly
CBC and Differential :
normal

WBC RBC Platelet

Hb g/dL 10^3/uL
10^3/uL 10^6/uL

15 3.3 10.2 347

INFECTION
Chemistry: on 13th day CRP 7.11mg/dl
K Na Cl Ca PO4 Mg
glucose mg/dl
mmol/L mmol/L mmol/L mg/dL mg/dL mg/dL

73.1 5.4 139 104 9.5 5 1.6

TEMP BP HR RR O2 sat.
37 88/47 139 48 98%
ASSESSMENT :
• CNS : poor response , hypotonic , poor acting
• Chest : SC I.C retractile Coarse
• CVS: S1+S2+O
• convulsions on day 13th then controlled until the
day 16th then appear again on the day 17th then
controlled again .
• continue Antibiotics until 10 days .
• on the 14th day Sepsis disappear
• OGT increase into 5 ml BID
• Cardiopulmonary monitor .
• Change position every 4 h .
• on eighteenth day they discontinued Vancomycin
and Tazocin but still on Meteclopromide .
 19 DAY -25 DAY
• patient still with left lung collapse developed
RD again .
• medication :
Drug name Dose frequency Route of
administration
Meteclopromide 0.25 mg TID OGT tube
add on Vancomycin 36.5 TID IV
20 day meropenem 98 mg BID IV
Phenobarbitone 15 mg OD Slow IV
discontinue Atrovent + 0.5 ml TID Nebulizer
on 24 normalS ( 3ml)
10% N-Acetyl 2 ml TID Nebulizer
cysteine
discontinue
on 25 Ranitidine 3.7mg TID IV
Omeprazole 2.5mg OD IV

add on 25 lasix 2.4 mg OD IV

 Abnormal
slightly
CBC and Differential :
normal

WBC RBC Platelet

Hb g/dL 10^3/uL
10^3/uL 10^6/uL

18 2.9 12.5 347

on day 21 on
LAP result : PSUDOMONAS
23 HOSPITAL ACQUIRED
Chemistry:
K Na Cl Ca PO4 Mg
glucose mg/dl
mmol/L mmol/L mmol/L mg/dL mg/dL mg/dL

80 4.3 132 103 9.5 4.2 1.6

Vital sign :
TEMP BP HR RR O2 sat.
37 110/80 167 49 98%
ASSESSMENT :
• continue the antibiotic until 10 days .
• Measure Vancomycin Trough after 3rd dose (
<40 µg/ml and <10 µg/ml, respectively )
• seizures were controlled
• on day 22 add multivitamins 0.5 mg + vit D 4
drops
• tachypnea on and off
• vital signs are stable .
 26 DAY -31 DAY
• patient still with left lung collapse , seizures
is control .
• medication :
Route of
Drug name Dose frequency
administration
Vancomycin 36.5 TID IV
meropenem 98 mg BID IV
Phenobarbitone 15 mg OD Slow IV
10% N-Acetyl
2 ml TID Nebulizer
cysteine
Ranitidine 3.7mg TID IV

Omeprazole 2.5mg OD IV

add on 26 IV Fluid 150 ml/kg/day OD IV

Midazolam 60 mcg/kg/h OD IV
lasix 2.4 mg OD IV
add on 26 ventoline 0.2 ml OD IV
 Abnormal
CBC and Differential :
slightly
normal
WBC RBC Platelet
Hb g/dL 10^3/uL
10^3/uL 10^6/uL

13 3.48 10.1 415

Chemistry:
K Na Cl Ca PO4 Mg
glucose mg/dl
mmol/L mmol/L mmol/L mg/dL mg/dL mg/dL

70.8 4.5 139 102 9.3 6 1.8

Vital sign :
TEMP BP HR RR O2 sat.
37 78/40 188 58 99%
ASSESSMENT :
• extend duration of the antibiotic until 14
days .
• Measure Vancomycin Trough ( <40 µg/ml and
<10 µg/ml, respectively )
• seizures were controlled
• increase OGT 45 ml ( to maximum ) on day
31 .
• on day 32 re-add the Midazolam dose in to 60
mcg .
• tachypnea on and off .
• vital signs are stable .
 PATIENT
STILL IN THE
HOSPITAL at
NICU .
INTERVENTIONS
1- INTUBATION PROPHYLAXIS
• 1- THERE IS NO GIT Bleeding after intubation, or Vomiting
or any kind of gastric problems or esophagitis WHY USE
RANITIDINE for 5 days ? < there is no reason !

• 2- If there is suspected to bleeding only give high dose

OMEPRAZOLE , according to study on MARS 2016 , DOSE
ALSO WAS WRONG according TO BNF , 2014 -2015 .

Maurice A Cerulli, MD, Mars 2016 ,

Upper Gastrointestinal Bleeding
Treatment &Management ,
 2- MANAGEMENT OF
SEIZURES

• MIDAZOLAM DOSE NOT WORK , why keep

use it ?

• That is right the Benzodiazepines increase the

activity of GABA, BUT GABA is Immature yet in
the neonate !

• when the GABA is Immature the CL Already inside

the cell and +ve Ions Out ! < NO MORE ENTRY
of CL inside the cell .
SO USE WHAT AS A SOCEND LINE
TREATMENT?
• According to Survey of 55 child neurologists

• Contemporary choice of second, add-on drug if

initial drug fails:

• – Topiramate is “anti-epileptogenic” and

neuroprotective 55% (30/55) among those
recommending TPM, 70% (21/30) perceived
treatment beneficial and 63% (19/30) saw no apparent
ADRs
 SO USE WHAT AS A SOCEND LINE
TREATMENT?
Levetiracetam: the anti-seizure
medication (no hepatic metabolism, limited
drug-drug interactions, low protein binding,
renal
elimination) and iv formulation .
47% (26/55)
treatment beneficial and 92% (24/25) saw no
apparent ADR
 3- ANTIBIOTICS

• According TO BNF to treatment Pseudomonal lung infection:

“Put your heart, mind, and soul into even your
smallest acts.
This is the secret of success.
”
Swami Sivananda
THANK YOU .