Text Book Reading

Hipoxic Ischaemic Encephalopaty

PRESENTAN:
DANIEL E. R.

MALAU

LECTURER:
PROF. DR. M. I. WIDIASTUTI, PAK, SP.S(K), M.SC

Definitions

Hypoxia or Anoxia: A partial (hypoxia) or complete

(anoxia) lack of oxygen in the brain or blood

Asphyxia: The state in which placental or pulmonary

gas exchange is compromised or ceases altogether

Ischemia: The reduction or cessation of bloodflow to

an organ which compromises both oxygen and
substrate delivery to the tissue

Hypoxic-Ischemic Encephalopathy: Abnormal

neurologic behavior in the neonatal period arising as
a result of a hypoxic-ischemic event.

Incidence of HIE

Occurs in 2-9 per 1000 live term births in developed

countries

WHO : 0.5 1 per 1000 live term birth

Surabya (dr Soetomo Hospital ) : 12.25 % fro,m 3405

live term birth

Etiology of HIE

Maternal:

Fetal:

HYPERTENSION

Anemia

Vascular Diseases

Infectio

Diabetes

Uterine Ruptur

Severe isoimmune hemolytic

disease

Cardiac arrhythmia

Uteroplacental:

Placental abruption

Cord prolapse

Uterine rupture

Patophysiology Hipoxic Ischemic Encephalopaty

PATHOPHYSIOLOGY
Potential pathways for brain injury after hypoxia-ischemia.

Perlman J M Pediatrics 2006;117:S28-S33

2006 by American Academy of Pediatrics

Clinical Staging of HIE (Sarnat and

Sarnat, 1976)

Diagnosis

There is no clear diagnostic test for HIE

Abnormal findings on the neurologic exam in the first few days
after birth is the single most useful predictor that brain insult
has occurred in the perinatal period

Essential Criteria for Diagnosis of HIE:

Metabolic acidosis (cord pH <7 or base deficit of >12)

APGAR SCORE 0-3 un first 5 minutes

Early onset of encephalopathy

Multisystem organ dysfunction

Assessment Tools in HIE

Amplitude-integrated EEG (aEEG)

When performed early, it may reflect dysfunction rather
than permanent injury
Most useful in infants who have moderate to severe
encephalopathy

Marginally abnormal or normal aEEG is very reassuring of

good outcome

Severely abnormal aEEG in infants with moderate HIE

raises the probability of death or severe disability from
25% to 75%

Assessment Tools in HIE

Evoked

Potentials

Brainstem

auditory evoked potentials,

visual evoked potentials and
somatosensory evoked potentials can be
used in full-term infants with HIE

More

sensitive and specific than aEEG

alone
However,

not as available as aEEG and

there is a lack of experience among
pediatric neurologists
Therefore

aEEG is preferred because of easy

access, application, and interpretation

Assessment Tools in HIE

Neuroimaging
Cranial

ultrasound: Not the best in assessing

abnormalities in term infants. Echogenicity
develops gradually over days
CT: Less sensitive than MRI for detecting
changes in the central gray nuclei
MRI: Most appropriate technique and is able
to show different patterns of injury. Presence
of signal abnormality in the internal capsule
later in the first week has a very high
predictive value for neurodevelopmental
outcome

Differential Diagnosis

3.

1.

Analgesia during delivery

2.

Viral, Sepsis, Meningitis

Kongenital Anomaly in central nervous system, heart and lung

4.

Neuromuscular diseases

5.

Trauma during delivery

THERAPY
1.

Adequate Ventilation

2.

Adequate Oxygenation,

3.

Temperature Controlled : Head Cooling and Whole Body Cooling

4.

Acidosis Metabolic Correction

5.

Blood Glucose Controlled ( between 75-100 mg/dl)

6.

Prevent Seizures

Management - Hypothermia

Has become standard of care

Whole-body and head-cooling available

Unclear if

one regimen is superior to the other -

currently either one is utilized, based on availability

Aim to get core (rectal) temperature to 33-35 C for 72 hours

Hypothermia - Mechanism of
Action

Reduces cerebral metabolism, prevents edema

Decreases energy utilization

Reduces/suppresses cytotoxic amino acid

accumulation and nitric oxide

Inhibits platelet-activating factor, inflammatory

cascade

Suppresses free radical activity

Attenuates secondary neuronal damage

Inhibits cell death

Reduces extent of brain damage

DEATH OR SEVERE DISABILITY AT 18 MONTHS OF

AGE SIGNIFICANTLY REDUCED!!

Criteria for Hypothermia

Hypothermia is not effective for every baby

Currently only used in infants > 35 weeks

Time interval between birth and initiation of

treatment important

Treatment must be started within 6 hours of

birth to be effective

HYPOTHERMIA
1.
2.

HEAD COOLING

WHOLE BODY COOLING

HEAD COOLING

WHOLE BODY COOLING

Pharmacologic Management

Allopurinol
Some

trials have shown a decrease in

mortality and a beneficial effect on free
radical formation, cerebral blood flow and
electrical brain activity

Meta-analysis

concluded that more trials

need to be done using allopurinol as an
adjunct to hypothermia to make a
conclusion on its effectiveness in treating
HIE

Pharmacologic Management

Opioids
A few

studies have demonstrated that morphine and

fentanyl may have a neuroprotective effect after HIE
with less severe signs of brain damage on MRI at 7 days
of life and better neurologic outcomes at 13 months of
age

However, long

term effects of these medications are not

known and more prospective randomized trials are
warranted.

Prognosis
It is variated , from mild to severe :
1.

Severa asphyxia

2.

Seizures that cant controlled for 12 hours or more

3.

Multi Organ Failure

4.

Neurological problem that persisten

5.

Persisten Oliguria

Microcephaly

Severe Abnormality in EEG

Ct Scan Severe Haemmorhage, periventrikel leukomalasi (PVL)

atau nekrosis.

MRI 24-72 hours after birth.

THANK YOU