Transcript Video Teri Campbell: Neonatal Transport & HIE Teri Campbell: Neonatal Transport & HIE May 19, 2025 Hi friends, thank you so much for coming to this talk. My name is Terry Campbell. I'm a flight nurse at the University of Chicago. I have no specialty teams where I fly, so I take care of all patients from micro preemies that can fit into my hand all the way to adult patients that are on ECMO. And what I find some of the most scary patients that I take care of are the really sick neonates. So today what we're gonna talk about is HIE. Um, hypoxic ischemic encephalopathy. Not only is that a mouthful, that's a lot of Latin, right? So that's scary, but the nice thing about Latin is it's telling us what the words mean. Hypoxia, every nurse knows what that means, right? Not enough oxygen to the blood or to the tissues ischemia, so there's a disruption in blood flow. So. The problem with that is we're not able to get the good things to the brain and the tissue and honestly we can't get rid of the cellular poop encephalopathy, that's a big word, difficult to say, but it just means that the brain is disrupted from its normal function. What's the pathophysiology? So with, with HIE we're going to have a primary. a perinatal insult. What does that mean? It means that something is happening in utero where that is, there's that disruption of blood and oxygen that's gonna be going to the fetal brain. All right, so we have that primary insult where we have the disruption of blood and oxygen. Everybody knows that's a bad thing babies need lots of oxygen and lots of blood going to their brain. Then what happens is that primary insult recovers, so maybe the mom was hypotensive. Maybe there was a kink in the umbilical cord that's going to be resolved. Now the baby's brain has this rush of blood and oxygen, and you know you would think that the brain would be very grateful and be like, thank you so much for this blood and oxygen. But what happens is we get something called a reperfusion injury. I call it ungrateful brain cells, OK? So when we're cooling our patients when we're using targeted temperature management, we're trying to mitigate or prevent the injury from these reperfusion injuries all right, so friends. We're talking about that pathophysiology when there is a disruption of blood and oxygen going to the brain and then that primary insult is over and we have that gush of blood, that gush of oxygen that goes to the brain that's not dissimilar to what we see with adults. So when we have adults that have a cardiac arrest and. Have that disruption of blood and oxygen and then we get Rask on those patients. Our adult patients also suffer from reperfusion injuries. Our babies have to be 36 weeks gestation. There has to have been some perinatal insult or hypoxic event that happened and. There could be other things that are going to be added to that list. So if our babies have an Apgar of less than 5 at 10 minutes, if there is continued resuscitation past 10 minutes of life, and the baby and or the baby needs mechanical ventilation, if there's documentation from our core gasses that our baby is in a metabolic or mixed acidosis. So what does that mean? Your pH is going to be less than 7 and your base deficit is going to be greater than 12 if you have an EEG that demonstrates encephalopathy or more commonly, what is your physical exam? So if we're looking at SARNET scores, which is kind of beyond the scope of this right now, do you have a SARET of 2 or a SARNEt of 3? And then the last thing that isn't automatic is if the baby has seizures. So if the baby has the seizures, that's it, the only criteria that you need and the baby is invited to the pool party. Now what babies are gonna be excluded? Babies that are younger than 36 weeks gestation, babies that we have the inability to cool within 6 hours, or we start cooling, stop cooling, start cooling, stop cooling. So we want to have that continuous cooling, um, babies that have profound congenital anomalies, babies that already are born with a significant coagulopathy, and any baby that is born with significant head trauma. What we know from TTM is that babies that receive cooling dramatically have a higher survival rate and they have dramatically less neurodevelopment disability, so those are all fantastic things for our really compromised babies. So what is happening physiologically in the. Brain during these reperfusion uh injuries we already know that the brain cells are being ungrateful but why? So the consequence of reperfusion injuries is we have cerebral edema we have a release of free radicals that are in the system and that is all leading to something that's called apoptosis. Sounds like a cool name for a band, but what it means is that the brain cells are literally going kui. So those are bad things and we want to prevent that from happening with our really vulnerable babies. So what are the benefits? The benefits is there is a decrease in mortality from 37 to 24%. There is a decrease in cerebral palsy from 30 to 14%. There is a decrease in moderate to severe disability from 62 to 44% and a decrease in blindness from 14 to 7%. If this is your baby, you want all of these. Benefits given to these babies. OK, so how can we cool our babies? There's multiple ways that we can do it. Part of it has to do with the resources of the hospital. So if we have a low resource hospital like a critical access hospital, they can cool babies passively. That means they take off the baby's clothing, they just have a diaper and they turn off the radiant warmer. Some of the consequences that are a little bit harder to control with past. Of cooling is we can overcool our babies, so it's gonna be very important that we're monitoring that temperature centrally if possible either with a rectal temperature or esophageal probe every 15 to 30 minutes or whatever your hospital's protocols are. Other ways that we can cool babies that we have more control over. There are cooling blankets that the baby will lie on. There are cool caps that we. Can put on our baby and there's also servo control products using gel. So what are some of the physical consequences that we're gonna see with our babies when we're cooling them? So as our baby is cooling, there's gonna be a decrease in their heart rate. So you're, you're gonna see that slowing of the heart rate and then conversely, after we've cooled the baby for 72 hours and we're going to increase that temperature, you're gonna see an increase in the baby's heart rate. During cooling, there's also going to be a decrease in urinary output that's going to be related to renal perfusion and renal flow and as a result of that you may also see some electrolyte changes so it's going to be important that you're going to be monitoring those as well. The other thing that we're gonna see is once we start warming that baby after our 72 hours of cooling, you may see a decrease in blood pressure. OK, why has to do with venal dilation. So as those blood vessels are dilating, you're gonna see a decrease in your blood pressure. So what does that mean for us as nurses? What do we need to measure while our babies are being cooled and warmed the heart rate, respiratory rate, your oxygen saturations and ideally you're gonna be doing um serial blood gasses and also assessing the blood glucose. We know that anytime we have any medical interventions there's always a risk for adverse effects. The good thing, the great thing about cooling is the benefits are tremendously higher than the associated risk, but what are some of them? There is a risk that our babies will have hypovolemia. They'll have hypernatremia, decreased renal impairment, decrease hepatic flow. And there can be seizures during the rewarming. There's also risks of ventricle dysrhythmias and bradycardia. So what are our goals for cooling? We want to cool our baby to 33 to 34 degrees, and we're gonna maintain that for 72 hours. There have been some great random control studies. They looked at if we cool them faster, do we have better outcomes, or if we cool them for longer, do we have better outcomes? We found. That this is our sweet spot is cooling them to 33 to 34 degrees for 72 hours and then they're going to gradually rewarm our babies. Thank you so much for joining this talk. I really appreciate it and although I've talked about national and international standards for cooling babies, it's really important that you're following the protocols of your own institution and that you're involving your families in a shared decision model. Thank you so much. Created by
