Download Moderate Hypothermia in Neonatal Encephalopathy: Safety Outcomes

Moderate Hypothermia in Neonatal
Encephalopathy: Safety Outcomes
Dorothea J. Eicher, MD*, Carol L. Wagner, MD*, Lakshmi P. Katikaneni, MD*,
Thomas C. Hulsey, ScD*, W. Thomas Bass, MD†, David A. Kaufman, MD‡,
Michael J. Horgan, MD§, Sheila Languani, MD储, Jatinder J. Bhatia, MD¶,
Lawrence M. Givelichian, MD#, Koravangatta Sankaran, MD#, and Jerome Y. Yager, MD#
Hypoxic-ischemic injury may cause multisystem organ
damage with significant aberrations in clotting, renal,
and cardiac functions. Systemic hypothermia may
aggravate these medical conditions, such as bradycardia and increased clotting times, and very little
safety data in neonatal hypoxic-ischemic injury is
available. This study reports a multicenter, randomized, controlled pilot trial of moderate systemic hypothermia (33°C) vs normothermia (37°C) for 48 hours in
infants with neonatal encephalopathy instituted within
6 hours of birth or hypoxic-ischemic event. The best
outcome measures of safety were determined, comparing rates of adverse events between normothermia
and hypothermia groups. A total of 32 hypothermia
and 33 normothermia neonates were enrolled in
seven centers. Adverse events and serious adverse
effects were collected by the study team during the
hospital admission, monitored by an independent
study monitor, and reported to Institutional Review
Boards and the Data and Safety Monitoring Committee. The following adverse events were observed
significantly more commonly in the hypothermia
group: more frequent bradycardia and lower heart
rates during the period of hypothermia, longer dependence on pressors, higher prothrombin times,
and lower platelet counts with more patients requiring plasma and platelet transfusions. Seizures as an
adverse event were more common in the hypothermia group. These observed side effects of 48 hours of
moderate systemic hypothermia were of mild to moderate severity and manageable with minor interventions.
© 2005 by Elsevier Inc. All rights reserved.
From the *Department of Pediatrics, Medical University of South
Carolina, Charleston, South Carolina; †Department of Pediatrics
Eastern Virginia Medical School, Norfolk, Virginia; ‡Department of
Pediatrics, University of Virginia, Charlottesville, Virginia;
§
Department of Pediatrics, Albany Medical Center, Albany, New
York; 储Department of Pediatrics, SUNY, Brooklyn, New York;
¶
Department of Pediatrics, Medical College of Georgia, Augusta,
Georgia; and #Department of Pediatrics, University of Saskatchewan,
Saskatoon, Saskatchewan, Canada.
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PEDIATRIC NEUROLOGY
Vol. 32 No. 1
Eicher DJ, Wagner CL, Katikaneni LP, Hulsey TC, Bass
WT, Kaufman DA, Horgan MJ, Languani S, Bhatia JJ,
Givelichian LM, Sankaran K, Yager JY. Moderate hypothermia in neonatal encephalopathy: Safety outcomes. Pediatr
Neurol 2005;32:18-24.
Introduction
In the translation of hypothermia as a neuroprotective
strategy from the well-established animal models to human neonates with neonatal encephalopathy, clinical trials
must begin to establish the safety of the therapy. Although
animal models have consistently demonstrated efficacy,
they do not readily allow investigation of the side effects
that may be observed in human neonates who are making
a transition from intra- to extrauterine life. With the
inherent difficulty of studying a perinatal asphyxia model,
only a few studies have investigated the safety of hypothermia in the unique setting of infant animals within 24
hours after birth [1,2]. Investigations in infant piglets with
hypoxic-ischemic injury and case reports of hypothermia
for human cardiac arrhythmias have suggested an increase
in systemic, as well as pulmonary vascular resistance,
decreased heart rate resulting in decreased cardiac output,
electrolyte abnormalities, and increased risk of sepsis with
hypothermia [3-6].
From clinical experience with hypothermic cardiopulmonary bypass for cardiac and neurosurgery and small
pilot trials of hypothermia in neonates, we anticipated
coagulopathy and bradycardia as the primary side effects
of systemic hypothermia in neonatal encephalopathy
Communications should be addressed to:
Dr. Eicher; PO Box 250917; Department of Pediatrics; Medical
University of South Carolina; 165 Ashley Ave.; Charleston, SC 29425.
Received December 2, 2003; accepted June 15, 2004.
© 2005 by Elsevier Inc. All rights reserved.
doi:10.1016/j.pediatrneurol.2004.06.015 ● 0887-8994/05/$—see front matter
[7-11]. However, these side effects may also occur in
normothermic hypoxic-ischemic infants as a result of
multiorgan system damage alone. The present randomized, controlled pilot trial was conducted to describe in
detail the adverse effects of hypothermia, compare these
rates among treatment groups, and obtain rates of adverse
outcomes for a power and risk benefit analysis for a
larger-scale clinical trial.
Methods
Infants qualified for the study if they were ⱖ35 weeks gestation,
ⱖ2000 gm birth weight, were ⱕ6 hours after birth or hypoxic-ischemic
insult. Entry criteria required one clinical indication of hypoxic-ischemic
injury (cord gas pH ⱕ 7.0 or base deficit ⱖ13, initial infant gas pH ⬍ 7.1,
Apgar score ⱕ5 at 10 minutes, continued resuscitation after 5 minutes,
fetal bradycardia with heart rate ⬍ 80 beats per minute lasting ⱖ15
minutes, or postnatal hypoxic-ischemic event with oxygen desaturation
⬍70% or arterial oxygen pressure ⬍35 for 20 minutes with evidence of
ischemia [chest compressions, hypotension, hemorrhage]) and two neurologic findings of neonatal encephalopathy (abnormalities of tone,
reflexes, state of consciousness, seizures, posturing, autonomic dysfunction). Maternal chorioamnionitis, sepsis at birth, birth weight or head
circumference ⬍10%, or presumed chromosomal abnormality were
exclusion criteria.
Randomization procedures are detailed in the accompanying article on
efficacy outcomes. Briefly, infants were screened for eligibility if they
had resuscitation, acidosis or low Apgar scores at birth, or an abnormal
neurologic examination at 1 hour of age, and were born in or referred to
a participating tertiary care center within 6 hours of birth or hypoxicischemic event. The parents of neonates who met entry criteria consented
before randomization by web-based program to either normothermia or
hypothermia treatment. Treatment was instituted initially in a participating institution’s delivery room or by their transport team at an outlying
hospital. If randomized to hypothermia, ice was applied to the head and
body for approximately 2 hours, then rectal temperature of 33 ⫾ 0.5 °C
was maintained on a servo-controlled cooling blanket for 48 hours
(Cincinnati Sub-Zero Blanketrol II, Cincinnati, Ohio). All patients had
rectal temperature probes, indwelling central lines, pulse oximetry and
cardiorespiratory monitoring, and urinary catheters. Rewarming by 0.5°C
was begun after 48 hours of hypothermia, if euvolemia and normocalcemia were present [12]. Morphine was used for analgesia at the
attending physician’s discretion, or fentanyl if cardiovascular compromise was significant. Seizures were treated with phenobarbital, and
lorazepam or phenytoin if required.
Primary outcome variables of safety were anticipated to be bradycardia
and disseminated intravascular coagulopathy, and a tendency toward
increased sepsis in the hypothermia vs normothermia groups.
Adverse outcome variables were initially identified as disseminated
intravascular coagulopathy, cardiac arrhythmias, persistent metabolic
acidosis, sepsis/pneumonia within the first 7 days of life, hypokalemia,
necrotizing enterocolitis, skin injury, extension of intracranial hemorrhage, persistent pulmonary hypertension, and the need for extracorporeal membrane oxygenation.
Laboratory Studies
The following laboratories were obtained at times specified by the
protocol: Arterial blood gasses were monitored every 6 hours for 72
hours. Electrolytes, complete blood counts, and platelet counts were
monitored every 12 hours for 72 hours. Coagulation studies were
monitored every 12 hours until normal ⫻ 2 without blood product
replacement. Liver function studies and cardiac enzymes were measured
on enrollment and at 48 hours. Head ultrasounds and echocardiograms
were obtained after enrollment and at 48-72 hours. Neonates were
anticipated to be too unstable for transport out of the unit for other
imaging studies. Electroencephalograms were obtained at 72-96 hours.
Management of Abnormal Laboratory Values
The management protocol for this pilot trial stipulated that pressors or
volume be used to maintain mean blood pressure greater than 35 mm Hg,
and blood products be used to maintain platelet counts greater than
50,000 cells/cc, prothrombin time ⬍17 seconds, and fibrinogen ⬎100
mg/dL. Sodium was to be maintained greater than 120 mEq/L, and
potassium ⬎3.0 mEq/L. Sodium bicarbonate was administered or ventilation adjusted to maintain pH ⬎ 7.25 and arterial carbon dioxide
pressure ⬎30 mm Hg.
Exit Criteria
Patients were withdrawn from treatment if they had a clinical diagnosis
of sepsis or meningitis (positive blood or cerebrospinal fluid culture), or
pneumonia (by chest radiograph and clinical diagnosis) in the first 36
hours of life, uncontrolled disseminated intravascular coagulopathy, or
sustained bradycardia ⬍70 beats per minute with hypotension and
acidosis on inotropic medications, which did not respond to rewarming to
34°C.
Data Collection
Data from vital signs, neurologic examinations, medications, blood
products and volume expanders, urine output, and laboratory and
radiographic studies were collected over the first 5 days after enrollment
for the database. Days after enrollment were not counted as calendar
days, but counted as 0-23 hours after enrollment for day 1, 24-47 hours
for day 2, 48-71 hours for day 3, and so forth. For example, in the
hypothermia group, after 48 hours of systemic hypothermia, rewarming
occurs at the beginning of day 3. Correct database entry was independently verified.
Canadian values for laboratory studies were converted from mol/L and
kPa units to g/L or Eq/L and mm Hg, respectively. Canadian prothrombin
values were not able to be converted, owing to different methodology,
and those patients were omitted from calculations involving prothrombin
times. Extracorporeal membrane oxygenation patients (four normothermia patients) were omitted from all analyses of thrombocytopenia,
disseminated intravascular coagulopathy, and replacement blood
products.
Dopamine and dobutamine are expressed in total amounts milligrams
per kilogram of birth weight given. This measurement does not translate
strictly into standard clinical expressions of micrograms/kg/minute.
However, pressors are frequently titrated minute by minute, making data
collection for these variables difficult. Therefore data on total amount of
pressors were collected every 24 hours, which gives an accurate view of
not just the lowest or highest concentrations of pressors required in a day,
but the extent of cardiac support required.
Monitoring for Adverse Events
Abnormal laboratory/radiographic tests obtained any time during
hospitalization were evaluated for clinical significance using predetermined abnormal values for expected adverse events. Adverse events are
defined as conditions present any time during the hospitalization, but not
present at baseline (enrollment), or a baseline condition that initially
resolved and later recurred. Serious adverse events are defined as adverse
events that prolonged hospitalization, were life-threatening, or required
significant intervention. The designation of adverse event does not imply
causation, and the possibility of a serious adverse event being related to
the treatment is determined by the principal investigator at each site,
according to Institutional Review Board regulations. All adverse events
Eicher et al: Systemic Hypothermia in Neonatal Encephalopathy 19
Table 1.
Clinical status at enrollment
Gestation
Birth weight
Chest compressions
Mean cord pH
Mean cord base deficit
Median Apgar @ 5 min
Median Apgar @ 10 min
Sarnat stage III
Sarnat stage II
Sarnat stage I
Normal examination (withdrawn)
Sarnat data incomplete
Hypothermia
(n ⴝ 32)
Normothermia
(n ⴝ 33)
Total
38.8 ⫾ 1.9 wk
3241 ⫾ 775 gm
21
6.95 ⫾ 0.19
⫺18 ⫾ 8.3
2
4
25
5
1
1
0
39.1 ⫾ 1.4 wk
3550 ⫾ 819 gm
20
6.96 ⫾ 0.23
⫺16 ⫾ 7.5
2
3
25
5
1
0
2
P ⫽ 0.5
P ⫽ 0.1
41 (66%)
P ⫽ 0.9
P ⫽ 0.6
P ⫽ 0.6
P ⫽ 0.9
50 (77%)
10 (15%)
2 (3%)
1 (2%)
2 (3%)
and serious adverse effects during the hospital admission were collected
by the study team and recorded in the case report form. The independent
monitor performed 100% monitoring of data points in the case report
form during site visits for the first 34 patients in the study and for the first
3 to 4 patients at each site. Thereafter, only entry criteria, laboratory
values, medications, blood product replacement, adverse events, and
serious adverse effects were monitored. After the initial hospitalization,
adverse event data collection was limited to the serious adverse event of
death. All adverse effects and serious adverse effects were monitored at
the halfway point and annually during the study by a National Institutes
of Health Data and Safety Monitoring Committee. Serious adverse
effects were also reported to the lead institution’s and the local Institutional Review Boards.
Statistical Comparisons of Adverse Effects
We used chi-square or Fisher exact tests for categorical variables, the
pooled t test for continuous variables that were normally distributed, and
Satterthwaite t test for continuous variables when unequally distributed.
Laboratory values are reported as means if normally distributed, specifically looking at mean highest or mean lowest values to analyze
hypothermia’s potential adverse effects. Where not normally distributed,
such as Apgar scores, medians were used with Kruskal-Wallis test for
significance. Where abnormal laboratory or vital sign values would have
been corrected by a therapeutic action, such as giving pressors to
maintain a mean blood pressure, further detail was developed through
subanalyses. These extensive subanalyses help evaluate if there are real
differences between groups not readily determined by looking at simple
mean values.
Results
Demographics
Seven participating sites enrolled 65 infants, 32 randomized to hypothermia, 33 to normothermia. Three
hypothermia infants were withdrawn after randomization
but before completion of hypothermia treatment because
of parental request [2] and normal neurologic examination
[1], and the latter does not have data available for safety
analysis. Two normothermia patients were withdrawn
between 24-36 hours of age as a result of sepsis at birth, an
exclusion criterion, and are not included in this safety
analysis, because they may have metabolic derangements
confounded by their underlying disease. There were no
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significant differences in gestation, birth weight, sex, race,
numbers of inborn vs outborn, or condition on enrollment
(chest compressions, cord pH, cord base deficit, Apgar
scores, or Sarnat stage) between the hypothermia and
normothermia groups (Table 1). (Further details of clinical
characteristics of the cohort are presented in the accompanying article on efficacy outcomes.)
Table 2 lists observed frequencies of adverse events by
organ system, with statistical comparison of these adverse
events between treatment groups whenever possible. Adverse events listed in Table 2 are defined as conditions
present any time in the first 5 days but not present at
baseline (enrollment), or as baseline conditions that initially resolved and later recurred. There were no significant differences in baseline medical conditions on enrollment for any side effect. Also included in Tables 3-5 are
analyses of data broken by day to give an indication of
events that occurred during hypothermia treatment and
those that persisted after rewarming.
Electrolyte and Renal Dysfunction
There were no differences in metabolic derangements
between groups, except in metabolic acidosis (pH ⬍ 7.25)
after enrollment which was worse in the normothermic
group. Renal dysfunction was equally common in both
groups, with the exception of hematuria, which was
significantly more common in the hypothermia group.
Cardiac Adverse Events
Bradycardia (heart rate ⬍80 beats per minute) was significantly more common in the hypothermia group, and the
mean lowest heart rate was significantly lower throughout the
period of hypothermia (days 1-3). After rewarming (days
4-5), neither the mean lowest heart rate nor bradycardia were
different between groups (data not shown).
Hypothermia may have deleterious effects on other aspects
of cardiac function. Significantly lower mean blood pressures
were observed on day 3 in the hypothermia group (mean 37
Table 2.
Adverse effects
Electrolyte disturbances
Hypokalemia ⬍ 3.0 mEq/dL
Hyponatremia ⬍ 130 mEq/dL
Metabolic acidosis (pH ⬍ 7.25)
Mean total bicarbonate infusion mEq/kg over 5 days
Renal function
Oliguria (urine output ⬍ 1 cc/kg/hr)
Hematuria
Renal failure (creatinine ⬎ 1.7 mg/dL)
Thrombocytopenia (excluding ECMO patients)
Platelets ⬍ 150,000
Lowest platelet count over 5 days, mean
Total volume platelets transfused over 5 days, mean cc/kg
Number of patients who required any platelets
Coagulopathy (excluding ECMO patients)
DIC (defined as PT ⬎ 17, or Fibrinogen ⬍ 100)
Highest PT over 5 days, median, in seconds
Lowest fibrinogen over 5 days, mean, mg/dL
Volume plasma; mean total over 5 days, cc/kg
Number of patients who required any plasma
Cardiac function
Bradycardia, heart rate ⬍ 80 beats/min
Mean lowest heart rate, beats/min
Total days on pressors, median (excluding ECMO)
Myocardial ischemia
Mean CK MB at 48 hr (IU/L)
Mean troponin I at 48 hr, ng/mL
Hematologic indices
Neutropenia
Anemia
Infections
Pneumonia
Sepsis after 48 hr
Urinary tract infection
Persistent pulmonary hypertension (PPHN)
PPHN
PPHN requiring nitric oxide
PPHN requiring ECMO
Other significant adverse events
Stridor
Tremors
Seizures
Mean time of late seizure onset
Hypothermia
(n ⴝ 31)
Normothermia
(n ⴝ 31)
P Value
9
15
1
8.2 ⫾ 8.2
9
17
8
7.9 ⫾ 5.5
1.0
0.7
0.03*
0.9
27
21
2
28
13
3
1.0
0.04*
1.0
20
105 ⫾ 60
55 ⫾ 28
11
12
160 ⫾ 65
50 ⫾ 15
4
0.095
0.002*
0.7
0.078
19
20.6
138 ⫾ 79
40 ⫾ 45
23
18
17.7
180 ⫾ 98
31 ⫾ 26
11
0.34
0.14
0.1
0.5
0.007*
11
89 ⫾ 23
5
16
100 ⫾ 131
3.0 ⫾ 3.5
2
110 ⫾ 31
2
15
77 ⫾ 62
3.7 ⫾ 11.6
0.005*
0.003*
0.02*
0.7
0.008*
0.8
2
14
0
8
0.093
1
1
2
2
0
3
1.0
9
5
0
5
1
1
0.2
0.01*
9
8
7
34.1 hr
1
1
1
4.5 hr
0.01*
0.03*
0.05*
1.0
Abbreviations
CK MB ⫽ Myocardial-brain fraction of creatine kinase
DIC
⫽ Disseminated intravascular coagulopathy
ECMO ⫽ Extracorporeal membrane oxygenation
PPHN ⫽ Persistent pulmonary hypertension of the newborn
PT
⫽ Prothrombin time
* Statistically significant P values are indicated in bold.
⫾ 9 mm Hg) compared with the normothermia group (44 ⫾
10 mm Hg, P ⫽ 0.006). Cardiac echocardiograms obtained
between 0-24 hours and repeated 48-72 hours after enrollment indicated worsening right ventricular function in two
hypothermia patients. There were no cases of worsening in
left ventricular function in either group. However, greater and
longer cardiac inotropic support was required in the hypothermia group compared with the normothermia group (Tables 2 and 3).
Coagulopathy and Thrombocytopenia
Coagulopathy and thrombocytopenia may contribute to
an increased clinical risk of bleeding. Both were more
prevalent in the hypothermia group by laboratory indices,
analyzed both with and without the patients on extracorporeal membrane oxygenation. More hypothermia patients
required plasma and platelet transfusions than normothermia patients (Table 2).
Eicher et al: Systemic Hypothermia in Neonatal Encephalopathy 21
Table 3.
Number of patients on pressors (excluding ECMO patients)
Dobutamine
Hypothermia
Normothermia
Dopamine
Hypothermia
Normothermia
Day 1
Day 2
Day 3
Day 4
Day 5
9
5
P ⫽ 0.4
10
2
P ⴝ 0.02*
12
2
P ⴝ 0.006*
9
1
P ⴝ 0.01*
6
1
P ⫽ 0.1
17
12
P ⫽ 0.36
16
11
P ⫽ 0.34
16
8
P ⫽ 0.07
15
7
P ⫽ 0.06
13
6
P ⫽ 0.09
Abbreviations
ECMO ⫽ Extracorporeal membrane oxygenation
* Statistically significant P values are indicated in bold.
There were usually two complete blood counts and
clotting studies obtained each day on each patient, and
taking the highest prothrombin time value and lowest
platelet value per day yielded a truer picture of increased
laboratory indices of coagulopathy in the hypothermia
group compared with the normothermia group. Mean
lowest platelet counts were significantly lower in the
hypothermia group for every day of data collection (Table
4). The median highest prothrombin time values were
significantly higher in the hypothermia group on day 4
(Table 5).
However, clinical manifestations of coagulopathy were
uncommon. Central nervous system bleeds or infarcts
were detected on the first head ultrasound in three hypothermia patients (old choroid plexus cyst/hemorrhage,
cortical and spinal infarcts with maternal cocaine use,
large thalamic and cerebellar hemorrhages with maternal
blood pressure of 245/158 before delivery) and two
normothermia patients (subdural hemorrhage, spinal cord
infarcts). These were likely related to antenatal or intrapartum conditions, but hypothermia had been initiated for
3-12 hours before the first ultrasound. Two bleeds were
detected on the second ultrasound at 48 hours after
enrollment. One hypothermia patient had a rebleed of an
old central nervous system hemorrhage sometime in the
first 4 days of life, and one normothermia patient had a
small new bleed in the corona radiata. One patient in each
group had evidence of pulmonary hemorrhage, with a
hemorrhage in the one normothermia patient on extracorporeal membrane oxygenation perhaps precipitated by
Table 4.
circuit clotting and circuit change (the patient died). All
were reported as serious adverse events.
Hematologic Indices and Infections
Hematologic indices were monitored as markers for
infection. Two cases of neutropenia as an adverse event
occurred in the hypothermia group, and one case of sepsis
after 7 days in the hypothermia group (Table 2). However,
the pilot trial numbers were too small to detect differences
in such rare events as sepsis, pneumonia, or necrotizing
enterocolitis.
Pulmonary Hypertension
Pulmonary vascular resistance has been demonstrated to
be increased with hypothermia, but may also be present
under normothermic conditions after hypoxic-ischemia.
Therefore evaluation of both numbers and severity of this
adverse event is necessary. Although pulmonary vascular
resistance can not be measured directly in neonates, nitric
oxide treatment and extracorporeal membrane oxygenation are surrogate measures of the severity of pulmonary
hypertension. Significantly more hypothermia patients
required nitric oxide than normothermia patients, but only
one normothermic patient required extracorporeal membrane oxygenation as an adverse event (Table 2). The
decision to go on bypass was made after randomization in
that normothermic patient, and before randomization in
three other normothermic patients.
Mean lowest daily platelet count (excluding ECMO patients)
Hypothermia
Normothermia
Day 1
Day 2
Day 3
Day 4
154 ⫾ 58
202 ⫾ 79
P ⫽ 0.013*
120 ⫾ 56
182 ⫾ 76
P ⴝ 0.001*
111 ⫾ 65
172 ⫾ 80
P ⴝ 0.004*
117 ⫾ 58
200 ⫾ 81
P ⴝ 0.0005*
Abbreviations
ECMO ⫽ Extracorporeal membrane oxygenation
* Statistically significant P values are indicated in bold.
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Table 5.
Median highest prothrombin time (excluding ECMO patients)
Hypothermia
Normothermia
Day 1
Day 2
Day 3
Day 4
18.9
17.7
P ⫽ 0.5
15.5
13.9
P ⫽ 0.1
16.9
14.3
P ⫽ 0.07
15.6
12.7
P ⴝ 0.02*
Abbreviations
ECMO ⫽ Extracorporeal membrane oxygenation
* Statistically significant P values are indicated in bold.
Other Significant Adverse Events
Seizures were significantly more common in the hypothermia group as an adverse event than in the normothermia group (Table 2). For this variable, all infants who had
not seized before or during enrollment were considered to
have the adverse event of seizures, which were largely
clinically identified, as continuous electroencephalographic recording was not routinely performed. There was
also a trend toward more abnormal electroencephalograms
at 72 hours in the hypothermia group (24/26 or 92% in the
hypothermia group, 18/23 or 78% in the normothermia
group, P ⫽ 0.23).
Stridor was more common in the hypothermia group,
perhaps related to ventilator temperature of humidified air,
which was reduced in this pilot trial from normal 36°C to
34°C. This condition may have increased the transient
tracheal swelling after extubation, but stridor was quickly
dispelled with inhalation of racemic epinephrine (routine
treatment), and no infant required reintubation because of
stridor.
Serious Adverse Events
Serious adverse events of death was also an outcome
variable. The overall study death rate was 37% (24/65),
with only one death occurring after hospital discharge.
Using intent-to-treat analyses, 10 of 32 (31%) hypothermia infants expired, vs 14 of 33 (42%) normothermia
infants, P ⫽ 0.35.
Other than death, there were five serious adverse events
reported for the entire study that prolonged hospitalization,
were life-threatening, or required significant intervention
in the judgment of the center’s principal investigator.
Among normothermia patients, one infant had subglottic stenosis after extubation causing stridor and requiring a
tracheostomy, which prolonged hospitalization. One patient had gastric bleeding after gastric tube placement for
inability to feed by mouth, and required a transfusion. One
patient with Escherichia coli sepsis was on extracorporeal
membrane oxygenation when the circuit clotted, and the
infant had a pulmonary hemorrhage.
Among hypothermia patients, one patient had been on
dobutamine and norepinephrine for cardiac compromise at
the time of enrollment, and subsequently had an acute drop
in mean blood pressure to 11 mm Hg, responding to
dopamine and a fluid bolus. One patient had an old
choroid plexus hemorrhage documented on first head
ultrasound. A subsequent head ultrasound revealed a
rebleed into this same site, sometime in the first week; this
was judged to be possibly related to hypothermia treatment. (This patient is included in Table 1 as extension of
old bleed.)
Temperature Stability as a Safety Measure
Hypothermia patients had greater variability in temperature than normothermia patients, as detailed in the accompanying article on efficacy outcomes. The mean
difference in high-low daily rectal temperatures from 24 to
48 hours after enrollment was 1.6 ⫾ 0.6 °C in the
hypothermia group vs 1.0 ⫾ 0.5 °C in the normothermia
group (P ⬍ 0.001). Temperature variation was well
tolerated in the hypothermia group, and no known adverse
events were temporally related to lower temperatures.
Hyperthermia, defined as temperature ⱖ39°C, was present
in seven hypothermia patients and five normothermia
patients. Hyperthermia occurred in two patients in each
treatment group during the first 72 hours (includes treatment and rewarming period), and in five hypothermia
patients and three normothermia patients after 72 hours.
Patients who were ⬎38.5°C at any time were treated with
acetaminophen [4], skin probe change, bed adjustment or
unswaddling [7], and hypothermia blanket [1] to maintain
normal temperature range.
Discussion
Although there is clinical experience with deep hypothermia for short periods during cardiopulmonary bypass
in neonates and children, there is little clinical experience
with more prolonged periods of moderate hypothermia in
human neonates. In an attempt to move this potential
neuroprotective therapy rapidly to the clinical arena, small
pilot trials were performed using either systemic or selective head cooling. Pilot trials with small numbers of
patients will only reveal common, serious safety concerns
and cannot address differences in these safety outcomes by
treatment group. Even our larger pilot trial does not have
Eicher et al: Systemic Hypothermia in Neonatal Encephalopathy 23
the power to detect infrequent adverse events or to
evaluate all adverse events for statistical significance.
To help identify areas of possible increased risk with
hypothermia treatment, our adverse event data were analyzed from several perspectives to provide information on
the incidence and severity of these adverse events. We
then looked at potential antecedents or markers for adverse
events, such as absolute neutrophil count for sepsis,
pressor dependence for cardiac compromise, and requirements for blood products in both treatment and control
groups. This detailed analysis of observed side effects
allows one to draw some conclusions about the safety of
48 hours of moderate hypothermia.
Induced hypothermia in the setting of neonatal hypoxicischemic injury carries an increased risk for bradycardia
and mild cardiac compromise, with a longer dependence
on pressors that continued after the period of rewarming.
Systemic hypothermia was associated with an increase in
abnormal clotting studies with higher prothrombin times
and lower platelet counts for several days after rewarming,
the clinical significance of which appears to be limited to
greater numbers of patients receiving replacement blood
products. In addition, although temperature regulation for
the hypothermia group manifested larger variation than the
normothermia group, and most of the hypothermia group
had temperatures lower than the predefined target range at
some point in treatment, no bleeding, bradycardia, or other
adverse event could be attributed to these temperature
variations in the pilot data.
Clinical seizures were unexpectedly more common and
much later in onset in the hypothermia group compared
with the normothermia group, as were electroencephalographic abnormalities at 72 hours after insult. The exact
timing of hypoxic-ischemic injury is frequently unknown
in neonatal encephalopathy, making data on the timing of
seizures difficult to evaluate in pilot trials owing to small
patient numbers. Although a delay of seizure activity
might be an expected outcome of hypothermia, these data
need to be further evaluated in the design of a larger trial,
which should consider including continuous electroencephalographic recordings to obtain electrical correlation
for clinical seizures.
Not all statistically significant adverse events observed
with moderate hypothermia are clinically significant. The
laboratory values for coagulopathy are good examples
where there are statistical differences that may not infer
clinical risk, once values are within the normal range.
However, in some cases in the present study, abnormalities persisted up to days 4 and 5, after which point
detailed, day-specific data for these indices were not
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Vol. 32 No. 1
collected. Longer periods of monitoring some of these
indices and particular attention to increased severity instead of simple incidence, would be helpful to assess the
safety and continued adverse effects of hypothermia.
Detection of clinical side effects with hypothermia that
extend beyond the treatment period in this pilot trial
should augment management of these adverse effects in a
larger trial. In general, these observed side effects of 48
hours of moderate systemic hypothermia of 33°C were of
mild to moderate severity and manageable with minor
interventions. Continued reporting on the adverse effects
of hypothermia in future trials will continue to deepen our
understanding of the effects of this promising therapy.
This trial was funded by the National Institutes of Neurologic Disorders
and Stroke, R01 NS38602.
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