From the Guidelines
Management of hypoxic-ischemic encephalopathy in adults should prioritize a multidimensional prognosis assessment, including cerebral imaging, electroencephalogram (EEG), and laboratory determination of neuron-specific enolase, to guide therapy limitation discussions with relatives when there is no prospect of recovery of cerebral functions and regaining consciousness. When assessing prognosis, it is crucial to consider comorbidities and their impact on the patient's overall condition 1. In cases where the EEG shows a treatable non-convulsive status epilepticus, antiepileptic treatment should be attempted, even if the overall prognosis is uncertain 1. Key aspects of management include:
- Treating epileptic seizures that affect quality of life, even with a poor prognosis, using anticonvulsant therapy that does not compromise quality of life more than the seizures themselves 1
- Considering alternative modes of administration for antiepileptic drugs, such as buccal, intramuscular, subcutaneous, or rectal, especially in palliative care settings 1
- Addressing delirium through open communication, explanation of the clinical situation, and non-pharmacological measures like a calm environment, orientation, fall prophylaxis, and calm communication before considering drug therapy 1
- Using haloperidol as an option for treating hyperactive delirium, although there is currently no pharmaceutical therapeutic option for hypoactive delirium 1. It is essential to perform an EEG diagnosis in patients with persistent consciousness disorder after HIE or those with suspected hypoactive delirium to identify potentially treatable non-convulsive status epilepticus 1. By prioritizing these aspects and tailoring management to the individual patient's needs and prognosis, healthcare providers can optimize outcomes in terms of morbidity, mortality, and quality of life for adults with hypoxic-ischemic encephalopathy.
From the Research
Management of Hypoxic-Ischemic Encephalopathy in Adults
- The management of hypoxic-ischemic encephalopathy (HIE) in adults is a complex process, with various treatment modalities being explored 2.
- Therapeutic hypothermia is currently the main therapy in clinical use, although its efficacy remains to be investigated 2, 3.
- Other treatment modalities, such as drug therapy and stem cell therapy, have been explored in the treatment of HIE, exhibiting certain neuroprotective effects 4.
- Cardiovascular management following HIE is also crucial, with individualized management utilizing targeted neonatal echocardiography (TnECHO) potentially enhancing care 5.
Treatment Strategies
- Hypothermia therapy stands as the sole standard treatment for neonatal HIE, albeit providing only partial neuroprotection 4.
- Employing drug therapy or stem cell therapy as adjunctive treatments to hypothermia therapy holds great significance 4.
- Experimental treatments, such as those aimed at ameliorating the effects of secondary energy failure, are being explored in neonates and animal models 6.
Pathophysiology and Prognosis
- The pathophysiology of HIE is now better understood, with the emergence of serum-based biomarkers, placental pathology, and magnetic resonance imaging as useful tools to predict long-term outcomes 3.
- The precise pathophysiological mechanisms underlying HIE are not entirely understood, with contributions from hypoxia-ischemia, reperfusion injury, inflammation, oxidative stress, mitochondrial dysfunction, excitotoxicity, ferroptosis, endoplasmic reticulum stress, and apoptosis 4.
- Right ventricular (RV) dysfunction is associated with adverse neurodevelopment, highlighting the importance of cardiovascular management in HIE patients 5.