Management of Birth Asphyxia in NICU: A Comprehensive Protocol
Therapeutic hypothermia should be initiated within 6 hours of birth for term or near-term infants with moderate-to-severe hypoxic-ischemic encephalopathy (HIE), maintaining strict temperature control at 33-34°C for 72 hours with slow rewarming over at least 4 hours. 1
Initial Resuscitation and Assessment
- Begin with airway management and effective ventilation, which remains the primary focus of initial resuscitation 1
- Start with room air (21% oxygen) for term infants rather than 100% oxygen, titrating oxygen based on pulse oximetry readings 1
- Assess heart rate as the primary vital sign to judge resuscitation efficacy, using auscultation of the precordium 1
- Monitor oxygen saturation continuously using pulse oximetry 1
- Evaluate for signs of moderate-to-severe HIE including altered level of consciousness, abnormal tone, abnormal reflexes, and seizures 1
Criteria for Therapeutic Hypothermia
- Term or near-term infants (≥36 weeks gestation) 1
- Evidence of perinatal asphyxia (Apgar score ≤5 at 10 minutes, need for resuscitation at 10 minutes, or severe acidosis) 1
- Moderate to severe encephalopathy as defined by clinical examination 1
- Treatment must be initiated within 6 hours of birth 2
Therapeutic Hypothermia Protocol
- Cool to target temperature of 33-34°C for 72 hours 1, 2
- Use servo-controlled cooling devices available in India such as Tecotherm Neo or Olympic Cool-Cap 3
- Monitor core temperature continuously via rectal or esophageal probe 2
- Rewarm slowly at a rate of approximately 0.5°C per hour (minimum 4 hours total) 1, 2
- Ensure multidisciplinary care with capabilities for respiratory support, IV therapy, anticonvulsant administration, and monitoring 1
Seizure Management
- Monitor for seizures using continuous amplitude-integrated EEG (aEEG) if available 4
- For seizures, administer Phenobarbital as first-line treatment 5
Phenobarbital Administration Protocol:
- Initial loading dose: 20 mg/kg IV divided in 1-2 doses 4
- Additional dose: 10-20 mg/kg if seizures persist 4
- Maximum rate of administration: Do not exceed 60 mg/min 5
- Therapeutic level: 10-25 μg/mL in serum 5
- Available brands in India: Gardenal (Sanofi), Luminal (Mankind Pharma) 6
- Administration technique: Use slow IV injection through a larger vein (not dorsum of hand); carefully observe vital signs during administration 5
Supportive Care
- Maintain adequate ventilation and oxygenation 1
- Monitor for and treat complications such as:
- Initiate intravenous glucose infusion to avoid hypoglycemia 1
- Monitor electrolytes, renal function, and liver function 2
Expected Outcomes and Benefits
- Therapeutic hypothermia reduces risk of death or major neurodevelopmental disability by 22-33% 2
- For every 5-7 infants treated, one fewer infant will die or have significant neurodevelopmental disability 2
- Cerebral palsy risk is reduced by approximately 48% 2
- Risk of blindness is reduced by approximately 52% 2
- Risk of deafness is reduced by approximately 58% 2
Follow-up Care
- Arrange for comprehensive neurodevelopmental follow-up 3
- Long-term follow-up should continue to at least 18 months of age 3, 6
- Consider early intervention services for infants showing signs of developmental delay 6
Common Pitfalls and Caveats
- Avoid initiating cooling beyond 6 hours of life as efficacy decreases significantly 3
- Do not attempt therapeutic hypothermia without proper monitoring equipment and trained staff 1
- Avoid rapid infusions of volume expanders in premature infants as this increases risk of intraventricular hemorrhage 1
- For phenobarbital, avoid inadvertent intraarterial injection which can lead to severe complications including gangrene 5
- Consider discontinuing resuscitation if there has been no detectable heart rate for 10 minutes, though this decision should be individualized based on circumstances 1