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Encephalopathy
Definitions
Anoxia
is a term used to indicate the consequences of complete lack of oxygen as a
result of a number of primary causes
Hypoxia
refers to an arterial concentration of oxygen that is less than normal
Ischemia
refers to blood flow to cells or organs that is insufficient to
maintain their normal function
Biagioni E, Mercuri E, Rutherford M, et al: Combined use of electroencephalogram and magnetic resonance
imaging in full-term neonates with acute encephalopathy. Pediatrics 2001;107:461
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Hypoxic-ischemic encephalopathy
Is an important cause of permanent
damage to CNS cells that may result in
neonatal death or be manifested later
as cerebral palsy or mental deficiency
Nelson Textbook of Pediatrics 19th ed.2010 . pages 566 - 568
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Effects of Asphyxia
System Effect
II.Cardiovascular
1.Hypoxic-ischemic encephalopathy
1.Myocardial ischemia
2.Infarction
2. Poor contractility
3. Intracranial hemorrhage
3. Cardiac stun
4.Seizures
4. Tricuspid insufficiency
5. Cerebral edema
5. Hypotension
6. Hypotonia
7. Hypertonia
Cowan F, Rutherford M, Groenendaal F, et al: Origin and timing of brain
lesions in term infants with neonatal encephalopathy. Lancet 2003;361:73642.
05/26/2010
Effects of Asphyxia
System Effect (cont.)
V. Adrenal
III. Pulmonary
1. Pulmonary hypertension
Adrenal hemorrhage
2. Pulmonary hemorrhage
3. Respiratory distress syndrome
VI. Gastrointestinal
1. Perforation
IV. Renal
Acute tubular or cortical
necrosis
Effects of Asphyxia
System Effect (cont.)
VII. Metabolic
1. Inappropriate secretion of antidiuretic hormone
2. Hyponatremia
3. Hypoglycemia
4. Hypocalcemia
5. Myoglobinuria
VIII. Integument
Subcutaneous fat necrosis
IX. Hematology
Disseminated intravascular coagulation
Cowan F, Rutherford M, Groenendaal F, et al: Origin and timing of brain
lesions in term infants with neonatal encephalopathy. Lancet 2003;361:73642.
05/26/2010
Asphyxia
is considered in infants with:
1.
2.
3.
Hypoxic-ischemic encephalopathy:
i. Altered tone
ii. Depressed level of consciousness
iii. Seizures
And
4. Other multiorgan system signs
Battin MR, Dezoete A, Gunn TR, et al: Neurodevelopmental outcome of
infants treated with head cooling and mild hypothermia after perinatal
asphyxia. Pediatrics 2001;107:480
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Fetal hypoxia
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(2) Shock severe enough to interfere with the transport of oxygen to vital
organs as a result of
i. Overwhelming infection
ii. Massive blood loss
iii. Intracranial or adrenal hemorrhage
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Department
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Pathophysiology
Within minutes of the onset of total fetal hypoxia:
1.Bradycardia
2. Hypotension
3. decreased cardiac output
4. severe metabolic as well as respiratory acidosis occur
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Clinical Manifestations
Hypoxic-Ischemic Encephalopathy in Term Infants
Signs:
Stage 1
Stage 2
Stage 3
Stuporous
coma
Hypotonic
Flaccid
Flexion
Decerebrate
I. Level of consciousness
Hyperalert , Lethargic
Normal
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Clinical Manifestations
Hypoxic-Ischemic Encephalopathy in Term Infants
(cont.)
Signs:
Stage 1
Stage 2
Stage 3
Hyperactive
Absent
V. Myoclonus
Present
Present
Absent
Weak
Absent
Strong
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Clinical Manifestations
Hypoxic-Ischemic Encephalopathy in Term Infants
(cont.)
Signs:
Stage 1
Stage 2
Stage 3
Mydriasis
Miosis Unequal
VII. Pupils
VIII. Seizures
None
Common
Decerebration
IX. Electroencephalographic
Normal
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Burst suppression
to isoelectric
Clinical Manifestations
Hypoxic-Ischemic Encephalopathy in Term Infants
(cont.)
Signs:
Stage 1
Stage 2
Stage 3
X. Duration
<24 hr
if progresses; otherwise,
Days to weeks
Variable
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Treatment
Therapy is supportive and directed at the organ system manifestations
Blood volume,
Hemodynamic status
Acid-base balance
Possible infection
is important
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Treatment
(cont.)
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Treatment
(cont.)
Department
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Prognosis
The outcome of hypoxic-ischemic encephalopathy ranges from complete
recovery to death
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Prognosis (Cont.)
Severe encephalopathy characterized by :
1.Flaccid coma
2.Apnea
3.Absence oculocephalic reflexes
4. Refractory seizures
Is associated with a poor prognosis
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Prognosis (Cont.)
1. A low Apgar score at 20 min
2. Absence of spontaneous respirations at 20 min of age
3. Persistence of abnormal neurologic signs at 2 wk of age
predict death or severe cognitive and motor deficits
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Prognosis (Cont.)
Brain death
after neonatal hypoxic-ischemic encephalopathy is diagnosed by:
1. Clinical findings of coma unresponsive to pain, auditory, or visual stimulation
2. Apnea with Pco2 rising from 40 to over 60 mm Hg
3. Absent brainstem reflexes
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Thank you
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