Case of HIE - October 2024
Case
A term neonate was admitted to the neonatal intensive care unit (NICU) following an emergent cesarean section due to maternal uterine rupture and fetal bradycardia. The newborn required extensive resuscitation, including chest compressions and intubation. Initial arterial blood gases revealed profound metabolic acidosis (pH < 6.5), and the neurological examination was consistent with severe hypoxic-ischemic encephalopathy (HIE). The APGAR scores were 0 at one and five minutes. Therapeutic hypothermia was initiated.
The baby was found to have seizures on aEEG and was treated with medications: phenobarbital, phenytoin and eventually Keppra. AEEG is outlined here with the seizures that were detected by the clinical team and treated.
What is your interpretation and management?
A hemodynamics assessment was performed on day 2 of life. At this point, the blood pressure was 61/43. The baby was on 35% FiO2 with saturations 99 in pre and 93 in post-ductal areas. On NIRS, the cerebral saturation was 88 and the renal saturation was 85. Hemoglobin was 130. The baby had be started on iNO 20 ppm by the medical team due to pre-post ductal saturation differences. At the time of the evaluation, the patient had received fresh frozen plasma for a high INR and signs of coagulopathy on the coagulogram and was hyponatremia (116 of sodium), despite restriction of the total fluid intake to 45 mL/kg/day. Urine output was 0.5 - 1 mL/kg/hr.
UAL Gaz arterial: 7.38 / CO2: 31 / Bic 17.5 / BE: -7 / PaO2: 126. Lactate 2.8. Calcium 1.05 mmol/L.
Baby had a capillary refill of 3 seconds on therapeutic hypothermia but with good central pulses. The baby was non-reactive to manipulation. No liver edge was palpated on exam and auscultation of heart sounds was benign. Heart rate was 120-130 beats per minute.
A TnECHO was performed on iNO 20 ppm. What would be your interpretation and management ? Images and clips are below:
Please provide your interpretation and management plan here
Cerebrovascular assessment
Parasternal Long Axis View
Parasternal Short Axis View
Apical Views
Subcostal Views
Suprasternal view
