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A Randomized Trial of Laryngeal Mask Airway in Neonatal Resuscitation
In a randomized trial comparing ventilation with a cuffless laryngeal mask airway and with a face mask in neonates with asphyxia, the laryngeal mask airway was not superior to the face mask with respect to early neonatal death and moderate-to-severe hypoxic–ischemic encephalopathy.
Journal Article
Big Bad Wolf
\"A choking wolf is rushed to City Hospital, and a lost little girl in a red coat has been found, looking for her missing granny. What on earth did the wolf eat?\"-- Provided by publisher.
Book
Perinatal asphyxia and associated factors among neonates admitted to a specialized public hospital in South Central Ethiopia: A retrospective cross-sectional study
Perinatal asphyxia continues to be a significant clinical concern around the world as the consequences can be devastating. World Health Organization data indicates perinatal asphyxia is encountered amongst 6-10 newborns per 1000 live full-term birth, and the figures are higher for low and middle-income countries. Nevertheless, studies on the prevalence of asphyxia and the extent of the problem in poorly resourced southern Ethiopian regions are limited. This study aimed to determine the magnitude of perinatal asphyxia and its associated factors.
A retrospective cross-sectional study design was used from March to April 2020. Data was collected from charts of neonates who were admitted to NICU from January 2016 to December 31, 2019.
The review of 311 neonates' medical records revealed that 41.2% of the neonates experienced perinatal asphyxia. Preeclampsia during pregnancy (AOR = 6.2, 95%CI:3.1-12.3), antepartum hemorrhage (AOR = 4.5, 95%CI:2.3-8.6), gestational diabetes mellitus (AOR = 4.2, 95%CI:1.9-9.2), premature rupture of membrane (AOR = 2.5, 95%CI:1.33-4.7) fetal distress (AOR = 3,95%CI:1.3-7.0) and meconium-stained amniotic fluid (AOR = 7.7, 95%CI: 3.1-19.3) were the associated factors.
Substantial percentages of neonates encounter perinatal asphyxia, causing significant morbidity and mortality. Focus on early identification and timely treatment of perinatal asphyxia in hospitals should, therefore, be given priority.
Journal Article
Peer-assisted learning after onsite, low-dose, high-frequency training and practice on simulators to prevent and treat postpartum hemorrhage and neonatal asphyxia: A pragmatic trial in 12 districts in Uganda
An urgent need exists to improve and maintain intrapartum skills of providers in sub-Saharan Africa. Peer-assisted learning may address this need, but few rigorous evaluations have been conducted in real-world settings. A pragmatic, cluster-randomized trial in 12 Ugandan districts provided facility-based, team training for prevention and management of postpartum hemorrhage and birth asphyxia at 125 facilities. Three approaches to facilitating simulation-based, peer assisted learning were compared. The primary outcome was the proportion of births with uterotonic given within one minute of birth. Outcomes were evaluated using observation of birth and supplemented by skills assessments and service delivery data. Individual and composite variables were compared across groups, using generalized linear models. Overall, 107, 195, and 199 providers were observed at three time points during 1,716 births across 44 facilities. Uterotonic coverage within one minute increased from: full group: 8% (CI 4%‒12%) to 50% (CI 42%‒59%); partial group: 19% (CI 9%‒30%) to 42% (CI 31%‒53%); and control group: 11% (5%‒7%) to 51% (40%‒61%). Observed care of mother and newborn improved in all groups. Simulated skills maintenance for postpartum hemorrhage prophylaxis remained high across groups 7 to 8 months after the intervention. Simulated skills for newborn bag-and-mask ventilation remained high only in the full group. For all groups combined, incidence of postpartum hemorrhage and retained placenta declined 17% and 47%, respectively, from during the intervention period compared to the 6‒9 month period after the intervention. Fresh stillbirths and newborn deaths before discharge decreased by 34% and 62%, respectively, from baseline to after completion, and remained reduced 6‒9 months post-implementation. Significant improvements in uterotonic coverage remained across groups 6 months after the intervention. Findings suggest that while short, simulation-based training at the facility improves care and is feasible, more complex clinical skills used infrequently such as newborn resuscitation may require more practice to maintain skills. Trial Registration: ClinicalTrials.gov NCT03254628.
Journal Article
Mitochondrial dysfunction in perinatal asphyxia: role in pathogenesis and potential therapeutic interventions
Perinatal asphyxia (PA)-induced brain injury may present as hypoxic-ischemic encephalopathy in the neonatal period, and long-term sequelae such as spastic motor deficits, intellectual disability, seizure disorders and learning disabilities. The brain injury is secondary to both the hypoxic-ischemic event and oxygenation–reperfusion following resuscitation. Following PA, a time-dependent progression of neuronal insult takes place in terms of transition of cell death from necrosis to apoptosis. This transition is the result of time-dependent progression of pathomechanisms which involve excitotoxicity, oxidative stress, and ultimately mitochondrial dysfunction in developing brain. More precisely mitochondrial respiration is suppressed and calcium signalling is dysregulated. Consequently, Bax-dependent mitochondrial permeabilization occurs leading to release of cytochrome c and activation of caspases leading to transition of cell death in developing brain. The therapeutic window lies within this transition process. At present, therapeutic hypothermia (TH) is the only clinical treatment available for treating moderate as well as severe asphyxia in new-born as it attenuates secondary loss of high-energy phosphates (ATP) (Solevåg et al. in Free Radic Biol Med 142:113–122, 2019; Gunn et al. in Pediatr Res 81:202–209, 2017), improving both short- and long-term outcomes. Mitoprotective therapies can offer a new avenue of intervention alone or in combination with therapeutic hypothermia for babies with birth asphyxia. This review will explore these mitochondrial pathways, and finally will summarize past and current efforts in targeting these pathways after PA, as a means of identifying new avenues of therapeutic intervention.
Journal Article
Initial lactate levels linked to oliguria in term neonates with perinatal asphyxia
Background
Oliguria is a sign of impaired kidney function and has been shown to be an early predictor of adverse prognoses in patients with acute kidney injury. The relationship between urine output (UOP) and early lactate levels in neonates with perinatal asphyxia (PA) has not been extensively explored. This study aimed to investigate the link between oliguria during the first 24 h of life and early lactate levels in neonates with PA.
Methods
The medical records of 293 term neonates with asphyxia from 9216 hospitalized newborns were retrospectively analyzed, including 127 cases designated as the oliguria group and 166 cases as controls. Peripheral arterial blood gas after PA and UOP within 24 h after birth were analyzed. Logistic regression analyses and receiver operating characteristic curve analysis were conducted.
Results
Oliguria occurred in 43.34% of neonates with PA. The median UOP of the oliguria and control groups were 0.65 and 1.46 mL/kg/h, respectively. Elevated lactate levels after PA are an independent risk factor for oliguria in the following 24 h (p = 0.01; OR: 1.19; 95%CI: 1.04–1.35) and show a moderate discriminatory power for oliguria (AUC = 0.62). Using a cut off value of 8.15 mmol/L, the positive and negative predictive values and the specificity were 59.34%, 63.86%, and 78.30%, respectively.
Conclusion
Neonates with elevated lactate levels after PA face a risk of oliguria in the following 24 h. Based on early elevated lactate levels after resuscitation, especially ≥ 8.15 mmol/L, meticulously monitoring UOP will allow this vulnerable population to receive early, tailored fluid management and medical intervention.
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Journal Article
Hypothermia for perinatal asphyxia: trial-based quality of life at 6–7 years
ObjectiveTo assess the impact of hypothermic neural rescue at birth on health-related quality of life (HRQL) in middle childhood.DesignSix-year to 7-year follow-up of surviving children from the Total Body Hypothermia for Neonatal Encephalopathy (TOBY) Trial.SettingCommunity study including a single parental questionnaire to collect information on children’s HRQL.Patients145 children (70 in the control group, 75 in the hypothermia group) whose parents consented and returned the questionnaire.InterventionsIntensive care with cooling of the body to 33.5°C for 72 hours or intensive care alone.Main outcome measuresHRQL attributes and utility scores using the Health Utilities Index (HUI).ResultsAt 6–7 years, speech appeared disproportionately affected when compared with other aspects of HRQL but levels of normal emotional functioning were similar in both groups. The mean (SE) HUI3 HRQL scores were 0.73 (0.05) in the hypothermia group and 0.62 (0.06) in the control group; mean difference (95% CI) 0.11 (−0.04 to 0.26).ConclusionsFindings of non-significant differences were not unexpected; the study used data from long-term survivors in a neonatal trial and was underpowered. However, results favoured moderate hypothermia and so complement the clinical results of the TOBY Children study. The work provides further insight into the long-term HRQL impact of perinatal asphyxial encephalopathy and provides previously unavailable utility data with which to contemplate the longer term cost-effectiveness of hypothermic neural rescue.Trial registration numberThis study reports on the follow-up of the TOBY clinical trial: ClinicalTrials.gov number NCT01092637.
Journal Article
Neonatal Encephalopathic Cerebral Injury in South India Assessed by Perinatal Magnetic Resonance Biomarkers and Early Childhood Neurodevelopmental Outcome
Although brain injury after neonatal encephalopathy has been characterised well in high-income countries, little is known about such injury in low- and middle-income countries. Such injury accounts for an estimated 1 million neonatal deaths per year. We used magnetic resonance (MR) biomarkers to characterise perinatal brain injury, and examined early childhood outcomes in South India.
We recruited consecutive term or near term infants with evidence of perinatal asphyxia and a Thompson encephalopathy score ≥6 within 6 h of birth, over 6 months. We performed conventional MR imaging, diffusion tensor MR imaging and thalamic proton MR spectroscopy within 3 weeks of birth. We computed group-wise differences in white matter fractional anisotropy (FA) using tract based spatial statistics. We allocated Sarnat encephalopathy stage aged 3 days, and evaluated neurodevelopmental outcomes aged 3½ years using Bayley III.
Of the 54 neonates recruited, Sarnat staging was mild in 30 (56%); moderate in 15 (28%) and severe in 6 (11%), with no encephalopathy in 3 (6%). Six infants died. Of the 48 survivors, 44 had images available for analysis. In these infants, imaging indicated perinatal rather than established antenatal origins to injury. Abnormalities were frequently observed in white matter (n = 40, 91%) and cortex (n = 31, 70%) while only 12 (27%) had abnormal basal ganglia/thalami. Reduced white matter FA was associated with Sarnat stage, deep grey nuclear injury, and MR spectroscopy N-acetylaspartate/choline, but not early Thompson scores. Outcome data were obtained in 44 infants (81%) with 38 (79%) survivors examined aged 3½ years; of these, 16 (42%) had adverse neurodevelopmental outcomes.
No infants had evidence for established brain lesions, suggesting potentially treatable perinatal origins. White matter injury was more common than deep brain nuclei injury. Our results support the need for rigorous evaluation of the efficacy of rescue hypothermic neuroprotection in low- and middle-income countries.
Journal Article