الفهرس 
Hypoxic Ischemic EncephalopathyOnly 14 pages are availabe for public view
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Abstract
Objective: to compare the neuroprotective role of systemic administration of recombinant erythropoietin versus therapeutic whole body modest hypothermia in near term and older neonates with HI insult and their practical feasibility applications to ameliorate the process of the HI insult and its subsequent morbidity and mortality in those neonates and to evaluate their effects on the serum levels of brain derived neurotrophic factor and neuron-specific enolase.
Design: prospective case control study, from September 2007 to February 2010
Setting: at NICU of obstetrics & gynecology department and pediatrics department, Ain Shams University Hospitals
Patients: 45 near term and older neonates subdivided into 4 groups; rEpo, Hypothermia, Supportive care and Healthy control groups. The first 3 groups were diagnosed as neonatal asphyxia according to (Shankaran et al, 2005). All neonates involved in this study were subjected history taking, clinical examination including determination of Apgar score, determination of gestational age, birth weight, length and occipitofrontal circumference, neurological (including Thompson’s score day 1 and 5), chest, heart and abdominal examination. Laboratory investigations were done for all patients including CBC, CRP, initial blood culture and sensitivity, serum electrolytes, renal and liver functions. In patients and control groups blood sample was taken at ≤ 6 hr and day 5 postnatal to measure serum NSE and BDNF.
Interventions: Patients management for supportive, rEpo and hypothermia groups were conducted according to NICU-Ain Shams University guidelines. rEpo group received rEpo subcutaneously at day 1 at a dose of 1500 U / kg. Hypothermia group received hypothermia within 6 hours of birth to maintain the rectal temperature between 33°C - 34°C for 72 hours, induced by placing wrapped cool packs (about 18 cm 15 cm 2 cm in size). One cool pack was placed on either sides of the patient. These cool packs had been kept in a refrigerator at a set temperature of about 10°C and were exchanged for new cooled ones, when the rectal temperature started to rise above 34. The infant was then rewarmed at 0.5°C per hour by slow phase of passive rewarming to rectal temperature between 36.6 °C – 37.2°C over 3-7 hours through discontinuation of cooling and covering the infant.
Assessment of blood flow velocity in MCA using duplex pulsed Doppler ultrasound at day 1, day 3-7 postnatal and whenever any neurological deterioration occurred, MRI brain done at 21-28 days, we used the (BG/W) score. Neurological examination was done at age of 3months using neuromuscular function scale.
Results: hypothermia group needed the most aggressive inotropic support while rEpo group needed the least one. However, none of our patients in the hypothermia group received volume expansion or additional inotropes during rewarming. Clinical seizures were found most in the rEpo group and least in the supportive group. Hypothermia group had the latest mean of age to start or reach the full nasogastric feeding, yet, none of the supportive group and only one of the rEpo group reached oral feeding, while 6 of the hypothermia group reached oral feeding.
Patients have higher serum BDNF levels compared to healthy neonates on day 1 and 5. BDNF level increases over the first 5 days after delivery. BDNF is significantly higher in stage III HIE than stage II, higher in non survivors than survivors and in hypothermia group or rEpo group was higher than supportive group. Serum NSE is significantly higher on day 1 compared to day 5, day1 and 5 are higher in all patients groups than in the control group, and patients with severe HIE have higher NSE on day 1 and 5 compared to moderate HIE.
CBF velocity normally increases on 3-7 day and treatment with either hypothermia or rEpo can mimic natural changes in the CBF.
Hypothermia or rEpo therapy was associated with decreased mortality in patients with HIE especially with stage II. Hypothermia group has better (BG/W) MRI score and better neuromuscular function scale score at 3m than in rEpo group.
Conclusions: Therapeutic hypothermia can safely be a standard therapy in developing countries using cooling packs with close monitoring and it has better outcome than rEpo therapy.