Malcolm Battin

Neonatologist ACH,Chair NE Working

Group, PMMRC

“ That it will ever come into general use, notwithstanding its value, is extremely doubtful; because its beneficial application requires much time and gives a good bit of trouble both to the patient and the practitioner; because its hue and character are foreign and opposed to all our habits and associations”

London Times 1834

Cooling Control P value Relative Risk (95% CI)

CoolCap 59/108 73/110 0.096 0.82 (0.67, 1.02)

TOBY 74/163 86/162 0.18 0.86 (0.68, 1.07)

NICHD 45/102 64/103 0.01 0.71 (0.54, 0.93)

Eicher 14/27 21/25 0.02 0.62 (0.41, 0.92)

China 28/88 35/69 0.02 0.63 (0.43, 0.92)

ICE 55/107 67/101 0.03 0.77 (0.62-0.98)

NeoNet 28/55 46/56 0.001 0.62 (0.49, 0.81)

P Shah. Seminars In Fetal and Neonatal Medicine 2010

P Shah. Seminars In Fetal and Neonatal Medicine 2010

Shankaran S et al. N Engl J Med 2012;366:2085-92.

WeeFIM ratings were completed at 7–8 y of age on 62 (32 cooled; 30 std) of 135 surviving children with neuro-developmental assessment at 18 mo

Guillet R et al. Pediatric Research 2012

Only intervention that modifies outcome

Standard of care Available in all level 3 units Most effective < 6 hrs after insult

Potential issues with access: Cooling did not take place in 27/82 cases (33%). Ongoing plan to review potentially eligible cases Delay

Geographical

Smaller units & primary birthing centres Service provision

Poor uptake by a tertiary centre

Inadequate guidelines and protocols

NE Working Group Data

Equity in availability but variable mode

▪ informal survey NZ 3o centres

Formal collection on timing + clinical data

ANZNN

Cooling is an entry criteria

Delayed reporting

Complete capture Accurate

information LMC input Timely Protected Web based

1st year of data in PMMRC report 2012

NZPSU 1/12 email

Paediatricians

PMMRC NEWG

LMC

Website

Baby form

Mother form

Local dataCoordinator

Potential issues with access Potential issues with transport

• 37 / 42 babies satisfactory WRT target range • 5 excessive cooling with no monitoring• Passive cooling resulted in 1.8 h earlier initiation

Kendall et al. Arch. Dis. Child. Fetal Neonatal Ed. 2010

Potential issues with access Potential issues with transportProblems with temperature control in

NICU

• Rapid induction ~ 30-120 min. • Potential overshoot

• acceptable if < 1 °C. • Maintenance phase for 72 hrs

• minimal fluctuations • servo-controlled most stable

• Rewarming • slow and controlled • rates of 0.2–0.5 °C/hr • V. minimal overshoot

• Ongoing temperature monitoring • ensure no fever

Robertson Fetal and Neonatal Medicine 2010

Infant Rectal Temp During Cooling Using SHC, WBC And

WBC Servo

Hoque N et al. Pediatrics 2010©2010 by American Academy of Pediatrics

Temperature Profile

28

30

32

34

36

38

0:0

5:1

10:2

15:3

20:4

25:5

30:6

35:7

40:8

45:9

50:1

0

55:1

1

60:1

2

65:1

3

Time

Tem

per

atu

re Core

Surface

Set-Point

Potential issues with access Potential issues with transportProblems with temperature control in

NICUPotential cooling complications

• A form of panniculitis • Involves back, scalp, arms• 12 / 1239 cases in TOBY register of WBC• Moderate-to-severe hypercalcemia in 8 / 10 with calcium measurement • Skin lesions appeared after completion of cooling run • Moderate hypothermia is a risk factor for SCFN• Need to be aware of SCFN • Monitor blood calcium

P Shah. Seminars In Fetal and Neonatal Medicine 2010

Guidelines for cooling should ensure timely availability and access for all Evidence gap analysis by NZ guidelines group

March 2012 Local centre guidelines to inform transfer of babies

The key to safe transfer is core temperature monitoring

Long term follow-up data vital NE working group data collection ANZNN