G210(P) Challenges facing clinicians when redirecting care in severe hypoxic ischemic encephalopathy (HIE). Does diagnostic certainty come at the cost of improving survival with potential severe disability?

Abstract

Objective To investigate the challenges faced when redirecting care in severe HIE and how this impacts on survival with severe disability. Methods Retrospective observational study of 10 patients with severe neonatal HIE who had redirection of care considered from 2012 to 2015. Data were collected from Badger net and medical notes. Results 9 out of 10 had therapeutic hypothermia. 1 patient never had therapeutic hypothermia due to brain stem death. 6 did not complete the therapeutic hypothermia (4 died and 1 had severe persistent pulmonary hypertension). 5 patients died (50%) and 5 survived. In those who survived, 2 parents refused redirection of care. 3 had MRI brain prior to the decision for redirection of care. The mean age at redirection of care for the babies who died was 2.1 days (range 1–4) compared to 3 days (range 2–4) in those that survived. The mean Thompson score in those who died was 12 (range 10–16) and those who survived 8 (range 6–13). Cerebral function monitoring in 8 patients showed severe abnormalities (low voltage/burst suppression/status epilepticus). In 2 patients the CFM had significant artifact and was difficult to interpret. Full montage EEG in the survived patients showed features of HIE insult in 4 cases and featureless in one case. MRI brain was done in the 5 patients that survived and all had severe changes (MRI scores 2A, 2B, 2A/2B and 3- Scores based on Neonatal Institute of Child health and Human development Neonatal Research Network). Conclusion Our findings suggest that redirection of care is difficult for both parents and clinicians and awaiting more information can delay redirection of care with the likelihood of survival with risks of severe neurodevelopmental delay. Clinicians are often not confident in making this call based on CFM and clinical examination alone. A full montage EEG at 48 hours may aid prognostication and can be done at the bedside. Parental awareness of window of opportunity is appropriate in these settings.