Dr Maksudur Rahman MBBS, DCH, FCPS (Paed)), MD (Neonatology) - - PowerPoint PPT Presentation

Dr Maksudur Rahman

MBBS, DCH, FCPS (Paed)), MD (Neonatology) Assistant Professor Neonatology Department. Bangladesh Institute of Child Heatlh & Dhaka Shishu (Children) Hospital

Correlation of cardiac impairment

with the severity of hypoxic ischemic encephalopathy and its immediate outcome.

Perinatal asphyxia is an insult to fetus or

newborn due to a lack of oxygen (hypoxia) and /or a lack of perfusion(ischemia) to various organs which will manifest as difficulty in establishing spontaneous respiration evident by delayed cry after birth. .

• Immediate morbidity and mortality of

perinatal asphyxia is due to multiorgan dysfunction .

• The incidence of myocardial

dysfunction in perinatal asphyxia ranges from 29 to 62%.

Respiratory distress, congestive cardiac

failure, cardiogenic shock and systolic murmur(Tricuspid regurgitation and Mitral regurgitation ) are common feature related to cardiac impairment.

 Cardiac troponin-I is more sensitive and

specific than other cardiac enzymes.

 Echocardiographic changes in perinatal

asphyxia are pulmonary hypertension, RV- hypokinesia , LV hypokinesia, Mitral regurgitation, RV/LV dilatation.

 Assessment of the cardiac impairment in

asphyxiated neonates may help to understand severity of perinatal asphyxia and predict its

• utcome.

 To find out the cardiac function impairment in

perinatal asphyxia in order to understand its relation with the outcome.

Specific Objectives

A) To asses cardiac function



Clinically



Serum Troponin- I



2-D Color Doppler Echocardiography.

B)To correlate cardiac impairment with

 Stages of HIE  Mortality  Hospital stay

Of Asphyxiated neonates

• Study d

dy design- Cross sectional study

• Study p

dy period- January 2012-december 2012

• Pl

Plac ace o

• f study- Neonatal ward of Dhaka Shishu

hospital

• Study p

dy popu pulation- Neonate admitted in Dhaka Shishu hospital

• Samp

ample S Siz ize -60

• Sampl

pling M Methods ds-Purposive.

Inclusion criteria : Admitted neonates Age = 0-72 hours , Gestational age=35-42 weeks and along with following

• H/o failure to breathe spontaneously

immediately after birth and/or

• H/o delayed /no cry after birth and/or

 H/o requirement of resuscitation and/or  APGAR score ( at 5minute <5),when

available.

Exclusion criteria-

 Major congenital anomaly .  Clinical features consistent with congenital

infection .

 Neonate with Sepsis ,meconium aspiration

syndrome

 Congenital heart disease .

 Hypoxic-ischemic encephalopathy was

categorized clinically according to modified sarnat & sarnat stages (without EEG).

 Serum cardiac troponin-I, echocardiography  Newborn was thoroughly examined with

special attention to heart rate, blood pressure, capillary refill time at admission and during hospital stay and was monitored upto discharge or death.

 All data were recorded systematically in

preformed data collection form.

 Statistical analyses of the results was done by

using a computer with SPSS-17 program.

 The results were presented in tables , diagram &

graphs.

 Statistical tests X2,Odds ratio ,Multiple logistic

regression analysis for significance of difference were done.

 Total Cases-60  Male= 36 (60)%

Female= 24 (40%)

 Full term- 44 (74%)

Preterm- 16 (26%)

Thirteen (21.7%) newborns were in group –I, 35(58.3%) in

Group-II and rest 12(20%) in group-III.

Figure-1: Distribution of newborns according to severity of encephalopathy

5 10 15 20 25 30 35

13(21.7%) 35(58.3%) 12(20%)

HI HIE-I I H HIE-II II HIE-III III

N=60 N=60

Clin Clinica ical l feat atures Number er(N (N) Percent ntage(% e(%) Convulsion 43 71.7% Respiratory distress 32 53.3% Comatose/ stuporous 11 18.3% Pallor 17 28.3%

10 20 30 40 50 60

Troponin-I raised Troponin-I normal

53.3% 42.7% Fig Figure-2: 2:Percentage of Raised S troponin- I in Perinatal Asphyxia

Echocardiography Changes number percentage Pulmonary hypertension 16 26.6% Tricuspid regurgitation(TR) 27 45% Ventricular dysfunction 19 31.7% RV/RA dilatation 18 30% LA/LV dilatation 5 8.3%

Table-2: Echocardiography changes(n=60)

28(47 %) 32(53 %)

cardiac impairment absent cardiac impairment present

5 10 15 20 25 30 35 1 2 3

12(92 % 15(43 %) 1(9%)

1(8%) 20(57%) 11(91%) cardiac impairment present cardiac impairment absent

HIE-I HIE- II HIE- III Chi Value P value Cardiac impairment

P A

1 13 20 15 11 1 18.17 .0001

33.40 % 66.60 %

Gro Group-III III

100%

Gro roup-I 69.6 0% 31.4 0% Gro roup-II cure De…

Above figure shows that mortality of study newborns and were found 11 among 35 (31.4%) in group-II,8 among 12( 66.6%) in group- III and none in group-I.

14(44% 18(56% ) Mortality

cure death

Factors Death No Death OR (95% CI) P value ( X2test) Cardiac impairment 18 14 30.60 (3.70- 253.21) .00001 No cardiac impairment 1 27

Cardiac impairment & Mortality

• OR=Odd Ratio>1=Significant risk factor.
• Level of significant=p < 0.05.

Factors >10 days) ≤10 days) OR (95% CI) P value ( X2 test) Cardiac impairment

15 17

7.35 (1.85-29.35)

.004

No cardiac impairment

3 25 Cardiac impairment & prolong hospital stay

• OR=Odd Ratio>1=Significant risk factor.
• Level of significant=p < 0.05.

Conclusion:

Cardiac impairment directly correlates with the

• utcome of perinatal asphyxia and is a significant

risk factor for morbidity and mortality. Simultaneously other organ impairments also contribute to severity of morbidity and mortality in perinatal asphyxia.

 Small sample size  Single centre study  Financial constraint.

THANK YOU

Organs Number Percentage CNS 60 100% Respiratory 35 58.3% cardiac 32 53.3% Hepatic 12 20% Renal 20 33.3%

̈Table-3: Percentage of organ involvement in Perinatal asphyxia

Organ Sig. Exp(B) Cardiac impairment .184 10.404 Respiratory impairment .734 1.846 Renal impairment .459 1.740 Hepatic impairment .025 6.601

Tabl ble-8 : Multiple logistic regression of

• rgan impairment for mortality

*Exp(B) represents the ratio change in the odds of the event of interest for one unite change in the predictor Sig.=level of significant <.05

 Troponin I

I: Raised ≥0.183µg/l

 Card

rdiac imp c impair irment:

 1)Clinical feature of cardiac involvement  (Tachycardia/bradycardia and CRT>3Sec/

hypotension/systolic murmur ) with or without

 2) S.Troponin-I >0.183µg/l. with or without  3) Echocardiographic finding (pulmonary

hypertension , RV-hypokinesia LV hypokinesia, Tricuspid regurgitation,Mitral regurgitation and RV/LV dilatation).10,12,21