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Multi-Organ Dysfunction in Neonates with Hypoxic-Ischemic Med. J. Cairo Univ., Vol. 78, No. 1, December 461-467, 2010 www.medicaljournalofcairouniversity.com Multi-Organ Dysfunction in Neonates with Hypoxic-Ischemic Encephalopathy LAILA H. MOHAMMED, M.D.; MAI A .KHAIRY, M.D.; NAGY A. EL-HUSSIENY, M.D.*; MOHAMMED H. ZAAZOU, M.D.* and RAGHDAA M. ALY, M.D.* The Departments of Pediatrics, Faculty of Medicine, Cairo University and Ahmed Maher Teaching Hospital*. Abstract Introduction Perinatal hypoxic-ischemic cerebral injury remains an NEONATAL hypoxic-ischemic encephalopathy important recognized cause of cerebral palsy. Most cases of (HIE), the most common neurologic complication hypoxic-ischemic encephalopathy (HIE) result from injury in the perinatal period, is a major cause of chronic in the prenatal period secondary to intrauterine asphyxia, with disturbance of gas exchange across the placenta. disability in childhood [1] . HIE is termed as neonatal encephalopathy that results from systemic hypox- The aim of this study was to assess the patients of hypoxic- emia and decreased cerebral perfusion leading to ischemic encephalopathy regarding the patterns of each organ/ [2] system dysfunction in relation to the outcome and also assess- ischemia . ment of occurrence of multi-organ/system dysfunction and its relation to outcome and the severity of acidosis. Etiology of perinatal HIE includes those cir- cumstances that can affect the cerebral blood flow Our study included 100 full term neonates diagnosed as in the fetus and neoborn compromising the supply HIE. Data wre collected from patients’ files including full of oxygen to the brain. They may develop antepar- maternal history, detailed neonatal history, general and systemic tum (20%), intrapartum (30%), intrapartum and examination, laboratory studies and the outcome of each one. antepartum (35%), or postpartum (10%). HIE de- Some risk factors associated with HIE were assessed velops in the setting of perinatal asphyxia, which among our patients. Meconium staining of the amniotic fluid is a multi-organ system disease [3] . was found to be the most common risk factor in our study. Hypoxia and ischemia can cause damage to Multi-organ dysfunction occurred in 74% of cases, with the renal dysfunction being the commonest to occur followed almost every tissue and organ of the body and by pulmonary dysfunction. While regarding the outcome, various target organs involved have been reported cardiovascular dysfunction was associated with the highest to the kidneys in 50%, followed by central nervous incidence of mortalities followed by pulmonary dysfuncction. system (CNS) in 28%, cardiovascular system (CVS) We also found that two-organ dysfunction was the com- in 25% and lungs in 23% cases [4] . monest to occur followed by one-organ dysfunction. Highly significant relation was found between the number of organ Multi-organ dysfunction (MOD) is one of four dysfunction and the occurrence of death. consensus based criteria for the diagnosis of intra- partum asphyxia. The theoretical concept behind Among all our patients (100 patients), death occurred in MOD is the diving reflex (conservation of blood 40% of cases, while 60% of cases were discharged. On the flow to vital organs at the cost of non-vital organs) other hand, death occurred in 39 cases (52.7%) among the the multi-organ dysfunction (MOD) group (74 patients) while (Shah et al., 2004). 35 patients (47.29%) were discharged. Excessive stimulation of glutamate receptors Key Words: Organ – Dysfunction – MOD – Neonates – Hypoxic appears to play an important role in the pathogen- ischemic encephalopathy. esis of neonatal brain injuries caused by lack of oxygen [5] . Correspondence to: Dr. Laila H. Mohammed, the Department Improved understanding of the pathophysiolog- of Pediatrics, Faculty of Medicine, Cairo University. ical mechanism involved in perinatal brain lesions 461 462 Multi-Organ Dysfunction in Neonates with Hypoxic-Ischemic Encephalopathy helps to identify potential targets for neuroprotec- 5- Laboratory studies: CBC, ABG, liver function tive interventions [6] . tests (ALT, AST, SB), kidney function tests + + (BUN, S.CREAT., Na and K ). Aim of the work: 6- Cranial ultrasonography (whenever available). To assess the patterns of involvement of each major organ/system and combinations of involve- 7- Outcome whether death or discharge. ment in infants with post-asphyxial hypoxi- Outcome was studied in relation to individual cischemic encephalopathy. organ dysfunctions and in relation to number of organ/system involved. Patients and Methods All patients were then divided into two groups, This is a retrospective study carried out on 100 the first group included patients with PH<7, and hypoxic-ischemic neonates who were admitted on the second one included patients with PH >_7. Both their first day of life to the Neonatal Intensive Care groups were then compared regarding mode of Unit (NICU) in Kasr El-Aini University and Ahmed delivery, risk factors, distribution of organ affection, Maher Teaching Hospitals, Cairo, Egypt, over a the occurrence of multi-organ affection and the period of 18 months from June 2007 to December relation to the outcome. 2008. • Criteria for organ/system dysfuncyion: • Inclusion Criteria (Neonates with HIE criteria): Renal dysfunction: 1- Having one or more of the followings: Anuria or oliguria (0.5<ml/Kg/hr) for 24 hours Five minutes Apgar score of <5, and/or meta- or more, and/or serum creatinine concentration bolic acidosis indicated by a base deficit more than 1mg%, and/or serum urea concentra- >_ 16mmol/L, and/or delayed onset of respiration tion more than 40mg%. for five or more minutes. Cardiovascular dysfunction: 2- Neonates who needed mechanical ventilation. Hypotension treated with ionotropes for more 3- Neonates with evidence of encephalopathy as than 24 hours to maintain blood pressure within altered consciousness and/or seizures. the normal range. • Exclusion Criteria: Pulmonary dysfunction: 1- Preterm babies (<37 weeks gestation). Need for ventilatory support with oxygen re- quirement more than 40% during the first 4 2- Babies with congenital anomalies including hours of life. dysmorphism, congenital viral infections, inborn errors of metabolism,and hemorrhagic shock Hepatic dysfunction: without evidence of intrapartum asphyxia. Aspartate aminotransferase > 10IU/I or alanine aminotransferase > 100IU/I at any time during Data were collected from patients’files as follows: the first week after birth. 1- Full maternal history including personal (name, Gasteroinetestinal dysfunction: age, gravidity and parity) and medical (anemia, hypertension, diabetes mellitus and drug intake). GIT bleeding with or without vomiting or ab- dominal distention. 2- Detailed obstetric history (duration of pregnancy, number of births, mode of delivery and occur- Hematologic dysfunction: rence of complications as APH, PROM, MSAF Signs of DIC with bleeding tendency. and cord around the neck). 3- Neonatal history (estimated gestational age, sex, • Statistical Analysis: Apgar score at 1 and 5 minutes and method of We used computer programs Microsoft Excel resuscitation if needed). 2003 (Microsoft corporation, NY, USA) and SPSS 4- Clinical examination including general (RR, (Statistical Package for the Social Science; SPSS HR, ABP and TEMP.) and systemic (neurolog- Inc., Chicago, IL, USA) version for Microsoft ical, chest, heart and abdominal). Windows. Laila H. Mohammed, et al. 463 Results Table (5): Mean and standard deviation of laboratory parameters among the studied cases. Table (1): Sex distribution among cases. Laboratory Std. Minimum Maximum Mean parameters deviation Sex distribution Number Percentage pH 6.7 7.45 7.175 0.1440 Males 57 57% pO 24 12.122 2 88.9 40.95 Females 43 43% pCo2 11 99 32.50 17.013 HCo3 4 69 13.12 7.878 BE -28 -11 -16.18 3.648 Table (2): Mode of delivery among cases. Hb 4.1 20 13.097 2.9383 TLC 2 48 10.97 7.205 Mode of Vaginal delivery Cesarean section PLT total 10 816 200.81 152.338 delivery N=54 N=46 BUN 3 122 33.995 24.5013 ≥ Creatinine 0.1 3.8 1.238 0.7930 pH 7 46 (52.2%) 42 (47.8%) 88 (88%) Na 120 154 137.89 6.914 pH <7 8 (66.7%) 4 (33.3%) 12 (12%) K 2 8 5.50 1.402 p-value: 0.348 Bilirubin 0.4 23.4 5.463 4.1273 ALT 4 597 75.78 99.702 AST 23 1397 156.06 208.336 Table (3): Maternal and obstetric problems among cases. Obstetric pH >_7 pH <7 Total Table (6): Occurrence of multi-organ dysfunction (MOD) p-value problems n=88 n=12 n=100 among cases. 2 Maternal 16 18 0.898 pH >_7 pH <7 Total MOD diseases (88.9)% (11.1%) (18%) n=88 n=12 n=100 Placental 4 2 6 0.097 yes 63 11 74 abnormalities (66.7%) (33.3%) (6%) (85.13%) (14.86%) (74%) PROM 1 2 13 0.687 No 25 1 26 (84.6%) (15.4%) (13%) (96.15%) (3.84%) (26%) Meconium 29 5 34 0.550 staining (85.3%) (14.7%) (34%) Cord around 4 0 4 0.470 neck (100%) (4%) 74% MOD Obstructed 16 3 19 0.572 labor (84.2%) (15.8%) (19%) Fig. (1): Occurrence of multi-organ dys- Table (4): Clinical presentation of the studied neonates. function (MOD) among cases. Clinicalpresentation Number percentage Table (7): Distribution of organ dysfunction among MOD 1-Neurological: group. a-Convulsions 92 92% b-Lethargy 48 48% pH >_7 pH <7 Total Organ/system p-value c-Irritability 4 4% N=63 N=11 N=74 2-Respiratory: Renal 42 5 47 0.178 a-Delayed initiation of respiration 25 25% (89.3%) (10.7%) (63.5%) b-Respiratory distress 24 24% c-Meconium aspiration 34 34% Pulmonary 30 5 35 0.578 (85.7%) (14.3%) (47.3%) 3-Renal: a-Anuria 6 6% Hepatic 22 4 26 0.589 b-Oliguria 4 4% (84.7%) (15.3%) (35.1%) 4-Gastrointestinal: Cardiac 19 2 21 0.339 a-Abdominal distention 10 10% (90.4%) (9.6%) (28.4%) b-Vomiting 5 5% c-GIT bleeding 4 4% Gastrointestinal 2 2 4 0.103 (50%) (50%) (5.4%) 5-Cardiac: a-Hypotension 21 21% Hematological 0 1 1 0.016 b-Tachycardia 15 15% (100%) (1.35%) 464 Multi-Organ Dysfunction in Neonates with Hypoxic-Ischemic Encephalopathy Table (8): Distribution of organ dysfunction in relation to One organ outcome.
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