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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Temperature during transport according to hypoxic-ischemic encephalopathy severity&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Hypoxic-ischemic encephalopathy &#40;HIE&#41; was once a disorder orphan of an effective therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">1</span></a> It has become a time-dependent emergency&#44; after clinical trials demonstrated the efficacy of cooling started within 6<span class="elsevierStyleHsp" style=""></span>h of birth in reducing the risk of death or disability and increasing the rate of disability-free survival at 18&#8211;24 months of age&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">1&#8211;3</span></a> Animal models and infant studies have indicated that the earlier cooling is initiated after the injury&#44; the more likely it is to be successful&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">4&#8211;6</span></a> Furthermore&#44; experimental evidence has shown a lack of neuroprotective efficacy of hypothermia with delayed cooling&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">4&#44;7</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Most asphyxiated infants are born in non-tertiary neonatal units and they must be transferred urgently to a center equipped with a hypothermia program to start this therapy as soon as possible&#46; In order not to delay the neuroprotection provided by cooling&#44; it is recommended to begin this therapeutic intervention at the referring hospital before the transfer&#44; by turning off the external sources of heat and keeping the infant cooled during transport&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">8&#8211;10</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Most asphyxiated newborn infants being transferred are passively cooled&#46; Several reports have studied the efficacy and safety of passive cooling during transport of asphyxiated newborns&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">9&#8211;16</span></a> Target temperatures are often not achieved and overcooling ranges from 11&#37; to 34&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">9&#8211;13</span></a> However&#44; these studies do not outline medical complications during transport nor indicate whether the efficacy in maintaining target temperatures and complications are related to the severity of the HIE in the first 6<span class="elsevierStyleHsp" style=""></span>h of life&#46; The aim of the present study was to assess the relationship between the efficacy of passive hypothermia and adverse events during transport and the severity of the HIE&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">During the five-year study period &#40;January 2009&#8211;December 2013&#41;&#44; the neonatal intensive care unit &#40;NICU&#41; of the Hospital Sant Joan de Deu &#8211; Hospital Cl&#237;nic-Maternitat was one of the two regional centers offering therapeutic hypothermia for children with HIE born in Catalonia &#40;32&#44;000<span class="elsevierStyleHsp" style=""></span>km<span class="elsevierStyleSup">2</span> territory&#44; approximately 71&#44;000 births per year&#41;&#46; A coordinated program including both regional referral cooling centers and the pediatric transport service &#40;Pediatric Emergency Medical System&#41; was established in Catalonia in November 2009 for asphyxiated infants&#46; The transport team includes a pediatrician&#44; a pediatric nurse&#44; and a driver&#47;technician&#46; The therapeutic hypothermia transport guideline establishes a target rectal temperature of 33&#8211;35<span class="elsevierStyleHsp" style=""></span>&#176;C and instructions for using the lowest possible dose of sedatives &#40;fentanyl&#41; if needed&#46; Referring centers are instructed to remove external heat sources in asphyxiated infants&#46; They are transferred in closed incubators&#44; and rectal temperature is monitored every 15<span class="elsevierStyleHsp" style=""></span>min&#46; Infants with confirmed or suspected severe congenital disorder were excluded from the hypothermia protocol and they are not referred&#46; The physicians who refer or transport the infant are in direct telephone contact with the referral NICU&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Data from all newborns<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>34 weeks&#8217; gestational age with HIE born at or transferred to this NICU &#40;level IIIC&#41; during the study period were collected and inserted into a prospective database&#46; The database contains all records obtained during the transfer of outborn patients&#44; including the temperatures after stabilization at birth&#44; on departure from the referring center&#44; during the transport &#40;at least one every hour&#41;&#44; and on admission to this unit&#46; For this study&#44; rectal temperatures at admission ranging from 33&#46;0<span class="elsevierStyleHsp" style=""></span>&#176;C to 35&#46;0<span class="elsevierStyleHsp" style=""></span>&#176;C were considered as in the target range&#44; &#60;33&#46;0<span class="elsevierStyleHsp" style=""></span>&#176;C as overcooling&#44; and from 35&#46;0<span class="elsevierStyleHsp" style=""></span>&#176;C to 36&#46;9<span class="elsevierStyleHsp" style=""></span>&#176;C as normothermic&#46; Transport records were reviewed to assess noteworthy events occurring during transport&#46; Adverse events were classified as &#40;a&#41; untoward incidents related to intensive care &#40;<span class="elsevierStyleItalic">e&#46;g&#46;</span> accidental extubation&#44; occlusion of endotracheal tube&#44; and exhaustion of oxygen supply&#41;&#44; or &#40;b&#41; physiological deterioration related to critical illness &#40;<span class="elsevierStyleItalic">e&#46;g</span>&#46;&#44; worsening hypotension and increased inotropic support or hypoxemia&#44; hypoglycemia&#44; cardiac arrhythmia&#44; major bleeding&#44; and need for cardiopulmonary resuscitation&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">On arrival at this unit&#44; infants were considered to have HIE if they met the following criteria&#58; &#40;1&#41; Apgar score<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>5 at 10<span class="elsevierStyleHsp" style=""></span>min&#44; or need for resuscitation&#44; including endotracheal intubation or mask ventilation for more than 10<span class="elsevierStyleHsp" style=""></span>min after birth&#44; or acidosis &#40;pH<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>7&#46;0 and&#47;or base deficit<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>16<span class="elsevierStyleHsp" style=""></span>mmol&#47;L in umbilical cord blood or arterial&#44; venous&#44; or capillary blood&#41; within 60<span class="elsevierStyleHsp" style=""></span>min from birth&#59; &#40;2&#41; neonatal encephalopathy&#44; defined as a syndrome of neurologic dysfunction manifested by a subnormal level of consciousness with or without seizures &#40;moderate or severe HIE&#41; or palmary hyperexcitability&#44; tremor&#44; overactive myotatic reflexes&#44; hypersensitivity to stimulation&#44; or startle responses&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">17</span></a> Continuous aEEG recordings for 72<span class="elsevierStyleHsp" style=""></span>h were initiated immediately after admission&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The severity of HIE was assessed immediately after admission and always before starting therapeutic hypothermia in the NICU&#46; Encephalopathy was classified as mild&#44; moderate&#44; and severe in accordance with the semi-quantitative score which included the aEEG findings &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">18&#44;19</span></a> Infants who were sedated during the transfer were maintained in passive cooling for at least 3<span class="elsevierStyleHsp" style=""></span>h in order to reduce the possible effect of the sedative on the neurological state&#46; Then&#44; an additional clinical examination and grading of HIE was performed&#46; Newborns with moderate or severe HIE received whole-body cooling &#40;Technotherm<span class="elsevierStyleSup">&#174;</span> TSmed 200 N&#44; SP&#44; Brazil or Criticool&#44; MTRE Ltd&#44; Israel&#46;&#41; and were maintained at a rectal temperature of 33&#46;5<span class="elsevierStyleHsp" style=""></span>&#176;C for 72<span class="elsevierStyleHsp" style=""></span>h&#44; following which they were slowly rewarmed &#40;&#8804;0&#46;5<span class="elsevierStyleHsp" style=""></span>&#176;C per hour&#41;&#46; A systematic research protocol was followed in all patients with HIE transferred to or born in this hospital&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Statistical analyses</span><p id="par0040" class="elsevierStylePara elsevierViewall">Continuous variables were compared using Student&#39;s <span class="elsevierStyleItalic">t</span>-test&#44; Mann&#8211;Whitney&#39;s <span class="elsevierStyleItalic">U</span> test&#44; or the non-parametric Kruskall&#8211;Wallis test&#44; as appropriate&#46; Categorical variables were compared using the <span class="elsevierStyleItalic">&#967;</span><span class="elsevierStyleSup">2</span> test or Fisher&#39;s exact test&#46; The linear relationship between different variables and the departure&#44; transport&#44; and admission temperatures was evaluated using Pearson&#39;s &#40;<span class="elsevierStyleItalic">r</span>&#41; or Spearman&#39;s &#40;rs&#41; correlation coefficient&#46; In order to study temperature curves according to HIE severity group&#44; the General linear mixed model was used&#46; Linear regression analysis was performed to adjust for the effect of confounding factors using binomial regression models&#46; Relative risks &#40;RR&#41; adjusted were estimated using Poisson regression with robust error variance&#46; A <span class="elsevierStyleItalic">p</span>-value of &#60;0&#46;05 was considered to indicate significance&#46; All statistical analyses were performed using SPSS version 17 &#40;SPSS Inc&#46; &#8211; Chicago&#44; IL&#44; USA&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Ethics</span><p id="par0045" class="elsevierStylePara elsevierViewall">The hospital ethics committee approved this study&#44; and the parents&#8217; permission was obtained in all cases prior to inclusion in the study&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0050" class="elsevierStylePara elsevierViewall">From January 2009 to December 2013&#44; 99 patients with HIE were attended in this unit&#44; 68 of whom were referred for possible treatment with therapeutic hypothermia&#46; Sixty-seven were transferred by the Pediatric Emergency Medical System of Catalonia&#46; All were transferred by road ambulance&#44; except for one who was born in the Balearic Islands and transferred by helicopter&#46; One patient&#44; who was born at home and transferred by a non-pediatric team&#44; was excluded from the study&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Perinatal data of the 67 infants transferred are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; All patients were passively cooled in their centers until the transport team arrived&#46; <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> presents the median time from the decision to transfer to admission to this NICU&#59; age on admission&#59; distance traveled&#59; and the temperatures after stabilization at birth&#44; on departure from the referring center&#44; during transport&#44; and on arrival at this Unit&#46; The mean distance traveled was 49<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>54<span class="elsevierStyleHsp" style=""></span>km&#44; and the longest was 172<span class="elsevierStyleHsp" style=""></span>km&#44; except for the patient transferred from the Balearic Islands &#40;283<span class="elsevierStyleHsp" style=""></span>km&#41; by helicopter&#46; There were no significant differences between the temperature on departure from the referring centers and the temperature on arrival at this unit &#40;34&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;5 <span class="elsevierStyleItalic">vs</span>&#46; 34&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;3<span class="elsevierStyleHsp" style=""></span>&#176;C&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;7&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Out of 67 infants referred&#44; 56 &#40;84&#37;&#41; were managed without any external heat source throughout transport&#44; 11 &#40;16&#37;&#41; needed an external heat source to prevent excessive cooling&#44; and only one child who had fever needed to be cooled with cold water bags&#46; Temperature on departure&#44; during transport&#44; or on arrival to this Unit were not related to the following perinatal variables&#58; intrapartum sentinel event &#40;<span class="elsevierStyleItalic">i&#46;e</span>&#46; uterine rupture&#44; placental abruption&#44; cord prolapse or amniotic fluid embolism&#41;&#44; meconium-stained fluid&#44; Apgar scores&#44; and advanced resuscitation&#46; However&#44; emergency cesarean section&#44; umbilical artery pH&#44; and severe HIE were correlated with temperature on departure and on arrival at this NICU&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">When stratifying by HIE severity&#44; no significant differences were observed in temperature after stabilization at birth&#44; time between the decision to transfer and admission&#44; nor in age at admission&#46; A correlation was observed between the temperature on departure and the temperature on admission to this hospital in infants with moderate &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">s</span></span> 0&#46;65&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41; and severe HIE &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">s</span></span> 0&#46;745&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; but not in infants with mild HIE &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">s</span></span> 0&#46;58&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;1&#41;&#46; There were differences in rectal temperature on departure&#44; during transport&#44; and on arrival at this NICU according to the severity of HIE &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#44; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; In a stepwise regression analysis&#44; the association between temperature on departure from the referring center and on arrival at this NICU remained significant regarding umbilical artery pH &#40;B1&#46;62&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05 and 1&#46;65&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#44; respectively&#41; and severe HIE &#40;B-0&#46;96&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05 and &#8722;0&#46;72&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#44; respectively&#41;&#44; after adjusting for birth weight&#44; advanced resuscitation&#44; and Apgar scores&#46; When adjusting for all perinatal variables and transfer time&#44; the subgroup of patients with severe HIE had a departure temperature 0&#46;9<span class="elsevierStyleHsp" style=""></span>&#176;C lower than the other groups&#44; as well as a 0&#46;7<span class="elsevierStyleHsp" style=""></span>&#176;C lower arrival temperature&#46; Infants with severe HIE had a greater risk of having temperature &#60;33<span class="elsevierStyleHsp" style=""></span>&#176;C on admission &#40;RR 4&#46;5&#59; 95&#37; CI&#58; 1&#46;1&#8211;19&#46;3&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Almost half &#40;46&#37;&#41; of the transferred patients were sedated during transport&#46; No significant associations were observed between sedation and the severity of HIE nor with the temperature on admission&#46; Infants with severe HIE most often received inotropic support &#40;21&#47;27&#44; 77&#46;7&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; and mechanical ventilation &#40;28&#47;45&#44; 62&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41;&#46; Noteworthy events during transport were reported in 14 &#40;21&#37;&#41; infants&#46; A trend toward more complications or comorbidities during transport was observed in infants with severe HIE &#40;29&#37; <span class="elsevierStyleItalic">vs</span>&#46; 12&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;082&#41;&#46; The main adverse event was physiological deterioration during transport &#40;13&#47;14&#41;&#44; mainly hypotension and need for increased inotropic support with or without fluid expansion &#40;7&#47;14&#41;&#44; hypoglycemia and need for glucose bolus &#40;4&#47;14&#41;&#44; and bleeding from the endotracheal tube with desaturation &#40;3&#47;14&#41;&#44; but only one patient needed to have the tube changed due to occlusion&#46; One patient suffered cardiorespiratory arrest&#44; requiring advanced resuscitation&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Of the 67 transferred infants&#44; therapeutic hypothermia was finally applied to 59 &#40;88&#37;&#41;&#46; Four infants with mild HIE were not cooled&#44; and four infants with severe HIE did not receive therapeutic hypothermia&#44; three due to a moribund state on admission and one due to arrival at more than 8<span class="elsevierStyleHsp" style=""></span>h of age&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0080" class="elsevierStylePara elsevierViewall">In this study&#44; a strong negative association was observed between temperatures on departure from referring centers&#44; during transport&#44; and on arrival of asphyxiated infants at this NICU&#44; and the severity of neonatal HIE and umbilical arterial cord pH&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">A significant proportion of asphyxiated infants requiring therapeutic hypothermia for moderate or severe HIE are born outside centers equipped to provide it&#46; The Spanish Society of Neonatology recommends the transfer of such neonates to hospitals that provide tertiary care including therapeutic hypothermia&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">20</span></a> Response time and transport time are not low enough&#44; as HIE treatment is time-dependent&#44; given the urgency to establish therapeutic hypothermia within 6<span class="elsevierStyleHsp" style=""></span>h of birth&#46; While it could be expected that the timeframes to referral to NICU would be greater in infants with mild or moderate HIE&#44; the present data provide no evidence of substantial variation in timeframes to NICU referral depending on the severity of HIE&#46; There are currently no evidence-based guidelines for the provision of cooling during transport of neonates with suspected HIE&#46; Because there is limited evidence to support servo-controlled cooling during transport&#44;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">10&#44;11&#44;16</span></a> nowadays most infants with HIE are transferred with passive cooling&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">9&#44;10</span></a> In the present study&#44; one-third of the infants who were passively cooled before and during transport were outside the target temperature range &#40;33&#8211;35<span class="elsevierStyleHsp" style=""></span>&#176;C&#41; upon arrival at the referral center&#46; A similar ratio has been reported in some studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">13&#44;15</span></a> but it was clearly lower than others reporting more than 70&#37; of infants with temperatures outside the target range&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">14&#44;16</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">The incidence of overcooling with passive hypothermia ranges from 11&#37; to 34&#37;&#44;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">12&#8211;14&#44;16&#44;21</span></a> and it is higher than that observed when using servo-controlled cooling in neonatal transport &#40;&#60;11&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">12&#44;16</span></a> The present data are consistent with prior studies that demonstrated the safety of passive cooling&#44; with a low rate of overcooling &#40;16&#37;&#41; and complications &#40;21&#37;&#41; during transport&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">13&#44;15</span></a> Most neonates with HIE were transferred by road&#59; although the distances were relatively short&#44; the present overcooling rate was lower than those reported in other studies with patients covering shorter distances of transport&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">12&#44;14&#44;16</span></a> In these studies&#44; over one-third of infants passively cooled were overcooled at admission&#46; The lower rate of overcooling during transport observed in the present might be related to the regional guidelines for the referral centers and pediatric transport team&#44; which recommend vigilant temperature control before referral and during transport&#46; It is not known whether the rate of infants with severe HIE transferred was higher in the aforementioned studies&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Due to the range of severity of HIE of the patients transferred to this NICU&#44; it was possible to analyze which factors were related with temperature during transport&#44; providing unique and important insights about it&#46; Umbilical artery pH and severity of HIE were the independent factors related with temperature on departure&#44; during transport&#44; and on admission&#44; after adjusting for birth weight&#44; advanced resuscitation&#44; Apgar scores&#44; and transfer time&#46; The subgroup of patients with severe HIE showed a departure temperature 0&#46;9<span class="elsevierStyleHsp" style=""></span>&#176;C lower than the other groups&#44; as well as a 0&#46;7<span class="elsevierStyleHsp" style=""></span>&#176;C lower arrival temperature&#46; In the entire cohort of infants passively cooled during transport&#44; overcooling was observed mostly in infants with severe HIE&#46; It must be stressed that&#44; in the present study&#44; HIE severity was determined following a common scale supervised in every case by neonatologists with specific expertise in neonatal neurology&#44; and that the clinical examination was supported in all cases by aEEG findings&#44; which have been correlated with neurodevelopment outcome&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">22&#44;23</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">It has been known for more than 50 years that asphyxiated infants lose temperature at a higher rate than their non-asphyxiated peers&#44; in relation to reduced oxygen consumption and energy production&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">24&#44;25</span></a> Asphyxiated neonates with hypoxemia cannot produce an adequate amount of heat to increase their temperature&#44; and there is an active drop mechanism of thermoregulation&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">26&#44;27</span></a> In 1958&#44; Burnard &#38; Cross reported that infants with asphyxia &#40;defined as failure to establish respiration within three minutes of birth&#41; presenting lower rectal temperatures&#44; taking 18<span class="elsevierStyleHsp" style=""></span>h to achieve temperatures similar to healthy infants&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">25</span></a> Similar data were reported by Robertson et al&#46;&#44; who noticed that asphyxiated infants not exposed to hypothermia took 15&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14&#46;6<span class="elsevierStyleHsp" style=""></span>h to achieve normothermia&#46; The failure of the thermal adaptive response&#44; &#8220;natural cooling&#8221;&#44; is used to achieve passive cooling before and during neonatal transfer period&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">28</span></a> The impaired heat production should be more consistent after severe hypoxic-ischemic injury&#59; this is indirectly supported by the present finding of a relationship between the umbilical artery pH and the severity of HIE and the temperature on departure&#44; during transport&#44; and on admission&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">It is difficult to compare the rate of adverse events during transport of infants with HIE in passive hypothermia observed in the present study&#46; It is not possible to elucidate whether adverse events reported would appear equally in infants transported non-passively cooled or in those actively cooled&#46; O&#8217;Reilly et al&#46; did not find differences in adverse events between newborns with and without passive hypothermia during transport&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">15</span></a> Akula et al&#46; reported only a pulmonary hemorrhage and two device-related events&#44; and they did not provide a full list of adverse events and differences between both groups&#44; passively and actively cooled infants&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">11</span></a> In addition&#44; factors that limit adverse events during transport&#44; such as regular patient and equipment checks during transport&#44; meticulous preparation of the patient&#44; adapted sedation&#44; use of protocols&#44; and the level of education and experience of the teams&#44; can differ in each geographic area&#46; Nevertheless&#44; the present study demonstrated that physiological deterioration&#44; mainly hypotension and hypoglycemia&#44; as well as bleeding from the endotracheal tube with desaturation&#44; should be anticipated in patients with HIE transferred in passive hypothermia&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">A limitation of the present study is its retrospective design&#59; some additional unspecified data may have been overlooked and the reliability of the data recorded during transport could have been limited by the accuracy of patient transport records and narrative notes&#46; Furthermore&#44; a size effect &#40;type II error&#41; may have limited reaching a conclusion about whether children with severe HIE show more complications during transport&#46; Pre-transport severity of the patients was not established as it is usual in pediatric transport &#40;Pediatric Risk of Mortality score&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">29</span></a> and the severity of HIE was determined after arrival of asphyxiated infants at this NICU&#59; therefore&#59; it is not possible to rule out some degree of worsening of neurological status during transport&#46; In addition&#44; it is not possible to predict if efficacy would have been different in this sample if hypothermia-controlling devices had been used during transport&#46; Other studies have revealed a greater number of infants who achieve target temperature when controlled hypothermia is used during transport&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">11&#44;16</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">This study shows that the risk of overcooling during transport with passive hypothermia is higher in newborns with severe HIE and in those who had more severe acidosis at birth&#46; This observation provides useful information to identify those asphyxiated infants who require closer clinical surveillance to ensure temperatures in the target range during transport&#46; The most common adverse events that arise during the transport of infants with HIE with passive hypothermia are mainly related with physiological deterioration and bleeding from the endotracheal tube with desaturation&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflicts of interest</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest&#46;</p></span></span>"
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            0 => "Birth asphyxia"
            1 => "Hypoxic-ischemic encephalopathy"
            2 => "Neonatal transport"
            3 => "Therapeutic hypothermia"
            4 => "Passive cooling"
            5 => "Thermogenesis"
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            0 => "Asfixia no nascimento"
            1 => "Encefalopatia hip&#243;xico-isqu&#234;mica"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To determine if the efficacy of passive hypothermia and adverse events during transport are related to the severity of neonatal hypoxic-ischemic encephalopathy&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This was a retrospective study of 67 infants with hypoxic-ischemic encephalopathy&#44; born between April 2009 and December 2013&#44; who were transferred for therapeutic hypothermia and cooled during transport&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Fifty-six newborns &#40;84&#37;&#41; were transferred without external sources of heat and 11 &#40;16&#37;&#41; needed an external heat source&#46; The mean temperature at departure was 34&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;4<span class="elsevierStyleHsp" style=""></span>&#176;C and mean transfer time was 3&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;0<span class="elsevierStyleHsp" style=""></span>h&#46; Mean age at arrival was 5&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;5<span class="elsevierStyleHsp" style=""></span>h&#46; Temperature at arrival was between 33 and 35<span class="elsevierStyleHsp" style=""></span>&#176;C in 41 &#40;61&#37;&#41; infants&#44; between 35<span class="elsevierStyleHsp" style=""></span>&#176;C and 36&#46;5<span class="elsevierStyleHsp" style=""></span>&#176;C in 15 &#40;22&#37;&#41; and &#60;33<span class="elsevierStyleHsp" style=""></span>&#176;C in 11 &#40;16&#37;&#41;&#46; Infants with severe hypoxic-ischemic encephalopathy had greater risk of having an admission temperature<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>33<span class="elsevierStyleHsp" style=""></span>&#176;C &#40;OR&#58; 4&#46;5&#59; 95&#37; CI&#58; 1&#46;1&#8211;19&#46;3&#41;&#46; The severity of hypoxic-ischemic encephalopathy and the umbilical artery pH were independent risk factors for a low temperature on admission &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; Adverse events during transfer&#44; mainly hypotension and bleeding from the endotracheal tube&#44; occurred in 14 infants &#40;21&#37;&#41;&#44; with no differences between infants with moderate or severe hypoxic-ischemic encephalopathy&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The risk of overcooling during transport is greater in newborns with severe hypoxic-ischemic encephalopathy and those with more severe acidosis at birth&#46; The most common adverse events during transport are related to physiological deterioration and bleeding from the endotracheal tube&#46; This observation provides useful information to identify those asphyxiated infants who require closer clinical surveillance during transport&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Determinar se a efic&#225;cia da hipotermia passiva e eventos adversos durante o transporte est&#227;o relacionados &#224; gravidade da encefalopatia hip&#243;xico-isqu&#234;mica neonatal&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudo retrospectivo de 67 neonatos com encefalopatia hip&#243;xico-isqu&#234;mica &#40;nascidos entre abril de 2009 e dezembro de 2013&#41; transferidos para hipotermia terap&#234;utica e resfriados durante o transporte&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Foram transportados 56 rec&#233;m-nascidos &#40;84&#37;&#41; sem fontes externas de calor e 11 &#40;16&#37;&#41; precisaram de uma fonte externa de calor&#46; A temperatura m&#233;dia na sa&#237;da foi 34&#44;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;4<span class="elsevierStyleHsp" style=""></span>&#176;C e o tempo m&#233;dio de transporte foi 3&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#44;0 horas&#46; A idade m&#233;dia na chegada foi 5&#44;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#44;5 horas&#46; A temperatura na chegada ficou entre 33-35<span class="elsevierStyleHsp" style=""></span>&#176;C em 41 &#40;61&#37;&#41; neonatos&#44; entre 35&#176;-36&#44;5<span class="elsevierStyleHsp" style=""></span>&#176;C em 15 &#40;22&#37;&#41; e<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>33<span class="elsevierStyleHsp" style=""></span>&#176;C em 11 &#40;16&#37;&#41;&#46; Neonatos com encefalopatia hip&#243;xico-isqu&#234;mica grave apresentaram maior risco de temperatura &#60; 33<span class="elsevierStyleHsp" style=""></span>&#176;C na interna&#231;&#227;o &#40;RC 4&#44;5&#59; IC de 95&#37; 1&#44;1-19&#44;3&#41;&#46; A gravidade da encefalopatia hip&#243;xico-isqu&#234;mica e o pH da art&#233;ria umbilical foram fatores de risco independentes para uma baixa temperatura na interna&#231;&#227;o &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#46; Eventos adversos durante o transporte&#44; principalmente hipotens&#227;o e sangramento do tubo endotraqueal&#44; ocorreram em 14 neonatos &#40;21&#37;&#41;&#44; sem diferen&#231;as entre neonatos com encefalopatia hip&#243;xico-isqu&#234;mica moderada ou grave&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#227;o</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">O risco de super-resfriamento durante o transporte &#233; maior em rec&#233;m-nascidos com encefalopatia hip&#243;xico-isqu&#234;mica grave e naqueles com acidose mais grave no nascimento&#46; Os eventos adversos mais comuns durante o transporte est&#227;o relacionados a deteriora&#231;&#227;o fisiol&#243;gica e sangramento do tubo endotraqueal&#46; Essa observa&#231;&#227;o fornece informa&#231;&#245;es &#250;teis para identificar neonatos asfixiados que exigem maior vigil&#226;ncia cl&#237;nica durante o transporte&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0045">Please cite this article as&#58; Carreras N&#44; Alsina M&#44; Alarcon A&#44; Arca-D&#237;az G&#44; Agut T&#44; Garc&#237;a-Alix A&#46; Efficacy of passive hypothermia and adverse events during transport of asphyxiated newborns according to the severity of hypoxic-ischemic encephalopathy&#46; J Pediatr &#40;Rio J&#41;&#46; 2018&#59;94&#58;251&#8211;7&#46;</p>"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Grade&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Clinical items&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Clinical signs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">aEEG items&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">aEEG recording<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">d</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mild&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Alertness<br>Muscular tone<br>Motor responses<br>Reactivity<br>Clinical seizures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Normal<br>Altered&#58; hypotonia &#40;usually&#41; or hypertonia&#44;<br>Normal or slightly decreased<br>Normal or hiperexcitability&#58; increased myotatic reflexes&#44; tremor and&#47;or myoclonus<br>None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Background amplitude or pattern<br>SWC<br>Electrographic Seizures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Normal or moderately abnormal&#46;<br>Present or absent<br>Absent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Alertness<br>Muscular tone<br>Motor responses<br>Reactivity<br>Clinical seizures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lethargy or moderate stupor<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a><br>Altered&#58; usually hypotonia<br>Greatly decreased&#44; normal quality<br>Decreased tendon reflexes&#44; weak primitive reflexes<br>Present or absent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Background amplitude or pattern<br>SWC<br>Electrographic Seizures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Moderately or severely abnormal<br>Absent<br>Present or absent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Severe&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Alertness<br>Muscular tone<br>Motor responses<br>Reactivity<br>Clinical seizures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Severe stupor or coma<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a><br>Altered&#58; hypotonia &#40;usually&#41; or hypertonia<br>Absent or stereotyped&#46;<br>Primary reflexes absent<br>Present or absent<br>Frequent signs of brain stem dysfunction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Background amplitude or pattern<br>SWC<br>Electrographic Seizures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Severely abnormal<br>Absent<br>Present or absent&nbsp;\t\t\t\t\t\t\n
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Lethargy&#59; difficulty to wake up to noxious stimuli and when awake up maintains the alertness a few seconds &#40;&#8804;6&#8243;&#41;&#46;</p>"
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              "identificador" => "tblfn0020"
              "etiqueta" => "d"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0020">The worst aEEG segment of 30<span class="elsevierStyleHsp" style=""></span>min to 1<span class="elsevierStyleHsp" style=""></span>h in length before clinical evaluation&#46; Grading&#58; <span class="elsevierStyleBold">Normal trace</span>&#58; normal continuous voltage pattern &#40;upper margin &#62;10<span class="elsevierStyleHsp" style=""></span>&#956;V and lower margin &#62;5<span class="elsevierStyleHsp" style=""></span>&#956;V&#41;&#59; <span class="elsevierStyleBold">Moderately abnormal trace</span>&#58; discontinuous pattern &#40;upper margin &#62;10<span class="elsevierStyleHsp" style=""></span>&#956;V and lower margin &#8804;5<span class="elsevierStyleHsp" style=""></span>&#956;V&#41;&#46; <span class="elsevierStyleBold">Severely abnormal trace</span>&#58; burst suppression pattern &#40;upper margin &#60;10<span class="elsevierStyleHsp" style=""></span>&#956;V and lower margin &#60;5<span class="elsevierStyleHsp" style=""></span>&#956;V&#59; often accompanied by bursts of high voltage activity&#41;&#44; continuous low voltage &#40;upper margin &#60;10<span class="elsevierStyleHsp" style=""></span>&#956;V and lower margin &#60;5<span class="elsevierStyleHsp" style=""></span>&#956;V&#41;&#44; or isoelectric pattern &#40;upper and lower margin &#60;5<span class="elsevierStyleHsp" style=""></span>&#956;V&#44; with no burst of activity&#41;&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Scoring system for hypoxic-ischemic encephalopathy&#46;</p>"
        ]
      ]
      2 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Values are presented as total value &#40;percentage&#41;&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Transferred&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Gestational age &#40;weeks&#41;<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">38&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Birth weight &#40;g&#41;<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3050&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>617&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Male gender &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">44 &#40;65&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Growth restriction &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7 &#40;10&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cephalic presentation &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">56 &#40;90&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sentinel event &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">22 &#40;32&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Altered fetal heart rate &#40;NRFS&#41; &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">44 &#40;68&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Emergence cesarean section &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">48 &#40;71&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Meconium-stained liquor &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24 &#40;35&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Artery pH<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Base deficit<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">22&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Apgar 1<span class="elsevierStyleHsp" style=""></span>min<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 &#40;0&#8211;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Apgar 5<span class="elsevierStyleHsp" style=""></span>min<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 &#40;2&#8211;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Apgar 10<span class="elsevierStyleHsp" style=""></span>min<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7 &#40;5&#8211;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Advanced resuscitation &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">52 &#40;77&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Heart rate recovery time<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 &#40;1&#8211;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Moderate HIE &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24 &#40;35&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Severe HIE &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">34 &#40;50&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Whole-body hypothermia &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">59 &#40;88&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hospitalization &#40;days&#41;<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9 &#40;3&#8211;15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Death &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">27 &#40;40&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab1747477.png"
              ]
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          ]
          "notaPie" => array:2 [
            0 => array:3 [
              "identificador" => "tblfn0025"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0025">Mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0030"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0030">Median &#40;interquartile range&#41;&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Perinatal data of the newborns with hypoxic-ischemic encephalopathy transferred to this NICU&#46;</p>"
        ]
      ]
      3 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at3"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">HIE&#44; hypoxic-ischemic encephalopathy&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Total population&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Mild HIE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Moderate HIE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Severe HIE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hours since the decision to transfer to admission to our referring NICU &#40;h&#41;<a class="elsevierStyleCrossRef" href="#tblfn0035"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3<br>&#40;2&#8211;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3<br>&#40;2&#8211;4&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;5<br>&#40;1&#46;3&#8211;3&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#46;1<br>&#40;2&#8211;4&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age on admission &#40;h&#41;<a class="elsevierStyleCrossRef" href="#tblfn0040"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;4<br>&#40;4&#46;25&#8211;6&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;5<br>&#40;3&#46;5&#8211;6&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;7<br>&#40;4&#8211;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;9<br>&#40;4&#8211;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Distance traveled &#40;km&#41;<a class="elsevierStyleCrossRef" href="#tblfn0035"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">29<br>&#40;9&#8211;70&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">29<br>&#40;9&#8211;75&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">29<br>&#40;9&#8211;70&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">17<br>&#40;8&#46;25&#8211;75&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;98&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Temperature after stabilization at birth<a class="elsevierStyleCrossRef" href="#tblfn0040"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">34&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;6<br>&#40;33&#46;7&#8211;35&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">35&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;3<br>&#40;33&#46;5&#8211;36&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">34&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;1<br>&#40;33&#46;8&#8211;35&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">34&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;9<br>&#40;33&#46;7&#8211;36&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;47&nbsp;\t\t\t\t\t\t\n
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