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Hypoxic Ischaemic Encephalopathy (HIE) - management

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Brain injury secondary to inadequate oxygen delivery. Cardiac arrest is the most common cause, but HIE may also be caused by prolonged seizures, drowning, asphyxia, infectious/metabolic encephalopathy and low cardiac output states.

Principles of management

Avoidance of secondary injury (hypoperfusion, hypoglycaemia, hypoxia) while the brain recovers from the primary insult.

PICU Guidelines


  • All children with severe HIE require intubation for airway protection and to ensure adequate ventilation

Ventilation & Oxygenation

  • Volume Control mode to prioritise CO2 control
  • ParterialCO2 4.7- 5.3 kPa (note correlation to end tidal CO2 and set EtCO2 aims accordingly)
  • Titrate oxygen to keep PaO2 12-15 kPa


  • All children should receive invasive blood pressure monitoring
  • Invasive ICP monitoring is not recommended

Head Position

  • Head of Bed elevated to 30°
  • Avoid hip flexion
  • Keep head in midline


  • Children with HIE secondary to drowning, hanging1 or other traumatic etiology: remove hard collar. Use sandbags alongside manual stabilisation for log rolls
  • Continue c-spine stabilisation and log rolls until formally cleared


  • Worse survival and neurological outcomes occur with MAP <5th centile for age
  • Treat hypotension aggressively with IV fluid bolus +/- inotropes/vasopressors
  • Goal is to maintain MAP in upper range for age (i.e. 50-95th centile)
Age Goal MAP mmHg
< 2 years ≥55
2 - 6 years ≥60
>6 years ≥70
  • Use crystalloid to maintain CVP 4-8 mmHg
  • Noradrenaline may be required to achieve blood pressure targets

Therapeutic Temperature Management2

  • There is no evidence to support the use of moderate hypothermia (32 -33°C); however fever is associated with worse outcomes
  • Post Cardiac Arrest management:
    See Targeted Temperature Management Guideline
    Maintain core temperature 36°C for the first 36hrs then 36.5°C until 72hrs post injury/arrest.
    Use oesophageal or bladder temperature - not rectal probe


  • Sedation reduces intracranial pressure by reducing brain metabolism and energy expenditure
  • Refer to the PICU Sedation and Analgesia guideline appropriate to the age and weight of the child
  • Goal is deep sedation and analgesia during first 72 hours
  • Muscle relaxation will be required to prevent shivering for duration of Targeted Temperature Management

Fluids, Glucose & Nutrition

  • 70% maintenance fluid as isotonic saline ± potassium
  • Establish enteral feeding as tolerated
  • Maintain serum glucose 3.5 - 5.5 as hypoglycaemia can result in secondary brain injury
  • If blood glucose > 11mmol on two occasions - consider insulin infusion on consultant order

Sodium control

  • Maintain serum sodium >140mmol
  • If < 140 restrict to 50% maintenance fluid
  • 3% Hypertonic saline (dose = 3ml/kg over 1 hour) may be administered via central line3


  • Children receiving muscle relaxants should receive seizure prophylaxis regardless of EEG findings
  • Phenytoin: loading dose 20mg/kg followed by maintenance dose 3 mg/kg 8 hourly

Imaging & Neurophysiology

  • Perform an EEG within the first 24 hours to detect non convulsive status epilepticus which is common in HIE
  • Consider ongoing continuous/intermittent EEG monitoring


  1. Hanging injuries may result in vascular injury with a risk of subsequent stroke and require a CT angiogram to exclude this
  2. Refer to PICU Targeted Temperature Management Guideline
  3. Expect serum Na to rise by ~4mmol/L with 3ml/kg 3% saline


  • Abend NS, Licht DJ. Predicting outcome in children with hypoxic ischemic encephalopathy. Ped Crit Care Med. 2008 9:32-39
  • Moler FW, Sliverstein MD, Holubkov R et al. Therapeutic Hypothermia after Out-of-Hospital Cardiac Arrest in Children. N Engl J Med. 2015 May 14:372(20):1898-1908
  • Nielsen N, Wetterslev J, Cronberg T et al. Targeted Temperature Management at 33oC versus 36oC after Cardiac Arrest. N Engl J Med. 2013 369(23):2197-2206

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Document Control

  • Date last published: 03 October 2016
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Intensive Care Unit
  • Author(s): Anusha Guneshalingham, Jean Strock
  • Owner: Anusha Guneshalingham
  • Editor: John Beca
  • Review frequency: 2 years