P2C069: Reducing Subcutaneous Fat Necrosis During Whole Body Cooling in a Level 4 Neonatal Intensive Care Unit

Purpose/Objectives: Subcutaneous Fat Necrosis (SCFN) is a complication of therapeutic hypothermia with an incidence of up to 10% documented in the literature. Each year in our level 4 Neonatal Intensive Care Unit (NICU) approximately 10 infants are admitted with hypoxic ischemic encephalopathy (HIE) and undergo whole body therapeutic hypothermia. Upon review of these cases, it was noted that our rate of SCFN, as well as skin breakdown, was higher than that reported in the literature. Our objective was to reduce our rate of SCFN and skin breakdown in infant’s with HIE by 20% in 2021 through a multidisciplinary approach.

Design/Methods: A retrospective review was done of infants that received whole body therapeutic hypothermia for moderate or severe HIE from October 2019-September 2020. The incidence of SCFN or skin breakdown was 28% (4 of 14 patients). Review of the unit cooling process identified opportunities for improvement and SCFN and skin breakdown became a key performance indicator tracked and reported on annually thereafter. Recommendations were made for a SCFN Therapy Bundle. This bundle is composed of the following interventions: PT/OT orders on admission, full skin assessment Q4 hours, padding placed under cooling blanket, rotation clocks for positioning infants, position changes Q2 hours, and foam dressings to the occiput. Education regarding changes was completed in 2021, and a Cooling Committee was formed. This committee reviews all cases of HIE to identify opportunities for improvement, compliance with the SCFN Therapy Bundle, and tracking of the key performance indicator of SCFN or skin breakdown.

Results: Our baseline rate of SCFN and/or skin breakdown in infants undergoing therapeutic hypothermia was 28% from October 2019-Sept 2020. After initiation of the SCFN Therapy Bundle the rates were tracked monthly. In 2021, the rate of SCFN or any skin breakdown decreased to 14%, a 50% reduction and was 16% in 2022, a 42% reduction from baseline. Of note, the number of cases of total body therapeutic hypothermia in 2022 were lower than the typical average (total patients of 6). The SCFN Therapy Bundle was utilized in 100% of the HIE hypothermia cases in 2021 and 2022 and all cases were reviewed by the Cooling Committee.

Conclusion/Discussion: A multidisciplinary team approach to skin care in neonates with HIE receiving therapeutic hypothermia reduces the risk of significant skin breakdown including SCFN. Our target goal for the rate of SCFN was achieved through implementation of the SCFN bundle but remains slightly above that reported in the literature. Complication rates are also strongly impacted by a reduction in the number of patients admitted for HIE who are treated with therapeutic hypothermia. Our Cooling Committee is continuing to review the process including audits of each HIE case to evaluate other areas for improvement.