Therapeutic Hypothermia Pre-Transport Cooling Protocol

Pre-Transport Cooling Protocol for Referring Hospitals

• Therapeutic Hypothermia Pre-Transport Cooling Protocol packet

Therapeutic Hypothermia for Level IV NICUs

Inclusion Criteria

• Infants must meet clinical/biochemical criteria AND
• Infants must meet neurological criteria AND
• Infants must NOT meet any exclusion criteria

Clinical and Biochemical Criteria

Main criteria

• History of an acute perinatal hypoxic event
  • Abruptio placenta, cord prolapse, severe fetal heart rate abnormalities such as variable or late decelerations
• Apgar score ≤ 5 at 10 minutes of life
• pH ≤ 7.0 from cord blood or postnatal blood gas at ≤ 1 hour of life
• Base deficit ≥ 16 mEq/L on cord blood or postnatal blood gas at ≤ 1 hour of life
• Continued need for ventilation initiated at birth for at least 10 minutes

Step A

• If blood gas available
• If infant meets at least ONE of the main criteria, proceed to Neurological examination criteria

Step B

• If blood gas is not available or pH is 7.0-7.15 and base deficit is 10-15 mEq/L AND
• History of acute perinatal hypoxic event and Apgar ≤ 5 at 10 minutes of life OR
• Continued need for ventilation at birth and continuing at least 10 minutes
• If infant meets one of main criteria and step B, proceed to Neurological examination criteria

Neurological Examination Criteria (see Table 1)

• Seizures OR presence of 3 of the 6 categories on exam

Table 1. Neurological Examination Criteria

Exclusion Criteria

• Inability to initiate cooling by 6 hours of age
• Infants ≤ 36 weeks Post Menstrual Age
• Infants without evidence of hypoxic ischemic encephalopathy (HIE) or perinatal depression
• Presence of known chromosomal abnormality
• Presence of major congenital anomalies
• Severe intrauterine growth restriction (weight ≤ 1800gms)
• Infants in extremis
• Lack of parental consent

When Starting Hypothermia Use Preprinted NICU Body Cooling Orders

• Continuous EEG monitoring will be started with cooling protocol
• Infant is to be kept at 33.5 0 C for 72 hours
• Infant should not be given warmed O2
• Infant's HR may decrease to 70 BPM
• Resident will be called if T < 31oC or HR < 70 BPM - Notify attending
• After 72 hours, rewarming is done gradually over 6 hours by 0.5oC/h
• Seizures may occur during rewarming - continue EEG monitoring

Sarnat Staging (see Table 2)

• Document Sarnat Score in History and Physical
• Required by the State of California

Table 2. Sarnat Staging

Protocol

• Protocol for Whole-Body Hypothermia and Re-Warming