PLACE LABEL HERE

NEONATOLOGY SERVICE

INDUCED HYPOTHERMIA ADMISSION ORDERS

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

Diagnoses: (1) Hypoxic – Ischemic Encephalopathy (2) ______(3) ______(4) ______

Admit to ICU statusCode Status: Full code

Birth Weight: ______grams Current Weight:______grams Gestational Age:______weeks

Monitoring:

Admit to radiant warmer bed – keep heat source OFF

Place on cerebral function monitor (CFM) until at least 24 hours after re-warming is complete. May remove transiently during conventional EEG if indicated.

Place on cardiopulmonary monito and set apnea alarm at 20 seconds and HR limit at 70 – 200 bpm

Continuous pulse oximeter

Place pre- and post-ductal pulse oximeters

 Pulse Oximeter Target Range 90-95 %- Alarm Limits (89-96%)

 Pulse Oximeter Target Range ___ - ___ %- Alarm Limits (___ - ___ %)

Obtain vital signs (heart rate, respiratory rate, blood pressure, and pulse oximetry readings):

  • During cooling: Every 30 minutes for 0-4 hours, then every hour for 4-72 hours
  • During re-warming: Every hour
  • After re-warming is complete: Every hour for 2 hours, then every 3 hours

Record axillary and esophageal temperatures:

  • During cooling: Every 15 minutes for 0-2 hours, every 30 minutes for 2-4 hours, then every hour for 4-72 hours
  • During re-warming: Every 30 minutes
  • After re-warming is complete: Axillary temperature only every hour for 2 hours, then every 3 hours

Reposition the infant every 4 hours and assess skin

If 12 hour urine output is <2ml/kg/hr place indwelling urinary catheter with collection device

Induction of hypothermia therapy:

  • Place infantonTecoTherm Neo(or similar device) whole body cooling system
  • Place esophageal temperature probe
  • Use Servo-Control Complete Treatment Mode to maintain esophageal temperature at 33.5oC for 72 hours, then, re-warm to 37oC at a rate of 0.5oC per hour
  • Follow the step-by-step directions given on the deviceand in the procedure “GMC Induced Hypothermia, Neonatal” for the use of the TecoTherm Neo
  • The radiant warmer heat should be OFF at all times during cooling
  • Document temperature checks in the hypothermia log

Measurements:

Ballard exam (may be deferred until 24 hours after rewarming is complete) OR best estimate of gestational age by

physician or nurse practitioner (unless conceived via in vitro fertilization)

Weight on admission and then after re-warming every Monday, Wednesday, and Friday

Length and head circumference every Monday, plot all measurements on growth curve

Copy to pharmacy Order writer’s initials: ______

*3-38752* FORM 3-38752 REV. 04/2017 Page 1 of 3

PLACE LABEL HERE

NEONATOLOGY SERVICE

INDUCED HYPOTHERMIA ADMISSION ORDERS

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

Fluids and Nutrition:

NPO

Strict I & O

 D10W at 60 ml/kg/day (_____ ml/hr)

 D10W at ______ml/kg/day (_____ ml/hr)

Pre-mixed TPN solution (“Ready Bag)”, at ______ml/kg/day (_____ ml/hr)

Lipids 20% ______gm/kg/day (_____ ml/hr)

 Arterial line fluid: NS 0.45 with heparin 1 unit/ml at 1ml/hr

 UVC fluid: ______with heparin 1 unit/ml to run at ____ml/hr

 Total fluid intake of ______ml/hr (includes PAL or UAC fluids)

 Heparin flush q 4 hrs for maintenance of lumens of central lines

 ______

Imaging:

Cranial ultrasound STAT

 CXR stat if patient is in respiratory distress

 CXR and Abdominal X-rayfor esophageal probe placement

Conventional EEG @ 24 hours of age

MRI of head around 48 hours after re-warming is complete if stable per Physician/NNP

 ______

Laboratory tests:

Blood glucose monitoring on admission, then q 1 hr until stable, then q 4 hrs x 12 hrs, then q 12 hrs if WNL

Newborn Bloodspot Screening

  • Send on admission prior to initiation of intravenous fluids, unless initial screen already obtained
  • Send an additional newborn bloodspot screen at 72 hours of life on any infant initially tested prior to 24 hours of life.
  • If NPO at 72 hours of life, send an additional screen after initiation of enteral feedings and prior to discharge
  • For infants requiring blood product transfusion, collect initial newborn bloodspot screen prior to the transfusion. Collect an additional screen 120 days after the last transfusion.
  • For infants being transferred to another hospital prior to 24 hours of age, collect initial newborn bloodspot screen prior to transfer.

Blood culture, NNP, PT/PTT, CBC with diff, and type and crossmatch now

Arterial blood gas now. Temperature correct results to 37oC

 CBC with diff at 6 hrs of life

 CRP at 24 hours of life

Chem 7, magnesium, PT/PTT, CBC with diff in the am x 3 days

Chem 7, magnesium, PT/PTT, CBC with diff after cooling treatment completed- due ______@ ______

 ______

Scheduled Medications:

 Erythromycin ophthalmic ointment both eyes on admission, if not given at delivery

 Aquamephyton (2mg/ml): 1mg (0.5ml) IM, if not given at delivery

 Ampicillin 50 mg/kg IV q 12 hrs (_____ mg)

 Clindamycin 5mg/kg IV q 12 hrs(_____ mg)

Copy to pharmacy Order writer’s initials: ______

FORM 3-38752 REV. 04/2017 Page 1 of 3

PLACE LABEL HERE

NEONATOLOGY SERVICE

INDUCED HYPOTHERMIA ADMISSION ORDERS

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

Scheduled Medications (continued from previous page)

Claforan (cefotaxime) 50mg/kg IV q 12 hrs (_____ mg)

 Gentamicin 4 mg/kg IV q 24 hrs (______mg), Gentamicin trough level just prior to 4th dose and peak level 30 minutes

after 4th dose completed

 Morphine 0.1 mg/kg IV q 8 hours (_____ mg)

If both Morphine and Fentanyl are ordered, schedule so that Morphine and Fentanyl doses will alternate q 4 hrs

 FentaNYL 1mcg/kg IV q 8 hrs (_____ mg)

If both Morphine and Fentanyl are ordered, schedule so that Morphine and Fentanyl doses will alternate q 4 hrs

Phenobarbital loading dose 20mg/kg IV (_____ mg) now, then maintenance dose of 4mg/kg IV q 24 hours (_____ mg).

Start maintenance dose 12 hrs after the loadingdose

 Phenobarbital loading dose 20mg/kg IV (_____ mg) now, no maintenance dose.

______

 ______

PRN Medications:

 FentaNYL 1mcg/kg IV q 4 hrs prn for pain (_____ mg)

Morphine 0.1 mg/kg IV q 4 hrs prn for pain (_____ mg)

 Norcuron (vecuronium) 0.1mg/kg IV q 1 hr prn for paralysis

Aqua Tears (polyvinyl alcohol) eye lubricant apply to both eyes q 1 hrs prn while patient is receiving Norcuron

 ______

Other:

Social services consult

Hearing screen, CCHD screen, and Purple Cry training before discharge

 For infants 37 weeks at birth, upright position trial before discharge

 ______

 ______

______

Date Time Physician Signature PID Number

Copy to pharmacy

FORM 3-38752 REV. 04/2017 Page 1 of 3