NS 1800.14
Therapeutic Measures
NP 10/05
Parkland Health & Hospital System
Women & Infant Specialty Health
Nursery Services Procedure Manual
Total Body Cooling for Infants with Hypoxic Ischemic Encephalopathy
Practice
Statement Upon the written order of the attending neonatologist or neonatal fellow
the licensed nurse shall initiate, monitor and discontinue total body cooling
therapy on infants with moderate to severe Hypoxic Ischemic
Encephalopathy (HIE).
Total body cooling should be started on qualifying infant’s before 6 hours
of age.
Purpose
Total body cooling has been proven to decrease moderate and severe
disability or death in infants born with moderate to severe asphyxia.
Equipment Pre-printed provider orders:
 Phase 1 Initiation of Hypothermia # 6221
 Phase 2 Rewarming of Hypothermia # 6222-A
 Phase 2 Rewarming Worksheet # 6222-B
Blanketrol II Model 222R and Distilled Water
Hose # 286
Rectal/Esophageal Sterile Disposable Probe
Probe Adaptor Cable
Maxi-Therm Lite Pediatric Blanket (single patient use)
Maxi- Therm Lite Adult Blanket (single patient use)
IV pole
Procedure
A.
Eligibility Criteria
1. The attending or neonatal fellow shall evaluate all term infants ( 36 weeks
gestation) admitted to the NICU with a diagnosis of neonatal depression, acute
perinatal asphyxia or encephalopathy for total body cooling therapy.
2. Infants will be evaluated in two steps. Step A is an evaluation of clinical and
biochemical criteria followed by Step B a neurologic exam to assess the stage of
encephalopathy.
Step A
Evaluation of Clinical and Biochemical Criteria
All infants will be evaluated for the following parameters:
1. History of an acute perinatal event: abruptio placenta, cord prolapse, severe FHR
abnormality: variable or late decelerations
2. Apgar score  5 at 10 minutes.
3. Cord pH  7.0 or first postnatal blood gas pH  7.0 within 1 hour.
4. Base deficit on cord gas  16 mEq/L or first postnatal blood gas  16 mEq/L within 1 hour.
5. Continued need for ventilation initiated at birth and continued for at least 10 minutes.
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Therapeutic Measures
NP 10/05
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3. Based upon the above criteria infant’s meeting specific parameters shall be
catogorized as either A1 or A2.
A1 are those infants that have either a:
 Cord pH ≤ 7.0 or first postnatal blood gas pH ≤ 7.0 within 1 hour
OR
 Base deficit on cord gas ≥ 16 mEq/L or first postnatal blood gas ≥ 16
mEq/L within 1 hour.


A2 are those infants with no blood gas or a blood gas with the pH between
7.0 and 7.15 and base deficit between 10-15.9 mEq/L that have had an
acute perinatal event with either a:
 Apgar score ≤ 5 at 10 minutes
OR
 Need for ventilation initiated at birth and continued for atleast 10 minutes.
4. The attending physician or designee will perform a neurologic exam for infants in A1
and A2 categories. The infant must show signs of moderate or severe HIE in at least
3 of the following 6 categories to be eligible for total body cooling. Infants who
present with clinical seizures immediately qualify for total body cooling even if they
do not meet step B criteria.
Step B Neurological Exam
CATEGORY
SIGNS OF HIE
Normal
To
Mild
Moderate
Severe
1. LEVEL OF CONSCIOUSNESS
1
2 = Lethargic
3 = Stupor/coma
2. SPONTANEOUS ACTIVITY
1
3 = No activity
3. POSTURE
1
2 = Decreased activity
2=Distal flexion,
complete extension
2 = Hypotonia (focal or
general)
4. TONE
1
3 = Decerebrate
3 = Flaccid
5. PRIMITIVE REFLEXES
 Suck
 Moro
6. AUTONOMIC SYSTEM
1
1
2 = Weak
2 = Incomplete
3 = Absent
3 = Absent

Pupils
1
2 = Constricted

Heart rate
1
2 = Bradycardia
3 = Deviation/dilated/
non-reactive to light
3 = Variable HR

Respiration
1
2 = Periodic breathing
3 = Apnea
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Therapeutic Measures
NP 10/05
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B.
Cooling Procedures
1. Obtain pre-printed orders for Total Body Cooling. The attending physician or
neonatal fellow shall sign the Pre-Printed Initiation Cooling order sheet.
2. Gather equipment to the bedside.
3. Pre-cool the blanketrol blanket:
a. Attach the adult and pediatric hypothermia blankets to the hypothermia machine.
b. Place the adult hypothermia blanket on an IV pole.
c. Close the toggles on both the adult and pediatric blankets.
d. Fill the cooling unit reservoir with 4 liters of Sterile Water.
e. Plug in the system.
f. POWER ON - status light will come on which says "Check Set Point". Make
sure the temperatures are reading in the Celsius mode. The switch is on the
front of the unit beside the "On/Off Switch".
g. Push "TEMP SET" switch to pre-cool and lower temperature to 5°C by pushing
the down arrow▼. (Do not go <5° or the blanket will alarm).
h. OPEN the toggles on both of the cooling blankets.
i. Press MANUAL CONTROL to start cooling blanket (the blanket's motor should
come on).
j. Let blanket cool.
3. Place the esophageal probe 2cm above the diaphragm:
a. Determine esophageal temperature placement by measuring tip of nose to ear
lobe and down to the xiphoid process, then minus 2 cm. Mark the distance on
the tube with tape.
b. Warm the esophageal probe in warm water, and lubricate the first 5-cm.
c. Insert esophageal probe, preferably via the nares, and if not possible, then orally.
d. Confirm placement with a CXR.
4. Place the infant on the pre-cooled blanket 25x33” and attach esophageal
temperature probe to blanket. The blanket should be kept dry. The infant may be
placed directly on the blanket or one thin sheet may be placed over the blanket,
under the infant.
5. Place the IV pole with the adult blanket out of the way. Make sure none of the hoses
are kinked. The large blanket on the IV pole is needed to minimize large fluctuations
in the infant’s temperature.
6. Turn the infant’s radiant warmer to manual mode and decrease heat output to 0.
There should be no external heat source. Maintain temperature probe so the skin
temperature reading is on.
7. Press “TEMP SET” on the blanket and adjust the temperature to 33.5 oC with the ▲
arrow.
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Therapeutic Measures
NP 10/05
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8. Press "AUTO CONTROL" (blanket's motor should go on and off with cooling). To be
sure the unit is working properly, the wheel at the side of the unit will be turning.
Goal temperature 33.5 degrees C with an acceptable temperature range of 32.5
– 34.5 º C.
9. Record esophageal and skin temperature every hour for 12 hours then every 2
hours.
10. Record heart rate and blood pressure at baseline, hourly for 12 hours, then every 2
hours. If infant requires inotropic support record blood pressure at baseline, the
hourly while on inotropic support. Anticipate bradycardia.
11. Obtain blood gases at baseline, 4, 8, 12, 24,48, and 72 hours of age.
infant’s temperature on blood gas slip.
Record
12. Obtain serum electrolytes, BUN, and creatinine at baseline, 24, 48, and at 72 hours.
13. Check skin condition every 4 hours for areas of skin breakdown. Notify the provider
of areas of redness.
14. Use pulse oximetry cautiously, if at all. Obtain provider order’s to discontinue pulse
oximetry during hypothermia if not functioning properly.
15. Notify attending/neonatal fellow if temperature drops below 31 ºC.
16. A HUS shall be performed within 24 hours as clinically indicated.
17. The infant is to remain on the hypothermia blanket continuously for 72 hours. After
72 hours rewarming orders will be initiated.
C.
Re-warming Procedures
1. At the end of 72 hours obtain pre-printed provider order for rewarming.
attending or neonatal fellow shall sign the order form.
The
2. Obtain re-warming worksheet. Avoid rapid re-warming of the infant.
3. Press “TEMP SET” on the cooling unit.
4. Increase the temperature on the cooling unit by 0.5ºC every hour until the set point
temperature on the cooling unit is on 36.5 º C. Record esophageal and skin
temperature, heart rate, blood pressure and blanketrol readings hourly on the
rewarming worksheet.
5. Once the set point on the cooling unit has been on 36.5 for one-hour switch the
cooling unit to monitor only.
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Therapeutic Measures
NP 10/05
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6. Switch the radiant warmer temperature mode from manual to servo and set the
servo control temperature to 0.5ºC above infant’s skin temperature.
7. Increase the servo control temperature by 0.5ºC each hour until the servo control
reading is set 36.5ºC. Record esophageal and skin temperature, heart rate and
blood pressure readings hourly on the rewarming worksheet.
8. Once the infant’s skin temperature reaches 36.5ºC remove cooling blanket and
esophageal probe. Dispose of pediatric and adult blankets. Place machine in dirty
utility room for proper cleaning.
9. Obtain further vital sign per level of care and document on the NNICU flowsheet.
10. A MRI should be performed at discharged or at 44 weeks postconceptual age per
standard of care.