PLACE LABEL HERE
INDUCED HYPOTHERMIA
ADMISSION ORDERS
Neonatology Service
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).
DIAGNOSIS: Hypoxic – Ischemic Encephalopathy, Other: __________________________________________________
Admit to ICU status
Code Status: Full code
Birth Weight: _______________ grams
Current Weight: __________ grams
Gestational Age: ________ weeks
Admit to radiant warmer bed – keep power to OFF initially to accelerate cooling
MONITORING:
1. Place on cerebral function monitor (CFM). Do not discontinue without physician order.
2. Vital signs q 30 min x 3, then q 1 hr while on the cool cap.
3. Cardiopulmonary monitor
 place cardiopulmonary leads
 set apnea alarm at 20 seconds and HR limit at 70 – 200 bpm
4. 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 (___ - ___ %)
INDUCTION OF HYPOTHERMIA THERAPY:
5. Place infant on Olympic cool cap system for induced hypothermia for 72 hours or until discontinued by physician
6. Follow the step-by-step directions given on the device and in the procedure”Induced Hypothermia, Neonatal”.
The instructions given below are for general guidance only
 Maintain rectal temperature at 34-35oC while cooling infant
 When rectal temperature decreases to 35.5o C turn the radiant warmer on in the servo –mode and set the initial
servo-temperature to 37oC.
 Once the skin temperature stabilizes, adjust the servo temperature to about 0.5oC above the skin temperature to
maintain 100% radiant warmer heat output,
 Adjust cap temperature to maintain rectal temperature 34-35oC. Make adjustments in the range of 0.1-0.5oC
 Document hourly temperature checks in the hypothermia log
 Remove the cap every 12 hrs to inspect the scalp and skin for irritative injury
MEASUREMENTS:
7. 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)
8. Weight on admission and then after re-warming every Monday, Wednesday, and Friday
9. Length and head circumference every Monday, plot all measurements on growth curve
Order writer’s initials _______
Copy to pharmacy
*3-38752*
FORM 3-38752 INITIATED 01/2016
Page 1 of 3
PLACE LABEL HERE
INDUCED HYPOTHERMIA
ADMISSION ORDERS
Neonatology Service
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:
10. NPO
11. Strict I & O
 D10W at ______ ml/kg/day (_____ ml/hr)
 Pre-mixed TPN solution (“Ready Bag)”, ______ gram bag, at ______ml/kg/day (_____ ml/hr)
 Lipids 20% ________ gm/kg/day (_____ ml/hr)
 Arterial line fluid: ½ NS 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 1 unit/ml, 1 ml q 4 hrs for maintenance of lumens of central lines
 Normal saline flush q 4 hrs for maintenance of the lumen of peripheral IV lines
 __________________________________________________________
IMAGING:
12.  Cranial ultrasound
13.  CXR stat if patient is in respiratory distress
14.  CXR and Abdominal X-ray if UAC, UVC or PICC is placed
15.  _________________________________________________________
LABORATORY TESTS:
16. Blood glucose monitoring on admission, then q 1 hr until stable, then q 4 hrs x 12 hrs, then q 12 hrs if WNL
17. State Metabolic Screen at 24 hours of age (before transfusion, or before transfer to another facility).
If less than 24 hrs on feeds, repeat screen when infant is on full feeds
18. Blood culture now
19. Chem 7, magnesium, PT/PTT, CBC with diff, arterial blood gas now
20. Type and cross-match now
21.  CBC with diff at 6 hrs of life
22.  CRP at 24 hours of life
23. Chem 7, magnesium, PT/PTT, CBC with diff after 36 hours of head cooling- due ____________ @ _________
24. Chem 7, magnesium, PT/PTT, CBC with diff after cooling treatment completed- due ____________ @ _________
25.  __________________________________________________________
SCHEDULED MEDICATIONS:
26.  Erythromycin ophthalmic ointment both eyes on admission, if not given at delivery
27.  Aquamephyton (phytonadione) (2 mg/ml): 1mg (0.5 ml) IM, if not given at delivery
28.  Ampicillin 50 mg/kg IV q 12 hrs (_____ mg)
29.  Ampicillin 100 mg/kg IV q 12 hrs (_____ mg)
30.  Clindamycin 5mg/kg IV q 12 hrs (_____ mg)
31.  Claforan (cefotaxime) 50mg/kg IV q 12 hrs (_____ mg)
32.  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
Copy to pharmacy
FORM 3-38752 INITIATED 01/2016
Order writer’s initials _______
Page 2 of 3
PLACE LABEL HERE
INDUCED HYPOTHERMIA
ADMISSION ORDERS
Neonatology Service
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):
33.  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
34.  FentaNYL 1 mcg/kg IV q 8 hrs (_____ mcg)
If both Morphine and Fentanyl are ordered, schedule so that Morphine and Fentanyl doses will alternate q 4 hrs
35.  Phenobarbital loading dose 20 mg/kg IV (_____ mg) now, then maintenance dose of 4mg/kg IV q 24 hrs (___ mg)
Start maintenance dose 12 hrs after the loading dose
36.  Phenobarbital loading dose 20 mg/kg IV (_____ mg) now, no maintenance dose.
37.  __________________________________________________________
38.  __________________________________________________________
ONE TIME DOSE MEDICATIONS:
39.  HIE Phenobarbital Prophylaxis. Phenobarbital 40 mg/kg IV (_____ mg) now, infuse over 1 hour
PRN MEDICATIONS:
40.  FentaNYL 1 mcg/kg IV q 4 hrs prn for pain (_____ mcg)
41.  Morphine 0.1 mg/kg IV q 4 hrs prn for pain (_____ mg)
42.  Norcuron (vecuronium) 0.1 mg/kg IV q 1 hr prn for paralysis
43.  Akwa Tears Ophth (lanolin, mineral oil, petrolatum) eye lubricant apply to both eyes q 1 hrs prn while patient is
receiving Norcuron
44.  __________________________________________________________
REWARMING:
45. Remove the heat shield
46. Remove the cap
47. Adjust radiant warmer servo temperature to about 0.3oC above rectal temperature to begin rewarming,
and 0.2-0.3oC q 30 minutes or so over a 4 hr period
48. Obtain and document vital signs with each temperature increase of the radiant warmer
49. Monitor for clinical evidence of seizure activity
50. Resume routine NICU standards of care once the infant’s temperature reaches 37oC
OTHER:
51. Social services consult
52. Hearing screen, CCHD screen, and Purple Cry training before discharge
53. For infants < 37 weeks at birth, upright position trial before discharge
54.  __________________________________________________________
55.  __________________________________________________________
______________
Date
______________
Time
____________________________
Physician Signature
__________________
PID Number
Copy to pharmacy
FORM 3-38752 INITIATED 01/2016
Page 3 of 3