Therapeutic Hypothermia Candidacy Checklist
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thubtendrolmaTherapeutic Hypothermia Candidacy Checklist
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thubtendrolmaCANDIDACY FOR THERAPEUTIC / NEUROPROTECTIVE HYPOTHERMIA CHECKLIST
Directions: Start at the top and work through each numbered component
*Note: if patient is less than six hours old and meets the gestation, weight and blood gas criteria and has a witnessed seizure, patient is eligible for
hypothermia regardless of additional exam findings. Consult the tertiary center where cooling is offered to discuss any questions or concerns.
TIME of birth:__________ a.m./p.m. CURRENT AGE in hours/minutes: _________ h.________ min.
Studies may be in progress that permit therapeutic hypothermia on some infants who may not otherwise qualify for this therapy. This includes if the infant is > 6 hours
old, or is < 1800 grams, or is younger than 36 weeks gestation. Consult the tertiary center with patient information once the information has been gathered.
Clinical information
Gestation
Weight
pH = ___ Base deficit (BD) = ___
36 weeks gestation
Go to
Ask tertiary center
1800 grams
Go to
Ask tertiary center
Criteria met thus far.
Go to EXAM*
< 36 weeks gestation
< 1800 grams
OR, 1st baby blood gas at < 1 hour of life.
Time obtained: ___ : ___
Arterial Capillary Venous
or
Base deficit > 16
2 Weight
3 Blood gas
Go to
Or Base deficit 10 to 15.9
May not be eligible;
Go to 4 History of
No gas obtained
Source: Cord
Instructions
patient information)
pH 7.0
Blood gas
Criteria (place a check in the box that corresponds to the
Or pH 7.01 to 7.15
pH > 7.15 or Base deficit < 10
4 History of
acute perinatal event
acute perinatal event
Acute perinatal event
(check all that apply)
Apgar score at
1 minute ________
5 minutes ________
10 minutes ________
Resuscitation after delivery
(check all that apply)
___ PPV / intubated at 10 minutes
___ CPR
___ Epinephrine administered
Variable / late fetal HR decelerations
Prolapsed / ruptured or tight nuchal cord
Uterine rupture
Maternal hemorrhage / placental abruption
Maternal trauma (e.g. vehicle accident)
Mother received CPR
Any checked,
Go to 5 Apgar score
No perinatal event
Or
Indeterminate what the event was because of
home birth or missing information
May not be eligible;
Go to 5 Apgar score
Apgar 5 at 10 minutes (yes)
Criteria met thus far.
Go to EXAM*
pgar 5 at 10 minutes (no)
A
(no, was 6 or greater at 10 minutes)
Go to
C
ontinued need for PPV or intubated
at 10 minutes? (yes)
Criteria met thus far.
Go to EXAM*
PPV / intubated at 10 minutes? (no)
May not be eligible;
Go to EXAM*
Resuscitation after delivery
Decision tree template courtesy of Neonatology-Neurology Program at Childrens National Medical Center, Washington, D.C. Adapted with permission.
2013 The S.T.A.B.L.E. Program 6 th edition Reproduced with permission.
www.stableprogram.org