Registry for Therapeutic Hypothermia using MiraCradle® - Neonate Cooler

General Information

Neonate ID

Hospital

  

Name

Email

Sex

Male

Female

  
Gestational Age

Wks

Days

Birth Weight (g)

Date of Birth

Time of Birth

AM / PM

    

Place of Birth

   

Complete Postal Address (including pin code)

Inborn

Outborn

  

Father Name

Mother Name

Mobile No.

Alternate Mobile No.

Landline No.

Alternate Landline No.

Antenatal and Intrapartum Details

Obstetrical History

G

P

L

A

END

  
 

ANC

Yes

No

If yes, enter number of visits

 

Hospital / Place of antenatal Care

 

Maternal Complications in the antenatal period

GDM

PIH

HT

Thyroid disease

APH

IUGR

Twin

NIL

Others
   

Onset of labour:

Induced

Spontaneous

  
 

Duration of labour

Duration of ROM

    
 

Intrapartum complications:

Uterine rupture

Mec. stained liquor

Hemorrhage

Cord Prolapse

Shoulder dystocia

Ante partum Mg exposure

Abnormal CTG

Specify
 

Risk of sepsis

Maternal fever (> 37.6°C, > 99.7°C):

Chorioamnionitis

PPROM

Multiple PVs >3

PROM > 18 hours

Mode of Delivery:

Normal

LSCS after labour

Vacuum

Breech

Pre-labour LSCS

Forceps

Indication

Age of starting Cooling

   

Mode of Cooling: MiraCradle® - Neonate Cooler

Age when target temperature achieved

Note: This age calculation is required to estimate the effective time of cooling from the start

Clinical Details of Baby at Birth

AGA

SGA

LGA

Head Circumference

cm

Resuscitated >5 minutes:

Yes

No

Cried at

min (Outborn)

  

Apgar score

1 min

5min

10 min

20min
     

Initial Temperature of Baby (°C)

    

Blood gas results (worst set of results within 60 minutes including cord blood)

pH

pO2

PCO2

Base deficit

HCO3

   

Clinical Seizures

Yes

No

Encephalopathy

Yes

No

Criteria for defining moderate/severe encephalopathy 3/6 areas should be present
Category
Moderate Encephalopathy
Severe Encephalopathy
Level of consciousness
Lethargic
Stupor or Coma
Spontaneous activity
Decreased activity
No activity
Posture
Distal Flexion Complete extension
Decerebrate
Tone
Hypotonia (focal or generalized
Flaccid
Primitive reflexes
Suck
Weak
Absent
Moro
Incomplete
Absent
Autonomic system
Pupils
Constricted
Deviated, dilated or non-reactive to light
Heart rate
Bradycardia
Variable
Respiration
Periodic Breathing
Apnea
 

Thompson Score prior to cooling

Baby Age

Sign
0
1
2
3
Score
Tone
Normal
Hyper
Hypo
Flaccid
LOC
Normal
Hyper alert, stare
Lethargic
Comatose
Fits
None
Infrequent
Frequent >2/day
Posture
Normal
Fisting, cycling
Strong distal flexion
Decerebrate
Moro
Normal
Partial
Absent
Grasp
Normal
Poor
Absent
Suck
Normal
Poor
Absent / bites
Resp.
Normal
Hypervent
Brief apnoea
Apnoeic
Fontanelle
Normal
Full, Not tense
Tense

Total Score   
 

Day 1: Cooling hours 0-23
Hour:MM 00:00 = time when cooling is started

For first four hours, temperature to be monitored after every 15 minutes
HH:MM
Rectal Temp (°C)
Skin Temp (°C)
HH:MM
Rectal Temp (°C)
Skin Temp (°C)
00:15
00:30
00:45
01:00
01:15
01:30
01:45
02:00
02:15
02:30
02:45
03:00
03:15
03:30
03:45
04:00
05:00
06:00
07:00
08:00
09:00
10:00
11:00
12:00
13:00
14:00
15:00
16:00
17:00
18:00
19:00
20:00
21:00
22:00
23:00
 
 

Hypoxic Ischemic Encephalopathy Score Day 1

Baby Age

Sign
0
1
2
3
Score
Tone
Normal
Hyper
Hypo
Flaccid
LOC
Normal
Hyper alert, stare
Lethargic
Comatose
Fits
None
Infrequent
Frequent >2/day
Posture
Normal
Fisting, cycling
Strong distal flexion
Decerebrate
Moro
Normal
Partial
Absent
Grasp
Normal
Poor
Absent
Suck
Normal
Poor
Absent / bites
Resp.
Normal
Hypervent
Brief apnoea
Apnoeic
Fontanelle
Normal
Full, Not tense
Tense

Total Score   
 

Day 2: Cooling hours 24:00 to 47:00
HH:MM
Rectal Temp (°C)
Skin Temp (°C)
HH:MM
Rectal Temp (°C)
Skin Temp (°C)
24:00
25:00
26:00
27:00
28:00
29:00
30:00
31:00
32:00
33:00
34:00
35:00
36:00
37:00
38:00
39:00
40:00
41:00
42:00
43:00
44:00
45:00
46:00
47:00
 

Hypoxic Ischemic Encephalopathy Score Day 2

Baby Age

Sign
0
1
2
3
Score
Tone
Normal
Hyper
Hypo
Flaccid
LOC
Normal
Hyper alert, stare
Lethargic
Comatose
Fits
None
Infrequent
Frequent >2/day
Posture
Normal
Fisting, cycling
Strong distal flexion
Decerebrate
Moro
Normal
Partial
Absent
Grasp
Normal
Poor
Absent
Suck
Normal
Poor
Absent / bites
Resp.
Normal
Hypervent
Brief apnoea
Apnoeic
Fontanelle
Normal
Full, Not tense
Tense

Total Score   
 

Day 3: Cooling hours 48:00-71:00
HH:MM
Rectal Temp (°C)
Skin Temp (°C)
HH:MM
Rectal Temp (°C)
Skin Temp (°C)
48:00
49:00
50:00
51:00
52:00
53:00
54:00
55:00
56:00
57:00
58:00
59:00
60:00
61:00
62:00
63:00
64:00
65:00
66:00
67:00
68:00
69:00
70:00
71:00
 

Hypoxic Ischemic Encephalopathy Score Day 3

Baby Age

Sign
0
1
2
3
Score
Tone
Normal
Hyper
Hypo
Flaccid
LOC
Normal
Hyper alert, stare
Lethargic
Comatose
Fits
None
Infrequent
Frequent >2/day
Posture
Normal
Fisting, cycling
Strong distal flexion
Decerebrate
Moro
Normal
Partial
Absent
Grasp
Normal
Poor
Absent
Suck
Normal
Poor
Absent / bites
Resp.
Normal
Hypervent
Brief apnoea
Apnoeic
Fontanelle
Normal
Full, Not tense
Tense

Total Score   
 

Day 4: Cooling hours 72:00 to 95:00
HH:MM
Rectal Temp (°C)
Skin Temp (°C)
HH:MM
Rectal Temp (°C)
Skin Temp (°C)
72:00
73:00
74:00
75:00
76:00
77:00
78:00
79:00
80:00
81:00
82:00
83:00
84:00
85:00
86:00
87:00
88:00
89:00
90:00
91:00
92:00
93:00
94:00
95:00
 

Hypoxic Ischemic Encephalopathy Score Day 4

Baby Age

Sign
0
1
2
3
Score
Tone
Normal
Hyper
Hypo
Flaccid
LOC
Normal
Hyper alert, stare
Lethargic
Comatose
Fits
None
Infrequent
Frequent >2/day
Posture
Normal
Fisting, cycling
Strong distal flexion
Decerebrate
Moro
Normal
Partial
Absent
Grasp
Normal
Poor
Absent
Suck
Normal
Poor
Absent / bites
Resp.
Normal
Hypervent
Brief apnoea
Apnoeic
Fontanelle
Normal
Full, Not tense
Tense

Total Score   
 

Complications

Subcutaneous Fat Necrosis

Seizures

 

Arrhythmia

Coagulopathy

 

Clinical Bleeding

Type

 

Hypotension
Persistent mean blood pressure of <40mmHg

Electrolyte Disturbance Yes / No Specify

  

Sepsis

Organism

 

Probable sepsis

CRP

 

Leukopenia (< 5000)

ITR>0.2

  

Hypoglycaemia <47mg%

Hyperglycemia > 150mg%

  

Meningitis

     

Thrombocytopenia <1, 00,000

Lowest Platelets

 

PPHN

     

Others

NIL

     

Treatment

Ventilation:

CPAP

IMV

HFOV

Oxygen

Inotropes:

Dopamine

Dobutamine

Adrenaline

Others

Anticonvulsants:

Phenobarbitone

Phenytoin

Benzodiazepine

Others

Analgesics & Sedation:

Morphine

Fentanyl

Midazolam

Others
 
Neuroimaging
Done on day
Results
Ultrasound
MRI
CT
 

Other Diagnosis

Discharge at

day of life

            

Outcome:

A& W

AMA

Died

Specify Reason

Discharge status:

                

Feeding at discharge:

Oral

Tube feeds

       

Anticonvulsants:

Phenobarbitone

Phenytoin

Others

   
 

Neurological status at discharge/Day 7

Sign
0
1
2
3
Score
Tone
Normal
Hyper
Hypo
Flaccid
LOC
Normal
Hyper alert, stare
Lethargic
Comatose
Fits
None
Infrequent
Frequent >2/day
Posture
Normal
Fisting, cycling
Strong distal flexion
Decerebrate
Moro
Normal
Partial
Absent
Grasp
Normal
Poor
Absent
Suck
Normal
Poor
Absent / bites
Resp.
Normal
Hypervent
Brief apnoea
Apnoeic
Fontanelle
Normal
Full, Not tense
Tense

Total Score   
 

If cooling stopped before 72 hours Why?

 

Autopsy done

Yes

No

  

Report

 
 
Appendix