Clinical Pathway

Clinical pathway for the treatment of moderate/severe hypoxic ischemic encephalopathy If blood gas is available: Once infant meets either A1 or A2, proceed to neurologic examination (Step B). [...] All infants will be evaluated if any of these findings are part of their history: Step A A1 A2 If blood gas is not available, or pH 7.01 to 7.15, or base deficit 10 to 15 mEq/L Infants ≥ 35 weeks admitted to the Neonatal Intensive Care Unit (NICU) with an admitting diagnosis of neonatal depression, acute perinatal asphyxia or encephalopathy will be evaluated in two steps; evaluation by clinical a [...] History of an acute perinatal event (abruption placenta, cord prolapse, severe fatal heart rate (FHR) abnormality: variable or late decelerations) 2. [...] Cord pH or any postnatal blood gas pH at ≤1 hour of ≤7.0 4. [...] Base deficit on cord gas or any postnatal blood gas at ≤ 1 hour of ≥16 mEq/L 5. [...] Continued need for ventilation initiated at birth and continued for at least 10 minutes • Cord pH or any postnatal blood gas pH ≤ 7.0 or • Base deficit on cord pH or any postnatal blood gas at ≥ 16 mEq/L • Acute perinatal event and • An Apgar score ≤ 5 at 10 minutes or • [...] Please document specific findings in the medical record that led to the category of encephalopathy – even if the infant did not meet cooling criteria. [...] When findings are mixed, the extent of encephalopathy is determined by which category describes the majority of signs. If signs were equally distributed, categorize level of encephalopathy based on the level of consciousness. Exclusion criteria: inability to be evaluated by 6 hours of age The neurologic examination will be performed by an experienced examiner. [...] If the infant meets criteria A1 or A2 and criteria B and does not meet exclusion criteria, the infant is eligible for therapeutic whole body cooling. [...] Earlier MRI may be considered to make decisions about offering withdrawal of intensive care to families in severe cases. Pain/sedation management: • Pain stress may have adverse effects on infants with HIE • Low dose morphine or dexmedetomidine drip should be used, even if non-intubated patients • “Normal” heart rate may reflect stress or hypovolemia Seizure management: • Continuous EEG monitori