UK TOBY Cooling Register

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UK TOBY Cooling Register Patient identification number (PIN) Patient ospital number At centre, optional Cooling treatment provided at Name of Hospital Sex M F Mont and year of treatment M M / Y Y

1 UK TOBY Cooling Register Patient identification number (PIN) Patient ospital number At centre, optional Cooling treatment provided at Name of Hospital Sex M F Mont and year of treatment M M / Y Y Gestational age at birt weeks days Clinical Details of Baby at Birt Birt weigt gm Head circumference. cm First Gasp at min Resuscitated >10 minutes Yes No Apgar Score (please write X if unknown) 1 min 5 mins 10 mins 20 mins Blood gas results (worst set of results witin 60 minutes including cord blood) ph. po 2. kpa pco 2. kpa Base deficit Clinical Seizures * Yes No Encepalopaty Yes No Hypoxic Iscaemic Encepalopaty score prior to Tone Hypertonia Hypotonia Reflexes Hyperreflexia Hyporeflexia Absent Feeding Not tolerating Tick ere if born in centre and complete Cooling Centre Column Passive Cooling If Yes, enter age started Birt Hospital Active Cooling If Yes, enter age started Aids used for (please tick all tat apply) During Transport Temperature monitoring during transport? Yes No If Yes, continuous 4x/r Cooling centre wen target first acieved ( ) Pregnancy complications * None or please give details attac separate seet if necessary Mode of Delivery (please tick one) Pre-labour CS 1 In labour CS 2 SVD cepalic 3 SVD breec 4 Instrumental delivery 5 Delivery complications * None or please give details attac separate seet if necessary Congenital abnormalities apparent at birt None or please give details attac separate seet if necessary Was an aeeg or EEG performed prior to? (please tick) No aeeg EEG Initial CFM findings and age recorded Background (in te absence of artefacts) / Mildly abnormal 1 Moderately abnormal 2 Severely abnormal 3 Seizures Yes No 1 Upper margin >10, 2 Upper margin >10, Upper margin <10 Lower margin of trace >5 Lower margin <5 * Definitions for all items on tis forarked wit an asterisk may be found in te Clinician s Handbook and in te appendix to tis form Version 7 November

2 PIN Day 1 Cooling ours 0-23 Hour 0 = time wen maintenance of normotermia ceases Seizures * support * Mecanical, supplementary O 2 Day 2 Cooling ours Seizures * support * Mecanical, supplementary O 2 Day 1 (Please circle clearly as appropriate) Tone Hypertonia Hypotonia Day 2 (Please circle clearly as appropriate) Tone Hypertonia Hypotonia Reflexes Hyperreflexia Hyporeflexia Absent Feeding Not tolerating Reflexes Hyperreflexia Hyporeflexia Absent Feeding Not tolerating * Definitions for all items on tis forarked wit an asterisk may be found in te Clinician s Handbook and in te appendix to tis form 2 Version 7 November 2010

3 PIN Day 3 Cooling ours Day 4 Cooling ours Seizures * support * Mecanical, supplementary O Seizures * support * Mecanical, supplementary O 2 Day 3 (Please circle clearly as appropriate) Tone Hypertonia Hypotonia Day 4 (Please circle clearly as appropriate) Tone Hypertonia Hypotonia Reflexes Hyperreflexia Hyporeflexia Absent Feeding Not tolerating Reflexes Hyperreflexia Hyporeflexia Absent Feeding Not tolerating * Definitions for all items on tis forarked wit an asterisk may be found in te Clinician s Handbook and in te appendix to tis form Version 7 November

4 PIN End of information and outcome Equipment used to maintain servo control 1 manual control 2 Outcome (please tick all tat apply) 1 Discarged ome days 2 Transferred to anoter ospital (please also inform us of later discarge or deat information wen it becomes available to you) days Please give name of ospital if transferred (Please send a potocopy of tis completed form to te receiving ospital wit te baby) 3 Died days rs Post Mortem planned? Yes No performed? Yes No MRI scan performed or booked Yes No MRI results (if available) attac separate seet if necessary Cranial Ultrasound report Yes No Summary attac separate seet if necessary Diagnoses during admission (please tick all tat apply) SFN * at age days None SFN treated Yes No Cerebral imaging abnormality * if Yes, please explain in comment field below Pneumonia * Trombosis * Pulmonary airleak * Necrotising enterocolitis * Pulmonary aemorrage * Late onset sepsis * (>72 ours after birt) Pulmonary ypertension * confirmed by blood or CSF culture Renal failure treated wit dialysis Oter comments, including any relevant diagnosis (e.g. metabolic, congenital abnormality or infection) Please report any condition or event likely to be due to treatment or rewarming Full sucking feeds acieved before discarge? Yes No If Yes, please give age days If was stopped earlier tan 72 ours please explain wy Form completed by (please print clearly) D / M / Wat to do now If necessary information may be provided on extra page(s) clearly numbered wit te PIN. Inform parents tat a developmental assessment will be completed at about 24 monts of age. Keep a copy of te completed form for your records, and identify YOUR copy clearly wit patient details. Ensure tat te PIN and baby details are added to your local record of all Registered babies. D M Y Y If te baby is transferred to anoter ospital please send a copy of tis completed form wit te notes and a Register transfer letter (ttps// so tat tey are aware of te Register PIN for tis baby. Te copy tat is sent to te Register must not contain any patient identifiers. Return completed form to UK TOBY Cooling Register, National Perinatal Epidemiology Unit, FREEPOST (OF 2279), Oxford, OX3 7LF. Tel / tobyregister@npeu.ox.ac.uk * Definitions for all items on tis forarked wit an asterisk may be found in te Clinician s Handbook and in te appendix to tis form 4 Version 7 November 2010

5 Appendix Definitions Of Terms In Data Collection Form (version 7, November 2010) Arrytmia Sinus bradycardia below 80 bpm and oter arrytmias identified on ECG Cerebral imaging abnormality Including evidence of parencymal aemorrage as determined by ultrasound, ventricular dilatation (defined as >97t centile for gestational age) or te presence of porencepalic cysts or cystic leukomalacia CFM grade 1 Upper margin of trace >10 µv, lower margin >5 µv. 2 Upper margin of trace >10 µv, lower margin <5 µv. 3 Upper margin of trace <10 µv. Clinical Seizures Seizures observed witout aeeg or EEG diagnosis Coagulopaty Delivery complications Tis can include prolapsed cord, abruption, soulder dystocia, ruptured uterus, ead entrapment etc EDD Estimated Date of Delivery Use te best estimate (dates or ultrasound) based on a 40 week gestation Hypoglycaemia (infant) Blood glucose below 2.6 mmol/litre Hypotension (infant) Late onset sepsis (>72 ours after birt) confirmed by blood or CSF culture Any evidence of infection Meconium aspiration syndrome Te presence of meconium stained liquor at birt and severe respiratory witin 1 our of birt and compatible X-ray canges Necrotising enterocolitis Infants wit abdominal distension, gastric aspirate and/or blood in stools togeter wit abdominal X-ray sowing bowel oedema, pneumatosis or pneumoperitoneum, i.e. Bell s staging 2 or 3 Pregnancy complications Tis can include pre-eclampsia, maternal, tyroid disorder, diabetes, placenta praevia, known illicit drug use etc. Pulmonary airleak Any radiologically confirmed airleak serious enoug to affect management (including pneumotorax, pulmonary interstitial empysema, pneumopericardium, pneumoperitoneum and pneumomediastinum) Pulmonary aemorrage Copious bloody secretions wit deterioration requiring cange(s) in ventilatory management Pulmonary ypertension Severe ypoxaemia disproportionate to te severity of lung disease and evidence of a rigt to left sunt support Use of, supplementary oxygen Seizures Clinical or sub, identified on CFM / EEG Sepsis Any evidence of infection SFN Sub-cutaneous fat necrosis Trombosis Trombosis or trombo-embolism not related to an infusion line

Cooling guidance for babies presenting with moderate to severe hypoxic ischaemic encephalopathy within the North West London Perinatal Network

Cooling guidance for babies presenting with moderate to severe hypoxic ischaemic encephalopathy within the North West London Perinatal Network 1. INTRODUCTION Perinatal asphyxia severe enough to cause