The Royal Children's Hospital Melbourne

Nursing guidelines

Cooling in after death care

Introduction
Definition of terms
Assessment
Preparation of the Techniice sheets
Management
Disposing of the Techniice
Documentation
Family Centred Care
Companion Documents
Evidence Table
Introduction

The importance for bereaved families to be offered the opportunity to spend time with their child after death, in hospital and at home, is well described in literature. Previously the hurdles of environmental needs to maintain the integrity of the child’s body have limited the opportunity to provide this extended service to families of children older than one. Information on the other cooling options, such as Very Special Kids, which offers a Cool Room, and the use of the Cuddle Cot, a cooling mattress that can fit an infant, can be found on the Death of a Child CPG.

Techniice is a portable, disposable, cooling system that allows any family who wish to spend extended time with their child after death.

The aim of this guideline is to provide nursing, allied health and medical staff with an overview of the use and management of Techniice during after death care at the Royal Children’s Hospital, Melbourne.
Definition of terms

Techniice – A disposable sheet made of refrigerant polymer and high-density plastic, which is non-toxic, and can be frozen to provide optimal cooling for a deceased body
Assessment

Techniice is a single use disposable sheet made of high-density plastic and refrigerant polymer which is non-toxic. The thin flat sheets can be hydrated with water through a one-way perforation technology that allows water to be absorbed but not leak out. Once frozen the refrigerant polymer will maintain temperatures under –18oC, which means when rotating the product as needed, it can be used to keep a body cool for several days post death, allowing time for a family to spend time with their baby, child or teen.

Techniice is suitable for consideration:

In the circumstance where staff are waiting for family to be in attendance post death
Where there is expected to be a delay of 4 hours post death before the child is placed in the mortuary/be collected by Funeral Directors
Where family wish to spend extended time with the child after death (in hospital or at home)
The benefit of Techniice:

No age or size limitations (each cell can handle 30kg weight)
Portable which allows families to choose where their child is placed (arms, cot, bed, pram etc).
Available to all families, including supporting regional services
Reusable in the home setting (single patient use)
Minimal perspiration from cells (to allow optimal care of the body and reduce distress for family)
No need to arrange drop off equipment after use
Preparation of the Techniice sheets

Preparation involves two steps: hydration and freezing.

Consider the size of the child you are making the Techniice for prior to hydrating the sheets. Each Techniice sheet comes with 24 cells. In the case of a smaller neonate, or smaller sections of the child (such as under the neck) it is best to cut the sheets into the required size prior to hydrating them.

Below are the recommended number of sheets needed (they do not need to be cut into individual squares):

Preterm Neonate: Quarter to half a sheet
Infant: Half to full sheet
Young Child: Two to three full sheets
Teen: Four to six full sheets

If expecting to keep the body cool for several days, prepare and freeze double the number of sheets required to allow for rotation as needed.

It is safe to hydrate and freeze several precut sizes, to ensure some appropriately sized sheets are always available. The purpose bought freezer located in the RCH Body Hold will always have the following available:

10 x Neck sheets (2 cells)
10 x Quarter sheets
20 x Half sheets
20 x Full sheets
Hydration:

Techniice comes as dehydrated sheets which must be fully submerged into water prior to freezing.

An instructional video on this following process above can be found here (How to Hydrate Techniice Dry Ice Packs Sheets)

You will need: Techniice sheets, access to water, sink or bath and large dry towel

Fully submerge required number of Techniice sheets into a sink/bath of water (the warmer the water the quicker the absorption process)
Whilst submerged, scrunch the sheet, massaging each cell between your fingers. Air bubbles will come out as water enters each cell – this is normal.
If not already, flatten sheets out in the water to allow optimal uptake into each cell
If there are any cells that have not inflated, continue to massage these to help activation
Continue the above process for approximately 3-5 minutes until each cell has swelled. At peak they will become approximately 2cm in width.
Once all cells are fully inflated, remove the sheets and place them on a dry towel.
Carefully and thoroughly pat the sheets dry – this is very important as any residual water on the outside will turn to ice and cause the dampness

Image 1: Prior and after hydration (curtesy of techniice.com)
Freezing:

Techniice needs to be placed into the freezer flat with plastic side down. Separate sheets with a provided reusable silicone mat between each sheet to ensure the sheets do not stick to each other. Do not use cling wrap between sheets as these will stick to the sheets as they freeze and compromise the integrity of the product.

Sheets must remain in the freezer for a minimum of 24 hours for best results.

Once frozen they are ready for use.
Management

It is important to talk through the purpose of the Techniice with the family in a sensitive manner. The coolness of the sheets and subsequent cooling of the child can be distressing to family if they have not had the purpose of its use explained.

Ideally Techniice is placed to assist cooling as soon after death as appropriate. It is not compulsory but, in the circumstance, where it is expected that a child will not be transferred to the mortuary or picked up within 4 hours post death the use of Techniice will optimise the integrity of the body.

The frozen Techniice should not be placed directly to or under the body as it will damage the skin. It must be placed in a single thickness sheet (this can be either a hospital sheet or the family's own linen.

It is only required with initial cooling to place Techniice ice:

Behind head and neck
Over the abdomen of an older child or teen (this is commonly where odours arise from and the area which takes the longest to cool after death. Therefore, application immediately after death is important and may require 4 hourly rotations initially)

The other key locations that should always have Techniice are:

Behind the back including between the shoulder blades
Across the lower back/kidneys

Image 2. Suggested sheet placement on an older child courtesy of Queensland Health (2021).
Each sheet will commonly last at least 8-10 hours, though may need replacing earlier if noted to be warming up (they will feel soft and warm to touch). Environmental factors, such as cuddling, or the ambience of the room may hasten defrosting of the cells. In this case, the sheets may be rotated earlier.

When rotating the Techniice sheets, remove the prefrozen second set from the freezer, lift the child, or roll the child gently to their side and replace the defrosted sheets with the new frozen replacements, ensuring they are not placed directly onto the skin.

In the hospital setting the previous sheets must be discarded – do not place them back in the freezer, even if the intent is for the same patient. In the home setting the family may place them back in their home freezer to re-freeze. There is no need to repeat the hydration steps, the family can simply wipe the sheets down with a dry tea towel/cloth and place back in the freezer. Continue to rotate the sheets until after death care is no longer required (I.e the child is placed in the mortuary or collected by a funeral director).
Possible Complications:

Condensation: Any wetness from the product will be due to incomplete drying prior to the freezing process. To reduce this risk, the Techniice may be placed in a thin plastic zip lock bag prior to being covered with the chosen linen.
Tear in a cell: If this were to occur, though extremely unlikely, the product may be discarded following the usual disposable process described below. The internal product is non-toxic; usual hand washing with soap and water suffices.
Disposing of the Techniice

The contents of Techniice are non-toxic and safe to dispose in the normal waste in hospital and the household waste bin in a community setting, the product itself is designed to breakdown after long exposure to UV light. Techniice also offers a free recycling service at their Frankston outlet. In the circumstance where the child is under contact precautions, such as cytotoxic or droplet infection control, and there is concern the sheets have had contact with the child, then the product should be discarded in a provided hazardous or cytotoxic waste bin.
Documentation

Please note in the Death Checklist, under subtitle: Destination of Body, if the product has been used.

Family Centred Care:

Where feasible verbal consent for the use of the product should be sought prior to use
Family should be advised that they may continue to care and handle their child as they wish, including washing and bathing them, however handling may increase the rate of compromise of the child’s body. Techniice cannot remove this risk but will help stabilize the overall integrity
Sensitive education should still be provided on the expected physiological changes that occur to a deceased body over time (ie. Colour changes, odour, leakage of body fluids, stiffing of limbs). Reassurance that these processes are expected and may be minimised, but not avoided, with the correct use of Techniice
It is important to ensure families who are taking their child home have a Hospital Contact if they have any concerns or questions. This should be the contact phone number to the ward the patient has come from.
Companion documents

Death of a Child CPG

Use of Bereavement Facilities Policy and Procedure

Special thanks to Paediatric Palliative Care Service, Queensland for their advice and support in the development of this guideline.
Evidence table
The evidence table for this guideline can be accessed here.

Please remember to read the disclaimer.

The development of this nursing guideline was coordinated by Melissa Heywood, CNC, Victorian Paediatric Palliative Care Program, Jess Rowe, RN, Rosella, and Gemma Sutton, RN, Butterfly, and approved by the Nursing Clinical Effectiveness Committee. First published June 2022.