Canberra Hospital and Health Services Clinical



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Section 5 - Care of the Ventilated Infant



Purpose


This section outlines the procedures for a Registered Nurse caring for a ventilated infant. Mechanical ventilation is used to provide adequate cellular oxygenation and elimination of carbon dioxide in the critically ill infant.

Procedures


  1. When assuming care of the ventilated infant receive verbal handover from the previous shift and review the progress notes, focusing on the previous 24 hours

  2. Check emergency bedside equipment is functional i.e. suction equipment, Neopuff and resuscitation bag and mask

  3. Check ventilator including mode, parameters and alarm limits with the handover RM/N and against the flow chart and medically prescribed orders

  4. Critically analyse discrepancies regarding current settings with medical orders and actual management.

  5. Check humidifier temperature and maintain temperature

  6. Check ventilator circuit tubing is intact, clean and free of water

  7. Replace circuit every 6 (six) days, including humidifier base and label with date


Alert

To facilitate future tracking of equipment insert bar code from packaging in progress notes


  1. Change close system suction equipment every 3 (three) days or as necessary and label with date

  2. Perform physical assessment of the ventilated infant, systematically according to the nursing flow chart and document

  3. Minimally handle unstable, very ill infants

  4. Document the following on flowchart

    1. vital signs

    2. incubator/open care centre temperatures

    3. humidity in degrees

    4. skin colour and perfusion

    5. positioning

    6. ventilator parameters

    7. nitric oxide parameters if required

    8. fluid balance

    9. frequency of suction and description of secretions

    10. pain score

  5. Perform 4-6 hourly care (or as indicated by infant’s condition)

  6. Observe and assess response to handling and document on flow chart

  7. Obtain assistance as required to maintain stability of ETT and ventilator circuit when turning/changing infant’s position to prevent accidental extubation and disconnection

  8. Suction the ventilated infant according to Section 7 of this SOP-ETT Suction Closed System. Only perform as clinically indicated by assessing the following using auscultation and observation:

    1. decrease in air entry

    2. creps/rales rhonchi heard

    3. altered chest movement

    4. restlessness and frequent desaturation may indicate need for suction

  9. If suctioning does not improve infant’s condition, notify Medical Officer.


Alert

When caring for the muscle relaxed infant suction may be required at more regular and frequent intervals and remember to include oropharynx see SOP “muscle relaxed infant“
When caring for the infant after surfactant administration refer to Section 6 of this SOP-Surfactant Administration for guidance on suction intervals


  1. Employ continuous monitoring including:

    1. heart rate

    2. respiratory rate

    3. pulse oximetry

    4. BP monitoring arterial/non invasive as indicated

    5. transcutaneous P02 PC02 monitoring as determined by medical officer as per SOP “Transcutaneous monitoring”

  2. Set alarm limits using the SOP “observation and monitoring”.

  3. Analyse blood gas measurements as ordered by Medical Officer utilising the SOP “Arterial Blood Gas” initially 4 hourly reducing to daily when condition allows:

    1. check all IV fluids are infusing according to prescribed rate via infusion and/or syringe pump and total fluid volumes are correct

    2. check with handover RM/N and against IV order sheet

    3. inotropes must be infused via the Syringe Pump using Guardrails®

    4. notify Medical Officer of any discrepancies

  4. Check medication chart at beginning of shift for:

    1. drug dosages and intervals against medication yellow folder and notify Medical Officer of any discrepancies and submit Riskman

  5. Measure and calculate urine output accurately and document on flow chart notify MO if urine output is <1ml/kg/hour or exceeds intake

  6. Monitor type and consistency/frequency of stool output and document

  7. Communicate with infant’s parents in regard to:

    1. infant’s condition, proposed procedures and/or changes to treatment in everyday language

    2. encourage questions to ensure understanding of condition and treatment

    3. provide support and teaching as required.



Outcome


  • Effective ventilation has been based on observation of symmetrical chest wall movement, auscultation of equal air entry and blood gas analysis

  • Changes in condition have been acted on according to Medical orders and SOPs



Kangaroo Care & the Ventilated Infant





    1. Obtain help from a second RN

    2. Dress the infant in a nappy and beanie

    3. Do baseline observations of temperature, heart rate and respiratory rate

    4. Ask Parent to remove clothes from waist up and don gown so it opens to the front

    5. Parent to sit in low chair or recliner chair and offer a foot stool and pillows

    6. Check they are seated comfortably and in a draft free area

    7. Obtain assistance from second nurse - one nurse holds baby the other nurse supports ET tubes/ lines/ cardio/respiratory leads

    8. Check and clear ventilator tubes of water

    9. More stable infants may by briefly disconnected from ventilator

    10. Both nurses transfer infant and connections at the same time

    11. Place infant vertically on the mother/father’s chest

    12. Secure ventilator tubing to parent’s clothing at shoulder using tape

    13. Monitor cardio-respiratory status throughout transfer

    14. Position infant comfortably with legs and arms flexed and head on the side once placed on parent’s chest

    15. Cover infant with a warmed blanket and close mother’s gown around baby

    16. Inform parents how to recognise changes in their infants colour

    17. Assess infant’s stability throughout cuddle

    18. When returning infant to cot two nurses are required.



Criteria for returning infant to incubator/cot


  1. Increased O2 requirement of 10-20%

  2. Infant shows signs of distress i.e. apnoea/ bradycardia/ desaturation/ colour change, despite providing stimulation

  3. Hypothermia

  4. Baby remains unsettled and distressed.


Weights of equipment, leads and attachments to be deducted when weighing babies

Equipment

Weights

Vygon ETT

4 grams

Blue line ETT

3 grams

Neobar

2 grams

Closed circuit + Y piece suction (capped no tubing)

14 grams

Closed circuit + Y piece suction (capped no tubing) si ze G

22 grams

CPAP snorkel size

18 grams

CPAP snorkel size

20 grams

CPAP snorkel size

23 grams

CPAP hat small

28 grams

CPAP hat medium

36 grams

CPAP hat large

49 grams

Nasal cannula neonate

49 grams

Masimo sats probe

5 grams

Chest tube Fr 10

2 grams

Chest tube Fr 12

3 grams

Chest tube connector

4 grams

Trache care

26 grams

Trache care Y connector

4 grams

TCM Rings

1 grams

Pall IV filter

4 grams

Feeding tube size 5

2 grams

Feeding tube size 6.5

3 grams

Feeding tube size 8

4 grams

Arm board small

6 grams

Arm board large

9 grams

Chest leads (3m red dots) x3

6 grams

Ear muffs x 1

2 grams

3 way tap

4 grams

IV canulla

nil

Extension line

6 grams

Long line BD

5 grams

Multi flow (traffic lights)

8 grams

Multi flow bungs

2 grams

UAC

2 grams

UVC double lumen

2 grams

Hollister colostomy pouch

4 grams

Stoma bag with clip lock

10 grams

Urine bag

2 grams

Illiostomy bag

2 grams

Fitted name tag

2 grams

CPAP large Velcro + 2 small Velcro straps

10 grams

CPAP 2xside strips + 1 x toggle

10 grams

CPAP chin strap & 2 small Velcro straps

2 grams

Lipid filter

5 grams

Brainz leads x 5

35 grams

High flow nasal cannula

14 grams

Low flow nasal prongs

65 grams

Pneumotac

14 grams


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Section 6 - Surfactant Administration




Purpose


Surfactant replacement therapy is used in the treatment of Respiratory Distress Syndrome

primarily for premature infants, where there are varying degrees of deficiency. It is a complex and highly surface-active material, necessary for sustaining life by lowering surface tension thereby assisting alveoli expansion and allowing gas exchange to occur in the lungs.
These are the current recommendations for use of Surfactant in the Department of Neonatology at the Centenary Hospital for Women and Children based on the gestational age of the infant.

= 25+6 weeks


Immediate intubation and prophylactic surfactant in delivery/theatre

Aim for early extubation based on clinical assessment. INSURE not routinely practiced but can be used at consultant discretion



26 - 29 +6wks Aim for CPAP from birth and “early rescue” surfactant if required


Surfactant options

    1. If intubated as part of resuscitation, “early rescue” surfactant (in delivery suite/theatre)

    2. Early intubation and “rescue” surfactant in NICU (preferably within 2 hours) based on clinical assessment of work of breathing, PEEP >7cm H2O and O2 requirement ≥30% in the first 24 hours with chest X-ray consistent with hyaline membrane disease. May consider higher oxygen cutoff after 24 hours (>40%)

      1. INSURE(INtubation, SURfactant and Extubation) technique avoiding premedication (favoured in otherwise well babies)

      2. Intubation, surfactant and ongoing ventilation


Immediate intubation and prophylactic surfactant may be appropriate in babies at high risk of HMD (Not steroid covered, peri natal compromise) at discretion of senior medical staff.

≥30wks Aim for CPAP from birth and “early rescue” surfactant if required


Surfactant options

  1. If intubated as part of resuscitation, “early rescue” surfactant shortly after arrival in NICU if clinically consistent with HMD (work of breathing, FiO2 ≥30- 40%, and chest X-ray)

  2. Early intubation and “rescue” surfactant in NICU based on clinical assessment of work of breathing, PEEP >7cm H2O and O2 requirement ≥30-40% and chest X ray consistent with hyaline membrane disease.

    1. INSURE technique (favoured in otherwise well babies)

    2. Intubation, surfactant and ongoing ventilation

A higher oxygen threshold (≥ 40%) could be considered for more mature infants at consultant discretion


All gestations

Repeat dose surfactant can be given after 12 hours based on clinical need - work of breathing, PEEP/MAP and O2 requirements. A lower threshold of ≥ 30% FiO2 as well as reduced interval (6 hours) may be beneficial in complicated RDS (infection, meconium, peri natal compromise)


Also consider using Surfactant therapy in babies with severe meconium aspiration syndrome (MAS) or pneumonia.
Alert:

Please discuss use of curosurf and survanta in babies of Jewish, Hindu or Muslim background as these products are of animal origin.


Dosage

Curosurf: infants ≤27 weeks gestation and for MAS

Prophylactic/therapeutic: 200mg/kg (2.5ml/kg) with repeat doses of 100 mg/kg in 12 hours as per neonatologist’s discretion

(Maximum cumulative dose 400 mg/kg)

Survanta: ≥28 weeks gestation

Prophylactic and therapeutic: 100 mg/kg (4 ml/kg) with repeat doses in 12 hours as per neonatologist’s discretion

(Maximum cumulative dose 400 mg/kg)
Procedures

Prophylactic Therapy

Surfactant can be given immediately after birth in extremely premature infants, especially if they are ≤25 weeks gestation. Intubation at birth and administration of surfactant can be done in the delivery suite/OT. ETT position is confirmed clinically.


Rescue” Therapy

Early use of surfactant with therapeutic intent is preferred prior to lung disease becoming well established.


“Rescue” therapy can be given to babies intubated as part of resuscitation or to a baby currently on CPAP meeting criteria outlined above. Babies on CPAP can be given Surfactant with the INSURE technique or with ongoing ventilation.
Preparation for “Rescue” therapy

  • Correction of other causes of respiratory distress- hypothermia, hypoglycaemia, acidosis and hypovolaemia. However these things should not unnecessarily delay treatment in a baby with lung disease clinically consistent with HMD.

  • Arterial blood gas for baseline assessment may be beneficial

  • Monitoring of heart rate, respiratory rate, saturations and blood pressure

  • Chest X-ray to confirm diagnosis and check position of endotracheal tube (ETT) ideal but should not unnecessarily delay treatment

  • Umbilical artery and venous catheter insitu if considered necessary by consultant

  • Premedication should be provided prior to procedure if ongoing ventilation is planned, unless intubation is performed during urgent resuscitation

  • Suction ETT if indicated

  • Cut a size 5Fg gavage tube so the tip lies 1 cm above the end of the ETT

  • Warm the Surfactant at room temperature for 20 minutes or in the hand for 8 minutes before administration

  • Prime the feeding tube leaving only the required amount of surfactant in the syringe. DO NOT FILTER


Alert

DO NOT SHAKE THE BOTTLE


Equipment:

  • Alcohol Based Hand Rub (ABHR)

  • Surfactant (warmed to room temperature)

  • Appropriate syringe

  • Needle (For drawing up)

  • Sterile gloves

  • Gavage tube 5 Fg


Procedure

    1. Assemble equipment

    2. If baby already intubated proceed to standard procedure for surfactant administration (below)

    3. If on CPAP, consultant decision for INSURE technique or ongoing ventilation post surfactant treatment

    4. If ongoing ventilation intubate using premedication (unless intubation clinically urgent and cannot be delayed for preparation of drugs)


INSURE technique

  1. Place the infant in a supine position with the head in the midline. The base of the incubator should be kept flat throughout the procedure

  2. Ensure continuous application of mask Neopuff CPAP

  3. Set the Neopuff at PIP/PEEP: 20/6

  4. Ensure the ventilator is available at the infants bedside

  5. Intubate the infant with appropriate size endotracheal tube without use of premedication drugs,

  6. Check ETT position during insertion by noting appropriate positioning of vocal cord guide (heavy black mark near distal end of ETT) and by appropriate colour change on the Pedi-Cap

  7. Connect Neopuff to ensure immediate Neopuff ETT CPAP (Do not provide positive pressure breaths unless infant is truly apnoeic)

  8. Ensure equal air entry on both sides of the chest

  9. Insert the feeding tube all the way through the ETT

  10. Administer surfactant in a single bolus over 10-15 seconds. If there is significant desaturation or bradycardia, stop the administration temporarily

  11. Withdraw the catheter from ET Tube

  12. Immediately reconnect the Neopuff to provide ETT CPAP until infant recovers from surfactant administration

  13. The FiO2 may be temporarily increased by 10-15 % and /or PEEP may be increased up to 8cm H2O to assist recovery (Do not provide positive pressure breaths unless infant is truly apnoeic)

  14. Aim to extubate the infant within 5 minutes of surfactant administration (provided infant is breathing spontaneously and has SPO2 in the appropriate range without significant FiO2 requirement)

  15. Alert neonatal Fellow or Consultant immediately if there appears to be a need for prolonged ventilation

  16. Commence bubble CPAP at 6-8 cm H2O immediately following extubation

  17. Blood gas should be taken at 30 mins post surfactant administration and then as directed by medical team

  18. Following surfactant administration infant should be preferably nursed prone


ALERT

The registrar must stay at the bedside for 30minutes to observe the chest movement and any change in infants condition


Standard Procedure

  1. Disconnect ventilator/Neopuff and insert gavage tube into the ETT then quickly inject Surfactant down ETT. The baby may gasp and evenly distribute the Surfactant throughout the lung tissue. It may be given in a single or divided dose

  2. Immediately after administration of surfactant it may be necessary to increase the PIP for a short period of time to achieve chest wall movement if the surfactant blocks the ETT. This can be done using the Neopuff or reconnecting the baby to the ventilator and increasing the PIP. Positive pressure breaths may be required if apnoea or prolonged desaturation

  3. Reconnect the ventilator


Following surfactant administration by either method

  1. Avoid suctioning for as long as possible, in order for surfactant to be absorbed, subsequent suctioning should be as per baby's normal routine and/or on consultation with medical staff

  2. If all the contents of the vial were not used, opened vials can be re-used up to 12 hours after the first dose if kept refrigerated. The vial must be labelled with the date, time and patients name.

  3. Monitor the baby carefully following completion of surfactant, as there can be a rapid improvement in lung compliance and therefore there is a risk of over ventilation and associated problems:

    1. Pulmonary interstitial emphysema

    2. Pneumothorax

    3. Failure to reduce the inspired oxygen can result in hyperoxia

  4. Consider blood gas analysis:

    1. 13.1 30-60 minutes post dose (following insertion of IA line if deemed necessary)

    2. 13.2 2 hours post first dose if the baby is still intubated or at the discretion of the Neonatologist

    3. 13.3 Further gases are taken according to the Neonatologist and clinical condition

  5. Adjustments in ventilator settings may be required before the first blood gas depending on the speed of the response to surfactant

  6. The baby is to have minimal handling following procedure

  7. There must be a Medical Officer present or nearby for at least 30 minutes following surfactant administration

  8. Document in the baby's notes the time the treatment was given and how the baby coped with the procedure.


Outcome

  • The surfactant was administered as per Drug Policy Manual guidelines.

  • Where signs of complications of treatment were demonstrated intervention was initiated


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Section 7 - Endotracheal Suctioning Closed System



Purpose

This section describes the process by which tracheal secretions are removed from an Endotracheal Tube while using the closed system suction unit called Trach Care®


Trach Care enables aspiration to be performed without disconnecting the Ventilator circuit.

The advantages are:



  1. Better control of infections

    • Protection of the health care givers against air-borne germs breathed out by the patient

    • Protection of the patient against the pathogenic agents present in the environment

    • Reduced risk of cross contamination

    • Respect of aseptic procedures

  1. Physiological and psychological benefits

    • Maintain artificial ventilation

    • Maintain the respiratory parameters (which normally drop very quickly and recover very slowly)

    • Less traumatic


Equipment

  • Alcohol based hand rub (ABHR)

  • Appropriated sized closed tracheal suction system with appropriate size Y adaptor.

  • Low wall suction unit with control regulator gauge.

  • Suction tubing.

  • 2ml syringe

  • Sterile normal saline for clearing trachcare

  • Gloves.

  • Stethoscope.


Procedures

  1. Assess indication for suctioning which include:

    1. hypoxia,

    2. decrease in oxygen saturations

    3. tachypnoea

    4. decrease in chest movement

    5. restlessness/agitation

    6. audible rales/rhonchi on auscultation

  2. Check suction is working and maintain a pressure of 12-15 KPA/80-12mm by occluding suction tubing

  3. Measure the required distance the Trachcare will be advanced from the end of ETT (where it is cut ) plus 6 cms

  4. The measurement is marked by the colour-coded measurement on the Trachcare®

  5. Remove protective cap and unlock the inline suction valve by turning the suction thumb valve to open

  6. Attach the suction tubing to the end of the Trachcare®

  7. Open irrigation port and attach a 2ml syringe with 1ml of saline.

  8. Stabilize Trachcare® with non dominant hand and advance the catheter in its plastic sleeve to the premeasured distance (colour coded).

  9. Withdraw the Trachcare® catheter over 5 seconds whilst depressing the suction control valve, till the black tip is visible in the window dome.

  10. Observe amount, colour and consistency in the window near control valve prior to releasing suction

  11. Allow baby to recover before repeat suctioning

  12. Reassess baby to evaluate the effectiveness of the procedure.

  13. Flush the Trachcare® by instilling normal saline into the irrigation port, apply continuous suctioning via control valve.

  14. Rotate suction thumb valve to locked position.

  15. Disconnect suction tubing and replace protective cap.

  16. Ensure the irrigation port is free of normal saline by withdrawing syringe prior to removal of syringe.

  17. Close irrigation port and discard syringe.

  18. Document colour consistency and amount of secretions on NICU flow char

  19. Trachcare suction units are changed every 3 days or earlier if required

  20. Suction tubing is changed daily.


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Section 8 - Endotracheal (ETT) Suction Open Method

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