/ CHHS18/083

Canberra Hospital and Health Services

Clinical Guideline

Care of the Extremely Preterm and Low Birth Weight Baby – The Golden Hour

Contents

Contents

Guideline Statement

Scope

Section 1 – Extremely Preterm Early Management (e-PREM) bundle – The Golden Hour

Section 2 – Resuscitation at Birth & Thermoregulation

Section 3 – Skin Care and Humidification via an Isolette

Implementation

Related Policies, Procedures, Guidelines and Legislation

References

Definition of Terms

Search Terms

Attachments

Attachment 1 – ePREM Flow Chart – Extremely preterm early management Flow Chart

Attachment 2 – Compliance Checklist for ePREM Flow Chart

Guideline Statement

The purpose of this document is to outline a care bundle for the admission and ongoing management of the extremely low birth weight (ELBW)baby less than 1000grams and /or babies born less than 28 weeks gestation.

Background

In 2016 the Australian and New Zealand Committee on Resuscitation released recommendations which focused on: The golden hour, or initial first hour of neonatal life including neonatal resuscitation, post-resuscitation care, transportation to the neonatal intensive care unit, respiratory and cardiovascular support and the initial course in the nursery. Interventions in the first hour of life can have a significant impact on short and long term outcomes for very low birth weight babies.

Key Objective

The key objective of this guideline is to ensure compliance with the requirements of the care bundle and provide consistency of practice.

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Scope

This document pertains to the admission and care of ELBW babies and/orbabies born less than 28 weeks gestation.

This document is applicable to clinicians who are working within their scope of practice, including:

  • Medical Officers
  • Registered Nurses (RN) and Registered Midwives (RM)
  • Students under direct supervision.

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Section 1 – Extremely Preterm Early Management (e-PREM) bundle – The Golden Hour

The components of the Golden Hour include; Counselling and team briefing, delayed cord clamping, prevention of hypothermia, respiratory system support, cardiovascular system support, early nutrition, prevention of infection, laboratory investigation and communication with the family.

Preparation in NICU

Equipment

  • Compliance Checklist for e-Prem pack (see Attachment 2)
  • e-Prem pack
  • Curosurf + administration pack
  • Shuttle/ventilator/CPAP equipment
  • Assemble team

Procedure

  1. Ensure the neonatologist, neonatology fellow, NICU team leader and retrieval nurse have been informed of the pending delivery (see Attachment 1 e-PREM flow chart)
  2. Warm Curosurf in the isolette
  3. Prepare transport shuttle
  4. Prepare CPAP circuit/ventilator on shuttle
  5. Attach CPAP prongs to the CPAP circuit and leave in place
  6. Obtain compliance check list for e-Prem pack
  7. Prepare for INSURE (intubation/surfactant/extubation) if planned
  8. Prepare sterile preterm starter TPN (10%) and lipids at2g/kg/day
  9. Prepare antibiotics and caffeine
  10. Set-up for umbilical line insertion

Alert

The registrar is to request to delay the caesarean if a neonatologistis not yet present and it is safe to do so.

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Section 2 – Resuscitation at Birth & Thermoregulation

There are many interventions that need to be practiced in the golden hour to ensure that complications are minimised. The prime objective of the golden hour is to use evidence based interventions and treatment for better outcomes. In the golden hour, a standard approach is followed, derived from the best available evidence with the aim of practicing gentle but timely and effective interventions with non-invasive procedures. Prevention of hypothermia is an important consideration in this early management. Hypothermia is defined as a temperature <36.5°C. ELBW babies must maintain axillary temperature between 36.5-37.5°C.

Team Briefing- Lead by the Neonatologist or Senior Registrar/Fellow

Equipment

  • Neonatal resuscitation checklist
  • Delivery attendance sheet
  • Neonatal code blue resuscitation sheet

Procedure

  1. All members of the team are to introduce themselves
  2. Discuss the plan, communication, expectations and assign roles to team members
  3. Discuss any special considerations
  4. Ask for additional personnel or equipment if required
  5. Use closed communication by confirming any orders from the Team leader

Pre-resuscitation equipment checks

Equipment

  • Ohmeda Giraffe Isolette with shuttle. Use NICU transport cot (Mansell cot) in addition if twins are born
  • Temperature probe
  • Thermometer
  • Thermometer cover
  • Warm bedding: nest lined with abdominal sponge
  • Mefix
  • Humidifier reservoir
  • Bottle of sterile water for irrigation 500 mL
  • 1X Trans-warmer mattress (only to be used if the neopuff circuit is not available)
  • 1X sheet for trans-warmer mattress
  • 1X polyethylene wrap
  • Micro beanie or Continuous Positive Airway Pressure (CPAP) hat
  • 1X Fisher & Paykel (F&P) Humidified neopuff circuit- Resuscitation T-piece kit
  • 1X F & P Humidifier base MR225
  • 1XWater for injection 30mL
  • 1X30mL syringe
  • 1Xgrey wire
  • 1X42mm face mask
  • 1X35mm face mask
  • Ventilator/ CPAP circuit
  • Transport shuttle

Procedure

Both the medical and nursing staff are responsible for the following checks:

1.Check temperature in birthing suite/ operating room is set to 25°C

2.Check all equipment on the resuscitaire

3.Intubation equipment:

  1. Laryngoscopes
  2. Endotracheal tubes
  3. Mask
  4. Pedicap
  5. Introducer

4.Curosurf and administration pack

5.Switch heating on resuscitaire to manual and increase to 100% output

6.Place polyethylene wrap on top of warmed blankets onto resuscitaire with radiant warmer until ready to use. Radiant heat should remain on but do not allow polyethylene to overheat. Do not use conventional plastic wrap as this will melt under the radiant heater

7.Use the pre-activated trans-warmer mattress only if there has been insufficient time to warm the birthing room/theatre or resuscitaire or to set up the humidified neopuff system

8.Ensure cardiorespiratory monitor and pulse oximeter are ready for use

9.Ensure emergency drugs-adrenaline and syringes are available & calculate approximate dose

10.Ensure equipment for emergency Umbilical Vein Catheter (UVC) insertion and normal saline is available.

Humidification of the Neopuff Circuit

Resuscitation via Continuous Positive Airway Pressure (CPAP) or intubation using humidified gas in a closed Neopuff circuit assists in the prevention of hypothermia.

Procedure

  1. Fill neo-puff humidifier base with 30mL sterile water
  2. Attach CPAP prongs (smallest size) to the CPAP circuit and leave in place
  3. Turn neopuff settings to PIP 25, PEEP 5
  4. Ensure the flow of gas through the neopuff is set at 10L/min
  5. Turn on humidifier base

Neopuff set up with humidified base attached

In Birthing Unit:

  1. At birth receive baby in warm blankets with polyethylene wrap on top. Immediately wrap the baby’s entire body in polyethylene wrap, excluding the head and umbilical cord. Do not dry the baby
  2. Dry the baby’s head and cover with a beanie or CPAP hat
  3. Delay cord clamping for 1 minute if possible. Keep baby securely wrapped until the cord is cut
  4. Swaddle (wrap) the polyethylene wrapped baby with warmed blankets as soon as possible after resuscitation
  5. Proceed with resuscitation as required
  6. Babies who require positive pressure ventilation require a 3 lead ECG to ensure accurate monitoring of the baby’s heart rate during resuscitation
  7. Take the baby’s axillary temperature before leaving the birthing unit. If temperature > 37.2C remove chemically warmed mattress (if used) before placing baby into the isolette.

In Operating Theatres (OT) if born by Caesarean Section:

  1. If the baby is born by caesarean section the scrubbed nurse/midwife will receive the baby onto a sterile receiver wrap
  2. NICU nurse receives baby in warm blankets with polyethylene wrap on top. Immediately wrap the baby’s entire body in polyethylene wrap, excluding the head and umbilical cord. Do not dry the baby
  3. Delay cord clamping for 1 minute if possible. Keep baby securely wrapped until the cord is cut
  4. Swaddle (wrap) the polyethylene wrapped baby with warmed blankets as soon as possible after resuscitation
  5. Dry the baby’s head and cover it with a beanie/CPAP hat
  6. Babies who require positive pressure ventilation require a 3 lead ECG to ensure accurate monitoring of the baby’s heart rate during resuscitation
  7. Proceed with resuscitation as required
  8. Take the baby’s axillarytemperature before leaving the theatre. If temperature > 37.2°C remove chemically warmed mattress (if used) before placing baby into the isolette
  9. Prior to leaving the OT remove all accountable items from resuscitaire, e.g. grey wire and laryngoscope blade.

On arrival to the NICU:

  1. Add humidity to the isolette (if baby is <1000g and <28 weeks gestation)
  2. Weigh the baby with polyethylene wrap insitu in the isolette if possible
  3. Check and record the baby’s axillary temperature (maintain between 36.5 – 37.5°C ) on the observation chart and admission form
  4. Once the baby is stabilized and umbilical lines/intravenous cannulas are secured, the polyethylene wrap may be removed, the baby dried and humidity continued
  5. Commence preterm starter TPN (10%) and lipids at 2g/kg/day
  6. Aim to give caffeine and antibiotics (if required) within one hour of admission, as soon as access is obtained
  7. Nest and settle baby and minimally handle the baby
  8. Inform the family of the baby’s progress and emphasise the need for early expressed breastmilk (EBM)
  9. Start feeds with EBM 1ml 4th hourly as soon as EBM is available or use first expressed breastmilk for mouth care
  10. Complete e-PREM compliance checklist, See Attachment 2
  11. Determine ongoing respiratory requirements
  12. Obtain a detailed obstetric history from the clinical record

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Section 3 – Skin Care and Humidification via an Isolette

The skin is the largest organ of the body, functioning as a protective and regulatory barrier between the body and external environment. The skin of the ELBW baby is fragile and transparent due to the thin non- existent stratum corneum. This subsequently increases trans-epidermal water loss (TEWL) causing fluid and electrolyte imbalances, ineffective thermoregulation, increased permeability and absorption of creams and/or cleaning agents and greater risk of epidermal stripping when using adhesives. These factors lead to an increased risk of infection and delayed healing. The ELBW babymay not have fully mature skin until 30-32 weeks postconceptional age.

Alerts

The heat from Transcutaneous monitors (TCMs) can burn and TCM adhesive rings can cause epidermal stripping when removed. If a TCM is required, decrease the temperature settings to 43C and re-site 2-3 hourly.

Equipment

  • Ohmeda Giraffe isolette
  • Temperature probe
  • Small chest leads for babies born < 1000g
  • Warm bedding: nest lined with abdominal sponge
  • Monitor for Arterial Blood Pressure (ABP) and Saturations
  • Mefix ®
  • Cotton wool ball
  • Saturation wrap
  • Sterile water for injection 10mL ampoule
  • Tegaderm®
  • Pulse oximeter probe for babies <1000g
  • Chlorhexidine 0.2%
  • Humidifier reservoir
  • Bottle of sterile water for irrigation 500mL
  • Antifungal Cream and oral drops
  • Medication chart

Procedure

  1. If the baby has not been transported via the shuttle with the isolette attached,ensure the isolette has been warmed to an appropriate neutral thermal zone for the baby’s age and weight
  2. Place thebaby from the transport cot directly into the isolette whilst still wrapped in polyurethane wrap
  3. Weigh thebaby in the pre-warmed isolette.

Monitoring

  1. Apply mefix® to the baby’s feet before applying the pulse oximeter probe. Lightly press a cotton wool ball against the adhesive parts of the SaO2 probe and then attach to the baby’s foot with a saturation wrap
  2. Continue to monitor the baby using the chest leads for ELBW babies. Do not use conventional chest leads on these babies as they may cause skin damage or tears
  3. All adhesive tape for cannulas should have cotton wool pressed against it prior to applying to the baby to reduce the incidence of skin tears
  4. It is not necessary for an ELBW baby to wear an identification label. These may be attached to the isolette. An identification sticker must be attached to the umbilical lines and feeding tube.

Securing Umbilical catheters

  1. 0.2% Chlorhexidine is used to the clean the baby’s abdomen prior to the insertion of umbilical catheters
  2. Apply Tegaderm® to the abdomen around the umbilicus and use this as a base to secure the catheters using the goal post strapping as outlined in the Clinical Procedure Venous and Arterial Access and Management in Neonatal Intensive Care
  3. Tegaderm should be left in place when lines are removed until the baby is out of humidity
  4. Commence fluids at 80mL/kg/day unless otherwise indicated

Humidification

Background

Provision of a high humidity environment limitstransepidermal water loss, improvestemperature control and reduces the risk of fluid and electrolyte imbalance.

Commence humidity at 85% from admission for preterm babies 28 weeks gestation or less, or less than 1000 grams. Reduce humidity by 5% daily from day 7to14 as epidermal maturation occurs. Humidity is continually weaned until the humidity level reaches 40% when it is then turned off. This may take 7-10 days from the commencement of weaning. The reduction of humidity may alter the baby’s thermoregulation; therefore increase the cot temperature as indicated.

Equipment (humidification)

  • Ohmeda Giraffe isolette
  • Humidifier reservoir
  • Bottle of sterile water for irrigation

Procedure (humidification)

  1. Ensure humidity reservoir is correctly inserted
  2. To fill the reservoir grasp it and push down: the reservoir will tilt open for filling
  3. Fill to the line on the heater cylinder with sterile water for irrigation and tilt the reservoir back into place
  4. Do not fill the reservoir past the fill level as this will decrease the level of humidification within the isolette
  5. Use the LED Humidifier Screen on the graphics display of the isolette to set the desired humidity level
  6. Once umbilical lines have been inserted commence humidity at 85%
  7. The reduction of humidity may alter the baby’s thermoregulation; therefore increase cot temperature as needed to maintain baby’s temperature between 36.5 and 37.5 degrees
  8. Humidity reservoir should be changed weekly when the isolette is changed and sent for pasteurisation to reduce the potential risk of colonisation of the reservoir water
  9. Clean all skin creases, neck, ears and underarms every 6-8 hourly or as required.
  10. Apply antifungal creams to skin folds as per medication chart (antifungal creams should not be visible after application, a light smear is all that is required)
  11. Baby should be nursed with abdominal sponge between skin and bed to absorb any excess moisture. Linen should be changed with cares 6 – 8hrly as it becomes damp
  12. All babies born <1250g must be weighed daily for the first 7 postnatal days or until birth weight has been regained or for a longer period as directed by the Neonatologist
  13. To maintain skin integrity, prevent epidermal stripping and infection use a hydrocolloid dressing as a base between skin and tape when securing feeding tubes and nasal prongs
  14. Avoid the use of adhesives on the ELBW baby. Do not apply a urine bag to collect urine for testing, placecotton wool balls in the nappy
  15. Ensure that condensation within the isolette does not impair accurate observation of the baby

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Implementation

This Guideline will be:

  • Discussed in existing education i.e. in-service, in orientation of new staff, displayed in work rooms.
  • Sent out via all staff email and available on the CHHS Policy register on SharePoint.

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Related Policies, Procedures, Guidelines and Legislation

Legislation

  • Health Records (Privacy and Access) Act 1997
  • Work Health and Safety Act 2011
  • Human Rights Act 2004

Procedures

  • Non-Elective Caesarean Section (including classification of urgency)
  • Venous and Arterial Access and Management in Neonatal Intensive Care
  • Neonatal Routine Care
  • Urine Collection in Neonates procedure
  • Venepuncture Blood Specimen Collection procedure

Guidelines

  • Birth Requiring the Presence of a Neonatal Medical Team Member
  • Neonatal hypoglycaemia
  • Neonatal Intensive Care Drug Manual

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References

  1. Knoble, R. & Holditch –Davis, D. (2007) Thermoregulation and heat loss prevention after birth and during neonatal intensive care unit stabilization of extremely low birth weight babys. Journal of Obstetric, Gynaecologic and Neonatal Nursing, 36 (3) 280 - 287.
  2. Allwood, M.(2011) Skin Care Guidelines for Babys Aged 23-30 Weeks' Gestation: A Review of the Literature. Neonatal, Paediatric & Child Health Nursing, 14 (1) 20-27
  3. Bredemeyer, S. Reid, S. & Wallace, M. (2005) Thermal management for premature births Journal of Advanced Nursing 52(5) 482-489
  4. Telofski, L.S. Morello, P. Mak-Correa,C and Stamata, G.N (2011) The Baby Skin Barrier: CanWe Preserve, Protect, and Enhance the Barrier? Journal of Perinatology 31, S49–S56;
  5. ASingh, JDuckett, TNewton1 and MWatkinson, Improving neonatal unit admission temperatures in preterm babies: exothermic mattresses, polythene bags or a traditional approach? Journal of Perinatology (2010) 30, 45–49;
  6. Neonatal Resusitation: Specific Treatment Recommendations (ILCOR 2015)
  7. Robin BKnobelRNC, MSN, NNP, John EWimmerJrMD and DonHolbertPhD, Heat Loss Prevention for Preterm Babys in the Delivery Room, Journal of Perinatology (2005) 25, 304–308
  8. Sunita Vohra, MD, MSc, Robin S. Roberts, MSc, Bo Zhang, MPH, Marianne Janes, MHSc, Barbara Schmidt, MD, MSc: Heat Loss Prevention (HeLP) in the delivery room: A randomized controlled trialof polyethylene occlusive skin wrapping in very preterm babys, The Journal of Pediatrics, Volume 145, Issue 6, December 2004, Pages 750–753
  9. Williams, J. (2004). An investigation into the effect of a polyethylene wrap on the temperature regulation of the very low birth weight and premature baby during transfer to the neonatal intensive care unit: a systematic review. Health Care Reports, 2:(3): 53-78.
  10. Ashmeade, T. L., Haubner, L., Collins, S., Miladinovic, B., & Fugate, K. (2016). Outcomes of a neonatal golden hour implementation project. American Journal of Medical Quality, 31(1), 73-80.
  11. Australian Resuscitation Council. (2016, January 1). Guidelines - Australian Resuscitation Council. Retrieved March 15 2017
  12. Chawla, S., Amaram, A., Gopal, S., & Natarajan, G. (2011). Safety and efficacy of Trans-warmer mattress for preterm neonates: results of a randomized controlled trial. Journal of Perinatology, 31(12), 780-788.
  13. Doctor, T. N., Foster, J. P., Stewart, A., Tan, K., Todd, D. A., & McGrory, L. (2017). Heated and humidified inspired gas through heated humidifiers in comparison to non-heated and non-humidified gas in hospitalised neonates receiving respiratory support. Cochrane Library.
  14. Gardner, S. L., & Hernandez, J. A. (2016). Initial nursery care. In S. L. Gardner, B. S. Carter, M. Enzman Hines, & J. A. Hernandez, Merenstein & Gardner's Handbook of neonatal intensive care (8th ed., pp. 71-80). St Louis: Elsevier.
  15. Kai-Hsiang, H., Ming-Chou, C., Shu-Wen, L., Jainn-Jim, L., Yu-Cheng, W., & Reyin, L. (2015). Thermal blanket to improve thermoregulation in preterm infants: A randomized controlled trial. Pediatric Critical Care Medicine, 16(7), 637-643.
  16. Kalia, Y.N., Nonato, L.B., Lund, C.H. & Guy, R.H. (1998). Development of skin barrier function in premature infants. Journal of Investigative Dermatology, 111, 320-326.
  17. Kevat, A. C., Bullen, D. V., Davis, P. G., Omar, C., & Kamlin, F. (2017). A systematic

review of novel technology for monitoring infant and newbornheart rate. ACTA PAEDIATRICA: Nurturing the Child, 106(5), 710-720.