2.10.15 DRAFT: Infants <30 weeks 1st 72 hrs. of life clinical management guideline

  1. Neonatologist to attend all deliveries <30 weeks gestation
  2. All labs to ideally be on a schedule of start times based on 6/7am “AM labs” (e.g., ideally for line draw infant q4hr labs would be 6am, 10am, 2pm, etc.)

FEN:

  • Total fluids 70-80ml/kg/day to achieve minimum GIR of 6mg/kg/min
  • Use Starter TPN and D12.5W on admission to achieve GIR=6 goal
  • With first “real TPN”
  • Protein 3.5gm/kg/day
  • IL 3 gm/kg/day
  • Triglyceride level daily
  • UAC fluids: 1/3 NaAcetate + heparin at 0.8ml/hr
  • Change UAC fluid to 1/3 NS + heparin at 0.8 ml/hr IF serum bicarbonate level is ≥ 22 or if base deficit is <-7
  • ≤1kg: electrolytes and weights q12; >1kg: electrolytes and weights q24
  • Start minimal enteral feedings
  • Breast milk or donor breast milk 1ml q6hr x 72hr
  • Vitamin D supplementation 400IU po/ng daily
  • Occupational therapy consult for Osteopenia Prevention

RESPIRATORY:

  • All infants stabilized in DR with Neopuff CPAP+6 or PPV 25/6 (starting with 30% FiO2 and adjust based on targeted saturations) for first 5 minutes of life to see if spontaneous respiratory effort can be maintained on CPAP (unless unresponsive to PPV and needs to be intubated to proceed with CPR)
  • Goal oxygen saturations 88-95%
  • Caffeine load and maintenance therapy
  • Transition to NICU on Neopuff CPAP +6
  • Use mask only for first 48 hours
  • Blood gas minimum q12hr and as clinically indicated
  • CXR minimum q24hr and as clinically indicated
  • Failure deemed if:
  • Recurrent severe apnea requiring PPV
  • pH <7.20 and pCO2 >70
  • FiO2 >45%
  • Unless intubation is required emergently, obtain CXR BEFORE intubation if deemed “failing CPAP” to exclude pneumothorax as a treatable cause of failure
  • If requires intubation in DR: initial settings are PAC, 20/6, Rate 60.
  • Surfactant administration if requires intubation
  • Adjustments made in DR vent settings based on blood gases and chest rise/oxygen saturations
  • Blood gas obtained in DR once central access obtained
  • Goal ABG/VBG: pH 7.25-7.35, pCO2 45-60
  • Once in NICU, will only use PAC as mode of ventilation on Avea
  • Initial settings PAC 20/6, Rate 60 unless already adjusted based on blood gas from delivery room
  • If spontaneously breathing above set rate and blood gas shows over-ventilation, decrease vent set (apnea) rate to 40 and decrease PIP to achieve ideal blood gas values
  • Goal ABG/VBG: pH 7.25-7.35, pCO2 45-60
  • If not spontaneously breathing above set ventilator rate and blood gas shows over-ventilation, decrease vent rate incrementally down to minimum of 40 and then work to decrease PIP to achieve ideal blood gas values
  • Failure of conventional ventilation with need to move to high frequency ventilation deemed if:
  • Blood gases suboptimal with Rate= 60 and/or PIP>28
  • Oxygen needs >60% for >30 minutes
  • Blood gases minimum q4hr and as clinically indicated
  • CXR minimum q24hr and as clinically indicated
  • If requires high frequency ventilation
  • Blood gases minimum q4hr and as clinically indicated
  • CXR minimum q12hr to assess MAP lung expansion and as clinically indicated

EXTUBATION GUIDELINES:

Consider extubation by 18 hours of life

Extubation criteria:

  • FiO2 <0.3
  • Spontaneously breathing above set ventilator rate
  • PIP ≤ 20
  • PEEP ≤ 6
  • Caffeine being given
  • pH >7.25
  • pCO2 <60

REDOSING SURFACTANT GUIDELINE:

  • FiO2 >0.3
  • PIP >22

NONINVASIVE RESPIRATORY SUPPORT GUIDELINE:

  • For CPAP support use either CPAP of 6 or SiPAP 10/6
  • Leave on CPAP until FiO2 21% for minimum of 24 consecutive hours or 32 weeks CGA
  • If met criteria for FiO2 21% on CPAP, first attempt to wean off CPAP completely to room air. If unsuccessful and baby currently <32 weeks gestation, place back on CPAP and continue to try to wean completely off CPAP to room air as clinically indicated.
  • After a baby is 32 weeks CGA, if still requires non-invasive support and cannot wean to room air, may consider use of HFNC or LFNC.

CARDIOVASCULAR:

  • Double lumen UVC in all infants
  • Have a fluid always running through the second port – do not “heplock” as this increases risk of line becoming dysfunctional
  • UAC to be placed in all infants born at <27 weeks or if infant requires intubation
  • Hypotension deemed by 2 out of 3 parameters:
  • Prolonged capillary refill
  • Low urine output
  • Low blood pressure (i.e. Mean BP < gestational age in weeks)
  • Treatment of hypotension
  • NS flush 10ml/kg or colloid 10ml/kg once
  • If no improvement, discuss with Neonatologist or fellow re: use of second fluid bolus vs. starting pressor support
  • If hypotension or on pressors, follow iCa q12hr and treat to keep normal

INFECTIOUS DISEASE:

  • Unless in room air with no risk factors for infection, all infants will have admission blood culture and IV Ampicillin and Gentamicin initiated

NEUROLOGIC:

  • Indomethacin prophylaxis on all infants <1kg (of note, non-nutritive feedings and Vitamin D acceptable when receiving indomethacin)
  • Head ultrasound at 5-7 days of age
  • Midline head positioning ordered per protocol

HEMATOLOGY:

  • Coags only obtained if active bleeding
  • Infant blood type & DAT testing on admission
  • Hemoglobin and platelet count daily
  • Treat per clinical transfusion guidelines

GI:

  • First bilirubin level to be obtained at 12-24 hours of life.
  • Checked daily
  • Increase in total daily fluid goal by 20ml/kg/day if initiating overhead phototherapy

RENAL:

  • If urine output <1ml/kg/day over previous 12 hours
  • Consider use of bladder scanner to evaluate for urine and possible need for Foley catheter
  • Give NS 10ml/kg bolus
  • If no improvement in urine output over next 4 hours, give Lasix 1mg/kg IV
  • If no improvement in urine output over next 4 hours, consider more volume versus low-dose Dopamine

Confidential10/12/2018