Revised 1/2013

Guidelines for initial treatment of ELBW (<1000gm) infants for the firsts few days of life

1. IVF:

a.  NPO status

b.  Total fluids: 80 ml/kg/day

c.  UAC: 1/3 Sodium Acetate + heparin @ 0.8ml/hr

d.  UVC: starter TPN and D12.5W

i.  Starter TPN (D10W with some Calcium) to run at 1.5ml/kg/hr to deliver ~3gm/kg/day of protein

2. Laboratory values:

a. Weights BID

b. Glucoses at 30min, 1hr, 2hr of age then q6hr and prn if hypo/hyperglycemic

c. Na, K, Cl, iCa starting at 12 hours of life and then q12 hours

d. First bilirubin check at 12 hours of age

e. Admission coags to be checked on babies with significant metabolic acidosis (BE ≥9) or 5 minute APGAR ≤6

3. Medications:

a. Ampicillin & Gentamicin per protocol

b. Indomethacin

i.  0.1mg/kg/dose IV q24hours x 3 doses

ii.  Initiate dosing at 3-6 hours of life

iii.  If infant requires hydrocortisone therapy, dosing should ideally be given >24hours after the last indomethacin dose was given

c. Caffeine

i.  Caffeine should be initiated within 48 hours of expected extubation or by day of life 7, which ever comes sooner.

ii.  Rationale: national data suggests better success at extubation and less chronic lung disease in this population with caffeine started within 7 days of life.

d. Vitamin D

i.  400 IU/day PO/NG qday should be initiated within the first week of life.

ii.  This should be initiated regardless if the patient is otherwise NPO, unless the NPO status is due to concerns regarding bowel integrity (e.g. NEC, IUGR) or suboptimal blood flow (e.g. on pressors)

4. Hyperbilirubinemia

a. Increase total fluids by 20ml/kg/day if initiating overhead phototherapy

b. Start empiric overhead phototherapy for excessive bruising

c. Start overhead phototherapy if total bilirubin level is > 5 x weight in kg (e.g. for a 600gm infant, would start phototherapy at total bili of 3)

5. Ventilation

a. All babies <26 weeks gestation will be intubated in the DR and given a dose of Infasurf (3 ml/kg)

b. ELBWs who are intubated on admission should be placed on the following initial settings:

i.  PAC+VG

ii.  Rate = 60

iii.  PIP max = 30 (or less)

iv.  PEEP = 6 cm H2O

v.  Vt = 5 ml/kg

vi.  Itime = gestational age (ie. 28 weeker, I-time 0.28)

6. Fluid status assessment and recommended interventions

a. If weight down and Na > 150, consider increasing total fluids by 10-20 ml/kg/day and decreasing sodium in fluids

b. If weight up and Na > 150, consider diuretics and decreasing sodium in fluids. Would not recommend increasing total fluids if weight is up.

c. If hypotension and clinical signs of poor perfusion state, consider early initiation of pressors after 1 or 2 NS flushes to minimize both fluid and sodium overload

7. All babies born at <26 weeks gestational age WILL NOT be extubated in the first 72 hours of life unless directed to do so by the attending/fellow staff (even if on minimal ventilatory settings) -- rationale: review of our NICU data shows that in 2007-2008, no infants extubated within the 72 hour time frame successfully stayed extubated for more than 24 hours, it is the critical window for the majority of IVH to occur and acidosis/instability could be detrimental.