Care of the extremely preterm baby

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CHAPTER 14 Care of the extremely preterm baby

Mark Davies, David Cartwright

Initial care of the ELBW infant prior to transfer to Level 3 nursery

Avoid birth outside a hospital with a Level 3 neonatal unit! Transfer in utero if possible.

Resuscitation

• A B C (airway, breathing, circulation).
• Intubate or not? This depends on the paediatrician’s comfort zone — the default option is intubate and ventilate.
• Ventilation — beware high pressures, use peak inspiratory pressures (PIPs) just high enough to move the chest. Provide positive end expiratory pressure (PEEP) of 6–7 cmH2O.
• Oxygen saturation — aim for 85–92%.

Intubation/Ventilation

• The only absolute indication is apnoea.
• This depends on the paediatrician’s comfort zone — safest to intubate and ventilate unless baby looks very good.
• Endotracheal tube (ETT) size:

— use 2.5 if <1000 g
— try 3.0 if >1000 g.

• For oral ETT, tape at upper lip at:

— 7.0 cm if ∼1000 g
— 6.5 cm if ∼750 g
— 6.0 cm if ∼500 g.

• Chest X-ray — ETT tip should be at T1; should be at least 1 cm above carina (which is at T4).
• The enemy is atelectasis — use adequate PEEP: start with 6–7 cmH2O.
• If on CPAP (continuous positive airway pressure), start with 7–8 cmH2O; unless in air, then use 5 or 6 cmH2O.
• Surfactant: unless in air on lowish pressures, give surfactant (Survanta 4 mL/kg; Curosurf 2.5 mL/kg).
• Ventilator settings — a good starting point is:

— rate 60
— inspiratory time 0.5 s
— pressures (PIP/PEEP) 18/6 cmH2O.

Adjust PIP according to chest movement or blood gas results; wean PIP until chest movement OK, then wean rate.

Oxygenation

• Saturations 85–92% — never over 95%.

Don’t chase after elusive high saturations.

• If oxygenation poor despite adequate PaCO2 (partial pressure of carbon dioxide in arterial blood), then try:

— increase PEEP
— support heart: dobutamine, adrenaline
— increase blood pressure (BP): dopamine, adrenaline.

Always discuss inotrope use with a neonatologist before using.

Ventilation

• PaCO2 — high 40s (mmHg) or low 50s is OK; don’t chase normocarbia.
• Avoid PaCO2 <30 mmHg (strong association with adverse neuro-developmental outcome and chronic lung disease).
• Sedation — morphine/midazolam if baby resists ventilation:

— bolus of 0.06–0.1 mg/kg each is usually enough
— can infuse at 10 μg/kg/hr each if needed
— see pages 83–4.

Antibiotics

• Just give them! Penicillin and gentamicin unless mother has other known bacteria — take blood culture first. (Green liquor — ampicillin instead of penicillin.)

Blood pressure

• MABP in mmHg > GA in weeks is OK — if well perfused. (MABP = mean arterial blood pressure; GA = gestational age.)
• Low BP: 10 mL/kg Nsaline (some use albumin) ×2, then dopamine 3–5 μg/kg/min (see page 82). Timing of second Nsaline/albumin dose depends on response to first. (Nsaline = Normal saline, 0.9%.)
• If evidence of acute blood loss — replace with blood.
• Inotropes — dobutamine, dopamine, adrenaline (discuss with a neonatologist).
• Steroids (hydrocortisone IV — 1–2.5 mg/kg every 4–6 hours).

Correct acidosis

• Give slow bicarbonate infusion (over longer than 5 minutes):

— image

Vitamin K

• Smaller dose — 0.5 mg (i.e. 0.05 mL of Konakion MM Paediatric).

Fluids

• 80 mL/kg/day of 10% dextrose.

Thermoregulation

• Dry the baby immediately after birth or use a polyethylene wrap.
• Keep warm — skin temperature 36.3–36.8°C, axillary temperature 37°C.
• Woolly hat on baby, plastic or bubble wrap over baby, warmed humidified air into cot.
• If under a radiant warmer on an open cot, ensure skin temperature probe is covered with a reflective disc. Do not cover baby with blanket — that will stop the overhead warmer from warming the baby.

Lines

• Consultants only — put in an umbilical venous catheter (UVC) and maybe an umbilical arterial catheter (UAC). Never use the second umbilical artery if unsuccessful with the first — leave that for the staff at the Level 3 neonatal unit. An ELBW infant without adequate umbilical lines can be a major problem.
• Prep with aqueous chlorhexidine only.
• Measure tip of right shoulder to umbilicus — put UAC in this distance, or use the ‘ready reckoner’ tables on pages 166–8.
• Measure bottom end of sternum to umbilicus — put UVC in this far, or use the ‘ready reckoner’ tables on pages 166–8. UVC tip should be at the bottom of the heart between T8 and T9; if below T9 but good blood flowback when aspirated, then leave in place and use for 10% dextrose and urgent drugs.
• Do not use UVC for inotropes (or parenteral nutrition) unless tip is in the inferior vena cava or right atrium.

Skin

• No unnecessary tape.

Photographs

• … of the baby for parents to keep.

Mother

• Transfer to same hospital as baby as soon as possible, express breast milk.
• Warn parents — long time in hospital, intensive care nursery, on respiratory support and oxygen; neurosensory deficits; cerebral palsy; neuro-developmental problems; disability.

Guidelines for care of infants <1000 g / <28 weeks at a Level 3 nursery

1. Consultant or ‘attending’ neonatologist (and at least one registrar/fellow/resident/neonatal nurse practitioner) to be present at delivery.
2. Where indicated, intubate with a size 2.5 endotracheal tube (ETT) to:

— 7.0 cm if ∼1000 g
— 6.5 cm if ∼750 g
— 6 cm if ∼500 g.

Use a Neopuff or similar T-piece device (see page 8) to deliver PEEP and ventilate to transfer to nursery.

If not needing intubation, commence CPAP from delivery (Neopuff).

3. If ventilated:

— ventilate in intensive care at 80/min, inspiratory time 0.38 sec
— use volume-targeted ventilation (e.g. the Dräger ventilator with Volume Guarantee) 4 mL/kg
— monitor oxygen saturation continuously; target 85–92%.

4. Do not use a transcutaneous blood gas monitor.
5. Superficial swabs (groin and ear).
6. Surfactant — give early rather than late:

— give to all babies in this group who need intubation at birth, as soon as the ETT is in place
— give immediately if fraction of inspired oxygen FiO2 >0.3 or PIP >18 cmH2O (before lines and X-ray)
— give by 2 hours and repeat 6 hours later (see page 35) if FiO2 >0.25.

7. Insert:

— umbilical arterial catheter (UAC), 3.5FG — consultant or ‘attending’ neonatologist or a senior trainee should do this; little babies are not for learners.

Check with consultant whether high (T8–T12) or low (tip below L2). Some recommend low, reasoning that the catheter is larger than 1/2 the diameter of the aorta so why potentially compromise gut and kidney blood flow with that above mesenteric vessels?

— umbilical venous catheter (UVC), double lumen 3.5FG; prime with heparinised Nsaline. (Nsaline = Normal saline, 0.9%.)

Run:

— UAC: Nsaline or ½Nsaline with 1 unit heparin/mL, 0.5 mL/hr
— UVC primary lumen: 10% dextrose to total fluids 60–80 mL/kg/day
— UVC secondary lumen: Nsaline (no heparin), 0.2 mL/hr.

Use great care in swabbing the abdomen.

• Alcoholic chlorhexidine burns — apply very sparingly, with only a corner of the swab wet. Never allow any to run down the side of the abdomen.
• It’s the alcohol that burns — never allow a baby to lie in this. Never apply any dressing over wet alcohol.
• We recommend aqueous chlorhexidine — it’s easier and safer, especially in an emergency situation.

8. Antibiotics — penicillin 60 mg/kg every 12 hours and gentamicin 2.5 mg/kg every 36 hours.
9. If platelet count is >50 × 109/L then give prophylactic indomethacin IV 0.1 mg/kg daily for 3 days — start <12 hours (i.e. 0.08 mg if 800 g etc — be careful writing up the dose).
10. Chest/abdominal X-ray after ETT and umbilical lines; repeat the next day to recheck UVC position — sometimes they migrate (in). Repeat X-ray daily until UVC tip is in a stable position.
11. Clean neck with triclosan swab, then dry; apply a transparent, bio-occlusive, polyurethane dressing (such as Bioclusive, Tegaderm, Opsite); commence topical and enteral nystatin.
12. Monitor serum electrolytes with blood gases. Laboratory specimen for albumin, phosphate twice a week only.
13. Full blood count and film examination (FBC) on days 1, 3, 5 and 7; then twice weekly for 2 weeks; then weekly (with reticulocytes).
14. Cranial ultrasound on days 3, 10 and 42 is recommended as routine. Other units have different regimens; however, it is important to do early scan/s to detect intraventricular haemorrhage and a late scan (≥4 weeks) to detect cystic periventricular leucomalacia.
15. Commence parenteral nutrition on day 3 (via a correctly positioned UVC) if electrolytes stable (especially [K+] <5 mmol/L).

— Intralipid 20%: 10 mL/kg/day, with Vitalipid N 4 mL/kg/day.
— Commence enteral phosphate if [PO43−] is <1.0 mmol/L (see dose page 76).

We rarely need to do this now since we have put more phosphate in our parenteral nutrition.

— Soluvit N: 2 mL/kg Mon–Wed–Fri added to burette with parenteral nutrition line changes.

16. Insert a silastic central venous line (CVL) on day 3–7 as indicated, remove UVC then (by day 5 if possible).
17. Remove UAC on day 7–10.
18. Extubate to nasal CPAP, with prior theophylline, when the ventilator rate is ≤20/min.
19.

a Commence nasogastric feeds on day 2–3 as able, 1 mL every 3 hours.
b Increase feeds daily, as able, to 2 mL, 3 mL, 4 mL, then 5 mL every 3 hours.
c Change to 4 mL every 2 hours (if 5 mL every 3 hours is tolerated), and then increase by 1 mL every 12 hours.
d Commence iron supplementation (see page 76) if breast milk feeding at day 14. Not needed if formulafed.
e Fortify feeds when they are well tolerated.

20. Cease parenteral nutrition when feeds at ∼180 mL/kg/day.
21. Try suck feeds from 1600 g or 32 weeks, or sooner if baby is keen to suck.
22. Open cot at 1800 g.
23. Give first immunisation at day 56.
24. Home when all suck feeds, gaining weight, open cot and temperature OK.

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CHAPTER 14 Care of the extremely preterm baby

Mark Davies, David Cartwright

Initial care of the ELBW infant prior to transfer to Level 3 nursery

Avoid birth outside a hospital with a Level 3 neonatal unit! Transfer in utero if possible.

Resuscitation

• A B C (airway, breathing, circulation).
• Intubate or not? This depends on the paediatrician’s comfort zone — the default option is intubate and ventilate.
• Ventilation — beware high pressures, use peak inspiratory pressures (PIPs) just high enough to move the chest. Provide positive end expiratory pressure (PEEP) of 6–7 cmH2O.
• Oxygen saturation — aim for 85–92%.

Intubation/Ventilation

• The only absolute indication is apnoea.
• This depends on the paediatrician’s comfort zone — safest to intubate and ventilate unless baby looks very good.
• Endotracheal tube (ETT) size:

— use 2.5 if <1000 g
— try 3.0 if >1000 g.

• For oral ETT, tape at upper lip at:

— 7.0 cm if ∼1000 g
— 6.5 cm if ∼750 g
— 6.0 cm if ∼500 g.

• Chest X-ray — ETT tip should be at T1; should be at least 1 cm above carina (which is at T4).
• The enemy is atelectasis — use adequate PEEP: start with 6–7 cmH2O.
• If on CPAP (continuous positive airway pressure), start with 7–8 cmH2O; unless in air, then use 5 or 6 cmH2O.
• Surfactant: unless in air on lowish pressures, give surfactant (Survanta 4 mL/kg; Curosurf 2.5 mL/kg).
• Ventilator settings — a good starting point is:

— rate 60
— inspiratory time 0.5 s
— pressures (PIP/PEEP) 18/6 cmH2O.

Adjust PIP according to chest movement or blood gas results; wean PIP until chest movement OK, then wean rate.

Oxygenation

• Saturations 85–92% — never over 95%.

Don’t chase after elusive high saturations.

• If oxygenation poor despite adequate PaCO2 (partial pressure of carbon dioxide in arterial blood), then try:

— increase PEEP
— support heart: dobutamine, adrenaline
— increase blood pressure (BP): dopamine, adrenaline.

Always discuss inotrope use with a neonatologist before using.

Ventilation

• PaCO2 — high 40s (mmHg) or low 50s is OK; don’t chase normocarbia.
• Avoid PaCO2 <30 mmHg (strong association with adverse neuro-developmental outcome and chronic lung disease).
• Sedation — morphine/midazolam if baby resists ventilation:

— bolus of 0.06–0.1 mg/kg each is usually enough
— can infuse at 10 μg/kg/hr each if needed
— see pages 83–4.

Antibiotics

• Just give them! Penicillin and gentamicin unless mother has other known bacteria — take blood culture first. (Green liquor — ampicillin instead of penicillin.)

Blood pressure

• MABP in mmHg > GA in weeks is OK — if well perfused. (MABP = mean arterial blood pressure; GA = gestational age.)
• Low BP: 10 mL/kg Nsaline (some use albumin) ×2, then dopamine 3–5 μg/kg/min (see page 82). Timing of second Nsaline/albumin dose depends on response to first. (Nsaline = Normal saline, 0.9%.)
• If evidence of acute blood loss — replace with blood.
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