Care of the extremely preterm baby

Published on 03/06/2015 by admin

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Last modified 03/06/2015

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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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