Care of the extremely preterm baby

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).
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Jul 18, 2016 | Posted by in PEDIATRICS | Comments Off on Care of the extremely preterm baby

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