Transcript Neonatal Resuscitation… Yesterday, Today & Tomorrow

Chronic Lung Disease
Interventions
N. Singhal
University of Calgary
November 2006
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Outline
• Process
• Interventions proposed
– Infection – K. Aziz
– CLD – N. Singhal
• Interventions implemented
– Infection – K. Aziz
– CLD – N. Singhal
• Future directions – K. Aziz
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Review Process
• Cochrane reviews
• Systematic reviews
• Informal reviews
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CLD Group Interventions
• Process
– Experts selected topics
– Training provided for literature review
– Each centre given ONE topic to review
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Review Process
• Cochrane reviews
• Systematic
reviews
• Informal reviews
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Process cont’d
• Meeting of all centre/experts to
discuss areas for improvement
• Generated list of interventions
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Interventions Proposed
• Antenatal
– Treat urea plasma with
erythromycin
– Antenatal steroids
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Interventions Proposed
• Resuscitation
– Early within one hour prophylactic
surfactant <28 weeks or <1250 g.
– Diminish hand ventilation
– Decrease 100% oxygen exposure
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Interventions Proposed
• CPAP
– Early CPAP for babies in supplemental
oxygen
– Long term CPAP
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Interventions Proposed
• Ventilation
–Early use of
HFV
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Interventions Proposed
• Normocarbia
• Avoid hypocarbia
• PaC02 40-55 mm of Hg
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Interventions Proposed
• Saturation targets
• Saturation targets
• > 88 to < 94 ? 93
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Interventions Proposed
• Nutrition/Fluids
– Calories
– Decrease fluid use
– High dose Vitamin A
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Interventions Proposed
• Environment
– Pain
– Massage
– Noise
– NIDCAP
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CLD Interventions Implemented
• Antenatal:
-Antibiotics
-Expectant arrangement of PROM
-Antenatal steroids
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CLD Interventions Implemented
• Resuscitation
– Surfactant within 30 minutes
– Avoid hand ventilation
– Ventilation delivery room
– Only Laerdel bags with PEEP
– Blended gases
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CLD Interventions Implemented
• Ventilation
– Early HVF – not done
– Assist control and volume guarantee
–Not done specifically
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CLD Interventions Implemented
• Normocarbia
– PaC02 – 45-55 mm of Hg
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CLD Interventions Implemented
• Saturation targets
– Sat alarm limits 85-95%
– Goal 88-92%
• Physician orders oxygen as drug
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CLD Interventions Implemented
• Nutrition/Fluids
– ↓ TFI < 32 weeks first few days
– TPN within 24 hours
– TPN within 4 hours
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CLD Interventions Implemented
• Environment
– Renovations to unit
– ↓ sound levels
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CLD Interventions Implemented
• Others:
– Comment card for parents
– Avoid re-intubation with CPAP
– Perinatal referral policies
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Early CPAP – EPIC PDSA Cycle # 4
> 27 weeks and < 34 weeks
Respiratory Distress?
(based on clinical
judgment)
Yes
Intubate, BLES
transfer to NICU
(*may be given
in NICU after
transfer)
Extubate to
CPAP if FiO2 <.4
at 2 to 4 hours
of age and if
clinically stable
No
Stabilize then
transfer to NICU
Develops
respiratory
distress?
No
Routine
management***
Yes
Intubate, BLES
Routine
management***
If > 27 weeks, had HMD and on supplemental FiO2 in
first 24 hours of life should be on CPAP
*** wean from CPAP as per clinical indications
Extubate to
CPAP if FiO2 <.4
(no time frame)
Routine
management***
Thank you
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