The Golden Hour Guidelines

CLICK ABOVE FIGURE FOR BETTER VIEWING!

By Dr Betty Martinez (approved the Tulane Section of Neonatology and NNP group 12/2/2010), revised 8/31/2011 by Dr Phillip Gordon for PDSA 2.

RESPIRATORY

 INTUBATION EQUIPMENT

LARYNGOSCOPE WITH BRIGHT LIGHT, 2.5 AND 3.0 ETT, SEVERAL OF EACH

00.  0 STRAIGHT MILLER BLADES

FACE MASKS (PRETERM AND SOFT RIMMED. MAY USE THE CIRCULAR SMALL MASKS THAT COME WITH NEOPUFF)

NEOPUFF. SETTINGS 20/5

BLENDED OXYGEN. BEGIN AT .40 TO .50 FiO2 WITH POSSIBILITY OF 90 TO 100% IF NEEDED

PULSE OXIMETER AND PROBE (SHOULD BE IN THE OR)

BENZOIN, NEOBAR OR PINK TAPE

 SUCTION EQUIPMENT

BULB SYRINGE

MECHANICAL SUCTION, TUBING AND 8 AND 10 END-HOLE SUCTION TUBES

6 SUCTION TUBE FOR ETT

MECONIUM ASPIRATOR (NOT OPENED)

MEDICATIONS

D10W

EPINEPHRINE (1:10,000)

NORMAL SALINE

INFRASUR 3 ML AND 6 ML, WARMED AND NOT SHAKEN

UMBILICAL VEIN (3.5 OR 5 FR POLYURETHANE [STIFF]) SINGLE LUMEN CATHETER

UMBILICAL VESSEL CATHETERIZATION SUPPLIES 

STERILE GLOVES, BETADINE, SCALPEL UVC, UMBILICAL TAPE, 3-WAY STOPCOCK, TEGADERM OR WIDE TAPE

ADDITIONAL EQUIPMENT FOR <1000 G

WARMER PACK

SARAN WRAP WIDE ENOUGH TO COVER TOP OF OHW

SNUGGLY DEVICE

SINGLE TOWEL OVER SNUGGLY

2 PRE-CUT HATS

4 HEEL WARMERS (CANNOT BE PRE-WARMED) AND ONE PULSE OXIMETER

ALL OF THE ABOVE ARE PRE-WEIGHED AND THIS WEIGHT WILL BE SUBTRACTED FROM ADMIT WEIGHT

 ONE GALLON SUPERMARKET BAGGIE, NOT STERILE, WITH BOTTOM CUT COMPLETELY

 ESTIMATED FETAL WEIGHT BY GESTATIONAL AGE AND DEPTH OF ETT INSERTION. USING WORDS ON 2.5 ETT AS MARKERS

23 WEEKS            501 GMS         LENGTH 28.9 CM      ETT 6 CM       AND BREATH SOUNDS EQUAL TO 2 OBSERVERS

24 WEEKS            650 GMS         LENGTH 30 CM         ETT 6.6 CM

25 WEEKS            780 GMS         LENGTH 34.6 CM      ETT 6.8 CM

26 WEEKS            850 GMS         LENGTH 35.6 CM      ETT 7 CM

27 WEEKS            1000 GMS      LENGTH 36.6 CM      ETT 7 CM

28 WEEKS            1200 GMS      LENGTH 37.6 CM      ETT 7.2 CM

29 WEEKS            1400 GMS      LENGTH 38.6 CM      ETT 7.4 CM

30 WEEKS            1600 GMS      LENGTH 39.9 CM      ETT 7.5 CM

GOALS:

ADMISSION TO UNIT: AS CLOSE TO 36.5 AS POSSIBLE. NEUTRAL THERMAL ENVIRONMENT 36.5 TO 37.5.  AVOID HYPOTHERMIA (ADMIT TEMP <= 34.5)  (DIC, HYPOGLYCEMIA) AND HYPERTHERMIA (BRAIN INJURY)

ADMISSION TO UNIT WITH PIP 12 TO 16, Fi02 .21 TO .30

INFASURF DELIVERED WITHIN ONE HOUR OF LIFE FOR ELBW < 1KG

PREPARATION FOR DELIVERY

WORD FROM L&D THAT 23 TO 27 WEEK GESTATION IMMINENT DELIVERY

ASK THAT BABIES < 27 WEEKS BE DELIVERED IN OR TURN ON AND HUMIDIFY GIRAFFE TO .80 IF NOT ALREADY DONE

GET INFASURF 3 AND 6 ML VIALS FROM PYXIS

SET UP FOR UVC AND UAC DOUBLE LUMEN 3.5 UVC AND SINGLE LUMEN 3.5 FR UAC

MULTIDISCIPLINARY DECISION MADE THAT PARENTS WANT EVERYTHING POSSIBLE DONE FOR THE INFANT

STAFF IS CALLED. NNP AND RESIDENT, ADMIT NURSE TO PREPARE OR FOR DELIVERY

STAFF SHOULD BE AVAILABLE FOR DELIVERY

TEAM ASSIGNS ROLES: AIRWAY, CHEST COMPRESSIONS, UVC, MEDICATIONS, CLOCK MINDER

AGREE ON DOSING WEIGHT BY USING APPROXIMATE WEIGHT CHART.  DECIDE LENGTH OF INTUBATION BY USING 6 + EBW FOR LIP LENGTH.  DECIDE AMOUNT OF INFASURF 3 ML X 3BW, DIVIDE IN TWO EQUAL PORTIONS

OPERATING ROOM AMBIENT TEMPERATURE AS CLOSE TO 37C AS POSSIBLE

PREHEAT WARMER TO MANUAL CONTROL, FULL TEMPERATURE

OPEN WARMER PACK AND LAY SO THAT SARAN WRAP IS RIGHT ON MATTRESS, THEN SNUGGLY, THEN BLANKET.  PUT PRECUT HATS UNDER SNUGGLY.  HAVE HEEL WARMERS READY TO ACTIVATE AS SOON AS BABY IS BORN.

DOUBLE CHECK RESUSCITATION EQUIPMENT. NOT EVERYTHING HAS TO BE OPENED, BUT EVERYTHING SHOULD BE AT HAND

SET NEOPUFF TO BLENDER, 5 TO 8 LPM AT .40 PIP/PEEP 20/5

HAVE NEO-BAR OR TAPE PRE-CUT. BENZOIN AVAILABLE

IF USING THERMAL PACKET, TAKE IT FROM THE WARMER IN THE UNIT AND KEEP WARM.

BRING PACKET OF 4 PREWEIGHED HEEL WARMERS. BABY MUST BE WEIGHED IN THE UNIT WITH ALL CONTENTS OF WARMING PACK.

USE NEOPUFF FOR RESUSCITATION

PIP SET TO 16 TO 20. INITIAL PIP MAY BE AS HIGH AS 25 TO STABILIZE BABY.

DECREASE AS SOON AS HR >100.

EXPERIENCED INTUBATOR MAY CHOOSE FLOW-INFLATED BAG AND USE BARELY ADEQUATE CHEST RISE AND IMPROVEMENT OF HEART RATE TO MANAGE WEANING PIP AND FiO2

BABY IS BORN

 RECEIVE BLOODY BUNDLE FROM OB STAFF

 GENTLY REMOVE AS MUCH FLUID AS POSSIBLE, BUT DO NOT WASTE TIME WIPING ALL BLOOD OFF. BABY IS FREEZING

 IF USING PREWEIGHED PACK PLACE BABY ON BLANKET, PLACE HATS ON HEAD. HEEL WARMERS CAN BE ACTIVATED AND PLACED INSIDE FOLDED BLANKET SO THAT BABY IS NOT BURNED. ATTACH PULSE OXIMETRY PROBE TO FOOT.  THESE ACTIONS ARE PERFORMED IN A MANNER THAT PERMITS FREE ACCESS TO AIRWAY

 BEGIN RESUSCITATION.

 IF 23 WEEKER AND DECISION MADE TO GIVE PROPHYLACTIC SURFACTANT, INTUBATE  TO AGREED DEPTH, TWO TEAM MEMBERS SHOULD DOCUMENT SYMMETRIC BREATH SOUNDS

DELIVER INFASURF IN TWO BOLUSES, OVER 1 MINUTE.  ROTATING BABY GENTLY BETWEEN DOSES

 IF BABY WILL NOT BE GIVEN SURFACTANT PROPHYLACTICALLY IN OR, PROCEED WITH RESUSCITATION WITH NEOPUFF, FiO2 .40.  INTUBATE IF NECESSARY, TAPE AT PREDETERMINED LENGTH OT LIP.

 ATTACH NEOPUFF TO ETT AND BEGIN RESPIRATIONS  AT 20/5,  .40 FiO2. RATE 30 TO 40

 WATCH CHEST RISE CAREFULLY AND ADJUST PIP AS NECESSARY TO OBTAIN BARELY PERCEPTIBLE RISE AND DOCUMENT HEART RATE

 WHEN BABY IS STABLE, CLOSE LOOPS OF SNUGGLY OVER ARMS AND LEGS FOLDED IN FETAL POSITION. CLOSE SARAN WRAP OVER EVERYTHING, KEEPING HEAD WITH ETT AVAILABLE.

CONNECT NEOPUFF TO TRANSPORT BLENDED OXYGEN SYSTEM AND USE LOWEST POSSIBLE FiO2.

 ASSIGN TEAM MEMBER TO NOTE CHEST RISE AND BE AVAILABLE TO RAISE OR LOWER PIP ON NEOPUFF AS YOU TRANSPORT TO NICU.

 ARRIVAL TO NICU

 WEIGH BABY IN GIRAFFE. SUBTRACT PREWEIGHT AMOUNT OF WARMER PACK AND THIS WILL BE THE ADMIT WEIGHT

 ATTACH PULSE OXIMETER TO MONITOR. IF THERE IS FAIR WAVE FORM DO NOT TAKE TIME TO PLACE LEADS OR MEASURE BABY

 THE PULSE OXIMETER AND THE UAC WAVE FORM WILL BE YOUR HEART RATE

 IF INFASURF NOT GIVEN IN OR, TRY TO DELIVER IT AS SOON AS POSSIBLE AFTER ARRIVING IN NICU BEFORE ONE HOUR OF LIVE

 TWO INDEPENDENT OBSERVERS LISTEN TO LUNG FIELDS AND DETERMINE APPROPRIATENESS OF ETT DEPTH.

 AS SOON AS SURFACTANT GIVEN USE SATURATION READINGS TO WEAN SLOWLY FiO2 TO MAINTAIN SATS 85 TO 92% POST-DUCTAL, CALCULATE 4 TO 6 ML/KG AND WEAN PIP TO MAINTAIN DESIRED TIDAL VOLUME.  NO NEED FOR ABG’S.  HAVE FAITH MOST BABIES CAN BE VENTILATED WITH IMV 40 PS 1 – 2 LOWER THAN PIP, PIP 12 TO 16, PEEP 5 AND Fi02 TO MAINTAIN SATURATIONS 85 TO 92%.

 LEAVE BABY IN SNUGGLY, TIES CAN BE POSITIONED SO THAT UMBILICAL CATHETERS CAN BE PLACED IN THE USUAL STERILE FASHION. IF BABY VERY ACTIVE, MAY TIE DOWN IN USUAL FASHION.

 RADIOGRAPH TO DOCUMENT PLACEMENT OF ETT AND LINES

UVC AND UAC CATHETERS SECURED.

 RT MAKES SURE THAT THEY ARE OK WITH ETT TUBE PLACEMENT

 GASTRIC TUBE TO VENT

 CLOSE GIRAFFE BY 2 HOURS OF LIFE!

 BEGIN STARTER TPN, TOTAL FLUIDS 80 ML/KG. SUBTRACT UAC FLUIDS

 UAC STANDARD 7.7 MEQ SODIUM ACETATE TO 100 ML TOTAL VOLUME STERILE WATER SO THAT NA IS 0.077 MEQ/ML. ADD 0.5 UNITS HEPARIN/ML. THIS SHOULD PROVIDE APPROXIMATELY 0.9 UNIT HEPARIN/KG.HR FOR 500 GM MICROPREMIE

 LEAVE BABY ALONE UNTIL DESIRED HUMIDITY HAS BEEN REACHED

 AT THIS TIME NURSES CAN GO IN AND REMOVE DIRTY LINENS, MAKING SURE HEAD IS MIDLINE. CHEST LEADS CAN BE PLACED AT THIS TIME.

 IF THERE IS PROLONGED RESUSCITATION, BABY ARRIVED IN NICU WITH TEM <=34.5 BE CAREFUL WITH REWARMING.  AIM FOR 0.5 Co/HOUR.

IF THERE IS PROBLEM OBTAINING IV ACCESS, CONSIDER STARTING HUMIDITY AT .90.

ADJUST HUMIDITY OR FLUIDS BASED ON BMP OR ABG WITH LYTES AT 6 HOURS.

 23 WGA MICROPREMIES MAY NEED HFOV. IF UNABLE TO OXYGENATE USING <= .30 TO .40 FiO2. AFTER SURFACTANT GIVEN

 CONSIDER ASKING TO SET UP HFOV EVEN IF NO ABG AVAILABLE. MAP 10 TO 12, AMP 20 TO 24. HZ 12 TO 15 TO BEGIN.

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