2017 Pcep Specialized Newborn Care 4 PDF

Time-efficient, cost-effective perinatal education and training
PCEP
PCEP
PCEP IV
BOOK
Perinatal Continuing Education Program, 3rd Edition, Book IV
Perinatal Continuing Education Program, 3rd Edition Perinatal Continuing Education Program
3RD EDITION
EDITOR IN CHIEF, NEONATOLOGY
Robert A. Sinkin, MD, MPH, FAAP
EDITOR IN CHIEF, OBSTETRICS

PCEP Workbook Contents
EARN
UP TO
Specialized
MATERNAL AND FETAL EVALUATION AND IMMEDIATE
Christian A. Chisholm, MD, FACOG 54
CRED CME NEWBORN CARE (BOOK I)
IT
For more than 35 years, the Perinatal CONT S OR • Is the Mother Sick? Is the Fetus Sick?
A
Continuing Education Program (PCEP) HOUR CT • Fetal Age, Growth, and Maturity
S! • Fetal Well-being
has enhanced the knowledge and skills of • Is the Baby Sick?
Newborn Care
physicians, nurses, nurse midwives and • Resuscitating the Newborn
practitioners, respiratory therapists, and other • Gestational Age and Size and Associated Risk Factors
providers of care for pregnant women and newborns. • Thermal Environment
• Hypoglycemia
The third edition PCEP workbooks have been brought up-to-date
MATERNAL AND FETAL CARE (BOOK II)
with leading-edge procedures and techniques. These information-rich
• Hypertensive Disorders of Pregnancy
volumes are filled with concise information, step-by-step instructions,
• Obstetric Hemorrhage
and practice-focused exercises. They offer time-saving, low-cost • Perinatal Infections
solutions for self-paced learning or as adjuncts to instructor-led • Other High-risk Conditions
skills teaching. • Abnormal Glucose Tolerance
PCEP IS A PROVEN EDUCATIONAL TOOL FOR • Premature Rupture or Infection of the Amniotic
• Improving perinatal care know-how, policies, practices, and Membranes
procedures. • Preterm Labor
• Inducing and Augmenting Labor
• Teaching both practical skills and cognitive knowledge.
• Abnormal Labor Progress and Difficult Deliveries
• Saving time—self-paced self-study approach streamlines the
• Imminent Delivery and Preparation for Maternal/
learning process. Fetal Transport
• Saving money—provide top-notch education at low
NEONATAL CARE (BOOK III)
per-participant costs.
• Oxygen
• Encouraging cooperation and communication among diverse • Respiratory Distress
specialties and staffing levels. • Umbilical Catheters
• Simplifying education planning and budgeting. • Low Blood Pressure
• Intravenous Therapy
CONVENIENT, HASSLE-FREE CME OR CONTACT HOURS • Feeding
• Hyperbilirubinemia
Earn
AMA PRA Category 1 Credit(s)™ or ANCC contact hours
• Infections
are available from the University of Virginia. Visit
CME credits
www.cmevillage.com for more information. • Review: Is the Baby Sick? Identifying and Caring for
Sick and At-Risk Babies
or contact
The University of Virginia School of Medicine is accredited by
• Preparation for Neonatal Transport
the Accreditation Council for Continuing Medical Education
hours!
to provide continuing medical education for physicians. SPECIALIZED NEWBORN CARE (BOOK IV)
The University of Virginia School of Nursing is accredited as • Direct Blood Pressure Measurement
a provider of continuing nursing education by the American • Exchange, Reduction, and Direct Transfusions
Nurses Credentialing Center’s Commission on Accreditation. • Continuous Positive Airway Pressure
• Assisted Ventilation With Mechanical Ventilators
• Surfactant Therapy
THE PCEP WORKBOOKS AND RELATED PRODUCTS CAN BE PURCHASED DIRECTLY
• Continuing Care for At-Risk Babies
FROM THE AMERICAN ACADEMY OF PEDIATRICS AT SHOP.AAP.ORG.
AAP
PCEP
Perinatal Continuing Education Program
Specialized
Newborn Care
Book IV
00_FM_BKIV_PCEP_i-viii.indd 1 9/6/16 10:57 AM

American Academy of Pediatrics Publishing Staff The original version of these self-instructional
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Sales
John Kattwinkel, MD, FAAP
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Publications
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www.aap.org Lynn J. Cook, RNC, MPH
Information about obtaining continuing medical education and continuing education credit for book study may be
obtained by visiting www.cmevillage.com.
Several different approaches to specific perinatal problems may be acceptable. The PCEP books have been written to
present specific recommendations rather than to include all currently acceptable options. The recommendations in
these books should not be considered the only accepted standard of care. We encourage development of local
standards in consultation with your regional perinatal center staff.
Statements and opinions expressed are those of the authors and not necessarily those of the American Academy of
Pediatrics.
Every effort has been made to ensure that the drug selection and dosage set forth in this text are in accordance with
the current recommendations and practice at time of publication. It is the responsibility of the health care professional
to check the package insert of each drug for any change in indications and dosage and for added warnings and
precautions.
Products and Web sites are mentioned for informational purposes only and do not imply an endorsement by the
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Brand names are furnished for identification purposes only. No endorsement of the manufacturers or products
mentioned is implied.
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ISBN: 978-1-61002-058-9
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Library of Congress Control Number: 2016932958

Perinatal Continuing Education Program (PCEP), 3rd Edition
Textbook Editorial Board
Editors
Editor in Chief, Neonatology Editor in Chief, Obstetrics
Robert A. Sinkin, MD, MPH, FAAP Christian A. Chisholm, MD, FACOG
Charles Fuller Professor of Neonatology Associate Professor of Obstetrics and Gynecology
Division Head, Neonatology Vice Chair for Education
Medical Director for Newborn Services Medical Director, Labor and Delivery
Department of Pediatrics University of Virginia Medical Center
University of Virginia Children’s Hospital Charlottesville, VA
Charlottesville, VA
PCEP Editorial Board Members

Lorie Banker, BSN, RNC
Care Coordinator Barbara O’Brien, RN, MS
Golisano Children’s Hospital Program Director
Rochester, NY Office of Perinatal Quality Improvement
The University of Oklahoma Health Sciences
Melissa F. Carmen, MD, FAAP Center
Assistant Professor of Pediatrics Oklahoma City, OK
Division of Neonatology
University of Rochester Medical Center Chad Michael Smith, MD
Rochester, NY Associate Professor of Obstetrics & Gynecology
Medical Director, Labor & Delivery
Susan B. Clarke, MS, RNC-NIC, RN-BC, CNS Medical Director, Perinatal Patient Safety
Professional Development Specialist University of Oklahoma Health Sciences Center
Continuing Education and Outreach Medical Director, Oklahoma Perinatal Quality
Primary Nurse Planner Improvement Collaborative
Children’s Hospital Colorado Oklahoma City, OK
Aurora, CO
Jonathan R. Swanson, MD, MSc, FAAP
Ann Kellams, MD, FAAP, IBCLC, FABM Associate Professor of Pediatrics
Associate Professor, Department of Pediatrics Division of Neonatology
Director, Well Newborn and Breastfeeding Chief Quality Officer for Children’s Services
Medicine Services Medical Director, Neonatal Intensive Care Unit
University of Virginia Children’s Hospital University of Virginia Children’s Hospital
Charlottesville, VA Charlottesville, VA
Sally Ann Miller, CNM, NP Sharon Veith, MSN, RN

Advanced Practice Registered Nurse Assistant Professor
Women’s Services University of Virginia School of Nursing
University of Virginia Health System Charlottesville, VA
Charlottesville, VA
Sarah M. Wilson, RN, MSN, NNP-BC
Susan Niermeyer, MD, MPH, FAAP Neonatal Intensive Care Unit
Professor of Pediatrics University of Virginia Children’s Hospital
Section of Neonatology Charlottesville, VA
University of Colorado School of Medicine iii
Aurora, CO

Continuing Education Credit
AMA PRA Category 1 Credit(s)™, ANCC contact hours or hours of participation are avail-
able to all perinatal health care professionals: physicians, nurses, respiratory therapists, nurse
practitioners, nurse midwives, and all others who care for pregnant women or newborns
based on their accreditation bodies.
The American Medical Association’s AMA PRA Category 1 Credit(s)™ (CME credits) are
available to physicians. ANCC contact hours are available to nurses, nurse practitioners, and
nurse midwives. Hours of participation are available to respiratory therapists and any other
healthcare professionals who provide care to pregnant women or newborn babies for submis-
sion to their professional organizations to satisfy their continuing education.
Accreditation and Designation Statements

The University of Virginia School of Medicine is accredited by the Accreditation Council for
Continuing Medical Education (ACCME) to provide continuing education for physicians.
The University of Virginia School of Medicine designates this enduring material for a maxi-
mum of 54 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit com-
mensurate with the extent of their participation in the activity.
The University of Virginia School of Medicine awards 54 hours of participation (equivalent to

AMA PRA Category 1 Credit[s]™) to each non-physician participant who successfully com-
pletes this educational activity. The University of Virginia School of Medicine maintains a rec
ord of participation for six (6) years.
The University of Virginia School of Nursing is accredited as a provider of continuing nursing

education by the American Nurses Credentialing Center’s Commission on Accreditation.
The University of Virginia SONCE awards 54 contact hours for nurses who participate in this
educational activity and complete the post-activity evaluation.
Disclosure of Financial Relationships

All the authors and editorial board members listed on the previous pages have disclosed that
they have no relevant financial relationships with any commercial interest.
AMA PRA Category 1 Credit(s)™, ANCC Contact Hours or Hours of Participation

Credit is awarded upon passing the book exams, not individual educational unit posttests.
Possible credits: Book I, 14.5; Book II, 15.5; Book III, 16.5; Book IV, 7.5.
To obtain either AMA PRA Category 1 Credit(s)™, ANCC contact hours or hours of partici-
pation register online at www.cmevillage.com (navigate to the PCEP pages) and pass the
book exams.

IV
BOOK Specialized Newborn Care
Unit 1: Direct Blood Pressure Measurement.............................. 1
Skill Unit: Transducer Blood Pressure Monitoring
Unit 2: Exchange, Reduction, and Direct Transfusions............ 19

Skill Unit: Exchange Transfusions
Unit 3: Continuous Positive Airway Pressure........................... 55

Skill Unit: Delivery of Continuous Positive Airway
Pressure
Unit 4: Assisted Ventilation With Mechanical Ventilators........ 69
Skill Unit: Endotracheal Tubes
Unit 5: Surfactant Therapy...................................................... 95

Skill Unit: Surfactant Administration
Unit 6: Continuing Care for At-Risk Babies............................ 111
Subsection: Babies With Special Problems
Pretest Answer Key.....................................................................155
INDEX��157
vii

For more information, see the other books in the Perinatal Continuing Education Program
(PCEP) series.
Book I: Maternal and Fetal Evaluation and Immediate Newborn Care
Introduction: What You Need to Know Unit 6: Gestational Age and Size and Associated Risk Factors
Unit 1: Is the Mother Sick? Is the Fetus Sick? Skill Unit: Estimating Gestational Age by Examination of
Skill Unit: Determining Fetal Presentation With Leopold a Newborn
Maneuvers Unit 7: Thermal Environment
Unit 2: Fetal Age, Growth, and Maturity Skill Units: Radiant Warmers
Unit 3: Fetal Well-being Incubators and Neutral Thermal Environment
Skill Unit: Electronic Fetal Monitoring Unit 8: Hypoglycemia
Unit 4: Is the Baby Sick? Skill Unit: Blood Glucose Screenings
Skill Units: Electronic Cardiorespiratory Monitoring Glossary
Pulse Oximetry Pretest Answer Key
Unit 5: Resuscitating the Newborn Index
Skill Units: Suctioning
Management of Oxygen in the Delivery Setting
Free-Flow Oxygen and Positive-Pressure
Ventilation
Endotracheal Intubation
Chest Compressions
Emergency Medications
Apgar Score
Book II: Maternal and Fetal Care

Unit 1: Hypertensive Disorders of Pregnancy Unit 7: Preterm Labor
Unit 2: Obstetric Hemorrhage Unit 8: Inducing and Augmenting Labor
Unit 3: Perinatal Infections Unit 9: Abnormal Labor Progress and Difficult Deliveries
Unit 4: Other High-risk Conditions Unit 10: Imminent Delivery and Preparation for Maternal/Fetal
Unit 5: Abnormal Glucose Tolerance Transport
Unit 6: Premature Rupture or Infection of the Amniotic Pretest Answer Key
Membranes Index
Skill Units: Sterile Speculum Examination
Tests With Suspected or Proven Rupture
of Membranes
Book III: Neonatal Care

Unit 1: Oxygen Unit 5: Intravenous Therapy
Skill Units: Administering Oxygen Skill Unit: Peripheral Intravenous Infusions
Measuring Oxygen Concentration Inserting and Managing Peripheral
Mixing Oxygen and Compressed Air Intravenous Infusions
Heating and Humidifying an Oxygen/Air Unit 6: Feeding
Mixture Part 1: Feeding Principles
Monitoring Oxygen Part 2: Tube Feeding
Peripheral Arterial Blood Gas Sampling Skill Unit: Nasogastric Tube Feedings
Unit 2: Respiratory Distress Unit 7: Hyperbilirubinemia
Part 1: Respiratory Distress Appendix: Identification and Treatment of Jaundice
Part 2: Apnea During the First Week After Birth
Part 3: Pneumothorax Unit 8: Infections
Skill Units: Detecting a Pneumothorax Unit 9: Review: Is the Baby Sick? Identifying and Caring for Sick
Transillumination and At-Risk Babies
Chest Radiograph Evaluation Subsections: Vital Signs and Observations
Treating a Pneumothorax Tests and Results
Needle Aspiration Unit 10: Preparation for Neonatal Transport
Chest Tube Insertion Subsection: Caring for Parents of Transported Babies
Appendix Pretest Answer Key
Unit 3: Umbilical Catheters Index
Skill Unit: Inserting and Managing Umbilical Catheters
Unit 4: Low Blood Pressure
Skill Unit: Measuring Blood Pressure
viii

Unit 1: D
irect Blood Pressure
Measurement
Objectives................................................................................................................................ 2
1. What are the 2 general types of blood pressure monitoring? .................................... 4
2. How are direct blood pressure measurements made? ............................................... 4
Unit 1: direct blood pressure measurement/ contents

3. Why is direct blood pressure measurement used? ..................................................... 4
4. What equipment is needed for direct blood pressure monitoring? ........................... 4
5. What are reference neonatal blood pressure ranges? ................................................. 6
6. How do you interpret blood pressure waveforms? ..................................................... 8
Figures
Figure 1.1. Systolic and Diastolic Blood Pressure During First Day After Birth................. 6
Figure 1.2. Systolic and Diastolic Blood Pressure for Babies of Different Gestational
Ages During First 5 Days After Birth............................................................... 7
Figure 1.3. Systolic Blood Pressure for Babies of Different Postmenstrual Ages................. 7
Figure 1.4. Arterial Waveform........................................................................................... 8
Skill Unit: Transducer Blood Pressure Monitoring.......................................................... 13
01_Unit1_BKIV_PCEP_001-018.indd 1 7/25/16 11:41 AM

Unit 1: direct blood pressure measurement
Objectives
In this unit you will learn the
A. Difference between direct and indirect blood pressure monitoring
B. Reasons for direct blood pressure monitoring
C. Equipment needed for direct blood pressure monitoring
D. Interpretation of blood pressure waveforms

Unit 1 Pretest
Before reading the unit, please answer the following questions. Select the one best
answer to each question (unless otherwise instructed). Record your answers on
the test and check them against the answers at the end of the book.
1. A damped pressure tracing may be caused by each of the following findings except
A. Air bubbles in the tubing
B. Hypotension
C. Severe anemia
D. A clot at the tip of the umbilical catheter
2. True False Special intravenous tubing is needed for direct blood pressure
monitoring.
3. True False A narrowed pulse pressure may indicate certain congenital heart
defects.
4. True False The reference range of direct blood pressure measurements is
different than the reference range for indirect blood pressure
measurements.
5. True False When a direct blood pressure monitoring waveform shows slow
decrease in pressure during diastole, it may indicate increased sys-
temic vascular resistance.
6. The transducer for direct blood pressure measurement should be level with the
A. Baby’s heart
B. Electronic monitor
C. Umbilical catheter
D. Intravenous infusion pump
7. Direct blood pressure measurement is used for each of the following reasons except
A. Continuous blood pressure monitoring
B. Increased accuracy of the measurements
C. Obtaining information about a baby’s cardiac status
D. Measurement of acid-base balance

1. What are the 2 general types of blood pressure monitoring?

A. Indirect blood pressure measurement
Indirect measurement is the typical way in which blood pressure is measured. An inflat-
able cuff is wrapped around an arm or a leg. The cuff is then inflated to a pressure
somewhat higher than the anticipated blood pressure. Manual palpation or a mechani-
cal device is used to detect changes in arterial flow as the cuff is deflated. (See Book III:
Neonatal Care, Unit 4, Low Blood Pressure.)
B. Direct blood pressure measurement
Direct blood pressure measurement occurs when the measuring device is connected to a
catheter inserted directly into an artery. An umbilical or a peripheral artery may be used
as the monitoring site.
2. How are direct blood pressure measurements made?

An arterial catheter is connected to special tubing that resists changes in pressure. This non-
distensible tubing is used to transmit the arterial pressure at the catheter tip to a transducer.
The transducer converts the mechanical pressure of blood in an artery into an electrical signal.
The electrical signal is displayed as a waveform on a screen. The resulting pattern is the blood
pressure waveform.
3. Why is direct blood pressure measurement used?

Direct monitoring is used in sick babies who have an arterial catheter in place. It is especially
important for unstable babies. The 3 primary advantages of direct monitoring are
• It allows continuous blood pressure monitoring.
• It gives the most accurate form of blood pressure measurement.
• The waveform shape may suggest certain clinical conditions.
4. What equipment is needed for direct blood pressure monitoring?

General points regarding direct blood pressure monitoring are presented here; details of the
technique are covered in Skill Unit: Transducer Blood Pressure Monitoring. The following
equipment is needed for direct blood pressure monitoring:
A. Arterial catheter
In babies, an umbilical arterial catheter is most commonly used. Occasionally, a small
catheter is placed in one of the peripheral arteries, usually a radial artery, and then con-
nected to the appropriate monitoring equipment.
B. Electronic monitor with waveform display
This monitor has one channel that allows continuous cardiac (electrocardiogram) moni-
toring and another channel for blood pressure monitoring. It has a calibrated screen
where the blood pressure waveform is displayed, as well as a digital readout of the sys-
tolic, diastolic, and mean blood pressures.
C. Non-distensible tubing
This connects the arterial catheter and transducer. It is made of stiff plastic and is some-
times called high-pressure tubing.
D. Transducer
Several brands of disposable transducers are available.

E. Transducer cable
This connects the transducer with the electronic monitor. Sometimes the transducer and
cable are a single unit.
F. Intravenous pump
This pump should be able to deliver a low volume of fluid (,1 mL/h). It should also be
able to deliver fluid continuously, rather than in pulses. Usually, this is a syringe pump.
G. Intravenous solution
To obtain continuous blood pressure readings, the system must remain open between the
catheter and transducer. This significantly increases the risk of clot formation within the
catheter unless a continuous infusion of intravenous (IV) fluid is maintained.
Physiologic (normal) saline will cause less sludging of blood in a catheter than will a glu-
cose solution; however, small babies may receive excessive sodium and insufficient glu-
cose if normal saline is used to help keep the catheter patent. Calculate the requirements
of your patient. (See Book I: Maternal and Fetal Evaluation and Immediate Newborn
Care, Unit 8, Hypoglycemia, and Book III: Neonatal Care, Unit 5, Intravenous Therapy.)
Whichever IV solution is selected, heparinizing it with 0.5 to 1.0 U of heparin per millili-
ter of IV solution and infusing it at a rate of at least 0.5 mL/h is generally recommended
for arterial lines.
H. Mechanism to hold transducer at the level of the baby’s heart
Sometimes the transducer is mounted on an IV pole with a holder that may be raised
or lowered as the baby’s position is changed. Most commonly, however, transducers are
designed to rest on the bed alongside the baby.
Self-test
Now answer these questions to test yourself on the information in the last section.
A1. Indirect blood pressure measurement uses an __________ __________ wrapped around the baby’s
arm or leg, while direct blood pressure measurement uses a __________ inserted into an __________.
A2. What are the 3 primary reasons for using direct blood pressure monitoring?
A3. True False A continuous infusion should be given through an umbilical arterial catheter
when it is being used for continuous blood pressure monitoring.
A4. True False Non-distensible tubing is an optional piece of equipment for continuous direct
blood pressure monitoring.
A5. True False An intravenous pump that delivers fluid in regular, tiny pulses is the preferred
type of pump to use with a direct blood pressure monitoring arterial catheter.
Check your answers with the list near the end of the unit. Correct any incorrect answers and review
the appropriate section in the unit.

5. What are reference neonatal blood pressure ranges?

Figures 1.1, 1.2, and 1.3 show the reference ranges of blood pressure for babies of different
birth weights and at different gestational and postmenstrual ages. These are the same graphs
that were first presented in Book III: Neonatal Care, Unit 4, Low Blood Pressure.
110
100
Systolic Blood Pressure (mm Hg)
90
Upper limit
80
of normal
70
60
50
40
30 Lower limit
20 of normal
10
0
750 1,000 1,250 1,500 1,750 2,000 2,250 2,500 2,750 3,000 3,250 3,500 3,750 4,000
Birth Weight (g)

70
Diastolic Blood Pressure (mm Hg)
60 Upper limit
of normal
50
40
30
20
10 Lower limit
of normal
0
750 1,000 1,250 1,500 1,750 2,000 2,250 2,500 2,750 3,000 3,250 3,500 3,750 4,000
Birth Weight (g)

Figure 1.1. Systolic and Diastolic Blood Pressure During First Day After Birth
Adapted with permission from Macmillan Publishers Ltd. Zubrow AB, Hulman S, Kushner H, Falkner B. Determinants of blood
pressure in infants admitted to neonatal intensive care units: a prospective multicenter study. J Perinatol. 1995;15(6):470–479.

80 55
37 weeks
75 50
37 weeks
33–36 weeks
70
Diastolic Blood Pressure (mm Hg)

Systolic Blood Pressure (mm Hg) 45
33–36 weeks
65 29–32 weeks
40
29–32 weeks
60
28 weeks 28 weeks
35
55
30
50
45 25
40 20
1 2 3 3 4 5 1 2 3 3 4 5
Days Since Birth Days Since Birth
Figure 1.2. Systolic and Diastolic Blood Pressure for Babies of Different Gestational Ages
During First 5 Days After Birth
Adapted with permission from Macmillan Publishers Ltd. Zubrow AB, Hulman S, Kushner H, Falkner B. Determi-
nants of blood pressure in infants admitted to neonatal intensive care units: a prospective multicenter study.
J Perinatol. 1995;15(6):470–479.
Figure 1.3. Systolic Blood Pressure for Babies of Different Postmenstrual Ages
Adapted with permission from Macmillan Publishers Ltd. Zubrow AB, Hulman S, Kushner H, Falkner B. Determinants of blood
pressure in infants admitted to neonatal intensive care units: a prospective multicenter study. J Perinatol. 1995;15(6):470–479.

6. How do you interpret blood pressure waveforms?

A. Blood pressure waveform: normal configuration
Figure 1.4 shows a normal newborn blood pressure waveform, as it appears in relation
to a cardiac monitor (electrocardiogram) tracing.
Peak Pressure
Dicrotic Notch
100
Aortic
Pressure 50
(mm Hg) Minimum Pressure
0
Systolic Phase Diastolic Phase
Electrocardiogram
0 0.5
Time (seconds)
Figure 1.4. Arterial Waveform
The shape of the pattern corresponds with events happening within the heart. These are
described as follows:
• Systolic phase: Time during which the heart is ejecting blood
• Peak pressure: The highest point during systole (systolic pressure)
• Dicrotic notch: Point of closure of the aortic valve
• Diastolic phase: Time during which the heart is filling with blood
• Minimum pressure: The lowest point during diastole (diastolic pressure)
• Pulse pressure: The difference between peak and minimum pressures
• Mean pressure: The average pressure of the complete cardiac cycle
The key segments to recognize are the sharp rise during systole, the dicrotic notch, and
the slower fall in pressure during diastole.
In addition to displaying the blood pressure waveform, nearly all monitors digitally dis-
play continuous readings of systolic, diastolic, or mean arterial pressure (or any combina-
tion of those).
B. Blood pressure waveform: abnormal configuration
1. Damped waveform
The most common cause of an abnormal pressure waveform is a damped tracing
in which the waveform “flattens out.” Usually, the systolic pressure will seem to be
decreased and the diastolic pressure will seem to be increased, causing little change in
the mean arterial pressure. These changes may be subtle or more dramatic, leading to
an almost flat line for a pressure tracing. A damped waveform with subtle changes can
be recognized by the disappearance of the dicrotic notch.

A damped tracing may be caused by

• Air bubbles within the tubing or at the transducer: These air bubbles may be
very tiny. Careful inspection of the full length of the tubing and all connections is
required. If air bubbles are found, they should be flushed from the system while
taking care not to infuse any into the baby. Flush the tubing and transducer by
– Turning the stopcock off to the baby
– Opening the transducer to air
– Flushing the IV fluid through the transducer and out the port that is open to
air
• Kink in the tubing: This is a rare occurrence but should be considered whenever
a waveform is damped.
• Hypotension: A baby in shock may also seem to have a damped waveform.
Always be sure to check the blood pressure values by indirect means and assess
the baby’s clinical condition.
• Clot at the tip or within the lumen of the catheter: This is the most common
reason for a damped tracing. If this is the suspected cause of a damped wave-
form, aspirate blood from the catheter. Then slowly flush the catheter with 0.5
to 1.0 mL of flush solution. Reopen the system between the catheter and trans-
ducer. If the waveform remains damped, and no other cause for a damped trac-
ing can be found, the catheter needs to be removed.
If a waveform is damped because of a suspected clot at the tip or

within the lumen, the catheter needs to be removed and replaced
with a new one.
2. Abnormally shaped waveform

Waveforms of particular shape, or changes in a baby’s waveform, may suggest abnor-
mal findings in cardiac status. These findings are usually subtle and should be consid-
ered only suggestive of the corresponding problem.
Finding Possible Cause
• Slow pressure increase • Poor left ventricular contractility
during early systole • Aortic stenosis
• Slow pressure decrease • Increased systemic vascular resistance
during diastole
• Rapid pressure decrease • Left-to-right shunting, such as from a
during diastole patent ductus arteriosus
C. Abnormally wide or narrow pulse pressure

Pulse pressure is the difference between peak systolic and minimum diastolic pressures.
Wide or narrow pulse pressure may suggest certain cardiac abnormalities. A change in
pulse pressure may suggest the development of certain problems, such as a pneumotho-
rax or pneumopericardium, which may affect cardiac function.
Reliable normal values of pulse pressure in newborns have not been defined. A pulse
pressure less than 10 mm Hg, however, is generally considered too narrow.
A pulse pressure significantly greater than the value of the diastolic pressure is generally
considered too wide. For example, a systolic pressure of 60 mm Hg and a diastolic pres-
sure of 20 mm Hg give a pulse pressure of 40 mm Hg, which is significantly greater than
the diastolic pressure.

Pulse Pressure Possible Cause

• Narrowed • Coarctation of the aorta
• Pneumothorax
• Pneumopericardium or hemopericardium
• Aortic stenosis
• Hypoplastic left side of the heart
• Shock (cardiogenic, septic, or hemorrhagic)
• Heart failure
• Widened • Patent ductus arteriosus
• Aortopulmonary window
• Arteriovenous fistula
• Truncus arteriosus
• Hyperthyroidism
• Aortic regurgitation
These waveform findings are only suggestive of the abnormalities listed and must be considered
together with other clinical and diagnostic findings. Consult your regional perinatal center if
you have any questions about a baby’s cardiac status.
Self-test
B1. A damped waveform may be caused by
Yes No
____ ____ Hypotension
____ ____ Air bubbles in the tubing
____ ____ Patent ductus arteriosus
____ ____ Clot at the catheter tip
B2. True False The pulse pressure is the same as the mean pressure.
B3. True False The lowest point of the waveform indicates the diastolic pressure.
B4. List 2 possible causes of a narrowed pulse pressure.
B5. List 2 possible causes of a widened pulse pressure.
10

Self-test Answers
These are the answers to the Self-test questions. Please check them with the answers you gave and
review the information in the unit wherever necessary.
A1. Indirect blood pressure measurement uses an inflatable cuff wrapped around the baby’s arm or leg,
while direct blood pressure measurement uses a catheter inserted into an artery.
A2. Provides most accurate form of blood pressure measurement
Allows continuous measurement of blood pressure
Produces waveform shape that may aid in the diagnosis of certain clinical conditions
A3. True
A4. False.
Reason: Only non-distensible tubing allows accurate transmission of pressure between the
catheter and transducer without being “lost” in the elasticity of regular intravenous tubing.
A5. False.
Reason: An intravenous pump that delivers a low volume of fluid continuously, rather than in
pulses, is the preferred type of pump for direct blood pressure monitoring.
B1. Yes No
X Hypotension
X Air bubbles in the tubing
X Patent ductus arteriosus
X Clot at the catheter tip
B2. False.
Reason: The pulse pressure is the difference between peak (systolic) and minimum (diastolic)
pressures. Mean blood pressure is the average pressure of the complete cardiac cycle.
B3. True
B4. Any 2 of the following causes:
• Coarctation of the aorta
• Pneumothorax
• Pneumopericardium or hemopericardium
• Aortic stenosis
• Hypoplastic left side of the heart
• Shock (cardiogenic, septic, or hemorrhagic)
• Heart failure
B5. Any 2 of the following causes:
• Patent ductus arteriosus
• Aortopulmonary window
• Arteriovenous fistula
• Truncus arteriosus
• Hyperthyroidism
• Aortic regurgitation
11

Unit 1 Posttest
After completion of each unit there is a free online posttest available at
www.cmevillage.com to test your understanding. Navigate to the PCEP pages
on www.cmevillage.com and register to take the free posttests.
Once registered on the website and after completing all the unit posttests, pay the
book exam fee ($15), pass the test at 80% or greater and earn continuing education
credits. Only start the PCEP book exam if you have time to complete it. If you take the
book exam and are not connected to a printer, either print your certificate to a .pdf file
and save it to print later or come back to www.cmevillage.com at any time and print a
copy of your educational transcript.
Credits are only available by book, not by individual unit within the books. Available
credits for completion of each book exam are as follows: Book I: 14.5 credits; Book II:
15.5 credits; Book III: 16.5 credits; Book IV: 7.5 credits.
For more details, navigate to the PCEP webpages at www.cmevillage.com.
12

Unit 1: direct blood pressure measurement/skill unit: transducer blood pressure monitoring
SKILL UNIT
Transducer Blood Pressure Monitoring

This skill unit will teach you the principles of continuous electronic blood pressure monitoring.
Study this skill unit, and then attend a skill practice and demonstration session. You will learn
how to apply the principles studied in this unit to the specific equipment used in your hospital.
To master the skill, you will need to demonstrate each of the following steps correctly, using
the specific equipment available in your hospital:
1. Assemble equipment.
2. Set up continuous infusion.
3. Flush tubing and transducer with infusion fluid.
4. Connect tubing to “baby’s” (manikin’s) arterial catheter.
5. Level transducer with baby’s heart.
6. Zero monitor.
7. Set alarms.
8. Measure baby’s blood pressure.
13

PERINATAL PERFORMANCE GUIDE
Using Transducer Blood Pressure Monitors

ACTIONS REMARKS
Preparing the Equipment

1. Collect the equipment. The baby should have an arterial catheter
• Electronic monitor already in place. A 3-way stopcock should
• Non-distensible (high-pressure) tubing already be attached to the end of the
• Transducer catheter.
• Transducer cable
• Infusion pump that can deliver less than In general, syringe pumps are used.
1 mL/h in continuous (not pulsatile) flow
• Heparinized intravenous (IV) solution This is usually pharmacy prepared.
• Three-way stopcock
• Adjustable-height clamp to hold trans- Many transducers are designed to rest on
ducer at the level of the baby’s heart the baby’s bed, next to the baby. Know the
(optional) requirements of the transducer you are
using.
2. Assemble the equipment. Most transducer kits come preassembled
with tubing for the IV infusion ➝ transducer
➝ stopcock ➝ non-distensible tubing al-
ready connected in the proper sequence. If
yours is not preassembled, connect the
pieces in that sequence.
3. Set up the continuous infusion. Any appropriate IV solution heparinized
with 0.5 to 1.0 U/mL may be used. See sec-
tion 4.G in the unit.
4. Flush the heparinized IV solution through Be sure to clear the tubing of all air bub-
the IV tubing, transducer, stopcock, and bles, including very tiny bubbles. Snapping
non-distensible tubing. a fingernail or tapping gently against the
transducer or tubing can help dislodge stub-
born bubbles.
As an additional safeguard, non-distensible If the tubing is flushed slowly, air bubbles are
tubing that has an air-bubble filter incor- generally less of a problem. Also, hold the
porated into it is available. Know the fea- transducer so the exit to the non-distensible
tures of the tubing used in your hospital. tubing is uppermost. This will help ensure
that the transducer fills completely and no
air bubbles are trapped in a corner of it.
5. Connect the non-distensible tubing to the
stopcock that is at the end of the baby’s
arterial catheter.
14

ACTIONS REMARKS
Preparing the Equipment (continued)

6. Use a syringe on the third port of the stop- There is no need to pull blood into the sy-
cock (the stopcock that is connected to the ringe or even fill the catheter with blood.
arterial catheter) to draw blood into the You just need to see a flash of blood in the
catheter, to be sure there is a brisk blood catheter and observe that the catheter can
return before beginning to infuse fluid be aspirated easily.
through the catheter.
7. Turn the stopcocks so they are open be- Double-check to be sure no air bubbles are
tween the baby’s arterial catheter and IV in the tubing.
fluid, as shown in the figure below.
8. Begin infusion of the heparinized IV fluid. Neither this infusion rate nor the IV fluid
Infusion at a rate of at least 0.5 mL/h is used is designed to fulfill a baby’s fluid re-
generally recommended. quirements, but rather to keep the catheter
patent. Keep track of the volume infused
because even this low infusion rate can pro-
vide a significant volume for small babies.
Arterial Non-distensible Fluid

Stopcock Stopcock Transducer
catheter tubing infusion
Third port Third port

(used when blood (used to zero
drawn—closed) transducer—closed)
Configuration During Infusion:

System Open Between Intravenous Fluid and Arterial Catheter
15

ACTIONS REMARKS
Calibrating the Blood Pressure Monitor

9. With the baby supine, level the transducer In some cases, it may be useful to tape the
with the baby’s heart. Use the baby’s transducer to a small folded blanket that is
midaxillary point to approximate the level placed next to the baby. This will keep the
of the heart. In most cases, this may be ac- transducer flat and raise it slightly off the
complished by simply putting the trans- bed, to the midaxillary level of the baby’s
ducer flat on the bed next to the baby. chest.
Sometimes transducers are clamped to a However the transducer is positioned, it is
pole beside the bed. They should be important that the position relative to the
clamped at a point level with the baby’s baby remain constant. Changing the trans-
midaxillary area. ducer level compared to the baby will result
in false readings.
Arterial Non-distensible Fluid

Stopcock Stopcock Transducer
catheter tubing infusion
Third port Third port

(used when blood (open to air)
drawn—closed)
Configuration During Calibration:

System Closed to Arterial Catheter (Baby), Open Between Transducer and Air
10. Zero the monitor.

• Open the transducer to atmospheric
pressure. This is done by turning the
system off to the baby and open be-
tween the transducer head and air, as
shown in the figure above.
• Adjust the display so that the blood In most cases, this is accomplished by sim-
pressure reads zero. ply pressing a “zero” button on the monitor
screen.
Note: Some monitors need to be cali- Be sure you know the requirements of the
brated to both zero and a higher specific equipment used in your hospital.
number, usually 100 mm Hg.
16

ACTIONS REMARKS
Calibrating the Blood Pressure Monitor (continued)

11. Begin to monitor the baby.
• Close the system to atmospheric pres- The system should, again, be configured the
sure and reopen it between the IV infu- same way as shown in the figure after step 8.
sion and baby’s arterial catheter.
• Cap the port that was open to atmo-
spheric pressure with a syringe or sterile
cap.
• Check again to be sure no air bubbles Sometimes air enters the stopcock, and then
have entered the tubing. the tubing, when the stopcock is opened to
air during calibration.
• Check to be sure the monitor is set for a Most monitors have 2 or 3 pressure scales
scale appropriate to neonatal blood that may be used. Generally, the 0 to 100 mm
pressure values. Hg scale is used for babies. If a different
scale is used, the waveform may sometimes,
depending on a baby’s blood pressure, ap-
pear to be off the screen.
Measuring the Baby’s Blood Pressure

12. Set the alarm limits appropriate to the ba- Determine if the alarm limits on your moni-
by’s blood pressure. tor can be set for systolic/diastolic or mean
If the baby is initially hypotensive, readjust blood pressure (or both). Then set the alarm
the alarm limits as the blood pressure is limits 5 to 10 mm Hg higher and 5 to 10 mm
corrected. Hg lower than the baby’s blood pressure
reading.
13. Observe the character of the pressure If the waveform is damped, investigate the
waveform. Determine if the waveform is a cause. Review section 6.B.1 in the unit.
damped or an undamped tracing.
14. Read and record the baby’s blood pres- Usually, the baby’s systolic, diastolic, and
sure. This may be read from the screen or mean arterial pressures are recorded (eg,
the digital readout. 65/45 MAP 53). If a digital readout is not
available, only the systolic and diastolic
pressures can be read from the waveform
tracing on a calibrated monitor screen.
15. Regularly, routinely examine the tubing to If any air bubbles are found, remove them
be sure no air bubbles have entered the from the system.
system.
16. Periodically check the baby’s blood pres- Direct and indirect blood pressure readings
sure by indirect measurement with an in- should correlate very closely.
flatable cuff.
17. Periodically repeat steps 9 through 11 to The transducer setup is commonly cali-
calibrate the monitor. brated 2 to 3 times a day, whenever the dis-
posable transducer and tubing are changed,
and whenever there is a question about
waveform quality.
17

Unit 2: Exchange, Reduction, and Direct
Transfusions
Objectives ............................................................................................................................. 20
Unit 2: Exchange, reduction, and direct transfusions/ contents

Exchange Transfusions in the Management of Hyperbilirubinemia................................. 23
1. What is an exchange transfusion?............................................................................... 23
2. Why is an exchange transfusion done?....................................................................... 23
3. What type of donor blood is used?............................................................................. 24
4. How should the blood be preserved?.......................................................................... 24
5. How much blood is used for an exchange transfusion?............................................ 25
6. What else is done to prepare blood for an exchange transfusion?.......................... 25
7. How is an exchange transfusion performed?............................................................. 26
8. Will a baby ever need more than one transfusion?................................................... 28
9. What are the potential complications of an exchange transfusion?........................ 28
Partial Exchange Transfusions in the Management of Polycythemia
or Severe Anemia................................................................................................................. 30
1. What is a partial exchange transfusion?..................................................................... 30
2. What is polycythemia?................................................................................................. 30
3. How is a reduction exchange transfusion done for polycythemia?.......................... 31
4. What are the potential complications of a reduction exchange
transfusion for polycythemia?..................................................................................... 32
5. When is a partial exchange transfusion used for severe anemia?............................ 33
6. Why is a partial exchange transfusion done for severe anemia?.............................. 33
7. How is a partial exchange transfusion done for severe anemia?............................. 33
Direct Transfusions in the Management of At-Risk and Sick Babies................................ 34
1. What is a direct transfusion?........................................................................................ 34
2. Why are direct transfusions done?.............................................................................. 34
3. How is a direct transfusion done?............................................................................... 35
4. What are the potential complications of a direct transfusion?................................. 36
Table
Table 2.1. Potential Complications of Exchange Transfusions.......................................... 28
Recommended Routines.................................................................................................... 37
Skill Unit: Exchange Transfusions...................................................................................... 41
19
02_Unit2_BKIV_PCEP_019-054.indd 19 9/7/16 12:29 PM

Unit 2: exchange, reduction, and direct transfusions
Objectives
In this unit you will learn
A. Why exchange, reduction, and direct transfusions are performed
B. What type of donor blood is used
C. The effects of anticoagulants on donor blood
D. How to prepare donor blood
E. How exchange, reduction, and direct transfusions are performed
F. How to monitor the baby for potential complications
20

Unit 2 Pretest
1. True False Blood glucose screening test results should be checked immediately
after any exchange transfusion.
2. True False When an umbilical arterial catheter is used in an exchange transfu-
sion, it is used only to withdraw blood from the baby.
3. True False No baby should have more than one exchange transfusion.
4. True False Packed red blood cells (hematocrit .70%) of appropriate group and
type should be used for an exchange transfusion.
5. A reduction exchange transfusion is different from an exchange transfusion for
hyperbilirubinemia because
A. A larger volume of blood is exchanged.
B. Infectious complications are more likely to occur.
C. Blood is not given.
D. Rebound hypoglycemia is more likely to occur.
6. What is the preferred age of donor blood used for an exchange transfusion?
A. 1 to 10 days.
B. 10 to 15 days.
C. 15 to 20 days.
D. Age of the blood is not an issue.
7. True False A term, 4,000-g (8 lb 13 oz) baby with tachypnea who has been
treated for hypoglycemia and has a venous hematocrit of 68%
should be considered for a reduction exchange transfusion.
8. True False Phototherapy lights should be used after every exchange transfusion
for hyperbilirubinemia.
9. True False All preterm babies should be transfused with packed red blood cells
if their hematocrit is less than or equal to 25%.
10. True False Capillary blood from a heel stick sample is the preferred way to test
a baby’s hematocrit.
11. Which of the following findings is a possible sign of anemia in a stable, growing,
preterm baby?
A. Rapid weight gain
B. Hypoglycemia
C. Hyperbilirubinemia
D. Tachypnea
21

12. Which of the following babies is at lowest risk for polycythemia?

A. 30-week-old baby who is appropriate for gestational age
B. 40-week-old baby who is small for gestational age
C. 43-week-old baby who is appropriate for gestational age
D. 38-week-old baby of a diabetic mother
13. A 1,800-g (3 lb 15½ oz), preterm baby is severely anemic and requires a transfusion
of packed red blood cells. How much blood would you give?
A. 10 mL
B. 18 mL
C. 36 mL
D. 162 mL
22

Exchange Transfusions in the Management of Hyperbilirubinemia

Notes
• This section will discuss exchange transfusions only for hyperbilirubinemia. Exchange trans-
fusions for other purposes (eg, sepsis, disseminated intravascular coagulation, or metabolic
disorders) require other techniques and types of donor blood.
• Although an exchange transfusion was a common procedure prior to availability of Rh
immune globulin to prevent development of erythroblastosis fetalis, more recently it is rarely
required and therefore associated with increased risk. It is recommended that an exchange
transfusion be performed in a facility with personnel experienced in performing the proce-
dure, particularly if the baby is preterm.
1. What is an exchange transfusion?

An exchange transfusion entails withdrawing a small amount of blood from a baby and replac-
ing it with an equal amount of donor blood, then repeating this process many times until most
of the baby’s blood has been removed and replaced with donor blood. Usually a double volume
exchange transfusion is performed, using 180 mL/kg of a blood product.
Routes of Exchange
• An umbilical venous catheter (UVC) alone may be used to perform an exchange transfusion.
• Umbilical venous and arterial catheters may be used simultaneously, with blood withdrawn
through the arterial catheter and infused though the venous catheter.
• Blood may also be withdrawn through an umbilical arterial catheter (UAC), peripheral arte-
rial catheter (PAC), or UVC and infused through a peripheral intravenous (PIV) line.
Blood should not be infused through a peripheral arterial catheter. Infusion through
a central arterial catheter is a very high-risk procedure and should be used only as a
last resort.
2. Why is an exchange transfusion done?

There are 3 purposes for an exchange transfusion in the treatment of severe
hyperbilirubinemia.
• Remove bilirubin.
• Remove sensitized red blood cells (RBCs) and replace them with non-sensitized RBCs (for
hyperbilirubinemia due to blood group incompatibility).
• Remove circulating antibodies (for hyperbilirubinemia due to blood group incompatibility).
Note: Refer to Book III: Neonatal Care, Unit 7, Hyperbilirubinemia, to determine when
exchange transfusions should be used to treat hyperbilirubinemia.
23

3. What type of donor blood is used?

It is recommended that blood for an exchange transfusion be irradiated to reduce the likeli-
hood of viral contamination and possibility of sensitization from white blood cell contamina-
tion. While most blood for exchange is reconstituted RBCs and plasma, platelets should not
be added to the product. Platelet count should be checked after the transfusion, and platelets,
transfused if needed.
A. Hyperbilirubinemia due to Rh incompatibility

• Rh-negative RBCs of the baby’s blood group (A, B, AB, or O) resuspended in plasma
of an ABO group compatible with the baby
or
• Type O, Rh-negative RBCs resuspended in type AB plasma
B. Hyperbilirubinemia due to ABO incompatibility
• Group O, Rh-compatible RBCs resuspended in plasma of the same ABO group as the
baby, or in group AB plasma
4. How should the blood be preserved?

The freshest available and most suitable blood should be used. It is important to know the
anticoagulant used and how that substance may affect the baby. Older blood may have a
higher potassium concentration, leading to hyperkalemia, and the pH of the blood may be
affected (either increased or decreased) depending on the type of anticoagulant used. Citrate
phosphate dextrose adenine (CPDA-1) is the anticoagulant used most often, and it can cause
any of the following problems:
• Hypocalcemia: Citrate binds the electrolyte calcium; therefore, calcium replacement may
be necessary during or shortly after an exchange transfusion (or at both times). Calcium
replacement should be given if the baby shows signs of hypocalcemia. Signs of hypocalce-
mia include jitteriness, seizures, tachycardia, or apnea. Monitoring of the QT interval on
electrocardiogram may also alert the provider to a decrease in calcium levels in the baby.
The QT interval may become prolonged in the setting of hypocalcemia.
If the baby is symptomatic, 1 to 2 mL of calcium gluconate in 10% (100 mg/mL) con-
centration is given slowly (over approximately 10 minutes) through a UVC, with the tip
located in the inferior vena cava. Calcium gluconate in 10% concentration may be diluted
with sterile water for injection to 5% and 2 to 4 mL given, as described in Skill Unit:
Exchange Transfusions.
The baby’s heart rate must continuously be electronically monitored. The calcium infusion
is stopped immediately if the baby’s heart rate begins to slow. (See the skill unit for the
details of calcium administration.)
• Hypoglycemia: Babies with Rh isoimmune disease often have hyperactive insulin-
secreting cells. In addition, any baby may develop “rebound hypoglycemia” once the
exchange transfusion has been completed, due to the high concentration of dextrose in
CPDA-1–preserved blood. Any baby receiving an exchange transfusion should have blood
glucose screening test results checked immediately after the exchange and hourly for sev-
eral more hours.
24

• Acidosis or alkalosis: CPDA-1–preserved blood has a pH range of 7.5 to 7.6 at the begin-
ning of storage but may fall to 7.0 or lower as storage time lengthens. Most babies can
metabolize the preservative without difficulty. With citrate-preserved blood, alkalosis may
develop as citrate is metabolized in the liver to form bicarbonate. The resulting metabolic
alkalosis may persist for several days.
• Hyperkalemia: For an exchange transfusion in babies, use of CPDA-1–preserved donor
blood that does not exceed 10 days of age is recommended. Blood stored for more than 10
days may develop potassium levels that are dangerously high for babies.
5. How much blood is used for an exchange transfusion?

Generally, 180 mL of donor blood for every kilogram (1,000 g) of the baby’s weight is used
for an exchange transfusion. When 180 mL/kg is used, it is called a double volume exchange
because a baby’s average blood volume is 90 mL/kg. A double volume exchange transfusion
will remove and replace 85% to 90% of a baby’s original blood.
Immediately after a double volume exchange, the baby’s bilirubin level can be expected to be
one-third to one-half the pre-exchange bilirubin level.
6. What else is done to prepare blood for an exchange transfusion?

A. Determine the hematocrit.
The hematocrit of blood used for an exchange transfusion should generally be higher
than the hematocrit of adult blood because
• Newborn hematocrits are generally higher than adult hematocrits.
• Babies with Rh or ABO incompatibility may be anemic because of the rapid break-
down of their RBCs.
Blood used for neonatal exchange transfusions should have a hematocrit of 45% to
55%. Most blood banks can prepare blood with appropriate hematocrit by mixing
packed RBCs and plasma in the necessary ratio.
B. Warm the blood.
The blood should be warmed using a commercially available blood warmer with
• Constant temperature readout
• Adjustable thermostat
• Alarm system to prevent overheating the blood
Note: Radiant warming devices or older immersion warmers without the characteristics
listed above are dangerous and should not be used.
Summary of Preparation Steps
The following 5 steps should be taken to prepare donor blood for an exchange transfusion:
1. Select the appropriate blood group and Rh type.
2. Know the anticoagulant used and the age of the blood.
3. Calculate the volume of blood to be exchanged.
4. Know the hematocrit of the blood prepared by the blood bank.
5. Warm the blood with a commercial device that has the necessary safety features.
Do not add platelets to the blood constituted for exchange. Check platelet count after the pro-
cedure and transfuse platelets if indicated.
25

Self-test
A1. What are 4 possible problems with the use of citrate phosphate dextrose adenine–preserved blood?
A2. The hematocrit of donor blood used in an exchange transfusion should be _________% to _________%.
A3. True False Blood is best warmed under a radiant warmer.
A4. Immediately after a double volume exchange transfusion, the baby’s bilirubin will be _________ to
_________ the level it was before the exchange.
A5. Identify whether each of the following methods may be used to withdraw or infuse blood (or do both).
Withdraw Infuse
Yes No Yes No
Umbilical arterial catheter (unless route of last resort) ____ ____ ____ ____
Peripheral arterial catheter ____ ____ ____ ____
Umbilical venous catheter ____ ____ ____ ____
Peripheral intravenous line ____ ____ ____ ____
Check your answers with the list that follows the Recommended Routines. Correct any incorrect
answers and review the appropriate section in the unit.
7. How is an exchange transfusion performed?

Although the precise details of the techniques for exchange transfusion are given in the skill
unit, several points are especially important and therefore mentioned here.
A. Methods of exchange
• Pull-push method: The method in which a small volume of the baby’s blood is with-
drawn (pulled) through a UVC, followed by an equal volume of donor blood infused
(pushed) through the UVC to the baby. This pull-push cycle is repeated until the
exchange transfusion is completed.
• Continuous method: The method in which the baby’s blood is withdrawn through one
line and, simultaneously, an equal amount of donor blood is infused through a second
line.
Blood may be withdrawn from a UVC or an arterial catheter and given in equal vol-
ume through a PIV line. The baby’s blood may also be withdrawn through an arterial
catheter, and donor blood may be infused simultaneously through a UVC.
Although the continuous method has the advantage that it can be performed more
quickly, it has the disadvantage that catheters and syringes are more likely to become
clotted with blood. If clots develop, the UVC, PIV line, or syringes (or any combina-
tion of those) need to be replaced.
Regardless of the exchange method, blood should not be infused through a peripheral
artery, and infusion through a central arterial catheter, which is extremely risky, should
be done only as a last resort. The risk of tissue damage from the unintentional infusion
26

of emboli due to air bubbles or tiny blood clots is much greater when blood is infused
through an artery rather than a vein.
For either exchange method, withdrawal and infusion should be done slowly and
steadily to avoid sudden shifts in the baby’s blood pressure. Sudden shifts in blood
pressure have been associated with intraventricular bleeding in newborns, particularly
in preterm babies. Withdrawal and infusion rates no faster than 2 to 3 mL/kg/min are
recommended.
Summary of Exchange Routes
• Pull-push method: Blood is alternately withdrawn and infused in small incre-
ments through a UVC.
• Continuous method: Blood is withdrawn through one line and simultaneously
infused through another. Appropriate withdrawal and infu-
sion routes are
Withdrawal Route Infusion Route
UAC UVC or PIV line
PAC UVC or PIV line
UVC PIV line
B. Catheter position
Ideally, the tip of a UVC should be in the inferior vena cava or low right atrium, as con-
firmed by radiograph.
If this position cannot be achieved and bilirubin levels are considered to be dangerously
high, an exchange transfusion can be performed through a UVC when the catheter tip is
still in the umbilical vein and has not yet entered the vena cava, but there is a somewhat
greater risk of liver damage. In this case, the catheter should be inserted only a few cen-
timeters until blood return is obtained easily. Sclerosing drugs, such as calcium, should
probably not be infused through a catheter in this position.
Regardless of umbilical venous catheter location, blood flow should be ob-

tained easily from the catheter before starting any exchange transfusion.
If a UAC is used to withdraw blood, it should be inserted and positioned as outlined in

Book III: Neonatal Care, Unit 3, Umbilical Catheters. A PIV line in any location may be
used to infuse blood. Both lines should be periodically flushed with heparinized saline to
avoid clotting, as described in the skill unit.
C. Keeping blood mixed

The actual process of exchanging the baby’s blood for donor blood takes approximately
1 to 2 hours to complete, depending on the volume of blood and exchange method used.
During this time, it is important to mix the donor blood several times to prevent further
separation of the RBCs from the plasma. Mixing the blood is done by gently agitating
the donor blood bag by hand every 10 to 15 minutes.
If the blood is allowed to settle during the procedure, the baby will receive mostly plasma
at the end of the exchange transfusion. This may cause the baby to have a low post-
exchange hematocrit.
27

D. Record keeping
• At least 2 people are required for a pull-push exchange transfusion. After the UVC is
inserted, the second person is required to keep precise records of the blood exchanged
and medications, if any, given to the baby.
• Three people are generally required for a continuous exchange. One to withdraw the
baby’s blood, one to infuse the donor blood, and one to keep records.
With either method, each small increment of blood withdrawn and given is recorded, as
well as a “running total” of all blood removed from and given to the baby.
Precise, detailed records are extremely important to avoid unintentionally overloading the
baby with fluid, or leaving the baby in a hypovolemic state at the end of the exchange.
8. Will a baby ever need more than one transfusion?

Most babies with hyperbilirubinemia do not require an exchange transfusion. Refer to Book
III: Neonatal Care, Unit 7, Hyperbilirubinemia, to determine if and when a particular baby
needs an exchange transfusion.
In a baby, hyperbilirubinemia severe enough to require one exchange may require more than
one exchange. An exchange transfusion will not remove all of the baby’s circulating bilirubin.
In addition, rebound hyperbilirubinemia may occur after an exchange is completed. The baby’s
bilirubin level should be checked every 4 to 6 hours after an exchange.
Phototherapy lights should always be used after every exchange transfusion for
hyperbilirubinemia.
9. What are the potential complications of an exchange transfusion?

An exchange transfusion is an important, but invasive, therapeutic measure for a baby with
severe hyperbilirubinemia. With careful preparation and monitoring of the baby’s cardiac and
metabolic status, the following complications can be minimized or avoided (Table 2.1).
Table 2.1. Potential Complications of Exchange Transfusions

Possible Complications Means to Monitor/Prevent Complications
Vascular
• Formation of air or blood • Use careful technique when infusing through an umbilical venous
emboli catheter, as shunts to the arterial side are common in newborns.
• Thrombosis • Do not infuse through a peripheral arterial catheter. Avoid infusing
through a umbilical arterial catheter unless absolutely necessary.
• Intravenous infiltration • Be sure there is adequate blood return from the catheter, and do
not leave the catheter in place longer than necessary. Flush the
lines periodically with heparinized saline.
• If a peripheral intravenous line is used to infuse donor blood, ob-
serve the site carefully throughout the infusion for sign of infiltra-
tion. These signs may include swelling at the site or difficulty in
flushing the line or infusing blood.
28

Table 2.1. Potential Complications of Exchange Transfusions (continued)

Possible Complications Means to Monitor/Prevent Complications
Cardiac
• Arrhythmias • Monitor continuously with electronic heart rate monitor.
• Check electrolytes if heart rate pattern changes.
• Volume overload, volume • Keep precise records of blood given to and taken from the baby.
depletion
• Cardiorespiratory arrest • Obtain blood pressure measurements at least every 15 minutes
during the exchange.
• Continuously monitor baby with electronic heart rate monitor.
• Keep resuscitation equipment at bedside.
Clotting
Catheter clotted Be aware that this is more likely to happen when an arterial catheter
is used to withdraw blood during a continuous exchange. Periodi-
cally flush the umbilical or peripheral arterial catheter with a small
volume of heparinized saline.
Metabolic
• Hypocalcemia (low blood Obtain blood studies for glucose, calcium, potassium, sodium, and
calcium level) bilirubin after the exchange transfusion and as indicated by the ba-
• Hypoglycemia (low blood by’s condition.
glucose level)
• Hyperkalemia (high blood
potassium level)
• Rebound hyperbilirubinemia
• Acidosis or alkalosis
Infectious
• Sepsis • Maintain sterile technique throughout the exchange transfusion.
• Serum hepatitis • Blood bank screens blood donors carefully and tests blood.
• Cytomegalovirus • Blood bank screens blood donors carefully and tests blood.
• Use blood that has undergone leukoreduction when available.
• HIV • Blood bank screens blood donors carefully and tests blood.
Miscellaneous
• Mechanical injury to donor • Use only a commercial blood warmer that has passed quality
cells inspection for temperature control and alarm system.
• Perforation of the inferior • This is rare, but if resistance is met when an umbilical venous
vena cava catheter is inserted, it should not be forced further.
• Hypothermia • Warm the blood to 37.0°C (98.6°F).
• Maintain temperature control of the baby during the procedure.
• Tanning (injury from over- • Do not warm the blood under a radiant warmer. Be sure the tem-
heating) of the red blood perature of a commercial blood warmer does not go above 38.0°C
cells (100.4°F).
• Anemia • Be sure the blood bank measures the hematocrit of the donor blood.
• Mix the blood frequently during the procedure.
• Thrombocytopenia • Check a post-exchange platelet count. Reconstituted red blood cell
products do not contain viable platelets.
29

Self-test
B1. True False If an umbilical venous catheter is used to withdraw a baby’s blood for an
exchange transfusion, the donor blood can be infused through an arterial
catheter.
B2. List at least 2 possible cardiac complications of an exchange transfusion.
B3. Following an exchange transfusion for hyperbilirubinemia, a baby’s bilirubin level should be checked
every _______ to _______ hours.
B4. List at least 3 possible metabolic complications of an exchange transfusion.
Partial Exchange Transfusions in the Management of Polycythemia or

Severe Anemia
1. What is a partial exchange transfusion?

A partial exchange transfusion is the process of withdrawing a calculated amount of the baby’s
blood and replacing it with an equal amount of packed RBCs or physiologic (normal) saline,
depending on whether the baby is being treated for too many RBCs (polycythemia) or too few
(severe anemia). In either condition, the baby’s initial total blood volume may be normal or
even excessive, resulting in varying degrees of heart failure.
2. What is polycythemia?
Polycythemia is a condition in which a baby has more RBCs than normal, with a resulting
increase in hematocrit. When the hematocrit, drawn from a free-flowing large vessel, is higher
than approximately 65%, blood flow may become sluggish.
Sluggish blood flow may, in turn, cause poor tissue perfusion. The organs most affected by
sluggish flow may vary from baby to baby, leading to a wide range of possible problems.
Some babies with hematocrits between 65% to 70% will not show any of the following signs,
but almost all babies with hematocrits 70% or above will show one or more of them:
• Plethora (ruddy appearance) • Congestive heart failure
• Cyanosis • Tremors
• Lethargy • Seizures
• Poor feeding • Hypoglycemia
• Respiratory distress • Hyperbilirubinemia
A. How is polycythemia diagnosed?
Blood drawn from a vein or an artery should be used to measure a baby’s hematocrit. A
baby’s capillary blood, or blood obtained when a heel stick is done, should not be used.
30

While capillary blood, from a finger stick, will provide accurate results in adults, this is
not true for babies.
Blood obtained from heel sticks in babies can give falsely high hematocrit values due to
venous stasis. Alternatively, if the heel is squeezed excessively to collect the blood sample,
interstitial fluid may dilute the sample and give falsely low hematocrit values.
Polycythemia should not be diagnosed from a baby capillary (heel stick) blood
sample. Only blood drawn from a free-flowing vein or artery should be used.
B. Which babies are at risk for polycythemia?

1. Babies who experience chronically low in utero oxygen concentrations
Fetuses who were exposed to somewhat lower oxygen concentrations over a relatively
long period will increase the number of RBCs they produce to help improve their oxy-
genation. These include
• Small-for-gestational-age babies or babies who experienced intrauterine growth
restriction
• Post-term babies
2. Babies who received extra blood from the placenta
• In utero fetal-fetal transfusion (during a twin or multiple gestation) resulting from
an abnormal connection between placentas (Generally, the donor fetus is anemic,
while the recipient fetus is polycythemic.)
• In utero maternal-fetal transfusion resulting from abnormal connections within the
placenta causing the fetus to receive blood directly from the mother
• Delayed cord clamping at the time of delivery
3. Babies who are large for gestational age, especially babies of diabetic mothers
The reasons for this are not entirely clear.
4. Babies with certain chromosomal abnormalities, such as Down syndrome
C. Which babies with polycythemia need to be treated?
Complications of untreated polycythemia may include thromboembolic events, such
as cerebral artery thrombosis, necrotizing enterocolitis, and acute tubular necrosis.
Long-term motor and mental disabilities have also been associated with untreated
polycythemia.
Currently, there is some controversy over which babies should be treated. In general,
however, most experts agree that the following babies need treatment:
• Babies with venous or arterial hematocrits greater than or equal to 70%
• Babies with venous or arterial hematocrits between 65% to 70% who have signs or
symptoms of polycythemia
3. How is a reduction exchange transfusion done for polycythemia?

The procedure for performing a reduction exchange transfusion is similar to an exchange
transfusion done for hyperbilirubinemia. The difference is that blood is withdrawn from the
baby and saline, instead of blood, is given to the baby.
The purpose of a reduction exchange transfusion is to reduce the baby’s RBC mass. Therefore,
some of the thick (polycythemic) blood is removed and a solution that will dilute the baby’s
blood is infused. Saline, plasma, or 5% albumin may be used, but, for a variety of reasons,
31

saline is recommended. In addition, a full exchange is not performed. Only enough blood to
lower the baby’s hematocrit to an acceptable range is exchanged.
A. How do you calculate the amount of blood to exchange?
Use the following formula to determine the amount of blood that should be withdrawn
from a baby. The amount of blood withdrawn is also the amount of diluent (normal
saline) that should be given to the baby.
Blood to Withdraw (in small aliquots)
baby’s blood volume 3 (actual hematocrit 2 desired hematocrit) 5 amount of blood to withdraw
actual hematocrit
Normal Saline to Infuse (in small aliquots)
calculated amount of blood to be withdrawn 5 amount of saline to infuse
Example: A 3,000-g (6 lb 10 oz) baby has a hematocrit of 75%. The baby’s blood vol-
ume is 90 mL/kg (Book III: Neonatal Care, Unit 4, Low Blood Pressure). The
baby’s total blood volume, therefore, is 270 mL (90 mL 3 3 kg 5 270 mL).
You wish to reduce the hematocrit to 55%.
(75% 2 55%)
270 mL 3
75%
20%
270 mL 3
75%
4
270 mL 3 5 72 mL of blood to withdraw from the baby and
15
72 mL of normal saline to infuse
B. What methods are used to perform a reduction exchange transfusion?
• Pull-push technique: 5 to 10 mL of the baby’s blood is withdrawn (pulled) through
a UVC and discarded, followed by normal saline infused (pushed) through the UVC.
This pull-push cycle is repeated until the desired volume of blood has been exchanged
(see calculation above).
• Continuous method: Withdrawal of blood from one line and simultaneous infusion of
normal saline through a second line.
Blood may be withdrawn through a UAC, UVC, or PAC. Saline may be given through
a PIV line or UVC. Some experts consider the preferred routes to be withdrawal
through a PAC and replacement infusion through a PIV line.
Withdrawal of blood and infusion of normal saline need to be done slowly to avoid
sudden shifts in the baby’s blood pressure. Sudden shifts in blood pressure have been
associated with intraventricular bleeding in newborns, particularly in preterm babies.
A withdrawal rate no faster than 2 to 3 mL/kg/min and an infusion rate no

faster than 2 to 3 mL/kg/min are recommended.

4. What are the potential complications of a reduction exchange

transfusion for polycythemia?
Complications of a reduction exchange transfusion are similar to those outlined earlier for
exchange transfusions for hyperbilirubinemia but do not include complications directly related
32

to use of blood products. For example, the risk of viral infections associated with the transfu-
sion of blood is not a possible complication of a reduction exchange transfusion because blood
is not given to the baby.
Some experts suggest waiting to feed a baby for 24 to 72 hours after a reduction exchange
transfusion. Polycythemia, by itself, may be associated with intestinal injury and has been
reported to increase the risk for developing necrotizing enterocolitis. While the baby is fed
nothing by mouth, the baby will need to receive intravenous fluids to maintain hydration and
blood glucose.
5. When is a partial exchange transfusion used for severe anemia?

In the case of severe anemia, the goal is to increase, rather than decrease, the RBC mass.
A. Why might severe anemia develop during gestation?

Rarely, a fetus may become extremely anemic for the following reasons:
• Chronic hemolysis from blood group incompatibility with the mother or from an in
utero viral infection
• When the fetus is the donor of a fetal-fetal or fetal-maternal in utero transfusion
• From causes unknown
B. How may the fetus be affected by severe in utero anemia?
If the anemia is very severe, the fetus may die in utero or may develop edema (hydrops
fetalis), which may or may not be detectable by antenatal ultrasound. The low oxygen-
carrying capacity created by the paucity of RBCs will often result in these fetuses not
tolerating labor well and requiring resuscitation at birth.
6. Why is a partial exchange transfusion done for severe anemia?

The purpose of a partial exchange transfusion in the case of severe anemia is to increase, rather
than decrease, the concentration of RBCs in the blood, so as to increase the oxygen-carrying
capacity and reverse heart failure. If the anemia has been developing over weeks or months, the
fetus will have retained sufficient plasma so that blood volume is normal or even increased. In
such cases, a direct transfusion of packed RBCs may result in worsening of the heart failure.
If a partial exchange for hydrops becomes necessary, it may be needed at birth, so you should
have appropriately matched packed RBCs available in the delivery room.
7. How is a partial exchange transfusion done for severe anemia?

The process for performing a partial transfusion for anemia is the same as the process
described previously for polycythemia except for the product used for infusion. In the case of
severe anemia, the goal is to increase the concentration of RBCs without increasing the total
blood volume. Therefore, instead of infusing normal saline and removing blood that is too
thick, you will be removing the thin, anemic blood and transfusing packed RBCs.
For a case of severe anemia you can use a similar mathematical method as that described previ-
ously for polycythemia to calculate the total amount of blood to be exchanged for normal saline.
volume exchanged (milliliters) 5
(hematocrit desired 2 hematocrit initial)
baby’s blood volume 3
(hematocrit donor RBCs 2 hematocrit initial)
However, clinicians generally exchange a total volume of 20 mL/kg, repeat the hematocrit test
and assess the baby’s condition, and then may perform a second partial exchange if judged to
be necessary. Either the pull-push or continuous method may be used.
33

Self-test
C1. True False Untreated polycythemia has been associated with permanent intellectual
disability.
C2. Blood for determining a baby’s hematocrit should be taken from an __________________ or a
__________________.
C3. List at least 5 possible signs of polycythemia.
C4. In general, babies with hematocrits equal to or greater than _________% need to be treated for
polycythemia.
C5. A 1,980-g (4 lb 6 oz), 38-week-old baby that is small for gestational age is tachypneic with a hemato-
crit of 66%. You rule out other causes for her respiratory distress and determine she needs a reduc-
tion exchange transfusion. How much blood would you exchange if her desired hematocrit is 50%?
______________ mL blood withdrawn
______________ mL physiologic (normal) saline given
Direct Transfusions in the Management of At-Risk and Sick Babies
1. What is a direct transfusion?

A direct transfusion is the process of infusing packed RBCs into a baby through a PIV line.
2. Why are direct transfusions done?

Several studies, designed to decrease the exposure to donor blood, recommend transfusion
standards for certain hematocrits and disease severity categories (eg, Bell EF, Strauss RG,
Widness JA, et al. Randomized trial of liberal versus restrictive guidelines for red blood cell
transfusion in preterm infants. Pediatrics. 2005;115[6]:1685–1691 and Kirpalani H, Whyte
RK, Andersen C, et al. The Premature Infants in Need of Transfusion [PINT] study: a ran-
domized, controlled trial of a restrictive [low] versus liberal [high] transfusion threshold for
extremely low birth weight infants. J Pediatr. 2006;149[3]:301–307). There continues to be
ongoing research in the optimal timing and degree of anemia at which to transfuse babies,
especially preterm babies. Much of this research is focused on neonatal morbidities related to
transfusion as well as long-term neurodevelopmental outcomes.
Because a very small risk of infection (HIV, hepatitis, etc) from blood transfusion
still exists, as few transfusions as possible are performed. However, some babies
will require at least one, or perhaps many, transfusions.
A. Sick babies who require ventilatory support

Often, sick or at-risk babies have numerous laboratory studies, which cumulatively result
in a large quantity of blood being withdrawn. The specific quantity of blood drawn
34

before a transfusion is indicated is controversial. However, in a sick baby who is requir-

ing assisted ventilation, packed RBCs may be transfused when the baby’s hematocrit
drops below the standard that is set for that facility, usually the mid-30s.
B. Babies who are hypovolemic
Babies who are, or are suspected of being, hypovolemic because of blood loss may be
given direct transfusions to increase their blood volume. The management of babies with
hypovolemia is discussed in greater detail in Book I: Maternal and Fetal Evaluation and
Immediate Newborn Care, Unit 5, Resuscitating the Newborn, and Book III: Neonatal
Care, Unit 4, Low Blood Pressure.
C. Babies who have signs of anemia
Normally, even without any blood being withdrawn for laboratory studies, healthy term
babies will become anemic during the first 6 to 8 weeks after birth. Preterm babies or
babies who have had blood withdrawn for laboratory studies usually develop anemia
sooner, and with a greater drop in hematocrit, than healthy term babies. Stable preterm
babies often continue to grow well and have normal vital signs, even though they may
become quite anemic with hematocrits of 25% or lower.
Some anemic babies, however, will demonstrate signs of anemia that may require one or
more direct transfusions to resolve the problems. Signs of anemia include
• Tachycardia
• Tachypnea
• Apnea
• Failure to gain weight
The decision of when to transfuse a baby who is anemic is controversial. Most experts
recommend not transfusing babies who are anemic but have no signs or symptoms of
anemia. When a baby develops signs such as tachycardia, tachypnea, or apnea, you
should evaluate the baby for all the possible causes of these problems. (See Book III:
Neonatal Care, Unit 9, Review: Is the Baby Sick? Identifying and Caring for Sick and
At-Risk Babies, Subsection: Vital Signs and Observations.)
If the most likely cause of the baby’s problems is anemia, you need to weigh the risks
of transfusion against the risks of problems the baby is demonstrating. When signs of
anemia are significant, and the baby’s hospitalization is being prolonged because of these
problems, a transfusion of packed RBCs may be necessary.
3. How is a direct transfusion done?

• Packed RBCs should be compatible with the baby’s blood.
• Usually a volume of 10 to 15 mL/kg is transfused.
Example: A sick, 1,500-g (3 lb 5 oz), preterm baby who requires ventilator support has a
hematocrit of 34%. You elect to transfuse the baby with 10 mL/kg.
10 mL 3 1.5 kg 5 15 mL of packed RBCs to be transfused
• Packed RBCs are given through a PIV line.
• Follow your hospital’s protocol for acquiring parental consent and for the filtering, iden-
tification, and disposal of blood.
• A transfusion is usually given over approximately 2 to 4 hours. A transfusion that is
given too quickly may cause volume overload, which may lead to increased respiratory
distress in the baby.
35

• In a sick baby, the hematocrit should be checked 12 to 24 hours after transfusion. This
allows time for the transfused blood to equilibrate in the baby’s circulation. In a stable
baby, you can generally wait to check the hematocrit until the next time blood is drawn
for laboratory studies.
4. What are the potential complications of a direct transfusion?

A. Infection
Serious infections, such as HIV or hepatitis, can occur after blood transfusion. Currently,
blood banks extensively test blood before it is used. Despite these efforts, a very small
number of individuals receiving blood may develop an infection.
B. Emboli
Small blood clots can pass through an intravenous line. Blood is usually filtered by the
blood bank before it is sent to the nursery. If this is not done, a filter should be inserted
between the blood being transfused and the baby before the transfusion is given.
C. Elevated potassium levels
Older blood can have high levels of potassium. In general, this is not dangerous because
the total amount of potassium that will be given to the baby is small. In very small, sick
babies, however, an added potassium load can result in an elevation of potassium to a
level that can cause heart arrhythmias. Therefore, you should always use the freshest
blood available.
Self-test
D1. True False Some babies will require a transfusion of packed red blood cells when their
hematocrits fall below 40%, while other babies with hematocrits of 25% or
lower will not require a transfusion.
D2. List 4 reasons transfusions of packed red blood cells are used.
D3. True False Certain viral infections may occur as a result of a blood transfusion.
D4. Blood should be filtered before it is transfused to prevent the infusion of ________________.
36

Exchange, Reduction, and Direct Transfusions
Unit 2: exchange, reduction, and direct transfusions/ recommended routines

Recommended Routines
All the routines listed below are based on the principles of perinatal care presented in the unit
you have just finished. They are recommended as part of routine perinatal care.
Read each routine carefully and decide whether it is standard operating procedure in your
hospital. Check the appropriate blank next to each routine.
Procedure Standard Needs Discussion by

in My Hospital Our Staff
__________________ __________________ 1. Establish a policy of obtaining a radiograph for

umbilical catheter placement before an elective
exchange transfusion.
__________________ __________________ 2. Establish a policy of providing continuous elec-
tronic cardiac monitoring for all babies under-
going an exchange transfusion.
__________________ __________________ 3. Establish a policy of monitoring blood pressure
at least every 15 minutes during an exchange
transfusion.
__________________ __________________ 4. Establish a routine of determining hematocrit,
as well as serum glucose, calcium, potassium,
sodium, and bilirubin, after every exchange
transfusion.
__________________ __________________ 5. Establish a routine of warming blood before an
exchange transfusion, using a commercial blood
warmer with appropriate temperature control
and alarm features.
__________________ __________________ 6. Establish a policy of using phototherapy after
any exchange transfusion for hyperbilirubinemia.
__________________ __________________ 7. Establish a policy of checking the hematocrits
of all babies at risk for polycythemia.
__________________ __________________ 8. Establish a policy of using only venous or arte-
rial (not capillary) blood to determine the he-
matocrit of a newborn at risk for polycythemia.
__________________ __________________ 9. Establish a policy of monitoring all babies with
hematocrits greater than 65% for signs of
p
olycythemia.
__________________ __________________ 10. Establish a policy for the hematocrit below
which a baby who is critically ill (ventilated,
unstable) will be transfused.
__________________ __________________ 11. Establish a policy of monitoring the hemato-
crits of sick babies and stable, growing preterm
babies.
__________________ __________________ 12. Establish a policy of monitoring babies with
low hematocrits for signs of anemia.
37

Self-test Answers
A1. Hypocalcemia
Hypoglycemia
Acidosis/alkalosis
Hyperkalemia
A2. The hematocrit of donor blood used in an exchange transfusion should be 45% to 55%.
A3. False.
Reason: Blood should be warmed only with a commercial blood warmer that has the appro-
priate temperature control and alarm features.
A4. Immediately after a double volume exchange transfusion, the baby’s bilirubin will be one-third to one-
half the level it was before the exchange.
A5. Withdraw Infuse
Yes No Yes No
Umbilical arterial catheter X X*
Peripheral arterial catheter X X
Umbilical venous catheter X X
Peripheral intravenous line X X
*Unless route of last resort.
B1. False.
Reason: Blood may be withdrawn from an artery but should not be infused into a peripheral
artery or through an umbilical arterial catheter (unless an umbilical arterial catheter is the
route of last resort). The risk of tissue damage from unintentional infusion of air bubbles or
tiny clots is much greater with an infusion through an artery rather than a vein.
B2. Any 2 of the following complications:
• Arrhythmia
• Volume overload or depletion
• Cardiorespiratory arrest
B3. Following an exchange transfusion for hyperbilirubinemia, a baby’s bilirubin level should be checked
every 4 to 6 hours.
• Hypocalcemia
• Hypoglycemia
• Hyperkalemia
• Rebound hyperbilirubinemia
• Acidosis or alkalosis
C1. True
C2. Blood for determining a baby’s hematocrit should be taken from an artery or a vein (not heel stick).
C3. Any 5 of the following signs:
• Plethora
• Cyanosis
• Lethargy
• Poor feeding
• Respiratory distress
• Congestive heart failure
• Tremors
• Seizures
• Hypoglycemia
38

C4. In general, babies with hematocrits equal to or greater than 70% need to be treated for polycythemia.
C5. 44
44
D1. True
D2. Replace blood withdrawn for laboratory tests.
Treat hypovolemic babies.
Treat stable babies who have symptomatic anemia.
Maintain hematocrit of approximately 40% in sick babies.
D3. True, although risk is extremely small.
D4. Blood should be filtered before it is transfused to prevent the infusion of tiny blood clots.
39

Unit 2 Posttest
40

Unit 2: exchange, reduction, and direct transfusions/ skill unit: exchange transfusions
SKILL UNIT
Exchange Transfusions
This skill unit will teach you how an exchange transfusion is performed. Not everyone will be
required to learn how to conduct an exchange transfusion; however, all staff members should
read this unit and attend a skill session to learn the equipment and sequence of steps so they
can assist with the preparation for an exchange transfusion.
Although the following steps are the same as the ones used in clinical practice to perform an
exchange transfusion, manikins and models should be used for demonstration and practice of
this skill.
The staff members who will be asked to master all aspects of this skill will need to demonstrate
each of the following steps correctly:
1. Prepare the “baby” (manikin) for the exchange transfusion.
2. Prepare the donor “blood.”
3. Insert an umbilical venous catheter, an umbilical or a peripheral arterial catheter, a periph-
eral intravenous line, or a venoarterial catheter, as needed. Identify proper location of umbil-
ical venous and arterial catheters on radiograph to indicate appropriate positioning of the
catheter.
4. Demonstrate the pull-push method or the continuous method (or both).
5. Record blood exchanged, vital signs, etc.
6. Monitor the baby during the exchange.
7. Monitor the baby after the exchange.
41

Performing Exchange Transfusions

Note: W
hile this skill unit describes the procedure for an exchange transfusion for hyperbili-
rubinemia, the same basic techniques are used for a reduction exchange for poly
cythemia. As you know, the amount of blood withdrawn and the replacement fluid
given are both different, but the techniques for how the blood is withdrawn and the
volume is replaced are the same.
ACTIONS REMARKS
Preparing the Baby for an Exchange Transfusion

Several things must be done to prepare a baby
before the actual exchange transfusion begins.
1. Send a sample of baby’s and mother’s If a baby has a significant risk of needing an
blood for crossmatching. exchange transfusion, notify the blood bank
and send appropriate samples early. Prepara-
tion of an appropriate blood product may re-
quire several hours.
2. Do not give enteral feedings for 3 to 4 This will reduce the chance the baby will
hours or aspirate stomach contents just vomit (and possibly aspirate) during the
prior to the exchange. procedure.
3. Establish a properly warmed and oxygen- Exchange transfusions can be done with the
ated (if the baby requires supplemental ox- baby inside an incubator or under a radiant
ygen) environment for the baby during the warmer. Wherever care is provided, it must
exchange. be possible to establish and maintain a sterile
field.
4. Consider establishing a peripheral intrave- During the exchange, the amount of blood
nous (PIV) line. given will usually be the exact amount with-
drawn. A separate intravenous (IV) line is
helpful to provide a constant infusion of fluid
and glucose during the exchange, and IV ac-
cess in case of an emergency.
5. Attach a cardiac monitor to the baby. This Continuous cardiac monitoring is important
monitor should provide a continuous sig- so any change in the baby’s heart rate can be
nal of the baby’s heartbeat. High and low instantaneously detected.
heart rate alarms should be set.
6. Attach a blood pressure cuff to one of the Because the baby may get too much or too
baby’s extremities and obtain a measure- little volume during the procedure, or de-
ment at least every 15 minutes. velop a complication, it is important to moni-
tor blood pressure.
42

ACTIONS REMARKS
Preparing the Baby for an Exchange Transfusion (continued)

7. Collect resuscitation equipment and place The mortality rate associated with exchange
it at the baby’s bedside. This equipment in- transfusions is less than 1%, although it is
cludes higher if the baby is premature or ill. Unex-
• Resuscitation bag and mask (assembled pected, unexplained cardiac arrest does
and connected to an oxygen source) occasionally occur.
• Laryngoscope, endotracheal tubes, Fewer and fewer perinatal health care
stethoscope, etc professionals are experienced with exchange
transfusions. This makes being prepared for
• Emergency medications
the unexpected increasingly important.
• At least 2 people trained in neonatal re-
suscitation present with the baby
throughout the entire procedure
8. Prepare the blood.
a. Be sure the blood is antigen-negative
for passively acquired antibodies.
b. Know the anticoagulant used and the See section 4 in Exchange Transfusions in the
age of the blood. Request blood that is Management of Hyperbilirubinemia.
10 days or older. For citrate phosphate dextrose adenine anti-
coagulated blood, be especially careful to
observe the baby for signs of hypocalcemia,
and check for the possible development of
hypoglycemia.
Donor blood, especially older blood, will
need to be washed by the blood bank to re-
duce potassium levels.
c. Calculate the volume of blood needed. Generally, double volume exchange transfu-
sions using 180 mL of donor blood for every
kilogram of the baby’s weight are used.
Example: D
ouble volume exchange transfu-
sion for a baby weighing 2,600 g
(5 lb 12 oz) would require
468 mL of donor blood
(180 mL/kg 3 2.6 kg 5 468 mL).
d. Request that the hematocrit of the Most blood banks can prepare donor blood
blood be between 45% to 55%. so it has an appropriate hematocrit.
43

ACTIONS REMARKS

e. Warm the blood to 37.0°C (98.6°F) by Do not use true packed red blood cells with
using a commercial blood warmer that high hematocrit values. See section 6.A in
has Exchange Transfusions in the Management of
• Constant temperature readout Hyperbilirubinemia.
• Adjustable thermostat Do not use blood warmers without precise
• Automatic alarm system to prevent thermostatic control because these may cause
warming the blood above 38.0°C mechanical trauma to the red blood cells.
(100.4°F)
Do not heat the blood under a radiant
warmer or in a water bath warmer because
this may “tan” the surface red blood cells and
produce intravascular hemolysis.
9. Prepare the fluid lines.
a. Insert an umbilical venous catheter Use the sterile procedure and insertion tech-
(UVC) if you will use the pull-push nique outlined in Unit 3, Continuous Positive
method. Airway Pressure, Skill Unit: Delivery of Con-
• Measure the baby to determine the tinuous Positive Airway Pressure.
appropriate distance to insert the Maintain sterile technique throughout the
UVC. catheterization and exchange transfusion.
• Use a size 5F catheter for most babies
Everyone involved should wear sterile gowns
with a birth weight over 1,000 g (2 lb
and gloves. If the baby is inside an incubator,
3 oz).
masks are not necessary but should be used if
the baby is on a radiant warmer.
b. Insert an umbilical arterial catheter If the baby does not require a UAC for other
(UAC), peripheral arterial catheter reasons (eg, monitoring arterial blood gases,
(PAC), UVC, or PIV line (or any combi- central blood pressure), either the pull-push
nation of those) if you are using the method through the UVC or continuous
continuous method. method through a UVC and PIV line is pref-
See section 7.A in Exchange Transfu- erable.
sions in the Management of Some clinicians place a PAC and use it for
Hyperbilirubinemia. withdrawal, with infusion through a UVC or
PIV line.
44

ACTIONS REMARKS

10. Determine the placement of the catheters
by radiograph.
• Ideally, a UVC tip should be at the junc-
tion of the inferior vena cava and right
atrium.
Heart
• On radiograph, the UVC tip should be
Diaphragm
above or at the level of the diaphragm
(see illustration). Liver
• It is also possible to perform an

exchange transfusion through a UVC
when the catheter tip is still in the
umbilical vein and will not pass into
the inferior vena cava. However, there Umbilicus
is a somewhat greater risk of liver dam- Catheter

outside
age. In this case, the catheter should be baby
inserted only 1 to 2 cm and infusion of

sclerosing drugs, such as calcium, should
be avoided.
Wherever the UVC is placed, you
should be able to obtain blood flow
into the catheter very easily. Optimum Location for Umbilical Venous
• A UAC tip should be between L3 and L4 Catheter Tip
if using a “low UAC.” Alternatively, the
UAC may be placed as a “high UAC,”
with its tip placed between T6 and T9.
(The UAC is not shown in the illustra-
tion. See Book III: Neonatal Care, Unit 3,
Umbilical Catheters.)
• A PAC is commonly placed in the
radial artery.
45

ACTIONS REMARKS

11. Collect the appropriate equipment. Com-
mercial sterile exchange transfusion kits
are available, or you can make your own
kit with the following equipment:
Pull-Push Method
• One 4-way stopcock
• 6-, 10-, or 12-mL syringe
Continuous Method
• Three 3-way stopcocks
• One 50- to 60-mL syringe for each
150 mL of blood to be withdrawn
• One 50- to 60-mL syringe for blood
infusion
• 5- to 6-mL syringe for heparinized
saline flush
Either Method
• Blood filter (Sometimes blood filters are
incorporated into IV tubing.)
• Intravenous tubing between the donor
blood and stopcock
• Plastic bag or container to collect blood
removed
• Intravenous tubing between stopcock
and collection container
• Two 5-mL syringes to obtain pre-
exchange and post-exchange
laboratory samples
46

ACTIONS REMARKS
Performing an Exchange Transfusion

12. Assemble the equipment as shown in one
of the diagrams that follow, depending on
whether you will use the pull-push or con-
tinuous method.
Pull-Push Method
Donor blood
Blood filter
Blood warmer
Baby with
Syringe 4-way stopcock umbilical
venous
catheter
Collection bag for baby’s blood
47

ACTIONS REMARKS
Performing an Exchange Transfusion (continued)

13A. Pull-Push Technique See step 13B for a description of the continu-
a. Open the UVC to the 10- or 12-mL ous method.
syringe.
b. Pull 5 or 10 mL of blood slowly from For small babies, only 5-mL volumes should
the baby, at a rate no faster than 2 to be withdrawn or given at a time. For larger
3 mL/kg/min. babies (.3,000 g [6 lb 10 oz]) with stable vi-
c. Turn the stopcock off to the UVC and tal signs, the individual exchange amounts
open to the collection container. may be 10 mL.
d. Push the blood out of the syringe and
into the collection container.
e. Turn the stopcock off to the collection
container and open to the donor
blood.
f. Withdraw 5 or 10 mL (an amount
equal to the volume just withdrawn
from the baby) from the blood donor
unit.
g. Close the stopcock to the donor unit
and open it to the UVC.
h.
Slowly push the donor blood out of Be sure to hold the syringe upright so that
the syringe and into the UVC, at a any air bubbles in the syringe will not be
rate no faster than 2 to 3 mL/kg/min. pushed unintentionally into the baby.
i. Leave the stopcock open to the UVC Withdraw and replace the blood in a slow
and slowly withdraw another 5 or and steady fashion. Rapid shifts in blood
10 mL of blood from the baby. volume can be quite hazardous to a baby.
Continue this pattern of pulling blood
from the baby, discarding it, and push-
ing donor blood into the baby until
180 mL/kg of baby’s weight of donor
blood has been exchanged.
j. It should take approximately 1 to There is no advantage to rushing through an
2 hours (depending on the amount of exchange transfusion because the rate of the
blood to be exchanged) to complete a exchange has little effect on the amount of
pull-push exchange. bilirubin removed and, as noted earlier, rapid
shifts in fluid volume can be harmful.
48

ACTIONS REMARKS

Continuous Method
Infusion System Removal System
Donor blood Baby with peripheral arterial catheter,

umbilical arterial catheter, or
umbilical venous catheter
Blood filter
Collection
3-way bag for
stopcock #1 baby’s
blood
Blood warmer
Syringe with
50-mL 3-way 3-way
heparinized
syringe stopcock stopcock #2
saline
Baby with umbilical

venous catheter or
peripheral intravenous line 50-mL
syringe
49

ACTIONS REMARKS

13B. Continuous Method
Infusion steps and removal steps should
be done simultaneously.
Infusion Steps Removal Steps
a. Turn the stopcock so that the 50- to a. Turn stopcocks 1 and 2 so the 50- to
60-mL syringe is open to the donor 60-mL syringe is open to the PAC, UAC,
blood. or UVC being used to withdraw the
b. Fill the syringe with 50 mL of donor baby’s blood.
blood. b. Withdraw the baby’s blood at a rate of
c. Turn the stopcock off to the donor 2 to 3 mL/kg/min.
blood and open it to the UVC or PIV c. When 50 mL have been withdrawn, turn
line being used for infusion. stopcock 1 off to the catheter and open to
d. Begin to infuse the donor blood at 2 the collection bag.
to 3 mL/kg/min. d. Quickly eject the blood into the collection
e. Repeat steps a through d above until bag.
the desired volume (usually 180 mL/ e. Turn stopcock 1 off to the collection bag
kg) of donor blood has been infused. and open to the catheter.
It is important that the rate of infusion f. Repeat steps a through e above. Perform
and withdrawal of blood remain equal steps g through j after every 150 mL of
and constant, so that shifts in the baby’s baby’s blood has been withdrawn.
blood volume do not occur. g. Turn stopcock 1 off to the catheter and re-
place the 50- or 60-mL syringe with a new
one.
h. Open stopcock 2 between the heparinized
saline (5 U of heparin per 1 mL saline) sy-
ringe and the catheter.
i. Open stopcock 1 to the catheter.
j. G
ently flush the catheter with 1 to 2 mL of
heparinized saline. Periodically changing
the 50- or 60-mL syringe and flushing the
catheter will help prevent clot formation.
k. Repeat steps a through j above until the
desired volume (usually 180 mL/kg) of
blood has been withdrawn.
50

ACTIONS REMARKS

14. With either method, the first 5 or 10 mL
of blood withdrawn from the baby should
be used for pre-exchange laboratory studies.
• Bilirubin
• Hematocrit
• Electrolytes
• Calcium
• Other (coagulation studies, chro-
mosomes, or other tests that may be
indicated for the baby undergoing the
exchange)
15. Record each volume of blood withdrawn Every time one operator withdraws blood
and infused on a tally sheet. Use a form from or gives blood to the baby, he or she
similar to the one at the end of this unit. should call out the volume to another person
who records it.
At the end of the exchange, the total The recorder also maintains a “running total”
amount of blood given should equal the of how much blood has been withdrawn and
total amount of blood withdrawn. given.
16. Check and record the baby’s vital signs at
least every 15 minutes during the exchange.
17. Observe for signs of hypocalcemia, Hypocalcemia is more likely to develop when
including citrate phosphate dextrose adenine–preserved
• Jitteriness blood is used, rather than heparinized blood.
• Seizures
• Apnea
If any of the following signs develop or
hypocalcemia is documented, See Book III: Neonatal Care, Unit 3, Umbili-
a. Flush the catheter with heparinized nor- cal Catheters, for recommendations regarding
mal saline. heparin concentration in heparin flushes.
b. Give 100 to 200 mg calcium gluconate Risks are associated with the administration
per kilogram slowly through the UVC of IV calcium gluconate. Therefore, calcium
or PIV line. Use 5% (50 mg/mL) con- should probably not be given unless the baby
centration (dilute 10% calcium gluco- has developed signs of hypocalcemia.
nate with equal parts sterile water to
make 5%).
c. Stop the calcium infusion immediately if Calcium injected rapidly, especially through
the baby’s heart rate begins to slow. a UVC, can cause cardiac arrest. Be sure the
d. Flush the catheter with heparinized nor- calcium and subsequent flush solution is
mal saline; then continue with the ex- given slowly.
change transfusion.
51

ACTIONS REMARKS

18. Mix the donor blood several times during This is to prevent settling of the donor blood,
the exchange. which would result in the baby receiving
mostly plasma at the end of the exchange.
19. Obtain a blood sample for post-exchange Use the last blood withdrawn from the baby
laboratory studies. for these studies.
• Glucose
• Bilirubin
• Hematocrit
• Platelet count
• Electrolytes
• Calcium
• Coagulation studies
Note: Within 30 minutes after the exchange transfusion has been completed, the bilirubin
level may rebound to a level approximating the pre-exchange level. This is due to equi-
librium being established between extravascular and plasma bilirubin concentrations.
It is unlikely that the bilirubin level will continue to rise that rapidly; however, it is impor-
tant to continue to check the bilirubin every 4 to 6 hours after an exchange transfusion.
A baby with hyperbilirubinemia severe enough to require one exchange transfusion may
require several exchange transfusions.
20. Remove the catheters unless another ex- Babies with evidence of severe hemolysis (eg,
change is anticipated. If a PIV line was a baby who requires an exchange transfusion
used for blood infusion, it may be con- within the first few hours after birth) will
verted into an IV lock until needed. probably require several exchanges. For these
babies, leave the catheters in place for several
hours until the trend of bilirubin rise can be
determined.
Caring for a Baby After an Exchange Transfusion

21. Continue to check the baby’s vital signs
every 15 to 30 minutes for 3 to 4 hours.
22. Monitor glucose hourly for several hours. Hypoglycemia is more likely to occur after,
rather than during, an exchange.
23. Reinstitute phototherapy. Phototherapy should be used after every ex-
change transfusion performed for
hyperbilirubinemia.
24. Continue to observe for complications. See section 9 in Exchange Transfusions in the
Management of Hyperbilirubinemia.
25. Consider withholding several feedings Some clinicians believe that the intestines
while maintaining hydration and blood may have experienced a trauma from altera-
glucose intravenously. tions in perfusion.
52

Date�� Laboratory values
Baby’s name_____________________________________ Pre-exchange
Exchange transfusion #___________________________ Hematocrit _________ Potassium _________
Birth weight_____________________________________ Bilirubin _________ Sodium _________
Birth date_______________________________________ Calcium _________ Chloride _________
Time____________________________________________ Other ______________________________________
Mother’s blood group____________________________ Post-exchange
Baby’s blood group_______________________________ Hematocrit _________ Potassium _________
Coombs_________________________________________ Bilirubin _________ Sodium _________
Blood used: group________________________________ Calcium _________ Chloride _________
Hematocrit______________________________________ Glucose _________ Other _________
Time exchange started____________________________ Coagulation studies __________________________
Time exchange ended_____________________________ Total Volume Withdrawn

From baby __________________________________
Staff conducting the exchange_____________________
Total Volume Given
________________________________________________ To baby ____________________________________
________________________________________________
________________________________________________
53

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54

Unit 3: Continuous Positive Airway
Pressure
Objectives.............................................................................................................................. 56
1. What is continuous positive airway pressure?........................................................... 58
2. How does continuous positive airway pressure work? ............................................ 58
Unit 3: continuous positive airway pressure/ contents

3. Which conditions benefit from continuous positive airway pressure?.................... 58
4. When should a baby receive continuous positive airway pressure?........................ 59
5. How is continuous positive airway pressure given?.................................................. 59
6. How much pressure is used?........................................................................................ 60
7. How is a baby weaned from continuous positive airway pressure?........................ 60
8. How is continuous positive airway pressure given by high-flow
nasal cannula?............................................................................................................... 61
Skill Unit: Delivery of Continuous Positive Airway Pressure............................................ 63
55

Unit 3: continuous positive airway pressure
Objectives
A. How continuous positive airway pressure (CPAP) works
B. When CPAP should and should not be used
C. How CPAP is administered
D. When and how a baby is weaned from CPAP
56

Unit 3 Pretest
1. Which of the following is an appropriate way to provide nutrition to babies requiring
continuous positive airway pressure (CPAP) for acute respiratory disease who have
achieved cardiovascular stability?
A. Intravenous fluids
B. Tube feedings
C. Nipple feedings with a special nipple
D. None of the above
2. For which of the following babies would CPAP be most appropriate?
A. Post-term baby with choanal atresia
B. Preterm baby who is cyanotic because of congenital heart disease
C. Term baby with a pneumothorax
D. Preterm baby with respiratory distress syndrome
3. True False All babies with respiratory disease should receive CPAP.
4. True False High-flow nasal cannula can be used to deliver a consistent level
of CPAP.
5. Which of the following statements best describes the purpose of CPAP?
A. Control the baby’s respiratory rate.
B. Decrease the baby’s metabolic rate.
C. Increase the baby’s arterial oxygen concentration.
D. Decrease the baby’s chance of developing a pneumothorax.
6. Which of the following indicates the general range of pressure used with nasal
CPAP when used in the treatment of respiratory distress syndrome?
A. 2 to 4 cm H2O pressure
B. 4 to 8 cm H2O pressure
C. 10 to 14 cm H2O pressure
D. 14 to 18 cm H2O pressure
7. A baby with respiratory distress syndrome is receiving nasal CPAP at 8 cm H2O
pressure and an inspired oxygen concentration (Fio2) of 60%. Arterial blood gas
results at these settings reveal that Pao2 5 94, Paco2 5 45 mm Hg, and pH 5 7.32.
Which of the following next steps is the most appropriate one to take to adjust the
baby’s CPAP and oxygen therapy?
A. Decrease the Fio2 to 40% to 50%, and decrease the nasal CPAP to 6 cm H2O
pressure.
B. Decrease the Fio2 to 50%, and maintain the nasal CPAP at 8 cm H2O pressure.
C. Maintain the Fio2 of 60%, and discontinue the nasal CPAP.
D. Maintain the Fio2 of 60%, and increase the nasal CPAP to 10 cm H2O pressure.
57

1. What is continuous positive airway pressure?

When babies breathe normally, they pull air into their lungs by contracting their diaphragms,
then exhale by allowing the air to flow passively out of their lungs against the atmospheric
pressure in room air. Continuous positive airway pressure (CPAP) is a technique that allows
babies to exhale against pressure that is slightly higher than atmospheric pressure.
Delivery of CPAP requires the baby’s airway to be connected to a system that can be pressur-
ized. The most common method of connecting the airway to a CPAP system is through nasal
prongs or a nasal mask.
2. How does continuous positive airway pressure work?

Pulmonary compliance is a measure of the stiffness of the lungs, as measured by how much
pressure is required to deliver a certain amount of volume. In lungs with normal compliance,
alveoli stay open during expiration. In lungs with poor compliance (stiff lungs), alveoli tend to
collapse during expiration. When this happens, the baby must re-expand the collapsed alveoli
during each inspiration. Babies with respiratory distress syndrome (RDS) have poor lung
compliance.
Continuous positive airway pressure is not a form of mechanical ventilation. Air and oxy-
gen are not forced into the lungs during inhalation. The baby must continue to breathe
spontaneously.
The pressure provided with CPAP prevents alveoli from collapsing during expiration. The
grunting heard in babies with RDS who are not receiving CPAP is due to the baby’s own effort
to hold open the alveoli by exhaling against a partially closed glottis (upper airway).
Oxygen diffuses across the thin membranes of the alveoli into surrounding capillaries. The
blood flow carries the oxygen from the lung capillaries to the heart and then to blood vessels
throughout the body.
Oxygen cannot enter collapsed alveoli and, therefore, cannot reach the capillaries surrounding
those alveoli. Continuous positive airway pressure improves arterial oxygenation by keeping
alveoli open, thus allowing more places for oxygen to enter the bloodstream.
3. Which conditions benefit from continuous positive airway

pressure?
Continuous positive airway pressure is effective in the treatment of lung disease due to poor
lung compliance. It is most commonly used for babies with RDS.
Continuous positive airway pressure is not useful, and may even be harmful, for
babies with normal lung compliance.
In general, CPAP should not be used for babies with respiratory distress due to factors such as
birth asphyxia, most types of cyanotic congenital heart disease, or pneumothorax.
A few babies with respiratory distress due to factors other than RDS and some small preterm
babies with apnea may also benefit from CPAP. Management of babies with these special con-
ditions is not discussed in this unit.
58

4. When should a baby receive continuous positive airway pressure?

Continuous positive airway pressure is most useful to treat babies who have mild RDS that is
not severe enough to require endotracheal intubation and mechanical ventilation. Continuous
positive airway pressure is also useful for babies who were intubated for surfactant therapy,
then extubated after surfactant was given.
Before CPAP is used, the baby will usually have findings in a chest radiograph compatible with
RDS (low lung volumes, air bronchograms, and a ground-glass appearance) and grunting respi-
rations or chest retractions (or both). However, since preterm babies born at less than approxi-
mately 30 weeks’ gestation almost always have poor lung compliance after birth, many experts
recommend beginning CPAP in such babies, even before they exhibit signs of RDS, to prevent
alveolar collapse and avoid the need for surfactant therapy.
5. How is continuous positive airway pressure given?

The system for delivering CPAP may be a mechanical ventilator set to CPAP mode or a device
that is made solely for delivery of CPAP. It can also be delivered for short periods with a flow-
inflating resuscitation bag or T-piece resuscitator. (See Book I: Maternal and Fetal Evaluation
and Immediate Newborn Care, Unit 5, Resuscitating the Newborn.) Several points are espe-
cially important to remember when setting up and maintaining a CPAP system.
A. Flow rate
There should be a sufficient liter-per-minute flow rate through the tubing to prevent the
baby from re-breathing his or her own exhaled air. As a general guideline, a combined air
and oxygen liter-per-minute flow rate of 8 to 12 L/min should be used.
B. Pressure regulation
The CPAP delivered to a baby is measured in centimeters of water (cm H2O). Pressure
adjustment should not be attempted until the nasal prongs or mask is positioned properly
on the baby. (See Skill Unit: Delivery of Continuous Positive Airway Pressure.)
If using a mechanical ventilator, set it on CPAP mode and adjust the pressure by turning
the appropriate dial on the front of the ventilator. The pressure delivered to the baby then
registers on the front of the ventilator.
C. Safety pop-off valve
Mechanical ventilators and stand-alone CPAP devices have safety valves built in to pre-
vent CPAPs from reaching dangerously high levels. With nasal CPAP, the baby’s mouth
also acts as a natural pop-off valve. It should not be taped shut.
Because babies generally breathe only through their noses, pressure applied through the
nasal prongs will usually not escape from the open mouth until a pressure of approxi-
mately 10 cm H2O or greater is reached. This allows adequate CPAP to be delivered to
the lungs but reduces the chance of the baby inadvertently receiving too much pressure.
Set the high-pressure alarm on the CPAP delivery system approximately 2 cm H2O above
the set CPAP.
D. Stomach vent
Insert a 5F, 6.5 F, or 8F feeding tube into the baby’s stomach through the mouth, gener-
ally using the larger size for larger babies. Tape the tube in place and leave the end open.
When nasal prongs or a mask is used to deliver CPAP, the air/oxygen mixture is forced
primarily into the lungs, but some of the flow may be diverted down the esophagus and
into the stomach. The open feeding tube provides a vent so that the stomach does not
become distended with gas.
59

E. Oxygen concentration
Continuous positive airway pressure is a delivery system for oxygen/air and pressure. The
concentration of oxygen delivered through that system must still be regulated according
to oxygen saturation or arterial blood gas values (or both). In general, a baby should be
started on CPAP with the same inspired oxygen concentration (Fio2) that was previously
being delivered to the baby.
If a baby receiving nasal CPAP is crying vigorously, room air (21% oxygen) may be
inhaled through the mouth. Be sure the baby has been quiet for several minutes before
assessing the response to CPAP. The state of oxygenation is assessed with either oximetry
or arterial blood gas determination (or both). Assessment of ventilation requires arterial
blood gas analysis. If the baby’s oximeter fluctuates considerably as a result of crying and
breathing through the mouth, an oxygen hood plus nasal CPAP may be helpful to main-
tain constant oxygenation.
F. Feedings
Babies receiving CPAP for acute respiratory distress who are not yet stable generally
should not be fed human (breast) milk or formula, either by tube or nipple. Gastrointesti-
nal motility is decreased in sick babies with respiratory disease. This means that a feeding
is likely to stay in the stomach longer.
Because of this, a baby is much more likely to regurgitate some of the milk (or formula)
or gastric juices (or both) and aspirate this fluid. Severe aspiration pneumonia could
result. It is, of course, extremely important to maintain intravenous therapy for any baby
receiving CPAP who is not receiving enteral nutrition.
Tube feedings may be used for some babies who have recovered from severe respiratory
distress but still require CPAP at relatively low pressure.
6. How much pressure is used?

When nasal CPAP is used for RDS, 4 to 6 cm H2O is generally the appropriate starting pres-
sure. Lower pressure than this is usually ineffective.
Sometimes, the pressure may need to be increased to as much as 8 cm H2O. Lower CPAP may
be needed if the baby received surfactant. Make adjustments according to oximetry and arte-
rial blood gas measurement results.
7. How is a baby weaned from continuous positive airway pressure?

As the baby’s respiratory disease improves, decrease the Fio2 according to arterial blood gas
and pulse oximetry values. When the baby requires approximately 35% Fio2, begin decreasing
the CPAP in steps of 1 to 2 cm H2O pressure at a time.
With continued improvement in the baby’s condition, alternate between lowering the Fio2 and
lowering the CPAP. Oxygenation should be assessed constantly by pulse oximetry, and ventila-
tion should be assessed intermittently by arterial blood gas measurements. Discontinue CPAP
when the baby is comfortable on 3 to 4 cm H2O pressure with an oxygen requirement of 25%
to 30% and normal arterial blood gases.
Continue the baby’s oxygen therapy using an oxygen hood. Be prepared to increase the Fio2
slightly for a short while after CPAP is stopped. Adjust the Fio2 according to oximetry or arte-
rial blood oxygen concentrations (or both).
Preterm babies born at less than 30 weeks’ gestation may benefit from remaining on 4 to 5 cm
CPAP, even at low concentrations of oxygen, to prevent atelectasis in the first few weeks of life.
60

8. How is continuous positive airway pressure given by high-flow

nasal cannula?
There is evidence that a nasal cannula, delivering greater than 2 L/min flow directly to a baby’s
nares, will result in the baby receiving some element of CPAP. However, the specific amounts of
CPAP and oxygen delivered by high-flow nasal cannula technique can fluctuate widely and are
unpredictable. Therefore, CPAP by this technique is not recommended for babies with acute
respiratory disease and is not covered in this unit.
61

Unit 3 Posttest
62

SKILL UNIT
Delivery of Continuous Positive Airway Pressure

This skill unit will teach you how to set up and maintain a system for delivery of continuous
positive airway pressure (CPAP) using nasal prongs or masks. Not everyone will be required to
learn how to administer CPAP. However, all staff members should read this skill unit to learn
the equipment and sequence of steps so they can assist with this treatment.
Unit 3: continuous positive airway pressure/ skill unit:

each of the following steps correctly:
delivery of continuous positive airway pressure

1. Collect and assemble equipment.
2. Establish desired oxygen concentration, temperature, and flow rate within the CPAP system.
3. Select prong size; position and secure nasal prongs.
4. Insert orogastric tube; tape in place and leave open.
5. Regulate CPAP.
6. Set high-pressure alarm.
63

Using Continuous Positive Airway Pressure

ACTIONS REMARKS
Preparing the Equipment for Nasal CPAP Delivery

1. Collect the following equipment:
• Nasal prongs or mask The nasal prongs shown in this skill unit
• Apparatus to secure the nasal prongs or are available from www.medtronic.com
mask (search “Argyle CPAP nasal cannula”).
• Oxygen source Some other brands are shown with refer-
• Air source ences later in the skill. Follow the manufac-
• Mechanical ventilator with CPAP mode turer’s directions for use and method of ap-
or stand-alone CPAP device plication to the baby.
• Heater/humidifier
• In-line thermometer (may be incorpo-
rated in the heater/humidifier)
• Frame to support the tubing, if needed
• Orogastric tube
2. Assemble all of the above equipment.
3. Make the following preparations for pro-
viding oxygen and positioning and secur-
ing the prongs: Small size
• Select the appropriate-sized nasal prongs (extra small not shown)
or mask. Follow the manufacturer’s rec-
ommendations that accompany the
brand in your hospital.
Following is a general guideline:
– Extra-small size for babies weighing less
than approximately 1,000 g (2 lb 3 oz)
– Small size for babies weighing between Large size
approximately 1,000 and 1,500 g (2 lb 3
oz–3 lb 5 oz)
– Large size for babies weighing more
than approximately 1,500 g (3 lb 5 oz)
Note: D
ifferent brands of prongs and
masks will vary slightly in shape.
• Check the oxygen concentration flowing
through the system.
• Check the temperature registered on the Be sure this is within the baby’s neutral
in-line thermometer. thermal environment temperature range.
• Adjust the CPAP system flow rate. Usually 8 to 12 L/min flow is adequate.
64

ACTIONS REMARKS
Preparing the Equipment for Nasal CPAP Delivery (continued)

• Occlude the tubing that connects to the Any pressure in the system will be delivered
prongs or mask and check to see that directly to the baby’s lungs as soon as the
the pressure reads zero. tubing is connected to the nasal prongs or
mask. If this pressure is too high, it could
cause a pneumothorax.
Preparing the Baby for Nasal CPAP

Use a commercially available surgical mask Be careful to position the mask over the
that has one string on each of the 4 corners. baby’s occiput. It should not go over the
Place this mask over the back of the baby’s back of the baby’s neck or it will pull the
head. Use the strings to tie the nasal prongs or nasal device in the wrong direction.
mask in place.
When positioned correctly, the upper segment
of the nosepiece should be vertical and at a
right angle to the baby’s face. The prongs
should rest comfortably within the baby’s
nose. If using a nasal mask, the nasal mask
should rest comfortably over the nose without
occluding the nostrils.
Some clinicians have recommended that a
small piece of adhesive skin prep (eg, Tega-
derm) with 2 holes made in it be placed on the
Surgical mask
upper lip and nasal columella (septal skin) to
decrease skin irritation.
There are also other commercially available nasal prongs and masks that are packaged with
an apparatus designed to secure them. Some are illustrated on the next page. Follow specific
manufacturer’s directions for use and method of application to the baby.
65

ACTIONS REMARKS
Preparing the Baby for Nasal CPAP (continued)
Hudson Nasal Prongs CPAP System

www.hudsonrci.com/Products
Medin CPAP System (Search “infant nasal CPAP.”)
www.medin-innovations.com/en
Reproduced with permission from Medical
Innovations GmbH.
CareFusion Infant Flow LP nCPAP System

www.carefusion.com
Courtesy and © Becton, Dickinson and Company. Reproduced with permission.
66

ACTIONS REMARKS
Preparing the Baby for Nasal CPAP (continued)

4 Position either the prongs in the baby’s Nasal prongs should fit fully inside the
nares or the mask over the nose. baby’s nostrils, but not press on the baby’s
nose or upper lip.
Nasal mask should fit comfortably over the
baby’s nose without occluding the nostrils.
5. Position the tubing. • Align the securing device symmetrically
Place the tubing in a neutral position so it around the skull.
does not pull or press against the baby’s • Be sure that the upper segment of the
nose. nosepiece is at a right angle with the
baby’s face.
By evenly distributing the pressure of the
device between the nasal bridge and septum,
the risk of skin breakdown is minimized.
6. Insert an orogastric tube. This is a feeding The purpose of the tube is to act as a vent,
tube that is inserted through the baby’s so the baby’s stomach does not become dis-
mouth instead of the baby’s nose. tended from swallowed air.
Check tube position, tape it in place, and Check the position of the tube by listening
leave it open to air. over the stomach with a stethoscope and in-
jecting a small amount of air through the
tube with a syringe.
It is important to leave the tube un-capped
and periodically check for gastric distention.
Adjusting CPAP
7. Regulate the pressure by adjusting the
CPAP or positive end-expiratory pressure Oxygen
analyzer
knob on the ventilator or delivery device. Peak-INSP.
20
• Generally, pressures of 4 to 6 cm H2O CPAP IMV
10
End-Exp.
are used initially. 20
18
Pressure
16 40 50 60
• Lower or raise the pressure in 1 to 2 cm 14
12
30
20
70
80
10 10 90
H2O increments as the baby’s condition 8

6
Oxygen concentration
Inspiratory
4
indicates (as determined by arterial 2 time Temperature
blood gases and oximetry). Flow Expiratory

time
In the illustration on the right, this knob

is labeled “end-exp” for end-
expiratory pressure.
67

ACTIONS REMARKS
Adjusting CPAP (continued)

8. Set the high-pressure alarm on the ventila-
tor or CPAP delivery mechanism to signal
if the pressure within the system reaches
2 cm H2O above the set CPAP.
Maintaining Nasal CPAP

9. Periodically check For all the items listed in the left column,
check, record, and readjust, if necessary, at
least once every hour.
• In-line temperature Keep this within the baby’s neutral thermal
environment range.
• Oxygen concentration Whenever a baby receives oxygen therapy
with an oxygen hood, nasal CPAP, or endo-
tracheal tube and mechanical ventilator, it is
essential to adjust the inspired oxygen con-
centration according to oximetry and arte-
rial blood gas results, and carefully monitor
the concentration so that sudden changes do
not occur.
• Continuous positive airway pressure Adjust this when the baby is quiet (not
crying). Frequent readjustments may be
necessary.
• Flow rate Flow rate of 8 to 12 L/min is generally
adequate.
• Alignment of nasal prongs or mask Adjust this according to the specific way in
which the prongs or mask you are using are
designed to fit in relation to the baby’s nose.
Often inspect the baby’s face and skin Both the securing device and nasal prongs/
around the prongs/mask and device. mask can cause skin irritation or break-
Adjust the way the device is secured, to down (or both). Prongs/mask can press on
adjust the pressure points caused by secur- the nose or around it, and some of the de-
ing the device to the baby’s face. vices may press/rub against the forehead.
Frequent skin checks, removing the head-
gear (if possible), and alternating between
nasal prongs and mask will help maintain
skin integrity.
10. Remove the CPAP apparatus and use an Preterm babies born at less than 30 weeks’
oxygen hood to deliver the desired concen- gestation may benefit from remaining on
tration of oxygen once the baby requires 4 to 5 cm CPAP, even at low concentrations
less than approximately 35% oxygen and of oxygen, to prevent atelectasis during the
3 to 4 cm H2O pressure. first week of life.
68

Unit 4: A
ssisted Ventilation With
Mechanical Ventilators
Unit 4: assisted ventilation with mechanical ventilators/ contents

Objectives.............................................................................................................................. 70
1. What is mechanical ventilation?.................................................................................. 73
2. Which babies need mechanical ventilation?............................................................... 73
3. When do you start mechanical ventilation?............................................................... 73
4. What kind of mechanical ventilator should be used?.................................................74
5. How do you set up a mechanical ventilator? ............................................................. 75
6. What initial settings are used?..................................................................................... 76
7. How do you adjust the ventilator after the baby has been connected?.................. 78
8. What are suggested ventilator adjustments for various clinical findings?.............. 79
9. What can go wrong?..................................................................................................... 80
10. What else should you do for a baby receiving mechanical ventilation?.................. 81
Tables
Table 4.1. Suggested Initial Settings for Mechanical Ventilation....................................... 77
Table 4.2. Suggested Changes to Ventilator Setting.......................................................... 78
Table 4.3. Goal Arterial Blood Gas Parameters................................................................ 78
Skill Unit: Endotracheal Tubes........................................................................................... 85
69

Unit 4: assisted ventilation with mechanical ventilators
Objectives
A. The principles of mechanical ventilation
B. Which babies may require mechanical ventilation
C. What criteria are used for starting mechanical ventilation
D. How to set up a ventilator for babies with various types of respiratory problems
E. How to adjust ventilator settings
This unit is intended to teach only indications for, and initiation of, mechanical ven-
tilation, such as what might be needed for a sick baby prior to neonatal transport. It
will not address long-term management of ventilated babies or weaning of babies
from ventilators. Babies requiring mechanical ventilation for any length of time
should be treated in intensive care nurseries, where different philosophies about
ventilator management may be practiced.
70

Unit 4 Pretest
1. Which of the following measurements cannot be adjusted independently on most
infant ventilators?
A. Peak airway pressure
B. End-expiratory pressure
C. Inspiratory time
D. Inspired oxygen concentration
E. Expiratory resistance
2. Which of the following measurements is least reliable for determining the need for
mechanical ventilation?
A. Capillary Pco2
B. Capillary Po2
C. Arterial pH
D. Arterial Pco2
E. Arterial Po2
3. Which of the following statements is correct when determining ventilator settings
for a baby with respiratory distress syndrome compared to a baby with normal find-
ings in lungs?
A. End-expiratory pressure should be higher.
B. Inspiratory time should be shorter.
C. Expiratory time should be longer.
D. Peak inspiratory pressure should be lower.
4. In which of the following cases is mechanical ventilation most indicated?
A. A 3,500-g (7 lb 11 oz) baby with congenital pneumonia who is breathing 50%
oxygen and has a Pao2 of 60, Paco2 of 48, and pH of 7.28
B. A 1,500-g (3 lb 5 oz) baby with respiratory distress syndrome who is breathing
80% oxygen and has a Pao2 of 45, Paco2 of 65, and pH of 7.28
C. A 1,000-g (2 lb 3 oz) baby with no lung disease who has an apneic spell that
responds to tactile stimulation
D. A 3,000-g (6 lb 10 oz) baby who had severe perinatal compromise and has a Pao2
of 70, Paco2 of 25, and pH of 7.20 while breathing 21% oxygen
5. Which of the following statements is correct when determining ventilator settings
for a term baby with meconium aspiration compared to a preterm baby with respira-
tory distress syndrome?
A. Inspiratory time should be longer.
B. Expiratory time should be shorter.
C. End-expiratory pressure should be higher.
D. Rate should be faster.
71

6. Which of the following measurements is least likely to suggest a blocked endotra-

cheal tube?
A. Poor chest movement
B. High Paco2
C. High pH
D. Low Pao2
72

1. What is mechanical ventilation?

Mechanical ventilation assists, and sometimes controls, the breathing of babies who cannot
move enough air with spontaneous respiration. An oxygen hood increases the concentration of
oxygen a baby breathes. Continuous positive airway pressure (CPAP) prevents the alveoli from
collapsing during exhalation, but only a mechanical ventilator provides artificial ventilation. The
baby must be intubated with an endotracheal tube for treatment with a mechanical ventilator.
Mechanical ventilators work by forcing a humidified oxygen/air gas mixture into an intubated
baby’s lungs at a preset flow, maximum pressure, and time of inspiration. At the end of the
inspiration time, the flow is stopped automatically and the gas is allowed to escape either by
passive or active exhalation with a preset time (expiratory time).
2. Which babies need mechanical ventilation?

Mechanical ventilation is required for babies who cannot move enough gas in and out of their
lungs to achieve adequate oxygenation of the blood or adequate removal of carbon dioxide
from the blood (or both). Most of these babies will be in respiratory distress. (See Book III:
Neonatal Care, Unit 2, Respiratory Distress.)
Babies may require mechanical ventilation because of primary lung disease, such as respira-
tory distress syndrome (RDS), or because of respiratory depression from generalized illness, a
congenital malformation, birth injury, or extreme prematurity. Examples include babies with
severe recurrent apnea, diaphragmatic paralysis from birth injury, or hypoventilation from sep-
sis, brain hemorrhage, or some other central nervous system insult. Extremely preterm babies
have weak respiratory musculature and may need mechanical ventilation, even if they do not
have significant lung disease.
3. When do you start mechanical ventilation?

Mechanical ventilation is initiated when a baby demonstrates respiratory failure. Respiratory
failure is defined as inadequate spontaneous ventilation, even though the baby may be mak-
ing considerable respiratory efforts. Arterial blood gases are the principal way to decide when
respiratory failure occurs. Any one of the following factors indicates mechanical ventilation is
needed:
A. Very high or rapidly rising Pco2 and low pH
Babies will normally increase their breathing rate when blood carbon dioxide (Pco2)
levels begin to rise. This increased respiratory rate results in lowering Pco2 to normal.
Therefore, if Pco2 is high, the baby is not moving enough air in and out of functional
lung tissue.
As Pco2 rises, pH falls. Consider mechanical ventilation when
• Pco2 is consistently greater than 60 mm Hg.
• Pco2 is consistently greater than 45 mm Hg and pH is less than 7.25.
B. Low Pao2 despite appropriate oxygen and CPAP therapy
If lung disease becomes severe enough, the baby’s own respiratory efforts may not be suf-
ficient to provide adequate oxygenation. Consider mechanical ventilation if Pao2 is less
than 45 mm Hg or saturations are consistently less than 85% with baby breathing 70%
to 80% inspired oxygen.
Some experts believe that a baby with worsening RDS can effectively be treated by being
intubated, given surfactant, and then extubated, and started on nasal CPAP.
73

C. Extremely preterm baby

Although it is controversial, some experts advise electively intubating and mechanically
ventilating extremely low-birth-weight babies (,1,000 g [2 lb 3 oz] birth weight) at birth
or extremely low-gestational-age babies (,26 weeks’ gestation), rather than waiting for
them to develop respiratory failure. Early, elective intubation is done to avoid acidosis
and other problems likely to develop with respiratory failure. These tiny babies are also
candidates for surfactant therapy.
Other experts, however, believe that mechanical ventilation can be avoided by early use
of nasal CPAP to establish functional residual capacity. Several studies have demon-
strated that early use of CPAP does not increase adverse outcomes compared to elective
intubation in the delivery room.
D. Surfactant therapy
Intubation is required for surfactant administration. (See Unit 5, Surfactant Therapy,
in this book.) Many of these babies will require mechanical ventilation for a time after
surfactant is given.
E. Absence of breathing (apnea)
If a baby has apneic spells requiring repeated stimulation or bag-and-mask assistance,
mechanical ventilation may be required.
4. What kind of mechanical ventilator should be used?

Many different brands of mechanical ventilators are available. Some deliver a specific volume
of gas, whereas others deliver a specific gas flow and pressure for a specific time. This unit will
discuss only the more common pressure/flow/time-regulated ventilators. Be sure your ventilator
has the following qualities:
A. Designed for babies
Ventilators designed for adults usually do not have the fine adjustment capabilities
required for babies.
B. Infant tubing circuit
Babies’ lungs require only small volumes of gas. If the tubing that connects the ventila-
tor to the endotracheal tube contains a large volume of gas, this gas will be compressed
with each ventilator “breath.” This causes the size of the breath that enters the endotra-
cheal tube to be far smaller than the infant-sized breath initially produced by the ven-
tilator. Therefore, the tubing should contain a small volume (diameter ,2 cm) and be
non-distensible.
C. Heated humidifier with thermostat control in the circuit
Ventilator gas should be heated to between 34.0°C and 36.0°C (93.2°F and 96.8°F) and
humidified to greater than 90%. This prevents lung injury secondary to cold air and
inhibits excessive evaporative losses from the respiratory system with dry air.
D. Oxygen concentration adjustable from 21% to 100%
74

Self-test
A1. Most infant ventilators work by
A. Delivering a preset volume into the lungs
B. Delivering a preset pressure for a preset time
A2. List 3 examples of babies who may require mechanical ventilation because of poor respiratory
muscle function.
A3. Respiratory failure requiring mechanical ventilation is indicated by

High _____________________________________________________________________________________________
Low _____________________________________________________________________________________________
Low _____________________________________________________________________________________________
A4. Infant ventilator tubing circuits should have the following characteristics:
A5. True False Respiratory failure refers only to babies who stop breathing completely.
A6. List 2 indications for mechanical ventilation other than respiratory failure or severe apnea.
Check your answers with the list near the end of this unit. Correct any incorrect answers and review
5. How do you set up a mechanical ventilator?

The objective of mechanical ventilation is simple: to move air and oxygen sufficiently to nor-
malize arterial blood gases. The method of achieving this will depend on the type of disease
being treated. The following ventilator settings will need to be adjusted:
• Peak inspiratory pressure (PIP): This is the maximum pressure that the ventilator reaches to
force gas into the lungs. If the pressure is too low, gas movement will be inadequate; if it is
too high, the lungs can be damaged and a pneumothorax can result.
• Positive end-expiratory pressure (PEEP): This is the pressure at the end of expiration and is
identical to CPAP. If the expiratory pressure is too low, the alveoli may collapse (in babies
with poor lung compliance); if it is too high, expiration will be restricted and gas movement
will be inadequate.
• Inspiratory time (TI): This is the time during which the ventilator delivers its inflation pres-
sure. If TI is too short, the PIP will not reach the alveoli and gas movement and lung infla-
tion will be inadequate; if TI is too long, exhalation will be inadequate. Prolonged TI will
also restrict lung blood flow due to compression of lung blood vessels by distended alveoli.
• Expiratory time (TE): This is the time during which the baby passively exhales. If TE is too
short, expiration will be insufficient and gas will be trapped in the lungs, possibly causing
lung damage and a pneumothorax. With most ventilators, TE cannot be set independently
but is determined by TI and the rate. Expiratory time is calculated with the following
formula:
TE 5 (60/rate) 2 TI
75

For example, a ventilator for a baby with RDS is set for a TI of 0.3 seconds and rate of 45.
TE 5 (60/45) 2 0.3
TE 5 11∕3 2 0.3
TE 5 1.0 seconds
• Rate: The rate or breaths per minute is determined by the lengths of TE and TI. Most venti-
lators have a separate knob that allows adjustment of the rate. This knob works by chang-
ing the length of TE. Thus, you set only the TI and rate. If the rate is too low or very high,
gas movement will be inadequate. If the rate is slightly high, gas movement will be excessive
and Paco2 will be too low.
• Inspired oxygen concentration (Fio2): This should be adjusted from 21% to 100% as deter-
mined by oxygen saturation or arterial blood gas values (or both), as outlined in Book III:
Neonatal Care, Unit 1, Oxygen.
• Flow rate: This is the speed at which the ventilator delivers a breath. If flow rate is too low,
it may not be possible for the ventilator to reach the desired PIP; if too high, the lungs may
be damaged. For most babies, regardless of illness, approximately 8 L/min will be adequate.
If very high PIP or very fast ventilator rates are required, a higher flow rate may be neces-
sary. Many of the newer ventilators do not have a separate setting for flow rate, because the
flow rate adjusts electronically depending on the ventilation pattern selected.
• Mean airway pressure (MAP): Mean airway pressure is the average pressure in the airway
throughout the respiratory cycle. It is a function of PIP, PEEP, TI, rate, and flow rate set-
tings. It is not independently adjustable on most ventilators, but will change when any one
of the other settings is increased or decreased. The MAP value is displayed on most infant
ventilators.
Along with Fio2, MAP is important in determining a baby’s oxygenation. In addition to
Fio2, adjustments in MAP may also be used to achieve an acceptable Pao2.
6. What initial settings are used?

If you decide that mechanical ventilation is indicated, you should first stabilize the baby by
assisting ventilation with bag or T-piece resuscitator and endotracheal tube breathing. During
this time, the endotracheal tube should be secured in place and the ventilator, set up at the
bedside.
Set the PIP, PEEP, TI, rate, flow rate, and Fio2 before the baby is connected. Test these settings
by occluding the opening of the connector, which will later be attached to the baby’s endotra-
cheal tube. Finer adjustments will be required after the baby is connected to the ventilator.
If a manometer is included in your bag-breathing system (see Book I: Maternal and Fetal
Evaluation and Immediate Newborn Care, Unit 5, Resuscitating the Newborn, Skill Unit:
Free-Flow Oxygen and Positive-Pressure Ventilation), the ventilator PIP and rate may be set
to match the most effective bag ventilation; therefore, note the maximum pressure and rate
at which you are bag breathing for the baby or match the settings being used with the T-piece
resuscitator.
It is also important that you consider the disease process when deciding on initial set-
tings (Table 4.1). Following are relative settings for various conditions as well as specific
initial settings.
76

Relative Ventilator Settings for Various Lung Conditions
Normal Findings in Lungs

(eg, apnea with no lung disease)
PIP Low
PEEP Low
TI Short
TE Long
Rate Slow
Fio2 Usually 21% (room air)
Airway Disease Alveolar Disease

(eg, meconium aspiration) (eg, RDS or pneumonia)
PIP High PIP High
PEEP Low PEEP High
TI Short TI Long (but not longer than TE)
TE Long TE Short
Rate Relatively fast Rate Relatively slow
Fio2 Equal to Fio2 before Fio2 Equal to Fio2 before
mechanical ventilation and mechanical ventilation and
adjust to oxygen saturation as adjust to oxygen saturation as
measured by pulse oximetry measured by pulse oximetry
Table 4.1. Suggested Initial Settings for Mechanical Ventilation

Disease State PIP PEEP TI Rate Fio2 Flowa
(cm H2O) (cm H2O) (sec) (breaths/min) (%) (L/min)
Alveolar 25 4–5 0.4 40 b
8–10
(eg, respiratory distress
syndrome, pneumonia)
Airway 18–22 3–4 0.3–0.4 60 b
8–10
(eg, aspiration)
Normal findings in lungs 12 2 0.3 30 b
8–10
(eg, apnea)
Abbreviations: Fio2, inspired oxygen concentration; PEEP, positive end-expiratory pressure; PIP, peak inspiratory pres-
sure; TI, inspiratory time.
a
Determined automatically by most new ventilators.
b
Individualize Fio2 depending on Fio2 before mechanical ventilation and results of pulse oximetry or arterial blood
gas determinations (or both).
Some babies will have a combination of problems and require settings between 2 categories.
For example, an extremely low-birth-weight baby (,1,000 g [2 lb 3 oz]) may have only mild
RDS but require mechanical ventilation because of very weak respiratory muscles. Although
the baby has RDS, much lower peak pressure and PEEP will probably be required than if the
baby were bigger or had more severe lung disease (or both). Many experts are advising short TI
and rapid rates to use lower PIP and perhaps cause less trauma to the lungs of extremely low-
birth-weight babies.
77

7. How do you adjust the ventilator after the baby has been
connected?
After the ventilator has been connected to the baby, the peak pressure and PEEP may be
slightly lower than you had set them earlier. This is expected because the baby’s lungs have
been added to the system. Before changing any settings, evaluate chest movement, skin color,
oximetry, and blood gases if available.
The following table suggests several possible actions for various abnormal findings (Table 4.2).
Which action you choose will depend on the initial settings of the ventilator, the disease you
are treating, and the severity of disease.
Any ventilator change you make to correct one variable (such as Pao2) is also likely to affect
another variable (such as Paco2). Use continuous pulse oximetry and obtain an arterial blood
gas approximately 20 to 30 minutes after any significant change in ventilator setting (Table
4.3). It is generally recommended to make only one ventilator change at a time. Making more
than one change simultaneously is likely to confuse what it was that caused the response in the
baby’s ventilation.
Table 4.2. Suggested Changes to Ventilator

Setting
Pao2 Paco2 PIP PEEP Rate
Low Low ↑
Low High ↑
High Low ↓
High High ↓
Normal High ↑
Normal Low ↓
Table 4.3. Goal Arterial Blood Gas Parametersa

Parameter Preterm Baby Term Infant
pH 7.25–7.35 7.30–7.40
Paco2 (mm Hg) 45–55 40–50
Pao2 (mm Hg) 45–55 50–70
a
In venous and capillary blood gas values, Pao2 is not reliable, pH is typi-
cally higher, and Paco2 is typically higher. However, in babies with poor
perfusion to the upper or lower extremities, neither venous nor capillary
blood gas values should be used.
78

8. What are suggested ventilator adjustments for various clinical

findings?
If the baby’s condition changes, assess the baby and the functioning of the ventilator.
A. To check the ventilator, consider

• Is the proper Fio2 being delivered?
• Is the tubing loose or disconnected?
• Does the pressure reach the preset PIP with each breath?
• Does the pressure fall to the preset PEEP between each breath?
• Have the TI, TE, or rate settings been unintentionally changed?
B. To check the baby, consider
Chest Movement • Rises and Falls With Each Breath

No change
• Moves Little to Not at All
– Check endotracheal tube placement.
– Check for blocked endotracheal tube (suction).
– Increase PIP.
– Decrease PEEP.
– Increase TI.
• Moves Too Much
– Decrease PIP.
– Decrease TI.
Skin Color • Pink and Well Perfused

No change
• Blue
– Increase Fio2 (guided by oximetry).
– If sudden cyanosis, check for pneumothorax.
– Increase MAP.
• Pale and Mottled
– Decrease PEEP.
– Increase TE.
– Check for pneumothorax.
– Consider nonrespiratory etiology.
79

Arterial Blood Gases • Pao2, Paco2, and pH Normal

No change
• Pao2 Low (,40 mm Hg)
– Increase Fio2 (guided by pulse oximetry).
– Increase MAP. (See note below.)
• Pao2 High (.80 mm Hg)
– Decrease Fio2.
– Decrease MAP. (See note below.)
• Paco2 High (.50 mm Hg) or pH Low (,7.25) (or Both)
– If sudden change, check for pneumothorax.
– Increase PIP.
– Decrease PEEP.
– Increase rate.
– Decrease TI.
• Paco2 Low (,35 mm Hg) or pH High (.7.45) (or Both)
– Decrease PIP.
– Decrease rate.
9. What can go wrong?

If requirement for mechanical ventilation is anticipated for longer than a few hours, the baby
should be transferred to an intensive care nursery.
Mechanical ventilation of babies is an invasive, potentially dangerous therapy that

requires constant attendance by an experienced team.
Possible complications
• Air leaks: Pneumothorax should be suspected immediately if the baby’s condition suddenly
deteriorates. Insertion of a chest tube may be lifesaving. Air leaks into the lung tissue, peri-
cardium, or mediastinum can also occur and are detectable on chest radiograph.
• Blocked or displaced endotracheal tube: If the endotracheal tube becomes dislodged from
the trachea or blocked with mucus, the ventilator will continue to cycle, but the baby’s vital
signs will deteriorate. Suction the tube and attempt to ventilate the baby with a resuscita-
tion bag connected to the endotracheal tube. Check breath sounds and chest movements.
Check the return of CO2 with a colorimetric CO2 detector. Check the depth of insertion
of the endotracheal tube using the numerical markings on the side of the tube. It may have
inadvertently moved out of appropriate position. If there is no improvement in the baby’s
condition, remove the endotracheal tube and assist the baby’s ventilation with bag and
mask until a new endotracheal tube can be inserted.
Note: If
a ventilator adjustment is being made in response to an unacceptable Paco2, but with a normal Pao2, keep
the MAP constant by adjusting one of the other settings that also affects MAP. (See section 5.) If the Pao2 is
too low or too high, adjust the Fio2 first and then consider adjusting the MAP, usually by adjusting the PEEP
or PIP.
80

• Endotracheal tube slips in too far: If the tube slips in too far, it may enter the airway of one
lung and block air entry to the other lung. In this case, breath sounds will be unequal when
you listen with a stethoscope over the right and left lateral chest. In addition, one side of
the chest may rise more than the other. Check the depth of insertion of the endotracheal
tube. If the tube is in too deep, pull the tube back slightly as you listen with a stethoscope
for improved breath sounds.
• Disconnected or malfunctioning ventilator: Most ventilators are equipped with alarms that
will sound if the tubing becomes disconnected. Even without an alarm, a tubing or power
disconnection can be detected because the airway pressure gauge will not rise normally
with each breath.
If a ventilator malfunctions, don’t panic! Simply connect a resuscitation bag or

T-piece resuscitator to the endotracheal tube and assist the baby’s ventilation until
the problem can be located and corrected.
10. What else should you do for a baby receiving mechanical

ventilation?
All babies receiving mechanical ventilation should have continuous electronic cardiac and pulse
oximetry monitoring and experienced staff in constant attendance. Complete resuscitation
equipment should be at the bedside.
Remember that continued monitoring for other risk factors (eg, hypoglycemia, hypother-
mia, etc) is essential to the baby’s total care. These more routine activities should not get lost
because a baby is receiving sophisticated respiratory support.
81

Self-test
B1. List 5 controls that require adjustment on most infant ventilators.
B2. Circle the appropriate ventilator setting for each of the 3 lung conditions.
Alveolar Disease Airway Disease Normal Findings
in Lungs
Peak inspiratory pressure High/Low High/Low High/Low
Positive end-expiratory pressure High/Low High/Low High/Low
Inspiratory time Long/Short Long/Short Long/Short
Expiratory time Long/Short Long/Short Long/Short
Rate Slow/Fast Slow/Fast Slow/Fast
B3. List 3 observations or findings to consider before adjusting a ventilator.
B4. List 4 common complications of mechanical ventilation.
Check your answers with the list on the next page. Correct any incorrect answers and review the
appropriate section in the unit.
82

Self-test Answers
A1. B. Delivering a preset pressure for a preset time
A2. Any 3 of the following examples:
• Severe generalized illness
• Birth injury causing diaphragmatic paralysis
• Hypoventilation from sepsis, brain hemorrhage, or some other central nervous system insult
• Extreme prematurity
A3. Paco2
Pao2
pH
A4. Contain small volume of gas (tubing diameter #2 cm).
Be non-distensible.
A5. False. Reason: Babies who have inadequate ventilation despite spontaneous respirations are also in
respiratory failure.
A6. Extreme prematurity (birth weight less than approximately 1,000 g [2 lb 3 oz])
Surfactant therapy
B1. Peak inspiratory pressure
Positive end-expiratory pressure
Inspiratory time
Rate
Oxygen concentration
B2. Alveolar Disease Airway Disease Normal Findings in Lungs
Peak inspiratory pressure High High Low
Positive end-expiratory pressure High Low Low
Inspiratory time Long Short Short
Expiratory time Short Long Long
Rate Slow Fast Slow
B3. Any 3 of the following observations:
• Chest movement
• Skin color
• Breath sounds that are equal or unequal
• Arterial blood gases
• Percent of oxygen saturation
B4. Air leaks, such as a pneumothorax
Blocked or displaced endotracheal tube
Endotracheal tube that slips in too far
Disconnected or malfunctioning ventilator
83

Unit 4 Posttest
84

Unit 4: assisted ventilation with mechanical ventilators/ skill unit: endotracheal tubes
SKILL UNIT
Endotracheal Tubes
This skill unit will teach you how to secure an endotracheal tube and how to suction it. Both
of the skills described in this unit are to be carried out by teams of 2.
Not everyone will be required to learn and practice these skills; however, all staff members
should read this unit and attend a skill session to learn the equipment and sequence of steps so
they can assist with these skills.
correctly each of the following steps:
Securing an Endotracheal Tube
Tape Method (used for relatively short duration intubations)
1. Cut and split 2 strips of adhesive tape.
2. Hold the endotracheal tube at the proper level.
3. Place one strip of tape on the manikin’s upper lip and wrap the loose end around the tube.
4. Tape the other strip in the reverse direction and wrap it around the tube.
5. Listen to the “baby” to recheck correct tube placement.
Commercial Stabilizer Method (for intubations of longer duration) (Use the brand stocked
in your hospital.)
1. Select the appropriate-sized stabilizer for the tube.
2. Hold the endotracheal tube at the proper level.
3. Secure the stabilizer to the manikin’s face.
4. Properly secure the tube into the stabilizer and lock in place.
5. Listen to the baby to recheck correct tube placement.
Suctioning an Endotracheal Tube
1. Collect the appropriate equipment and suction catheters for the tube and baby to be
suctioned.
2. Adjust the suction pressure.
3. Determine the length of suction catheter to be inserted.
4. If not using an in-line device, bag breathe for the baby using the appropriate pressure and
rate, before and after suctioning.
5. Suction the baby’s endotracheal tube.
6. Monitor the baby’s response and oxygen saturation; adjust inspired oxygen concentration as
necessary.
7. Suction the baby’s mouth.
8. Readjust the baby’s inspired oxygen concentration, if it had been increased.
85

Managing Endotracheal Tubes

In Book I: Maternal and Fetal Evaluation and Immediate Newborn Care, Unit 5, Resuscitating
the Newborn, you learned how to insert and check for proper placement of an endotracheal
tube. You also learned how to secure the tube in place with adhesive tape. If you anticipate that
the endotracheal tube will be required for longer than several hours (ie, for a baby requiring
mechanical ventilation), the tube should be fixed in place more securely than with tape alone.
Be sure the baby is being adequately ventilated and that an assistant is holding the tube in
place while it is being secured.
Securing and suctioning an endotracheal tube are 2-person procedures.
Two different methods for long-term stabilization of an endotracheal tube are described. The
first method uses materials generally available in most hospitals. The second method requires
the purchase of a commercial stabilizer.
ACTIONS REMARKS
Securing an Endotracheal Tube Without a Commercial Stabilizer

1. After inserting the endotracheal tube (see Continue to ventilate the baby while some-
Book I: Maternal and Fetal Evaluation and one else secures the tube in place. Hold the
Immediate Newborn Care, Unit 5, Resusci- tube firmly against the palate with your in-
tating the Newborn), confirm correct dex finger until it is secure.
placement by attaching a CO2 detector
looking for a color change with each exha-
lation. Also, listen over the chest for equal
breath sounds on each side and over the
stomach for absence of breath sounds.
CO2 detector
Reproduced with permission from American Academy of Pediatrics,

American Heart Association. Weiner GM, ed. Textbook of Neonatal
Resuscitation. 7th ed. Elk Grove Village, IL: American Academy of
Pediatrics; 2016.
86

ACTIONS REMARKS
Securing an Endotracheal Tube Without a Commercial Stabilizer (continued)

2. Thoroughly dry the skin around the baby’s
mouth.
3. Secure the tube in place with tape. Some hospitals prefer to use a commercially
available endotracheal tube stabilizer (see
next section).
• Place a strip of clear adhesive dressing
between the baby’s nose and upper lip.
• Cut 2 pieces of ½-in (1-cm) adhesive
tape 4 in (10 cm) long.
• Split each piece for half its length.
• Stick the unsplit section of the tape and
one tab across the baby’s upper lip (on
top of the clear adhesive dressing).
• Wrap the other tab in a spiral around
the endotracheal tube.
• Place second tape in reverse direction.
• Listen with a stethoscope for breath

sounds over both sides of the chest, and
over the stomach. You should hear dis-
tinct breath sounds over both lungs and
no, or soft, distant sounds over the
stomach. Listen again after taping to be
sure the tube has not been displaced.
Reproduced with permission from American Academy of Pediatrics,

American Heart Association. Weiner GM, ed. Textbook of Neonatal
Resuscitation. 7th ed. Elk Grove Village, IL: American Academy of
Pediatrics; 2016.
87

ACTIONS REMARKS
Securing an Endotracheal Tube With a Commercial Stabilizer

1. Be sure the stabilizer fits the brand of en- This skill describes 2 brands of stabilizers.
dotracheal tube being used. Others are available. Follow the directions
supplied by the manufacturer of the brand
used in your hospital.
Portex Neonatal RSP Endotracheal Tube Stabilizer
2. Collect the necessary equipment and supplies.
• Endotracheal tube holder of the correct Holders are manufactured to fit tubes of
size to match the endotracheal tube be- various sizes (2.5 mm, 3.0 mm, 3.5 mm,
ing used 4.0 mm).
• Slip-lock (packaged with holder)
3. If the tube was previously taped, remove Note the markings on the tube at the level
the tape and ask an assistant to hold the of the baby’s lip. Be sure the tube is held at
tube in place. this position.
4. Peel off the protective backing from the The cylinder should be located over one
holder and stick the holder to the baby’s corner of the mouth, while the tube is tem-
face with the cylinder located over either porarily held on the other side of the mouth
side of the mouth. (endotracheal tube not shown in illustration).
5. Slide the endotracheal tube to the other The height of the cylinder is slightly less
side of the baby’s mouth and slip it into than 2 cm; therefore, the top of the cylinder
the groove of the cylinder. Be sure to main- may now be used as a reference point for
tain the tube at its original insertion depth the markings on the tube (previous marking
(ie, take care not to push the tube in or at the lip plus 2 cm).
pull it out slightly as you slide it from one
corner of the mouth to the other).
88

ACTIONS REMARKS
Securing an Endotracheal Tube With a Commercial Stabilizer (continued)

6. Place the slip-lock around the tube, down
over the cylinder, and then turn it to lock
in place.
The slip-lock has a slot that allows it to be
placed over the tube from the side. Slip-lock
Be careful not to position the slip-lock up-
side down. The side with the smaller diam- Cylinder
eter should be toward the baby. If posi-
tioned correctly, the writing imprinted on
the top of the slip-lock will be visible.
Holder
Endotracheal tube
NeoBar Endotracheal Tube Stabilizer

2. Collect the necessary equipment and The following instructions are a summary of
supplies. the instructions supplied by the manufac-
• Endotracheal tube holder of the correct turer. Be sure to read the manufacturer’s full
size to match the endotracheal tube be- instructions before use.
ing used
• Measuring tape that comes with the
NeoBar
3. Using the NeoBar tape, measure from the • Use the measuring tape that comes with
midline at nasal septum to the opening of the NeoBar to determine which size bar
the ear canal. to use.
• The corresponding color on the tape that
falls over the opening of the ear canal cor-
responds to the NeoBar size for the baby.
If size borders 2 colors, use the larger size.
89

ACTIONS REMARKS
Securing an Endotracheal Tube With a Commercial Stabilizer (continued)

4. Prepare the hydrocolloid tabs by warming
them. Hold the tabs either in your hands
for 60 seconds or under radiant heat.
5. Pull off the covering on the tabs and se-
cure the tabs onto the bony prominence in
front of both ears (the far side of the
cheek).
6. Position the NeoBar across the center of
the mouth between the upper and lower
lip without touching the lips.
7. Tape the endotracheal tube to the NeoBar.
Begin by wrapping ½-in (1-cm) cloth tape Change the NeoBar every 5 to 7 days, or
around the arch of the NeoBar and then when clinically indicated. Slowly peel back
bring the endotracheal tube to the plat- tabs as you saturate with water or saline.
form (center arch) and wrap the tape For emergency removal, carefully cut the
around both. thin portion of the NeoBar with blunt scis-
sors, at the junction of the bar and tab.
Checking/Changing Endotracheal Tube Position

1. Obtain a portable chest radiograph to The tube tip should be visible by radiograph
check for tube placement. just below the level of the clavicles and 1 to
2 cm above the carina (point where the
mainstem bronchi branch from the trachea).
2. Adjust the tube position (farther out or in),
if necessary.
• Tape method: Remove the adhesive tape.
Hold the tube in place as it is being re-
taped in the new position.
• Commercial device: Follow instructions • Portex RSP: The tube may be adjusted by
appropriate for each device. simply unlocking the slip-lock, sliding the
tube the desired distance, and then relock-
ing the slip-lock. If the endotracheal tube
needs to be replaced, you will usually
need to remove and replace the stabilizer
too.
• NeoBar: Un-tape the tube, adjust,
and re-tape.
90

ACTIONS REMARKS
Checking/Changing Endotracheal Tube Position (continued)

3. Check to be sure the tube has not slipped
since the radiograph was obtained.
• Watch to see if the chest is moving
symmetrically.
• Listen to both sides of the chest for
equal breath sounds and over the stom-
ach to be sure the tube is not in the
esophagus.
• If in doubt, insert a CO2 detector or
check position with a laryngoscope and
obtain another chest radiograph.
Suctioning an Endotracheal Tube

1. Collect the necessary equipment and
supplies.
• Appropriate-sized suction catheter Suction catheter sizes for various-sized
• Sterile gloves endotracheal tubes:
• ½-mL sterile saline Endotracheal Tube Suction
• Suction source and tubing Inner Diameter Catheter Size
• Resuscitation bag with pressure 2.5 mm 5F or 6F
manometer 3.0 mm 5F or 6F
3.5 mm 6F or 8F
4.0 mm 6F, 8F, or 10F
If secretions are thin, select a small catheter
to decrease the chances of collapsing the
lung during suctioning. If secretions are
thick, select the largest possible catheter.
2. The endotracheal tube may need to be suc- An endotracheal tube bypasses the baby’s
tioned periodically to be sure it is clear for normal mechanism to clear the lungs of mu-
maximum airflow. cus and debris.
Endotracheal tube suctioning should not Listen to the chest with a stethoscope. If
be done routinely, but only as needed to coarse rhonchi, rather than clear breath
clear secretions. sounds, are heard, or the baby has increased
distress or an increasing oxygen require-
ment, the baby may need suctioning.
3. Monitor oximetry and adjust inspired oxy- Suctioning is stressful for a baby and can
gen concentration as necessary. cause the blood oxygen concentration to fall
temporarily. It is important for you to mini-
mize the degree and duration of that drop.
4. Completely occlude the suction source.
Adjust the vacuum to approximately 60 to
80 mm Hg.
91

ACTIONS REMARKS
Suctioning an Endotracheal Tube (continued)

5. Connect the hub of an appropriate-sized Leave the rest of the catheter within the
catheter to the tubing from the suction sterile package.
source.
6. Put on a pair of sterile gloves and remove Suctioning should be performed as a sterile
the suction catheter from its package. procedure.
7. Estimate the length of the endotracheal Except in unusual circumstances, the pur-
tube and hold the suction catheter that dis- pose of the suction catheter is only to clear
tance from the tip of the catheter. the endotracheal tube itself of mucus. If the
catheter is repeatedly permitted to extend
significantly beyond the tip of the endotra-
cheal tube, the tracheal mucosa can be dam-
aged.
Some catheters are made with centimeter
marks printed on the catheter. If the endo-
tracheal tube also has centimeter marks, the
depth of suctioning can be judged by match-
ing the catheter and endotracheal tube
markings.
8. Have an assistant disconnect the endotra- Suctioning is a 2-person procedure.
cheal tube from the bag or ventilator.
9. Quickly insert the suction catheter only to Stimulation from the catheter tip will proba-
the measured distance. Begin suctioning by bly cause the baby to cough. Avoid excessive
occluding the thumbhole on the catheter stimulation.
and continue suctioning as the catheter is If the heart rate falls significantly, the
withdrawn. baby turns blue, or oxygenation drops
dramatically, stop the procedure and assist
ventilation with a resuscitation bag and
appropriate oxygen.
10. Do not insert the catheter too far. The trachea can be damaged or even perfo-
rated by suctioning that is too vigorous.
92

ACTIONS REMARKS
Suctioning an Endotracheal Tube (continued)

11. The assistant should connect the resuscita- Suctioning may cause some collapse of lung
tion bag and deliver several breaths at segments, which need to be reinflated after
slightly higher pressures than the baby was the procedure.
receiving prior to suctioning.
12. If significant amounts of material (mucus, If the suctioned material is thick, consider
meconium, etc) are retrieved, repeat steps instilling ½ mL of sterile physiologic (nor-
8 through 11 once the baby’s oxygenation mal) saline down the endotracheal tube.
is stable again.
13. Gently suction the baby’s mouth to clear it To avoid contamination of the baby’s air-
of any saliva or mucus. way, always suction the mouth after the tra-
chea has been suctioned.
14. Return the baby’s inflation pressure and
inspired oxygen concentration to the pre-
suctioning levels.
15. Reconnect the baby to the ventilator or
continue bag breathing for the baby.
In-line Suction
• In-line suction (eg, the Ballard Suction device) is a suction system that remains attached to
the endotracheal tube at all times. Follow manufacturer’s instructions for use.
• This allows for repeated sterile suction without preparing a sterile field or use of sterile
gloves.
• It also reduces the risk of exposure of the caregiver to respiratory secretions.
• Post a sign at the bedside of the baby, giving the safe depth of catheter insertion.
• Replace the in-line suction when it becomes visibly soiled or the number markings have
worn off.
93

Unit 5: Surfactant Therapy
Objectives.............................................................................................................................. 96
1. What is surfactant? ...................................................................................................... 98
2. When is surfactant made during fetal development?................................................ 98
3. What is surfactant deficiency?..................................................................................... 99
4. How can surfactant deficiency be treated?................................................................100
5. Does maternal steroid administration affect neonatal respiratory distress
syndrome and the need for surfactant therapy?.......................................................100
Unit 5: surfactant therapy/ contents

6. Are all surfactant preparations the same?.................................................................100
7. How do you give surfactant?......................................................................................102
8. Which babies should be treated and when?..............................................................103
9. How often should you give surfactant?.....................................................................104
10. What are the recognized complications of surfactant therapy?..............................104
11. Should surfactant always be given in an intensive care facility?.............................105
Figures
Figure 5.1. Normal and Collapsed Alveoli....................................................................... 98
Figure 5.2. Fetal Lung Development................................................................................. 99
Skill Unit: Surfactant Administration...............................................................................109
95

Unit 5: surfactant therapy
Objectives
A. The nature of surfactant deficiency
B. How surfactant deficiency is treated
C. Which babies are likely to benefit from surfactant therapy
D. The recognized complications of giving surfactant
E. The general considerations for administration of commercial preparations of surfactant
96

Unit 5 Pretest
1. Which of the following statements about natural surfactant is accurate?
A. Contains phospholipids and proteins
B. Raises surface tension in the alveoli
C. Prevents alveolar collapse during inspiration
D. Is manufactured in the liver
2. Which of the following statements best describes the action of natural surfactant
when it is injected through an endotracheal tube?
A. Spreads very slowly to the lower airways
B. Is mostly absorbed into the pulmonary circulation and degraded by the liver
C. Will have a direct effect on alveolar stability
D. Is most commonly given as a powder
3. Which of the following statements about surfactant deficiency is accurate?
A. It is the cause of respiratory distress syndrome.
B. Incidence increases with increasing gestational age.
C. It can be treated with intravenous surfactant.
D. It is only seen in preterm babies.
4. Which of the following babies is at lowest risk for developing respiratory distress
syndrome?
A. Baby was born at 29 weeks’ gestation.
B. Mother has diabetes mellitus.
C. Baby is infected with group B b-hemolytic streptococcus.
D. Mother is infected with HIV.
5. Preterm babies who have been stressed in utero have a__________ incidence of
respiratory distress syndrome.
A. Higher
B. Lower
6. Which of the following methods of surfactant administration is appropriate?
A. Bolus instillation into the trachea
B. Intravenous drip
C. Intratracheal drip
D. All of the above
7. True False All commercial surfactants contain the same components.
8. True False Betamethasone or dexamethasone given to a pregnant woman, plus
surfactant given to the preterm baby, is more beneficial than surfac-
tant given alone.
9. True False By 32 weeks’ gestation, approximately 60% of fetuses are produc-
ing adequate surfactant to prevent respiratory distress syndrome.
10. True False All surfactant components are produced by the lung at the same
time during gestation.
11. True False Studies have shown that the earlier surfactant is used, the more
effective it is.
97

1. What is surfactant?
Surfactant is a complex of substances (phospholipids and proteins) that are essential to normal
lung function. The substances are produced by special cells in the lining of the alveoli and are
then secreted onto the surface of the alveoli. The surfactant components work together to alter
the surface tension at the air-liquid interface, so that the alveoli will remain open and not col-
lapse completely during exhalation (Figure 5.1).
Normal Collapsed
alveoli alveoli
Figure 5.1. Normal and Collapsed Alveoli
2. When is surfactant made during fetal development?

The various components of the surfactant complex are produced at different stages of fetal
development (Figure 5.2). All components are necessary for normal physiologic function of the
complex, but all are not produced and secreted until midway through the third trimester. By
32 weeks’ gestation, approximately 60% of fetuses will have adequate surfactant for normal
extrauterine respiration.
The surfactant that is secreted into alveoli also appears in the amniotic fluid because of fetal
respiration and a net efflux of lung fluid. The presence of surfactant or, more specifically, its
components (eg, lecithin or phosphatidyl glycerol) as a sign of fetal lung maturity can be mea-
sured from an amniotic fluid sample obtained by amniocentesis. (See Book I: Maternal and
Fetal Evaluation and Immediate Newborn Care, Unit 2, Fetal Age, Growth, and Maturity.)
98

Embryonic period Fetal period
Alveolar
Saccular
Canalicular
Birth
Pseudoglandular
Embryonic Surfactant
2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38
Weeks
Gener- 0 2 4 6 8 10 12 14 16 17 18 19 20 21 22 23
ations
Bronchi Bronchioles Terminal Respiratory Alveolar ducts Alveolar
bronchioles bronchioles sac
Conducting zone Transitional and respiratory zones
Figure 5.2. Fetal Lung Development

Based on University of Fribourg, University of Lausanne, University of Bern. Respiration tract. Phases of lung development. In: Hu-
man Embryology: Organogenesis. http://www.embryology.ch/anglais/rrespiratory/phasen01.html. Accessed June 20, 2016.
3. What is surfactant deficiency?

Without adequate surfactant, alveoli will collapse during exhalation, causing respiratory dis-
tress syndrome (RDS) to develop in the baby. (See Book III: Neonatal Care, Unit 2, Respiratory
Distress.) Factors that increase the risk of surfactant deficiency include
A. Preterm birth: All surfactant components have not yet been produced by the lung. The
more preterm a baby is, the greater the risk of RDS.
B. Maternal diabetes mellitus: Excess insulin produced by the fetus in response to high
maternal blood glucose inhibits surfactant production. (See Book I: Maternal and Fetal
Evaluation and Immediate Newborn Care, Unit 2, Fetal Age, Growth, and Maturity.)
C. Pneumonia: Inflammation of the lung causes leakage of serum proteins into the alveoli;
these proteins inhibit surfactant function.
D. Aspiration syndrome: Foreign substances such as meconium, blood, or amniotic fluid
aspirated into the alveoli may inactivate surfactant.
Conversely, preterm babies who have had a moderate amount of stress (eg, intrauterine growth
restriction due to placental insufficiency) in utero may have a decreased incidence of RDS
because the stress may stimulate natural surfactant production.
99

4. How can surfactant deficiency be treated?

Surfactant deficiency in newborns can be treated by administration of surfactant to the airways
of the lung; several liquid surfactant preparations are available commercially. Because of its
tendency to spread rapidly, surfactant placed in the trachea will move very quickly throughout
the airways of the lungs to have a direct effect on maintaining alveolar stability. In addition,
the administered surfactant will eventually be absorbed by the lungs and re-secreted as natural
surfactant.
5. Does maternal steroid administration affect neonatal respiratory

distress syndrome and the need for surfactant therapy?
Administration of steroids (betamethasone or dexamethasone) to the pregnant woman prior to
delivery will stimulate fetal surfactant production and secretion, thus decreasing the chance of
a preterm baby developing RDS. If RDS is present, however, surfactant therapy acts additively
with antenatal corticosteroids to reduce the severity of RDS. See Book I: Maternal and Fetal
Evaluation and Immediate Newborn Care, Unit 2, Fetal Age, Growth, Maturity, and Book II:
Maternal and Fetal Care, Unit 7, Preterm Labor, for more information and recommendations
regarding antenatal administration of steroids.
6. Are all surfactant preparations the same?

No. The surfactant preparations that are available commercially are not the same compounds.
They can be divided into 2 groups.
A. Natural surfactants
Beractant (Survanta), calfactant (Infasurf), and poractant (Curosurf) are surfactant
preparations that have been extracted from animal lung, although by different methods.
These preparations contain all the surfactant phospholipids and 2 of the 3 proteins, but
in different proportions.
B. Synthetic surfactants
Synthetic surfactant preparations have been manufactured from phospholipids and
spreading agents or protein analogues designed to replace the surfactant-specific proteins
present in natural surfactants. Lucinactant (Surfaxin) is a synthetic surfactant contain-
ing the peptide sinapultide (KL4 acetate), 1,2-dipalmitoyl-sn-glycero-3-phosphocholine,
1-palmitoyl-2-oleoyl-sn-glycero-3-phosphoglycerol (as the sodium salt), and pal-
mitic acid. It was approved for use in the United States by the US Food and Drug
Administration in 2012.
Each of the commercial preparations has been studied extensively. All have been shown to be
effective in treating RDS. While relatively minor differences are among the natural surfactants,
the natural surfactants as a group seem to have a more rapid onset of action and striking effect
on oxygenation and lung compliance than the synthetic surfactants that have been developed.
No studies have been large enough to demonstrate a clear difference in mortality or chronic
lung disease for any of the preparations.
100

Self-test
A1. The naturally occurring surfactant complex is composed of 2 groups of substances:
________________ and ________________.
A2. Surfactant works by __________________ surface tension in the alveoli and preventing alveoli from
collapsing during __________________.
A3. True False All components of the surfactant complex appear for the first time at 32
weeks’ gestation.
A4. True False A preterm fetus who has been subjected to chronic stress will have a greater
chance of developing respiratory distress syndrome.
A5. List 4 factors known to increase the likelihood of a baby developing respiratory problems from sur-
factant deficiency.
A6. True False When commercially available surfactant is given through an endotracheal
tube, it will eventually be absorbed by the lungs and re-secreted as natural
surfactant.
A7. True False Preterm babies born to women who were given betamethasone or dexameth-
asone are more likely to require surfactant therapy than preterm babies born to
women who did not receive steroids.
A8. True False All commercially available surfactants contain the main components of natu-
rally occurring surfactant, but in different proportions.
101

7. How do you give surfactant?

All the surfactant preparations are given directly into a baby’s trachea through an endotracheal
tube, although each manufacturer recommends a different administration technique. Survanta,
Infasurf, and Curosurf are recommended to be given through a catheter that is inserted into the
endotracheal tube.
Recommendations regarding the need to divide the dose and tilt the baby into various posi-
tions also differ considerably. No studies have clearly demonstrated any one technique is supe-
rior to another. Bolus administration, however, has been shown to be preferable to aerosol or
slow-drip administration, although new techniques for aerosol delivery are being evaluated.
Correct endotracheal tube position is very important to ensure that the surfactant is
administered into the trachea, not into one main stem bronchus and thus into only
one lung.
After surfactant administration, the compliance (stiffness) of the lung is likely to change quite
rapidly. As compliance improves (lungs become less stiff), you should make corresponding
changes in ventilator or bag-breathing pressures. Usually, a rapid decrease in peak inspiratory
pressure is needed first, but other changes may also be needed.
Monitor oxygen saturation continuously, check arterial blood gases frequently, and adjust the
baby’s inspired oxygen concentration and inspiratory pressure according to percent saturation
and Pao2 results. Low Paco2 is also an important indication to decrease peak inspiratory pres-
sure and rate.
To minimize the chance of a pneumothorax occurring, anticipate likely changes in

the baby’s lung compliance following surfactant administration. Make appropriate
reductions in ventilation pressures promptly in response to oxygen saturation and
blood gas results.
Following surfactant administration, some clinicians recommend assisting ventilation with an

anesthesia bag and in-line manometer for a brief period, rather than immediately reconnecting
the baby to a ventilator. A T-piece resuscitator can also be used to ventilate the baby during
surfactant administration. Inspiratory pressure should be monitored continuously and adjusted
immediately, according to apparent changes in lung compliance and oxygen saturation read-
ings. Once the oxygen saturation seems to have stabilized, reconnect the baby to the ventilator
with settings that reproduce those used to bag breathe for the baby.
Alternatively, the baby may remain on the ventilator during surfactant administration if an in-
line catheter is used. In this scenario an experienced clinician should be available at the bedside
during surfactant administration to adjust ventilator settings accordingly, as the compliance of
the lungs changes.
As noted in the following text, several studies have demonstrated that many babies with mild
to moderate RDS can be extubated immediately following the surfactant administration and
maintained on nasal continuous positive airway pressure (CPAP) alone.
102

8. Which babies should be treated and when?

If a baby has moderate to severe RDS, has already had endotracheal intubation for treatment
of RDS, and requires more than 30% to 40% oxygen to maintain satisfactory oxygen satura-
tion as measured by pulse oximetry, most experts agree that the baby should receive surfac-
tant therapy. However, there is not uniform agreement as to when a baby should be primarily
intubated for surfactant administration. Both animal and human studies have shown that the
earlier surfactant is administered, the more effective it will be. However, since endotracheal
intubation is required for the administration, the timing of administration can be influenced by
many factors. The following 3 scenarios have been advocated:
A. Administer surfactant prophylaxis solely on the basis of gestational age.
On the basis of early surfactant clinical trials, some clinicians continue to advocate
intubating all babies below a certain gestational age (recommendations have ranged from
,28–,30 weeks) within 5 to 10 minutes following birth, administering surfactant, and
then weaning mechanical ventilation as oximetry and arterial blood gases indicate. This
strategy will result in unnecessarily intubating and treating some babies who would not
have required either intubation or surfactant. However, randomized controlled stud-
ies have demonstrated an overall average benefit to the group being so treated, when
compared to a group receiving no surfactant until the baby requires CPAP and eventual
intubation for management of respiratory distress.
B. Administer surfactant prophylaxis solely on the basis of gestational age but followed by
immediate extubation to nasal CPAP, after the surfactant has been given.
Randomized controlled trials have shown no difference in outcome compared to those
treated using scenario A, although one study showed that once babies are intubated, a
large proportion tend to remain intubated (ie, once a patient has been intubated, clini-
cians are hesitant to extubate).
C. Initiate nasal CPAP at birth, and maintain on nasal CPAP, for all babies born below a
certain gestational age (eg, 32 weeks) until they require intubation for respiratory failure.
Then intubate and administer surfactant.
This strategy has been advocated enthusiastically by many clinicians but has not been
shown in carefully controlled studies to result in a difference when compared to those
treated with strategy A or B. One study has shown an increased incidence of pneumotho-
rax in those maintained initially on CPAP alone, using 8 cm H2O pressure.
There is currently insufficient evidence on which to base a firm recommendation for any
1 of the 3 strategies (listed above) over another.
If surfactant is to be given prophylactically in the delivery room, the baby should receive
any necessary resuscitation measures prior to surfactant administration, as well as have
vital signs stabilized and correct endotracheal tube position carefully ensured by clini-
cal examination. Usually, these resuscitative or stabilization measures (or both) can be
accomplished quickly, allowing surfactant to be given within 5 to 10 minutes
following birth.
103

Administration of surfactant after respiratory disease has developed is termed “rescue”

therapy. Many clinicians elect to administer surfactant prophylactically to babies born
extremely preterm and to use a rescue approach for more mature babies who develop
respiratory distress after birth. Some experts advise a modified approach in which surfac-
tant is not given prophylactically but rather is given if a preterm baby develops the slight-
est signs of RDS. These modifications have not been rigorously tested and their use must
be guided by clinician preference. The presence and timing of maternal antenatal steroid
administration may also influence the decision.
Several reports have demonstrated that babies, including term babies, with aspiration
syndrome, pneumonia, and perhaps acute RDS also benefit from surfactant rescue ther-
apy. There is currently insufficient information to recommend specific criteria for treat-
ing such babies. However, some studies have shown that administration of surfactant to
patients with respiratory failure due to meconium aspiration syndrome may reduce the
need for extracorporeal membrane oxygenation in this population. (See El Shahed AI,
Dargaville PA, Ohlsson A, Soll R. Surfactant for meconium aspiration syndrome in term
and late preterm infants. Cochrane Database Syst Rev. 2014;14[12]:CD002054.)
9. How often should you give surfactant?

Depending on the preparation used, if a baby was treated prophylactically or received the first
dose soon after birth, a single dose of surfactant will often suffice. However, because surfac-
tant may be absorbed, metabolized, or inactivated after administration (or any combination of
those), repeat doses are sometimes given.
Recommendations regarding repeat doses vary. If a baby continues to require endotracheal
intubation, positive-pressure ventilation, and an inspired oxygen concentration of 30% to 40%
or higher, many clinicians will give a repeat dose every 6 to 8 hours, until a maximum of 4
doses has been given.
10. What are the recognized complications of surfactant therapy?

A. Administration to only one lung
If surfactant is given into one lung (because the endotracheal tube was too low), the
baby may develop a marked compliance difference between the 2 lungs. This can result
in major problems with ventilation; the treated lung can become overinflated, while the
other lung cannot be inflated as well at the same pressure. Therefore, it is important to
have a clinician experienced in endotracheal intubation of neonates present to evaluate
endotracheal tube placement prior to administration of surfactant. Before administering
surfactant, confirm correct endotracheal tube position by
• Visualizing the vocal cord stripe on the endotracheal tube before removing the
laryngoscope
• Listening with a stethoscope laterally over both sides of the chest for equal breath
sounds
• Obtaining a chest radiograph to confirm tube placement (usually not done when sur-
factant is given in the delivery room)
104

B. Development of air leaks

If bagging or ventilator pressures are not decreased as lung compliance changes, the
baby may develop a pneumothorax or pulmonary interstitial emphysema (bubbles of air
within the lung tissue).
C. Endotracheal tube that becomes slippery
The phospholipids in surfactant make it extremely slippery. After surfactant administra-
tion, the endotracheal tube, the tube connector, and the baby’s airway may also be slip-
pery, perhaps making tube adjustment, tube security, or reintubation difficult. Be certain all
connections are tight and all adjustments have been made before administering surfactant.
D. Endotracheal tube that becomes blocked with the surfactant solution
Sometimes, during surfactant administration, the surfactant solution will back up into
the endotracheal tube and prevent gas movement. If liquid is seen to be blocking the
tube, use slightly higher pressure and longer inflation time for several breaths until the
tube clears. If the baby’s condition deteriorates despite these measures, the surfactant can
be suctioned from the tube or the tube can be replaced.
E. Severe oxygen desaturation that occurs during administration
Babies with severe RDS may not tolerate the introduction of liquid into their endotra-
cheal tubes. Most manufacturers recommend that the dose be divided into 2 or 4 ali-
quots. After each partial dose, the baby should be ventilated for a few minutes, until the
oxygen saturation is greater than 90%, before the next partial dose is given.
11. Should surfactant always be given in an intensive care facility?

Surfactant administration requires considerable expertise with endotracheal intubation and
mechanical ventilation. Babies who require surfactant usually also require intensive care for
management of other immature organ systems, in addition to the lungs. It is recommended
that surfactant therapy be given only in hospitals appropriately equipped and staffed for,
and experienced in, the management of low-birth-weight and premature babies, including
use of mechanical ventilators. (See American Academy of Pediatrics, American College of
Obstetricians and Gynecologists. Neonatal complications. In: Guidelines for Perinatal Care.
7th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2012:347.)
An appropriate exception may be administering surfactant in a non-intensive care setting to a
baby with severe RDS for whom there may be a significant delay in transport to an intensive
care nursery. If surfactant is to be given under these conditions, it should be administered by
individuals skilled in endotracheal intubation who have reviewed in detail the specific rec-
ommended techniques for administering the commercial surfactant being used. In addition,
familiarity and skill with rapid lowering of inspiratory pressures with either bag breathing or
ventilator adjustment following surfactant administration is important. In some settings, the
neonatal transport team will provide this service.
105

Self-test
B1. Which of the following techniques have been shown to be important for administering all commer-
cially available surfactant products?
Yes No
____ ____ Administration through a special endotracheal tube connector, which has a side port
____ ____ Careful positioning of the endotracheal tube tip in the mid-trachea
____ ____ Turning the baby 360 degrees
____ ____ Monitoring oxygen saturation during administration
____ ____ Anticipating changes in lung compliance and adjusting ventilation pressures
accordingly
B2. True False Studies have shown that surfactant given immediately after birth is more effec-
tive than waiting until a baby develops significant respiratory disease.
B3. Many clinicians recommend that a baby who continues to have significant respiratory distress after
initial surfactant administration be re-treated in ______ to ______ hours.
B4. List 4 possible complications of surfactant therapy.
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Self-test Answers
A1. The naturally occurring surfactant complex is composed of 2 groups of substances: phospholipids and
proteins.
A2. Surfactant works by altering surface tension in the alveoli and preventing alveoli from collapsing dur-
ing exhalation.
A3. False.
Reason: The various components of surfactant are first produced at different times during
gestation. By 32 weeks, 60% of fetuses have adequate surfactant for normal extrauterine
respiration.
A4. False.
Reason: Fetuses subjected to chronic stress are less likely to develop respiratory distress
syndrome.
A5. Preterm birth
Maternal diabetes mellitus
Pneumonia
Aspiration syndrome
A6. True
A7. False.
Reason: Antenatal steroids and neonatal surfactant have an additive effect on preventing
respiratory distress syndrome.
A8. True. Beractant (Survanta), calfactant (Infasurf), and poractant (Curosurf) contain all the natural
phospholipids, but only 2 of the 3 proteins; synthetic surfactants contain synthetic phospho-
lipids, and no surfactant-specific protein, and currently none are available commercially.
B1. Yes No
____ X Administration through a special endotracheal tube connector, which has a side port
X ____ Careful positioning of the endotracheal tube tip in the midtrachea
____ X Turning the baby 360 degrees
X ____ Monitoring oxygen saturation during administration
X ____ Anticipating changes in lung compliance and adjusting ventilation pressures
accordingly
B2. True
B3. Many clinicians recommend that a baby who continues to have significant respiratory distress after
initial surfactant administration be re-treated in 6 to 8 hours.
• Administration to one lung
• Development of air leaks (pneumothorax, etc)
• Endotracheal tube that becomes slippery
• Endotracheal tube that becomes blocked with surfactant
• Severe oxygen desaturation that occurs during administration
107

Unit 5 Posttest
108

SKILL UNIT
Surfactant Administration
There are several different commercial surfactant preparations. Each has been shown to be
Unit 5: surfactant therapy/ skill unit: surfactant administration

effective in preventing and treating neonatal respiratory distress syndrome, although the tech-
niques for administration vary significantly among the different preparations. Each manufac-
turer has prepared detailed instructions regarding the recommended method for administering
that company’s particular product. These instructions are available in written and video for-
mats. You may be asked to participate in a skill session to practice surfactant administration
according to the methods recommended for the surfactant chosen for use in your hospital.
Because administration techniques vary considerably for the different products, it is recom-
mended that your hospital use only one brand of surfactant and that all staff become skilled
in using that particular product. Switching between brands makes it more difficult to become
skilled in the use of each product and increases the risk of errors in administration.
109

Unit 6: Continuing Care for At-Risk Babies
Objectives.............................................................................................................................112
1. What is continuing care? ............................................................................................115
2. Which babies require continuing care?......................................................................115
3. What specific issues are involved in continuing care?..............................................115
Unit 6: continuing care for at-risk babies/ contents

4. What is involved in discharge of a baby?.................................................................. 132
Subsection: Babies With Special Problems.................................................................... 136
1. What special problems may be encountered in babies requiring
continuing care? ......................................................................................................... 136
2. How do you care for these special problems?.......................................................... 138
Tables
Table 6.1. Timing of First Eye Examination Based on Gestational Age at Birth............. 127
Table 6.2. Monitoring and Treatment Guidelines for Babies With Special Problems...... 140
Recommended Routines.................................................................................................. 149
111

Unit 6: continuing care for at-risk babies
Objectives
In this unit you will learn to
A. Provide long-term care for an at-risk baby who remains in your hospital for longer than
several days.
B. Provide continuity of care for an at-risk baby who returns from an intensive care nursery to
your hospital.
C. Recognize the special problems some sick or preterm babies may develop, and the monitor-
ing and treatment guidelines for those problems.
D. Plan for the discharge of an at-risk baby.
112

Unit 6 Pretest
1. A term baby with short bowel syndrome returned recently to your nursery from a
regional perinatal center. Which of the following measurements is least important for
you to monitor in this baby?
A. Urine pH
B. Weight gain
C. Frequency of stools
D. Blood electrolytes
2. Two weeks ago, a 1,500-g (3 lb 5 oz), preterm baby returned to your hospital after
3 weeks in a regional perinatal center. The parents live in your town and have visited
the baby once in the past 2 weeks. What would you do?
Yes No
_____ _____ Request consultation from social service department staff.
_____ _____ Call the parents and chat with them about their baby.
_____ _____ Begin making plans for the baby to be sent to a foster home.
3. Which of the following babies is at highest risk for developing hydrocephalus?
A. Term baby treated for hypoglycemia
B. 1,000-g (2 lb 3 oz), preterm baby requiring assisted ventilation
C. 36-week postmenstrual age baby who received an exchange transfusion
D. 1,800-g (3 lb 15½ oz) baby born at 40 weeks’ gestation
4. All of the following statements regarding retinopathy of prematurity are correct
except
A. Laser photocoagulation may be helpful in reducing poor visual outcome from
retinopathy of prematurity.
B. Retinopathy of prematurity is unlikely to develop in babies born at term.
C. Mild to moderate retinopathy of prematurity may completely resolve.
D. All preterm babies with a Pao2 greater than 100 mm Hg will develop retinopathy
of prematurity.
5. A preterm baby requires assisted ventilation and several weeks of intensive care at a
regional perinatal center. Now the baby is stable, weighs 1,500 g (3 lb 5 oz), has no
respiratory distress, and is returning to your nursery for further weight gain. Which
of the following things should be done for this baby?
Yes No
_____ _____ Measure baby’s head circumference once a week.
_____ _____ Start the baby on phenobarbital.
_____ _____ Weigh the baby daily.
_____ _____ Give iron dextran (Imferon) intramuscularly.
_____ _____ Check the baby’s hematocrit at least once a week.
_____ _____ Attach the baby to a cardiac or respiratory monitor.
113

6. True False A 4,540-g (10 lb) baby has seizures controlled on a certain drug
dose. By the time the baby reaches 9,070 g (20 lb), he should be
receiving twice as much medication.
7. True False When a preterm baby reaches 1,500 g (3 lb 5 oz) and respiratory
disease has resolved, it is safe to assume the baby will not have an
apneic spell.
8. True False Nipple feedings should be used for any baby who has a gag reflex
and can suck on a nipple.
9. True False Babies with chronic lung disease can grow completely new, healthy
lung tissue.
10. True False After a baby with hydrocephalus has a shunt placed, it is no longer
necessary to measure the baby’s head circumference.
11. True False It is a good sign if a baby with congenital heart disease gains 60 g
(2 oz) or more per day for several days in a row.
12. True False Babies requiring theophylline or caffeine to control apneic spells may
have the drug stopped and be sent home the next day, as long as
they have reached a weight of 1,800 g (3 lb 15½ oz).
13. True False Any baby with short bowel syndrome will need an ostomy (colos-
tomy or ileostomy) for the rest of his or her life.
14. All of the following findings are common causes of anemia in preterm babies except
A. Blood taken from the baby for laboratory tests
B. Drop in hemoglobin level or hematocrit that occurs after birth
C. Bronchopulmonary dysplasia
15. Which of the following things should you do when supplementing a baby’s nipple
feedings with tube feedings given through a nasogastric or an orogastric tube?
A. Feed the baby as much as he or she will take by nipple, and then insert a feeding
tube and give the remainder of the feeding through the tube.
B. Feed the baby as much as he or she will take by nipple while a feeding tube is in
place, and then give the remainder of the feeding through the tube.
16. All the following steps are important in weaning a baby from an incubator except
A. Putting a stocking cap on the baby’s head
B. Wrapping the baby in blankets
C. Recording the baby’s daily weight during the weaning period
D. Adjusting the room temperature to neutral thermal environment during the
weaning period
17. Indicate which of the following things should be routinely checked for a hospitalized
baby with congenital heart disease and congestive heart failure:
Yes No
_____ _____ Blood electrolytes
_____ _____ Volume of urine output
_____ _____ Stool pH
_____ _____ Hematocrit
_____ _____ Weight gain
_____ _____ Blood calcium
114

1. What is continuing care?

At-risk babies, even though they are not sick, require certain daily caretaking activities and
types of monitoring.
These babies may have been born in your hospital and have recovered from their initial acute
newborn problems, or they may have been transferred to your hospital from another insti-
tution. If they have been transferred for continuing care, it is important that there has been
complete and effective communication about the baby’s history, ongoing problems, and need
for special assessment and follow-up.
2. Which babies require continuing care?

A. Babies who need additional weight gain
Preterm babies who have recovered from their initial illness are now at risk, but stable,
and need continued hospitalization until they gain adequate weight to be discharged.
B. Babies who need to continue to mature
Preterm babies often need to continue to mature physiologically. Physiological matura-
tion involves a variety of functions, including feeding skills, temperature control, and
establishing regular respirations.
C. Babies who need special monitoring/intervention
Any baby who has recovered from an initial illness but has a special medical problem
that requires continued hospitalization for special monitoring or intervention.
3. What specific issues are involved in continuing care?

The following list is routine care practices needed for babies requiring continuing care:
A. Temperature control
Babies less than 1,500 to 1,600 g (3 lb 5 oz–3 lb 8 oz) should be kept in an incubator in the
appropriate neutral thermal environment. (See Book I: Maternal and Fetal Evaluation and
Immediate Newborn Care, Unit 7, Thermal Environment.) When they reach a weight of
approximately 1,500 to 1,600 g, you may begin to wean them from the incubator to a crib.
• How do you wean a baby from an incubator to a crib?
Step 1. Dress the baby in a single-layer shirt or sleeper, wrap him with one blanket,
and place a stocking cap on his head. Reduce the heat in the incubator by
0.2°C to 0.5°C. Monitor the baby’s temperature, maintaining an axillary tem-
perature greater than 36.4°C (97.6°F).
Step 2. If the baby’s temperature is stable after 3 to 6 hours, continue to decrease the
incubator temperature slowly, as indicated above, until an incubator tempera-
ture of 27.0°C to 28.0°C (80.6°F–82.4°F) is achieved. Continue to monitor
the baby’s temperature during this process, maintaining an axillary tempera-
ture greater than 36.4°C (97.6°F). Do not decrease by more than 2.0°C in the
first 24 hours, and no more than 1.0°C in subsequent 24-hour periods. It is
appropriate to add one additional blanket to cover the baby. It is not appro-
priate to leave the port holes of the incubator open.
Step 3. Once the baby’s temperature is stable and the incubator has been weaned
down to 26.0°C to 27.0°C (78.8°F–80.6°F), place the baby in an open crib.
This process could take several days to achieve. Continue to monitor the
baby’s temperature.
115

Note: If the baby becomes cold (temperature ,36.5°C or ,97.8°F) at any time, add
an additional blanket and check for abnormal routes of heat loss. Do not use
more than 2 blankets at any given time. If the baby continues to be cold and all
other routes of heat loss have been checked, place the baby back in the incuba-
tor at the appropriate neutral thermal environment and wait at least 24 hours
to begin the weaning process again.
• What is “kangaroo care”?
Kangaroo care means skin-to-skin contact between a baby’s body and parent’s chest.
This usually provides sufficient thermal support for a baby to maintain a normal body
temperature while outside an incubator. The baby should be naked except for a diaper
and in direct contact with the bare skin of the parent’s chest. The baby should wear a
cap and be covered with a blanket that is placed over both the baby and the parent’s
chest.
Note: Any benefits of kangaroo care have been shown to diminish dramatically if the
baby is on the parent’s chest for only a few minutes. If a parent has only a short
time to spend with the baby at a particular visit, moving the baby for this brief
period is not recommended, especially if the baby is small and attached to a
number of monitors, intravenous lines, and other equipment.
If a breastfeeding mother does not wish to provide kangaroo care, put a cap on the
baby and wrap the baby in extra blankets. It may also be possible to use a radiant
warmer positioned over the baby and mother.
In all situations when a baby is outside an incubator, the baby’s temperature should be
monitored frequently.
• What can go wrong?
The baby may have a normal temperature but be using a lot of calories to keep warm.
This may cause the baby to lose weight or fail to gain it. Any baby who has just been
weaned to a crib and loses weight for 2 to 3 days in a row should be placed back in an
incubator for at least 24 hours before undergoing the weaning process again.
Caution: Weight loss may occur for other reasons too. You should consider
• Checking for infection
• Assessing feeding pattern and caloric intake
B. Feeding
• Postmenstrual age (sometimes referred to as postconceptional age, calculated as gesta-
tional age at birth plus postnatal age)
To determine a baby’s current postmenstrual age, take the gestational age at birth and
add the number of weeks that have passed since birth. Babies less than approximately
32 weeks’ postmenstrual age should be fed with tube feedings. It is unusual for a baby
to have sufficiently achieved neurologic maturity to coordinate sucking, swallowing,
and breathing before 32 weeks’ postmenstrual age.
116

Begin to feed by nipple when a baby meets all of the following criteria:
• Reaches a postmenstrual age of 32 weeks
• Shows signs of readiness for oral feeds (sucks on a pacifier for 3 minutes with a
normal suck-burst-rest pattern, transitions to an alert state, and tolerates holding)
• Has a gag reflex
• Has a normal respiratory rate (,70 breaths/min)
• Is not critically sick (eg, stable respiratory status, not on vasopressors)
• Can demonstrate proficiency to suckle at the breast or from a nipple on a bottle
Feeding may be from a bottle or by breast if the mother desires to breastfeed. Babies
who will be breastfeeding should be encouraged to explore the breast during kanga-
roo care, even if they are less than 32 weeks’ postmenstrual age. They will generally
not latch on to the breast and, even if they aspirate a small amount of breast milk, it
will generally not injure the lungs.
Sucking on a pacifier should be used during tube feeding. This has been shown to aid
in gastric motility and progression in oral feeding skills.
• Temperature control
Some babies may be ready to feed by mouth before they are able to control their
temperatures outside an incubator. If a baby weighs less than 1,500 g (3 lb 5 oz) but
otherwise meets criteria for oral feedings, the feedings may be given in the incubator.
• Fatigue
Frequently, babies tire when they first start to feed by nipple. For this reason, it is
often necessary to begin with one oral nipple feeding per day, working up to alternate
feedings by mouth with tube feedings, and to supplement feedings taken by mouth
with tube feedings.
Note: You may leave the feeding tube in place during a nipple feeding, but never
insert it immediately after a feeding. This may cause the baby to vomit and
aspirate milk into the lungs.
Wait at least 1 hour after a feeding before inserting a feeding tube.
• How do you transition from tube to oral feedings?

To alternate feedings by mouth with tube feedings, follow these steps.
Step 1. Give the baby the full feeding by tube (nasogastric or orogastric tube).
Step 2. At the time of the next feeding (2–3 hours later), give the baby the feeding by
nipple (breast or bottle).
Step 3. Give the next feeding by feeding tube.
Step 4. Repeat the previous cycles for 24 hours. If the baby is taking feedings well by
mouth, increase the number of nipple feedings and decrease an equal number
of tube feedings until the baby is taking all feedings by mouth.
117

Some babies will be unable to take the entire amount of a feeding by mouth and will
require supplemental feedings. To supplement partial oral feedings with tube feedings,
follow these steps.
Step 1. Give the baby the full feeding by tube. Leave the tube in place.
Step 2. At the time of the next feeding (2–3 hours later), give the baby as much of the
scheduled feeding by mouth as the baby will tolerate.
Step 3. Subtract the amount the baby took by mouth from the total amount of the
planned feeding. The remaining amount should now be given through the
feeding tube.
Example
• The planned feeding is 40 mL every 3 hours.
• The baby takes 20 mL by mouth.
• 40 mL – 20 mL 5 20 mL of the feeding that has not been taken.
• Give the remaining 20 mL to the baby through the feeding tube.
As a baby becomes less tired during feedings, the amount taken by nipple will
increase. Do not force a baby to take more by mouth than the baby is capable of
eating easily. This just tires the baby and makes it less likely that the next feeding by
nipple will go well. Some experts recommend not supplementing with tube feedings if
the baby takes greater than 75% of her planned feeding by mouth.
Note: Other feeding methods, such as cup feeding and finger feeding, have been used.
The value and safety of these techniques for preterm babies are undergoing evalua-
tion and, therefore, will not be discussed here.
See Book III: Neonatal Care, Unit 6, Feeding, for additional information about feeding
preterm babies, and their vitamin and iron requirements.
C. Assessment of growth
The following growth chart can be used to plot growth of a female baby born preterm
while that baby remains hospitalized. There are separate growth charts for boys and girls.
The x-axis is labeled Gestational Age, but the meaning is postmenstrual age, or “cor-
rected” gestational age. Once the baby has regained birth weight (see Book III: Neonatal
Care, Unit 6, Feeding), this chart can be used to plot incremental weight, length, and
head circumference. Both male and female charts may be downloaded for printing from
http://ucalgary.ca/fenton/2013chart.
118

119

• Weight
It is important for a baby to have consistent weight gain before being discharged.
Daily weights should be obtained and recorded on a growth chart that shows the nor-
mal weight gain for preterm babies. (See Book III: Neonatal Care, Unit 6, Feeding.)
Most preterm babies will be ready for discharge when their weight has reached 1,800
to 2,000 g (3 lb 15½ oz–4 lb 61∕ 2 oz), as long as they have met all other discharge cri-
teria. Stable preterm babies should demonstrate steady weight gain of approximately
20 to 30 g (7∕ 10 –1 oz) every day.
Many preterm babies are initially fed a 24 kcal/oz formula. They are usually changed
to a 22 kcal/oz formula when they reach approximately 1,800 g (3 lb 15½ oz).
Babies receiving breast milk may also have supplements added to it to increase the
caloric density and vitamin content. See Book III: Neonatal Care, Unit 6, Feeding,
for additional information about feeding preterm babies, and their vitamin and iron
requirements.
If the baby loses weight or does not gain weight appropriately several days in a row,
you should think
– Is the baby getting adequate calories?
– Is the baby cold?
– Is the baby infected?
Example
Baby Crosby is a preterm baby who was transferred back to your hospital when he
was 14 days of age. His growth chart was sent with him.
Several days after arrival at your hospital, daily weights show Baby Crosby to be gain-
ing less than 20 to 30 g/d (7∕ 10 –1 oz/d). His growth is no longer following the curve on
the chart.
You examine the baby and find that his vital signs, color, activity, and feeding pattern
are all normal. You check the amount of calories he is receiving and find it is adequate.
Baby Crosby is being weaned from his incubator. You note that for the past several
shifts he has been slightly cold, with an axillary temperature of 36.4°C (97.6°F).
You place him back in the incubator for several days. His weight gain gradually
returns to normal and again follows the line that other babies of his birth weight
follow.
• Head circumference
It is important to measure the head circumference and record it on the middle curves
of the growth chart. Head size for some babies will increase more rapidly than nor-
mal, while for other babies head growth will be less than normal. Because the normal
increase in head size is only a very small amount each day, head circumference is usu-
ally measured on a weekly (not daily) basis. Normally, a preterm baby’s head circum-
ference will increase between 0.5 and 1.0 cm each week.
120

Increased Head Growth/Hydrocephalus

Babies of very low weight or those who were critically ill who sustained an intraven-
tricular hemorrhage are at highest risk for developing hydrocephalus. Babies with
hydrocephalus may have
– Rapidly increasing head circumference (.1.25 cm/wk)
– Bulging fontanels
– Split sutures
– Eyes that look downward (“sunsetting eyes”)
– Prominent veins over the scalp
– Increased irritability
– Persistent vomiting
– Apnea
If you note any of these signs, the baby should be observed very carefully
and evaluated by ultrasonography for possible hydrocephalus.
Babies with severe intrauterine growth restriction may have a bulging fontanelle and
split sutures as their nutrition and subsequent brain growth improves. Cranial ultra-
sound in these babies would show normal ventricular size.
Decreased Head Growth
Head size for some babies will not increase as expected. These babies may have had
severe perinatal compromise or a congenital infection. Rarely, they may have prema-
ture closure of the cranial sutures and fusion of the cranial bones. They should be
evaluated by ultrasonography. Imaging studies, such as computed tomography and
magnetic resonance imaging, may be indicated. Consult your regional perinatal center.
If head growth is very poor, the family should be counseled regarding the possibility
of developmental compromise, and the baby’s developmental progress, followed with
regular, detailed evaluations.
• Length
Length should be measured and recorded every week. The most accurate measurement
requires that 2 individuals assist in measuring a baby. Normally, a baby’s length will
increase approximately 0.5 cm/wk.
If length is not increasing, the baby likely has inadequate caloric intake. Less common
causes for poor increase in length include malabsorption or rickets.
D. Monitoring for apnea
1. Which babies should be monitored?
Preterm babies and sick babies of any postmenstrual age may have apneic spells. (See
Book III: Neonatal Care, Unit 2, Respiratory Distress.) For this reason, they require
electronic monitoring of heart and respiratory rates. Babies in the following groups
should be monitored:
• All preterm babies less than 1,800 g (3 lb 15½ oz)
• All babies less than 35 weeks’ postmenstrual age
• Any baby who has had an apneic spell
• All sick babies
121

2. How long should these babies be monitored?

Preterm babies should be electronically monitored until they are apnea-free and have
reached a
• Weight of 1,800 g (3 lb 15½ oz)
and
• Postmenstrual age of 35 weeks or more
Babies who have had an apneic spell, regardless of weight or postmen-

strual age, should be electronically monitored until apnea-free.
The specific length of monitoring time is controversial. Most experts agree that moni-
toring until a baby is apnea-free for 5 to 8 consecutive days is adequate. (See the fol-
lowing information if medication is required to treat frequent apnea episodes.)
3. How do you monitor a baby receiving medications to prevent apnea?
Some babies have such frequent episodes of apnea that medications (caffeine or, less
commonly, theophylline) are used to decrease the number of apneic spells by stimulat-
ing the central nervous system.
If a baby referred to you is receiving caffeine or theophylline, you should
• Provide continuous electronic cardiorespiratory monitoring. (See Book I: Maternal
and Fetal Evaluation and Immediate Newborn Care, Unit 4, Is the Baby Sick?, Skill
Unit: Electronic Cardiorespiratory Monitoring.)
• Obtain blood samples if the baby continues to have apnea, apnea recurs, or the
baby has tachycardia or vomiting. These latter signs may be due to too much drug
in the blood. Too little medication can lead to an increase in the number or severity
of apneic spells.
4. How long does a baby require medication to treat apnea?
Most preterm babies stop having frequent apneic spells when they reach a weight of
approximately 1,800 g (3 lb 15½ oz). Regardless of a baby’s weight, the medication
should be stopped when apneic spells have decreased to only 1 to 2 mild spells a day.
This will allow time for the drug to be metabolized and removed from the baby’s body
to determine if the baby will have apneic spells when the drug is no longer present in
the blood. The amount of time required for caffeine to be removed from the body var-
ies depending on the baby but generally takes between 5 to 8 days. Theophylline has
a shorter half-life but a much larger adverse effect profile and is not widely used for
apnea of prematurity.
Some centers obtain a blood level of caffeine or theophylline to ensure that only mini-
mal traces of the drug (,5 mg/L) (ie, subtherapeutic level) are present after discontinu-
ing its administration, followed by 5 to 8 consecutive days without an apneic spell.
Most experts are reluctant to discharge babies receiving theophylline or caffeine except
in rare, special cases, with very careful follow-up arrangements among you, the family,
and the regional perinatal center. Babies who are discharged on caffeine or theoph-
ylline and not followed carefully may eventually outgrow their original drug dose,
resulting in a low blood level of the medication. They may then have a serious apneic
spell at home.
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5. When can a baby who has had apnea go home?

• Predischarge preparation
Apnea may lead to hypoxia and bradycardia. If a spell is severe and goes unde-
tected, some babies will die.
In general, however, if a baby is off medication and has had no apnea for 5 to
8 consecutive days, it is very unlikely there will be a severe apneic spell at home.
Therefore, babies who have had apnea may be discharged home when the baby
– Has had no apneic attacks for 5 to 8 consecutive days (If a medication was used
to treat apnea, then the baby’s blood should be tested and shown to be subthera-
peutic [ie, ,5 mg/L], followed by 5 to 8 consecutive apnea-free days.)
– Maintains temperature in a bassinet or open crib
and
– No longer has any other problems
Or
• Home apnea monitoring
Occasionally, some babies are sent home on apnea monitors. These may include
– Babies who have demonstrated apnea despite weighing more than 1,800 g
(3 lb 15½ oz) and reaching a postmenstrual age of 35 weeks or more
or
– Technology-dependent babies who have abnormal regulation of breathing or
with symptomatic chronic lung disease or airway abnormalities
Discharging a baby with home apnea monitoring requires careful coordination
among the family, the regional perinatal center staff, and you. The family must
have had good instruction in use of the monitor and cardiopulmonary resuscitation
training. The monitor company must be available to assist the family and care for
the monitor.
Discharge of a baby to home monitoring requires extremely careful

follow-up. Consult your regional perinatal center staff about these spe-
cial situations.
E. Monitoring for anemia

Almost all preterm babies will develop anemia at some time prior to discharge from the
hospital.
1. Why does a baby develop anemia?
Preterm and sick babies are at risk for developing anemia due to
• Lower hematocrits at birth in premature babies
• Blood taken from the baby for various laboratory tests
• Normal drop in hemoglobin level or hematocrit that occurs in all babies during the
first several weeks after birth
• Iron deficiency
• A combination of these factors
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2. How do you monitor a baby’s anemia?

The baby’s hematocrit or hemoglobin level should be checked every 1 to 2 weeks. If
the hematocrit is less than 25%, it should be checked every 3 to 4 days.
3. What degree of anemia is dangerous?
Most babies do not have problems until the hematocrit is less than 25%. If the hema-
tocrit is less than 25%, you should look for the following signs:
• Sustained increase in heart rate (.160 beats/min)
• Sustained increase in respiratory rate (.60 breaths/min)
• Onset of apneic spells or an increase in the number or severity of apneic spells
• Failure to feed well and gain weight
4. What do you do if a baby who is anemic develops signs of anemia?
The baby may need a blood transfusion, or an addition or change in medication for
apnea, or an increase in caloric intake for poor weight gain. Discuss the best treatment
for each specific baby with your regional perinatal center staff.
Because of concern for transmission of infections (HIV, cytomegalovirus, hepatitis) by
blood transfusions, many experts recommend transfusing anemic babies only if they
are clearly symptomatic from anemia. Before giving a transfusion, you should inform
the baby’s parents, discuss the risks and benefits of transfusion with them, and obtain
a signed informed consent from them.
Note: Some regional perinatal centers give erythropoietin (a drug that stimulates red
blood cell production in the bone marrow). If you receive a baby who is being
given this medication, consult with the regional perinatal center staff about
dosage, duration of therapy, monitoring, and iron supplementation.
5. Why does a baby require iron?
Preterm babies are born with insufficient iron stores for their subsequent growth. At
4 to 6 weeks of age, the infant’s bone marrow begins producing red blood cells. The
babies, therefore, require a source of iron.
A baby transferred back to your hospital may have some degree of anemia and will
likely be receiving supplemental iron.
6. How is supplemental iron provided?
Additional iron may be provided through the use of commercially available, iron-
fortified formulas for formula-fed babies or with iron supplements for breastfed
babies.
A normal dosage is 2 mg/kg of elemental iron per day. This amount is provided in
iron-fortified formulas when a formula-fed baby is taking full feedings. If a baby is
iron deficient, receiving breast milk, or had a birth weight of less than 2,000 g
(4 lb 61∕ 2 oz), 5 to 6 mg/kg of elemental iron per day should be considered.
If supplements are used, whether for breastfed babies or a baby with severe iron defi-
ciency, liquid ferrous sulfate given daily is started around 2 to 4 weeks of age when the
baby is tolerating feedings. (See Book III: Neonatal Care, Unit 6, Feeding.) If a baby
has received a blood transfusion, iron supplementation should be held for 2 weeks fol-
lowing the transfusion.
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F. Administering immunizations
Preterm or chronically ill babies who require prolonged hospitalization should be immu-
nized. Most babies, including preterm babies, who are 8 weeks’ postnatal age respond
appropriately to immunizations.
• Administration of the following vaccines should be considered for all babies at 8
weeks’ postnatal age, regardless of their degree of prematurity:
– Diphtheria, tetanus, acellular pertussis vaccine
– Haemophilus influenzae type b conjugate vaccine
– Enhanced inactivated poliovirus vaccine
– Pneumococcal conjugate vaccine
• Vaccines should be administered in full doses.
• Combination vaccines are now available.
• Rotavirus vaccine should not be administered to the hospitalized baby.
• Administration of hepatitis B vaccine should follow the schedule outlined in Book III:
Neonatal Care, Unit 8, Infections.
• For babies returning to your hospital after a period of intensive care, you will need to
determine which vaccines have already been given and when the next doses are due
according to the standard schedule.
• In general, vaccine-related adverse effects are no more common in preterm than term
babies, although there are some reports of more apneic or bradycardic spells as well as
increased need for oxygen.
Palivizumab (respiratory syncytial virus [RSV] prophylaxis): The American Academy of
Pediatrics recommends that palivizumab (a monoclonal antibody against RSV) be given
before discharge and then monthly during RSV season to babies in the groups listed
below. Respiratory syncytial virus season usually runs from October through April, but
may start earlier or end later in certain areas.
Eligibility Criteria for Palivizumab Administration
• Preterm baby less than 29 weeks’ gestation.
• Preterm baby with chronic lung disease (CLD) who is younger than 12 months at the
start of RSV season. Chronic lung disease is defined as a baby born at less than 32
weeks’ gestation who requires greater than 21% supplemental oxygen or positive pres-
sure ventilation for at least the first 28 days after birth.
• Preterm baby with CLD who is between 12 months and 2 years of age at the start of
RSV season and continues to require medical therapy. Medical therapy is defined as
needing corticosteroid therapy, diuretics, or supplemental oxygen during the 6-month
period prior to RSV season.
• Babies with hemodynamically significant congenital heart disease who are younger
than 12 months at the start of RSV season. These include babies who
– Require medication to control congestive heart failure
– Have moderate to severe pulmonary hypertension
– Have cyanotic heart disease (preoperative or postoperative)
Other babies who qualify for palivizumab administration include babies with cystic
fibrosis, anatomic pulmonary abnormalities, or neuromuscular disorders, as well as
babies who have had a cardiac transplantation or are severely immunocompromised dur-
ing RSV season.
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G. Screening for hearing deficits

Preterm and sick babies are at risk for hearing deficits. These babies should have a hear-
ing screening before discharge.
Universal screening of all neonates, whether sick, at risk, or well, is recommended and is
mandated in most states.
The following factors place babies at risk for hearing loss:
• Birth weight less than 1,500 g (3 lb 5 oz)
• Any of the congenital TORCH infections (See Book III: Neonatal Care, Unit 8,
Infections.)
• Severe perinatal compromise
• Exposure to ototoxic medications
• Bacterial meningitis
• Severe hyperbilirubinemia
• Family history of childhood hearing impairment
• Malformations that involve the head or neck
• Stigmata or other findings associated with a syndrome known to include hearing
impairment
When and how should hearing screening be done?
Hearing should be evaluated before discharge or by 3 months of age for all babies.
Initial screening involves electrophysiological response to sound, using instruments
designed for newborns. However, it is recommended that babies who required more than
5 days of neonatal intensive care unit care be tested using brainstem auditory evoked
response technology, because of their increased risk of nerve injury. If results of the initial
screening are equivocal, the baby should be referred for formal diagnostic testing. All
babies should continue to have routine hearing tests at well-baby examinations.
Some babies are at increased risk of progressive hearing loss in early childhood and
will require rescreening after discharge, even if they have passed the initial newborn
screening.
H. Screening for retinopathy of prematurity
Retinopathy of prematurity (ROP) is an eye disease of preterm babies that may result
from many different factors, including oxygen therapy. The degree of visual impair-
ment may range from slight impairment to total blindness. The likelihood and severity
increases with the degree of prematurity. Once ROP has developed, it must be closely
followed with repeated examinations. The damage may progress to cause retinal detach-
ment if not treated promptly, or it may completely resolve.
At-risk, preterm babies need to be examined at recommended times to detect the changes
of ROP and provide treatment before permanent vision loss occurs.
1. Which babies need examinations for ROP?
In general, the following babies should have a dilated funduscopic examination by an
ophthalmologist with experience in ROP:
• Any baby born at less than 30 weeks’ gestation or with birth weight less than or
equal to 1,500 g (3 lb 5 oz)
• Any baby with a birth weight between 1,500 (3 lb 5 oz) and 2,000 g (4 lb 61∕ 2 oz)
but an unstable clinical course and believed to be at high-risk for ROP
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2. When and how should ROP screening be done?

Timing of the first examination depends on the baby’s gestational age at birth (Table
6.1). The initial examination may have been done at the regional perinatal center
before the baby was discharged. First examinations should be performed on babies on
the basis of their initial gestational age and corrected postmenstrual age.
Table 6.1. Timing of First Eye Examination Based on

Gestational Age at Birth
Gestational Age Age (weeks) at Initial Examination
(weeks) at Birth Postmenstrual Age Chronologic Age
22 31 9
23 31 8
24 31 7
25 31 6
26 31 5
27 31 4
28 32 4
29 33 4
30 34 4
Older gestational age, Consider timing based on severity of
high-risk factors c omorbidities.
The timing of follow-up examinations is dictated by the findings of the first examina-
tion. If both retinas are fully vascularized at the time of the first examination, addi-
tional examinations may not be needed. If the retinas are not fully vascularized, repeat
examinations are indicated, even if there is no initial evidence of ROP.
The examining ophthalmologist will recommend follow-up examinations based on the
initial retinal findings. If the retina is not fully vascularized, follow-up examinations
will be recommended at intervals ranging from less than 1 week to as long as 3 weeks.
The ophthalmologist will also recommend when treatment is indicated.
To minimize the risk of retinal detachment, treatment generally should be

performed within 72 hours of treatable disease being identified.
Clear communication among clinicians and with parents must stress that follow-up is
essential to successful therapy and there is a critical period during which treatment, if
needed, can be carried out to prevent severe vision loss or blindness.
Even if laser therapy is not indicated, it is important for an ophthalmologist to follow
the baby so the parents will know what to expect for and from their baby. In addition,
babies who have had ROP, whether or not treatment was required, are at higher risk
for other vision disorders, including strabismus, amblyopia, cataract, etc. Eyeglasses
may be indicated in some cases and are most beneficial when fitted at an early age.
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I. Late head ultrasound

Most preterm babies born at less than 30 weeks’ gestation will have had a cranial ultra-
sound examination during their acute illness. Current recommendations include a repeat
head ultrasound at 36 to 40 weeks’ postmenstrual age to detect late development of
unsuspected intraventricular hemorrhage, increase in size of the ventricles, or periven-
tricular leukomalacia (a risk factor for cerebral palsy) (or any combination of those).
Although controversial, it is generally not recommend for babies to receive magnetic
resonance imaging studies prior to discharge unless clinically indicated.
J. Sleep position/sleep environment
There is strong evidence that prone (on the stomach) sleeping increases the risk of sudden
infant death syndrome. While there are often good reasons for prone positioning during
acute care, continuing-care babies should be placed on their backs for sleep. This will
get them accustomed to the sleeping position that will be safest at home, and encourage
parents to put their baby “back to sleep” after discharge. With rare exceptions, babies
should be placed supine (on the back) for sleep after discharge home.
As a further precaution against an apparent life-threatening event, soft objects, such as
pillows and stuffed or plush toys, should not be in a baby’s sleeping area. Teach the par-
ents that loose or excessively soft bedding should also be avoided and clothing should be
close fitting. A one-piece sleeper with no blanket or quilt may suffice.
K. Assessment of family
The birth of an at-risk or sick baby may create enormous emotional and financial stresses
for a family or single parent.
Feelings of anxiety, guilt, inadequacy, and anger are common. Additionally, geographic
distance often separates the baby from parents, making visiting difficult. The family, par-
ticularly the mother, may experience a sense of isolation. Young or inexperienced parents
may be overwhelmed by their new responsibilities.
All these factors influence the normal process of parent-baby bonding and subsequent
interactions of the baby and the baby’s family. Because of the increased stresses cre-
ated by the birth of an at-risk or sick baby, these babies are at risk for poor growth and
neglect. Close, frequent contact between the parents and their baby is important to the
development of a healthy relationship.
Personnel caring for these babies must be aware of this high-risk situation. It is important
to promote parent-baby attachment and teach parenting skills, as well as observe family
interactions.
1. How can you assess parent-baby interaction?
• Keep a record of telephone calls made by the parents.
• Keep a record of visits.
• Keep a record of caregiving activities taught to the parents and performed success-
fully by them.
• Assign one nurse to be primarily responsible for communicating with the family.
• Have daily or weekly discussions, starting from the date of admission, among the
nurses, physicians, and social workers concerning the progress of parent-baby
attachment and family interactions, and promptly address any identified problems.
• Start assessment immediately and modify it, as necessary, as the baby’s hospital
course progresses. Do not wait until the baby is ready for discharge to assess family
interactions, teaching that has been done and is needed, and the parents’ ability to
care for their baby.
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2. What can you do to promote parent-baby attachment and positive family interaction?
• Maintain liberal or unlimited visiting hours.
• Make time available to instruct the mother or parents in the routine care of the
baby.
• Allow and encourage the parents to stay for long periods and care for the baby as
much as possible while the baby is in the hospital (change diapers; bathe, hold, and
rock the baby; provide frequent and extended kangaroo care [if parents wish to do
so]; feed the baby; and learn to perform any special procedures the baby will need
after discharge).
• Make time to answer questions.
• Praise the parents for well-performed tasks.
• Be patient with timid and inexperienced parents.
• Involve social service and request increased assistance for families with marked
social, transportation, or economic problems.
• Consider involving public health agencies to aid in assessment of the home
environment.
• Arrange for the mother or parents to “room in” with the baby and provide all daily
care prior to discharge.
• Request psychiatric assistance for parents with marked emotional problems.
L. What is developmental care?
Much interest has centered on modifying the nursery environment, to reduce light, noise,
handling, and interrupted sleep when providing care to sick and at-risk babies. These
measures have come to be lumped under the term developmental care and have been
used for acutely ill babies and babies needing continuing care.
Many developmental care measures make intuitive sense, and some are particularly
welcomed by parents. Although data are accumulating suggesting that individualized
care and family involvement can preserve the child’s development and outcome, large,
well-designed studies are needed to identify what actually makes a difference in neonatal
outcome before specific recommendations can be made regarding these care measures.
The staff in some neonatal intensive care units believe in caring for babies in a relatively
constant low-light environment while they are extremely immature and critically ill. As
these babies approach term and are getting ready for discharge, they should be exposed
to the day-night light variation they will encounter at home.
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Self-test
A1. Give 2 reasons a baby may need continuing care.
A2. List at least 7 basic components of continuing care for preterm babies.
A3. What are 3 important ways to assess the growth of babies requiring continuing care?
A4. Preterm babies who need continuing care should be monitored for ____________ until they weigh
more than ____________ g (____________ oz), have reached a postmenstrual age of ____________
weeks, and have had no apneic spells for ____________ to ____________ consecutive days.
A5. True False Most babies respond to immunizations when they reach 8 weeks’ postnatal
age, regardless of their gestational age at birth.
A6. True False To give a supplemental feeding, you first feed the baby as much as the baby
will eat, then insert a feeding tube and give the remainder of the calculated
volume of feeding.
A7. Which of the following actions is important in weaning a baby from an incubator to a crib?
Yes No
_____ _____ Place a stocking cap on the baby’s head.
_____ _____ Begin antibiotics.
_____ _____ Give the baby at least 25% more calories.
_____ _____ Wrap the baby in extra blankets.
A8. If a baby’s head grows more rapidly than normal, the baby may be developing ____________.
A9. After being weaned to a crib, a baby does not gain weight for several days in a row. List 4 possible
reasons for the lack of weight gain.
A10. Babies requiring medications to treat apnea need 2 types of monitoring.
A11. True False Babies may not have a gag reflex even though they are at 32 to 34 weeks’
estimated postmenstrual age.
A12. True False A 2,100-g (4 lb 10 oz) baby who requires caffeine for management of apneic
spells has had no apnea for 5 to 8 consecutive days. The baby may be safely
discharged home with no additional monitoring needed.
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A13. A baby should be evaluated for possible hydrocephalus if the head circumference grows more than
_______________________________ cm/wk.
A14. A normal weight gain is ______________________________ to ______________________________ g/d
(______________________________–______________________________ oz/d).
A15. Name 2 drugs that may be used for certain babies to decrease the number of apneic spells.
A16. A 1,900-g (4 lb 3 oz) baby has an apneic spell. The baby should be monitored until no apnea has
occurred for _______________________________ to _______________________________ consecutive
days.
A17. Name at least 3 signs that indicate when a low hematocrit may be dangerous.
A18. Name at least 3 ways to assess parental-baby bonding.
A19. It is recommended that a baby’s

• Weight be determined every _______________________________
• Head circumference be determined every _______________________________
• Length be determined every _______________________________
A20. Name 3 reasons a baby who requires continuing care may become anemic.
A21. Which of the following encourage parent-baby attachment?

Yes No
_____ _____ Unlimited visiting hours
_____ _____ Adapting care routines for parents who wish to provide “kangaroo care”
_____ _____ Many nurses caring for the baby and talking with the family
_____ _____ Involvement of social service in special cases
_____ _____ Teaching parents how to bathe and feed their baby
A22. List 2 groups of babies who should receive an eye examination.
A23. True False During respiratory syncytial virus season, babies in certain groups should
receive palivizumab prior to discharge from the hospital.
A24. True False Routine immunizations with diphtheria, tetanus, acellular pertussis; enhanced
inactivated poliovirus; and pneumococcal conjugate can be given at 8 weeks of
age for most preterm babies, but the dose of each vaccine should be reduced
from that given to healthy, term babies.
A25. True False Treatment for retinopathy of prematurity should be carried out within 72 hours
of a treatable condition being identified.
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4. What is involved in discharge of a baby?

Preparation for discharge is an important task. Although most babies will have few, if any,
major problems at the time of discharge, care must be taken to ensure that both baby and fam-
ily are ready for home care to begin.
A. What are the criteria for discharge?
• Baby’s weight is approximately 1,800 to 2,000 g (3 lb 15½ oz–4 lb 61∕ 2 oz).
Note: Some mature but growth-restricted babies (eg, small for gestational age) may be
discharged at a lower weight, if gaining weight appropriately.
• Baby is gaining weight.
• Baby can maintain normal body temperature in a crib.
• Baby is eating well by nipple or breastfeeding well every 3 to 4 hours.
• Baby has been
– Apnea-free 5 to 8 consecutive days, never requiring caffeine
or
– Apnea-free 5 to 8 consecutive days and off caffeine with a subtherapeutic drug level
(,5 mg/L) prior to the start of the apnea countdown
or
– Apnea-free on caffeine and you have detailed plans for careful follow-up of drug
levels
or
– Discharged on a monitor and you have detailed plans for careful follow-up
Note: Some centers use slightly different discharge criteria for babies with apnea.
• Baby’s medical condition is stable. For example, if the baby has congestive heart fail-
ure, it is well controlled on medications.
• The baby is stable when breathing room air or on low-flow oxygen therapy. If the
baby will be discharged on home oxygen therapy, then oxygen equipment, home
cardiorespiratory monitor, and oximeter should be arranged through a home medical
equipment agency. Parents need to be trained in oxygen and monitor use. The primary
care physician should be informed about the baby’s special medical needs. Usually, the
regional perinatal center will also continue to be involved in the baby’s care.
• Baby’s hematocrit is stable or not rapidly falling. No baby who has symptoms from
anemia should be discharged. A baby may be discharged if the hematocrit is as low as
22% as long as the baby is otherwise doing well. Close follow-up by the baby’s pri-
mary care physician will be important.
• Appropriate neonatal screening tests have been done (metabolic screening studies, eye
examinations, hearing screening, etc).
– Many babies do not pass their initial hearing screening. Most will pass on repeat
testing; therefore, it is reasonable to repeat the screening prior to discharge.
– Many premature babies have abnormal results on their newborn metabolic screen-
ings, especially screenings for congenital adrenal hyperplasia and hypothyroidism. In
addition, babies whose blood has been transfused prior to screening do not have a
valid hemoglobinopathy screening result, and this screening will need to be repeated
in several weeks. It is important that newborn metabolic screening issues have been
resolved prior to discharge, or clearly identified for follow-up.
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• Immunizations have been given according to the baby’s age and history.
or
Arrangements have been made for the baby’s primary care physician to see the baby
soon after discharge and to give the immunizations.
– Palivizumab has been given, as appropriate, according to the baby’s age, history, and
risk factors, and the season of the year.
– Encourage parents to receive influenza vaccine prior to or during the flu season.
Likewise, siblings and other caregivers should receive influenza vaccine.
• Baby’s parents have demonstrated the ability to care for their baby, and the home situ-
ation is considered acceptable.
• Baby can tolerate a car seat. The American Academy of Pediatrics recommends that
any baby born at less than 37 weeks’ gestation be observed in a car seat, before dis-
charge, to monitor for apnea, bradycardia, and oxygen desaturation.
In general, the duration of observation should be longer than the length of time the
baby will be in the car seat during the trip from the hospital to home, or 2 hours mini-
mum. If the baby does not tolerate the car seat for this duration, the baby may not be
ready for discharge, or consideration should be given to using a lying-down car bed.
B. How do you plan for discharge?
• Anticipate the discharge a minimum of 2 weeks before the baby goes home.
• Notify the parents of the possible discharge date. Solicit and answer their questions
and concerns.
• Notify any special individuals or groups involved in the care of the child (consultants,
public health department, social services, etc).
• Check the parental visiting record and home environment. If the home situation seems
unacceptable/unstable, request evaluation by a public health nurse or social service (or
both).
• If the baby requires special medications or treatments, make certain the parents
understand the baby’s medical condition, are able to give the medicine appropriately,
and can perform any necessary treatment. It is also recommended that parents bring
in discharge prescriptions to ensure the medication formulation, concentration, and
directions are the same as prescribed.
• Inform the parents of expectations for the baby’s feedings—anticipated volumes,
frequency of feeds, type of formula, and feeding preparation if the baby will be bottle-
fed. If the baby is being discharged on a higher caloric formula, instruct the parents in
its preparation. Breastfed babies will usually be discharged on a vitamin D supplement
(usually a tri-vitamin or multivitamin) and iron. If the baby is eligible for the Special
Supplemental Nutrition for Women, Infants, and Children program, complete the pro-
gram prescription. Additionally, providing instructions to the primary care physician
regarding when to change caloric density is helpful.
• Perform a detailed, thorough physical examination.
• Document weight, length, and head circumference measurements. These will be impor-
tant for outpatient follow-up care.
• Provide car seat instruction and testing, using the same seat the parents will use for
the baby.
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• Talk with the parents frequently, and on the day of discharge. Answer questions,
explain the hospital course, and help parents anticipate the course the baby will follow
for the next several weeks or months.
• Review the immunization schedule.
• Make appointments for well-baby care.
• Arrange for a home visiting nurse or other community-based home visiting program
to assess the baby and the home situation if the baby has significant medical problems
or the social situation seems unstable.
• Make appointments, as necessary, for follow-up hearing tests or eye examinations (or
both). Ensure clear communication with the parents and other care providers regard-
ing follow-up eye examinations and the critical need to keep appointments according
to the schedule recommended by the examining ophthalmologist.
• Refer eligible babies to local early intervention programs for babies at high-risk for
neurodevelopmental delay. Eligibility requirements vary by region.
• Prepare information to send to the baby’s follow-up physicians or primary care physi-
cian (or both). Include history and current status of problems, growth measurements
at discharge, any medications with details about measuring serum levels and need to
adjust for weight, and a list of follow-up appointments.
• In addition to sending written information, for babies with complex medical problems
or discharge needs, consider contacting the baby’s primary care physician directly.
• Reinforce the need for the at-risk baby to be seen for serial developmental evaluations.
Many regional perinatal centers have follow-up clinics. Appropriate babies for serial
developmental follow-up include very low-birth-weight (birth weight ,1,500 g
[3 lb 5 oz]) and extremely low-birth-weight (birth weight ,1,000 g [2 lb 3 oz]) babies,
as well as babies with a history of intraventricular hemorrhage, seizures, hydro-
cephalus, hypoxic-ischemic encephalopathy, chronic lung disease, or other chronic
medical conditions.
134

Self-test
B1. True False A baby who has been started on a new drug to treat an unstable medical con-
dition can be discharged the same day.
B2. True False An asymptomatic baby with a stable hematocrit of 22% to 24% can be
discharged.
B3. A baby is medically ready for discharge. However, despite repeated attempts to contact the parents,
you have been unable to reach them for 2 weeks. One day, they appear unexpectedly at the hospital
and want to take their baby home. What would you do?
B4. List at least 5 activities important in planning for discharge.
B5. True False An appropriate-size-for-gestational-age baby weighs 1,400 g (3 lb 1 oz), has

never had an apneic spell, and is gaining weight steadily. This baby can safely
be discharged home at this time.
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Subsection: Babies With Special Problems
1. What special problems may be encountered in babies requiring

continuing care?
Most babies referred to you will be stable, preterm babies. However, some babies who recover
from an initial severe illness will develop special problems requiring frequent, but not constant,
attention.
For example, some babies who were born extremely preterm or who required assisted ventila-
tion for treatment of severe respiratory distress syndrome may develop lung damage. These
babies can eventually recover but may require supplemental oxygen for long periods. They may
have needed numerous blood gas determinations during the acute phase of the disease. At this
stage of the illness, they need blood gas analyses much less often, especially if continuous pulse
oximetry is used. Sudden changes are not expected, yet the babies must be monitored for this
special problem as well as receive the routine care described earlier in this unit.
The following list is problems sometimes seen in babies recovering from acute neonatal ill-
nesses. If you are caring for a baby with one of these problems, your regional perinatal center
can give you more specific information about the cause, treatment, and prognosis of the par-
ticular problem in that particular baby.
A. Chronic lung disease
Postneonatal CLD (formerly termed bronchopulmonary dysplasia) is a form of lung
disease thought to result from the combined effects of high concentrations of oxygen and
trauma to the lungs from ventilator therapy. It is generally defined as requiring supple-
mental oxygen at 36 weeks’ postmenstrual age. Some extremely preterm babies will
develop CLD, even if they did not need therapy with a ventilator or high oxygen concen-
tration. Babies with CLD may require supplemental oxygen by nasal cannula for weeks
or even months.
In general, these babies exhibit steady improvement and progressively require less oxygen
to maintain a good blood oxygen concentration. It is important to remember, however,
not to decrease supplemental oxygen too quickly because chronic low blood oxygen may
cause serious, permanent damage to the heart and lung blood vessels.
Unlike adults with CLD, these babies form new, healthy lung tissue as they grow and,
therefore, may eventually recover completely. If they become ill, it is usually related to the
onset of pneumonia or fluid retention.
Occasionally, some babies will require supplemental oxygen for such long periods that
you, the regional perinatal center, and the family decide it is most reasonable that the
baby be cared for at home. These are very special cases, with the baby receiving supple-
mental oxygen and other medications at home, and will be managed by you and the
regional perinatal center together.
B. Gastroesophageal reflux
Gastroesophageal reflux occurs when stomach contents reflux into the esophagus. This
disorder, apparently more common in preterm than term babies, is being diagnosed with
increasing frequency in sick and at-risk babies. It presents typically with frequent spitting
or vomiting after feedings or continual regurgitation and may be associated with apnea
and bradycardia.
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Treatment regimens may include thickening feedings and positioning. There is no evi-
dence that the use of acid inhibitors (H2-receptor antagonists or proton pump inhibitors)
decreases reflux and there is increasing evidence that acid inhibition can increase a baby’s
risk for sepsis and necrotizing enterocolitis.
Consult with your regional perinatal center staff to establish a treatment plan specific to
each particular baby.
C. Short bowel syndrome
Sometimes babies are born with less than the normal length of intestines. Other babies
have variable lengths of intestine removed during surgery for certain types of bowel dis-
ease, such as necrotizing enterocolitis.
Sometimes these babies have ostomies. If an ostomy is present, it will require special care,
and parents should receive detailed instructions. Ostomies may be permanent, or the
bowel may be reconnected at a later date.
Babies with a decreased amount of intestine for any reason may have trouble absorbing
milk or formula. They may have problems with weight gain, blood electrolyte imbalance,
or dehydration (or any combination of those). Breast milk remains the preferred feeding
because of growth hormones and digestibility. If breast milk is not available, infant for-
mulas with partially hydrolyzed protein or amino acid–based formulas are often needed.
These babies will also require frequent weight checks and occasional checks of blood
electrolytes. Blood electrolyte samples are needed more often if the volume of ostomy
output or number of stools increases.
D. Cholestatic jaundice
Babies who have required long periods of parenteral nutrition therapy may develop
elevations of their direct (conjugated) bilirubin level. This may be associated with eleva-
tions of their liver enzyme levels. In most cases, this condition will resolve over time with
no long-term complications. Abdominal ultrasound may be performed to rule out other
causes. Many babies benefit from the drug ursodiol, which stimulates bile solubility and
flow. Monitoring usually includes serial measurements of total and direct bilirubin and
liver enzyme levels. If conjugated bilirubin level is very elevated and stool is lacking pig-
ment, provide liquid “ADEK” for a water-soluble form of fat-soluble vitamins until the
cholestasis resolves and consider gastroenterologic expertise.
E. Seizures
There are many causes of seizures in the newborn period. Babies may be sent home from
nurseries on anticonvulsants, such as phenobarbital. These babies must be monitored for
the recurrence of seizures and have their anticonvulsant drug dose adjusted as they grow.
Some will require determination of blood levels of their anticonvulsant medication.
They must also be observed carefully for signs of developmental delay.
F. Hydrocephalus
Babies who were ill at birth will occasionally develop hydrocephalus, particularly if
they were born extremely preterm and developed an intraventricular hemorrhage. These
babies may require the insertion of a shunt to prevent accumulation of excess cerebrospi-
nal fluid in the brain. The shunt may malfunction and fluid pressure may build up. These
babies may also get shunt infections. Babies with shunts must be monitored for change
137

in activity or increase in head size (or both), which would suggest a shunt malfunction or
infection.
Babies with mild hydrocephalus, but without shunts, should have head circumferences
and tenseness of their fontanels checked frequently. Coordinate with the regional perina-
tal center to schedule follow-up cranial ultrasound examinations.
G. Congenital heart disease/patent ductus arteriosus
Babies with congenital heart disease may be cyanotic (blue) or acyanotic (pink), depend-
ing on the type of abnormalities in the formation of their hearts.
Cyanotic babies frequently require surgery early in life. They require monitoring for the
level of blood oxygen, medication levels, and development of acidosis, and for “blue
spells.”
Babies with acyanotic heart disease are frequently on medications for congestive heart
failure. They require monitoring for signs of congestive heart failure and may need
adjustment of their medications.
Many premature babies have a patent ductus arteriosus (PDA) during their acute illness.
Medications (indomethacin or ibuprofen) may have been used to close the PDA or surgi-
cal ligation may have been required. Some babies may continue to have a small PDA that
is causing no or minimal symptoms. A systolic murmur may be heard. The usual course
for these PDAs is to eventually close on their own. However, follow-up with a pediatric
cardiologist should be arranged.
Soft, systolic murmurs are often heard in the growing, premature baby. These “physi-
ological,” “innocent,” or “flow” murmurs are not associated with other symptoms. They
are often associated with mild to moderate anemia, causing rapid blood flow through the
lung.
2. How do you care for these special problems?

Certain routines of monitoring and treatment should be carried out for these babies. Use the
following guidelines (Table 6.2), but do not hesitate to call the regional perinatal center if you
have questions or the baby appears to be worsening.
Note that the intervals suggested for monitoring are intended for stable babies. An unstable
baby may need more frequent monitoring.
Knowledge of the best treatment for these conditions changes rapidly.

Frequent communication with your regional perinatal center staff is important if you
are caring for a baby with a special problem.
138

Self-test
C1. Name 2 types of congenital heart disease.
C2. True False A baby with seizures appears normal at the time of discharge. In spite of this,
the child should be assessed later for the appearance of developmental delay.
C3. Babies with hydrocephalus may require insertion of a __________________________ to prevent accu-
mulation of excess cerebrospinal fluid.
C4. True False Babies who require supplemental oxygen for months generally recover and can
be discharged from the hospital.
C5. True False Visual impairment from retinopathy of prematurity may range from slight
impairment to total blindness.
C6. Babies with cyanotic congenital heart disease may require monitoring for
C7. Two major problems with shunts used to treat hydrocephalus are ____________________________ and
_____________________________.
C8. When babies with chronic lung disease become ill, it is usually with ______________________________
or _____________________________.
C9. Babies with acyanotic congenital heart disease are frequently on medications for
________________________________________________________________________________.
C10. The dose of anticonvulsant drugs should be adjusted according to the
A. Length of the baby
B. Weight of the baby
C. Head circumference of the baby
139

06_Unit6_BKIV_PCEP_111-154.indd 140
140

Table 6.2. Monitoring and Treatment Guidelines for Babies With Special Problems
Monitoring Reason for Monitoring Abnormality Action
A. CLD (Formerly Termed Bronchopulmonary Dysplasia)
Weight Babies with CLD may retain fluid in their lungs Rapid increase in weight • Decrease baby’s fluid intake, perhaps by in-
(every day) and may have right-sided heart failure. gain creasing caloric density in feeds.
• Increase diuretic dose or begin diuretics.
Babies with CLD require more energy to Lack of weight gain. • Review concentration of calories in formula or
breathe. Therefore, they may require more than human (breast) milk supplements.
the normal number of calories to breathe and • Check the baby’s blood oxygen concentration.
grow. Babies with chronically low blood oxygen will
not gain weight well. The baby’s oxygen satura-
tions should be maintained slightly higher
(eg, 92%–96%).
Medications Babies with CLD are frequently on several med- • Worsening arterial blood Increase the dose appropriate for the weight.
ications. These medications may require fre- gases
quent adjustment in dose. Some medications are • Increased weight gain
tapered routinely, while others are increased
gradually as the baby grows.
Aminophylline Babies with CLD often have bronchospasm. • Increased wheezing (too • Monitor level and adjust dose (keep approxi-
Aminophylline is now seldom used as a bron- little drug) mately 10–12 mcg/mL).
chodilator for these babies but may be required • Tachycardia, 180 beats/ • May need to increase dose on basis of serum
if the baby develops reactive airway disease or min (too much drug) level.
asthma. • Recurrent vomiting • May need to decrease or hold dose on basis of
Dosage (after loading dose): 1.5–3.0 mg/kg/dose serum level.
every 6–8 hours, depending on baby’s age.
Albuterol Nebulized albuterol is frequently used to de- • Increased wheezing (too • Give dose immediately; monitor heart rate.
crease bronchospasm in babies with CLD. little drug)
Dosage: 0.1–0.5 mg/kg/dose every 4–6 hours. • Tachycardia, 180 beats/ • May need to hold dose and increase interval be-
min (too much drug) tween doses.
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Caffeine citrate Used more often than aminophylline since the • Restlessness Therapeutic level: 8–20 mcg/mL
therapeutic index is greater, although relative ef- • Recurrent vomiting
fect on bronchospasm is not well defined and
availability in outpatient settings is limited.
Loading: 20 mg/kg enterally or intravenously
over 30 minutes.
Maintenance: 5–8 mg/kg enterally or intrave-
nously every 24 hours.
Spironolactone (Al- Dosage: 1–3 mg/kg/dose every 24 hours, given May cause hyperkalemia; • Monitor serum electrolytes.
dactone) orally use with caution in patients • Try to wean off medication as lung disease
receiving supplemental i mproves.
potassium. • Consider adding potassium chloride to feedings
Furosemide (Lasix) Dosage: 1–4 mg/kg/d divided into 3–4 doses • Electrolyte abnormalities to correct hypochloremic alkalosis.
Chlorothiazide Dosage: 10–20 mg/kg/dose every 12–24 hours, (hypochloremic alkalosis
given orally from chloride loss)
• Osteopenia and kidney
stones from increased cal-
cium excretion

Hematocrit Babies with CLD may become worse if they be- Hematocrit ,30% for • Look for cause of anemia.
(every week) come anemic. babies still requiring oxygen • Treat cause of anemia.
therapy • Consider transfusion if oxygen requirements are
high and baby is not improving.
Electrolytes Diuretics may cause abnormalities in serum so- Decreased levels of sodium, • Increase sodium, potassium, and chloride intake
(every week) dium, potassium, chloride, or calcium (or any potassium, and chloride in diet.
combination of those). Low chloride excretion • A decrease in serum sodium in face of increased
has been associated with poor growth and poor weight may indicate excess fluid retention, in
outcome. High calcium excretion has been asso- which case sodium chloride therapy would be
ciated with renal calculi. contraindicated.
• Consider decreasing dose of furosemide or add-
ing spironolactone (or both).
CLD may lead to fluid overload with a dilu- Decreased sodium level Assess for weight gain. Restrict fluids; increase di-
tional decrease of serum sodium. uretic dose.
141
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142

Table 6.2. Monitoring and Treatment Guidelines for Babies With Special Problems (continued)
Chest radiograph Babies with CLD frequently develop Pneumonia (Always com- • Consider antibiotics.
pneumonia. pare with prior baseline • Provide chest physical therapy.
radiograph.)
Electrocardiogram CLD may lead to right ventricular hypertrophy. Worsening right ventricular • The baby’s oxygen saturations should be main-
or echocardiogram hypertrophy tained slightly higher (eg, 92%–98%). Make
certain baby’s Pao2 is $60 mm Hg or oxygen
saturation is 92%–98% (or both) during sleep
and all activities.
• Make certain baby is on adequate doses of
diuretics.
• Extended periods of suboptimal oxygenation or
deteriorations should be evaluated with an
echocardiogram or electrocardiogram. Consider
in babies ,30 weeks’ gestation who still require
supplemental oxygen at 36 weeks’ gestation.
• Consult regional perinatal center if there is
worsening right ventricular hypertrophy as sug-
gested by electrocardiogram or echocardiogram;
CLD may be inadequately treated.
Heart rate and Any hospitalized baby requiring supplemental Bradycardia • Administer oxygen.
oximetry oxygen should have continuous electronic heart • Assess for increased secretions and blocked
monitoring rate and oximetry monitoring. Bradycardia may a irway.
occur with desaturations. Oximetry should be • Assess for infection.
used to determine supplemental oxygen needed.
9/6/16 11:34 AM
Physical findings Babies with CLD frequently have reactive air- Increased wheezing • Assess arterial blood gas or oxygen saturation
Note: Sustained ways and demonstrate marked bronchospasm (or both).
decrease in (wheezing). Often, these babies require bron- • Assess bronchodilator level/dose and diuretic
respiratory chodilators. Bronchospasm can also result from dose.
rate is a good chronic hypoxia. • Consider immediate dose of an inhaled bron-
indicator of chodilator.
improve- • Assess for pneumonia.
ment. Rales may be due to infection, or fluid retention Increased rales and in- • Assess arterial blood gas or oxygen saturation.
in the lungs. Babies with CLD may also have creased hepatosplenomegaly • Assess diuretic dose.
hepatosplenomegaly from right-sided heart • Assess for pneumonia.
failure.
Babies with CLD may have excess secretions Excess secretions, signs of • Increase frequency of chest physical therapy.
that, if not removed, predispose the baby to pneumonia Give at least twice a day.
pneumonia. • Assess for pneumonia.
Supplemental Fio2 As the baby improves, you will be able to lower None Decrease Fio2 for saturations consistently .94%
the Fio2 required to maintain a Pao2 of approx-
imately 60 mm Hg and an oxygen saturation of

90%–94%.
Any Fio2 greater than that necessary to main- Persistently high Fio2 • Monitor arterial blood gases or oxygen
tain a Pao2 of 60 mm Hg (or oxygen saturation saturation.
of 90%–94%) may be unnecessarily damaging • Decrease Fio2 for consistent Pao2 .70 mm Hg
to the lungs of babies with chronic disease. or oxygen saturation .94%.
Too low an Fio2 may cause a low Pao2, in- Cyanosis, increased bron- • Monitor arterial blood gases or oxygen
creased bronchospasm, or decreased blood flow chospasm, tachypnea, s aturation.
to the lungs and may also inhibit the or wheezing • Increase Fio2 for consistent Pao2 ,60 mm Hg
baby’s growth. or oxygen saturation ,90%.
143
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144

Blood gas Initially, blood gases are frequently monitored on None None
sick babies, but monitoring frequency decreases
as the baby grows older and more stable. Gener-
ally, capillary blood gases 1–2 times/wk on ba-
bies requiring positive pressure with continuous
pulse oximetry provides adequate monitoring.
Oxygen Pao2 should be kept approximately 60 mm Hg. Pao2 ,60 mm Hg or oxy- • Increase supplemental oxygen.
Oxygen saturation, during all activities (feeding, gen saturation ,90% • Look for cause of decreased Pao2 (pneumonia,
sleeping), should be kept slightly higher than increased secretions, worsening right-sided heart
that for respiratory distress syndrome failure).
(eg, 90%–94%). • Assess for bronchospasm.
Carbon dioxide Carbon dioxide level is usually increased in CLD. Increased Paco2 over base- • Assess for pneumonia.
• If carbon dioxide is getting progressively line value • Obtain chest radiograph.
higher, the baby’s condition is worsening. • Suction secretions.
• If carbon dioxide is decreasing, the baby is
improving.
pH pH is usually normal in these babies. If it is in- Decrease in pH • Assess for bronchospasm.
creased or decreased, the baby may be worsen- • Assess for pneumonia.
ing or improving. • Obtain chest radiograph.
• Suction secretions.
B. ROP
Evaluation by oph- Examine babies born at 30 weeks’ gestation or Blindness may occur if • Laser coagulation therapy may be helpful. If
thalmologist with birth weight ,1,500 g (3 lb 5 oz), and ba- retinopathy is not needed, it should be performed within 72 hours
bies with a birth weight between 1,500–2,000 g treated appropriately. of a treatable condition being identified.
(3 lb 5 oz–4 lb 61∕ 2 oz), but with an unstable • Contact your regional perinatal center staff for
clinical course and believed to be at high-risk information concerning management and referral.
for ROP. If the retinas are not fully vascular- • Intraocular injection of monoclonal antibody
ized, repeat examinations are indicated by ges- (bevacizumab) to vascular endothelial growth fac-
tational age and retinal status, even if there was tor may be used to treat early, aggressive disease.
no initial evidence of ROP. Dilated funduscopic • Have corrective eyeglasses (if prescribed)
examination should be done by an ophthal fitted early.
mologist with experience in ROP.
9/6/16 11:34 AM
Family’s under- Families may have difficulty accepting that their Denial by the family of the Counsel family that keeping examination, treat-
standing of the dis- baby may be at risk for vision impairment. baby’s condition, or inade- ment, and follow-up appointments is essential for
ease and interaction quately informed about the optimal preservation of sight.
with their baby condition and importance of
follow-up
C. Gastroesophageal Reflux
Weight Babies with gastroesophageal reflux may regur- Lack of weight gain Consider formula/milk thickeners.
gitate so much that they do not satisfactorily
gain weight.
Medications Babies with gastroesophageal reflux are some- • More reflux events Consult regional perinatal center staff.
times on medications to improve gastric empty- • Increased apnea/
ing and gastrointestinal motility. bradycardia
D. Short Bowel Syndrome
Weight An increase in weight is a sign of adequate in- Decrease in weight • Assess caloric intake.
(every day) take and absorption. A decrease in weight is a • Assess number of stools or volume of ostomy
sign of malabsorption. output, stool pH, electrolytes, and serum urea

nitrogen.
Formula-fed babies who have more stools or in- Increase in output • Assess for malabsorption of carbohydrates by
creased ostomy output may develop checking pH of the stool. pH ,6 suggests car-
malabsorption. bohydrate malabsorption.
• Put baby on half-strength formula or temporar-
ily clear liquids.
Electrolytes and se- Babies with increased fluid losses through the • Decreased sodium level • Increase sodium intake in diet.
rum urea nitrogen intestine may develop electrolyte abnormalities. • Decreased potassium • Increase potassium in diet.
• Increased serum • Assess for signs of dehydration and consider ad-
urea nitrogen ministration of intravenous fluids.
145
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146

D. Short Bowel Syndrome
Family understand- Family must be educated regarding ostomy care, • Lack of instruction • Teach family importance of their care and
ing of condition or care of buttocks, and taught warning signs • Lack of interest observations.
such as increase in stools or ostomy output. • Observe family’s ability to provide all details of
care.
E. Seizures
Anticonvulsant As the baby grows and gains weight, the anti- Increase in seizure activity • Monitor drug levels.
drugs convulsant dose will need to be increased. • Adjust dose of anticonvulsant.
After administering a loading dose to achieve • Consult regional perinatal center staff.
suppression of seizures, use a maintenance dos-
age of 3.5–5 mg/kg/d of phenobarbital.
Measure serum levels periodically. Adjust dose
as necessary to keep a serum level of 20–30
mcg/mL.
F. Hydrocephalus
Head circumference Worsening hydrocephalus or a malfunctioning Head circumference in- • Obtain cranial ultrasound.
(daily) shunt will cause head circumference to increase. creases .1.25 cm/wk or • Consult regional perinatal center staff.
0.25 cm/d, over several
days.
Signs of infection Babies with shunts in place may develop infec- • Irritability • Obtain blood cultures, complete blood cell
tions around or within the shunt. • Lethargy count, etc.
• Vomiting • Consult regional perinatal center staff.
• Fever
• Tense fontanel
G. Poor Head Growth
Head circumference Provide continued surveillance of babies with Head circumference does • Assess caloric intake and weight gain.
(weekly) severe perinatal compromise. not increase at least 0.5 cm/ • Monitor developmental progress.
wk for several weeks. • Obtain cranial ultrasound.
• Discuss concerns with family.
• Consult regional perinatal center staff.
9/6/16 11:34 AM
H. Poor Parent-Baby Attachment

Number of visits/ Sick or preterm babies are more frequently ne- • Few visits Make time to listen to parents, counsel parents,
phone calls glected than healthy, term babies. • Few phone calls and teach parenting and caregiving skills.
Interaction among Preterm babies are also more often born to Excessive friction among • Involve your hospital’s social service
family members mothers who are family members department.
• Young • Consult public health department.
• Poor
Parenting skills • Substance users • Poor parenting skills • Consult a psychiatrist if family problems are
• Young, single, first-time parent • Inadequate resources severe.
• Indigent • Detain the baby until family/social problems are
resolved or situation is stable enough for the
baby to be discharged.
Readiness of home No readiness in the home Arrange frequent follow-ups with visiting nurse
for the baby and regular follow-ups with physician.
I. Congenital Heart Disease
Heart rate Worsening CHF or hypoxia will affect heart • Increase in heart rate • Assess for CHF.

rate. • Decrease in heart rate • Assess for hypoxia.
Weight (every day) Worsening CHF will result in fluid retention • Weight gain .20–30 g/d • Assess for increasing CHF (increased rales, in-
and excessive weight gain. (7∕10 –1 oz/d) creased hepatosplenomegaly).
• Decrease in weight • Consider an increase in diuretic dose.
• Assess for inadequate caloric intake.
Hematocrit A low hematocrit may cause CHF. • ,30% • Assess cause for anemia.
A high hematocrit may mean chronically worse • .60% • Assess for increasing CHF.
hypoxia in a cyanotic baby. • Consult regional perinatal center staff.
Medications Babies with heart disease may be on medica-
tions whose dose will need to be increased with
growth and weight gain.
Diuretics Diuretics help prevent fluid retention resulting Worsening CHF Increase dose appropriate for weight.
from CHF.
147
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148

I. Congenital Heart Disease
Electrolytes (every Diuretics may cause excessive sodium, potas- Decrease in sodium level Carefully increase dose of sodium supplement, but
week) sium, chloride, or calcium (or any combination consider that a decrease in serum sodium in face
of those) loss. of increased weight may indicate worsening CHF.
Decrease in potassium Increase potassium supplement.
Decrease in chloride Increase chloride supplement (usually as potas-
sium chloride) or decrease diuretic dose.
Hypercalciuria Monitor for renal calculi with urinalysis and pos-
sibly renal ultrasound.
Chest radiograph Observe for signs of CHF or pneumonia. Lung infiltrates or enlarging • Increase diuretic dose.
heart size (or both) • Consider antibiotics.
Electrocardiogram Babies with heart disease may develop worsen- • Increasing left or right Consult regional perinatal center staff.
or echocardiogram ing right or left ventricular hypertrophy or dem- ventricular hypertrophy
onstrate arrhythmias. • Development of arrhyth-
mias
Physical Worsening CHF will cause increased rales, hep- • Increased rales • Adjust dosage for weight.
examination atosplenomegaly, and a gallop rhythm of • Increased • Consult regional perinatal center staff.
the heart. hepatosplenomegaly
• Presence of gallop
Abbreviations: CHF, congestive heart failure; CLD, chronic lung disease; Fio2, inspired oxygen concentration; ROP, retinopathy of prematurity.
9/6/16 11:34 AM
Continuing Care for At-Risk Babies

Recommended Routines
All the routines listed below are based on the principles of perinatal care presented in the unit
Unit 6: continuing care for at-risk babies/ recommended routines

you have just finished. They are recommended as part of routine perinatal care.
Carefully read each routine and decide whether it is standard operating procedure in your
hospital. Check the appropriate blank next to each routine.
Procedure Standard Needs Discussion

in My Hospital by Our Staff
__________________ __________________ 1. Establish the following policies for continuing-

care babies:
__________________ __________________ • Maintain in an incubator until the baby
weighs approximately 1,600 g (3 lb 8 oz) to
1,700 g (3 lb 12 oz).
__________________ __________________ • Feed by tube feedings until the baby reaches
32 to 34 weeks’ postmenstrual age, demon-
strates a gag reflex, and can coordinate suck-
ing, swallowing, and breathing.
__________________ __________________ • Weigh daily.
__________________ __________________ • Measure head circumference and length
weekly.
__________________ __________________ • Monitor for apnea until the baby
__________________ __________________ – Weighs 1,800 g (3 lb 15½ oz)
__________________ __________________ – Reaches a postmenstrual age of 35 weeks
__________________ __________________ – Has been apnea-free for 5 to 8 consecutive
days (off medication)
__________________ __________________ • Periodically measure the baby’s hematocrit.
Discharge the baby on iron-fortified formula
or supplemental iron (or both), unless there
are contraindications.
__________________ __________________ • Start assessment of the home environment
and begin to teach caregiving skills as soon
as a baby is admitted.
__________________ __________________ • Record family visiting patterns and perfor-
mance of caregiving skills.
__________________ __________________ 2. Develop a predischarge checklist to review for
all continuing-care babies.
__________________ __________________ 3. Develop a system for periodically communicat-
ing with the regional perinatal center staff re-
garding the progress of any continuing-care
baby who has a special problem.
149

Self-test Answers
A1. Any 2 of the following reasons:
• Additional weight gain
• Monitoring of special problems
• Physiological maturation to improve functions such as temperature control, regular respirations, and
feeding
A2. Any 7 of the following components:
• Temperature control
• Feeding
• Assessment of growth
• Apnea monitoring
• Monitoring for anemia
• Assessment of family
• Administering immunizations
• Screening of hearing
• Screening for retinopathy of prematurity
• Accustoming baby to supine (back) sleep position
• Late head ultrasound
A3. Weight
Head circumference
Length
A4. Preterm babies who need continuing care should be monitored for apnea until they weigh more than
1,800 g (3 lb 15½ oz), have reached a postmenstrual age of 35 weeks, and have had no apneic spells
for 5 to 8 consecutive days.
A5. True
A6. False.
Reason: A feeding tube should not be inserted during or shortly after a feeding. Doing so may
cause the baby to vomit and thus increase the risk that the baby will aspirate some of the
feeding.
A7. Yes No
X Place a stocking cap on the baby’s head.
X Begin antibiotics.
X Give the baby at least 25% more calories.
X Wrap the baby in extra blankets.
A8. If a baby’s head grows more rapidly than normal, the baby may be developing hydrocephalus.
A9. Baby is cold.
Caloric intake is inadequate.
Baby is acidotic.
Baby is infected (septic).
A10. Continuous electronic heart and respiratory rate monitoring
Checking blood level of the medication
A11. True
A12. False.
Reason: Prior to discharge, babies should be apnea-free for 5 to 8 consecutive days after
the medications have been stopped and the baby’s blood has been tested and shown to be
drug-free (except in very rare circumstances when home monitoring may be used and careful
follow-up is ensured).
A13. A baby should be evaluated for possible hydrocephalus if the head circumference grows more than
1.25 cm/wk.
150

A14. A normal weight gain is 20 to 30 g/d (7∕10–1 oz/d).

A15. Theophylline
Caffeine
A16. A 1,900-g (4 lb 3 oz) baby has an apneic spell. The baby should be monitored until no apnea has
occurred for 5 to 8 consecutive days.
A17. Any 3 of the following signs:
• Sustained heart rate faster than 160 beats/min
• Sustained respiratory rate faster than 60 breaths/min
• Onset or increase in apneic spells
• Poor feeding and poor weight gain
A18. Any 3 of the following ways:
• Record telephone calls and visits made by the parents.
• Record caretaking activities taught to parents and performed by them.
• Assign one nurse to be the primary nurse communicating with the family.
• Have regular, frequent discussions among the nurses, physicians, and social workers concerning
parent-baby attachment and family interactions.
• Start assessment early, so there is time to address any problems or provide adequate teaching
before the baby is ready for discharge to home.
A19. Day
Week
Week
A20. Any 3 of the following reasons:
• Blood taken for laboratory tests
• Iron deficiency
• Normal drop in hemoglobin level and hematocrit that occurs in all babies in the weeks following
birth
• Lower hematocrits of babies born preterm
A21. Yes No
X Unlimited visiting hours
X Adapting care routines for parents who wish to provide “kangaroo care”
X Many nurses caring for the baby and talking with the family
X Involvement of social service in special cases
X Teaching the parents to bathe and feed their baby
A22. Any baby born at 30 weeks’ gestation or less or with a birth weight of 1,500 g (3 lb 5 oz) or less
Any baby with a birth weight of 1,500 g to 2,000 g (3 lb 5 oz–4 lb 61∕2 oz) with unstable course and
thought to be at high-risk for retinopathy of prematurity
A23. True
A24. False.
Reason: Diphtheria, tetanus, acellular pertussis; Haemophilus influenzae type b conjugate;
enhanced inactivated poliovirus; and pneumococcal conjugate vaccines should each be given
in the usual dose of 0.5 mL for preterm and term babies.
A25. True
B1. False.
Reason: Babies requiring medication should have their conditions stabilized and their
response to any new medication assessed before being discharged.
B2. True. However, babies with signs of anemia should not be discharged.
151

B3. Evaluate the parents’ readiness and ability to care for their baby at home.
• Observe the parents taking care of their baby (feeding, bathing, diapering, etc). Encourage the par-
ents to visit for several hours or days (or both). Assist them in making these arrangements.
• Ask the parents what preparations they have made at home for the baby.
• Determine a system for medical follow-up for the baby.
• Find out what questions or misunderstandings (or both) the parents have about their baby. Provide
them with the correct information.
• Contact a social service, public health department, etc, if additional assistance or follow-up care is
needed.
B4. Any 5 of the following activities:
• Plan ahead.
• Determine if the baby is medically ready for discharge.
• Review parental visiting record and interaction with baby.
• Assess parents’ ability to care for their baby. Solicit and answer their questions and concerns.
• Assess parents’ ability to give medications or provide special care measures (or both), if the baby
needs any.
• Notify any special individuals or groups involved in the baby’s care; make appointments for well-
baby care, and for any special follow-up examinations that may be needed.
• Determine if preparations have been made in the home for the baby. Assess home environment.
• Determine what medical or social service follow-up (or both) will be needed and how this will be
done.
• Document weight, length, and head circumference.
• Perform a detailed physical examination. Prepare information to send to the baby’s follow-up and
primary care physicians.
• Review immunizations; make appointments, as necessary, for follow-up hearing and eye
examinations.
• Provide car seat testing and use instructions.
Reason: Preterm babies are at risk for apneic spells until they reach a weight of 1,800 g
B5. False.
(3 lb 15½ oz) or more and a postmenstrual age of 35 weeks or more.
C1. Cyanotic (Babies are blue.)
Acyanotic (Babies are pink.)
C2. True
C3. Babies with hydrocephalus may require insertion of a shunt to prevent accumulation of excess cere-
brospinal fluid.
C4. True
C5. True
C6. Arterial oxygen concentration
Blood level of drugs used to treat their condition
Development of acidosis
“Blue spells,” or times when the baby becomes extremely cyanotic
C7. Two major problems with shunts used to treat hydrocephalus are shunt blockage and shunt infection.
C8. When babies with chronic lung disease become ill, it is usually with pneumonia or fluid retention.
C9. Babies with acyanotic congenital heart disease are frequently on medications for congestive heart
failure.
C10. B. Weight of the baby
152

Unit 6 Posttest
153

PCEP
Perinatal Continuing Education Program
Pretest Answer Key

Book IV: Specialized Newborn Care
Unit 1: Direct Blood Pressure Measurement

1. C. Severe anemia 5. True
2. True 6. A. Baby’s heart
3. True 7. D. Measurement of acid-base balance
4. False
Unit 2: Exchange, Reduction, and Direct Transfusions

1. True 8. True
2. True 9. False
3. False 10. False
4. False 11. D. Tachypnea
5. C. Blood is not given. 12. A. 30-week baby who is appropriate for
6. A. 1 to 10 days. gestational age
7. True 13. B. 18 mL
Unit 3: Continuous Positive Airway Pressure

1. A. Intravenous fluids 6. B. 4 to 8 cm H2O pressure
2. D. Preterm baby with respiratory distress 7. A. Decrease the Fio2 to 40% to 50%, and
syndrome decrease the nasal CPAP to 6 cm H2O
3. False pressure.
4. False
5. C. Increase the baby’s arterial oxygen
concentration.
Unit 4: Assisted Ventilation With Mechanical Ventilation

1. E. Expiratory resistance 5. D. Rate should be faster.
2. B. Capillary Po2 6. C. High pH
3. A. End-expiratory pressure should be
higher.
4. B. A 1,500-g (3 lb 5 oz) baby with respira-
tory distress syndrome who is breathing
80% oxygen and has a Pao2 of 45,
Paco2 of 65, and pH of 7.28
155
07_AnsKey_BKIV_PCEP_155-156.indd 155 9/6/16 11:35 AM

Pretest answer key
Unit 5: Surfactant Therapy

1. A. Contains phospholipids and proteins 6. A. Bolus instillation into the trachea
2. C. Will have a direct effect on alveolar 7. False
stability 8. True
3. A. It is the cause of respiratory distress 9. True
syndrome. 10. False
4. D. Mother is infected with HIV. 11. True
5. B. Lower
Unit 6: Continuing Care for At-Risk Babies

1. A. Urine pH 6. True
2. Yes No 7. False
X Request consultation from 8. False
social service department 9. True
staff. 10. False
X Call the parents and chat 11. False
with them about their baby. 12. False
X Begin making plans for the 13. False
baby to be sent to a foster 14. C. Bronchopulmonary dysplasia
home. 15. B. Feed the baby as much as he or she
3. B. 1,000-g (2 lb 3 oz), preterm baby re- will take by nipple while a feeding tube
quiring assisted ventilation is in place, and then give the remainder
4. D. All preterm babies with a Pao2 greater of the feeding through the tube.
than 100 mm Hg will develop retinopa- 16. D. Adjusting the room temperature to
thy of prematurity. neutral thermal environment during
5. Yes No the weaning period
X Measure baby’s head cir- 17. Yes No
cumference once a week. X Blood electrolytes
X Start the baby on X Volume of urine output
phenobarbital. X Stool pH
X Weigh the baby daily. X Hematocrit
X Give iron dextran (Imferon) X Weight gain
intramuscularly. X Blood calcium
X Check the baby’s hematocrit
at least once a week.
X Attach the baby to a cardiac
or respiratory monitor.
156
07_AnsKey_BKIV_PCEP_155-156.indd 156 9/6/16 11:35 AM

Index
A method of measurement, 4 Continuing care, 112, 115
Abnormally shaped waveforms, 9 monitoring types, 4 administering immunizations
Abnormally wide or narrow pulse normal ranges, 6–7 during, 125
pressure, 9–10 posttest, 12 assessment of family during,
ABO incompatibility, 24 pretest, 3 128–129, 147
Absence of breathing. See Apnea self-tests, 5, 10–11 assessment of growth during,
Acidosis, 25 transducer monitoring, 5, 10–11, 118–121
Air leaks 13–17 assessment of head growth dur-
mechanical ventilation and, 80 waveforms interpretation, 8–10 ing, 147
surfactant therapy and, 105 Body weight, 120 cholestatic jaundice and, 137
Albuterol, 140 Bradycardia, 123 chronic lung disease and, 136,
Aldactone, 141 BUN. See Blood, urea nitrogen 140–144
Alkalosis, 25 congenital heart disease and, 138,
Alveoli
C 147–148
Caffeine, 141 developmental care and, 129
collapsed, 98
Calibration, blood pressure monitor, discharge and, 132–134
normal, 98
16–17 gastroesophageal reflux and, 136
Aminophylline, 140
Cardiac complications of exchange hearing deficits and, 126
Anemia
transfusions, 29 hydrocephalus and, 137, 146
monitoring for, 123–125
Catheter, arterial, 4, 9 late head ultrasound during, 128
severe, 33, 35
Catheter, peripheral arterial (PAC), monitoring and treatment
Anticonvulsant drugs, 146
Book IV: index

23, 32 guidelines for babies with
Apnea
Catheter, umbilical arterial (UAC), special problems,
mechanical ventilation and, 74, 77
23, 27, 32 140–148
monitoring for, 121–123
Catheter, umbilical venous (UVC), monitoring for anemia during,
Arterial blood gases
23, 26–28, 32 123–125
chronic lung disease and, 144
CHD. See Congenital heart disease monitoring for apnea during,
mechanical ventilation and, 78, 80
(CHD) 121–123
surfactant therapy and, 102
Chest movement and mechanical patent ductus arteriosus and, 138
Arterial catheter, 4
ventilation, 79 posttest, 153
Aspiration syndrome, 99
Chest radiographs, 142, 148 pretest, 113–114
surfactant therapy for, 104
Chlorothiazide, 141 recommended routines, 149
Assessment
Cholestatic jaundice, 137 retinopathy of prematurity and,
of family, 128–129, 147
Chronic lung disease (CLD), 136, 126–127, 144–145
of growth, 118–121, 146
140–144 seizures and, 137, 146
Assisted ventilation. See Mechanical
Citrate phosphate dextrose adenine self-tests, 130–131, 135, 139,
ventilation
(CPDA-1), 24, 25 150–152
B CLD. See Chronic lung disease short bowel syndrome and, 137,
Blocked or displaced endotracheal (CLD) 145–146
tubes and mechanical Clots sleep position/environment and,
ventilation, 80 within catheters, 9 128
Blood complications of exchange trans- special problems that may be
amount used for exchange transfusions, 29 encountered in babies
fusion, 25 exchange transfusion and, 27 requiring, 136–138,
preparation for exchange transfu- Commercial stabilizers, 86–90 140–148
sion, 25 Complications, potential specific issues involved in,
preservation, 24–25 direct transfusion, 36 115–131
types of donors, 24 exchange transfusions, 28–29, temperature control during,
urea nitrogen, 145 32–33 115–116
Blood pressure, 2 mechanical ventilation, 80–81 which babies require, 115
calibration of the monitor, 16–17 surfactant therapy, 104–105 Continuous method of exchange
equipment needed, 4–5 Congenital heart disease (CHD), transfusion, 26–27, 32,
measuring, 17 138, 147–148 49, 50
157
08_Index_BKIV_PCEP_157-160.indd 157 8/12/16 1:05 PM

index
Continuous positive airway pressure managing, 86–93 H

(CPAP), 56, 58, 73 securing, 86–90 Head circumference, 120–121, 146
adjusting, 67–68 suctioning, 91–93 Hearing deficits, 126
conditions that benefit from, 58 surfactant therapy and, 102, 105 Heart disease, congenital, 138
delivery, 59–60, 63–68 Equipment Heart rate and oximetry monitor-
given by high-flow nasal can- blood pressure monitoring, 4–5 ing, 142
nula, 61 continuous positive airway pres- Heated humidifier with thermostat
maintaining, 68 sure (CPAP), 64–65 control in circuit, 74
mechanism, 58 Exchange transfusions, 20, 23, 41 Hematocrit, 25, 30, 35, 141, 147
posttest, 62 blood amount used for, 25 HFNC. See High-flow nasal cannula
preparing babies for, 65–67 caring for babies after, 52–54 (HFNC)
preparing equipment for nasal in management of hyperbilirubi- High-flow nasal cannula (HFNC),
delivery, 64–65 nemia, 23–30 61
pressure used in, 60 need for more than one, 28 Home apnea monitoring, 123
pretest, 57 partial, 30–34 Hydrocephalus, 121, 137–138,
surfactant therapy and, 103–104 performing, 47–52 146
weaning babies from, 60 posttest, 40 Hyperbilirubinemia, 24
when babies should receive, 59 potential complications of, exchange transfusions in manage-
CPAP. See Continuous positive air- 28–29 ment of, 23–30
way pressure (CPAP) preparing babies for, 42–46 Hyperkalemia, 25
CPDA-1. See Citrate phosphate dex- preparing blood for, 25 Hypocalcemia, 24, 51
trose adenine (CPDA-1) preservation of blood for, 24–25 Hypoglycemia, 24
pretest, 21–22 Hypotension, 9
D reasons for, 23 Hypovolemic, 35
Damped waveform, 8–9 recommended routines, 37 Hypoxia, 123
Delayed cord clamping, 31 reduction, 31–33
Developmental care, 129 self-tests, 26, 30, 34, 38–39 I
Diabetes mellitus, maternal, 99 techniques, 26–28 Immunizations, 125
Diastolic phase, 8 types of donor blood used for, 24 Indirect blood pressure measure-
Dicrotic notch, 8 Expiratory time (TE), 75 ment, 4
Direct blood pressure measure- Extremely low birth weight (ELBW) Infant tubing circuit, 74
ment, 4–5. See also Blood babies, 77 Infections
pressure Eye examination, first, 127 complications of direct transfu-
Direct transfusions, 34 sion, 36
posttest, 40 F complications of exchange trans-
potential complications of, 36 Family, assessment of, 128–129, 147 fusions, 29
reasons for, 34–35 Fatigue and feeding, 117 hydrocephalus and, 146
recommended routines, 37 Feedings Initial settings, mechanical ventila-
self-tests, 36, 38–39 continuing care and, 116–118 tion, 76–77
techniques, 35–36 continuous positive airway pres- Inspiratory time (TI), 75
Discharge of babies, 132–134 sure (CPAP) and, 60 Inspired oxygen concentration. See
Diuretics, 147 Fetal lung development, 99 Oxygen concentration
Donor blood, 24 Flow rate (Fio2)
continuous positive airway pres- Intravenous (IV) pump, 5
E sure (CPAP), 59 Intravenous (IV) solution, 5
Echocardiogram, 142, 148 mechanical ventilation, 76 In utero fetal-fetal transfusions, 31
ELBW. See Extremely low birth Furosemide, 141 In utero maternal-fetal transfusions,
weight (ELBW) babies
31
Electrocardiogram, 142, 148 G Iron supplementation, 124
Electrolytes, 141, 145, 148 Gastroesophageal reflux (GER), 136,
IV pump. See Intravenous (IV) pump
Electronic monitors with waveform 145
displays, 4 Gestational age J
Emboli and direct transfusions, 36 first eye examination and, 127 Jaundice, cholestatic, 137
Endotracheal tubes, 80, 81, 85 surfactant therapy and, 103
checking/changing the position Growth assessment, 118–121 K
of, 90–91 head growth, 146 Kangaroo care, 116
158

index
L NeoBar endotracheal tube stabilizer, Potassium levels and direct transfu-

Lasix, 141 89–90 sion, 36
Late head ultrasound, 128 Non-distensible tubing, 4 Prematurity
Lung development, fetal, 99 mechanical ventilation and, 74
Lung disease, chronic. See Chronic O retinopathy of, 126–127,
lung disease (CLD) Oximetry monitoring, 142 144–145
Oxygen concentration (Fio2) surfactant therapy and, 99
M chronic lung disease and, 143 Preparation of blood for exchange
MAP. See Mean airway pressure continuous positive airway pres- transfusion, 25
(MAP) sure (CPAP) and, 60 Preservation of blood, 24–25
Maternal diabetes mellitus, 99 mechanical ventilation and, 74, Pressure regulation, continuous
Maternal steroid administration, 100 76 positive airway pressure
Mean airway pressure (MAP), 76 Oxygen desaturation, severe, 105 (CPAP), 59, 60
Mean pressure, 8 Pretests
Mechanical ventilation, 70, 73 P continuing care for at-risk babies,
adjusting, 78–80 PAC. See Peripheral arterial catheter 113–114
arterial blood gases and, 78, 80 (PAC) continuous positive airway pres-
commercial stabilizers, 86–90 Palivizumab, 125, 133 sure (CPAP), 57
how to set up, 75–76 Parent-baby interaction and attach- direct blood pressure measure-
initial settings, 76–77 ment, 129, 147 ment, 3
managing endotracheal tubes for, Partial exchange transfusions, exchange, reduction, and direct
86–93 30–34 transfusions, 21–22
posttest, 84 Patent ductus arteriosus (PDA), mechanical ventilation, 71–72
potential complications, 80–81 138 surfactant therapy, 97
pretest, 71–72 PDA. See Patent ductus arteriosus Pull-push method of exchange trans-
self-tests, 75, 82–83 (PDA) fusion, 26–27, 32, 48
suggested adjustments for various Peak inspiratory pressure (PIP), 75 Pulse pressure, 8
abnormal or clinical find- Peak pressure, 8 abnormally wide or narrow, 9–10
ings, 78, 79–80 PEEP. See Positive end-expiratory
surfactant therapy during, 102 pressure (PEEP) R
types of, 74 Peripheral arterial catheter (PAC), Rate of breaths, 76
what to do for babies receiving, 81 23, 32 RDS. See Respiratory distress syn-
when to start, 73–74 Peripheral intravenous (PIV) line, drome (RDS)
which babies need, 73 23, 26–27, 35 Reduction exchange transfusions,
Meconium aspiration, 77 PIP. See Peak inspiratory pressure 31–33
Metabolic complications of exchange (PIP) recommended routines, 37
transfusions, 29 PIV. See Peripheral intravenous (PIV) Respiratory distress syndrome (RDS)
Minimum pressure, 8 line continuous positive airway
Monitoring Pneumonia, 77, 99 pressure (CPAP) and,
for anemia, 123–125 surfactant therapy for, 104 58–59
for apnea, 121–123 Polycythemia, 30–33 maternal steroid administration
chronic lung disease, 140–144 Portex neonatal RSP endotracheal and, 100
gastroesophageal reflux, 145 tube stabilizer, 88–89 mechanical ventilation for, 73.
head circumference, 146 Positive end-expiratory pressure See also Mechanical
hydrocephalus, 146 (PEEP), 75, 77, 78 ventilation
parent-baby attachment, 147 Postmenstrual age and continuing surfactant therapy for, 99, 102,
retinopathy of prematurity, care, 116–117 103, 104, 105
144–145 Posttests Respiratory syncytial virus (RSV),
and treatment guidelines for blood pressure measurement, 125
babies with special prob- 12 Retinopathy of prematurity (ROP),
lems, 140–148 continuing care, 153 126–127, 144–145
continuous positive airway pres- Rh incompatibility, 24
N sure (CPAP), 62 ROP. See Retinopathy of prematurity
Nasal CPAP. See Continuous positive mechanical ventilation, 84 (ROP)
airway pressure (CPAP) surfactant therapy, 108 RSV. See Respiratory syncytial virus
Natural surfactants, 100 transfusions, 40 (RSV)
159

index
S Surfactant therapy, 74, 96 U

Safety pop-off valve, continuous delivery, 102, 109 UAC. See Umbilical arterial catheter
positive airway pressure how often to give, 104 (UAC)
(CPAP), 59 in intensive care facilities, 105 Ultrasound, late head, 128
Screening maternal steroid administration Umbilical arterial catheter (UAC),
for hearing deficits, 126 and, 100 23, 27, 32
for retinopathy of prematurity, during mechanical ventilation, Umbilical venous catheter (UVC),
126–127 102 23, 26–28, 32
Seizures, 137, 146 posttest, 108 Ursodiol, 137
Self-tests potential complications, 104–105 UVC. See Umbilical venous catheter
blood pressure measurement, 5, preparations, 100 (UVC)
10–11 pretest, 97
continuing care, 130–131, 135, self-test, 101, 106–107 V
139, 150–152 surfactant components and, 98 Vascular complications of exchange
mechanical ventilation, 75, 82–83 surfactant deficiency and, 99–100 transfusions, 28
surfactant therapy, 101, 106–107 surfactant made during fetal Ventilation, mechanical. See
transfusions, 26, 30, 34, 36, development and, 98 Mechanical ventilation
38–39 which babies to treat with, Ventilatory support and direct trans-
Severe anemia, 33, 35 103–104 fusion, 34–35
Severe oxygen desaturation, 105 Synthetic surfactants, 100
Systolic phase, 8
W
Short bowel syndrome, 137,
Waveforms, blood pressure, 8–10
145–146
Skin color and mechanical ventila-
T Weaning babies
TE. See Expiratory time (TE) from continuous positive airway
tion, 79
Temperature control, 115–116, 117 pressure (CPAP), 60
Sleep position and environment, 128
TI. See Inspiratory time (TI) from incubators to cribs,
Solution, intravenous, 5
Transducers, 4 115–116
Spironolactone, 141
air bubbles within, 9 Weight, body, 120
Stabilizers, commercial, 86–90
blood pressure monitoring,
Steroid administration, maternal, 100
13–17
X
Stomach vent, continuous positive X-rays, chest. See Chest radiographs
cable, 5
airway pressure (CPAP), 59
Transfusions. See Direct transfusions;
Suctioning endotracheal tubes,
Exchange transfusions
91–93
Tubing, non-distensible, 4. See also
Supplemental inspired oxygen
Endotracheal tubes
concentration, 136. See
air bubbles within, 9
also Oxygen concentration
kinks in, 9
(Fio2)
160

Time-efficient, cost-effective perinatal education and training
PCEP
PCEP
PCEP IV
BOOK
Perinatal Continuing Education Program, 3rd Edition, Book IV
Perinatal Continuing Education Program, 3rd Edition Perinatal Continuing Education Program
3RD EDITION
EDITOR IN CHIEF, NEONATOLOGY
Robert A. Sinkin, MD, MPH, FAAP
EDITOR IN CHIEF, OBSTETRICS

PCEP Workbook Contents
EARN
UP TO
Specialized
MATERNAL AND FETAL EVALUATION AND IMMEDIATE
Christian A. Chisholm, MD, FACOG 54
CRED CME NEWBORN CARE (BOOK I)
IT
For more than 35 years, the Perinatal CONT S OR • Is the Mother Sick? Is the Fetus Sick?
A
Continuing Education Program (PCEP) HOUR CT • Fetal Age, Growth, and Maturity
S! • Fetal Well-being
has enhanced the knowledge and skills of • Is the Baby Sick?
Newborn Care
physicians, nurses, nurse midwives and • Resuscitating the Newborn
practitioners, respiratory therapists, and other • Gestational Age and Size and Associated Risk Factors
providers of care for pregnant women and newborns. • Thermal Environment
• Hypoglycemia
The third edition PCEP workbooks have been brought up-to-date
MATERNAL AND FETAL CARE (BOOK II)
with leading-edge procedures and techniques. These information-rich
• Hypertensive Disorders of Pregnancy
volumes are filled with concise information, step-by-step instructions,
• Obstetric Hemorrhage
and practice-focused exercises. They offer time-saving, low-cost • Perinatal Infections
solutions for self-paced learning or as adjuncts to instructor-led • Other High-risk Conditions
skills teaching. • Abnormal Glucose Tolerance
PCEP IS A PROVEN EDUCATIONAL TOOL FOR • Premature Rupture or Infection of the Amniotic
• Improving perinatal care know-how, policies, practices, and Membranes
procedures. • Preterm Labor
• Inducing and Augmenting Labor
• Teaching both practical skills and cognitive knowledge.
• Abnormal Labor Progress and Difficult Deliveries
• Saving time—self-paced self-study approach streamlines the
• Imminent Delivery and Preparation for Maternal/
learning process. Fetal Transport
• Saving money—provide top-notch education at low
NEONATAL CARE (BOOK III)
per-participant costs.
• Oxygen
• Encouraging cooperation and communication among diverse • Respiratory Distress
specialties and staffing levels. • Umbilical Catheters
• Simplifying education planning and budgeting. • Low Blood Pressure
• Intravenous Therapy
CONVENIENT, HASSLE-FREE CME OR CONTACT HOURS • Feeding
Earn
AMA PRA Category 1 Credit(s)™ or ANCC contact hours
• Infections
are available from the University of Virginia. Visit
CME credits
www.cmevillage.com for more information. • Review: Is the Baby Sick? Identifying and Caring for
Sick and At-Risk Babies
or contact
The University of Virginia School of Medicine is accredited by
• Preparation for Neonatal Transport
the Accreditation Council for Continuing Medical Education
hours!
to provide continuing medical education for physicians. SPECIALIZED NEWBORN CARE (BOOK IV)
The University of Virginia School of Nursing is accredited as • Direct Blood Pressure Measurement
a provider of continuing nursing education by the American • Exchange, Reduction, and Direct Transfusions
Nurses Credentialing Center’s Commission on Accreditation. • Continuous Positive Airway Pressure
• Assisted Ventilation With Mechanical Ventilators
• Surfactant Therapy
THE PCEP WORKBOOKS AND RELATED PRODUCTS CAN BE PURCHASED DIRECTLY
• Continuing Care for At-Risk Babies
FROM THE AMERICAN ACADEMY OF PEDIATRICS AT SHOP.AAP.ORG.
AAP

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Time-efficient, cost-effective perinatal education and training

EDITOR IN CHIEF, OBSTETRICS

00_FM_BKIV_PCEP_i-viii.indd 1 9/6/16 10:57 AM

00_FM_BKIV_PCEP_i-viii.indd 2 9/6/16 10:57 AM

PCEP Editorial Board Members

Sally Ann Miller, CNM, NP Sharon Veith, MSN, RN

00_FM_BKIV_PCEP_i-viii.indd 3 9/6/16 10:57 AM

Accreditation and Designation Statements

The University of Virginia School of Medicine awards 54 hours of participation (equivalent to

The University of Virginia School of Nursing is accredited as a provider of continuing nursing

Disclosure of Financial Relationships

AMA PRA Category 1 Credit(s)™, ANCC Contact Hours or Hours of Participation

00_FM_BKIV_PCEP_i-viii.indd 5 9/6/16 10:57 AM

Unit 2: Exchange, Reduction, and Direct Transfusions............ 19

Unit 3: Continuous Positive Airway Pressure........................... 55

Unit 5: Surfactant Therapy...................................................... 95

Unit 6: Continuing Care for At-Risk Babies............................ 111

Subsection: Babies With Special Problems

Pretest Answer Key.....................................................................155

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Book II: Maternal and Fetal Care

Book III: Neonatal Care

00_FM_BKIV_PCEP_i-viii.indd 8 9/6/16 10:57 AM

Unit 1: direct blood pressure measurement/ contents

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01_Unit1_BKIV_PCEP_001-018.indd 2 7/25/16 11:41 AM

01_Unit1_BKIV_PCEP_001-018.indd 3 7/25/16 11:41 AM

1. What are the 2 general types of blood pressure monitoring?

2. How are direct blood pressure measurements made?

3. Why is direct blood pressure measurement used?

4. What equipment is needed for direct blood pressure monitoring?

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5. What are reference neonatal blood pressure ranges?

Birth Weight (g)

Birth Weight (g)

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Diastolic Blood Pressure (mm Hg)

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6. How do you interpret blood pressure waveforms?

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A damped tracing may be caused by

If a waveform is damped because of a suspected clot at the tip or

2. Abnormally shaped waveform

C. Abnormally wide or narrow pulse pressure

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Pulse Pressure Possible Cause

B5. List 2 possible causes of a widened pulse pressure.

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Transducer Blood Pressure Monitoring

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PERINATAL PERFORMANCE GUIDE

Using Transducer Blood Pressure Monitors

Preparing the Equipment

01_Unit1_BKIV_PCEP_001-018.indd 14 7/25/16 11:41 AM

Preparing the Equipment (continued)

Arterial Non-distensible Fluid

Third port Third port

Configuration During Infusion:

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Calibrating the Blood Pressure Monitor

1. Establish a policy of obtaining a radiograph for