Surfactant Protocol

Introduction:

The following were developed as clinical guidelines. Clinical circumstances should dictate the management of specific cases. Dosing should occur as soon as possible when indicated to minimize the period of mechanical ventilation prior to dosing. Infants must be intubated to receive surfactant.

Infants 28 weeks and younger

Should receive prophylactic administration in the delivery room only if their resuscitation requires intubation.

All Infants

Should receive surfactant administration in the NICU within the first one to two hours of life. Surfactant administration should occur if they have radiologic evidence of hyaline membrane disease, require intubation, and need an Fi0₂ > 0.40 to maintain a PaO₂ > 80 torr.

Re-dosing

Infants should be considered for subsequent doses if they deteriorate after a response to a previous dose. At minimum, they should be evaluated every 6 hours and given repeat doses if they require an Fi0₂ > 0.30 to maintain a PaO₂ > 80 torr. The clinical condition and response to previous doses should dictate the number of doses with a maximum of four.

POINTS OF EMPHASIS:

WARM SURFACTANT PRIOR TO ADMINISTRATION (8 MIN. IF VIAL IS HAND HELD OR 20 MIN. SITTING AT ROOM TEMPERATURE).
DO NOT HEAT BY ARTIFICIAL METHODS.
DO NOT SHAKE THE SURFACTANT.
ASSESS BREATH SOUNDS FOR EQUALITY. THE ETT MUST BE IN GOOD PLACEMENT, PRIOR TO DOSING SURFACTANT.
SUCTION INFANT PRIOR TO THE DOSING PROCEDURE AND AVOID SUCTIONING POST DOSING FOR AT LEAST 2 HOURS (UNLESS CLINICALLY INDICATED).
A PHYSICIAN, NURSE, AND RESPIRATORY THERAPIST, ALL EXPERIENCED IN SURFACTANT ADMINISTRATION SHOULD BE PRESENT.
OBSERVE THE INFANT FOR ACUTE EFFECTS OF ADMINISTRATION SUCH AS BRADYCARDIA OR HYPOXIA AND MODIFY DOSING AS APPROPRIATE.

EQUIPMENT NEEDED:

A WARMED VIAL OF SURFACTANT (each vial contains 8.0 cc)
10 CC SYRINGE AND NEEDLE
BALLARD SUCTION CATHETER
STERILE SCISSORS OR BLADE

PROCEDURE

Pre-dosage:

Surfactant is kept in the nursery refrigerator and the clinician in charge (fellow, NNP, etc.) will be responsible for bringing it to the delivery. The paper work attached to the vial must be sent to the pharmacy by the unit secretary in order to replace the vial and bill the patient.
Before surfactant is given to a newborn it must be warmed.
1. Vial may be warmed by sitting at room temperature for 20 minutes
2. Vial may be warmed by holding it in your hand for 8 minutes

· Do not shake

· Do not heat by artificial warming methods

Administration:

The administration of surfactant to the newborn requires two people. The procedure is facilitated if one person administers the dose, while another person positions and monitors the baby and takes care of the ventilation of the infant.

1. First Person

Fixes Ballard to ETT
Using sterile technique draws up the warmed surfactant dose plus 0.5cc (To prime the Tube). Leave the needle in the vial, connect the 2nd syringe and draw up the remaining surfactant. Label the unused syringe with the drug, date and time the vial was opened, and the date and time eight hours from the opening time. This is when the drug will expire. Any excess surfactant should be drawn up, labeled and placed in the NICU medication refrigerator.

Second Person
1. Suctions the baby, {if necessary}
2. Reconfirms that the ETT is in good placement by hearing equal bilateral breath sounds.

Dosing:

1. The total amount of surfactant to be given in the delivery room should be based upon the estimated fetal weight, the 50% for the infant’s gestational age, or an experienced clinician’s best estimate.

2. The total dose (4cc/kg) is divided into two aliquots given in the two positions as below:

Infant placed on the right side
Infant placed on the left side

After an infant has received prophylactic surfactant in the delivery room, the clinician in charge of the resuscitation will complete a log sheet that will be maintained for quality control

.Added 11/03/2003