VLBW infants and positioning - page 2

I worked in a unit in the past where we kept all infants less than, I think it was 1500 gms, who were on a ventilator, in the midline position for the first 7 days of life. This meant they had to... Read More

  1. by   Love_2_Learn
    At the 30 bed Level III perinatal regional center NICU I worked in before I came to where I am now, we definately kept the baby's head midline with their body for at least the first 3 to 5 days. We would keep them positioned on their right or left side or we would have them lie supine and use the "Angel Frame" to help hold their ET tubing in such a way as to keep the babies facing midline. The same company who makes the "Angel Frames" has a new one made just for high frequency oscillators; I saw them at the Neonatal Network Nursing Conference this past September. Where I work now they don't have "Angel Frames" so the poor babies usually lie flat and face either right or left. I do my best to be assigned these tiny babies so I can position them on their sides so they can stay midline as much as possible the first few days. I don't have any research to back this up but as I understand it, having their head turned sharply away from midline increases venous pressure in the neck veins. I remember learning this from the Clinical Nurse Specialist at my previous NICU. When I think of it in a physiological perspective it really does make sense, especially when I think about how very fragile their germinal matrix is during the first few days. I hope SteveRN21 can supply us with the information he has because I'd love to take it to the small NICU where I work now!
  2. by   prmenrs
    Before there were "angel frames", we used to take that thick "umbi tape" and thread it under the connection from vent to ET tube and suspend it from the overhead part of the warmer. Don't know if that helps...
  3. by   Zippedodah
    We still do the hang from the warmer or top of the isolette when we need too.
  4. by   cathys01
    I had an oscillator kid for the last four days and I turned him every three hours - left side with head midline, supine midline, right side with head midline. Yes, it's a pain in the butt to do it, but they shouldn't be left in one position for days at a time. It does require extra help to turn because of the inflexibility of the HFOV tubing, but it's definitely doable.
  5. by   Gompers
    Quote from cathys01
    I had an oscillator kid for the last four days and I turned him every three hours - left side with head midline, supine midline, right side with head midline. Yes, it's a pain in the butt to do it, but they shouldn't be left in one position for days at a time. It does require extra help to turn because of the inflexibility of the HFOV tubing, but it's definitely doable.
    Now, that's something we do have a policy on, and we don't turn oscillator kids very much because they're usually unstable. They need to have their heads facing the vent because of how stiff the tubing is - it's up to us if we have them on their backs, side with head midline facing vent, or on their abdomen (rare). When they first go on HFOV, we don't turn their heads for 24 hours. Then after that, it's Q12H for turning. It just takes so much to turn the whole baby around in the bed (the vent always stays on the same side of the bed) and many of them don't tolerate the turn well at all. So instead we use gel pillows and things like that to keep pressure off the skin for those long hours spent in the same position. We rarely see skin breakdown on these babies' scalps unless they're extremely edematous.
  6. by   cathys01
    I should clarify that this was a 29 weeker that was 2 days old when he went on the oscillator. He was fairly stable (no pressors, etc), but his gasses were crappy. He was on nasal canula, then CPAP, then Servo, then HFOV - then his gasses stabilized and yesterday we were weaning and getting him ready to move back to traditional vent.

    We still do try to turn the patients if we can, even the micros before DOL 3, but no prone positioning because the head can't be midline if they are prone. It seems to me that the kids are always calmer if they are on their sides than supine for some reason. We are definitely taught that the turning of the head can increase the risk for IVH, so we don't do it.
  7. by   PremieOne
    SteveRN21, I would be very interested in your protocol. We do keep our infant's midline for about 72 hours and if they are stable we will place them on their abdomen. We provide nesting to all our infant's no matter what size or GA. We use snugglies and artificial sheepskin to protect them.
    Last edit by sirI on Dec 14, '06 : Reason: edit personal information
  8. by   KatrinaPM
    SteveRN21, I would be very interested as well. The past two years I have worked in two different NICUs and never was this mentioned by anyone regarding the positioning of infants midline for the first 72 hours. But considering that most bleeds occur in that time period, it really makes sense. Any articles or specific references would be greatly appreciated. Thanks!
  9. by   megann0103
    Hi SteverRN- I'm in the process of starting my thesis, which involves choosing one intervention for my unit to initiate in order to decrease our incidence of IVH. I would love to see your policy, and some of the articles that you researched... Would there be any way to share the wealth of knowledge?
  10. by   MegNeoNurse
    Hi there This is what our NICU practices as well. It is a NAAN recommendation to decrease the incidence of IVH in preterm infants. Our practice is <28 weeks midline x 7 days and no holding by parents until the 7 day HUS is obtained. Midline does not mean supine!!! As long as the baby's nose is in line with their umbilicus, this is midline. So they can be positioned right side, midline for example. The reason for this is that if the infant's head is turned to one side or the other, this increases the pressure in the cerebral vessels increasing the incidence of IVH. This is still developmentally appropriate positioning!!!

    In terms of supporting literature I do not know off the top of my head, but I will ask our unit's educator. She's all about supporting literature.

    Hope this helps
  11. by   MegNeoNurse
    Quote from dawngloves
    I've never heard of the corrilation between postioning and IVH. I'm curious to see how babies's heads are postioned midline while on an oscillator.
    We practice <28 weeks midline x7days. I've taken care of MANY infants that fit this criteria that are on oscillators and have no had any issues keeping them midline. The circuit tubing is very rigid, but in the last year we have a new circuit connector that is corregated and therefore more pliable. When repositioning an oscillated baby I have an RT or another RN available to help me move the oscillator and I keep the kid positioned and watch the tube.
  12. by   MegNeoNurse
    Quote from dawngloves
    Our director would have a cow if he saw oscillating babies on anything but their backs.
    What is her indication for keeping them supine? I cannot imagine keeping a kid in the same position for the entire time they are on the oscillator........
  13. by   MegNeoNurse
    Quote from Gompers
    Now, that's something we do have a policy on, and we don't turn oscillator kids very much because they're usually unstable. They need to have their heads facing the vent because of how stiff the tubing is - it's up to us if we have them on their backs, side with head midline facing vent, or on their abdomen (rare). When they first go on HFOV, we don't turn their heads for 24 hours. Then after that, it's Q12H for turning. It just takes so much to turn the whole baby around in the bed (the vent always stays on the same side of the bed) and many of them don't tolerate the turn well at all. So instead we use gel pillows and things like that to keep pressure off the skin for those long hours spent in the same position. We rarely see skin breakdown on these babies' scalps unless they're extremely edematous.
    Our frequency of repositioning and cares depends on the acuity of the baby. We used to use oscillators as "last-ditch-effort" vents... but lately our neos are down to put a kid up on the oscillator on admit as its more gentle to the lungs so they are not generally as unstable as the osc. babies used to be. I personally think that there is a correlation with HFOV and IVH within the first week, no definate supporting literature yet. Still too much of a coincidence that there have been 4 kids in our unit in the past few months, born <28wks, on HFOV within the first few DOL and all have atleast a Gr. III bleed? Anyway......

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