Acuity and Ratio

[SteveNNP, MSN, NP]

Oh yeah...24 weekers on CPAP or NIMV, those kids are sometimes worse than an intubated kid!

I know, right??

It seems like all you do for your entire shift is keep that airway clear, and coax them to breathe....

It's amazing though when you have a micro who was never intubated, and went home BPD-free thanks to you being vigilant.

24 weeker on CPAP??! :chuckle

I had a former 23 weeker who was put onto CPAP on about day 7 of life. Hes still on it after 3 weeks....at a CPAP of 8. His poor little nose.

[SteveNNP, MSN, NP]

Hes still on it after 3 weeks....at a CPAP of 8.

A PEEP of 8!!????:omy:

Whoo.. get that chest tube setup ready.....

I had him again after about 2 weeks. Hes now been on it for close to 3 weeks, and we went down to a PEEP of 7. His nose is red, but amazingly no breakdown. Though he screams bloody murder every time I touched it. I'm sure his nose is sore.

I'm honestly surprised they didn't just reintubate. I'm hoping we can get him off tomorrow.

[wensday, MSN, RN, APN, NP]

Oh yeah...24 weekers on CPAP or NIMV, those kids are sometimes worse than an intubated kid!

I know CPAP is great for these little lungs but I feel so mean strapping it to their tiny faces, plus they always seem to be so much more irritable. Give me a vent any day (but don't tell the NNP who's trying to get all our tiny ones onto CPAP!).

We've just finished a randomised trial actually, either vent or intubate, give curosurf and put onto CPAP. Will be the long term outlook that gives us our answers though.

[SteveNNP, MSN, NP]

From the data I've heard lately, most trials in progress and newly completed are all saying that the INSURE method is becoming the gold standard for all preemies.

Intubate

Surfactant

Extubate

....to nasal CPAP, Vapotherm, HFNC, etc... no ventilation unless required.

I can honestly say that this approach makes the most sense to me. I can't wait to go somewhere that actually does this, like my old unit did. Here we do the NCPAP method. CPAP. Nothing else. No one gets surfactant except as a rescue. (seen it 2x in a year) And your CO2 better be >70 to get a vent.

[RainDreamer, BSN, RN]

Intubate

Surfactant

Extubate

....to nasal CPAP, Vapotherm, HFNC, etc... no ventilation unless required..

That's exactly what we do. We always surf the little ones and then extubate to whatever they tolerate (NCPAP or HFNC).

No one gets surfactant except as a rescue.

Wow, really? It's amazing they make it on NCPAP without being surfed. I personally think surfactant is some good stuff! What's the reason against using surfactant?

[SteveNNP, MSN, NP]

Wow, really? It's amazing they make it on NCPAP without being surfed. I personally think surfactant is some good stuff! What's the reason against using surfactant?

We have a MD (old as dirt) who "invented" bubble cpap back in the 1970s. He's not a neonatologist, or even a peds intensivist. He's an anesthesiologist. Anyway, he has become the unofficial NICU pulmonologist. His theory is that putting babies on NCPAP stimulates the production of surfactant, and conserves it in the alveoli. He considers the risk of surfactant greater than not getting it... so all our pts are placed on NCPAP (the ones that need support) and surfactant is withheld until:

1) severe RDS develops (ummm what did you think would develop? a set of term lungs?)

2) fio2 requirements are >60%

3) Co2 >70mmHg. (also the threshold for intubation)

We do have a pretty decent success rate. Our last study showed a 9% BPD rate. Most babies never get surf, but they all get terrible RDS, a lot of pneumos, and desat and brady for months. (did I mention we hardly use caffeine either? "Side effects" wooooooooo) The ones who get surfed and intubated are the 23-24 weekers. We RARELY have anyone over 26 weeks intubated.

So the nurse is always at the bedside, performing sx/chest PT, repositioning, stimulating, etc. Terrible developmental care.

This same MD is responsible for us having old crappy vents, nasal intubation, no inline sx, and no nasal cannulas. Anyone who needs o2 is on NCPAP.

I personally see a huge amount of NEC here. It's not because we feed early, it's because we allow too high of a Co2, and constant bradys/desats.

I really hope no one other than Elizabells joins this board from my unit. While it's a very prestigious unit, I do NOT agree with the stuff we do. I rarely care for preemies anymore. I ask for cardiac patients, who rarely need the above interventions, and therefore I do not feel the guilt of having my hands tied by this physician who is living in the dark ages.

I will take some valuable lessons about early extubation and aggressive weaning from this place, but that's all. January 2010, and I'm outta here...

[elizabells, BSN, RN]

God, I hope I don't get in trouble for this, but... you know why our BPD rate is so low? Because 21% CPAP doesn't count as an oxygen requirement. How many 3 month old kids do we have still on RA CPAP? Yeah, that's right. Our numbers would be WAY different if that counted.

Doctor Ancient Vent is the same one who is responsible for our abhorrent pain management practices, in case anyone was wondering. Shocking, I know.

I've seen more surf given to PPHN of unknown origin kids than preemies in my time on the unit, btw. Given it x 3 to those kids (once on ECMO! Imagine how fun it was turning that kid about!) and x 1 to a vented preemie.

[SteveNNP, MSN, NP]

Geez, we're just a pair of Negative Nancies tonight, huh?

[elizabells, BSN, RN]

I have to go back to work tomorrow. What's your excuse?

But seriously, I do want to say that our unit is AMAZING at some things. Our CDH survival rates are really high. We do crazy cardiac surgeries. We take kids that even CHOP won't touch sometimes.

And I also want to emphasize that my last comment in NO WAY is trying to imply that our unit is dishonest about our BPD rates. Those are the rules everyone plays by, we don't falsify data or anything shady. It's just that I don't think the criteria for BPD accurately reflect clinical realities. FiO2 requirement does not equal respiratory support requirement.

Thank you, that is all.

[ilstu99]

I have to say that we're pretty flexible on the ratio. The MAX is 1:3, though, even for the feeder/growers.

But, you know, some feeder/growers are a HUGE time and effort compared to others (I mean....I love you, baby N, but you know what I'm talking about there), and some 24-weekers are just hanging out in their boxes and cooking...without any other than their Q6's. So we usually assess ratio needs by infant NEEDS rather than basic status.

We have an RN supervisor and free-floating charge, so if that "stable" 24-weeker goes down the tank, the FFC can take over my feeder/grower until s/he can be reassigned.

At daily rounds, the RN reports the baby's current needs status, and assignments are based on that.