blood gases and your standard of care regarding them

Sweeper933 · Sep 8, 2008

Wow.

For the most part, any baby

For any baby on the vent, they get blood gases drawn every morning, as well as when they are acting up, or to follow-up on a change. If we are trying to wean settings, we will turn down the vent, then get a gas a few hours after - to avoid getting multiple gases.

NEC rule outs always get serial x-rays (usually every 6 hours) to make sure they haven't perfed. Not to mention all of the blood work that gets sent (culture, cbc, gas...).

Sorry to hear that your unit has strayed away from some of this, hope this helped.

SteveNNP, MSN, NP · Sep 8, 2008

I went from a unit that overdrew labs like crazy, to the one I am at now, where we are much more prudent. Admit labs remained the same. Babies who are on NCPAP for days, and are clinically stable might get a CBG drawn every 4-5 days, along with lytes and a cbc if they are not on full feeds. Bilis are drawn q12 until normal while on lights. Babies on vents get gases q 12-24 or even longer if stable. HFOVs get them q6-12 and as needed. We look at the baby's clinical appearance, saturation, and cofactors. Babies on full feeds and 21% NCPAP rarely get labs.

It took some getting used to, but I like this a lot better. We are able to get umbilical and arterial lines out within days. We rarely need to transfuse for lab induced anemia.

For NEC, we typically do AP/ LLD panels q6, then q12, then q24 if there are no acute changes in bowel gas patterns.

The thing to remember with the NEC baby you mentioned, is that the enormous base deficit probably occurred when the baby perfed or developed pneumatoses....a negative BD does not necessarily cause NEC, but is a definite sequela OF NEC.

HOWEVER, I have never felt that if it was clinically indicated (eg the -7 BD you mentioned) I couldn't get lab orders. If it's needed, the baby gets it. Less protocol, and more clinical-sign based.

If you feel like you are providing substandard care, and putting your license in jeopardy, it may be worth going to you manager, then division director, then consider leaving.

Best of luck!

dawngloves, BSN, RN · Sep 8, 2008

Sounds like underkill in your unit. Perhapes there needs to be a written protocol of caring for admissions with respiratory distress. Like "Blood gas and CXR on admission, one hour after therapy started, then one hour after changes made in therapy or if pt shows signs of distress"

I can't imagine not getting a gas on a pt after you make vent changes or starting them on o2 or CPAP. How do you know it's working??

NICU_babyRN, BSN, RN · Sep 9, 2008

Not a single gas in 21 days? I don't work in "intermediate Care" nursery all that much-usually in the intensive care therapy wher our sickest babies are taken care of. In Intermediate care though, gas and other labs are only done qM/thurs and as clinically indicated. If an infant has been on CPAP for a while, daily gases are only done if we are trying to wean. Really labs become "as clinically indicated" once the babe is stable, grower/feeder, off IVF.

Admission labs for almost all babies include: CBC c diff, gas, type&screen. At 12 hours of life we get lytes, Ionized Cal, bili and gas. Then for three days we get lytes, Ion. cal, gas, bili q12hrs. We skip the gas if the babe is on room air and showing no distress.

If an infant is on nasal vent or intubated, but stable, gases are done qAM.

Unstable vent, HFOV get at least q12hr labs unless they look like they are improving clinically.

for babes on TPN and lipids, we also do Alk Phos, Phos, Lytes, Trig qM/Thursday. a lot of our babes get daily lytes so we TPN can be customzied daily.

It sounds like a lot of labs, but we really taylor lab needs based on what the baby is doing. there's no "set protocol" that MUST be used for all infants. It's very evidence based.

X-rays: Upon admission, but we usually wait until lines are placed.

Anytime an infant has a "blown up belly" we do at least one x-ray. If Pneumatosis/NEC, we'll do q6hr KUB/LLD and then q8 or 12hr.

Overall, I say we have a happy medium!

texas2007, BSN, RN · Sep 9, 2008

Admission: Everybody gets an xray, art gas (there's a few who don't), blood cultures, CBC D&P, NG/OG to gravity, NPO

After that: Baby sets the tone. If no acute issues, we usually get a chemistry panel, hematocrit, and retic every Monday morning. If a baby starts having electrolytes issues then we'll get a panel q 8 or q 12, or daily if on IVF...preemies get a hematocrit sent daily for 1st week...gasses can be as often as q1 hr if unstable or q am if chronic vent. Once they are extubated, they get a gas 2 hrs after the change and then are usually dc'd if tolerated, wouldn't get another one unless they were showing s/s resp distress. Then there's the always fun sepsis workup: CBC D&P, CRP, Blood cx, sometimes a blood gas, sometimes UA, sometimes a lumbar puncture... :stone: Xrays are q am for most vents, some of the more chronic babies will move to q mon am and q thurs am, and as always as needed for tube placement, resp distress etc. Ecmo babies get a DIC screen, and Hct sent q 12 and the Ecmo specialist pulls off blood hourly to test the clotting factors at the bedside to adjust the Heparin to...proly more labs are sent down but I can't recall off the top of my head.

UTVOL3 · Sep 9, 2008

Throughout my many years of NICU nursing I've experienced numerous changes in practice and standards, but this one has me concerned, so I'm asking for your input. Our neos have set up a corporation with another group of neos and now we are drastically decreasing our lab draws and x-rays. Eg: 29 week admit, placed on Cpap and on admit had no x-ray, no blood culture, and no gas. Baby arrived at 2000 and nothing ordered for morning lab either. My pt last night, a 1000 gm three week old now 29 weeker who is on mask/prong siPap has not had a gas in 10 days. Her two gases before that showed an increasing base deficit which went from -7 to -9, and then we just stopped checking gases. She is on 21-40% oxygen with still frequent desats and is slowly being advanced on feedings. When we make vent changes only about 50% of the time will a follow-up gas be ordered, and then often it is ordered by one of our 'old school' NNP's. As nurses we are told that we can follow the babies clinically and that we have done way too much lab in the past. One of our worst case scenarios was a 1300 Gram infant who was off and on CPAP for days and when her belly 'blew up' and they ordered a gas and CBC I looked back on the chart to compare results with a prior gas and it had been 21 days ago!!!! She had a huge deficit of -17 and we all wondered how long that had been going on. For our NEC kids we used to to get serial every 4-6 hour flat plates and often decubs as well, and now we can't count on that either. Our old staff sarcastically jokes that the kids get more lab drawn on transport than they do in the unit!!

Our neos and NNPs are thankfully trying to decrease the # of uneccessary lab draws for the long termers, a blessing if you have to stick heels for labs every day that no one is even doing anything with. But even they will get serum lytes and a hct about every 10 days. Not every single admit gets a full work up but the vast majority do. If it's a kid that is just coming to us for size, has no respiratory distress and we know why it delivered early, (i.e., preeclampsia in mother vs. dropped in in labor,) they might just get a baseline CMP and CBC at 8 or 12 hrs of age. Our NNPs are really good at looking at the profile and saying hmmm, I think this kid could use a blood gas. Just to see what their deficit is. They very rarely will change vent settings without a repeat, only in an instance where they are going to be weaning in another 30 min or an hour anyway.

I can see why you are uncomfortable. I would be too! One day when I get time I would love to go over the research, but, that is a lifetime away right now I am sure. :rolleyes: