Brand new nurse here for the NICU!

adventure_rn, MSN, NP · Jun 7, 2017

Congrats. In the future you may get more responses if you post in the 'Neonatal/NICU' forum on the Specialties page.

It's awesome that you're trying to look things up now, but you really don't have to worry until you get started. You preceptor will assume you don't know anything about neonates (since they basically aren't covered in nursing school) and will explain all of this info to you. They can also explain your unit-specific policies and therapies (for instance, I've literally never heard of SiPAP). Also, if you have a respiratory therapist, ask them to explain the mechanism behind the various respiratory therapies; they are the experts, and often know better than nurses. That said...

CPAP is just the general category of respiratory support that uses expiatory pressure to improve compliance by keeping the alveoli open; the baby breathes out against a tiny bit of pressure to prevent alveolar collapse. There are different types of CPAP products available (i.e. AirLife vs. RAM cannula vs. Bubble); bubble CPAP is a type of CPAP in which kids breathe out against a column of water, which generates bubbles (kind of like blowing bubbles into a glass of water through a straw).

I just googled SiPAP (like I said, I've never heard of it), and it sounds like NIV-NAVA (non-invasive ventilation, nerually-adjusted vent assist). Basically, you hook the CPAP equipment up to the ventilator, so the baby is 'on the vent' without actually being intubated (hence NIV, 'non-invasive ventilation'). It has an esophageal probe that sits at the level of the diaphragm and senses when the baby takes a breath. It's basically CPAP that can also occasionally give breaths (positive pressure ventilation) when the baby doesn't breathe, and can give extra pressure to support the breaths that the baby initiates.

The main thing you need to know for neonatal BP is that we mostly just care about the MAP, which should be at least the baby's gestational age (or up to 10-15 above). For instance, in a brand-new 32-weeker, you expect the map to be about 32 - 42. You really only worry about hypotension, and BP generally isn't very accurate in kids >48 hours old (except those sedated with with art-lines); unless an art-line is present or the kid is acting shocky, we don't often make treatment decisions based on BP in older kids because it's so inaccurate. It's hard to find a good reference for normal systolic and diastolic since they change depending on the kid's gestational and chronological age. If you've got a kid on titratable pressors (i.e. dopa, dobuta), who BTW should definitely have an art-line, you may have a chart like this http://www.adhb.govt.nz/newborn/Guidelines/images/GraphNeonatalBPperAge.gif which will give you approximate ranges of systolic and diastolic. With experience, you'll get a sense for appropriate systolic and diastolic values; for now just focus on the MAP.

Coffee Nurse, BSN, RN · Jun 7, 2017

1. CPAP = continuous positive airway pressure. SiPAP = synchronized intermittent positive airway pressure.

In a nutshell: CPAP provides a continuous low pressure to generate PEEP (positive end expiratory pressure) in the lungs, helping to prevent atelectasis and reducing the work of breathing for a baby. SiPAP provides PEEP but also gives intermittent "puffs" of higher pressure to help the lungs expand as the baby inhales, further reducing the work of breathing. SiPAP is a step up support-wise from CPAP, but not as much support as invasive ventilation (i.e. through an endotracheal tube).

Bubble CPAP is just another way of generating PEEP, but someone else will need to explain how it works as I've not used it before.

2. As a rule of thumb, a preemie's mean blood pressure should be at least his corrected gestational age - for example, a 25-weeker who's three weeks old should have an MBP of at least 28. You can have situations where a baby has a lower MBP than this because he has a PDA and consequently a wide pulse pressure - say, the same baby with a BP of 46/18. That gives you a MBP of 27, but as the systolic pressure is reasonable and as long as the baby is cardiovascularly stable (not tachycardic or desaturating a lot, etc), that would be an acceptable reading.

Good luck! Make sure you have a look around the NICU forum, there's lots of good information there.

Coffee Nurse, BSN, RN · Jun 7, 2017

Jinx!

It has an esophageal probe that sits at the level of the diaphragm and senses when the baby takes a breath.

:nailbiting: I don't know why this squicks me out more than an OGT, but seriously, an esophageal probe? We rarely use the synchronize feature on our SiPAP machines (they're set to a regular backup rate instead, which I know isn't ideal but that's just what my unit does for some reason), but when we do we just stick an apnea probe to the abdomen. One less thing inside the poor kiddo!

**NICU Guy, BSN, RN** · Jun 7, 2017

but seriously, an esophageal probe?

The Edi catheter has a feeding cannula built in, plus it is far more accurate than sticking an apnea probe to the abdomen. It is no different than the patient have an OG feeding tube.

meanmaryjean, DNP, RN · Jun 7, 2017

OP: In a specialized area of healthcare/ nursing such as NICU- you really need to not 'Google' information. Look for professional organizations, peer-reviewed journals about your specialty, and gold standard texts.

Editorial Team / Admin · Jun 8, 2017

Welcome to allnurses.com

Thread moved to NICU forum for even more replies.

adventure_rn, MSN, NP · Jun 8, 2017

I don't know why this squicks me out more than an OGT, but seriously, an esophageal probe? We rarely use the synchronize feature on our SiPAP machines (they're set to a regular backup rate instead, which I know isn't ideal but that's just what my unit does for some reason), but when we do we just stick an apnea probe to the abdomen. One less thing inside the poor kiddo!

The Edi catheter has a feeding cannula built in, plus it is far more accurate than sticking an apnea probe to the abdomen. It is no different than the patient have an OG feeding tube.

Ugh, EDI caths don't gross me out, but they do drive me nuts sometimes. Especially in the little micros, they can sometimes misinterpret other local innervation (i.e. cardiac) as diaphragmatic innervation, and the poor kid ends of autocycling at 90 breaths per minute. Haven't really found a good solution besides constant probe depth adjustment.

I've worked at some places that use the EDI cath for feeds, and others that don't because they thought it clogged too easily w/ high cal breast milk (in which case you need the EDI plus an OG). I do like that fact that the EDI cath can be open to vent 24/7 while the OG tube is giving a feed; the EDIs aren't great at venting since they're so small, but at least you can then have a constant source of gastric decompression for their giant, distended CPAP/NIV bellies.

Julius Seizure · Jun 8, 2017

I just googled SiPAP (like I said, I've never heard of it), and it sounds like NIV-NAVA (non-invasive ventilation, nerually-adjusted vent assist). Basically, you hook the CPAP equipment up to the ventilator, so the baby is 'on the vent' without actually being intubated (hence NIV, 'non-invasive ventilation'). It has an esophageal probe that sits at the level of the diaphragm and senses when the baby takes a breath. It's basically CPAP that can also occasionally give breaths (positive pressure ventilation) when the baby doesn't breathe, and can give extra pressure to support the breaths that the baby initiates.

Maybe SiPAP works slightly differently (my experience is PICU), but NAVA (when used with an intubated patient) will not deliver extra breaths unless the patient is apneic, and then the vent switches into a backup mode - not extra breaths in NAVA mode.

NAVA essentially senses the electrical impulses coming from the diaphragm and coordinates its pressure supported breaths with what the diaphragm is already trying to do. The point is that, as the diaphragm gets stronger, you can turn down the machine to make the diaphragm have to do more of the work. Its like strength/endurance training for your diaphragm.

OP, I'm not sure that is any clearer than mud since you haven't started your job yet, but as you learn ventilator management, it will make more sense. Congratulations on the new job!

Semper_Gumby · Jun 9, 2017

I'm not a new nurse, but I am new to NICU and find this information very helpful!

There used to be a 'new grad in the NICU' thread stickied, I haven't had a chance to look for it but I remember it being full of good information. Wonder how much of it has changed?

kp1987 · Jun 11, 2017

I'm glad other hospitals use the mean rule of gestation or higher. We have a new Neo who says there isn't any real evidence that it's accurate so now we are focusing on both D/S as well as mean. Has anyone every come across any research saying a mean above or around gestation in weeks is the best bet? Just curious?

babyNP., APRN · Jun 11, 2017

I'm glad other hospitals use the mean rule of gestation or higher. We have a new Neo who says there isn't any real evidence that it's accurate so now we are focusing on both D/S as well as mean. Has anyone every come across any research saying a mean above or around gestation in weeks is the best bet? Just curious?

It's based off of a recommendation from 1992 from the Joint Working Group of the British Association of Perinatal Medicine- as the lecture I had in grad school and I quote, "despite a complete lack of published evidence." lol.

Keep in mind that hardly anything we do in the NICU has actually been truly vetted. Until a few years ago, we didn't even have good data on the proper dosage of Ampicillin which is ubiquitous in the NICU.

OP, for the purposes of your learning, yes the "gestational age" is the general rule of thumb for MAPs (with exceptions like PDAs etc as mentioned above). Keep in mind that hypotension is only a symptom of a larger problem. What you are actually worried about is shock. You should be looking for signs and symptoms of shock, like delayed capillary refill time, decreased urine output, tachycardia, skin temperature & color, etc etc.

Hypertension does happen in babies and can indicate a renal issue, with work up including electrolytes with renal function, a renal ultrasound, etc etc. Much rarer than hypotension, but it does occur and should be followed carefully. A rule of thumb (but again, grossly generalized and not based on really anything) is monitoring for systolics >100. In my personal clinical experience, the renal teams I've worked with won't treat until systolics are >120 and then will give hydralazine.