NCPAP hats/systems

NICURN29 · Nov 24, 2008

How were his gases? If the PaCO2 on a baby drops too far, our docs will extubate even the little ones...to prevent damage from the low PaCO2.

Oh, and we make our own CPAP hats out of stockinette and use safety pins and rubber bands to attach the tubing to the hats.

300g · Nov 26, 2008

I typed up a really well thought out response... then lost it to log out time. So, here's a revised edition!

I'm also looking for a great preventative IVH protocol that would address sedation for vented VLBW (we rarely provide any) and that addresses ET to NCPAP issues.

I've worked in units that utilize sedation and units that don't. I see a general trend away from sedation in "min-stim" protocols. This is partially due to decreased intestinal motility and really a lack of evidence that supports use of sedation. Studies haven't shown a decrease in IVH for sedated neonates. IVH, as you know, is caused by a CHANGE in blood pressure. Even if the neonate is sedated, a rapid increase OR rapid drop in blood pressure can cause IVH.

I'm not quite understanding your question though. You're requesting sedation protocols for intubated neonates, but have concerns with extubations causing IVH... correct?

Common sedation protocols for intubated neonates include the use of Morphine (0.01-0.02 mg/kg/hr) or Fentanyl (1-5 mcg/kg/hr) and/or Versed (0.01-0.06 mg/kg/hr) or Ativan (0.05-0.1 mg/kg/dose q4-8 hr) Hourly N-PASS (or other appropriate pain scale) scoring. However, like I stated, I see a general trend away from sedation simply because the patient is intubated. I see more and more orders for PRN doses for agitation and less and less "preventative" drips.

I never understood why we used Morphine... (which causes increased ICP)...?

Dad asked more than once, "Is this good for him?"

It's really tough to teach parents "decreased environmental stimuli" in these situations, isn't it? Just as hard as enforcing "no cell phones" when 'bored' nurses are texting... ugh!

I know all about saving lungs with early extubation, but at the expense of heads??

This sucks, doesn't it? Nothing is worse than literally watching those fontanels fill after an extubation. I've seen many. I've also seen many successful extubations. I think it just really depends on the patient and their ability to handle stress. I don't see any benefit to keep an E/VLBW intubated for 72 hours to confirm "readiness" for extubation. You have a very narrow window for successful extubation. 72 hours in the life of a E/VLBW is a very long time.

I have applied NCPAP just prior to extubation to retain as much lung volume as possible. This seems to work well. Additionally, if it's taking you 10 minutes post-extubation to apply the hat/appliance... make sure everything is in place and on the patient prior to extubation. The hats shouldn't be tight. Make sure they fit properly, you may need a bigger size or get creative and construct one that fits properly. Anything to reduce the stress and time handling the neonate.

I've never seen any implementation of sedation FOR extubation. As you know, this can decrease respiratory drive and lead to unnecessary reintubation.

As for the NCPAP... hat with velcro sounds like Drager, but I could be wrong. There are so many!

We're currently having a nasal septal breakdown crisis in our unit. It's awful. Of course, the nurses are being blamed and I think they're only partially at fault. Certainly, good nursing care is essential, but my current research is leading me to believe that part of the problem is the CPAP units that are attached to some way to the head. I've found NO nasal septal breakdown in neonates on non-restrictive devices such as the Argyle prongs attached directly to duoderm cheekpads with the tubing free. Additionally, there is no periorbital edema.

I'm curious to other NICU nurses thoughts on this.

I hope I've addressed at least some of your questions! I understand and feel your concern.

cc_nurse · Nov 26, 2008

I k I hate our hats and when I was traveling one unit used beise hats with flaps numbered 1,2,3 that folded around the head and made a hat and then you velcrowed CPAP to it. Does anyone out there know brand name/company?

I believe you are referring to SiPap by Viasys - here is a pic of the machine http://www.nichemedical.com.au/web/pictures/1488sq.jpg

We use that one and traditional bubble ncpap with hat and rubber bands/safety pins to hold tubing in place . I really have come to prefer the Sipap version.

iyqyqr · Nov 27, 2008

THanks, 300g, for your long and thoughtful note,

I will clarify a few things in my note, hoping to get more responses.

It is my understanding that 90% of IVH's occur in the first 48 hours in the VLBW population. (Oct 2008 Devel conf) Doing as much right as we can during that window is imperative. It seems to me that if gases are WNL (CO2 mid 30's) that it would not hurt to keep babe on the vent, see if one dose of Curosurf will be enough, sedate with PRN's if he is restless or flailing about, (not drips) get him loaded with Caffeine, and then extubate to NCPAP. My unit does not generally order even PRN's while intubated, yet, I'm sure intubated adults and peds cases are routinely sedated, aren't they?? I would guess being so tiny and having an ET in and being suctioned as needed would be painful at times. What do your units do for VLBW intubated ones?

I wasn't wanting sedation for extubation. I believe our hats are too tight and the process of getting the dang things on is too much stress, so I'm searching for the other design, where you create the hat out of a flat triangular piece. I plan to contact the unit I used these at when I was traveling.

An update on my little tyke: His parents asked me to primary him, so we've all bonded. (smile) He did fail his NCPAP run and was retubed on day 4, which was his third intubation!! (On day 1 his ET plugged and they removed it and replaced it. He had a head ultrasound 11/26

and only has a Grade 1 IVH. I'm amazed and delighted for him and his folks.:)

UTVOL3 · Nov 28, 2008

It seems to me that if gases are WNL (CO2 mid 30's) that it would not hurt to keep babe on the vent, see if one dose of Curosurf will be enough, sedate with PRN's if he is restless or flailing about, (not drips) get him loaded with Caffeine, and then extubate to NCPAP.

The only thing is, when you have a CO2 in the mid 30s and a kid that is improving you may very well have a CO2 of oh, nineteenish at the next blood draw. That's bad for the head too.

My unit does not generally order even PRN's while intubated, yet, I'm sure intubated adults and peds cases are routinely sedated, aren't they?? I would guess being so tiny and having an ET in and being suctioned as needed would be painful at times. What do your units do for VLBW intubated ones?

We have been making a PRN sedation order standard for several years now. Having an ETT in place is painful. However just having an order for pain meds on your chart doesn't always mean they are going to get administered properly as needed, KWIM? That is one of my pet peeves.

I believe our hats are too tight and the process of getting the dang things on is too much stress, so I'm searching for the other design, where you create the hat out of a flat triangular piece.

If it is that tight that you are worried about it then yeah, I'd say it's probably too tight. I have not seen one made like you described. I did a quick Google but didn't come up with much. Who is in charge of new product evaluation at your hospital? They might be able to help. We have several hat designs available to us. For a VLBW baby though, the one we typically use is one of the volunteer homemade ones, IDK why but they seem to not squish the head as much. Plus they are easy to work with a bili mask. We use thin ribbon or rubber bands to attatch the tubing. Is there not a next size up you can use? That might sound like a dumb question but we mostly use the Arabella hats, and if an RT grabs the stuff to set them up, the weight guide is there on the package but sometimes the weight has little to do with head circumference. And sometimes, certain people who open the package just can't accept that the hat DON'T FIT! :banghead:

I hope you find something for your little ones.

He had a head ultrasound 11/26
and only has a Grade 1 IVH. I'm amazed and delighted for him and his folks.:)

Probably because of the excellent nurse he has to watch over him!

iyqyqr · Nov 28, 2008

The only thing is, when you have a CO2 in the mid 30s and a kid that is improving you may very well have a CO2 of oh, nineteenish at the next blood draw. That's bad for the head too.
Your're right about that AJA, and we don't check gases as often as I'm used to, despite many of these babes having radial art lines or UAC's. I just know that many of these kiddos honeymoon at first after that first dose of Curo, and then they crump and have to be retubed. We have superb RT's who can slip in an ET, but it is still a stress to the baby.
We have been making a PRN sedation order standard for several years now. Having an ETT in place is painful. However just having an order for pain meds on your chart doesn't always mean they are going to get administered properly as needed, KWIM? That is one of my pet peeves.
PRN sedation orders is one of the first things I want our develop committee to address, so I'm hoping for change in this area.
If it is that tight that you are worried about it then yeah, I'd say it's probably too tight. I have not seen one made like you described. I did a quick Google but didn't come up with much. Who is in charge of new product evaluation at your hospital? They might be able to help. We have several hat designs available to us. For a VLBW baby though, the one we typically use is one of the volunteer homemade ones, IDK why but they seem to not squish the head as much. Plus they are easy to work with a bili mask. We use thin ribbon or rubber bands to attatch the tubing. Is there not a next size up you can use? That might sound like a dumb question but we mostly use the Arabella hats, and if an RT grabs the stuff to set them up, the weight guide is there on the package but sometimes the weight has little to do with head circumference. And sometimes, certain people who open the package just can't accept that the hat DON'T FIT!
I hope you find something for your little ones.
If the hats aren't real snug, the prongs which are very short won't stay in and we alternate prongs with mask every 4-6 hours. The RT's use the tighest they can in hopes they won't be constantly called to the bedside to adjust the CPAP when the alarm goes off. I did contact a friend in the unit I worked at that had the good design and will post it after she sends it to me.
Probably because of the excellent nurse he has to watch over him!

Thanks, AJA, for the vote of confidence. I love these wee ones and always as I care for them I picture their brain in my hands and the dreams that their parents have for them. I still am in regular contact with 8 prior primaries, who are all doing amazing, even one who had bilateral G4's. He has no shunt, and is advanced for a a 3 yo. (But I know that they can still present with difficulties at school age, so I pray lots.)

Thanks for your kind response, AJA. :heartbeat