my 2 days old 24 weeker (decided she was actually 26 weeks, by appearance) collapsed post extubation, while on nCPAP for 12-15 minutes...
I know they do that sometimes, but in this case I'm afraid is my fault
She was breathing 40, on her own while on SIMV, RR20 Fio2air. After extubation I didn't put her straight to nCPAP. She was doing well in air so I cleaned her mouth, eyes, ears, AND since the Xray technician was there ready for my baby, I hold her straight for that XRay. At the end of the procedure she went bradicardic and apnoeic I had to mask+bag her with 100% O2, than I put her on nCPAP. She did well on nCPAP for 15-20 minutes then went apnoic, bradicardic, saturations dropped to 20%. We bagged her, but this time chest wouldn't move. Sats dropped to 8, HR 20 , off colored. Quickly reintubated and ventilated on CMV, she needed FIO2 40-50% and PIP 18! I feel very guilty about the whole situation. But is not the first time I cleaned baby's face between extubation and nCPAP and nothing went wrong. Is it because I kept baby in air for too long this time, by doing the XRay as well??
pLEASE, HELP ME TO LEARN FROM THIS INCIDENT, as I find myself willing to find excuses and blame everybody like "the baby didn't crashed while cleaning her face or doing the XRay, but after being on nCPAP for 15 minutes!!" or "she perhaps still had lots of secretions in her lungs since the ETT was coted in yellow thick secretions" or maby because she was given one dose of survanta only??
I have to write an incident report tonight, so I'll be waiting here at the edge of my com for any word of comfort
And I thank you all from now for any reading/training sugestions that I might need to consder, so I will never put a baby at risk again :uhoh21:
Oct 10, '05
Don't be so hard on yourself - it's happened to all of us.
Nicumom is right - it's all about PEEP. Those babies just don't have the reserve needed to keep their lungs from collapsing.
This is what we do, when we extubate a baby...
About ten minutes before extubation, we'll do a good suction to remove any secretions that have built up in the lungs - just as long as the baby hasn't just received surfactant, of course. While the baby recovers from the suctioning, we'll get EVERYTHING ready. Tape is cut, new NG tube is ready, the CPAP/Vapotherm/high flow cannula is up and running, warm wet washcloth or gauze is prepared, and Polaroid camera is at the bedside. If we're nervous about the extubation, we'll have a doc or NNP come over - otherwise it's just the nurse and the respiratory therapist. We usually pull off all the tape and stuff during extubation, and then it only takes a few seconds to wipe the baby's face down with the washcloth or gauze. Someone grabs a quick "naked face" picture for the parents, and then we immediately get going on the new taping and stuff. If it's vapotherm or a high flow cannula, we actually put this on the baby first so that it's already blowing up the nose while we're taping and dropping the feeding tube. All in all, it's usually less than one minute that the baby is not getting PEEP.
Now, if there is a problem with the equiptment or you forgot to set something up, just have someone hold the bag against the baby and provide CPAP with that. Don't have to actually bag the baby, just give some PEEP with the bag while you get your stuff together. Like, if that X-ray tech was really in a hurry, you could hold the mask on the baby with PEEP while you do the film, so that she's not compromised.
It's so tempting, though, when they are on such low vent settings and doing so great off the vent, to let them go for a few minutes. They look so beautiful and perfect, just a miniature baby, and they have such a look on their faces when they are breathing on their own for the first time. We've all been there - either didn't hook up the CPAP because we couldn't bear to shove all that stuff up the baby's nose when they looked so relaxed, or didn't have our stuff set up so it took a few minutes to start CPAP. And there are some babies that actually do well on room air after extubation, but you never know so it's best to just hurry things along just in case.
But as long as the baby is okay now, you can just use this as a learning experience. I'm sure that the next time you extubate, you'll be the opposite - NO ONE will be able to stop you from getting that CPAP going STAT! You'll be a woman on a mission!
ETA: Was the baby already bolused on Caffiene or Theophylline when the extubation occurs? I only ask because we have some docs that don't automatically order it and want to "wait and see" if the baby really needs it post-extubation. Yeah, like a 26 weeker is going to have a mature respiratory drive?!?!
Last edit by Gompers on Oct 10, '05