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Discussion

surfactant

Last night, I cared for a 25 week baby girl. She is 4 days old on the HFOV Jet. She required about 30 % fiO2 (give or take some). On my shift (the night shift) she was sheduled to get her 5th dose of surfactant. Yes that's right, her 5th dose. We did an ABG at midnight and it was great. The doc even went down one on the PIP (from 20 to 19). At 3 am , she received her surfactant (3ml for a .67 kg baby) via the ETT by the RT. One hour later we checked another ABG and she was acidodic and her PCO2 went up to 67 (previous one was in the high 40's). At this time we increased the pip back to 20. Her bloodsugar was 172 (previous ones were both 154) So my head starting to think...what is happening here?

One hour later, I noticed she was was getting restless, requiring more O2 (from 30 to 40%). We checked yet another fiO2 and bang...her CO2 was 92 and her pH was 7.02. And on top of this her blood sugar was 235. Right away we brought the PIP to 22 and ordered a stat CXR. I also gave her ativan. The CXR surprisingly looked great, much better then the previous XR and her ETT was in the correct position. This all happened approx 3 hours after receiving her 5th dose of surfactant. The charge nurse and I realized she needed to be suctioned and I suctioned her ETT and all that came out was surfactant. After I was done suctioning, her stat came up to near 100%. We did an ABG and everything was back to normal. Literally. He pH was 7.3, PCO2 was 48. We weaned the pip back to 20. her bood surgar was starting to come down. Wow.

Could this 5th dose of surfactant be too much for this tiny baby?

I've been trying to do some research on this and I have only found the surfactant to give temp bradycardia/desats and pulm hem. Anyone else have any experience on this? Our policy states that we don't suction babies 4 hours after surfactant administration. Obviously I needed to suction her earlier then this because her tiny lungs weren't able to absorb it.

I left the unit in tears. I felt as though the treatment we gave her failed. Although I realized suctioning her was probably the best move I did for her. I feel like calling the unit and finding out how she is doing.

Thanks for listening. Any comments are greatly appreciated.

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It appears as though your baby was experiencing a partial occlusion of her ETT as evidenced by a stress reaction (elevated blood sugar), restlessness, falling O2sats, and increasing CO2 levels. Was that occlusion caused by the surfactant? It certainly is possible. Was it caused by a mucuos plug that you dislodged by suctioning? That's possible too.

You may never know what caused the tube to become occluded, but you learned a valuable lesson in assessing your baby, and intervening to relieve the occlusion, even though suctioning at that time may not have been ideal, according to the surfactant protocol. You provided the care she needed at the moment to stabilize her condition, which was the right thing to do. It would have harmed her to hold off on suctioning just for the sake of the surfactant protocol.

I marvel sometimes that babies can tolerate relatively large doses of liquid surfactant, but crump when they get a drop of humidity down their tubes. Sometimes you just can't predict how these kiddos will respond. Perhaps her lungs were effectively producing their own surfactant by that time, and her final dose was just too much liquid for her to tolerate.

What references does your unit use for medication? We primarily use the Neofax, and from what I remember, it says that you can give 4 doses in the first 48 hours of life. Someone please correct me if I am wrong. Were the docs going by her blood gas, CXR and O2 requirement? I'm just wondering why she got 5 doses, only because I don't think I've ever seen more than 3.

It sounds like as far as caring for the baby, you did the right thing by suctioning her. We typically wait at least an hour to suction, more if the baby can tolerate it. Did you call the unit to check up on her? I do that sometimes if we have a bad night, and if it is one of my primaries, I usually ask the nurse to let the parents know I say hi and that I was checking on them. Hope the baby is doing well.

I'm curious too as to why they would give a 5th dose if she was pretty stable (as you said she was requiring 30% FiO2, had a great ABG at midnight, and they weaned the PIP).

I'm wondering why they gave 5 doses as well. Our babies never get more then two.

We sometimes give as many as 3 doses, and is is usually dependent on their oxygen requirements and what pressers they are requiring to be adequately ventilated.

I've seen a 3rd dose given too, if it's warranted. But not when the baby is requiring only 30% FiO2, has a great ABG, and they're weaning on the vent settings.

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