Non-Invasive Monitoring

Transcription

1 Grey Nuns and Misericordia Community Hospital Approved by: Non-Invasive Monitoring Neonatal Policy & Procedures Manual : Assessment : Oct 2015 Date Effective Oct 2015 Gail Cameron Senior Director Operations, Maternal, Neonatal & Child Health Programs Next Review Oct 2018 Dr. Sharif Shaik Medical Director, Neonatology, MCH Dr. Paul Byrne Medical Director, Neonatology, GNH Purpose To provide clear guidelines for infants requiring non-invasive monitoring. Applicability All Covenant Health Neonatal staff and physicians Policy Statement Principles Decision regarding which infants require non-invasive monitoring and the duration of monitoring required are made collaboratively between neonatologist/designates, nurses, and respiratory therapists. HEART RATE All babies admitted to the NICU will have continuous heart rate monitoring unless ordered otherwise. The initial alarm limit settings will be 100 beats / minute (low) and 200 beats / minute (high). Alarm limits may be adjusted following a team discussion. A guideline for lower limit adjustment is 70% of baseline heart rate as long as oxygen saturation levels remain within normal limits. High limits could be reset at 125% of baseline. RESPIRATORY RATE All babies admitted to the NICU will have continuous respiratory monitoring unless ordered otherwise. The respiratory rate graph provides valuable information in association with heart rate and saturation monitoring to trend respiratory effort with desaturations and / or bradycardia events. Alarm limit values are variable depending on the infant s respiratory rate. Apnea alarms are set by default to alarm for a 20 second apnea. PULSE OXIMETRY 1. Continuous pulse oximetry is indicated in the following situations: a. All infants with respiratory distress b. All infants on supplemental oxygen c. All infants who are ventilated d. All infants with congenital heart disease e. All infants with apnea or bradycardia spells f. All infants with compromised airways eg. Pierre-Robin Sequence g. All infants with chronic lung diseaseas per Neonatologist/Designates order h. All infants with tracheostomy

2 Page 2 of 5 Principles 2. All infants admitted from a referring hospital should have pulse oximetry to assess the need for supplemental oxygen. a. If saturations are in the normal range for two hours, when there is not supplemental oxygen, then discontinue pulse oximetry. b. If there is a history of cyanosis, apnea and bradycardia, or respiratory distress, maintain continuous saturation monitoring until otherwise ordered by Neonatologist/Designate 3. Intermittent pulse oximetry monitoring is indicated for convalescent infants with congenital heart disease or chronic lung disease when stable before discharge. Guidelines Ideal pulse-oximeter saturation values vary depending on the condition of the infant. Saturation monitor settings will be ordered by the neonatologist or designate on admission and reviewed for changes daily. In most situations, the settings will be determined by a condition associated profile programmed into the monitor. The profile chosen will be identified on the monitor. Pulse oximetry probes are to be re-sited every 8 hours. The position change is documented on the nursing flow sheet.

3 Page 3 of 5 Monitor Setting Premie NO device Premie on resp device Term NO device Term on resp device Extended Cardiac Car Seat Defining Characteristics Not on O 2 37wk 37wk on O 2 Labile SpO 2 (ie. PDA,CLD) Individualized Car Seat SpO 2 Alarm Limit or as ordered High & Low SpO 2 Delay Time 30 Sec 30 Sec 30 Sec 30 Sec 30 Sec 30 Sec 10 sec * low SpO2 only Minimum SpO or as ordered Minimum SpO 2 0 Sec 0 Sec 0 Sec 0 Sec 10 Sec 0 Sec Delay time Red alarm only for SpO2 <88. This is a significant event H: L: Please use a bubble (along with a fish) for all patients that require individualized SpO2 settings as determined by the multidisciplinary team during rounds. Averaging time for All Profiles = 10 seconds Definitions: SpO2 Alarm Limit Above or below this limit alarm will sound after delay time is reached. High & Low SpO2 Delay Time 30 seconds SpO2 must be above or below the limit for 30 seconds Minimum SpO2 Delay Time 0 seconds When SpO2 drops below this level a red alarm occurs immediately. Averaging Time 10 seconds For Extended and Car Seat profile only 10 second delay. SpO2 is averaged over 10 seconds and then displayed on the monitor. The display is updated with every beat.

4 Page 4 of 5 Guidelines FOR END-TIDAL MONTORING Correct placement of the endotracheal tube is indicated by the presence of carbon dioxide. A non-invasive disposable carbon dioxide detector or in-line CO 2 monitor is used to determine placement of the endotracheal tube in the trachea.. The CO 2 monitor may be inaccurate if the cardiac output is very low or absent (eg. cardiac arrest). If there is no detectable heartbeat, do not use the CO 2 monitor as an indicator of correct or incorrect placement of the endotracheal tube. Non-invasive carbon dioxide monitoring is considered for ventilated patients when frequent blood sampling is not available or not desired (to reduce blood loss through sampling) and when the infant: a. has unstable ventilation requirements b. is intra-operative c. is weaning from the ventilator Documentation Values monitored and recorded where appropriate in patient care record. Note saturation and end tidal measurements when drawing gases. Site change of oximeter probe. Saturation monitor profile selected. BLOOD PRESSURE 1. A blood pressure is recorded on admission. It may be a cuff BP or from an arterial line. 2. Blood pressures are monitored continuously and charted hourly for patients with arterial lines. 3. Infants receiving respiratory support should have a BP done every shift or as ordered 4. Cuff Blood pressures should be taken every 15 minutes or as ordered if an infant is unstable or the blood pressure is not within normal limits.. 5. Blood pressure monitoring for patients without arterial lines and receiving continuously infusing inotrope or afterload reducing agent. Every 5-15 minutes during titration, then every 60 minutes once stable and for duration of infusion. Every 10 minutes during initiation and stabilization phase of inotrope and afterload reducing agent. Every 15 minutes during weaning phase of medication administration As ordered for long-term use of continuously infusing inotropes and afterload reducing agents. 6. Blood pressures may be taken more frequently with specific medication administration and post-operatively as per policy. 7. CVP monitoring is done as ordered NEURO-VITAL SIGNS 1. Neuro-vital signs should be taken every 1-4 hours in infants with neurological

5 Page 5 of 5 compromise. Signs include pupil size, pupil reaction to light, eye opening, level of response to stimulation, and best motor response. 2. Pain and sedation scores are done on admission, near the start of each shift when appropriate developmentally, and every four hours for patients who could be expected to experience pain. More frequent scoring may be indicated by condition and response of patient as directed by scale. 3. Withdrawal scores are done as ordered on at-risk patients. TEMPERATURE Temperature monitoring is done using guidelines in the Temperature Management Policy BLOOD GAS MONITORING Blood gases are monitored as ordered. Note values related to assisted ventilation, oxygenation and carbon dioxide monitoring when drawing the blood gas. References Adapted with permission from Stollery Children s Policy and Procedure Manual: July 2012 MacDonald,M.,G., Ramasethu, J.,Rais-Bahrami, K., (2013) Continuous Blood Gas Monitoring, Atlas of Procedures in Neonatology (5 th ed. pp 65-74) Philadelphia: Wolters Kluwer/ Lippincott Williams & Wilkins Revisions October 2003

6 Page 6 of 5 Original Signed GAIL CAMERON SENIOR DIRECTOR OPERATIONS MATERNAL, NEONATAL & CHILD HEALTH PROGRAMS COVENANT HEALTH GREY NUNS & MISERCORDIA HOSPITALS December 2015 DATE Original Signed DR. SHARIF SHAIK MEDICAL DIRECTOR NEONATAL PROGRAM COVENANT HEALTH MISERCORDIA HOSPITAL DATE Original Signed December 2015 DR. PAUL BYRNE MEDICAL DIRECTOR NEONATAL PROGRAM COVENANT HEALTH GREY NUNS HOSPITAL DATE