Approved by: Surfactant Administration Gail Cameron Senior Director Operations, Maternal, Neonatal & Child Health Programs Dr. Paul Byrne Medical Director, Neonatology Neonatal Policy & Procedures Manual Policy Group: Respiratory December 2015 Date Effective December 2015 Next Review December 2018 Dr. Sharif Shaik Medical Director, Neonatology Purpose To provide a framework for the use of surfactant replacement therapy in the management of sick neonates. Policy Statement Applicability Principles Early and effective CPAP in preterm infants may stabilize lung surfactant function and avoid the need for mechanical ventilation. A trial of CPAP (>5 cm water) is warranted before considering surfactant rescue therapy. Prophylactic surfactant is no longer indicated at any gestation. All Covenant Health Neonatal staff and physicians. Surfactant is produced and secreted in lung alveoli. Production of surfactant may be impaired due to immaturity, inflammatory pulmonary conditions, or genetic diseases, giving rise to problems with inflation and ventilation of the lung. Exogenous surfactant can be administered via the endotracheal route, and has been demonstrated to reduce mortality and complications (pneumothorax in particular) from moderate to severe respiratory distress syndrome (RDS). Benefit from surfactant instillation has also been demonstrated in severe meconium aspiration syndrome (specifically in babies already requiring ventilation in greater than 50% oxygen), and in respiratory deterioration induced by pulmonary hemorrhage. Guidelines for Surfactant Administration A. Non-ventilated neonates: Infants with known radiological evidence of RDS and receiving adequate CPAP (>5 cm H2O) should be intubated and given surfactant under the following conditions in the first 72 hours of life: 1. FiO 2 requirements > 0.40 to maintain saturations 88-92% after the resuscitation period. 2. Marked work of breathing despite adequate application of CPAP (>5 cm water) Ideally, CPAP is provided with an infant flow driver device. 3. PaCO 2 > 65 mmhg or ph <7.15 (venous) 4. Poor perfusion requiring colloid/crystalloid or inotropes 5. Apnea unresponsive to stimulation and Caffeine > 6 episodes requiring stimulation in 6 hours
Policy No. Page 2 of 5 1 episode requiring PPV B. Intubated infants 1. Infants with radiological evidence of RDS who are intubated will receive exogenous surfactant therapy under the following conditions in the first 72 hours of life. a. Infants should receive surfactant without delay if they require supplemental oxygen with Fi0 2 >.30. Early rescue surfactant is beneficial. b. Infants with RDS who have persistent or recurrent oxygen and ventilation requirements within the first 72 hours of life may have repeated doses of surfactant. c. Administration of more than three doses has not been shown to have a benefit. d. Retreatment should be considered when there is a persistent or recurrent oxygen requirement of 30% or more. It may be given 4-6 hours after the initial dose. Administration as early as 2 hours after the previous dose may be considered when there continues to be high oxygen/ventilation requirements. e. Intubated infants with RDS should receive exogenous surfactant therapy before transport if they have any oxygen requirements. 2. Intubated infants with meconium aspiration syndrome (MAS) and infants with pneumonia requiring more than 50% oxygen should receive exogenous surfactant therapy. 3. Intubated newborn infants with pulmonary hemorrhage that leads to clinical deterioration that leads to an increase in oxygen of 20% should receive exogenous surfactant therapy. 4. Surfactant therapy should be used with caution in pulmonary hypoplasia or pulmonary hypertension. Routine use of surfactant in diaphragmatic hernia may increase mortality. Procedure Surfactant Administration 1. Natural surfactants are used in preference to synthetic surfactants. 2. Surfactant may be administered when an order from a Neonatologist/designate is obtained. The order should specify the type and volume of surfactant to be administered. 3. Neonatologists/designates, registered respiratory therapists, and registered nurses may administer surfactant. 4. A registered respiratory therapist should be present during surfactant administration.
Policy No. Page 3 of 5 5. Surfactant should be administered with pressure regulated ventilation. This is by a T-piece resuscitator or ventilator. If these two routes are unavailable or ineffective, positive pressure ventilation is given with a flow inflating bagger. Every effort is taken to prevent hyperoxia during the process and the Fi0 2 is titrated to keep oxygen saturations less than 95%. 6. Consideration should be given to increasing PIP and/or PEEP by 2 cm water or more if oxygenation is compromised with surfactant administration. 7. Evidence of airway occlusion following surfactant administration, despite an increase in ventilation pressures may require endotracheal suction. 8. A Neonatologist/designate should be immediately available during administration and are notified if any complications ensue during surfactant administration. 9. Tolerance of the dosing procedure should be noted on the nursing care record. Surfactant administration is documented according to medication guidelines. Adjunctive Therapies: Ventilation: Infants with RDS or significant parenchymal lung disease would normally be managed with a PEEP or CPAP of >5 to 6 cm water. Lower pressures may be required to stabilize functional residual capacity following surfactant administration. Optimization of PEEP or CPAP should be considered before and after surfactant dosage if there is evidence based oxygen requirement or pulmonary graphics. Extubation: Early extubation should be considered Caffeine: Caffeine dosing should be optimized prior to intubation for apnea. Related Documents References Ventilated Infant Care of, T-Piece Ventilation Adapted with permission from Stollery Children s Policy and Procedure Manual: http://insite.albertahealthservices.ca/assets/policy/clp-capital-nicu-pp-respiratory-surfactantadmin-pol.pdf Surfactant Administration 2012 Fetus and Newborn Committee of the Canadian Paediatric Society (2005). Recommendations for neonatal surfactant therapy. Paediatric Child Health, 10, 109-116. Updated Jan 30, 2015 Morley, C.J., Davis, P.G., Doyle, L.W., Brion, L.P., Hascoet, J, Carline, J.B. (2008) Nasal CPAP or intubation at birth for very preterm infants. New England Journal of Medicine. 358, 700-708. SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network (2010). Early CPAP versus surfactant in extremely preterm infants. New England Journal of Medicine, 362, 1970-9
Policy No. Page 4 of 5 Revisions Surfactant Administration Policy June 2010 Surfactant Administration Procedure February 2009 Surfactant Administration July 2011 Surfactant Administration December 2015
Policy No. Page 5 of 5 Signing GAIL CAMERON SENIOR DIRECTOR OPERATIONS MATERNAL, NEONATAL & CHILD HEALTH PROGRAMS GREY NUNS & MISERCORDIA HOSPITALS May, 2016 DR. PAUL BYRNE MEDICAL DIRECTOR NEONATAL PROGRAM GREY NUNS HOSPITAL May 2016 DR. SHARIF SHAIK MEDICAL DIRECTOR NEONATAL PROGRAM MISERICORDIA HOSPITAL May, 2016