SARASOTA MEMORIAL HOSPITAL TITLE: NURSING PROCEDURE Management, Monitoring & Documentation of a Clinically Significant Cardiopulmonary Event (CSCPE) (NUR47) DATE: REVIEWED: PAGES: 9/09 9/17 1 of 6 PS1094 ISSUED FOR: RESPONSIBILITY: RN, LPN, MST Neonatal Nursing PURPOSE: DEFINITIONS: To provide a process for management, monitoring, treatment and documentation of clinically significant cardiopulmonary events in infants in the Neonatal Intensive Care Unit (NICU). Clinically Significant Cardiopulmonary Event (CSCPE): 1. An apneic event > = 20 seconds 2. An apneic event < 20 seconds accompanied by a bradycardia < 80 bpm for any duration 3. An apneic event < 20 seconds with desaturation <85% or accompanied by central cyanosis for any duration 4. A bradycardia < 80 bpm for > 10 seconds 5. Oxygen desaturation < 85% or central cyanosis for >10 seconds ( if no pulse oximeter was being used) Induced Significant Cardiopulmonary Event Events that occur during procedures such as, but are not limited to suctioning, eye exams, feedings, OG/NG insertions or events that are pacifier related. Events requiring vigorous stimulation document as CSCPE. Do not document self-resolved events with HR <80 for < 10 sec. for Apnea <20 sec. Apnea: A respiratory pause 20 seconds Bradycardia: Heart rate less than 80 bpm for more than 10 seconds. The lowest heart rate should be recorded. Desaturation: SpO 2 <85% for at least 10 seconds. The lowest SpO 2 should be recorded.
Periodic Breathing: A series of 3 or more respiratory pauses per minute longer than 3 seconds with intervals of respiration between pauses. This pattern of breathing is common in newborns and is usually not associated with significant bradycardia or desaturation. The term is only used when there is no significant bradycardia or desaturation. Stimulation: Gentle: Infant responds immediately to gentle strokes on body, repositioning or removal of pacifier Moderate: Infant responds to rubbing of the back, trunk or extremities, and/or flicking soles of the feet. Vigorous: Infant requires blow by oxygen, positive pressure ventilation or use of resuscitative drugs. PROCEDURE: Management of Infants with Apnea of Prematurity All infants less than 35 weeks 0 days gestation will be monitored on a cardiorespiratory monitor after birth until risk for developing apnea of prematurity is assessed. Infants > 35 weeks with history of duskiness should have pulse oximetry monitoring for minimum of 48 hours. Any changes to the procedure must be ordered by the physician. Pulse oximetry monitoring should continue until infant is consistently PO feeding > 75% of his/her feedings in 24 hours AND is free of CSCPE for a minimum of 7 days off caffeine therapy. If the infant has frequent episodes of CSCPE, a full clinical examination should be conducted including assessment of airway patency, thermal stability, blood pressure, glucose regulation and other potential causes of apnea.
While monitored, infants may be positioned prone, side-lying or supine, maintaining the infant s head in a neutral position. The cardiorespiratory monitor should be set with a 20-second apnea delay. Maintain the infant in a thermal neutral environment. Treatment options for CSCPE include medications, usually caffeine, nasal CPAP, Vapotherm or intubation. Responding to Monitor Alarms When the monitor alarms, the infant should initially be evaluated (observed) for respiratory movements, color, and heart rate. Assess the infant for hyperextension or flexion of the neck. This may cause or contribute to apnea/bradycardia. Reposition the head and neck if necessary. Maintain the head and neck in a neutral position. If the infant has a CSCPE appropriate tactile stimulation should be initiated. Positive pressure ventilation (PPV) should be administered if the infant does not respond to tactile stimulation and/or repositioning within 30 seconds. Do not continue to stimulate a baby who is not breathing within 30 seconds. Provide gentle ventilation for a few breaths with a ventilation bag (self-inflating or T-piece resuscitator) and face mask or until infant recovers effective respiration. Avoid vigorous manual ventilation as it may adversely affect the infant s CO2 level. The PPV should be set at the same oxygen level as the baby is otherwise requiring. Continue PPV if required until regular respiration, normal heart rate and color have returned.
Reassess respiratory effort, heart rate and oxygen saturation after 30 seconds of PPV if it is required for that length of time. Oxygen should be increased only if the baby does not improve after 30 seconds of PPV. DOCUMENTATION: Do Record On the Flowsheet: Any CSCPE and Induced CSCPE as defined above should be recorded under the CSCPE header in the Vital Signs Flowsheets. The duration of the episode should be from the time the monitor goes off and is confirmed by the nurse s assessment to be true until the episode resolves. Documentation should include duration, heart rate, oxygen saturation, color change, activity state and type of stimulation. DO NOT RECORD: Self-resolved events. Episodes of periodic breathing or respiratory pauses <20 seconds that are not associated with significant bradycardia or desaturation. Episodes related to monitor artifact. (events that were not witnessed should be checked in event review) Episodes of bradycardia that are self-resolved within 10 seconds and are not associated with a desaturation below 80% or respiratory pause. REFERENCE: 1. AAP, POLICY STATEMENT: Apnea, Sudden Infant Death Syndrome, and Home Monitoring. Committee on Fetus and Newborn. PEDIATRICS Vol. 111 No. 4 April 2003, pp. 914-917 2. Alvaro, R. MD. Apnea of Prematurity& Bradycardia (Cardiorespiratory Events): Management, Monitoring & Documentation Procedure, University of Manitoba, Neonatal Manual, 2006. 3. Stokowski, L.A. A Primer on Apnea of the Prematurity. Advances in Neonatal Care:
June 2005 - Volume 5 - Issue 3 - p 155-170 4. Butler, T. Jeffrey, MD, Kimberly S. Firestone, BS, RRT, Jennifer L. Grow, MD, and Anand D. Kantak, MD. Standardizing Documentation and the Clinical Approach to Apnea of Prematurity Reduces Length of Stay, Improves Staff Satisfaction, and Decreases Hospital Cost. The Joint Commission Journal on Quality and Patient Safety 40.6(2014):263-69. Print. 5. Alere Neonatal Clinical Management Guidelines. 8th Edition. REVIEWING AUTHOR (S): Heike Bucken RNC-NCC,CLC, NICU Clinical Coordinator Kathy Duffy RRT, Respiratory Therapy Lisa Biach RNC-NCC,CBC, NICU Discharge Coordinator Heather Graber RNC-NCC, CBC NICU Clinical Manager