2.10.15 DRAFT: Infants <30 weeks 1st 72 hrs. of life clinical
management guideline
1. Neonatologist to attend all deliveries <30 weeks gestation
2. All labs to ideally be on a schedule of start times based on 6/7am
“AM labs” (e.g., ideally for line draw infant q4hr labs would be
6am, 10am, 2pm, etc.)
FEN:
 Total fluids 70-80ml/kg/day to achieve minimum GIR of 6mg/kg/min
o Use Starter TPN and D12.5W on admission to achieve GIR=6 goal
 With first “real TPN”
 Protein 3.5gm/kg/day
 IL 3 gm/kg/day
 Triglyceride level daily
 UAC fluids: 1/3 NaAcetate + heparin at 0.8ml/hr
o Change UAC fluid to 1/3 NS + heparin at 0.8 ml/hr IF serum
bicarbonate level is ≥ 22 or if base deficit is <-7
 ≤1kg: electrolytes and weights q12; >1kg: electrolytes and weights q24
 Start minimal enteral feedings
o Breast milk or donor breast milk 1ml q6hr x 72hr
 Vitamin D supplementation 400 IU po/ng daily
 Occupational therapy consult for Osteopenia Prevention
RESPIRATORY:
 All infants stabilized in DR with Neopuff CPAP+6 or PPV 25/6 (starting with
30% FiO2 and adjust based on targeted saturations) for first 5 minutes of life
to see if spontaneous respiratory effort can be maintained on CPAP (unless
unresponsive to PPV and needs to be intubated to proceed with CPR)
 Goal oxygen saturations 88-95%
 Caffeine load and maintenance therapy
 Transition to NICU on Neopuff CPAP +6
o Use mask only for first 48 hours
o Blood gas minimum q12hr and as clinically indicated
o CXR minimum q24hr and as clinically indicated
o Failure deemed if:
 Recurrent severe apnea requiring PPV
 pH <7.20 and pCO2 >70
 FiO2 >45%
o Unless intubation is required emergently, obtain CXR BEFORE
intubation if deemed “failing CPAP” to exclude pneumothorax as a
treatable cause of failure
 If requires intubation in DR: initial settings are PAC, 20/6, Rate 60.
o Surfactant administration if requires intubation

o Adjustments made in DR vent settings based on blood gases and chest
rise/oxygen saturations
o Blood gas obtained in DR once central access obtained
 Goal ABG/VBG: pH 7.25-7.35, pCO2 45-60
o Once in NICU, will only use PAC as mode of ventilation on Avea
 Initial settings PAC 20/6, Rate 60 unless already adjusted
based on blood gas from delivery room
 If spontaneously breathing above set rate and blood gas shows
over-ventilation, decrease vent set (apnea) rate to 40 and
decrease PIP to achieve ideal blood gas values
 Goal ABG/VBG: pH 7.25-7.35, pCO2 45-60
 If not spontaneously breathing above set ventilator rate and
blood gas shows over-ventilation, decrease vent rate
incrementally down to minimum of 40 and then work to
decrease PIP to achieve ideal blood gas values
 Failure of conventional ventilation with need to move to high
frequency ventilation deemed if:
 Blood gases suboptimal with Rate= 60 and/or PIP>28
 Oxygen needs >60% for >30 minutes
o Blood gases minimum q4hr and as clinically indicated
o CXR minimum q24hr and as clinically indicated
If requires high frequency ventilation
o Blood gases minimum q4hr and as clinically indicated
o CXR minimum q12hr to assess MAP lung expansion and as clinically
indicated
EXTUBATION GUIDELINES:
Consider extubation by 18 hours of life
Extubation criteria:
 FiO2 <0.3
 Spontaneously breathing above set ventilator rate
 PIP ≤ 20
 PEEP ≤ 6
 Caffeine being given
 pH >7.25
 pCO2 <60
REDOSING SURFACTANT GUIDELINE:
 FiO2 >0.3
 PIP >22
NONINVASIVE RESPIRATORY SUPPORT GUIDELINE:
 For CPAP support use either CPAP of 6 or SiPAP 10/6
o Leave on CPAP until FiO2 21% for minimum of 24 consecutive hours
or 32 weeks CGA
o If met criteria for FiO2 21% on CPAP, first attempt to wean off CPAP
completely to room air. If unsuccessful and baby currently <32 weeks
gestation, place back on CPAP and continue to try to wean completely
off CPAP to room air as clinically indicated.
o After a baby is 32 weeks CGA, if still requires non-invasive support
and cannot wean to room air, may consider use of HFNC or LFNC.
CARDIOVASCULAR:
 Double lumen UVC in all infants
o Have a fluid always running through the second port – do not
“heplock” as this increases risk of line becoming dysfunctional
 UAC to be placed in all infants born at <27 weeks or if infant requires
intubation
 Hypotension deemed by 2 out of 3 parameters:
o Prolonged capillary refill
o Low urine output
o Low blood pressure (i.e. Mean BP < gestational age in weeks)
 Treatment of hypotension
o NS flush 10ml/kg or colloid 10ml/kg once
o If no improvement, discuss with Neonatologist or fellow re: use of
second fluid bolus vs. starting pressor support
o If hypotension or on pressors, follow iCa q12hr and treat to keep
normal
INFECTIOUS DISEASE:
 Unless in room air with no risk factors for infection, all infants will have
admission blood culture and IV Ampicillin and Gentamicin initiated
NEUROLOGIC:
 Indomethacin prophylaxis on all infants <1kg (of note, non-nutritive feedings
and Vitamin D acceptable when receiving indomethacin)
 Head ultrasound at 5-7 days of age
 Midline head positioning ordered per protocol
HEMATOLOGY:
 Coags only obtained if active bleeding
 Infant blood type & DAT testing on admission
 Hemoglobin and platelet count daily
o Treat per clinical transfusion guidelines
GI:

First bilirubin level to be obtained at 12-24 hours of life.
o Checked daily
o Increase in total daily fluid goal by 20ml/kg/day if initiating overhead
phototherapy
RENAL:
 If urine output <1ml/kg/day over previous 12 hours
o Consider use of bladder scanner to evaluate for urine and possible
need for Foley catheter
o Give NS 10ml/kg bolus
o If no improvement in urine output over next 4 hours, give Lasix
1mg/kg IV
o If no improvement in urine output over next 4 hours, consider more
volume versus low-dose Dopamine
Confidential 2/9/2016