Management- PINK

Oxygenation & Perfusion are essential for organ function and overall health. Monitoring is critical for preventing complications from decreased oxygen delivery and for preventing complications from decreased cardiac output. Insufficient oxygen levels can occur due to poor breathing and or ventilation. Oxygen demands will increase with stress. Managing fluid status helps prevent complications such as hypovolemia or dehydration. Critical for preventing complications from decreased cardiac output and ensuring adequate oxygen delivery. Insufficient oxygen levels can occur if the infant due to poor breathing and or ventilation. Hypoxia can impair glucose metabolism, leading to hypoglycaemia, which in turn leads to further hypoxia. Oxygen demands will increase with stress.

Strategies

Maintaining oxygenation and perfusion in premature and hemodynamically unstable infants in the Special Care Nursery is a critical component of neonatal care. These infants are vulnerable due to either immature organ systems or poor physiologic reserves. Strategies must be individualised and based on continuous assessment. Strategies include respiratory support (supplemental oxygen, high- flow nasal cannula (HFNC), Continuous Positive Airway Pressure (CPAP) and in the more unstable infant requiring NICU management mechanical ventilation and surfactant replacement therapy). Monitoring of oxygenation is essential via Pulse Oximetry and or Blood gas analysis with careful titration of any supplemental oxygen to avoid oxygen toxicity and or retinopathy of prematurity (ROP). And lastly positioning to optimise lung expansion

Interventions

Interventions include respiratory support (supplemental oxygen, high- flow nasal cannula (HFNC), Continuous Positive Airway Pressure (CPAP) and in the more unstable infant requiring NICU management mechanical ventilation and surfactant replacement therapy). Another essential component is monitoring of oxygenation via Pulse Oximetry and or Blood gas analysis with careful titration of any supplemental oxygen to avoid oxygen toxicity and or retinopathy of prematurity (ROP). Fluid management also needs to be targeted at the individual and continuously adjusted based on the infant’s evolving clinical condition.  And lastly positioning of the infant to optimise lung expansion

Maintain clear/patent airway: provide oxygen and or respiratory support to compromised infant.

Respiratory assessment: primary survey: look, listen & feel

Positioning: maintain clear airway (suction prn), initially consider prone position optimises lung expansion by decreasing the pressure of the diaphragm pushing up on the lungs, therefore enabling improved ventilation to the lungs

Incubator: enables visualisation of work of breathing & colour, infant is nursed naked in NTE

Monitor Perfusion Indicators: Check skin colour, capillary refill time less than 3 seconds, and peripheral pulses (strong or weak), signs of poor perfusion such as mottling, pallor.

Monitoring: On admission heart rate, respiratory rate, blood pressure, oxygen saturation and temperature then continuous monitoring of vital signs, to evaluate perfusion status, documented hourly or as directed by medical team.

Oxygen Monitoring: Continuously assess oxygen saturation levels and provide supplemental oxygen to maintain target levels (90-95% for preterm infants). Sats probe to be repositioned with cares 4-6 hourly to prevent pressure areas and or burns. (Oxygen saturation/ pulse oximetry and cardiorespiratory monitoring is a non-invasive means of obtaining immediate information on the infant’s O2 status). Blood gas (capillary or arterial).

Supplemental oxygen and or Respiratory Support: various options and will be on the guidance of a medical practitioner, ranging from supplementary oxygen in incubator, to non-invasive options (e.g., CPAP, high-flow nasal cannula) or invasive ventilation as needed for respiratory support, with protocols for weaning off as the infant stabilises.

Test & Procedures Chest X-Ray, septic workup

Intravenous therapy (IVT): Ensure proper hydration and adjust fluid intake based on clinical needs and laboratory results. (U &E’s, maintain Fluid balance chart)

BP monitoring & Correcting hypovolemia is essential as a stable cardiovascular status will assist in the recovery of respiratory distress.by improving gaseous exchange. Maintenance of the circulation cannot be over emphasised. The result of a reduction in circulating blood volume can cause pre-renal renal failure unless aggressive management is adopted. Volume replacement with blood of Fresh Frozen Plasma (FFP), saline or albumin is indicated. Blood & FFP are most beneficial as they theoretically not only replace volume but also contain immunoglobulins & clotting factors.  Saline is effective in treating hypotension as is albumin.  If volume replacement is insufficient to treat hypotension, inotropes may be commenced.

Haematological Management: Careful running of the total of blood taken for tests need to be recorded as sick infants tolerate anaemia badly.

Regular Skin Assessments: Perform with cares/nappy changes (4-6 hourly) to identify any signs of skin breakdown, rashes, or infections.

Evaluation

Improving condition, skin well perfused, brisk capillary refill,

• • Improvement in SpO₂ (maintained >90% on minimal O₂ support).
  • Improvement in SpO₂ (>95%) in room air, reduced respiratory distress, normal blood gas levels
  • Reduction in respiratory distress signs (decreased grunting, nasal flaring, retractions).
  • Stable respiratory rate within normal range (40-60 breaths per minute).
  • Improved blood gas results (PaO₂ within normal range, resolving respiratory acidosis).

Documentation: Record the infant’s temperature 4 hourly unless deviated from norm, then intervention required and reevaluate in one hour, note any deviations from normal and escalate accordingly

Treating the Underlying Cause- Depending on the cause of respiratory distress (e.g., prematurity (surfactant deficiency) infection, pneumonia, meconium aspiration, congenital anomalies, etc.), specific treatments such as antibiotics, inotropes, or surgical intervention may be required

Managing oxygenation & perfusion in some more commonly seen SCN presentations

*** this is a guide only: always refer to local policy and or guidelines to ensure you are practicing within hospital frameworks and your scope of practice***