2024 NNF SHINE

Short course in Neonatology

Workshop 2
Standard Operating Procedures

NATIONAL NEONATOLOGY FORUM

2024
 NNF SHINE
Short Course in Neonatology for Postgraduates
Workshop 2

Station 1 Oxygen Delivery devices and pulse oximetry

Following oxygen delivery devices are used in neonates.

1. Nasal prongs/canula : Nasal prongs/canula provide FiO2 between 25 to 45% with flow
rates of .5-2 L/min.

Among the various types of nasal prongs available, short bi-nasal prongs are most commonly
recommended.

They come in various sizes and the appropriate neonatal size prongs should be used. These
are the most preferred mode of providing oxygen.

2. Oxygen hood: The flow rates in the oxygen hood should be maintained between 2-
3L/Kg/min. These are capable of providing FiO2 between 30 to 90%. They have occludable
portholes on the sides. With one porthole opened it provides a FiO2 close to 40-50%, while
with both opened it provides 30-40%. With both port holes closed, 80-90% FiO2 can be
achieved.

Precautions

i. Oxygen saturation should not cross 95% in preterm infants as hyperoxia leads to
widespread free radicalinjury. Set appropriate alarm limits on pulse oximeter.

ii. Use oxygen analyzer to check the FiO2 when oxygen therapy is initiated and thereafter,
whenever a change in the flow rate is made or a change in the respiratory status of the
neonates has occurred.

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Humidification

Medical air and oxygen have almost no water vapour and is basically cold (15-200C) and dry
(0.3mg/L H2O).

Warm, moist air is essential for maintaining the structural and functional integrity of
respiratory tract. Cold and dry air can cause damage to airway epithelium and impair the
clearance of secretions and mucus. This effect is particularly seen when the flow rate
provided to the infant is above 1L/min.

Hence, it is recommended that heated and humidified air be provided for neonates whenever
providing respiratory support. Optimum heat and humidity recommended is 370C and
44mg/L H2O (100% relative humidity) for both invasive and non invasive ventilation. For
standard flow oxygen therapy, humidification is not needed.

Oxygen Concentrators

An oxygen concentrator is a device providing oxygen therapy to a patient at minimally to

substantially higher concentrations than available in ambient air. Oxygen concentrators are
less expensive than liquid oxygen and are the most cost-effective source of oxygen and a
more convenient alternative to tanks of compressed oxygen.

Room air contains 21% oxygen combined with nitrogen and a mixture of other gases. A
miniaturized compressor inside the machine pressurizes this air through a system of chemical
filters. This chemical filter is made up of silicate granules called Zeolite. The Zeolite will
sieve the nitrogen out of the air, concentrating the oxygen. Through this process, the system
is capable of producing medical grade oxygen up to 96% consistently. Most of the portable
oxygen concentrator systems available today provide high concentration of oxygen and also
maximize the purity of the oxygen.

Safety

The concentrator’s instruction manual indicates what maintenance is necessary; here are
some general guidelines to follow:

• The concentrator needs good, clean air to operate properly. Hence, operate the concentrator
in a well ventilated area

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• Wash the filters periodically (at least once in a week)

• Replace the filters periodically (at least once in a year)

• Ensure examination of the concentrator at least once in a year by the company engineer

There are also some very important safety issues to be kept in mind. Oxygen is dangerous in
the presence of fire.

Keep flammable materials safely away, and do not allow any heat sources to be near a
working oxygen concentrator.

In both clinical and emergency-care situations, oxygen concentrators have the advantage of
not being as dangerous as oxygen cylinders, which if ruptured or leaking, greatly increase the
combustion rate of a fire.

Oxygen concentrators are considered sufficiently foolproof to be used in neonatal units. They
can be used for more than one patient by using flow splitters. Oxygen concentrators need a
power source to function.

Parts

1. Machine with compressor

2. Flowmeter with/without splitter

3. Humidification bottle

Working

1. Plug on to the power supply

2. Switch on the concentrator using the ON/OFF button

3. Once the concentrator is on, a yellow light will come up

4. Next, adjust the flow to 3-4 liters. This light will be ‘on’ till the desired concentration of
oxygen is achieved, which in most concentrators is nearly 90-93%, after which it goes ‘off’

5. Every manufacturer has a specific way of showing the achieved desired concentration, in
some concentrators this yellow light will become green after achieving the desired
concentration

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Maintenance

1. Coarse filter –Ensure it is dust free and washed daily

2. Zeolite granules –Change every 20,000 hrs

3. Bacterial filter –Change every year

Trouble shooting

Alarm Possible reason Corrective action

Machine too noisy Coarse filter blocked by dust Wash filter daily
Machine gets heated Machine is near the wall Keep away from wall for
free circulation of air

Yellow light is not going off Desired oxygen May be due to high
concentration not reached humidity or the flow rate is
more, which exceeds the
capacity of zeolite material.
Decrease the flow rate.

Compressor heats up Malfunctioning of Look at the fan, it may be

compressor jammed, andchence may
need repair.

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Pulse oximeter

Objective

Upon completion of this section the participant should be able to:

i. Describe the parts of a Pulse Oximeter

ii. Demonstrate the working of the pulse oximeter

iii. Interpret Pulse Oximeter readings

iv. Describe daily maintenance, cleaning and troubleshooting

Parts

1. Display panel

i. Numeric display

ii. Graphic display

2. Control buttons

i. Power / standby button

ii. SpO2 alarm setting button

iii. HR alarm setting button

iv. Set button (alarm, volume, trend)

v. Alarm silence button

3. Electric cable

4. Extension cable for attachment of the patient sensor

5. Patient sensor which is to be connected to the extension cable

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Working

I. Connect to the mains

II. Switch on the machine

III. Set the alarm limits for heart rate 100 – 160 bpm

IV. Set saturation alarm limits—90 - 96%

V. Connect the patient sensor to the patient by wrapping it around the baby’s hand/foot and
then attach sensor/ probe to the pulse oximeter

VI. Pulse oximeter starts detecting signal from the patient and displays heart rate and
saturation in a few seconds. The values displayed may not be reliable in the presence of
shock, cold peripheries, excessive movement, electrical interference and exposure of probe to
bright ambient light. Values are reliable when the plethysmographic waveform or bar signal
is good. Values are reliable when the display is constant and not blinking or repeatedly
changing

Cleaning and Disinfection

i. Clean display panel with moist soft cloth

ii. Clean body with soft cloth dampened with soap water followed by moist soft cloth

iii. Clean reusable sensors with spirit after each patient use

Dos & Donts

i. Inspect sensor site every 2 to 4 hours for any erythema or discoloration

ii. Change sensor site every 4 – 6 hourly

iii. Do not apply sensor too tightly

iv. Do not apply probe to edematous or bruised sites

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Trouble shooting

Alarm Possible reason Corrective action

Ambient light Relocate Excessive light on sensor cover with opaque
paper/cloth

Interference detected Erratic signal with Remove interference

electromagnetic waves in
vicinity like TV, mobile
phone

Sensor failure Broken cable, faulty Replace sensor

photodiode, sensor damage

System failure Internal component failed Unit needs service/change

Low battery Low internal battery Connect to power

Check sensor Motion Low perfusion wrong position Reposition,

relocate

Side Effects & Dangers

i. Failure of operation

ii. Local reddening, blisters, skin discoloration, burn etc. because of the sensor placement

Maintenance

i. Cleaning the Oximeter as necessary

ii. Recharging the battery as necessary

iii. Replacing the fuses in power module as necessary

iv. Comprehensive/Annual maintenance contract

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Station 2 Exchange transfusion and monitoring

Aim of Procedure: To learn about:

1) How to prepare for blood exchange transfusion

2) How to do blood exchange transfusion

Preparation and Equipment

1. Obtain informed consent from parents/guardian

2. Obtain blood samples of baby and mother for cross match
3. Arrange for the blood as per the chart given below
4. Umbilical Catheter selection as per weight
3.5 Fr: < 1 kg, 4 Fr: 1-2 Kg, 5 Fr: 2-3 Kg, 7 Fr: > 3 kg
5. Sterile Gloves (2 Pairs)
6. Dressing Set
7. Cap / Mask / Gown (2 Pairs)
8. Spirit / Betadine / Chlorhexidine 2%
9. Drapes (2)
10. Syringe 2 ml (2), 5 ml (2), 10 ml (2), 20 ml (2)
11. IV Cannula 24 No. (1)
12. Three-Way Stop Cock (2)
13. Blood Transfusion Set
14. IV Set (2)
15. Plastic or glass bottle for disposal of blood
16. Saline/Sterile water
17. Transparent Dressing
18. Paper Tape / Tegaderm / Durapore
19. Surgical Blade
20. Sucrose Analgesia??
21. Exchange Cycle Chart Prepared
22. Cycle Volume and Cycle Number Determined
23. Pulse oximeter/ monitor attached
24. Resuscitation equipment checked

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Chart for reference for issue of blood for exchange transfusion

Baby Blood Mother’s Blood to be

group blood group issued

O O

O A O

B O
Baby Blood Mother’s Blood to be
AB O group blood group issued

O O Rh positive Rh positive
A A A, O Rh Positive Rh negative Rh negative

B O Rh positive Rh negative

AB A, O Rh Negative Rh negative Rh negative

O O

B A O

B B, O

AB B, O

O O

AB A A, O

B B, O

AB AB, B, A, O

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Steps of the Procedure

1. Take Informed consent from parents

2. Insert a peripheral IV line if not already in place.
3. Blood to be checked for fresh blood (collected within 72 hrs), Blood group as per
requirement Blood Bag No. and Blood Group Cross-checked
4. Keep Blood at room temperature, if blood warmer is not available.
5. Aspirate stomach contents before the procedure if fed within 4 hours.
6. The baby’s legs and hands are held in position with a cotton drape
7. Clean the umbilicus with spirit-betadine-spirit or Chlorhexidine swab
8. Clean the procedure area and drape with 3 sterile sheets so that only the umbilical
area is visible
9. Tie a gauze piece at the base of the umbilicus loosely
10. Cut the umbilicus at 1 cm above the base with the clean surgical blade; if the
cord has dried up, we may need to cut at the base carefully avoiding the skin.
11. Identify the umbilical vein is identified at 11 o clock position.
12. Cannulate the umbilical vein with a pre-saline-filled umbilical catheter attached
to 3-way cannula
13. Take proper aseptic precautions during cannulation
14. Keep Umbilical Catheter in-situ after ensuring free flow of blood
15. Connect the three-way connected to umbilical catheter
16. If umbilical catheter insertion is unsuccessful insert peripheral artery cannula.
17. Ensure blood bag is sufficiently warm
18. Connect transfusion set and IV set properly
19. Start first cycle with pull out
20. Push same volume in
21. Mix the bag intermittently
22. Monitor the hemodynamic during the procedure
23. Do the desired number of cycles
24. Ensure blood volume was sufficient for cycles
25. Send the last aliquot for PCV, TSB
26. Write the procedure notes
27. Note any complication during the procedure in the document

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Figure: Keep the resuscitation and suction equipment ready before the procedure

Figure: Position of stop clock (Connect proximal stop cock, which is towards the umbilicus
to the discarded bottle, connect distal stop cock, which is away from umbilicus to the fresh
whole blood)

Step 1: Pull out baby’s blood

Step 2: Discard the pulled-out blood

Step 3: Pull in fresh blood and push into the baby

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Station 3 Lumbar Puncture and CSF Examination

Objectives

The participants should be able to perform lumbar puncture (LP) and collect cerebral spinal
fluid (CSF) safely and efficiently in all indicated neonates.

Supplies

1. Surgical gloves – 2 pairs

2. Surgical gowns/cap/mask

3. Sterile drapes/ disposable sheets – 3

a. One with the hole to increase the visibility for LP site

4. Sterile containers/ – 4 in number

5. LP needle / sterile disposable 23G/24G/ 26G needle

6. Lab forms and specimen labels

7. Anti-septic solution

8. Sterile sponges for preparing the site

9. Mannequin for lumbar puncture

Indications

1. Suspected Central Nervous System (CNS) Infections (bacterial, fungal, viral)

2. Neonatal seizures/encephalopathies (non ketotic hyperglycemia)

3. Hydrocephalous (To relieve intracranial pressure in rapidly growing variety)

4. Administration of intrathecal medications

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Contraindications

1. Hemodynamic/cardiovascular instability

2. Severe respiratory distress

3. Soft tissue infection at the site of LP

4. Bleeding diathesis

5. Lumbosacral deformities

6. Increased intracranial pressure

Steps:

Procedure

1. Analgesic: Use sterile gauge soaked in 24%

sucrose/25% glucose or breast milk. Other
topical agents can be applied 30 minutes before
the procedure.

2. Position: Keep the neonate in lateral recumbent Figure 1 Lateral recumbent

position as shown in Figure 1 position

a. Place the child on their side near the edge

of bassinet in lateral decubitus position.

b. Draw the knees to upward and flex by

placing one arm of the assistant over the
Figure 2 Position and aseptic
knees and back of the baby. Stabilize the
precautions for lumbar
neck and flex by placing other arm of
puncture
assistant over the neck. Ensure that the
neck is not hyperflexed

c. Spine should be visualized and avoid

undue rotation. Avoid too much of
pressure until the needle is about to be
Figure 3 Showing PSIC and
inserted.
L4

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3. Aseptic precautions

a. Personnel doing the procedure should

wear cap, mask and follow proper hand
hygiene and then wear sterile gown
Figure 4 Needle placement
b. Both personnel should wear the sterile and direction
gloves

c. Clean the area (including the iliac crests

area) with appropriate solution as per the
hospital policy. Allow it to dry.

d. Apply the drapes to maintain asepsis as

shown in Figure 2

e. Make a hole in the disposable sheet if it

is not having

4. Identify the site

a. First identify the posterior-superior iliac

crests (PSIC) ( arrow mark represent in
Figure 3)

b. Draw an imaginary line between the

posterior superior iliac crests. The line
corresponds to L4 in neonates
( red dotted line represents)

5. Sterile needle has to be inserted in the midline

slightly towards head at angle of 70-900 through
L3/L4 or L4/L5 inter vertebral space aiming
towards the umbilicus with a steady pressure and
non-rotatory movement (Figure 4)

6. After entering the skin, allow the neonate to

settle, reorient and move forward

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 7. Advance the needle by 0.5 cm to 1.0 cm till you
see CSF coming

8. Collect CSF in sterile container. A minimum of

10 drops/tube is required for microbiological and
biochemical sterile containers and about 1-1.5
ml for culture.

9. For a therapeutic tap, we can remove volume up

to 2% of body weight (3 to 5 mL per kg body
weight)

10. Remove the needle slowly after you got

adequate sampling

11. Apply the pressure on the site to prevent ooze

12. Reposition the neonate gently

13. After the ooze ceases, apply sterile dressing

14. Monitor the vitals of the neonate

15. Discard the biomedical waste generated in the

procedure properly

16. Wash hands and document the procedure

If a bloody specimen is obtained:

• If the CSF becomes clearer in subsequent container, then is most likely a traumatic L
P. Adjustment of WBC counts in a traumatic lumbar puncture does not aid in the
diagnosis of meningitis in neonates.

• If blood does not clear in subsequent container and clot is formed, then most likely a
vein is punctured. Repeat in a different space.

• If blood does not clear and no clot is formed, then it is due to intracranial bleed.

Repeat the LP after 24-48 hours

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Dos

1. Monitor the neonate throughout the procedure

2. Abandon the procedure if neonate had developed apnea and desaturation

3. Disposable needle can be used for doing LP when special needles are not available

4. Take the consent from parents/guardian prior to procedure

Don’ts

1. Avoid in children having severe thrombocytopenia (<20,000) and deranged

coagulation profile (INR > 1.5)

2. Don’t draw the CSF from LP needle after insertion

3. Don’t touch the hub of the needle

4. Traumatic LP with blood in CSF: Can be used for microbiological culture. Other
findings need to be interpreted with caution. We can repeat LP after 24-48 hours if
needed.

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Station 4 CPAP and respiratory monitoring

Objective

Upon completion of this section the participant should be able to:

i. Enumerate the indications of use of CPAP

ii. Demonstrate the principle of working of CPAP

iii. Set up Bubble CPAP

iv. Monitor a baby on CPAP

v. Identify CPAP failure & wean a baby from CPAP

vi. Outline complications and contraindications of CPAP

Indications

1. Respiratory Distress Syndrome (RDS)

2. Term with RD - if RD score > 4/10 (With grunting/ retraction as one of the parameters)

3. Post extubation in preterm VLBW babies

4. Apnea of prematurity : >2 episodes per hour over 4 hours requiring physical stimulation or
one episode requiring bag and mask ventilation after starting methyxanthines

Principle

1. The distending pressure increases lung volumes and establishes functional residual
capacity while preventing further alveolar collapse and promoting surfactant release

2. CPAP splints the upper airways thereby reducing obstructive apnea and mixed apnea

3. Increased oxygenation and ventilation/ perfusion matching

4. Improves compliance and stabilizes the compliant chest wall, improving thoraco-
abdominal synchrony and reduces the work of breathing

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Optimal pressure to be used

1. RDS- Start at 5 cm H2O with FiO2 50% (titrate in steps of 5% to a maximum of 70% to
maintain a SpO2 91-95%). The pressure can be increased in increments of 1 cm H2O every
15-30 min up to a maximum of 8 cm H2O – if RD worsens or oxygenation is impaired
despite titrating FiO2 to a maximum of 70%. Babies with RDS should be given rescue
surfactant early in the course of the disease, if the FiO2 requirement is >30%

2. Apnea of Prematurity - Start at 4-5 cm H2O with FiO2 being titrated as required.

3. Post-extubation - Start at 4-6 cm H2O and FiO2 5-10% above the pre-extubation FiO2.

How to set-up a bubble CPAP

1. Connect the air and oxygen tubing

2. Set the flow using flowmeter (usually at 5-8 L/min)

3. Set up the inspiratory limb from the flowmeter to the humidifier and from the humidifier to
the patient end (e.g. nasal cannula)

4. Fill water in the humidifier and humidify the gases to 370C

5. Set up the expiratory limb - from the patient end to a chamber filled with sterile water.
Immerse it under water up to the required depth

Occlude the patient end of the ventilator circuit with your palm and observe if bubbling
occurs in the water chamber - If there are no bubbles, look for any leak in the circuit; if no
leak is found, increase the flow by 1 L/min and recheck.

Initiation of CPAP

1. Measure for prong/mask size using the nose guide supplied in each packet. While selecting
prongs it is important to select appropriate size so as to snugly fit into the nasal cavity and
have appropriate inter-nares distance. The biggest nasal prong, that comfortably fits the
nostril, should be used

2. Measure the cap size from the middle of the forehead, around the head to the nape of the
neck and then back to the middle forehead. DO NOT use a “head circumference”
measurement to determine cap size. Place the cap onto the infant’s head, checking that the
ears are in a normal position. Ensure the cap is pulled well down over the ears and down to
the nape of the neck
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3. Apply a skin friendly sticking tape such as tegaderm and a piece of cotton on overlying
skin of septum

4. The bubbles should be seen both during inspiration and expiration phases of respiration

5. For a given set pressure, increasing the flow rate of the gases will cause an increase in the
delivered pressure of CPAP. So while changing the CPAP pressures on a given patient, the
flow rate of the gases must be kept constant

6. Attach pulse oximeter

7. Insert the orogastric tube. The open end of orogastric tube should always be above the
level of stomach, to constantly deflate it with the excess gas that enters it during CPAP

Monitoring Clinical monitoring

1. Continuous monitoring as per the CPAP monitoring chart

2. X-ray chest - one CXR initially for establishing the diagnosis and to assess lung inflation. 6
to 8 spaces on the CXR is adequate inflation. If <6- increase PEEP and If >8- decrease PEEP

3. In case of sudden deterioration, one needs to rule out pneumothorax

4. ABG – individualised basis

5. PFAG (pre feed abdominal girth) charting q 2 hourly

CPAP failure

• Even on a CPAP of 7-8 cm H2O and 70% FiO2, if the neonate has excessive work of
breathing

• PCO2 >60mmHg with pH <7 OR PaO2<50 mmHg

• Recurrent apnea (More than 2 episodes per hour over 4 hours requiring physical stimulation
or one episode requiring bag and mask ventilation)

CPAP weaning

If the infant is stable on CPAP for 24 hours, first wean off the FiO2 to 30% (in steps of 5%)
and then wean thepressure to 4 cm H2O (in steps of 1 cm).

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Contraindications of nCPAP

• Choanal atresia

• Cleft palate

• Tracheo - esophageal fistula type C

• Congenital diaphragmatic hernia

• Hypotension requiring a second inotrope

Complications

• Pulmonary air leaks (PAL) -PAL tend to occur when oxygen requirements are decreasing
and lung complianceis improving

• Cardiac output is believed to decrease due to decrease in venous return, because CPAP
causes increase inintrathoracic pressures & decreased right ventricular stroke volume. These
effects can be minimized by usingoptimal CPAP

• CPAP Belly
• Nasal septal injury - divided into 3 stages
o Stage I: erythema not blanching, on an otherwise intact skin
o Stage II: superficial ulcer or erosion, with partial thickness skin loss
o Stage III: necrosis, with full thickness skin loss

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 Workstation 5
Intubation, surfactant administration

1. Intubation
A. Purpose: The participants should be able to perform endotracheal intubation safely, and
efficiently.
B. Supplies:
i. 2 pairs of sterile gloves
ii. Disposable ET tubes (sizes 2.5 mm to 4.0 mm internal diameter)
iii New batteries (AA/AAA size): 2 in number
iv. Straight blade laryngoscope with blade sizes 00,0, and 1
v. Bulb for laryngoscope
vi. Scissors
vii. Cut tapes for holding the tube in position
viii Bag and mask with reservoir and oxygen tubing
ix Suction catheters (8F to 10 F)
C. Steps
i. Gather the supplies
ii. Ensure you have a person to assist and help you
iii. Was hand and put on sterile gloves
iv. Place the neonate on a flat surface, with head in midline and neck slightly extended by
a shoulder roll
v. Enure that pulse oximeter is attached to right upper limb
vi. Ensure positive pressure ventilation has been given and SPO2 before attempting
intubation is above 95%
vii. Choose appropriate size blade (00 for very preterm, 0 for preterm, and 1 for term)
viii. Choose the appropriate size ET tube:
ix. <1000g/<28 weeks: 2.5 mm, 1000 to 2000 g/28-34 weeks: 3.0 mm, 2000-3000g/>34
weeks: 3.5 mm
x. Hold the laryngoscope in left hand and stabilize the infant’s hand with right hand
xi. Slide it over the tongue with the tip of blade resting on vallecula

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 xii. Lift the blade slightly lifting the tongue out of the way to visualize the pharyngeal
area
xiii. Clear secretions as needed
xiv. Visualise the epiglottis, insert the ET tube sliding it along the side of tongue till the
tube enters between vocal cord and upto black band (vocal cord guide)
xv. Complete the entire process in 30 seconds
xvi. Remove the laryngoscope while firmly holding against baby’s palate
xvii. Hold the tube against the baby’s palate
xviii. Administer PPV, observe symmetrical chest movements, equal air entry in upper
axilla, and rise in heart rate
xix. If the procedure is failed, remove the ET tube and resume PPV
xx. Repeat the entire process again
xxi. Assistant should check the distance between tip to lip to be correct (using nasotragal
length)
xxii. Secure the tube by tape to upper lip
xxiii. Continue PPV
xxiv. Cut the ET tube approximately 4 cm beyond the lip to reduce the dead space
xxv. Document the procedure with date, time, and indication
xxvi. Discard the biomedical waste

D. Points to emphasise
i. Always call for help to ensure an additional person to help and assist you
ii. Keep monitoring the vital parameters throughout the procedure and switch to bag and
mask ventilation in case of failed procedure
iii. Do keep a watch for complications of intubation like hypoxia, bradycardia,
pneumothorax, and apnea
iv. Follow asepsis protocol throughout the procedure

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2. Surfactant administration

INSURE technique of surfactant administration

A. Purpose: The participants should be able to administer surfactant by INSURE
technique safely and efficiently
B. Supplies:
i. 2 pairs of sterile gloves
ii. 5 ml syringe
iii. Feeding tubes 6F or 5F
iv. Sterile blade/scissors
v. Surfactant vial (empty, to mimic the method)
vi. Laryngoscope with appropriate size blades (size 0 and 00)
vii. ET tubes (2.5 or 3 as appropriate)
viii. T-piece resuscitator or self-inflating bag
ix. Oxygen and air source
x. Cardio-respiratory monitoring equipments (multipara monitor or pulse oximeter)
C. Steps
i. Gather the supplies
ii. Wear cap and mask
iii. Wash hands and put on sterile gown and gloves
iv. Premedicate with caffeine, if required
v. Draw the required amount of surfactant into syringe using large bore needle
vi. Measure the required length of feeding tube and cut in a sterile manner (Feeding tube
length= total length of ET tube + 3 cm for adapter)
vii. Discontinue CPAP, Intubate the baby with appropriate size ET tube
viii. Insertion length of ET tube to be determined prior using nasotragal length (desired
length from upper lip=NTL+1)
ix. Confirm the correct ET position using auscultation
x. Continuous monitoring using pulse oximeter/multipara monitor for heart rate and
saturation

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 xi. Administration of surfactant ( volume based on surfactant type) in 2-3 aliquots over 1-
3 minutes depending upon volume of surfactant taken using precut feeding tube
xii. Provide positive pressure ventilation using T-piece resuscitator with longer
inspiratory time (Ti)
xiii. Push 1-2 ml of air to flush the surfactant present in the feeding tube at the end
xiv. Extubate the baby and continue on CPAP after the procedure
xv. Discard the waste in appropriate bins
xvi. Wash hand and document the procedure

LISA technique of surfactant administration

A. Purpose: The participants should be able to administer surfactant by a thin catheter
safely and efficiently
B. Supplies:
i. 2 pairs of sterile gloves
ii. 5 ml syringe
iii. Feeding tubes 6F or commercially available surfactant catheter
iv. Surfactant vial (empty, to mimic the method)
v. Laryngoscope (preferably video laryngoscope) with appropriate size blades (size 0
and 00)
vi. Cardio-respiratory monitoring equipments (multipara monitor or pulse oximeter)
C. Steps
i. Gather the supplies
ii. Wear cap and mask
iii. Wash hands and put on sterile gown and gloves
iv. Premedicate with caffeine, if required
v. Increase CPAP pressure by 1-2 cmH2O and elevate the head end of the warmer bed
by 15-20 degrees
vi. Identify a helper to help in monitoring and to attach the syringe containing surfactant
to the feeding tube/LISA catheter
vii. Draw the required amount of surfactant into syringe using large bore needle
viii. Intratracheal insertion of thin catheter or feeding tube using direct laryngoscopy
ix. Insertion depth 0.5-1 cm beyond the vocal cord (desired insertion depth=NTL+1)
x. Confirm the correct ET position using auscultation

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 xi. Continuous monitoring using pulse oximeter/multipara monitor for heart rate and
saturation
xii. Administration of surfactant ( volume based on surfactant type) in 1-2 aliquots over 1-
3 minutes depending upon volume of surfactant taken using the feeding tube/LISA
catheter
xiii. Push 1-2 ml of air to flush the surfactant present in the feeding tube at the end
xiv. CPAP pressure back to the previous levels 10-15 minutes after the procedure
xv. Discard the waste in appropriate bins
xvi. Wash hand and document the procedure
D. Points to emphasize
i. Desaturation and bradycardia are common during surfactant administration
due to occlusion of the ET tube. Hence, adequate PPV should be provided in
between to achieve target saturation
ii. Push 1-2 ml of air to flush the surfactant present in the feeding tube at the end
otherwise some amount will get wasted in the feeding tube/LISA catheter
iii. Avoid sedation during the procedure
iv. The surfactant administered should not be cold. Hence, surfactant vial should
be taken out to room temperature as soon as surfactant administration is
planned
v. The surfactant bottle should be gently rolled between palms to liquify the
surfactant and should not be shaken vigorously.
vi. Aseptic technique should be followed during administration
vii. Do not suction for atleast 4-6 hrs after the procedure
viii. No role of change of position during and after the procedure

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 Workstation 6
Umbilical catheterization

A. Objective
The participants should be able to cannulate /catheterize umbilical venous or /and arterial
access
B. Supplies
i. Umbilical Catheter size 3.5 or 5 Fr
ii. Scalpel
iii. Curved iris forcep
iv. 3.0 silk and needle
v. 3 way stopcock
vi. 5 ml syringe
vii. 0.9 percent normal saline
viii. Sterile gauze
ix. Heparinised saline (10 units per ml )
x. Disinfectant ( eg. chlorhexidine 0.5 percent)
xi. Tape
xii. Manikin for umbilical access
C. Steps
i. Document about any local infection /signs of NEC and bruising of lower extremities
and /or feet and toes prior to placement
ii. Wash hands and followed by maximal sterile barrier
iii. All catheter must be attached to appropriate stopcock or syringe, flushed and filled
with normal saline before insertion to avoid aur emboli
iv. Drape around the umbilical stump with sterile towel , taking care are not to be obscure
infants face and upper chest
v. Tie a cord tie to prevent bleeding
vi. Cut the cord horizontally about 1-1.5 cm from the skin
vii. Identify vessel to be cannulated and immobilize cord

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Umbilical artery cannulation
D. Insert technique and establishing the UAC line
i. Using iris forcep, one of the two arteries is dilated
ii. Insert one point of curved Iris forcep into lumen upto 0.5cm and probe gently
iii. Remove the forcep, bring both point together and re introduced probe gently.Allow
points to spring apart and maintain in this open position about 15 sec to dilated lumen
iv. Grasp catheter 1cm with curved forcep and insert into dilated lumen
v. Advance with a firm steady motion mild upward traction of cord towards head of
infant while advancing may facilitate passage of catheter
vi. After advancing catheter about 5cm verify intraluminal position by checking for easy
withdrawal of blood and pulsation of blood /saline in the catheter, then clear with
flush solution
vii. Advance UAC to the pre determined length
viii. After dilation, 3.5 to 5 fr catheter attached to a 3 way stopcock flushed with normal
saline solution (without heparin) is inserted into the artery
ix. Central umbilical artery access requires advancement of the catheter to either to a
lower or high position.A low line lies just above the arotic bifurcation between 3rd
and 4th lumber vertebrae, and a high line lies above the diagram between the 6th and
9th thoracic vertebrae
x. To determine the optimal position for high or low catheter location, use formula or
graphs. If available USG may be used to confirm the position of the catheter tip
xi. Add low dose heparin (0.5-1 U/ml ) to the fluid infused through the UAC. A
commonly used solution is 0.45% NaCl with 0.5 to 1 IU heparin/ml running at 1 ml
/hr
xii. Securing the catheter to the abdominal wall using a bridge/goal post method of taping
xiii. Optimal duration of a UAC line is 5-7days

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Umbilical venous catheterization
A. Insert technique and establishing the UVC line
The umbilical vein is larger and thinner walled of the vessel and is usually at the 11 to 12 o
clock position
i. Gently insert the tip of iris forcep into lumen of vein to remove any clots
ii. Introduce flushed, NS filled UVC and advance to the predetermined length
iii. Direct the catheter cephalad or towards the head as the vein lies in this direction
iv. During resuscitation, an umbilical vein is only cannulated to approximately 2 to 4 cm
beyond the muco cutaneous junction and only until adequate blood return is obtained
v. In non-emergencies, the catheter is advanced until it is the inferior vena cava just
below the level of the right atrium
vi. Do not leave the catheter open to the atmosphere as there is a danger of air emboli
vii. There is little data to support the use of UVC heparinisation
viii. Optimal duration of UVC line is 7-10 days
B Points to emphasize
i. Use the formula 3X birth weight (in kg)+9 divided by 2 (+1) for UVC and birth
weight (in kg) X3+9 for UAC.
ii. For UAC use catheter size of 3.5 Fr for infants weighing <1200 g and 5 Fr for infants
weighing more than equal to 1200 g, and for UVC use catheter size of 5 Fr
iii. If there is excessive bleeding during cannulation of the umbilical vessels, the cord tie
placed at the base of the umbilical stump should be tightened.

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2. Peripherally inserted Central catheter ( PICC) insertion
A. Objective
The participants should be able to cannulate/catheterize device inserted into a peripheral vein
and thread into central venous circulation
B. Supplies
1. Supplies for swaddling the baby (optional)
2. Catheter equipment
a) 1.1 to 2F ( 28- to 23-gauge) catheter, with sufficient length to achieve appropriate
catheter tip placement for infants weighing <2500g
b) 1.9 to 3F (26- to 20-gauge ) catheter with sufficient length to achieve appropriate
catheter tip placement for infants weighing more than equal to 2500 g
3. Non toothed forceps
Procedure for PICC insertion in an infant
i. Determine the need for a PICC
ii. Obtain informed consent (as per hospital protocol)
iii Vein selection
Use in following order to prevent complications
a. UL>LL
b. Right side> Left side (as right more direct to the central circulation)
c. Basilic vein> Cephalic vein (as the former has larger lumen and follows straight path)
iv. Measure the length of the catheter to be inserted
C . Steps
i. Preparation of catheter: flush the catheter, attach a 10 ml syringe, (never use 1or 2ml
syringe because it can create high pressure leading to rupture of catheter) to the
catheter
ii. Position the patient as needed
iii. Arm insertion: abduct the arm to a 90 degree angle with patient s head turned towards
arm
iv. Axillary vein insertion: abduct the arm 100 - 130 degree angle or place the infants
hand by the head and puncture parallel and inferior to artery
v. Femoral vein insertion: position the infants "frog legged" insert the introducer at a 30
degree angle 1cm below the inguinal ligament and 5 mm medial to femoral pulse
vi. Insert the introducer bevel up to a 15 to 30 degree angle into the skin a few
millimetres before anticipated entry into the vein. Hold the skin taut below the level
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 of insertion to prevent the vein from rolling.A 30 degree angle is recommended for
insertion into the femoral vein.
vii. When the vessel is cannulated, observe for blood return ( blood return may be
observed or a " pop" may be felt.
viii. Using non toothed forcep, thread the catheter through introducing Needle in 0.5 to 1
cm increments to the pre-measured length
ix. To facilitate the insertion, flush with saline while threading the catheter if obstruction
realise
x. If a stylet is present, remove it slowly over a period of 30 - 60 sec
xi. Aspirate for blood return and flush the catheter
xii. Keep the catheter patent by flushing it intermittently with 0.5 ml flush solution in a 5
to 10 ml syringe
xiii. Catheter tip near SVC ( if upper limb) or IVC near diaphragm (if using lower limb)
xiv. Use sterile semi-transparent dressing
Ultrasound assessment of UVC position
i. Ideal location of UVC is to minimize the complications is outside the heart at the IVC/RA
junction
ii. ON CXR this may correspond to T9-T10 , just above right hemidiaphragm but below the
heart
iii. Ultrasound views
1. Standard views
a. Subcostal-parasaggital view
b. Parasternal short axis view
c. Apical four chamber view
d. Modified views
2. Parasternal short axis towards xiphoid

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D. Points to emphasize
i. Follow utmost asepsis during the procedure
ii. During confirming the position of the tip of the catheter the anatomical position of the
neonate should be same as that during the insertion of the catheter
iii. Follow the non-pharmacological pain relief measures and developmentally supportive
care
iv. The umbilical catheters/PICC only to be used after confirming the position by either a
bedside X-ray or point of care USG

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 Workstation 7
VAP and CLABSI prevention bundle, blood
culture technique
A. VAP prevention bundle
Steps Steps performed
(Yes/No)
1. Hand hygiene
a) Wash hand with soap and water
b) Wear mask, cap, gloves
c) Do not touch baby and baby's environment with gloves
d) Hand wash or hand rub after removing gloves
2. Endotracheal tube care
a) During intubation, aseptic technique to be maintained, mask and
gloves to be worn
b) Oral intubation to be preferred than nasal
3. Humidification
a) Heated humidifier is a must
b) Inspired gas at 37 degree celsius and 100 percent relative humidity
c) Always use auto refill technique for the humidifier to fill the water
d) no condensation in inspiratory limb
e) Drain condensate in water trap
f) consider condensate as an infectious waste and discard accordingly
4. Respiratory equipment care
a) Ventilator circuits and oxygen therapy equipments should be readily
available
b) Ventilator circuits should be used only once if disposable, and if
reusable it should be sterilized after each use ,as per unit infection and
sterilization protocol
c) Ventilator circuits should be changed when visible soiled
d) The respiratory care equipment should be handle under strict asepsis

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e) Endotracheal suction should be for preferably by two health
personnel with one person assisting in handling the suction catheter
aseptically.
f) CPAP system should not be allowed to standby for more than
12hours
g) Resuscitation bags not to be kept on bed ,but they have to be hung
outside the warmer
h) Resuscitation bags should be replaced once in a week
i) The circuit should be positioned parallel to the baby and in
dependent position
5. Position of infant
a) 30 - 45 degree elevation of head end
b) lateral decubitus is the preferred position
c) frequent change in position
6. Stress ulcer prophylaxis
a) acidic gastric content prevent bacterial contamination
b) Avoid using antacid like Ranitidine
7 . Oral hygiene
a) oral suction to prevent pooling of secretion
b) moisten the lip with saline
c) Avoid reusable suction tubes for oral suction
d) Chlorhexidine oral application is optional
8. Enteral feeds
a)Encourage oral feed through orogastrictube
b) prefer EBM formula
c) Trophic feed is not on enteral feeds
9. Shorter duration of intubation and ventilation
(Intubation and extubation to be done as per unit protocol)
a) Daily consideration of extubation readiness on morning rounds and
shift to non-invasive mode of ventilation as early as possible
b) Sedation vacation for all neonates who are on sedation
c) Consider use of non-invasive ventilation in the first place

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d) Wean off invasive ventilation as soon as possible
e) Prevent unplanned extubation
f) Avoid unnecessary re intubation
10.Post extubation
a) Frequent change in position ( as indicated clinically)
b) Oral and nasal suction as indicated clinically
c) Nebulization SOS
d) Watch for respiratory distress
(Signs of respiratory distress in ventilated neonates, which includes
work of breathing, subcostal or intercostal retraction, irritable on
ventilator, reduced SPO2 )

11. Continuing training and adults

a) Regular training of health care professionals
b) Re enforcement of hand hygiene practices in the unit
c) Regular audits of checklist

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B. CLABSI Prevention bundle
Bundle approach is a set of evidence based practice which are expected to improve patient
outcome. Individual element of bundle are protocolised well established practices.The whole
team must agree collectively and implement them reliably

Steps Steps
performed
(Yes/No)
1. Insertion bundle
a) Establish a central line kit or cart to consolidate all items necessary for
the procedure
b) performance hand hygiene with hospital approved alcohol based
products or antiseptic containing soap ,before and after palpating insertion
sites and also before and after inserting central line
c) Use maximum barrier precautions including sterile gown ,sterile gloves
,surgical mask, cap and larger sterile drape
d) Disinfect the skin with appropriate antiseptic before catheter insertion
e) Minimise the number of access point
f) keep connecting ports with UVC/UAC away from diaper area
g) Use either a sterile transparent semipermiable dressing or sterile gauze
to cover the insertion site
h) prefer upper limb vein over lower limbs vein
i) Ensure the catheter tip is at proper position
j) No blood strain should around the insertion site
k) The insertion should preferably be done by a skilled trained health
personnel who has assisted at atleast 5 catheter insertion before.
l) The health personnel should always be assisted by a second person
while inserting catheter
2. Maintenance bundle
a) Perform hand hygiene with hospital approved disinfectant before and
after changing dressing
b) Evaluate the catheter insertion site daily for the sign of infection and
dressing integrity

35
c) If the dressing is damp,soiled,or loose, change dressing aseptically and
disinfect the skin arround the insertion site with an appropriate antiseptic
d) Develop and use standard intravenous tubing set-up and changes
e) Maintain aseptic technique while changing the intravenous tubing and
when entering the catheter including "scrub the hub"
f) Maintenance bundle card to be displayed on the infant warmer for daily
audit.
g) Any creak in the circuit of central line should be done in the presence
of two health care personnel to maintain asepsis.
h) Daily review the catheter necessity with prompt removal when no
longer needed.
3. Hub care bundle
a) Cleanse hand with soap and water
b) Put on gloves
c) Establish sterile field under acess port
d) Place the syringes on edge of sterile field
e)Scrub access port with alcohol based solution/antiseptic being used in
NICU as per protocol, for 15 sec and allow to dry it (clean outside and on
the top but not inside )
f) Pick up syringe keeping the tip sterile
g) Attach the syringe to hub, keeping connection sterile
h) Review the need of central line daily and remove as early as possible.

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C. Blood culture
I. Objective
The participants should be able to perform venepuncture and collect blood sample for blood
culture from neonates, safely and efficiently
II. Supplies
i. 2 pairs of sterile disposable gloves
ii. disposable 24G and 26G Needle
iii. disposable 2ml and 5 ml syringes with needles
iv. swabs or Cotton balls soaked in antiseptic solution
v. pre labelled blood culture bottles
vi. lab forms and specimen labels
vii. Manikin or venepuncture arm for venepuncture
III. Steps
i. Identify an accessible vein, most commonly on dorsum of the hand or foot or
antecubital vein
ii. Collect all the items needed for blood culture
iii. Check for the absence of turbidity in the blood culture bottle media and indicates
that blood to be put in the bottle only if there is no turbidity
iv. Perform hand hygiene
v. Create a sterile area at bedside/tray
vi. Wear sterile / clean gloves
vii. Prepare a clean circular area of skin approx. 5cm diameter over proposed puncture
site by cleaning the area (3 spirit swab technique or chlorhexidine swabs)
viii. Allow it to dry
ix. Indicate that cleaning would be in concentric circles moving outward from the
centre
x. Puncture the vein with 24G or 26G needle
xi. Do not break the hub of needle
xii. Once blood starts flowing freely, gently withdraw the blood using 2ml syringe and
needle as the drop builds up at the hub of the needle.
xiii. Withdraw about 0.5-1 ml of blood
xiv. Insert the needle of the syringes into the cap and slowly inject the blood into the
bottle

37
 xv. Shake the bottle gently to mix the blood and the culture media
xvi. Label the sample
xvii. Ensure transfer to the lab immediately (maximum in the next 12 to 24 hours)
xviii. Remove gloves
xix. Document the procedure the patient file with date and time
xx. Discard the waste in the appropriate waste bag
IV Points to emphasize
i. Follow the non-pharmacological pain relief measures and developmentally supportive
care
ii. Needle of the syringe used for drawing blood should not touch the hub of the needle
iii. At least 0.5ml of blood to be taken, preferably 1 ml

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 Workstation 8
Chest tube insertion
A.technique
Purpose
Participants should be able to insert chest tube in neonates safely and effectively for various
indication
B. Supplies
i. Sterile gloves, sterile gown, cap, mask for the person doing procedure
ii. Neonatal surgery tray consisting sterile swab / cotton balls, sterile surgical drapes,
swab holder needle holder, scissors, mosquito clamp, straight hemostatic forcep and
towel clips.
iii. 70 percent isopropyl alcohol and 5 percent povidine iodine for antiseptic dressing for
term infants. For preterm infants, use 0.5 percent v/v chlorhexidine instead of
povidine iodine
iv. Surgical blade (no.15 )
v. Thoracostomy tube (polyvinyl chloride chest tube with or without trocar,size 8,10,12
Fr). Alternatively, pigtail catheter can also be used
vi. Multipurpose tubing adaptor for connecting chest tube with collection bag.
vii. Underwater seal bag
viii. Non absorbable silk suture on small cutting neddle (4-0).
ix. Towel roll, semi permeable transparent dressing
x. 2 percent lignocaine solution for local anaesthesia and 24 percent( or breast milk
dextrose) orally for analgesia.May need IV fentanyl( 1-2 micro gram/ kg) on a case to
case basis only in mechanically ventilated infants.
C. Steps
i. Puncture pleura with the hemostatic forceps
ii. A definite "give away" sensation will be felt in puncturing pleura
iii. After puncturing the pleura open hemostatic forcep just enough to pass the chest tube
iv. Keeping the hemostat in place , pass the tube between opened tips to the
predetermined depth

39
D. Advancement and final position
i. Palpate the chest wall at the entry site to confirm that tube is not in the subcutaneous
tissue
ii. For pneumothorax, direct chest tube upward towards apex of thorax and advance tip
to Mid clavicular line , ensuring that all the side holes with in pleural space .Final tip
position is in antero medial pleural space.
iii. For pleural connection, insert the tube posteriorly only deep enough to place the side
holes within pleural space.
iv. Connect the other end to chest tube with multipurpose adaptor and then to the
underwater seal drainage with negative pressure of 10-20 cm of water
v. Observe the movement of water meniscus in the drainage system.

E. Securing chest tube

i. Use 4-0 silk suture to close the skin incision with single interrupted suture on either
side of the tube
ii. Secure the tube by wrapping and then tying the suture tail around the tube .
iii. cover the insertion site with a small sterile gauze, transparent semi permeable
adhesive. Do not put a large dressing covering the whole chest especially in small
preterm infants.

F. Points to emphasize
i. Provide adequate analgesia during the procedure
ii While providing the incision keep away from the breast nodule
iii Make incision just above the lower rib
iv. Always get a X-ray to confirm the position
v. Always look for the signs of malposition

40