Procedure Change Decreases Likelihood of Adverse Events During Surfactant Administration

Abstract

Background: Premature infants are born with a lack of surfactant which requires replacement after birth by direct instillation into the lungs. Each brand recommends a different administration procedure. We initially utilized Brand A; it required patients to be rotated on each side and was administered in two aliquots. In October 2018, we switched to Brand B that did not require patients to be rotated on each side. Rotating patients increased the risk for unplanned extubation, aspiration, mainstem ETT (endotracheal tube) placement, and hemodynamic instability amongst other factors. These risks were associated with hypoxia, intraventricular hemorrhage, ventilator associated pneumonia, cardiopulmonary arrest, multiple intubations, bronchopulmonary dysplasia, and increased number of ventilator days.

Methods: A multidisciplinary team formed to evaluate risks and benefits of Brand B versus Brand A and the administration procedure. Administration via mechanical ventilation, via T-piece or manual ventilation with flow inflating resuscitation bag, slow instillation via medication administration catheter inserted to the tip of ETT or inserted to the end of patient wye and beginning of ETT (not directing inserting catheter into ETT), and division of dosage into 2 aliquots were evaluated. Based on a survey of other facilities and the manufacturing company’s recommendation, a standardized administration procedure was created. Procedure changes from Brand A to Brand B required the patient to maintain a supine position and deliver dose via one aliquot. Administration procedures maintained from Brand A to Brand B were manual ventilation with a flow inflating bag and quick installation of medication via administration catheter inserted to tip of ETT. Adverse events that occurred during surfactant administration were reviewed at weekly multidisciplinary meetings. The outcome measure was the number of events per administrations. Process measures were compliance with administration procedure and completion of administration checklist. Balancing measures were number of doses per patient and re-intubation rates.

Results: Brand A had 9 adverse events out of 151 administrations in 19 months. Brand B had 1 adverse event out of 124 administrations in 19 months. P value .036, 3.6%.

Conclusions: Brand B removed the rotation of the patient during administration; significantly reduced the rate adverse events related to surfactant.