As a NICU (Neonatal Intensive Care Unit) resident clinical pharmacist (RCP), what information should I present during rounds?

NICU Respiratory Care Practitioner (RCP) Rounds Presentation

As a NICU RCP, you should present a structured respiratory assessment covering ventilator settings and parameters, oxygen delivery and saturation targets, airway management status, and any respiratory interventions or concerns—while being prepared to discuss medication-related respiratory issues and participate in family-centered communication.

Core Respiratory Data to Present

Ventilator/Respiratory Support Parameters

• Current mode of support: Mechanical ventilation, CPAP, high-flow nasal cannula, or room air
• Specific settings:
  • Peak inspiratory pressure (PIP), positive end-expiratory pressure (PEEP), rate, FiO₂
  • For CPAP: pressure level and FiO₂
  • For high-flow: flow rate and FiO₂
• Measured parameters: Tidal volumes, minute ventilation, compliance, resistance if available 1

Oxygenation Status

• Current oxygen saturation and target range (typically 90-95% for preterm infants to balance ROP risk) 2
• FiO₂ requirements and recent trends (increasing, stable, weaning)
• Blood gas results if recent: pH, pCO₂, pO₂, base excess
• For infants with ROP risk or peripheral avascular retina, emphasize adherence to oxygen saturation targets of 90-95% to avoid sustained hyperoxemia 2

Airway Management

• Endotracheal tube details (if intubated): Size, depth at lip/nares, days in place
• Secretion management: Character, quantity, frequency of suctioning
• Extubation readiness or weaning plan if applicable
• Prevention measures for subglottic/tracheal stenosis in long-term intubated patients 3

Medication-Related Respiratory Considerations

Key Medications to Address

When relevant to your patients, be prepared to discuss:

• Caffeine: Dosing, timing, therapeutic levels if monitored 4
• Diuretics: For chronic lung disease management
• Bronchodilators: If being used
• Sedation/analgesia: Impact on respiratory drive and weaning 1
• Antibiotics: Particularly gentamicin and benzylpenicillin for respiratory infections 4

Common pitfall: Dosing errors are the most frequent medication-related problem in NICUs (36.7% of pharmacist interventions), so verify weight-based dosing is current and accurate 4. Neonates have immature hepatic and renal function affecting drug metabolism, requiring extended monitoring 1.

Clinical Assessment Points

Respiratory Monitoring Data

• Continuous monitoring: Heart rate, respiratory rate, oxygen saturation 1
• Capnography if available (required for deep sedation, recommended for moderate sedation) 1
• Work of breathing: Retractions, nasal flaring, grunting
• Breath sounds: Quality, symmetry, adventitious sounds

Trends and Changes

• 24-hour trajectory: Improvement, stability, or deterioration
• Recent interventions: Changes in settings, medications, or procedures
• Response to interventions: Quantify improvements or lack thereof

Family-Centered Communication

Be prepared to engage with parents during rounds, as guidelines strongly recommend parental participation in NICU rounds (Grade B recommendation) 5. This approach:

• Improves information sharing about patient condition
• Reduces parental anxiety
• Enhances efficiency of communication 5

When parents are present:

• Use clear, non-technical language when explaining respiratory status
• Allow time for questions after presenting clinical data 5
• Avoid using diagnostic terms without evidence (e.g., don't label as "allergy" or "colitis" without confirmation) 2

Structured Presentation Format

Present in this order for efficiency (rounds average 136 minutes for 17 patients, approximately 8 minutes per patient) 6:

1. Patient identifier and gestational age/corrected age
2. Current respiratory support and settings
3. Oxygen requirements and saturation trends
4. Recent blood gases or other objective data
5. Clinical assessment (work of breathing, secretions, breath sounds)
6. Relevant medications affecting respiratory status
7. Plan: Weaning strategy, medication adjustments, or escalation concerns

Special Considerations for Neonates

Former Preterm Infants

• Increased risk of apnea, particularly post-sedation 1
• May require extended post-procedure monitoring
• Immature drug metabolism necessitates careful dosing and monitoring 1

Chronic Lung Disease

• Long-term oxygen dependency considerations
• Growth parameters (weight gain is a critical outcome) 7
• Developmental supportive care integration 8

Documentation and Follow-Through

• Ensure all interventions discussed are documented with specific parameters 1
• Record vital signs at appropriate intervals: Every 5 minutes for deep sedation, every 10 minutes for moderate sedation 1
• Flag any medication-related concerns for pharmacist review (62.4% of pharmacist interventions are accepted by prescribers) 4

Critical pitfall: Avoid unnecessary sedation exposure in preterm infants due to concerns about effects on the developing brain, though evidence remains preliminary 1. Only sedate when the procedure will meaningfully change medical management.