What are the admitting orders for a 2.0 kg, 5-hour-old, 34-week gestation female infant with respiratory distress in the Neonatal Intensive Care Unit (NICU)?

NICU Admitting Orders for 2.0 kg, 5-hour-old, 34-week Gestation Female with Respiratory Distress

This 34-week infant with respiratory distress requires Level II or III NICU care with immediate respiratory support via CPAP, careful oxygen titration starting at 21-30% FiO₂, and close monitoring for potential surfactant administration if mechanical ventilation becomes necessary. 1, 2, 3

Admission Status and Level of Care

• Admit to: Level II or Level III NICU 1, 3
  • This 34-week, 2.0 kg infant meets criteria for Level II care (≥32 weeks, ≥1500g) if problems resolve rapidly 1, 3
  • However, respiratory distress may require Level III capabilities if mechanical ventilation exceeds 24 hours or subspecialty services are needed 1, 3

Diagnosis

• Primary: Respiratory distress syndrome, 34-week preterm infant 4, 5, 6
• Secondary: Prematurity (34 weeks gestation) 3

Vital Signs and Monitoring

• Continuous cardiorespiratory monitoring with heart rate, respiratory rate, oxygen saturation 1, 7
• Pulse oximetry on right hand/wrist continuously 1, 2, 7
• Temperature monitoring continuously (maintain normothermia 36.5-37.5°C) 1
• Blood pressure every 1-2 hours initially 1
• Respiratory rate, work of breathing assessment every 1 hour 7, 4
• Document: Grunting, retractions, nasal flaring, chest rise 7, 4, 6

Respiratory Management

Initial Respiratory Support

• Start CPAP at 5 cm H₂O via nasal prongs 1, 2
  • The American Heart Association firmly recommends CPAP as first-line for spontaneously breathing preterm infants with respiratory distress 1, 2
  • This approach reduces need for mechanical ventilation and improves outcomes 1, 2

Oxygen Therapy

• Start FiO₂ at 21-30% and titrate to target saturations 1, 2, 7
• Target oxygen saturations:
  • 70-80% at 5 minutes of age 1
  • 80-85% at 10 minutes 1
  • 85-95% thereafter 1
• Never start with ≥65% oxygen - associated with harm in preterm infants 2, 7
• Titrate FiO₂ in 5-10% increments based on pulse oximetry 2, 7

Criteria for Intubation and Mechanical Ventilation

• Intubate if:
  • Heart rate remains <100 bpm despite CPAP 2
  • Persistent apnea or gasping respirations 2, 7
  • FiO₂ requirement ≥50-60% on CPAP to maintain target saturations 2, 8
  • Severe work of breathing with impending respiratory failure 7, 4

Mechanical Ventilation Settings (if required)

• Mode: Pressure-limited ventilation via T-piece resuscitator preferred 1, 2
• Initial settings:
  • PIP: 20 cm H₂O (adjust based on chest rise, may need 30-40 cm H₂O) 1, 2
  • PEEP: 5 cm H₂O (firm recommendation for preterm infants) 1, 2
  • Rate: 40-60 breaths/minute 1, 2
  • Inspiratory time: 0.3-0.4 seconds 2
  • FiO₂: As needed to maintain target saturations 2
• Monitor: Chest rise, heart rate response, oxygen saturation 1, 2
• Adjust: PIP to achieve adequate chest rise without overdistension 1, 2

Surfactant Administration (if intubated)

• Give poractant alfa (Curosurf) 2.5 mL/kg (200 mg/kg) intratracheally if requiring mechanical ventilation with FiO₂ ≥0.60 8
• Administration technique:
  • Ensure proper endotracheal tube placement and patency 8
  • Administer via 5 French catheter in two divided aliquots OR single bolus through dual-lumen tube 8
  • Do not suction for 1 hour after administration unless significant airway obstruction 8
• Repeat doses: Up to two additional doses of 1.25 mL/kg at 12-hour intervals if needed (maximum total 5 mL/kg) 8
• Monitor for: Bradycardia, hypotension, tube blockage, oxygen desaturation during administration 8
• Consider INSURE technique: Intubate, give surfactant, rapidly extubate to CPAP 4, 6

Laboratory Studies

• Arterial or capillary blood gas on admission and PRN based on clinical status 4, 6
• Complete blood count with differential on admission 4, 6
• Blood culture × 1 on admission (before antibiotics) 4, 6
• C-reactive protein on admission and at 24 hours 4, 6
• Serum glucose on admission and every 4-6 hours initially 1
• Electrolytes, calcium, phosphorus, magnesium on admission and daily 3
• Monitor plasma phosphate closely in first days of life (risk of severe hypophosphatemia in preterm infants) 3

Imaging

• Chest X-ray (portable AP) on admission to evaluate lung fields, heart size, rule out pneumothorax 1, 4, 6
• Repeat chest X-ray after intubation to confirm tube placement, after surfactant, or if clinical deterioration 1, 4

Fluid and Nutrition Management

IV Fluids

• Start D10W at 60-80 mL/kg/day (adjust based on weight, clinical status) 3
• Add electrolytes after 24-48 hours once urine output established 3
• Goal: Maintain euglycemia (blood glucose 40-150 mg/dL), avoid hypoglycemia 1

Parenteral Nutrition (when NPO)

• Early PN composition for first days of life: 3
  • Calcium: 0.8-2.0 mmol/kg/day 3
  • Phosphorus: 1.0-2.0 mmol/kg/day 3
  • Magnesium: 0.1-0.2 mmol/kg/day 3
  • Molar Ca:P ratio: 0.8-1.0 (below 1) 3
• Advance to growing preterm infant requirements once stable 3

Enteral Feeding

• NPO initially until respiratory status stabilizes 4
• Consider trophic feeds (10-20 mL/kg/day) once on CPAP or minimal ventilator support 4
• Advance feeds cautiously as tolerated, monitoring for feeding intolerance 4

Infection Prophylaxis and Treatment

• Ampicillin 50 mg/kg IV every 12 hours (for <7 days age, adjust for renal function) 4, 6
• Gentamicin 4 mg/kg IV every 24 hours (for 34-week infant, adjust based on levels) 4, 6
• Duration: Minimum 48 hours pending blood culture results; complete 7-10 day course if sepsis confirmed 4, 6
• Rationale: Respiratory distress cannot reliably distinguish RDS from pneumonia/sepsis 4, 5, 6

Thermoregulation

• Maintain in servo-controlled isolette or radiant warmer 1
• Target axillary temperature: 36.5-37.5°C 1
• Avoid hypothermia and hyperthermia - both associated with increased morbidity 1

Additional Orders

• Nothing by mouth (NPO) until respiratory status stable 4
• Orogastric tube to low intermittent suction if significant abdominal distension 4
• Stress ulcer prophylaxis: Not routinely indicated in neonates 9
• DVT prophylaxis: Not applicable in neonates 9
• Minimal stimulation protocol - cluster care, dim lights, minimize noise 1

Critical Pitfalls to Avoid

• Do not start with high oxygen (≥65%) - causes harm without benefit in preterm infants 2, 7
• Do not omit PEEP - self-inflating bags require PEEP valve to deliver recommended 5 cm H₂O 1, 2
• Do not delay surfactant if intubated with FiO₂ ≥0.60 - early administration improves outcomes 8, 6
• Do not overlook hypophosphatemia risk - monitor plasma phosphate closely in first days, especially if growth-restricted 3
• Do not provide prolonged mechanical ventilation (>24 hours) in Level II facility - requires transfer to Level III 1, 3
• Do not assume late preterm infants are "near-term" - 34-weekers remain at significantly increased risk for morbidity 3
• Do not delay intubation if heart rate <100 bpm despite CPAP or severe respiratory failure 2, 7

Consultation

• Neonatology attending - notify immediately on admission 1, 4
• Respiratory therapy - at bedside for respiratory management 1, 3
• Consider transfer to Level III facility if requiring prolonged ventilation (>24 hours) or subspecialty services 1, 3