Sedation during treatment for rop

Background: Surgical intervention in babies with advanced retinopathy of prematurity
(ROP) can prevent blindness (1). These babies require sedation and analgaesia for the
procedure. They also require ventilatory support because of the sedation, the duration
of the procedure and pre-existing lung disease. Neuromuscular paralysis facilitates the
assisted ventilation and makes the treatment easier to perform. An audit of practice in
our unit and a survey of practice in various UK units has demonstrated that this
procedure is safe.
Staff involved in care : Sedation and respiratory support will usually be provided by a
Consultant Neonatologist during the procedure. An experienced SPR or an experienced
ANNP may also undertake the procedure although a Consultant Neonatologist must be
present at induction.
Communication : The Consultant Ophthalmologist will liase with the Consultant
Neonatologist when a baby reaches the treatment threshold and the timing of the
treatment session will be agreed.
If the baby is being transferred from another hospital, the Consultant Opthalmologist will
liaise with the referring hospital to ensure that a letter of referral to the neonatal team is
provided, including the results of Full Blood Count and Electrolyte measurements within
4 days of the planned procedure.
Parents should be given a copy of the Information sheet “Retinopathy of Prematurity”
Nursing staff from the eye clinic will inform the nursing shift leader to make an intensive
care cot available.
Intervention Threshold : Treatment will be given to all babies meeting the treatment
threshold as defined in the national guidelines (1).
Pre-op assessment
• Ensure consent for the procedure has been obtained.
• Attach monitors Pulse Oximeter ECG monitor • Pre-operative oxygen requirement and SpO2 should be recorded in the Badger • Ensure that a Full Blood Count and Electrolytes have been measured within the past 4 days or note measurements from blood gas machine when performing capillaryblood gas measurement.
• Insert reliable iv cannula - start iv fluids at 120 ml/kg/day Induction dose = 7.5 micrograms/kg dilute to 1 mlMaintenance infusion = 1-3 micrograms/kg/hr Draw up as per instructions in Datasheet and infuse using the Guardrailssystem.
Induction• Pre-oxygenate with mask ventilation • Give the Fentanyl slowly over two minutes. If the baby is not adequately, this dose • If a baby is already receiving mechanical ventilation and sedation prior to ROP treatment, the treating neonatologist can decide whether it is appropriate to useFentanyl for sedation, or to continue or increase the existing sedative regime.
• Give pancuronium. It may require more than 1 dose initially to achieve adequate PIP 17 -20cm H2O PEEP 3cm H2ORate 30 breaths/min Insp Time = 0.4FiO2 to keep SpO2 =>95% During procedure• Start Fentanyl infusion at 1 mcg/kg/hr - increase dose (to max of 3 mcg/kg/hr) if evidence of inadequate analgesia/sedation e.g. unstable heart rate or bloodpressure • Record Heart rate and SpO2 continuously in the Badger system.
• Record ventilator settings at the start of the procedure manually into the Badger system. Record hourly thereafter and record any changes made in ventilation.
• Record BP every 15 minutes – enter manually into the Badger system • Capillary blood gas after 15 to 30 minutes and repeat every hour during the • May need repeated pancuronium doses if procedure prolonged • Atropine (20micrograms/kg) may be used to treat persistent bradycardia due to • Ventilate until good respiratory effort established.
If ventilated prior to procedure - aim to return to previous settings within 8 hours.
If not ventilated prior to the procedure - once sedation / paralysis has worn off,wean rapidly from ventilator guided by clinical status rather than blood gasanalysis.
• Continue monitoring for at least 24 hours as there is an increased risk of apnoea.
Analgesia• Prescribe paracetamol (15mg/kg/dose 4-6 hourly, 4 doses max in 24 hours). Nurse caring for babies should determine need for analgesia.
Post op topical treatmentPrescribe the following topical treatment post operatively to all babies• Chloramphenicol ointment 1%, to both eyes 6 hourly for 5 days • Betamethasone eye drops, to both eyes, 6 hourly for 5 days • Homatropine 1% eye drops, to both eyes, 12 hourly for 2 days 1. Retinopathy of prematurity: Guidelines for screening and treatment. The Royal College of Ophthalmologists and The British Association of Perinatal Medicine. Thereport of a joint working party 1995 October 15th 2007 (version4-NICU2)


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