The Magical Hour: Why does it Matter?

Nicole Thompson-Bowie, NNP

NeonatalTrack

9/14/2016

Objectives

• Define the Golden Hour and its

History

• Review practices that can aid in

better outcomes for VLBW infants

• Explain ways for implementing

successful Golden Hour protocol

Golden Hour of Trauma

• Borrowed from emergency/trauma

medicine

• 1st 60 minutes following a multi-system

trauma. It is believed that the victims

chances of survival are greatest if he/she

receives definitive care within that 1st

hour

• taken from US military wartime experience 3R‘s Rule

Right patient

Right place

Right time

The Golden Hour of Neonatology • 1st hour of life is critical to

neonate

• Initial management can have

SIGNIFICANT impact on long

term complications

Why does the 1st hour Matter?

• Physiologic Transitional

changes

– lung expansion

– circulatory changes

– fluid balance

– metabolic independence

NICU Admission Issues • chaotic environment

• susceptible to errors and miscommunication

• requires teamwork

• SUCCESS contingent on:

• teamwork

• good communication

• medical knowledge

• clinical skills

VLBW Infants

• <1500 grams

• higher risk for mortality and

morbidities • surfactant deficiency

• poor thermal control

• poor energy stores

• susceptible to IVH

• born after complicated delivery

Goal of the Golden Hour • Evidence shows that

management in the delivery

room and NICU has significant

effect on infant morbidity and

mortality in VLBW population.

1. Utilizing team approach

2. Ensuring time awareness

3. Performing key interventions

Minimize Complications Long Term

Complications

Short Term

Complications

O ROP: Retinopathy of Prematurity

O CLD: Chronic Lung Disease

O IVH: Intraventricular Hemorrhage

O Developmental Delay

O Death

O Hypothermia

O Hypoglycemia

O Decreased LOS

2 Core Components Labor and Delivery NICU

O

Antenatally

• Neonatal Consult

• Antenatal transfer (if warranted)

• Antenatal corticosteroids

(Celestone)

• Antenatal MgSO4 for neuro-

protection

• Delivery room preparation

thermoregulation

respiratory

IV access

and fluid

Antibiotics Euglycemia

Circulation

Developmental

Key Things to Accomplish in that 1st Hour

1. Maintain Thermoregulation 36.5-37.5

2. Reduce IVH Risk

3. Provide Adequate Respiratory Support & O2 Use

4. Maintain Euglycemia

5. IV fluids and Protein Administration

6. Administration of antibiotics

7. Cardiovascular Stabilization

1. Thermoregulation • Cold stress can increase respiratory and

metabolic acidosis, inactivate surfactant,

increase hypoglycemia and can cause

DEATH

• Infants born to febrile mothers have a higher

incidence of seizures, cerebral palsy and

death

1. Maintain Thermoregulation 36.5-37.5

2. Reduce IVH Risk

3. Provide Adequate Respiratory Support & O2 Use

4. Maintain Euglycemia

5. IV fluids and Protein Administration

6. Administration of antibioitcs

7. Cardiovascular Stabilization

Hypothermia is

PREVENTABLE

Preventing Cold Stress Strategies

• Warm Delivery room to 77 degrees

• Place wet baby in polyethylene bag

• Cover head with wool cap or polyethylene

cap

• Utilize chemically activated gel mattress

• Warmed and humidified ventilators and

isolettes

• Warm blankets

2. Reduce IVH Risk • Poor cerebral blood flow Auto-regulation and fragile

germinal matrix vasculature infant at risk high

risk for IVH

• 99% happen in 1st 72 hours

50% happen in 1st 24 hours

1. Maintain Thermoregulation 36.5-37.5

2. Reduce IVH Risk

3. Provide Adequate Respiratory Support & O2 Use

4. Maintain Euglycemia

5. IV fluids and Protein Administration

6. Administration of antibioitcs

7. Cardiovascular Stabilization

What can

we do??

- Delayed Cord Clamping

- Minimal touch

- Keep head Midline for

72 hours

Delayed Cord Clamping (DCC)

• Current ACOG and NRP recommendations

are….” to perform DCC for 30-60 seconds

for stable premature infant.

First “stem Cell” transfusion ~15 ml/kg

• Decrease IVH risk by ~ 50% • Decreases risk of late onset sepsis

• Reduces # of blood transfusions and NEC risk

• Improved hemodynamics

• Not the same as cord milking !!

Another thing very injurious

to the child is tying and

cutting the naval string too

early. It should always be

left behind till the child has

breathed and pulsation in

the cord ceases.

Erasmus Darwin,

1801

Minimize IVH risk

3. Respiratory Issues

• VLBW infants are at high risk for RDS,

CLD and ROP

• Must provide adequate

– VENTILATION and OXYGENATION

1. Maintain Thermoregulation 36.5-37.5

2. Reduce IVH Risk

3. Provide Adequate Respiratory Support & O2 Use

4. Maintain Euglycemia

5. IV fluids and Protein Administration

6. Administration of antibioitcs

7. Cardiovascular Stabilization

Respiratory Strategies

• Early CPAP Use

• Surfactant within 1 hour of life if

intubated

• Use of T Piece resuscitator

• Prevent lung trauma

• Avoid oxygen toxicity

Minimize CLD, ROP

Respiratory Issues • Oxygen toxicity is harmful to all infants.. but esp

VLBW infant from as early as in the DELIVERY

ROOM

• Resuscitation with low O2 has proven to reduce

Chronic lung disease

• Pulse oximetry

• Targeted Pre-ductal Saturations

• Start at 21-100% from in the DR

Minimize ROP

4. Glucose Stability • Glucose nadir happens ~ 30-60 min of life in SICK

preterm infant

• Check accucheck within 30 min of life

• Dextrose infusion started by 30 minutes of life

• Prevent hypoglycemia

• BEWARE of: asphyxiated, IDM or IUGR infants

1. Maintain Thermoregulation 36.5-37.5

2. Reduce IVH Risk

3. Provide Adequate Respiratory Support & O2 Use

4. Maintain Euglycemia

5. IV fluids and Protein Administration

6. Administration of antibioitcs

7. Cardiovascular Stabilization

5. Fluid & Protein Administration • #1 GOAL Place IV access in 15-30 min of

delivery and run fluid with dextrose component • IV versus umbilical line placement

• #2 GOAL Should have protein administration (Starter TPN) within 2 hours of life avoid catabolism and tissue destruction for energy

6. Antibiotic Administration

• VLBW infant with risk factors for sepsis have

an increased mortality and morbidity risk

• GOAL IV antibiotics in within 1 hour of life

1. Maintain Thermoregulation 36.5-37.5

2. Reduce IVH Risk

3. Provide Adequate Respiratory Support & O2

Use

4. Maintain Euglycemia

5. IV fluids and Protein Administration

6. Administration of antibioitcs

7. Cardiovascular Stabilization

7. Cardiovascular stabilization

• Rarely are infants affected by acute delivery

blood loss needing volume replacement

• Difficult to assess “normal” BP

• Infant should be normotensive by 1 hour of life

• check BP as well as perfusion !!

1. Maintain Thermoregulation 36.5-37.5

2. Reduce IVH Risk

3. Provide Adequate Respiratory Support & O2

Use

4. Maintain Euglycemia

5. IV fluids and Protein Administration

6. Administration of antibioitcs

7. Cardiovascular Stabilization

1. Maintain Thermoregulation 36.5-37.5

2. Reduce IVH Risk

3. Provide Adequate Respiratory Support & O2 Use

4. Maintain Euglycemia

5. IV fluids and Protein Administration

6. Administration of antibiotics

7. Cardiovascular Stabilization

60 minutes and Counting …….

What does the Data Say??

• Compared 225 VLBW infant ~ 28 weeks and same weight…

• 106 no Golden hour

• 119 respected Golden Hour protocol

• RESULTS… statistical difference with significant improved short term outcomes in the Golden Hour group - Less Cold stress - Less episodes of hypoglycemia - 80% compliance with early protein and IVF

Implementation in your Unit

• Educate, Educate, Educate

• Enforce team-work…..multidisciplinary

effort

• Continued review of the literature

• Track the outcomes and areas for

improvement

Strategies to Use

• Simulation Based Learning

• Flow Diagrams

• Develop a Protocol

• Make it a Quality Improvement

Project

The One Hour APGAR 0 1 2

FiO2 >0.3 0.21-0.30 0.21

pCO2 <40 or >60 40-45

or 55-60

45-55

Temp <35 or >38 35-36 or

37.5-38

36-37.5

BP MAP < GA and

decreased

perfusion

MAP< GA or

Decreased

perfusion

MAP > GA and

normal

perfusion

Neuro Flaccid,

unresponsive

and/or seizures

Decreased tone

and reactivity

and/or irritibility

Normal tone

Reactivity

(+) activity

In Summary

• Goal of Golden Hour: give prompt medical

treatment in 1st 60 minutes of life to VLBW in

hopes to lessen mortality and morbidities

• 1. Standardize Care of VLBW infant

• 2. Prevent complications that may have long

term effects on neonates

• 3. Promote teamwork

thermoregulationn

respiratory

IV access

and fluid

Antibiotics Euglycemia

Circulation

Developmental

reduce IVH risk

Gentle handling

No rapid bolus

Head Midline 72 hrs

Watch CO2

reduce damage from

hypothermia Polyethylene bag or cap

Close monitoring of temp

reduce IVH risk Have normal BP by 1 hour of life

reduce hypoglycemia risk

IV access by 15-30 min of life

1st accucheck by 30 min of life

Dextrose infusion by 30 min of life

No need to wait for XRAY if UAC / UVC

placed

Antibiotics in by 1 hour

IV access within 15 min

Glucose infusion by 30 min

of life

GOAL !!! • Every Minute Counts!!!!!

Education and Ownership

= SUCCESS