Administration of Surfactant to newborns with or at risk of Respiratory distress syndrome (RDS) is now an established practice. In infants with RDS, surfactant stabilizes the alveoli, improves the lung compliance, decreases oxygen and ventilatory support. Presently 2 preparations of surfactant are available in the Indian market 1). Survanta 2). Curosurf.Survanta is a natural bovine lung extract containing phospholipids, neutral lipids, fatty acids, and surfactant-associated proteins to which colfosceril palmitate (dipalmitoylphosphatidylcholine), palmitic acid, and tripalmitin are added to standardize the composition and to mimic surface-tension lowering properties of natural lung surfactant. Each ml of Survanta contains 25 mg of phospholipids. It is an off-white to light brown liquid supplied in single-use glass vials containing 4 mL (100 mg phospholipids) or 8 mL (200 mg phospholipids).Curosurf is a white to creamy white suspension of poractant alfa (Porcine lung extract). Each milliliter of surfactant mixture contains 80 mg of total phospholipids (including 54 mg of phosphatidylcholine of which 30.5 mg is dipalmitoyl phosphatidylcholine) and 1 mg of Protein including 0.3 mg of SP-B. Curosurf is available in sterile, ready-to-use rubber-stoppered clear glass vials containing 1.5 ml (120 mg phospholipids) or 3 ml (240 mg phospholipids) of suspension.</sec><sec id="sec002"><title>Indications

JNNFI

Journal of Neonatology

0973-2179

National Neonatology Forum

jn-20-3-017

Procedures

Administration of surfactant

Srinivas

Murki

Department of Pediatrics, Niloufer Hospital, Hyderabad, India, E-mail: srinivas_murki2001@yahoo.com

7–92006

203288290

Administration of Surfactant to newborns with or at risk of Respiratory distress syndrome (RDS) is now an established practice. In infants with RDS, surfactant stabilizes the alveoli, improves the lung compliance, decreases oxygen and ventilatory support. Presently 2 preparations of surfactant are available in the Indian market 1). Survanta 2). Curosurf.Survanta is a natural bovine lung extract containing phospholipids, neutral lipids, fatty acids, and surfactant-associated proteins to which colfosceril palmitate (dipalmitoylphosphatidylcholine), palmitic acid, and tripalmitin are added to standardize the composition and to mimic surface-tension lowering properties of natural lung surfactant. Each ml of Survanta contains 25 mg of phospholipids. It is an off-white to light brown liquid supplied in single-use glass vials containing 4 mL (100 mg phospholipids) or 8 mL (200 mg phospholipids).Curosurf is a white to creamy white suspension of poractant alfa (Porcine lung extract). Each milliliter of surfactant mixture contains 80 mg of total phospholipids (including 54 mg of phosphatidylcholine of which 30.5 mg is dipalmitoyl phosphatidylcholine) and 1 mg of Protein including 0.3 mg of SP-B. Curosurf is available in sterile, ready-to-use rubber-stoppered clear glass vials containing 1.5 ml (120 mg phospholipids) or 3 ml (240 mg phospholipids) of suspension.</sec><sec id="sec002"><title>Indications

There are 3 main indications for surfactant administration in newborns

Prophylactic therapy

Neonates with gestation less than 30 weeks of gestation

Surfactant given within 15 minutes of birth before a diagnosis of RDS is made

Early Rescue therapy

Neonate with RDS (confirmed clinically & radiologically).

Surfactant given within first 2 hours of life

Late Rescue therapy

Neonate with RDS and requiring ventilation with a MAP of at least 8 cms of water and/or an FiO₂ > 30% (or a/A ratio < 0.22)

Surfactant given after 2 hours of birth

Repeat doses

Second or subsequent doses of surfactant are given if the infant with RDS is requiring ventilation and has a FiO₂ requirement of > 30%. A minimum duration of 6 hours is recommended between any 2 doses of surfactant. Surfactant is usually not continued beyond 3 days of life (72 hours).

Dose

Survanta 4ml/kg for the first and subsequent doses (dose is based on the total surfactant pool in a term healthy neonate).

Curosurf 2.5ml/kg for the first dose and 1.25ml/kg for the subsequent doses (1) or 1.25 ml/kg for all the doses.

Steps of administration

Stabilize the baby and allow normal perinatal transition

Before surfactant is given to a newborn it must be warmed. Vial may be warmed by sitting at room temperature for 20 minutes or holding it in hand for 8 minutes. Do not shake and do not heat by artificial warming methods.

Place the infant in the supine position and assess for equality of breath sounds in both the axillae (for confirmation of endotracheal tube position). Suction the ET if necessary

Note the Endotracheal Tube (ETT) length till the adapter. Cut a 5 French end-hole catheter so the tip will protrude just beyond the end of the endotracheal tube

Draw up the Surfactant with a large gauge needle (atleast 20G) and attach the catheter to the syringe

Insert the catheter into the ETT and administer the surfactant in 2 to 4 aliquots (each aliquot of 1 to 2ml) as rapidly as tolerated (2). Changing positions after each aliquot is not required (3). If a dual port/side port ET adapter is available the catheter may be inserted through the side port. This technique may help in better dispersal of surfactant by preventing interruption of PEEP during administration. Giving surfactant by infusion or by nebulization is not recommended.

After administration hand ventilate with an Ambu bag or increase the ventilation until the baby is stable

High frequency oscillation will not adequately disperse the surfactant; hence for babies on HFOV, hand bagging is necessary.

Subsequent ET Suction should be avoided for 4 hours (unless absolutely indicated for a blocked ET tube)

Following surfactant administration ventilator requirements may rapidly improve and ventilation should be adjusted appropriately. Do not leave the baby unobserved for at least another 4 hours

Surveillance after surfactant administration

The clinical response is unpredictable. Lung compliance usually improves, sometimes quite rapidly. Blood gases should be monitored frequently, and the ventilator should be adjusted to keep the PCO₂ above 40 mm Hg if possible. Occasionally, gas exchange deteriorates after Surfactant administration, requiring a temporary increase in PIP. In either case, close surveillance of chest wall movements and frequent monitoring of blood gases, especially during the first 4 hours after dosing, will minimize the complications of barotrauma and atelectasis

Precautions

Correction of acidosis, hypotension, anemia, hypoglycemia, and hypothermia is recommended prior to surfactant administration

Surfactant administration can be expected to reduce the severity of RDS but will not liminate the mortality and morbidity associated with other complications of prematurity

Efficacy of surfactant in infants less than 600 g birth weight or those with infections may be suboptimal and not as expected.

Should only be administered by those trained and experienced in the care, resuscitation, and stabilization of pre-term infants

Surfactant is stored refrigerator (2 to 8°Celsius). Unopened, unused vials of surfactant that have been warmed to room temperature may be returned to the refrigerator within 24 hours of warming, and stored for future use. Surfactant should not be removed from the refrigerator for more than 24 hours and should not be warmed and returned to the refrigerator more than once. Each single-use vial should be entered only once. Used vials with residual drug should be discarded.

Adverse reactions Transient episodes of bradycardia, decreased oxygen saturation, reflux of the surfactant into the endotracheal tube, and airway obstruction may occur during the procedure. Other reported effects include pallor, vasoconstriction, hypotension, hypertension, hypocarbia, hypercarbia, and apnea. Pulmonary hemorrhage after surfactant administration is now attributed to the improved lung compliance and opening of PDA

References1Prescribing Information Curosurf:

http://ww.dey.com/Curosurf/PrescribingInformation.htm

2Krause Martin

M.D.Schulte-Münting

Jürgen

PhDThomas

Hoehn

MD. Rate of Surfactant administration influences lung function and gas exchange in a surfactant deficient rabbit model. Pediatric Pulmonology, 1998: 25: 196–204.3Broadbent

Fok

T.H.

Dolovich

Walts

Coates

Bowen

Kiripalani

. Chest position and pulmonary deposition of surfactant in surfactant depleted rabbits. Arch Dis Child Fetal Neonatal Ed, 1995; 72: F84–F89.