Introduction

• Germinal Matrix - Intraventricular Haemorrhage (GM-IVH) is one of the most frequently encountered neurological problems of the premature neonate. This document outlines information and recommended best practice for assessing the risks and subsequent nursing care of the infant <30 weeks gestation.

Scope

• Applies to all Nurses caring for ELBW and VLBW babies in the Newborn Service.

Babies Most At Risk

• Infants between 23 and 32 week gestation are at risk, with infants under 30 weeks gestation being most at risk.  There are, however, exceptions to this.

Timing of GM-IVH

• 0-90% of bleeds in the first 3 days.
• 7-20% in the next 4 days until <5% after 7 days.

Haemodynamic Instability

• All haemorrhages seem to start in the germinal matrix as the thin walled blood vessels are vulnerable to damage due to disturbances in perfusion, caused by an increase, decrease or fluctuating blood pressure. Changes in blood pressure may occur as a result of handling, for example movement, crying, feeding, intubation, suctioning and stimulation.
• Hypotension/hypertension is often a recurring and difficult problem exacerbated by the fact that normal ranges for blood pressure in infants that are VLBW/ELBW has not been firmly established.
• In very low birthweight infants during the first 48-96 hours blood pressure is influenced by birthweight and gestational age.

Infant Positioning, Weighing and Optimal Haemodynamic Stability

Try to cluster cares to allow long rest periods particularly between stressful interventions. The frequency and duration of handling during intensive care have been shown to influence the occurrence and severity of hypoxaemia which can increase the risk of GM-IVH in VLBW/ELBW infants. Disruptive tactile stimulation can precipitate a negative physiologic chain of events and lead to intracranial pressure or cause haemodynamic fluctuations. Excessive handling can also initiate hypoxaemia.

When changing nappies care can be taken by sliding the nappy under to avoid raising legs as increase to intracranial pressure occurs when infants legs are lifted, especially if above the head. Position with the head midline and the head of the bed slightly elevated. Intracranial pressure is lowest when the head of the bed is elevated. Side lying with head in midline to avoid twisting of the infants body also reduces the risk of increasing intracranial pressure.

Infants <30 weeks should not be offered cuddles or kangaroo care in the first 5 days of life.Discuss at ward round if appropriate for family to be offered cuddles to infant >3 days old, stable and over 30 weeks gestational age. Infants that are 30 weeks and over should have their stability and disease process considered prior to offering cuddles. An infant that is not expected to survive may also be an exception to these guidelines

Blood Pressure Management

Monitor blood pressure diligently

1. Infants <32/40 with arterial lines have their BP monitored continuously and recorded hourly on observation sheet.
2. VLBW/ELBW babies and sick infants i.e. <32/40 weeks ventilated, Hudson CPAP, O2 requirement, without arterial lines may need 1-2 hourly cuff BP measurement initially. Discuss frequency with NS-ANP/medical staff.
3. The optimal mean is decided by NS-ANP/medical staff. BP should be equal to or greater than the gestational age in the first 24 hours.
4. Alarm limits on HP monitors should always be on and set at appropriate levels i.e. upper level slightly above recommended mean BP and lower alarm level set at slightly lower than desired mean BP.
5. Report fluctuations in BP, hypotension and hypertension to medical staff/NS-ANP.
6. Consider allowing recovery periods to avoid rapid BP fluctuations during handling.

Reduce fluctuations in blood pressure

1. Minimal handling and cluster cares to allow rest periods. Handle gently.
2. Refer to Suction Policy regarding babies on Hudson CPAP and IPPV. Pre-oxygenate as indicated and allow time for SpO2 to recover between suctions.
3. ELBW infants ideally should only be warm weighed with two people to facilitate procedure.
   • Infants <30 weeks are not to be weighed in the first 5 days unless requested by the medical staff or NS-ANP.
4. To avoid fluid overload, use accurate checking under RBP of rate of IV pumps.
   • Rate of intermittent infusions e.g. blood plasma, via Graseby or IVAC pump is also checked by two RNs and signed.
   • Volume limit on IV pumps to be set within 10% of limit.
5. Nurse infant flat or head of bed slightly raised, not head down. Head needs to be in line with body, not twisted so as not to increase intracranial blood flow and pressure.

If you cannot see an index above, please press the "Refresh" button of your browser.