Less Invasive Surfactant Administration Tips

[Nathan Sundgren]

So I've seen LISA done once, I've now done it once, next is to roll it out unit wide in our NICU. See one, do one, teach one, right? I'd like to hear from those of you that have been doing LISA/ MIST for a while now. What is the best tip you have? What do you know now that you wish you had known when you first did LISA? What barriers to implementation did you have when you started? Any feedback is welcome.

Also, I made a video for our nurses and respiratory therapists to just introduce the idea. Not too in depth, but something to get our education rolling. See what you think. 

 

[Stefan Johansson]

(Another) Great video! Many thanks for sharing!

[AngelaCondie]

Thanks for the video on LISA. That will change my technique- WOW!

Blessings, Angela

Bach Christian Hospital, Qalandarabad, Pakistan

[Tamimi]

Its great that alot of units are adopting it. I think the important things to sort out when starting LISA is having a clear criteria for weight and GA and pressure cut off. Also to discuss seduction options including low dose opioid vs none. 
 

also choosing the appropriate methods including maybe the Hobart methods using the angiocath that may be easier for operators.

[dj 188]

Sounds like you are starting off good. We’ve been doing it for a year and a half now. We needed to give it sooner than later was the biggest learning incite we had. Our threshold was too high sometimes still trying to get them through just NIV without surfactant, so we brought it back to 30% and have had better results. Wish we could get the Surfcath over here in the USA that would make it much easier than the makeshift catheters. Great job on the video! 

[Nathan Sundgren]

Thanks for the feedback @dj 188 and  @Tamimi . We do have clear guidelines on pressure settings and we are targeting above 30% FiO2 to make sure the surfactant is early rescue and not late. I have not wanted to necessarily limit weight or GA, but we recognize the biggest benefit is likely in the <1500 gram, and technically easiest in something larger than the sub 500g babies. I too wish we could get the surfcath. Drawing the line on the angiocath is my least favorite part of the whole thing.

[M C Fadous Khalife]

The final diagram is very interesting. Thanks

[Florian]

Thanks for sharing the video. In Rotterdam we use special MIST/LISA catheters from Chiesi (we are aware of the reported problems with the tip) and Vygon. This is, in our experience, (also in combination with videolaryngoscopy) even less invasive. Considering there is no need to use a Magill forceps.

[Nathan Sundgren]

@Florian I would love to use the catheters you are talking about, but they are not available in the United States. I specifically spoke to a Chiesi rep and they don't see making the effort to get FDA approval here anytime soon. 

@M C Fadous Khalife Glad you liked it.

[Narasimha Rao]

[mention=7787]Florian[/mention] I would love to use the catheters you are talking about, but they are not available in the United States. I specifically spoke to a Chiesi rep and they don't see making the effort to get FDA approval here anytime soon. 
[mention=7331]M C Fadous Khalife[/mention] Glad you liked it.

My colleagues here at a tertiary unit in England, seem to have taken a liking and preference to the vygon surfcath. It’s definitely worth considering


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[Leonie]

I work with Peter Dargaville and we use MIST all the time. It's so much more gentle than how we practiced even a few years ago. 

[Nathan Sundgren]

On 9/7/2020 at 6:05 PM, Tamimi said:

Its great that alot of units are adopting it. I think the important things to sort out when starting LISA is having a clear criteria for weight and GA and pressure cut off. Also to discuss seduction options including low dose opioid vs none. 
 

also choosing the appropriate methods including maybe the Hobart methods using the angiocath that may be easier for operators.

Do you have a max weight? We tried on a larger baby over the weekend and encountered more difficulty probably for multiple reasons. Is there a weight you have found that is too big for this procedure (assuming they are truly surfactant deficient)?

[Tamimi]

9 minutes ago, Nathan Sundgren said:

Do you have a max weight? We tried on a larger baby over the weekend and encountered more difficulty probably for multiple reasons. Is there a weight you have found that is too big for this procedure (assuming they are truly surfactant deficient)?

We don't have a max weight cut-off. We do use low dose sedation though. 0.5 mcg/kg fentanyl.  In most cases it does not cause apnea and babies are fine with some stimulation and increasing the PIP on NIPPV. I find the difficulty with the bigger ones is that they are fully awake while you have to do the procedure.

[AntoineBachy]

Thanks for nice video and sharings.
We were recently looking back to our less than 26 weeks population. Unfortunatly we have to confess that only a few finaly managed without invasive ventilation at some point (eventhough they recieved LISA or INSURE). We have undoubtely much better results with LISA in the 26-28 weeker population.

How do you succeed to avoid invasive ventilation even in the smallest children? Could you share your "golden hour" management protocol?
Do you have tips in order to keep constant CPAP pressure  anytime during this period (transfer, ...)?
Do you have readings to advice?
thanks in advance for sharing experiences

[Nathan Sundgren]

On 11/18/2020 at 1:55 PM, AntoineBachy said:

How do you succeed to avoid invasive ventilation even in the smallest children? Could you share your "golden hour" management protocol?
Do you have tips in order to keep constant CPAP pressure  anytime during this period (transfer, ...)?
Do you have readings to advice?
thanks in advance for sharing experiences

I'm not sure I have much advice to offer. Our nursing has worked hard to maintain CPAP. We are very fortunate to get 1:1 nursing staffing even for CPAP in the first 3 days for our small babies and we get 1:1 nursing for extubations to CPAP or NIPPV.