Dear Colleages, especially in Sweden,

I would like to know if you use INSURE technique (intubation, surfactant, extubation) for babies around 27-28 wks GA (# 1 kg) whose mothers are unbooked and didi not receive antenatal steroids.

Best Regards

Our current guideline in Stockholm, regarding prenatal transfer to a level-3 setting, is to centralize deliveries <27+0 weeks if no special circumstances are known, such as SGA, twins, malformations etc. In other words, "uncomplicated" deliveries at 27 and 28 weeks are born regularly in level-2 settings, since we expect those infants to do well on nasal CPAP, and (if needed) the INSURE technique.

Naturally, sudden deliveries and not treated with antenatal steroids, is a risk factor of mechanical ventilation. Ideally, those women may be transfered prenatally, but if that's not possible, infants are taken care by locally. If nCPAP and INSURE does not seem to be a good option (i.e. severe RDS), the infant is transfered postnatally after primary surfactant administration, and while being on mechanical ventilation.

In addition (and a bit off-topic), I think that the road to success, keeping tiny infants on nCPAP and performing INSURE, is good neonatal nursing.