NICU:  Respiratory:  Exosurf

Preparation

Prior to Exosurf administration, a CXR should be checked to verify ETT position, and the ETT should be well suctioned to clear secretions.
Replace the ETT adapter with the properly sized adapter provided in the kit (see instructions in kit)
Draw 8 cc of sterile water into a 10 cc syringe using sterile technique (a 10 cc vial is provided in the kit).  Inject the water into the powder vial to reconstitute the suspension.  The vial containing the powder is under vacuum and will pull water into the vial.  To mix the suspension, draw the mixture back into the syringe and allow it to flow back into the vial.  Repeat until the suspension is well-mixed.  Do not shake the suspension.
Dose is 5 cc/kg, given q12 hours for 3 doses.

Manual Administration

After dose is calculated, push extra Exosurf out of syringe to avoid accidental overdosage.
Screw the syringe onto the side port of the ETT adapter
Push half the dose in, a few drops at a time.  Try to time your pushes with inspiration.  Give the HALF dose over 10 minutes.  The head should be in midline and the torso flat.
Rotate the head and torso 45 degrees to the right.  Be careful not to dislodge the ETT.  Hold this position for 30 seconds.  Return to the previous position.
Give the second half of the dose as described above.
Rotate the head and torso 45 degrees to the left and hold for 30 seconds.  Again, be careful not to dislodge the ETT.
Avoid suctioning the ETT for 2 hours following Exosurf therapy unless absolutely necessary.

Administration by pump

Use of a programmable syringe pump provides more evenly spaced delivery of Exosurf into the ETT.
Prepare the suspension as previously described.  BEFORE wasting unneeded Exosurf, attach a syringe to a length of microbore IV tubing and then push out extra Exosurf.  This accounts for the drug that will remain in the tubing after the dose is given.
Program the pump to deliver half the dose over 10 minutes.  Hold the head and the ETT in midline. You must remain at the bedside during the entire process.
After half the dose is given, rotate the infant as described above.
Administer the second half of the dose as described above and rotate to the other side.
Ask a nurse to assist you with programming the pump.

Complications of Exosurf Therapy

There is an increased incidence of pulmonary hemorrhage with Exosurf therapy.  Monitor infant closely during and after administration.  Notify a fellow or attending immediately if blood is seen in the ETT during administration.
Exosurf will act quickly to increase lung compliance.  Check ABGs 30 minutes after dosage and be ready to wean the PIP quickly to avoid barotrauma, especially pneumothorax.  Also, watch chest rise closely every 5 to 10 minutes.  You may be able to wean the PIP based on chest rise before the ABG.