WHAT IS SURFACTANT? Natural endogenous surfactant is a compound of phospholipids, neutral lipids, and proteins that forms a layer between the alveolar surface and the alveolar gas and reduces collapse by decreasing surface tension with the alveoli. Surfactant deficiency is almost always associated with the formation of hyaline membranes in the immature lung and the onset of respiratory distress syndrome (RDS).
INDICATIONS Prophylactic administration - Infants at high risk of developing RDS due to short gestation (<32 weeks) or low birthweight (<1,300g) Rescue or therapeutic administration – preterm or full- term infants who require endotracheal intubation and mechanical ventilation because of increased work of breathing and increasing oxygen requirements
CONTRAINDICATIONS The presence of congenital anomalies incompatible with life beyond the neonatal period Respiratory distress in infants with laboratory evidence of lung maturity
CUROSURF Curosurf is a pulmonary surfactant consisting of an extract of natural pig lung surfactant. It consists of 99% polar lipids and 1% hydrophobic low molecular weight proteins. Curosurf contains no preservatives.
Directions for UseCurosurf should be inspected visually for discoloration prior to administration.The color of Curosurf is white to creamy white. Curosurf should be stored in arefrigerator at +2 to +8°C (36-46°F). Before use, the vial should be slowlywarmed to room temperature and gently turned upside-down, in order toobtain a uniform suspension. DO NOT SHAKE. 1. Locate the notch on the colored plastic cap. 2. Lift the notch and pull upwards. 3. Pull the plastic cap with the aluminum portion downwards. 4 and 5. Remove the whole ring by pulling off the aluminum wrapper. 6 and 7. Remove the rubber cap to extract content.
Administration equipment: - Syringe containing ordered dose of surfactant, warmed to room temperature - 5 French feeding tube or catheter, or endotracheal tube with delivery port - Mechanical ventilator or resuscitation bagResuscitation equipment: - Laryngoscope and endotracheal tube - Manual resuscitation bag and airway manometer - Blended oxygen source - Suction equipment to include catheters, sterile gloves, collecting bottle and tubing, and vacuum generator - Radiant warmer ready for useMonitoring equipment: - Neonatal tidal volume monitor, if available - Airway pressure monitor - Pulse oximeter or transcutaneous PCO2 - Cardiorespiratory monitor
Personnel – Surfactant replacement therapy should beperformed under the direction of a physician by credentialedpersonnel which include nurses and respiratory therapists.
Initial DoseThe initial recommended dose of Curosurf is 2.5 mL/kg birth weight. This dose maybe determined from the Curosurf dosing chart previously shown.For Endotracheal tube instillation using a 5 Fr catheter: Slowly withdraw the entire contents of the vial of Curosurf into a 3 or 5 mL plastic syringe through a large-gauge needle (e.g., at least 20 gauge). Attach the pre-cut 8-cm 5 end-hole French catheter to the syringe. Fill the catheter with Curosurf. Discard excess Curosurf through the catheter so that only the total dose to be given remains in the syringe. Before administration, the infants ventilator settings should be changed to a rate of 40-60 breaths/minute, inspiratory time 0.5 second, and supplemental oxygen sufficient to maintain SaO2>92%. Keep the infant in a neutral position (head and body in alignment without inclination). Briefly disconnect the endotracheal tube from the ventilator.
Endotracheal tube instillation using a 5 Frcatheter cont. Insert the pre-cut 5 French catheter into the endotracheal tube and instill the first half (1.25 mL/kg birth weight) of Curosurf. The infant should be positioned so that either the right or left side is dependent for the dose given . After the first half is instilled, remove the catheter from the endotracheal tube and manually ventilate the infant with 100% oxygen at a rate of 40-60 breaths/minute for one minute. When the infant is stable, reposition the infant so that the other side is dependent and administer the remaining half using the same procedures. Do not suction infant for at least 1 hour after administration unless there are signs of significant airway obstruction. Resume ventilator management and clinical care.
Endotracheal tube instillation using a 5 Frcatheter:
For endotracheal instillation using the secondarylumen of a dual lumen endotracheal tube: Slowly withdraw the entire contents of the vial of Curosurf into a 3 or 5 mL plastic syringe through a large-gauge needle (e.g., at least 20 gauge). Keep the infant in a neutral position (head and body in alignment without inclination). Administer Curosurf through the proximal end of the secondary lumen of the endotracheal tube as a single dose, given over 1 minute, and without interrupting mechanical ventilation. After completion of this dosing procedure, ventilatory management may require transient increases in FiO2, ventilatory rate, or peak inspiratory pressure (PIP).
Endotracheal instillation using the secondarylumen of a dual lumen endotracheal tube:
Repeat doses Up to two repeat doses of 1.25 mL/kg birth weight each may be administered, using the same techniques described for the initial dose. Repeat doses should be administered, at approximately 12-hour intervals, in infants who remain intubated and in whom RDS is considered responsible for their persisting or deteriorating respiratory status. The maximum recommended total dose (sum of the initial and up to two repeat doses) is 5 mL/kg.
PROCEDURAL COMPLICATIONSplugging of endotracheal tube (ETT) by surfactanthemoglobin desaturation and increased need for supplemental O2bradycardia due to hypoxiatachycardia due to agitation, with reflux of surfactant into the ETTpharyngeal deposition of surfactantadministration of surfactant to only one lung
PHYSIOLOGICAL COMPLICATIONSapneapulmonary hemorrhagemucus plugsincreased necessity for treatment for PDAmarginal increase in retinopathy of prematuritybarotrauma resulting from increase in lung compliance following surfactant replacement and failure to change ventilator settings accordingly
DOSING PRECAUTIONS The administration of surfactant should be interrupted if the infant experiences long episodes of bradycardia, decreased oxygen saturation, reflux of the surfactant into the ETT, or airway obstruction have occurred. Dosing may resume once the infant is stable.
Surfactant deficiency is almost always associated withthe formation of hyaline membranes in the immaturelung and the onset of respiratory distress syndrome.RDS is a major cause of morbidity and mortality inpremature infants. The incidence of RDS is morerelated to lung immaturity than gestational age.Direct tracheal instillation of surfactant has proven toreduce mortality and morbidity in infants with RDS.
1. Bower, Barnhart, Betiti, et al. “Surfactant Replacement Therapy." AARC Clinical Practice Guideline. (1994): <http://www.rcjournal.com/cpgs/srtcpg.html>.2. “Recommendations for Neonatal Surfactant Therapy." Pediatric Child Health. Vol 10. No 2 (2005): <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2722820/>.3. “Curosurf.” Cornerstone Therapeutics Inc. (June, 2012) http://www.drugs.com/pro/curosurf.html