Surfactant Administration Procedure Note (Neonate)

Date and time of procedure: [YYYY-MM-DD HH:MM]

Location: [NICU / Delivery room / Transport]

Gestational age at birth: [Weeks + days]

Postnatal age / Day of life: [Hours / DOL #]

Weight used for dosing: [kg] ([birthweight / current weight / protocol dosing weight]) (If current weight unavailable, document operational source used.)

Procedure Summary

[Indication in one sentence]. [Administration method: ETT instillation / INSURE / LISA/MIST / LMA]. [Surfactant product name] at [mg/kg], total [mg] ([mL]) administered. [Immediate tolerance statement]. (Limit to 2–4 sentences. Include complications if any, otherwise state tolerated without immediate complication.)

Indication & Clinical Context

[Primary indication]. [Objective severity markers prompting treatment: FiO₂ threshold, CPAP/PEEP/MAP level, blood gas trends, imaging findings if obtained]. [Rationale for chosen delivery method]. (Include explicit numeric thresholds and current values.)

Consent

[Informed consent obtained / Emergency or implied consent]. (If informed consent: document who provided consent and brief elements discussed. If emergency/implied: state why standard consent was not feasible.)

Pre-Procedure Status

• Vital signs: [HR bpm], [SpO₂ %], [BP if available]
• Respiratory support: [Mode] with [FiO₂], [PEEP/CPAP level], [rate/pressure/TV if applicable]
• Airway status: [If intubated: ETT size and depth at lip / If non-intubated: interface and CPAP/NIV level]
• Clinical assessment: [Work of breathing, air entry, hemodynamic stability]

Dose Calculation

• Product: [Surfactant product name] ([concentration mg/mL])
• Weight used: [kg] ([birthweight / current weight / protocol dosing weight])
• Ordered dose: [mg/kg] (and/or [mL/kg] per product labeling)
• Total dose: [mg] ([mL])
• Aliquot scheme: [# of aliquots] × [mL per aliquot] (Omit if not used.)
• Variance from standard protocol: [None / Rationale if dose differs from labeling]

Premedication

[Drug name], [dose], [route], [time]. (List each medication separately. If none given, state explicitly: No premedication given.)

Procedure Details

(Document the administration method used. Include only the relevant method-specific details below.)

• General: [Patient positioning], [oxygen/ventilation strategy maintained], [total administration time], [interruptions and corrective actions if any]
• ETT instillation: [ETT patency confirmed], [instillation method], [aliquot delivery and ventilation between aliquots], [reflux or obstruction if any]
• INSURE: [Intubation details: blade, ETT size, attempts, confirmation], [instillation details], [extubation timing], [post-extubation support mode/settings]
• LISA/MIST: [CPAP/NIV settings maintained], [laryngoscopy attempts], [catheter type/size and insertion depth], [instillation approach: slow vs aliquots], [PPV required: yes/no, duration if yes]
• LMA: [LMA size], [placement confirmation], [instillation details], [spontaneous breathing vs PPV required]

Tolerance & Adverse Events

• Lowest SpO₂: [%]
• Lowest HR: [bpm]
• Adverse events: [None / bradycardia / desaturation / hypotension / apnea requiring PPV / airway obstruction / ETT blockage or reflux / escalation of support / other] (Describe sequence and severity.)
• Interventions: [Paused instillation / suctioning / repositioning / FiO₂ increase / manual ventilation / medications / reintubation / other] (Include timing.)
• Dose completion: [Full dose completed / Incomplete: volume delivered and reason]

(If no complications, state explicitly: No complications observed during administration.)

Post-Administration Assessment

(Document at approximately 10–20 minutes post-dose.)

• Vital signs: [HR bpm], [SpO₂ %], [current FiO₂]
• Respiratory support: [Mode and settings after dosing]
• Clinical response: [Air entry, work of breathing]
• Ventilator adjustments: [Setting changes due to changing compliance] (Use specific numeric changes, e.g., "FiO₂ decreased from 0.45 to 0.30.")

Respiratory Plan

• Oxygen strategy: [FiO₂ wean plan and saturation targets]
• Ventilator/NIV plan: [Wean parameters; extubation criteria and timeline if intubated; post-extubation support and failure criteria if recently extubated]
• Monitoring: [Next blood gas timing], [chest radiograph if indicated]
• Redosing criteria: [Objective criteria and timing window for potential repeat dose]

Signature

[Author name], [Role/credentials], [Date], [Time]