NEONATAL INTENSIVE CARE UNIT

INTRODUCTION:

NICU is a very specialized unit where critically ill neonates are cared to reduce the neonatal
mortality and morbidity.

The admission to nenatal special care unit or intensive care unit has some criterias. If the child is
neonate in the critical condition, the neonate needs the care of intensive unit. Mostly from the
labour wards, operation theatres and hospital or any other referral, they will be sent to intensive
care unit (ICU).

CRITERIA FOR ADMISSION IN NICU:

Indications for admission to the neonatal intensive care unit are as follows:

 Low birth weight(2000 gms)

 Large babies (more than or equal to 4 kg).
 Birth asphysxia (Apgar score less than or equal to 6).
 Meconium aspiration syndrome; if symptomatic thick meconium seen in larynx.
 Severe jaundice
 Infant of a diabetic mother
 Neonatal sepsis/ meningitis
 Neonatal convulsions
 Severe congenital malformations/ cyanotic heart disease.
 O2 therapy/ parentral nutrition
 Immediately after surgery/cardiological investigations
 Cardiorespiratory monitoring, heart rate and respiratory rate is unstable.
 Exchange blood transfusion
 PROM/ foul smelling liquor
 Mother of hepatitis ‘B’ carrier
 Injurred neonate

Intensive care needs highly trained personnel including the intensive care specialist, trained
nurses and technicians. Sophisticated equipments for the monitoring and maintenance of vital
functions and the availability of continious laboratory support are essential in the intensive
care.

AIMS/GOALS OF NEONATAL INTENSIVE CARE UNIT:

The goals of a neonatal intensive care unit are:

 To improve the condition of the critically ill neonates keeping in mind the survival of
neonates so as to reduce the neonatal morbidity and mortality.
 To provide continuing inservice training to medicine and nursing personnel in the care of
the newborn.
 To maintain the function of the pulmonary, cardiovascular, renal and nervous system.
 To monitor the heart rate, body temperature, blood pressure, central venous pressure
and blood gases.
 The oxygen concentration of the blood is by oxygen analyzers.
 To check/ observe alarms systems signal, to find out the changes beyond certain fixed
limits set on the monitors.
 To administer precise amount of fluids and minute quantities of drugs through I.V.
infusion pumps.

PREPARATION OF NICU:

 Warm (33-36oC) incubator.

 Adequate light source.
 Resuscitation and treatment trolly stocked.
 History, continuation sheet, treatment and diet sheet, problem list and flow charts.
 Oxygen air and suction apparatus (as available in the unit).
 Suction – complete suction unit tubing and various sizes of suction catheters.
 Ventilation bag and mask of appropriate sizes.
 Vital signs monitors.
 Specific equipment as indicated by diagnosis.

ADMISSION PROCEEDURE IN NICU.

All babies admitted to the neonatal unit should have the following data recorded
carefully within 24 hours of admission (if poasible much sooner).

HISTORY AND EXAMINATION.

 Maternal history
 Paternal history
 Previous obstetric history
 Details of present pregnancy.
 Labour
  Delivery
 Apgar score.

ON ADMISSION

 Notify the doctor and the nurse in-charge.

 Resuscitate infant as necessary and maintain warmth.
 Check infant identification label.
 Quickly examine the infant from head to toe for obvious abnormalities if the condition
permits.
 Record weight, length and head circumfrence as soon as possible.
 Transfer to warm enviorment as soon as possible.
 Commonest observations are
(a) Temperature – Infant normal temperature range 36oC to 37oC.
(b) Heart rate (c) Respiration (d) Colour (e) Activity.
• Explain to parents.
• Handover from transferring unit staff.

RECORD KEEPING.

• Birth history: - Done in labour ward.

HISTORY
a) Ward history contains:-
• Apgar score and examination of new born infant sheet.
• Neonatal weight and feed sheet, progress chart.
b) Compiled history contains
• Patient registration form
• Progress sheet
• Intra uterine growth chart.
c) O2 flow sheets, fluid balance sheet etc.

LIFE THREATENING CONDITIONS WHICH REQUIRE NICU:

The following are the life threatening conditions in neonates:

 Apnea
 Baby with respirtory distress
 Birth asphyxia
 Convulsions
 Low birth weight babies (less than 1500 gm requring intensive care).
 Neonatal jaundice requiring exchange blood transfusion.
 Sepsis and meningitis.
HOW TO MAKE ROUND WITH THE CONSULTANT IN NICU:
The nurse should have the following recording and reporting while round with consultant:

1. Examine and evaluate assigned patients (neonates) each day.

2. Record keeping:
▪ Progress notes: it should reflect present status of infants and new or ongoing
problems.
▪ Problem list: A complete problem list is kept at the front of the progress notes.
❖ This must be kept current, new problem listed and resolved problem also noted.
❖ The number of the problems in the progress chart should be consistentwith the problem
list.
❖ Only active problem needs to be discussed. The problems should be collected from the
following areas:
(a) General status
➢ Better –worse- no change
➢ Pertinent physical findings.
(b) Nutrition:
➢ Weight, change appropriate? Inappropriate.
➢ Caloric status, source
➢ Plan of nutrition (feeding)
(c) Respiratory problems:
➢ Present status, pertinent physical findings, and laboratory findings.
(d) Infecton:
➢ If suspected or present, pertinent findings
➢ Culture results
➢ Plan of therapy e.g. How long antibiotic treatment is planned.

(e) Apnea:
➢ Number and severity of apneas/ bradycardia.
➢ Treatment/ ventillation
➢ Caffiene or theophylline levels.
(f) Cardiovascular:
➢ Physical findings
➢ Blood presssure
➢ Result of test such as echo
➢ Treatment plans
(g) Fluids and electrolytes:
➢ Intake and output, electrolytes
➢ Problems and plan
(h) Metabolic:
 ➢ Glucose, phosphorus, calcium balance or any problems
➢ Assessment and plan
(i) Neurological:
➢ Problems, changes, medication, plans
➢ Seizures, medication, blood levels, ECG results.
(j) Hematological:
➢ Anemia/coagulopathy, neutropenia etc
➢ Transfusions and plans
(k) Hepatic
(l) Renal problems
(m) Eyes
▪ Discharge: summaries/ transfer summaries must be done prior to discharge of patients.

INSTRUMENTS AND FACILITIES:

Apex institution or regional perinatal centre must be equipped with centralized O 2 supply,
suction facilities, incubators/ open care system, vital signs and transcutaneous ventilators and
infusion pumps which are mandatory to provide intensive neonatal care.

PHYSICAL FACILITIES: The neonatologist and the nurse incharge must be invoved while planning
the unit. The intensive care area should be localised preferably next to the labour ward and
delivery rooms. For economising the costs it would be preferably to have it combined with level
2 facilities through both the areas must have separate and adequate staff and the single
administrative control.

TEMPERATURE OF THE UNIT:

In the case of controlling the environmental temperature, the NICU should not be located on
top floor, but there must be adequate sunlight for illumination.

 The unit must have a fair degree or ventilation of fresh air through central air
conditioning is a must.the temperature inside the unit must be maintained at 28 oC +_
20C while the humidity must be above 50%.

SHIFTING:

In the case the unit is responsible for picking up babies, referred from the regional hospitals, it
should be with in easy access from the ambulance entrance and should have a separate
elevators.

PHYSICAL SET UP (SITE):

The NICU can be in a single area or it can be in multiple rooms with a capacity of 2-4 infants
each.

BED STRENGTH OF NICU:

One intensive care bed is generally required for 100 deleveries provided the prematurity ratio is
around 8% and hence for a population of 1 million, 30 intensive care beds, would be required
for aur country. These figures would require modifications based on the growth rate, no. of
premature deliveris and the load of high risk population it drains. Since the supportive services
to be provided for it would be uneconomically to have a NICu of less than 6-8 bed.

ASPECTS OF NICU
Two main inportanat aspects in NICU

1. Physical set up
2. Administrative set up.

Catagories of NICU: there are three main catagories of NICU:

1. Level I (mild)
2. Level II (moderate)
3. Level III (critical)

LEVEL OF NEONATAL CARE:

LEVEL I CARE:

This is the minimal care which can be provided by the mother under the supervision of basic
health professionals. Neonates weighting more than 2000 gm or having gestational age maturity of 37
weeks or more belong to this care includes care of delivery, provision of the warmth, maintenance of
asepsis, and promotion of breast feeding.

LEVEL II CARE:

This care includes requirement for resuscitation, maintenance of thermo neutral temperature,
intravenous infusion, gavage feeding phototherapy and exchange transfusion. 10-15 percent of the
newborn require care of this level. This care s is anticipated for the infants weighing in between 1500 &
1800 gm or having gestational age maturity of 32 to 36 weeks. These babies require specialized
neonatal care supervised by trained nurses and pediatricians.

LEVEL III CARE:

 This care includes life saving support system like ventilator and best suited special intensive
neonatal care. Three to five percent of newborn require care of this level. This level of care is for
critically ill babies, for those weighing less than 1500 gm or having gestational age maturity of less than
32 weeks.

Neonatal care units are arbitrarily & not precisely classified into the following units. But the goal
of all the units is to improve the clinical care of the critically ill neonate and to reduce the neonatal
mortality and morbidity. Neonatal care also includes training for medical and nursing personnel in the
care of newborn.

PHYSICAL SET UP

LOCATION:

(i) The neonatal unit should be located as close as possible to the labor rooms and obstetric
operation theatre, to facilitate prompt transfer of sick and high risk infants
(ii) For case of controlling the environmental temperature, the NICU should not be located on
the top floor, but there must be adequate sunlight for illumination.
(iii) The unit must have a fair degree of ventilation of fresh air.

Space between the patients:

• For the patient care, 100 square feet is required for each baby as it is true for any adult
bed.
• There should be gap of about 6 feet between two incubators. For adequate circulation
and keeping the essential life saving equipments, space needed about 120 square feet.
• Each patient station should have 12-16 central voltage established electrical outlets.
• 2 or 3 oxygen outlets.
• 2 compressed air outlets
• 2 to 3 suction outlets
• Additional power plug point would be required for the portable x-ray machine close to
the patient care area.

FLOOR:

• The unit facility should preferably be in a square space so that abundant open
unencumbered space is available.
 • The walls should be made of washable glazed tiles and windows should have two layers of
glass panes to ensure some measure of heat and sound insulation.
• Adequate number of deep wash basins with elbow or foot operated taps having constant
round-the-clock water supply should be provided.
• The doors should be provided with automatic door closers.

Water: hand washing

• The unit must have uninterrupted clean water supply and each patient care area must
also have a wash basin with foot or elbow operated tapes. Neat wash basin, placing
paper towel and receptical.
• The unit should be equiped with laminar air flow system, however alternatively air
conditioned with multipore filters and fresh air exchange of 12 per hours should be
provided.

Colour: the walls of the whole unit should be washable and have a white or slightly off white
colour for better colour appreciation for neonates.

Lighting: the lighting arrangements should provide uniform, shadow free illumination of 100
foot candles at the baby’s level. In addition, spot illumination should be available for each baby
for any procedure.

A generators back up is mandatory where there are frequent power fluctuations or power
failures.

Sounds: the acoustic characteristics should be such that the intensity of noise is kept well below
75 decibles.

The unit should also have an intercom and a direct outside telephone line so that parent can
have an easy access to the medical personnels in case of an emergency.

Rooms: Apart from the patient carearea including roomss for isolation and procedures there is
need of space for certain essential functions, like a room for scrubbing and gowning near the
entrance, side laboratory, mothers room, adequate stores for keeping consumable and non
consumable articles.

• A room for keeping the X-ray and ultrasound machines.

• One or two rooms each would be needed for doctors and nurses on the day and night
duties.
• There is a space available for a biomedical engineer to provide essential periodic
preventive maintenance of the costly equipments.
• Additional space will be required for educational activities and storing of data.
Ventilation: Minimum of six air changes, 2 air changes should be outside for filter the inner air.

• Effective air ventillation of nursery is essential to reduce nosocomial infections.

• The air conditioning ducts must be provided with millipore filters (0.5H) to restrict the
passsage of microbes.

Ventillated air: a simple method to achieve satisfactory ventilation consists of provision of

exhaust fan in a reverse direction near thew ceiling for input of fresh and uncontaminated air.
Fixation of other exhaust fan in the conventional manner near the floor for air exit.

Infection control measures: hand washing facilities.

• Each room should have a separate basin facilities, it can be used for children
• Sinks are regularly cleaned by disinfection.

ADMINISTRATIVE SET UP:

Medical Staff: the unit should be headed by a director who is fill time neonatologist with special
qualification and training in neonatal medicine.

• He should be responsible for maintenance of standard of patient care.

• Development of the operating budget.
• Equipment evaluation and purchase.
• Planning and development of education programme.
• Evaluation of effectiveness of perinatal care in the area.
• He should devote time to patient care services, research and teaching as well as co-
ordinate with level 1 and level 2 hospitals in the area.

Staff requirements:

• Neonatal physician 6-12 patient in the continuing care, inter mediate care and intensive
care areas.
• He should be available on 24 hours bases for consultation.
• A ratio of one physiciay in training to every 4-5 patient who requires intensive care ideal
round the clock.
• Services of other specialists like microbiologist, hematologist, radiologist, cardiologist,
and should be available on call.
• An anesthestist capable of administering anesthesia to neonate.
• Pediatric surgeon and pediatric pathologists should be available.

Nurses ratio:
 • Nurse patient ratio 1:1 maintained throughout day and night.
• A ratio of one nurse for two sick babies not requiring ventillatory support may be
adequate.
1. For an ideal nurse patient ratio, four trained nurses per intensive care bed ar needed.
2. Additional head nurse who is the over all incharge.
3. In addition to basic nursing training for level 2 care, tertiary care requires dedicated,
committed and trained staff of the highest quality.
4. There training must include training in handling equipment, use of ventillators and use
of mask resuscitations and even endotracheal intubation, arterial sampling and so on.

Experience:

The staff nurse must have a minimum of 3 years work experience in special neonatal care unit
in addition to having 3 months hands on training in intensive neonatal care unit.

Other staff:

• There is a special need of motivated staff responsible for upkeep and clenliness of the
unit.
• Special attention must also be made to train and educate others persons for their role in
the patient care.
• One sweeper should be available round the clock.
• Laboratory technician
• Public health nurse/ social workers
• Respiratory therapist
• Biomedical engineer
• Ward clerk can help in keeping track of the stoves
• Equipment and supports should include all that is necessary toresuscitation and
intermediate care areas.
• Supply should be kept close to the patient station so that nurse do not have to go away
from the neonate unnecessarily and nurses time and skills are used efficiently.
• There should be servo controlled incubators and open air system for providing adequate
warmth.
• Two-third of the bed strength should be open care system.
• When every incubators are being used, heat shields used inside the incubators would be
useful to further decrease the insensible water loses.
• Adequate number of infusion pumps for giving fluid (minimum 2 pint), parental nutrition
solutions and drugs should be available.
• Infant ventilators capable of giving the pressure ventilation and various cardiopulmonary
monitor.
Equipment required for any neonatal ICU and the quality required for 6 patient
beds :-

• Resuscitation set -6
• Open care system -4
• Incubators -2
• Infusion pumps -12
• Positive pressure ventilators -6
• Oxygen hoods, oxygen analyzers -6
• Heart rate apnea monitors without scope -6
• Phototherapy unit -6
• Electronic weighing scale -12
• Pulse oxymeters -6
• Transcutaneous PO2 and PCO2 monitor’s 2-3
• Non invasive B.P monitors 1-2
• Invasive B.P monitors 1-2
• ECG monitors without defibrillator -1
• Intracranial pressure monitors -1

Disposable articles required for the NICU:-

I.V. catheter, I.V. sets, bacterial filters, feeding tubes, endotracheal tubes, suction catheters,
three way adapters, umblical arterial and venous catheters, syringes, needles, ventilator
tubings, trocar and canula, pressure transducers foe invasive blood pressure.

Laboratory for NICU

• A micro chemistry laboratory attached to the unit and providing round the clock service.
• This should be well equipped to provide quick and reliable hematocrit, blood glucose
and total serum bilirubin.
• Facilities for total leukocytes counts and microscopic examination of peripheral blood
films for evidence of infection.
• Equipment for measures of specific gravity of urine and calcium should be available.
• House x-rays machine and an ultrasound machine shoud be mandatory for modern day
neonatal care units.

Documentations in NICU
 • The unit should have printed problem oriented sttionary for maintaining records,
admission and discharge slips etc.
• Records of all admission should be maintained in a register or on a computer.
• The information should be analysed and discussed at least once a month to improve the
effectiveness of the NICU in providing the services.

Education programme at NICU

• There should be continuing medical education programmes for physicians and nures in
the form of lecturers, demonstrations and group discussions.
• This should cover important issues like resuscitation, sterilisation to be maintained for
critically ill babies, putting in arterial catheters, conducting exchange transfusion,
maintenance of ventilators etc.
• Educational programmes covering the nurses and physician in the community should be
developed.
• There should be regular meetings with the obstetrician to discuss the perinatal condition
and care.
• Individual high risk cases.
• Education and follow up is necessary.
 LAYOUT MAP FOR A SINGLE CORRIDOR SPECIAL CARE NEONATAL UNIT FOR 24 INFANTS.
X-RAY LABOR PROCE GROWING WAITING
ROOM - DU-RE ROOM
NURSERY
ATORY ROOM

ROOM
DOCTORS

ROOM
NURSES

NURSING STATION
WA
CONFERENCE ROOM

CLEANING
AREA
MINIMAL ISOLATION
FORMULA ROOM

CARE ROOM
SPECIAL CARE ROOM
ROOM
STORE ROOM

FUMIGATION
CHAMBER
SCRUB
GOWN