INTRODUCTION:

The organization of a good quality special care neonatal unit is essential for reducing the neonatal
mortality and improving the quality of life among the survivors. During the past decades
improvements in the diagnostic and therapeutic approaches in the care of high risk infants have
influenced their prognosis favourably. Unfortunately many neonatal centres in the under developing
countries are unplanned and merely improvised .The paediatrician and nurse in charge of neonatal
services should be taken into confidence during the planning stage so that the special care neonatal
unit is based on their opinions for meeting the special needs of the infants. Adequate space,
availability of running water round-the-clock, centralized oxygen & suction facilities, maintenance of
thermo neutral environment & ready availability of plenty of linen & disposables are mandatory to
provide optimal level II newborn care. Facilities for management of common neonatal problems like,
perinatal hypoxia, LBW babies, respiratory distress syndrome, septicaemia, hyperbilirubinimia & life
threatening congenital malformation should be established

DEFINITION:

A neonatal intensive care unit (NICU), also known as an intensive care nursery (ICN), is an intensive

care unit specializing in the care of ill or premature newborn infants. Neonatal refers to the first 28
days of life.

OBJECTIVES:

1. To know about the physical set up and facility of NICU

2. To gain knowledge and the advanced equipments and procedure which are required during
the emergency condition of the newborn
3. To give the life support in serious condition
4. To know the different care of newborn and to give ventilation care who are unable to take
adequate respiratory normally
5. To gain knowledge about the skilful management of NICU
6. To gain knowledge about the drugs which are maintained recorded and registered
7. To know about the staffing pattern of NICU
8. To reduce mortality and morbidity rate of new born baby

HISTORICAL BACKGROUND:

Dr.B. C Roy Memorial Hospital for Children. A pretty old and reputed child care govt. hospital in
Kolkata, West Bengal. Hospital is in name of late Chief Minister of West Bengal, Dr. Bidhan
Chandra Roy. He was a famous doctor of his time and it is said that during construction work of this
hospital Dr. Roy used to come frequently and see the work progress holding an umbrella in his hand.
The place is at only 5 minutes walking distance from Phoolbagan crossing. The biggest Paediatric
Government Hospital in Eastern India providing NICU, PICU, SNCU facilities.

In 2007 Neonatal Intensive C are Unit of B.C Roy Post Graduate Institute of Paediatric Sciences
was inaugurated by Sourav Ganguly and it is situated at the first floor of the hospital having 20 beds.
PHYSICAL SETUP:

AN IDEAL NICU WARD SHOULD HAVE FACILITIES LIKE:

● Adequate space.
● Centralize oxygen and suction facilities.
● Maintenance of thermo neutral environment.
● Running water running the clock.
● Linens and disposables like gloves, mask etc.
● Equipments and articles of general and special use like IV stand, various procedure
trays, stethoscope, torch, syringe, bowels, kidney tray, feeding cup, jugs ,basin, etc.
● Machine like incubator, phototherapy unit , ventilator, monitors, etc.
● Stationary as per need.
● Toilets and bathrooms.

EMPHASIS SHOULD BE LAID ON THE FOLLOWING FACTOR:

● Asepsis
● Warmth or Thermo neutral environment
● Adequate nutrition with human milk
● Non stimulating noise free ward
● Safety from all biological, physical and chemical hazard

PHYSICAL SET UP:

SPACE:

Infant is provided with a minimum area of 100 sq . ft. However additional space is needed to
provide for additional facilities. Compromise on space leads to increased potential for
nosocomial infection. Space is allocated in ward for promotion of breast milk and its storage.

LOCATION:

It is located as close to the PICU to promote easy transfer of the neonate from one area to
another. The location is such that sunlight enters day time and enhances the brightness and
provide UV rays to promote asepsis.

FLOOR PLAN:

The ward is square shape so that abundant open space is available. A split unit either side of
corridor is not present for ease of mobility and for prevention of infection. The wall is made
of washable glazed tiles and windows have two layers of glass planes to ensure protection
from heat and sound insulation. The doors is provided with automatic door closers. In
addition to the care area, there is a nursing station, doctors room, store room, procedure room,
pantry,toilet and bathroom, milk storage room and cleaning area where used articles fomites
is washed and sterilized or disinfected.
 The ward have a clean area and infected area, separately located, where infants can be
segregated. The clean side is for children with non-infectious disease like renal problem,
congenital malformation etc and infectious side for children with infectious disease like
diarrhoea , open wound, communicable disease etc. Also there is a separate area for common
infectious problem.

VENTILATION:

Effective ventilation is necessary to reduce nosocomial infection. The most satisfactory

ventilation is achieved with laminar airflow system which is a bit expensive. A simple
method for achieving satisfactory ventilation consist of provision of exhaust fans in reverse
direction near ceiling for in put of fresh uncontaminated air and fixation of another exhaust
fan in conventional manner near the floor for air exit.

LIGHTING:

The ward is well illuminated and painted white to permit prompt detection of jaundice and
cyanosis. Lighting is achieved by cool white fluorescent tubes to provide at least to foot
candle, shadow free illumination at infants level .Spot illumination for many procedure is
provided by portable angle poise lamp having two, 15 watt fluorescent bulbs .

TEMPERATURE AND HUMIDITY:

The temperature of the ward is maintained around 28+-2 degree centigrade, in order to
minimize effect of thermal stress on babies. This is best achieved by air conditioning and use
of radiant heater and hot air blower in winters.

ACOUSTIC CHARACTERISTICS:

The ventilation system , incubators, air compressor, suction pumps and many other devices
used which use noises. Sound intensity in wards is not exceed 75 db. Excessive noise may
lead to hearing loss, physiological and behavioural disturbances like sleep disturbances,
startles and crying episodes etc.

ELECTRICAL OUTLETS:

There is adequate number of light and electrical power points attached to a common ground.
Each baby is provided at least eight electrical outlets. The use of adapters and extension
boards is avoided. The voltage supply to ward is stabilized with the help of a voltage servo
stabilizer.

AMBIENCE AND WARD CULTURE:

The surrounding of the unit is homelike and cheerful and the décor scaled to the child’s size.
Colourful attire instead of traditional white uniform worn by nurses to brighten ward
atmosphere as well as promote nurse – child –parent relationship.
COMMUNICATION SYSTEM :

The ward is provided with an intercom system for well connected to other unit of the
hospital. A direct external line telephone is present so that parents have an easy access to
enquire about the well being of their child and in turn they are readily connected whenever
needed.

HANDLING AND SOCIAL CONTACTS.

Handling of the baby is gentle and kept to the minimum without compromising care. Gentle
caressing, cuddling and touching by the mother is provided to comfort the baby and aid the
process of healing.

WARD PERSONNEL.

Sufficient number of adequately trained nurse is available in the ward sister. For 16 bedded
ward, 14 nurse is sanctioned to ensure availability of four nurse in each shift along with one
sister in charge in morning. There is equal distribution of nurses in each of the three shifts.
The nurse is imparted continuing in service training to update their knowledge. The ward
also have an independent senior resident doctor and one junior resident round the clock for
every 8 babies.

ANCILLARY SUPPORT STAFF :

● Physiotherapist
● Dietecians
● Technicians
● Radiographer
● Respiratory technician
 ● Biomedical engineers
● Cleaning staff
● Secretarial / clerical staff
● Social worker
● Nursing director
● Administrator
● Laboratory and blood bank representatives
● Quality assurance and improvement / member of audit committee
● Advise administration regarding equipment needs
● Establishing teaching and training system of staff
● Maintaining NICU statistics for mortality and morbidity.

STAFFING PATTERN:

Ward sisiter-1

In charge-1

Staff nurse-23

In each shift: Morning shift-6

Evening shift-5

Night shift-4

COMMON INSTRUMENTS UESD IN NICU:

▪ All the resuscitation equipments along with ventilator, self inflating neonatal resuscitation
bag, central supply of oxygen, central suction apparatus
▪ Oxygen concentrator
▪ Multiple parameter monitor
▪ Oxygen analyzer
▪ Bili blanket
▪ Infusion pump
▪ Radiant warmer
▪ Phototherapy
▪ Suction machine
▪ Incubator
▪ Ventilator
 During the last 2-3 decades a large number of monitoring devices for diagnostic and
therapeutic use for the high risk newborn infants have been developed. These have
considerably improved their intact survival. The maintenance of the existing equipments in
proper working condition is more important than acquiring new and sophisticated gadgets.

▪ Bag and mask resuscitator: Self inflating bag of 250-500 ml capacity is ideal for
resuscitation of newborn baby. Face masks (size 0, 1 and 2) should be rigid with a
cushioned rim to form a tight air seal fit on the face enclosing the mouth and nostrils.

▪ Oxygen and suction facilities: A centralized source of oxygen, compressed air and suction
outlet consoles (50 psi) affix on the wall is ideal. The suction pressure is regulated with a
pressure dial. Facility should be available for intermittent suction because continuous
suction may cause bradycardia and mucosal damage.

▪ Catheters, syringes and needles: Catheters, needles and syringes should be available
liberally in the unit. The availability of liberal supplies of disposables is crucial fro
reduction of nosocomial infections.
▪ Feeding equipment: Glass or stainless steel bowls of adequate size (120 ml) should be
available in the nursery for collection of expressed breast milk, mixing and preparing the
formula. A hot air autoclaving oven or a pressure steriliser should be provided for
autoclaving feeding equipment. Storage facility like a refrigerator should be available in
the nursery.

▪ Laminar flow system: It is useful for safe and aseptic formulation and mixing of drugs,
parenteral fluids and nutrients. Strict asepsis should be ensured by wearing mask, sterile
gown and disposable gloves while operating the laminar flow system.
▪

▪ Weighing machine: Accurate weighing record of babies is a sensitive index of their well
being and availability of a sturdy and reliable weighing machine fulfils the fundamental
need. A sensitive beam type weighing scale with a precision of + or – 10gms is a useful
equipment in the nursery.

▪ Incubators: The incubators are essential to provide an ideal micro environment for high
risk babies. About one third of nursery beds should comprise of incubators. The main
functions of an incubator are isolation, maintenance of thermo neutral environment, desired
 humidity and administration of oxygen. The incubator maybe of portable type for transport
of sick babies or stationed in the nursery.

▪ Radiant heat warmer: During various procedures, the infant loses body temperature,
unless he is kept warm by use of radiant heat warmer. A portable heat lamp with two 150
watt white ordinary or bakery bulbs or infra red bulb fixed on the wall about 2- 3 feet about
the level of table or trolley is necessary. The infrared heat is preferable because it directly
warms the subject without affecting the temperature of the intervening environment.

▪ Thermometers: Low reading (30-40°C) rectal thermometer is essential to assess the

severity of hypothermia. Electronic or tele thermometers with skin sensors or rectal probes
with an accuracy of + or – 0.1°C are ideal for continuous atraumatic monitoring of body
temperature.

▪ Oxygen concentrator: Oxygen concentrators are being indigenously manufactured and

they work both on battery and mains. The atmospheric air is passed through a chemical
 which absorbs all gases except oxygen. Depending on the flow rate various concentrations
of oxygen can be delivered to the patient.

▪ Oxygen head box (oxyhood): A square shaped box made of transparent plastic or perspex
which can enclose the head of the infant is useful for administration of higher
concentration of oxygen. It can be used whether the baby is nursed in an open cot or
incubator.

▪ Phototherapy unit: Phototherapy is now generally accepted as a safe and effective method
for treatment of neonatal hyperbilirubinemia. A light source designed to give irradiance or
flux of 8-10 uw/cm2/nm between 400-500nm wavelength range at the mattress is ideal.
Blue light is more effective than the red light but former interferes with the observation of
the infant.

▪ Heart rate monitor: These are ideal to monitor high risk infants and are especially useful
during prolonged procedures such as exchange blood transfusion and surgery.
▪ Respiratory rate and apnoea monitor: The respiratory monitor based on impedance
technique measures changes in the electrical resistance during breathing. The electrode is
fixed on the chest wall to pick up signals which are digitally displayed as respiratory rate.
The conventional apnea monitors are based on air mattress having plethysmographic
sensor. When infant stops breathing after a variable interval of 10-20secs depending upon
the preset lag, the instrument emit a beep and displays red warning signals.

▪ Multi channel vital sign monitor: The multi channel complex monitors are available to
display and record all the vital signs on an oscilloscope. They are equipped to record
temperature at different sites, heart rate, respiratory rate with apnoea alarm, invasive and
non invasive blood pressure and pulse oxymetry.

▪ Infusion pump: The infusion pump is a sophisticated electronic micro pump which
displaces fluid and a micro processor or pressure transducer controls the rate of fluid
delivery. The rate of infusion is depicted as drops/minute or in terms of volume through a
disposable cassette or plastic syringe. The latest infusion pumps have inbuilt alarms to
signal occlusion flow, air in the system, system failure, low battery charge etc.
▪ Bilirubin analyser: The instrument provides direct read out of total serum bilirubin which
is reliable for taking therapeutic decisions for the management of neonatal
hyperbilirubinemia.

▪ Transcutaneous bilirubinometer: The yellow discoloration of skin and subcutaneous

tissues can be quantitated and equated to total bilirubin value with the help of a
photoprobe. The probe is pressed against forehead or sternum. The light passes through
inbuilt fiberoptics and reflectometer and is analysed by computerised specro photometer to
provide immediate digital display of total bilirubin. It is a useful bed side screening method
for the young resident doctor to assess the degree of jaundice.

▪ Transcutaneous blood gas monitor: These are non invasive devices used for continuous
monitoring of oxygen tension in vivo. Transcutaneous monitoring measures skin-surface
PO2 and PCO2 to provide estimates of arterial partial pressure of oxygen and carbon
 dioxide (PaO2 and PaCO2). The devices induce hyperperfusion by local heating of the skin
and measure the partial pressure of oxygen and carbon dioxide electrochemically.
Transcutaneous blood gas monitoring is appropriate for continuous and prolonged
monitoring (eg.during mechanical ventilation, CPAP, and supplemental oxygen
administration).

▪ Pulse oxymeter: A pulse oxymeter is a medical device that indirectly monitors the
oxygen saturation of a patient's blood (as opposed to measuring oxygen saturation directly
through a blood sample) and changes in blood volume in the skin, producing a
photoplethysmograph. It is often attached to a medical monitor so staff can see a patient's
oxygenation at all times. Most monitors also display the heart rate. A blood-oxygen
monitor displays the percentage of arterial haemoglobin in the oxyhemoglobin
configuration. Acceptable normal ranges are from 95 to 100 percent, although values down
to 90% are common.

▪ Capnography: Capnography is the monitoring of the concentration or partial pressure of

carbon dioxide (CO2) in the respiratory gases. Its main development has been as a
monitoring tool for use during anaesthesia and intensive care. It is usually presented as a
graph of expiratory CO2 plotted against time, or, less commonly, but more usefully, expired
volume. The plot may also show the inspired CO 2, which is of interest when rebreathing
 systems are being used. The capnogram is a direct monitor of the inhaled and exhaled
concentration or partial pressure of CO2, and an indirect monitor of the CO 2 partial pressure
in the arterial blood. Capnographs usually work on the principle that CO 2 absorbs infra-red
radiation. A beam of infra-red light is passed across the gas sample to fall on to a sensor.
The presence of CO2 in the gas leads to a reduction in the amount of light falling on the
sensor, which changes the voltage in a circuit. The analysis is rapid and accurate, but the
presence of nitrous oxide in the gas mix changes the infra-red absorption via the
phenomenon of collision broadening.

▪ Neonatal ventilators: A neonatal ventilator is a medical device used in neonatal intensive

care units (NICU) to assist newborns in maintaining proper blood gas levels. Although
ventilation refers to the removal of carbon dioxide from the blood, these devices also help
deliver oxygen to the infant. These devices are typically used with premature babies whose
lungs have not fully developed, but can also treat full-term newborns who have breathing
problems. Neonatal ventilators take a variety of forms, but all are usually short-term
treatments until the the lungs are capable of regulating blood gasses properly. All neonatal
ventilators must be carefully monitored and maintained. A breathing device may be
harmful if it is not working properly or is exchanging gasses at the wrong time. It is also
possible to over-ventilate an infant with these devices, which may lead to chemical
imbalances such as alkalosis.
TRANSPORT OF SICK BABIES

Satisfactory transportation facilities are needed whether a baby is being transported from one
hospital to an intensive care unit or simply within the hospital from NICU to the operation
theatre, imaging department etc. The short distance transport within the hospital can be
accomplished in a transport incubator. The use of plastic basket with perforated sides coupled
with careful placing of hot water bottles is recommended for use in the rural setting. Skin to
skin contact with mother or a care taker is a useful modality for transport in rural setting and
resource poor situations.

Transport team and equipment

The neonates requiring special or intensive care should preferably be transported by a skilled
transport team the receiving tertiary care NICU should have a dedicated team and a protocol
for providing transport services. The transport vehicle should be checked for availability of
all equipments in working order and essential supplies, disposables and life saving drugs.
Customised transport ambulance should be equipped like a ‘mini NICU’ and should have a
multi-channel vital sign monitor, portable incubator and a ventilator. The neonate needing
transport should be transported with the quickest available transport through the shortest
possible route. The condition of the baby should be assessed before transfer. The goal of
every transport is to bring a sick neonate to a specialised neonatal center in a stable condition.
To avoid complications during transport, the infant should be as stable as possible before
leaving the referring hospital. Hypothermia, hypovolaemia, hypoglycaemia, acidosis and
seizures should be treated before baby is transferred. Oral feeding should be stopped and an
IV line should be established.

The principles of safe transport of sick babies are expressed by a number of mnemonics like
STABLE where each alphabet stands as follows:

S - Sugar

T - Temperature

A – Airway

B – Blood pressure

L – Lab work

E – Emotional support

SAFER where the alphabet stands for:

S – Sugar

A – Arterial circulatory support

F – Family support

E – Environment

R – Respiratory support

TOPS where the alphabet stands for:

T – Temperature

O – Oxygenation (airway and breathing)

P – Perfusion

S – Sugar
 Arrival at the receiving NICU

The transport team should remain in constant touch with the referral NICU during the course
of the journey. Ideally the referral center should have a dedicated communication facility.
The team should brief the NICU care givers regarding the status of the baby and immediate
clinical concerns. The clinical documents should all be handed over to the receiving unit. The
referring hospital and parents of the baby should be informed about the safe arrival and the
latest condition of the baby.

FUNCTIONS:

PATIENT’S TYPE: : Admission criteria

1. Birth weight less than2000grms

2. Large babies more than or equal to 4 kgs

3 . Gestational age less than36 weeks
4. Rh incompatibility
5. Gross congenital malformations
6. Maternal diabetes mellitus
7. Respiratory distress or any other systematic problems of the neonates.
8. Unwell or unwilling or unwed mother.
9. Hypoglycemia
10. Birth asphyxia
11. Meconium aspiration syndrome
12. Severe jaundice
13. Neonatal sepsis/meningitis

RECORDS MAINTAINED

1. Report register
2. Vesper register
3. Long line register
4. Pathology register
5. Medicine indent register
6. Milk indent register
7. Duty roster register
8. Allocation register
9. Autoclave register
 10. Communication register
11. ABG, pm line register
12. Infection control register
13. Admission register
14. Death register
15. Articles register
16. Stock register

CONCLUSION:

We have gained knowledge and practical view of an ideally set up neonatal intensive care unit.
There must be provision of mother based neonatal care unit for those babies who need more
observation , monitoring and support but do not need the facility of SNCU/ NICU. Must have
clean section, septic section , room for milk expression and breast feeding room. Equipment in
NICU donot necessarily impose the outcome of high risk neonate. The availability of adequate
space, freedom from congestion, maintenance of sepsis and presence of adequate nursing staff
are must. After completion of course we will apply various knowledge and practice regarding
NICU care in our respective field.
VISIT REPORT
ON
NICU