INTENSIVE CARE

PROCEDURES, EQUIPMENT
AND TECHNIQUES
NEONATAL INTENSIVE
CARE UNIT (NICU)
 INTRODUCTION

 NICU is a very specialized unit where critically ill neonatal cared to reduce the neonatal morbidity
and mortality. The admission to neonatal special care unit or intensive care unit has some can. If the
child is neonatal in the critical condition. Mostly from the labour wards, operation theatre and
hospital or any other referred they will be send to intensive care unit (ICU)
 LIFETHREATENING CONDITIONS WHICH
REQUIRE NICU

 nditions in neonates : -
APNEA RESPIRATORY CONVULSIONS babies (less than Neonatal Sepsis and
DISTRESS 1500 gm jaundice meningitis.
requiring requiring
intensive care exchange blood
transfusion. -
CRITIRIA FOR ADMISSION IN NICU

Indications for admission to the neonatal intensive care unit are as

follow.
 Low birth weight(2000gm)
  Large babies(more than or equal to 4kg)
  Birth asphyxia(apgar score less than or equal to 6)
  Meconium aspiration syndrome. If symptomatic/ thick
meconium seen in lab
  Sever jaundice  Infants of diabetic mother
CONTD….

 Neonatal sepsis/meningitis
  Neonatal convulsions
  Severe congenital malformation/cyanotic congenital heart
disease
  O2 therapy/parenteral nutrition
  Immediate after surgery/cardiological investigation
  Cardio respiratory monitoring, if heart Rate and respiratory
rate are unstable
CONTD….

 Exchange blood transfusion

 PROM/foul smelling liquor

 Mother of hepatitis ‘B’ carrier

 Injured neonate

 Intensive care needs highly trained personnel including the intensive care
specialist, and nurses and techniques. Sophisticated equipment for the
monitoring and if vital functions and the availability for continuous laboratory
support are in the intensive care.
AIMS/GOALS OF NEONATAL INTENSIVE CARE
UNIT

 To improve the condition of the critically ill neonates keeping in mind the survival of
neonate so as to reduce the neonatal morbidity and mortality.

 To provide continuing Inservice training to medicine and nursing personnel in the care
of the new born.

 To maintain the function of the pulmonary, cardio-vascular, renal and nervous system.

 To monitor the heart rate, body temperature, blood pressure, central venous pressure
and blood by non-invasive techniques.
CONTD…

 To measure 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 amounts of fluids and minute quantities of drugs
through I.V. infusion pumps
PREPARATION OF NICU

 Warm (33-36°C) 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).
 Oxygen line connected to oxygen and air flow meter.
 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 PROCEDURE IN NICU

Maternal
Labour History

HISTORY & Paternal Obstetrical

EXAMINATION History History

APGAR
Delivery Scoring
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
condition permits.
 Record Weight, length and head circumference as soon as possible.
 Transfer to warm environment as soon as. Possible
 Cornrnonest observations are :-

 (a) Temperature - Infant normal temperature range 36°C to 37°C -

Environment - See natural thermal environment charts.

 (b) Heart rate.

 (c) Respiration

 (d) Colour,

 (e) Activity. - Explain to parents - Hand over 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.
- 02 flow sheets, fluid balance sheet etc.
DOCUMENTATIONS IN NICU

 The unit should have printed problem oriented stationary 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 analyzed 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

nurses in the form of lecturers, demonstrations and group discussions.

 this should cover important issues like resuscitation, sterilization to be

maintained for critically ill babies, putting in arterial catheters, conducting

exchange transfusion, maintenance of ventilators etc

CONT…….

 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.

NICU EQUIPMENTS
ORGANIZING A NICU:
MAIN COMPONENTS TO BE CONSIDER
WHILE
• PHYSICAL FACILITIES
• PERSONNEL
• EQUIPMENTS
• LABORATORY FACILITIES
• PROCEDURE MANUAL
• TRANSPORT OF SICK INFANTS
• COOPERATION BETWEEN THE OBSTETRICIAN
AND NEONATOLOGIST
1.PHYSICAL FACILITIES:

• Location
• Space
• Floor plan
• Lighting
• Environmental temperature and
humidity
• Handling and social contacts
• Communication system
• Acoustic characteristics
• Ventilation
• Electrical outlets
LOCATION:

• Located as close as to labour room and obstetric

care unit
• Adequate sunlight for illumination
• Fair degree of ventilation for fresh air
SPACE:

• serve as a referral unit for the infants born outside the

hospital
• Each infant should be provided with a minimum
area of 100 sq. ft. or 10sq. meter
•Space for promotion of breast
feeding
 500-600 Gross square feet per bed.
Space includes patient care area, storage
area, space for doctors, nurses, other staff,
office area, seminar room area, laboratory
area and space for families
6 Feet gap between two incubators for
adequate circulation and keeping the
essential lifesaving equipment
FLOOR PLAN
 Open encumbered space
The walls should be made of washable glazed tiles and
windows should have
two layers of glass panes.
Wash basins with elbow or floor operated taps facility
having constant round-the clock water supply should be
provided.
The doors should be provided with automatic door
closers.
 Isolation room
VENTILATION
:
Effective air ventilation
Central air conditioning
LIGHTING
The whole unit must be well illuminated
and painted white
The lighting arrangement should provided
uniform shadow-free, illumination of 100
foot candles at the baby’s level
ENVIRONMANTAL TEMPERATURE
AND HUMIDITY
•The temperature inside the unit should be maintained at 28’
+_2’C, while the humidity must be above 50%.
• Portable radiant heater, infra red lamp can be used
ACOUSTIC CHARACTERISTICS
•The ventilation system, incubators, air
compressors, suction pumps and many other
devices used in the nursery produce noise.
•Sound intensity in the unit should be exceed 75
decibels.
•Telephone rings and equipment alarms
should be replaced by blinking lights.
COMMUNICATION SYSTEM:
•The unit should also have an intercom & a
direct outside telephone line
ELECTRICAL OUTLETS
•Each patient station should have 12 to 16 central
voltage – stabilized electrical outlets sufficient to
handle all pieces of equipment
• An additional power plug point
•There should be round-the-clock power back up
including provision of UPS system
 STAF
•FA direct who is a full time neonatologist
•One neonatal physician is required for every 6-10
patients
One resident doctor should be present in the unit
round-the-clock.
•Anesthetist - pediatric surgeon and pediatric
pathologist are essential persons in establishment of a
good quality NICU
PEDIATRICS INTENSIVE CARE
UNIT
 INTRODUCTION
Currently there are no well defined
guidelines for Pediatric Intensive Care
Units (PICUs) in the Indian context,
regarding unit design, equipment,
organization and staffing or admission and
discharge criteria for different levels of PICU
care.
 INTRODUCTION
CONTI…

The Indian Academy of Pediatrics (IAP)

Intensive Care Chapter and Indian Society for
Critical Care Medicine (ISCCM) Pediatric
Section jointly took the initiative to develop
such guidelines
 INTRODUCTION
CONTI…
The following is a description of specific
guidelines regarding: (i) Unit design; (ii)
Equipment; (iii) Organization and staffing;
(iv) Ancillary support services; and (v) Levels
of PICU care and admission and discharge
criteria and A list of recommended drugs to be
stored in PICU.
1. UNIT
DESIGN
 PICU SHOULD BE :
• a separate unit from the Neonatal and Adult
ICU dedicated to infants and children
• into consideration future adaptability and
expansion and must maximize the resource of
space, equipment, and personnel in a most
affordable way for individual institutions.
• located near lift with easy access to emergency
department and operation theatre, laboratory and
radiology department.
 1(A) SIZE OF PICU

• Six to ten beds is desirable.

• Additional beds may be required if

specialized surgery such as heart surgery,
neurosurgery and trauma surgery cases are
routinely expected.
 1(B) ROOM LAYOUT AND BED
AREA
• Patient area in open PICU should be 150 to
200 sq ft. In a cubicle, the minimum area
should be 200 to 250 square feet with at least
one wash basin for two beds.
• At least one, preferably two rooms should
have an isolation capability with an area of
250 square feet with an ante room (separate
area at least 20 square feet for hand washing
and wearing mask and gown) and separate
ventilation.
1(C) POWER SUPPLY AND
TEMPERATURE
CONTROL
• should preferably be centrally air conditioned and
should have central heating for temperature control.
• over head warmers
• Unit should have an uninterrupted power supply by
means of backup power sources such as invertors
and generators
 1(D) BEDS

• Availability of two or more air/water

mattresses
• Beds must have a railing
• Each bed should have an emergency alarm button
• A cart at the bedside to hold personal
belongings and required patient items.
 1(E) CRASH CART

• A crash cart with emergency drugs and portable

monitor/defibrillator should be readily accessible.
 1(F) CENTRAL STATION
• A central station should provide visibility to all
patient areas
• have capacity for all necessary staff functions.
Patient records should be easily available.
• Adequate space for computer, printers and
central monitor is essential.
• At least two telephoane lines should be
available.
 1(G) X-RAY VIEWING
AREA
• A distinctive area in PICU should be chosen for
viewing and storage of patient X-ray. An
illuminated viewing box should allow viewing
of several films.
 1(H) STORAGE
• Storage for vital supplies should be located within or
closely adjoining to PICU.
• A refri-gerator is essential for some
pharmaceuticals.
• An area must be provided for storage of large patient
care equipment items not in active use.
• An area must be provided for stretchers and wheel
chairs.
 1(I) CLEAN AND DIRTY UTILITY ROOM

• Clean and dirty utility rooms must be separate.

• Covered bins must be provided for soiled linen and waste
materials.
• An area for emptying and cleaning bed pans and urine
bottles is also necessary.
 1(J) WASTE DISPOSAL

• Mechanism of disposal of contaminated waste

(segregation of garbage and contami-nated medical
waste) and adequate disposal of needles and sharp
objects needs to be as per standard applicable
pollution control guidelines.
 1(K) CONFERENCE ROOM

• A room for Intensivist and staff for education, discussion of

difficult cases and other necessary meetings related to
quality improvement is desirable.

• This room should have a small library facility with ready

access to important intensive care books, journals and
policy manuals.
 1(L) STAT
LABORATORY
• A mini laboratory arterial bloodgas,
electrolyte, blood
with urea,
sugar creatinine,
,
 prothrombin time, partial thromboplastin time, complete blood count and urine
examination with Gram stain should be considered adjacent to the PICU.
• As an alternative to stat laboratory adjacent to PICU, a central main laboratory
facility with a turn around time (reporting time) of less than one hour for stat
laboratory test results is acceptable.
2. EQUIPMENTS
Equipment Essential Optional

(a) Diagnostic equipments

Otoscope/ophthalmoscope ×

Portable EEG ×

Portable X-ray ×

12 lead portable ECG ×

Blood gas machine ×

Glucometer ×

Portable ultrasound ×

Portable echo-cardiogram ×

(b) Procedural equipments

Emergency cart ×

Emergency drugs (see Annexure 2) ×

Ventilators (volume/pressure/peep pressure support, low tidal volume capacity (30 to 50 ml) with
nebulizer, humidification and alarms)

Noninvasive ventilator ×

High frequency ventilation ×

Nitric oxide (once licenced

in India) ×

Heliox ×
Microinfusion pumps ×

Defibrillator/cardiovertor ×

Portable suction ×

Pediatric Ambu bag ×

Mapleson anesthesia bag with circuit ×

T piece ×

Pediatric laryngoscope (curved and straight blades) ×

Endotracheal tubes (2.5–7 mm) ×

Pediatric size masks ×

Laryngeal mask airway ×

Intubating flexile laryngoscope ×

Nebulizer ×

Oxygen delivery devices ×

Rebreather mask ×

Nasal cannula ×

Non rebreather mask ×

Oxygen hood (head box) ×

Oxygen (portable) cylinders ×

Nasogastric tubes ×

Heating and cooling blanket ×

Transducers ×

Rectal thermometer probe ×

Glass thermometer ×

Noninvasive blood pressure monitor ×

Oxygen analyzer ×

Portable monitor ×

Pulse oximeter ×

End tidal CO2 ×

ECG ×

Respiratory rate ×

Temperature ×

Arterial pressure ×

Noninvasive blood pressure ×

Central venous pressure ×

Intracranial pressure ×

Arrhythmia alarms ×

Heart rate (high and low rate alarm) ×

Apnea alarms ×

Memory, trends ×

Printout feature ×

(d) Miscellaneous equipments

Phototherapy* ×

Overhead warmer ×

Bed side table ×

 3. ORGANIZATION AND STAFFING

3(a) Medical Director/Intensivist Incharge (5)

• should be a pediatrician trained and experienced in
critical care of children with following responsiblities:
o Establishing policies and protocols
o Smooth functioning of PICU with implementation of
policies and protocols including admission and
discharge criteria
 3. ORGANIZATION AND STAFFING
CONTI,,,,
o Quality assurance and improvement
o Establishing teaching and training system of
medical, nursing and ancillary staff
o Maintaining PICU statistics for mortality and
morbidity
o Being member of infection control
committee.
3 STAFFING
REQUIREMENTS
THEY
INCLUDE:
• · Intensivist/s
• · Resident doctors
• · Nurses,
• · Respiratory Therapists,
• · Nutritionist
• · Physiotherapist
• · Technicians, Computer programmer,
• · Biomedical Engineer, and
• · Clinical Pharmacist
• · Social worker or counsellor
• · Other support staff. Like cleaning staff, guards
and Class IV.
 3(A) MEDICAL
STAFF

• The medical staff should be round the clock

post graduate level pediatrician in PICU with
good airway and pediatric advanced life
support skills and active PALS certification.
3 (B) NURSING
STAFF
 3 (B) NURSING STAFF
CONTI,,,
• A ventilated patient needs one pediatric/ICU
trained nurse by the bed side.
• A very unstable patient (hypotensive/ hypoxemic
patient despite moderate support) may require two
nurses by the bed side.
• Other unventilated/relatively stable patients
(such as post operative patients and ones admitted
for overnight observation) may require only one
nurse per 2-3 patients.
 4. ANCILLARY
STAFF

• All PICU must be regularly staffed by physiotherapists, dieticians and

respiratory technicians for enhancing patient care.

• In addition, technicians, radiographers, and biomedical engineers should be

available on a 24 hours (in hospital) basis for emergencies/ problems that
require immediate attention such as power failure, central gas supply
problems, malfunctioning equipments, or need for urgent X-ray of chest in a
patient with suspected pneumothorax.
• Secretarial/clerical staff is essential to carry out
communication as well as paper work necessary for
smooth functioning of the unit.
• Presence of social worker is desirable to help
support families emotionally as well as financially in
stressful circumstances.
5. LEVELS OF PICU CARE AND
ADMISSION AND DISCHARGE
CRITERIA
5(a) Levels of PICU Care
• Two levels of PICU care are identified, level 3
and level 2. Level 3 (tertiary) PICU can be
organized with level 2 (step down/high
dependency) service in nearby but separate
area. In small private setups, level 3 and level
2 care can be provided in one unit if facilities
and equipment as well as personnel as
described below is available.
LEVEL 3 CARE (TERTIARY LEVEL PICU)
(a) Defined admission, discharge policies;
(b) Four to six ventilator beds;
(c) More than 200 ventilated patients per
annum;
(d) Pediatric intesivist heading the unit;
(e) One pediatrician with post graduate
training and experience in critical care
present in PICU at all times;
LEVEL 3 CARE (TERTIARY LEVEL PICU)
CONTI….
(f) Minimum one to one nursing on ventilated
patients;
(g) High level of monitoring possible in all
patients;
(h)24 hour access to blood bank, pharmacy,
pathology, operating theatre, and tertiary
level of imaging services;
(i)Educational and research activities; and
(j)Quality review/audit process in place.
5(B)1 ADMISSION CRITERIA TO LEVEL
3 CARE PICU
admission criteria :
• All patients requiring mechanical ventilation
• Patients with impending respiratory failure
(a) Upper airway obstruction (b) Lower airway
obstruction (c) Alveolar disease; and (d)
Unstable airway
• All pediatric patients after
successful resuscitation
5(B)1 ADMISSION CRITERIA TO LEVEL
3 CARE PICU
admission criteria :
Comatose patients
All types of shock/hemodynamic instability:
Bleeding emergencies,
Cardiogenic shock myocarditis,
cardiomyopathy, congenital heart disease
Neurogenic shock
• (f) Multiple trauma; Cardiac arrhythmias;
Hypertensive Emergencies; Severe acid base
disorders; Severe electrolyte abnormalities;
Acute renal failure; Patients requiring acute
hemodialysis, hemofilteration and peritoneal
dialysis; Post operative patients; Patients
requiring ECMO (Extra corporeal membrane
oxygenation), nitric oxide therapy (if
available); Malignant hyperpyrexia; Acute
hepatic failure; and All post transplant
patients
 5(B)(2) ADMISSION CRITERIA TO
LEVEL 2 CARE
(i) All ward patients requiring close moni-toring
due to potentially unstable conditions;
(ii) Croup (laryngotracheobronchitis) requir-ing
oxygen;
(iii)Asthma requiring hourly
nebulization/getting tired with increasing
oxygen requirement/mental status change;
(iv)All patients requiring more than 50% oxygen
to maintain saturations;
 CONTI,,,,
(v)Closed head injury/skull fracture admitted for
observation
(vi) Diabetes ketoacidosis with pH <7.2
(vii) Patients with episodes of apnea
(viii)Patients with significant abdominal trauma
with suspected renal/splenic/hepatic injury
(ix) Severe dehydration with mental status
change
(x)Post operative patients after major surgery with
significant post operative pain/blood loss/stress
(xi)Patients recovering from critical illness (level 3
care), but requiring close monitoring.
 DRUGS RECOMMENDED TO
BE STORED IN PICU
• Acyclovir, Adenosine (if available), Adrenaline,
Albumin 5%, 10%, 20%, Amiodarone,
Amphoterecin, Ampicillin, Amrinone (if available),
Atracurium, Atropine, Augmentin, Calcium
chloride, Calcium gluconate, Captopril,
Cefoperazone, Cefotaxime, Ceftazidine,
Ceftriaxone, Chlorpheniramine , Ciprofloxacin,
Cloxacillin, Dopamine, Droperidol, Desmopressin,
Dexamethasone, Dextran, Dextrose
(5%,10%,50%), Dextrose saline, Diazepam,
Dobutamine, Fentanyl, Fluconazole
 DRUGS RECOMMENDED TO
BE STORED IN PICU
• Flumazenil (if available), Phenobarbitone,
Hemeccel, Heparin, HES (starch),
Hydralazine, Hydrocortisone, Insulin,
Isolyte p, Kayaxelate
Ketamine, Ketorolac, Labetalol (if
available), Magnesium sulphate,
Magnesium trisilicate, Mannitol, THAM
(Tris hydroxy amino, methane),
Metronidazole, Midazolam, Morphine,
Naloxone, Neostigmine, Nifedipine
• Noradrenaline, Normal saline, Pancuronium,
Penicillin, Pentazocin, Pethidine, Phenergan,
Phenytoin, Potassium chloride, Propofol,
Propranolol, Ranitidine, Ringers lactate, Saline
3%, Sodium bicarbonate, Sodium
nitroprusside, Streptokinase, Succinyl choline,
Sucralfate, Thiopentone, Tiecoplanin (if
available),, Trinitroglycerine, Trinitroglycerine,
Vancomycin, Vasopressin, Vecuronium,
VitaminK, Xylocaine.
 REFERANCE
S:
• 1. Khilnani P. Pediatric critical care in the 21st century. Indian J
Pediatr 1998; 65: 707-708.
• 2. Driscoll S, Flemming M, Khilnani P. Establishing a new
pediatric
intensive care unit. Indian J Pediatr 1993; 331-339.
• 3. Yeh TS. Issues in unit management and design. In: Pediatric Cricial
Care. Eds. Fuhrman B, Zimmerman J, (St Louis) Mosby Year Book,
1995; pp 51-58.
• 4. Task Force on Guidelines, Society of Critical Care Medicine.
Recommendations for critical care unit design. Crit Care Med 1988;
16: 796-808.
• 5. Committee on Hospital Care and Pediatric Section of the Society
of Critical Care Medi-cine. Guidelines for pediatric Intensive care
units. Crit Care Med 1993; 21: 1077-1086.
• 6. Task Force on Guidelines, Society of Critical Care Medicine.
Recommendations for intensive care unit admission and discharge
criteria. Crit Care Med 1988; 16: 807-808.
• 7. Govil YC. Pediatric intensive care: An overview. Pediatrics Today
1999; 2: 567-570.