NEONATAL INTENSIVE CARE UNIT (NICU)

BY SURENDRA SHARMA

Steps organization of Neonatal Intensive Care

Reorganization of existing neonatal care facilities Developing the units should be
Basic level II High level II Level III

PHYSICAL FACILITIES

The neonatologist and the nurse in charge must be involved while planning the unit.

LOCATION
Neonatal unit should be located as close as possible to the labour rooms and obsteric operation theatre Adequate sunlight for illumination Fair degree of ventilation of fresh air

SPACE
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-theclock 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 babys level

ENVIRONMANTAL TEMPERATURE AND HUMIDITY

The temperature inside the unit should be maintained at 28 +_2C, 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.

STAFF
A 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

NURSES
A nurse : patient ratio of 1:1 maintained thought out day and night is absolutely essential for babies on multi system support including ventilatory therapy. For special care neonatal unit and intermediate care, nurse to patient ratio of 1:3 is ideal but 1:5 per shift is manageable. Head nurse is the overall in-charge In addition to basic nursing training for level-II car, tertiary care requires, staff nurse need to be trained in handling equipment, use of ventilators and initiation of life-support like use of bag and mask resuscitation, endotracheal intubations, arterial sampling and so-on. The staff must have a minimum of 3 years work experience in special care neonatal unit in addition to having 3 months hand-on-training in an intensive care neonatal unit.

OTHER STAFF

Respiratory therapist Laboratory technician Public health nurse or social worker Biomedical engineer Clark

EQUIPMENT
Equipment and supplies should including all that is necessary for resuscitation and intermediate care areas. Supplies should be kept close to the patient station so that nurses do not have to go away from the neonate unnecessarily and nurses time & skills are used efficiently. There should be servo-controlled incubators and open care systems for providing adequate warmth

EQUIPMENT FOR LEVEL III NURSING 6 BED

Sl.No 1 2 3 Item Resuscitation set Open care system Incubators 6 4 2 Nos

4 5 6 7
8

Infusion pumps Positive pressure ventilators Oxygen hoods, oxygen analyzers Heart rate apnea monitors with scope Phototherapy unit

12-18 6 6 6
6

EQUIPMENT FOR LEVEL III NURSING 6 BED

9 10 11 Electronic weighting scale Pulse oxymeters End tidal CO2 monitor 1 6 6

12
13 14 15 16 17 18 19

Transcutaneous PO2 & PCO2

Noninvasive Bp monitors Invasive Bp monitors ECG monitor with defibrillator Intra cranial pressure monitor Portable radiographic machine Portable ultrasound machine Blood gas analyzer

2-3
1-2 1-2 1 1 1 1 1

DISPOSABLE ARTICLES REQUIRED FOR THE NICU IV Catheters IV sets Micro burette sets Bacterial filters Feeding tubes Endotracheal tubes Suction catheters Three-way stopcocks Extension tubing Umbilical arterial and venous catheters Syringes, needles Trocar and cannula

LABORATORY FACILITIES

Microchemistry laboratory Well equipped to provide quick and reliable Facilities for creative protein, total leukocyte counts and microscopic examination of peripheral blood

TOWARDS A GENTLE AND FRIENDLY NICU ENVIRONMENT

It has been realized that physical and social environment of nursery affect the recovery and long term morbidity of the neonate. Attempts should be made to reduce unnecessary noise and light. Avoid excess of light Handling should be gentle Neonates including pre terms feel pain and painful stimuli can cause deleterious physiological responses. Analgesia should be provided during all procedure including ventilation. Parent should be allowed unrestricted entry to the nursery, They should be explained about various tubing and attachments to the baby and should be involved in care of their baby.

INDICATIONS FOR THE ADMINSSION TO NICU

Babies less then 30 weeks Very low birth weight baby of less then 1500 gms Cardiopulmonary monitoring Surfactant therapy Convulsions Severe birth asphyxia Assisted ventilation Total parenteral nutrition Major surgery

LEVELS OF NEONATAL CARE LEVEL I CARE

The minimal care 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. This care can be includes care of delivery, provision of the warmth, maintenance of asepsis, and promotion of breast feeding.

LEVELS OF NEONATAL CARE 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 this care This care s is anticipated for the infants weighing in between 1500 & 1800 gm or having gestational age maturity of 32 to 36 weeks.

LEVELS OF NEONATAL CARE 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.

OUTLINE OF MCH SERVICES

LEVEL I (at village) for low risk mother and neonate. FOR 75% WHERE Home Sub-centre PHC BY WHOM Upgraded PHC, Sub-district District hospitals , nursing homes, medical college hospitals Mother Trained birth attendant Multipurpose worker or ANM Doctors Anganwadi workers. Trained nurses Resident doctors Trained in obstetrics Neonatology and anesthesia COMPONENTS Basis care

II (at sub20% district) for higher risk mothers and neonates .

First referral units Special neonatal care

OUTLINE OF MCH SERVICES

III (in metropolit an centers for still higher risk mothers & infants)

5%

Large hospitals Medical college hospitals and institutes.

Specialists

Sophisticated care given by trained nurses, resident doctors, obstetrician neonatologist, pediatric surgeon, haematologist, radiologist, ultrasonologist & well equipped laboratories.

THE MCH SERVICES DIFFERENT LEVELS Level I Care: Prenatal care: Early detection of pregnancy. Identification of high risk pregnancy. Immunization against tetanus. Nutrition supplements with iron & folic acid. Antenatal assessments at 20,30,34 & 38 weeks of pregnancy. Assessment of pelosis. Early detection of fortal growth failure.

THE MCH SERVICES DIFFERENT LEVELS

INTERNAL CARE :
Proper management of labour and delivery. Adequate support of establishment of respiration oropharyngeal suction and warmth. Identification of low birth weight, preterm birth & malformations requiring immediate correction and their referral.

THE MCH SERVICES DIFFERENT LEVELS

LEVEL II CARE: Prenatal care: This must be offered to mothers at risk identified through the high risk approach or mothers developing complications during pregnancy and / or labour. Intranatal and neonatal care: Deliveries of all at risk mothers must be attended by a trained obstetrician and neonatologist at first referral units. The new-born are expected to get special care for anoxia hyperbilirubinaemia, respiratory distress syndrome and septicaemia.

THE MCH SERVICES DIFFERENT LEVELS

LEVEL III CARE: This level of care is meant for high risk pregnant women & neonates. Low birth weight babies Severe respiratory distress Serve anoxia at birth Shock & metabolic problems Intensive neonatal care unit having a full time neonatologist, trained nursing staff and resident doctors, equipped with biochemical laboratory support, ultra sound, electronic monitory of foetal condition, ventilation and respiratory support, blood transfusion arrangement & monitoring.

SUMMARY
So far we have seen about neonatal intensive care unit, its organization, physical facilities, personnel, equipment necessary, laboratory facilities and level of neonatal are and MCH services available at different level.

CONCLUSION

Thought NICU services require high technology input and expensive one should not lose sight of the human approach towards the fragile and sick babies & their anguished parents. To obtain best results from neonatal intensive care we need a well equipped unit.