Challenges Of Neonatal Intensive Care

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Challenges Of Neonatal Intensive Care

• O N Bhakoo
• MD, FAMS
• FIAP, FNNF
• Ex. HOD Pediatrics Neonatology
• PGIMER. Chandigarh

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Challenges OfNeonatal Intensive Care

• Normal Neonate
• High Risk Neonate
• Principals of Management
• Facilities required
• Improving quality of Care
• Reducing cost of Care
• Enhancing Patient Satisfaction
• Net working for neonatal care
• Summary

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NORMAL NEONATE

• Born at full term
• Birth weight above 2.5 kg
• Appropriate wt for G.A.
• Free from perinatal complications (BA)
• Free from Cong. malformations
• Asymptomatic
• Normal vital signs.
• Needs ordinary care by the mother
• L- I Care

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High Risk Neonates needing special care

• Level II SCBU / PMN
• LBW lt 2000gm.
• Preterm lt 34 wks.
• Moderate BA, HIE-1
• Moderately sick needing
• monitoring
• iv fluids, Oxygen,
• Phototherapy
• exchange transfusion

• Level III NICU
• VLBW lt 1500gm
• lt 32 wks.
• Severe BA HIE II or III
• Extremely sick with system failure.
• Needing-
• Intensive monitoring. Assisted ventilation.
• TPN.
• Post operative care.

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Management Principals for HRBs

• Objective. Survival without brain damage
• Thermo neutral environment
• Adequate nutrition incl.TPN.
• Monitoring- Vitals, Oxygen, ventilation BP.
  biochem.
• parameters, drug level.
• Assisted Ventilation, Rx Shock. Renal failure
  etc.
• Preventing complications HAI, NEC,
  Malnutrition, BPD, ROP, Deafness, Brain damage

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Facilities required

• A- SPACE 50 sq ft./ Pt L- II Care
• 100sq ft./Pt L-
  III
• B EQUIPMENT
• - Electronic weighing scale one for each unit..
• - Open care system
• or baby incubator
• - Vital sign monitor L II gt
  0.2 per bed
• - BP monitor
• - Apnea monitor
• - FiO2 monitor
• -SaO2 monitor L- III
  gt 1 per bed.
• - Resusc Kit.
• - Infusion pump
• - Infant ventilator

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Facilities Required / Equipment (cond 2)

• For Level- III Units Only
• Cold light source
• End tidal Co2 monitor monitors
• TcPO2 and TcPCO2 monitors
• ECG monitor with defibrillator
• Invasive BP monitor
• Intracranial pressure monitor
• ABG machine
• Portable X Ray Machine
• Portable Ultrasonography machine

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Facilities Required- ( cont-3)

• C LABORATORY FACILITIES
• Microchemistry Microbiology
• hematology Drug Monitoring
• D Pt Care Team
• Neonatologist, Nurses ( 41 )
• Resp. therapist, Nutritionist,
• Physiotherapist, Biomed. Engineer
• Perinatologist, Ped.Surgeon.
• Ophthalmologist, Audiologist.
  ,Developmental Pediatrician

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Facilities Required (cont. 4 )

• E - NEONATAL TRANSPORT-
• with facilities for
• Warming Transport Incubator
• Resuscitation and Asst. Ventilation
• ( portable ventilator)
• Monitoring
• Oxygen. Supply.

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Improving Quality Of Care

• .1. HAI.-
• Protocols for infection control.
• Continuing audit for infection.
• Units antibiotic policy Review
• .2.- Ongoing audit of Pts medical and Nursing
  records with spl. ref. to NEC,BPD. ROP, brain
  hemorrhage from preventive point of view.
• .3 Fatal outcome- Cause of death Lessons
• .4. Follow up of NICU survivors Protocols.
  Neurodevelopment ROP, deafness.
• .5. Compare your intact survival with other good
  NICUS

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Reducing cost of Care

• 1. Full utilization of facilities.
• - Equipment on rent / sharing with other
  units
• - Regionalization of Care
• 2. Shift to L- II care as soon as L- III care is
  not required.
• 3. Early discharge home Involve the mother in
  care
• 4. Reduce duration of hospitalization by
  preventing factors which prolong hospital stay
  eg. HAI, malnutrition, Ass. Ventilation.
• 5. Health insurance for NIC.

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Enhancing patient Satisfaction

• 1. High cost of care increases pt. expectations
  and hence the accountability of care provider.
• communication is the most sensitive aspect of
  NIC.
• 2. Keep family well informed about changing
  condition of the pt. Possibility of compromised
  outcome demands counseling truthfully yet with
  sensitivity, compassion and guarded optimism
• 3. Proper communication reduces the chances of
  litigation. Always keep proper records about pt.
  progress and the communications with the family.

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Net working in NICU

• This involves Out- reach Education and
  Regionalization of
• neonatal care.-
• 1. Out reach education means need based
  continuing education and training of the medical
  staff of peripheral units from where pt. are
  referred for L-III care. This is done by the
  staff from L-III unit.
• Topics of CME may be related to Cl. problem faced
  during the preceding month.
• 2. Regionalization means coordination of
  neonatal care between
• L-I, L II, L-III units in a small geographical
  area with about 20,000 deliveries per year. This
  system makes optimal utilisation of neonatal care
  facilities. Where ever implemented, it has lead
  to improved quality of care and reduced cost of
  care.

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Summary (Challenges of NICU)

• 1. NIC attempts to serve very sick and very small
  neonates without brain
  damage
• 2. NIC. Involves elaborate and expensive
  facilities and a dedicated team of
  administrators, doctors, nurses and
  technologists.
• 3. The challenges of improving the quality of
  care while keeping the cost affordable is not
  insurmountable. Out of reach education and
  Regionalization of care helps in achieving this
  goal.
• 4. Proper counseling of the family of a sick
  neonate is a continuing learning experience.