The first 28 days of life are the most crucial for survival. While on a global scale neonatal mortality is declining, 54% of the total deaths amongst Europe’s children under 5 occur in neonates. This sheds a light on the importance of adequate monitoring and care at the NPICU neonatal and paediatric intensive care unit.
Local causes of mortality in children under 5 years of age include:
- prematurity
- congenital anomalies
- non-communicable diseases (eg. heart disease, cancer, chronic respiratory disease, and diabetes)
- birth asphyxia (failure to establish breathing at birth) and trauma
- acute lower respiratory infections
- sepsis
- meningitis
The NPICU – Neonatal & Paediatric Intensive Care Unit
Malta’s only NPICU caters for limitless admissions of neonates and children up to 3 years of age, with the majority of these young patients being premature babies (babies born before the 37th week of gestation) and neonates (from birth to 28 days of age).
Classification of care in the NPICU is as follows:
- Intensive Care – 1 or 2:1 care ratio
- High Dependency Care – 1:1 care ratio
- Special Care – 1:2 care ratio
- Nursery – 1:4 care ratio
Apart from being allocated according to experience and training needs, NPICU nurses may need to act as transport team members, Basic Life Support educators, and link nurses.
Why Do Neonates Require Intensive Care?
Maternal Factors
- premature membranes rupture
- multiple pregnancy
- hypertension
- diabetes
- drug or alcohol exposure
- sepsis
- bleeding
- too much or too little amniotic fluid
Delivery Factors
- foetal distress
- birth asphyxia
- breech delivery
- meconium
- nuchal cord (umbilical cord wrapped around baby’s neck)
- ventouse (vacuum cup) / KIWI (most common type of ventouse that does not use a suction machine)
- cesarean
Baby factors
CHANGES AT BIRTH:
- independent breathing
- foetal to neonatal circulation
- metabolic adaptation to thermoregulation, glucose homeostasis, and fluid balance
POST-NATAL CHANGES:
- baby’s lungs become the primary respiratory organs
- lungs’ blood vessels respond to oxygen increase from vasodilation, promoting blood flow to the lungs
- increase in oxygen causes heart ducts to close, leading to neonatal circulation to establish itself
NORMAL CHANGES:
- during the baby’s first breaths, air replaces the fluid within the lung
THERMOREGULATORY CHANGES:
- at birth, intrauterine heat reservoir and heat exchange through the placenta is lost
- following birth, thermal stability is normally achieved independently, as they adapt to the new environment by the non-shivering thermogenesis process
- the newborn baby should be kept warm and dry straight from delivery, since becoming cold causes the brown fat stores to become depleted, leading to neonatal hypoxia and hypoglycaemia
GLUCOSE HOMEOSTASIS CHANGES:
- at birth, the baby stops obtaining glucose from the mother through the placenta, and starts to produce glucose independently, which, following birth, may cause a decrease in the baby’s blood glucose levels
- normally, if kept warm and is fed appropriately within the first few hours after birth, a full term baby is able to control his/her own blood glucose levels within normal limits
FLUID BALANCE CHANGES:
- at birth, fluid balance undergoes significant adaptive changes, including extra-cellular fluid contraction following delivery, where neonates may lose up to 10% of their total birth weight
Premature vs Full Term Babies
Premature babies commonly experience respiratory issues, including:
- respiratory distress syndrome (due to surfactant deficiency)
- chronic lung disease of prematurity (caused by oxygen dependency and persistent inflammatory changes of the lungs past 28 days following birth)
- apnoea of prematurity (due to immature brain stem)
NPICU Admission Guidelines
- 23 weeks-35 weeks or more than 42 weeks gestation
- birth weight of 450g – 2kgs, SGA (small for gestational age) and LGA (large for gestational age)
- respiratory issues – apnoea, cyanotic episodes, need for positive pressure ventilation, concerning respiratory distress, tachypnoea for over 1hr, perinatal asphyxia, and meconium aspiration
- gastrointestinal issues – feeding problems, bile-stained vomiting, signs of obstruction
- infection – sepsis suspicion, herpes, chlamydia, group B streptococcus
- malformations
- congenital heart defects
- infants of mothers with diabetes
- hypoglycaemia
- seizures
- surgical complications
- neonatal abstinence syndrome – conditions caused when a baby withdraws from certain drugs he’s been exposed to in the womb prior to birth
- hyperbilirubinaemia – higher-than-normal amount of bilirubin in the blood, causing jaundice
- monitoring
Monitoring
CONTINUOUS MONITORING of:
- heart rate
- respiratory rate
- arterial blood pressure
- pulse oximetry
- capnography
- cerebral function monitoring
INTERMITTENT MONITORING of:
- blood gases
- serum bilirubin
- blood glucose
- others as needed eg. haemoglobin, electrolytes, etc.
Central Lines
CVCs (central venous cannulas) can be used for longer than PVCs (peripheral venous cannulas). IV treatments as well as higher concentration IV fluids and TPN can be administered via a CVC with less irritation and damage to the veins.
UMBILICAL CATHETERS
A umbilical cord typically has 2 arteries and 1 vein. Catheters are placed into the blood vessel using sterile technique, followed by a confirmation x-ray to determine position.
An umbilical arterial catheter is used for:
- blood sampling
- ABGs
- invasive blood pressure monitoring
- DO NOT ADMINISTER IV FLUIDS IN AN ARTERIAL CATHETER!
An umbilical venous catheter is used for:
- IV fluid administration
- IV treatment
- exchange transfusion
- emergency access during resuscitation
PICC LINE
A PICC line – Peripherally Inserted Central Catheter – is a thread-like tube which is inserted in a small vein and threaded into a larger vein leading to the Superior Vena Cava.
- when handling the baby, the nurse should be extra careful as to not pull the catheter
- infusion lines should be carefully changed on alternate days using a sterile technique
NOTE: Neonatal PICC lines SHOULD NOT be used for blood sampling!
TUNNELED LINES
- a tunneled catheter is a catheter inserted under the skin, exiting on the chest a.k.a. Hickman
- the line is anchored in place by the Dacron cuff, helping to prevent infection
NON-TUNNELED LINES
- femoral line
- jugular
- subclavian
- brachiocephalic
INTRA-OSSEOUS LINES
TIVAD – TOTALLY IMPLANTED VENOUS ACCESS DEVICE
- Totally Implanted Venous Access Devices are only used in older children
- accessed and de-assessed by a certified nurse with a special needle – once needle is in place, it can be used like any other central line
PERIPHERAL ARTERIAL LINES
- used for frequent blood sampling
- provide accurate invasive blood pressure monitoring
- high risk
CENTRAL LINE MONITORING
Central line monitoring is very important since signs and symptoms may be indicating line blockages, vein irritation, thrombus, migration, and CLABSI (central line-associated bloodstream infection). Signs and symptoms that the nurse should watch out for include:
- extremity discolouration
- bleeding
- swelling
- extravasation
- dislodgement
- signs of sepsis
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