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ORGANIZATION OF A SPECIAL CARE NEONATAL UNIT:

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. Adequate space, availability of running water round- the-

clock, centralized oxygen and suction facilities, maintenance of thermo neutral environment and ready

availability of plenty of linen and disposables is mandatory to provide optimal level 2 newborn cares. Facilities

for management of common neonatal problems viz. perinatal hypoxia, LBW babies, respiratory distress,

syndrome, septicemia, hyperbilirubinemia and life- threatening congenital malformations should be established.

Effective and optimal management of newborn babies at birth, prevention of hypothermia and bacterial

infections and feeding of all babies with human milk should be ensured before establishing neonatal intensive

care facilities. The philosophy of specialized conservative management of high- risk newborn babies should be

fully exploited to bring down the neonatal mortality rate to less than 30 per 1000 live births before intensive

care facilities are launched.

PHYSICAL FACILITES:

SPACE: The size of the unit is related to the expected population intended to be served. In India, about 15 to 20

percent of newborn babies need special care. If the center is to serve as a referral unit for the infants born

outside the hospital, allowance should be made for additional physical facilities and space. In a maternity unit

having 2,000 deliveries per year, facilities for special care of 8 high- risk infants should be available. Each

infant should be provided with a minimum area of 100 sq.ft. Or 10M2. There should be no compromise on

space and its adequacy is crucial for reduction of nosocomial infection. Space should be allocated within the

nursery complex for promotion of breast feeding, expression of breast milk and its storage. The entry of visitors

to this area should be restricted and it should be kept adequately warm. Facilities for maintaining asepsis and

weighing the babies should be available in the transitional care room (TCR).

LOCATION: The neonatal unit should be located as close as possible to the labor room and obstetric operation

theater, to facilitate prompt transfer of sick and high- risk infants. The presence of an elevator in close proximity

is desirable for transport of out born infants. In tropical countries, the nursery should not be located on the top

floor of the hospital but there should be feasibility for the sunlight to peep into the nursery to enhance

brightness and provide ultraviolet rays to augment asepsis.

FLOOR PLAN: The unit facility should preferably be in a square space so that abundant open unencumbered

space is available. A split unit i.e. on either side of the hospital corridor should be avoided for ease of mobility

and for prevention of infections. The walls should be made of washable glazed tiles and windows should have

two layers of glass panes to ensure some measure of heat and sound insulation. Adequate number of deep wash

basins with elbow of foot operated taps, having constant round- the- clock water supply should be provided.

Built- in wall wooden cabinets with foldable covers are useful for stacking purposes. The doors should be

provided with automatic door closers. In addition to the special care area, minimal care and isolation rooms, x-

ray room, laboratory and a procedure room. The growing nursery is used with advantage for education of

mothers in child craft activities and promoting the practice of breast feeding. The cleaning area is used for

sterilization of equipment and for fumigation of incubators in a specially designed vapor proof chamber.

Isolation room is used to nurse potentially infected inborn or out born babies. The obviously infected inborn

with open sepsis should be admitted in a septic nursery, which must be located away from the SCNU and

manned by different nursing and resident staff.

VENTILATION: Effective air ventilation of nursery is essential to reduce nosocomial infections. The most

satisfactory ventilation is achieved with laminar air flow system which is rather expensive. When centralized air

conditioning is used, minimum of 12 changes of room air per hour are recommended. The air conditioning

ducts must be provided with Millipore filters (0.5 u) to restrict the passage of microbes. A simple method to

achieve satisfactory ventilation consists of provision of exhaust fan in a reverse direction near the ceiling for

input of fresh uncontaminated air and fixation of another exhaust fan in the conventional manner near the floor

for air exit. A constant positive air pressure should be maintained in the nursery so that contaminated air form

the corridors does not gain access into the nursery. The use of chemical air disinfection and ultraviolet lamps

are no more recommended.

LIGHTING: The nursery must be well illuminated and painted white or slightly off white to permit prompt

and early detection of jaundice and cyanosis. It is best achieved by cool white fluorescent tubes to provide at

least 100 foot candle, shadow- free illumination at the infant’s level. The number and exact location of fixtures

can be worked out taking into account size of the nursery, height of the ceiling, and availability or otherwise of

sunlight. Spot illumination for various procedures can be provided by a portable angle- poise lamp having two

15 watt fluorescent bulbs which when held at a distance of about one foot from the infant, produce about 100

foot candle intensity of light. In places where electrical failure is frequent and prolonged, the electrical failure is

frequent and prolonged; the electrical system of the nursery complex must be attached to a generator. Exposure

of preterm babies to strong light has been incriminated as a risk factor for the development of retinopathy of

prematurity. The nursery light should be dimmed at night to simulate day- night pattern to promote hormonal

surge and growth of babies.

ENVIRONMENTAL TEMPERATURE AND HUMIDITY: The temperature of the nursery complex must

be maintained around 26 ± 2C in order to minimize effects of thermal stress on the babies. This is best achieved

by centralized air conditioning having temperature control knobs in the nursery. In places where air

conditioning id not feasible, room temperature can be reasonably well maintained in winter by use of radiant

heaters and hot air blowers. Portable radiant heater, infrared lamp or bakery bulb can be used to provide

additional source of heat to an individual infant.

ACOUSTIC CHARECTERISTECS: the ventilation system, incubators, air compressors, suction pumps and

many other devices used in the nursery produce noise. Sound intensity in the nursery should not exceed 75 db to

protect hearing of nursery personnel and infants. Excessive noise may lead to hearing loss, physiological and

behavioral disturbances such as sleep disturbances, startles and crying episodes, hypoxia, tachycardia and

increased intracranial pressure. The fabrication and redesigning of nursery equipment should take into account

the desirability of minimizing noise by dampening the sound by acoustic or other means. It is desirable to have

effective sound proofing of ceilings, walls, doors and floor when a new nursery is designed. Telephone rings

and equipment alarms should be replaced by blinking light. Instead of air compressors, centralized sources of

compressed air, oxygen and suction should be provided. Decibel meter should be installed to monitor sound

effects of meaningful sounds such as gentle music or recording of parent voice should be harnessed to provide

physiologic stability to the babies.

HANDLING AND SOCIAL CONTACTS: Excessive and rough handling of delicate newborn babies is

associated with several adverse physiological consequences such as excessive cryi9ng sleep disturbances,

tachycardia or bradycardia, hypoxia and rise in blood pressure and intracranial pressure. Handling should be

gentle and kept to the barest minimum without compromising care. Soothing words, gentle stroking and rocking

should be practiced after a painful procedure. Gentle caressing, cuddling and touching by the mother are

desirable to provide comfort and confidence to the baby and aid the process of healing. Infants should be

exposed to gentle and soothing tactile, kinesthetic, vestibular, motor, auditory and visual experiences to provide

opportunities for early learning and improvement in behavior. Parents should be allowed unrestricted entry to

the nursery to provide these useful sensorimotor stimuli. It enhances the process of bonding between the baby

and the family.

COMMUNICATION SYSTEM: The nursery complex should be provided with an intercom system so that

additional person can be called for help in case of emergency without leaving the sick infant. A direct line

external telephone is mandatory so that parents have an easy access to inquire about welfare of their infants and

in turn they can be readily contacted whenever needed. Mobiles phones should not be used near the vicinity of

the nursery because the electromagnetic waves are likely to interfere with the functioning of the electronic

equipment.

ELECTRICAL OUTLETS: There should be adequate number (8-12 electrical points at the height of 4-5

feets) of light and power electrical points attached to a common ground. Each infant must be provided with at

least eight electrical outlets. The electrical equipment used in the nursery must be checked at least once a month

for leakage of current and adequacy of grounding. The voltage supply to the nursery should be stabilized with

the help of a voltage servo- stabilizer. There should be round- the- clock power back up including provision of

UPS system for the sensitive equipments.

PERSONNEL:

The survival of newborn babies depends upon the availability of specially trained nurses. The American

academy of pediatrics that one nurse is needed to offer special or intermediate nursing care to 3 babies or

intensive care to one infant. The National Neonatology Forum of India has recommended that at least one

trained nurse should be allocated to provide coverage to four babies in the special care neonatal unit. The

allowance should be kept for additional 25 percent staff to provide for the exigencies of day off and leave.

Therefore, for an 8- bedded SCNU, eight nurses should be sanctioned to ensure availability of two nurses in

each shift along with one additional sister incharge in the morning shift. There must be equal distribution of

nurse in the three duty shifts during 24 hours. The nurses must be imparted continuing in- service training in the

art of neonatal nursing and preventive maintenance of a variety of electronic equipments used in the SCNU. The

unit must have one pediatrician, independent senior resident doctor and one junior resident round- the- clock for

every 8 babies requiring special care. A laboratory technician should be available to operate bilirubinometer,

glucometer, microcentrifuge, CPR kits and blood gas analyzer. The resident staff and nurses working in the

NICU must be trained to properly handle and use the equipment. When ventilator facilities are established

respiratory therapist is a useful member of the neonatal team to monitor ventilator settings, provide tracheal

suctioning and chest physiotherapy. A pediatric pathologist, who is specially trained for conducting and

interpreting neonatal autopsies, is desirable to complement the functioning of the neonatal team.

Conference room

Doctor’s room

Store room

Formula room

Nurse’s room

Nurses station

Scrub gown

x- ray room

lab

Special care room

Proced room

Growing nursery

Minimal care room

Isolation room

Cleaning area

Fumigation chamber

EQUIPMENT:

A neonatal intensive care unit (NICU) can be a confusing place with lots of complicated-looking electronics,

dials, wires, tubes, strange noises, beeps, alarms, buzzers, flashing lights, pressure hoses, and bubbling

cannisters that are confusing to visitors and parents. Here is a sampler of the equipment that is commonly seen

in an NICU. Equipments are very important in NICU, for life saving purpose, sudden care. The maintenance of

the existing equipments in proper working condition is more important than acquiring new and sophisticated

gadgets. Date of installation and expiry of warranty period should be recorded. Photocopies of working and

service manuals should be available in the NICU while original documents should be kept in a safe custody.

Maintain a log book containing postal addresses, telephone and fax numbers of local dealers and suppliers of

equipment.

The equipments listed below:

AIRWAY EQUIPMENT

Pocket mask with oxygen port (should be widely available in all clinical areas)

Self inflating resuscitation bag with oxygen reservoir and tubing (ideally, the resuscitation bag should be

single use – if not, it should be equipped with a suitable filter)

Clear face masks, sizes 3,4 & 5

Oropharyngeal airways, sizes 2, 3 & 4

Nasopharyngeal airways, sizes 6 & 7

Portable suction equipment

Yankauer suckers

Tracheal suction catheters, sizes 12 & 14

Laryngeal mask airways (sizes 4 & 5), or ProSeal LMAs (sizes 4 & 5), or Combitube (small)

Magill forceps

Tracheal tubes – oral, cuffed, sizes 6, 7 & 8

Gum elastic bougie or equivalent device

Lubricating jelly

Laryngoscope handles (x 2) and blades (standard and long blade)

Spare batteries for laryngoscope and spare bulbs (if applicable)

Fixation for tracheal tube (e.g., ribbon gauze/tape)

Scissors

Selection of syringes

Oxygen mask with reservoir (non-rebreathing) bag

Oxygen cylinders

Cylinder key

CIRCULATION EQUIPMENT

Defibrillator (shock advisory module and or external pacing facility to be decided by local policy)

ECG electrodes

Defibrillation gel pads or self-adhesive defibrillator pads (preferred)

Selection of intravenous cannulae

Selection of syringes and needles

Cannula fixing dressings and tapes

Seldinger central venous catheter kit

Intravenous infusion sets

0.9% sodium chloride - 1000 mL x 2

Arterial blood gas syringes

Tourniquet

DRUGS

a) Immediately available prefilled syringes

Adrenaline (epinephrine) 1 mg (1:10,000) x 4

Atropine 3 mg x 1

Amiodarone 300 mg x 1

b) Other readily available drugs      Intravenous medications:

Adenosine 6 mg x 10 Adrenaline 1 mg (1:10,000) x 4

Adrenaline 1 mg (1:1,000) x 2

Amiodarone 300 mg x 1

Calcium Chloride 10 mL of 100mg per mL x 1

Chlorphenamine 10 mg x 2

Furosemide 50 mg x 2

Glucose 10% 500 mL x 1

Hydrocortisone 100 mg x 2

Lidocaine 100 mg x 1

Magnesium Sulphate 50% solution 2 g (4 mL) x 1

Midazolam 10 mg x 1

Naloxone 400 mcg x 5

Normal Saline 10 mL ampoules

Potassium Chloride for injection (See NPSA Alert)

Sodium Bicarbonate 8.4% - 50 mL x 1

     Other medications / equipment:

Salbutamol (5 mg x 2) and Ipratropium Bromide (500 mcg x 2) nebules Nebuliser device and mask

GTN spray

Aspirin 300 mg

ADDITIONAL ITEMS

Clock

Gloves/Goggles/Aprons

Audit forms

Sharps container and clinical waste bag

Large scissors

Alcohol wipes

Blood sample bottles

A sliding sheet or similar device should be available for safer handling

RESUSCITATION EQUIPMENT: emergency tray should be available in each infant care room of SCNU

containing Ambu bag and mask, infant laryngoscope, tracheal tubes of different sizes, sterile suction catheters,

oral mucus suction traps, and emergency drugs.

Bag and mask resuscitator: self inflating bag of 250- 750 ml capacity is ideal for resuscitation of a newborn

baby. It should be provided with a pop off valve or with facility to attach a pressure gauge. An oxygen reservoir

in the form of a corrugated tube to rubber bladder, help to increase the oxygen concentration to 90 to 100

percent. When self- inflating bag is used without an oxygen reservoir, it delivers 40- 60 percent oxygen because

room air enters the bag with each inflation. A one way valve allows delivery of oxygen at the bag is released so

that the exhaled air cannot re- enter the bag. A peep valve can be attached to the valve assembly to deliver

required PEEP. 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) affixed on the wall is ideal. De Lee trap for a single use by self oral suction with 12 Fr. In hospitals,

centralized suction, venture suction and electrical suction machines are used. The suction pressure is regulated

with a pressure dial. Facility should be available for intermittent suction because continuous suction may cause

bradycardial and mucosal damage. The suction pressure should be limited to 60- 80 cm of water (1.0 mmHg =

1-3 cm of H2O). Slow suction devices are used for continuous suction of chest cavity and upper pouch of

infants with esophageal atresia.

Catheters, syringes and needles: Nasogastric polyethylene feeding tubes (Fr. 6and 8), suction catheters,

umbilical vein catheters, small- vein infusion sets (G 23), medications (neoflon), and exchange transfusion sets

should be there in NICU. They are prepacked sterile by a process of gamma- irradiation. This should not be

reused after boiling. Only autoclaved syringes and needles should be used. The availability of liberal supplies of

disposables is crucial for reduction of nosocromial infection.

Feeding equipment: Glass or stainless steel bowls of adequate size (120 ml capacity) 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 sterilizer should be provided for autoclaving feeding equipment. Storage facility like a refrigerator

should be available in the nursery. The formula room should be equipped with working shelves having

laminated plastic surfaces or preferably these should be made of stainless steel so that can be washed and

cleaned.

Laminar flow system: These systems are useful for safe and aseptic formulation and mixing of drugs,

parenteral aggregate filter is used to filter out bacteria.tow types of system are available. Ina vertical type

system, the air flows from above downwards and it is recommended for use in the NICU. The horizontal flow

type system is used for tissue culture and microbiologic techniques. Ultraviolet light source in chamber is kept

on for 30 minutes before use to make the area of operation free of bacteria. The vertical flow of bacteria- free

filtered air maintains a positive pressure of 15 mm Hg to prevent entry of contaminated air into the chamber.

Weighing machine: Accurate weight record of babies is a sensitive index of their well being and availability of

a sturdy and reliable weighing machine fulfills a fundamental need. A sensitive beam- type weighing scale with

a precision of +/- 10g is useful equipment in the nursery. The change of cross infection should be minimized by

using a sterile paper or a towel over the pan before weighing each infant. Electronic weighing machine also

available.

Bassinets: A variety of bassinets are available for routine use in the nursery. It is desirable to use bassinets,

which can be easily cleaned and are equipped with a locker and head tilting mechanism. The locker can be used

to hold the supplies of an individual baby such as diapers, frocks, sterile gauze, cotton, thermometer, feeding

equipment and drugs etc. plastic Plexiglas’s or fiberglass bassinets with relatively low walls and placed at a

convenient height are desirable for ease of observation and examination of the infant. They can easily clean and

disinfected by antiseptic solutions. Alcohol or organic solvents should not be used to clean the elastic or

Plexiglas’s material due to risk of opacification.

Thermometers: Low reading (30-40° C) rectal thermometer is essential to assess the severity of hypothermia.

The severity of hypothermia in small babies may overlook if only conventional thermometers are used.

Electronic or tele thermometers with skin censors or rectal probes with an accuracy of ± 0.1° C are ideal for

continuous atraumatic monitoring of body temperature. These temperature monitors are also equipped with

acoustic and visual alarms set at a desired low and high temperature. Simultaneous monitoring of core and toe

temperature can provide useful information regarding state of peripheral perfusion.

Oxygen concentrator: oxygen concentrators are being indigenously manufactures and they work both on a

battery and mains. The atmospheric air is passed through a chemical which absorbs all gases except oxygen.

Oxygen air blender with an oxygen analyzer can be interposed to deliver a precise concentration of FiO2 but it

considerably enhanced the price of the device. Oxygen must be warmed (36.0- 36.5° C) and humidifier before

administration to the patient.

Oxygen head box: A square shaped box made of transparent or Perspex which can enclose the head of the

infant is useful for administration of higher concentration of material moulded as a single piece without any

joints. It should provided with an adjustable neck port or flexible occluding collar to create an effective seal to

prevent free entry of environmental air.

Oxygen analyzer: This is useful for monitoring ambient oxygen concentration in order to protect the infant

against oxygen toxicity. It helps to regulating the flow rate of oxygen so that desired concentration of oxygen is

delivered to the infant depending upon his clinical condition and oxygen requirements.

Perspex heat shield: heat shield made of perspex or transparent plexiglass measuring 18”×10” ×8” in a dome

shape is a very simple and useful device to reduce the heat loss by radiation and evaporation. The currently

available intensive care incubators are double- walled, which are credited to reduce radiative heat loss by 50

percent.

Radiant warmers are used when a baby is very unstable or extremely premature.

Small babies have a large surface area compared to their volume, and little

body fat, and cannot maintain their own temperature. The overhead arm

contains electric heating elements that are directed down toward the infant. A

thermostat is hooked up to a sensor on the baby's abdomen and adjusts the

power of the warmer up and down dynamically so that it delivers whatever heat

is necessary to keep the baby at the perfect temperature. The shelves attached to

the warmer allow monitors and other equipment to be placed conveniently near

to the baby, the glass side walls prevent the baby from being chilled by drafts,

and the open nature of the radiant warmer allows physicians and nurses to have

easy access to the baby from all sides during the most critical periods.

When a baby is relatively stable but still premature or requiring intravenous

fluids or other special attention, he or she is cared for in an "incubator." The

incubator keeps the baby warm with moistened air in a clean environment, and

helps to protect the baby from noise, drafts, infection, and excess handling.

Incubators were invented in France in the late 1800's and the earliest incubators

were, in fact, modeled after poultry incubators -- hence their name. Incubators

are sometimes called "isolettes," but "Isolette" is actually a brand name for a

particular company's incubator product. You'll see many varieties of incubators

in NICUs but whether they are flashy or plain, colorful or austere, they all do

basically the same job.

The scale is one of the most humble yet one of the most important pieces of

equipment in the NICU. Every feeding, IV solution, and medication is

calculated and based on the baby's weight, and it's critically important that the

weight be accurate, up-to-date, and readily available at all times. It's part of the

morning ritual in every NICU to weigh each baby at the same time and in the

same way each day, and then chart the weight on the baby's flowsheet. The

weight is carefully corrected for the weight of the diaper and any equipment

that is attached to the baby, as well as the clean piece of paper that the baby lies

on during the weighing. It is typically recorded in grams and is accurate to

within 5 grams. Note that one pound = 454 grams.

A physiologic monitor, sometimes called a cardiorespiratory monitor, is

attached to sensors on the baby and provides a constant read-out of the baby's

heart rate and rhythm, breathing rate, arterial or central venous pressure, and

other useful information. Alarms can be configured to provide an alert when

any of the vital signs being monitored goes above or below a certain limit.

Monitors come in a huge variety of shapes, sizes, configurations, and the most

recent models contain embedded computer systems that are capable of filtering

out false alarms, recording and reviewing data for extended periods, performing

some degree of trend analysis, and many other sophisticated functions.

The pulse oximeter, or "pulse ox," monitors the oxygen saturation of the baby's

blood. It does this by shining light through the baby's skin and measuring the

color of the light that is transmitted. Most of you are familiar with the concept

that red blood is arterial and blue blood is venous; this is another way of saying

that blood which is being pumped by the heart from the lungs to the body and

has a lot of oxygen in it is red, whereas blood that is returning to the heart

through the veins after oxygen has been removed by the body's tissues is blue.

By measuring the transmitted light at certain colors very precisely, the pulse

oximeter can provide an estimate of how much oxygen is in the blood. The

pulse oximeter can be fooled, however, when the flow of blood to the hands

and feet is poor, such as when the baby is cold, or when the baby's blood

pressure is low.

The "Dinamap" takes the baby's blood pressure at programmed intervals. It

inflates a plastic cuff around the baby's arm or leg, exactly like a nurse or

doctor taking a baby's blood pressure manually.

Infant ventilators (respirators) breath for the baby when the baby is too sick or

too weak to breath for itself. There are many different types and brands of

ventilators in use in NICUs; the one shown here, the Sechrist 100B, was

popular in the 1980's and is still in common use today.

Recent models of infant ventilators are heavily computerized and support

diverse modes of operation, including "assist control." Some models can

provide real-time data on the baby's pulmonary function.

An "oscillator," or "high frequency oscillatory ventilator" (HFOV), is a new

type of ventilator that came into use in the 1990's. The equipment shown here is

the Sensor-Medics 1000A, a popular brand. Unlike traditional ventilators,

which essentially inflate and deflate the baby's lungs like a set of billows, the

oscillator keeps the lungs open with a constant positive end-expiratiory pressure

("PEEP") and vibrates the air at a very high rate (up to 600 times per second).

The vibration helps gases to quickly diffuse in and out of the baby's airways

without the need for the "bellows" action which may damage delicate lung

structures. Although oscillators are not appropriate for every disorder and

situation, there is no doubt that because of their incredible power, oscillators

have made it easeir to care for the very sickest babies with certain types of lung

problems.

A "blender" mixes pure oxygen and air (or other gases) in precise ratios and

delivers the resulting mixture to the baby. The mixture is adjusted based on the

level of oxygen in the baby's blood, measured by pulse oximeter or blood gas

machine. Blenders are typically attached directly to ventilators, but may also be

used in a stand-alone configuration -- as shown here -- when a baby is receiving

oxygen during a resuscitation or by face mask or is in an oxygen "hood." The

orange box and water cannister attached about half-way down the pole heat and

humidify the gas mixture before it is delivered to the baby.

IV pumps, or infusion pumps, are a crucial item of equipment in an NICU.

Most sick babies have one or more intravenous (IV) or arterial lines, and the

fluid that is delivered through those lines must be very carefully regulated, all

the way down to the amount of 0.1 cc per hour (about 1/30 of a teaspoon per

hour). There are many brands, sizes, and shapes of IV pumps; the pump shown

here is called an IVAC.

Phototherapy lights, or "bili lights," are used when babies are jaundiced

(yellow). Some degree of jaundice, which is caused by the presence of a

molecule called bilirubin in the blood, is common and even normal in

newborns. However, in sick infants, jaundice can result from a variety of

problems, and when jaundice is extreme it can cause brain damage. During the

1970's, it was discovered that certain wavelengths of light (in the blue part of

the spectrum) can cause a chemical reaction that converts bilirubin into a

harmless form as blood passes through the skin. It's important to note that bili

lights do not deliver any ultraviolet light, so the babies are not in any danger of

sunburn or other toxic effects. However, as a safety measure, the babies' eyes

are usually shielded with a cloth covering when they are under bili lights.

A drainage pump may be hooked up to a naso-gastric (NG) tube or to other

tubes in order to keep secretions from accumulating in the stomach or to drain

other areas when the infant is very sick. These pumps can be adjusted to

provide constant or intermittent suction.

A blood gas machine analyzes a sample of the baby's blood, usually obtained

from an arterial catheter or from a "heelstick," and reports the pH and the level

of oxygen and carbon dioxide. It also calculates values for the bicarbonate

level, oxygen saturation, base deficit, and so on. These values are then used by

the neonatologist, nurse practitioner, or respiratory therapist to adjust the setting

of the ventilator and the oxygen blender. It was not practical to do blood gas

tests on babies until the 1970's, when simple techniques for umbilical arterial

catheterization were developed and blood gas machines appeared that could

perform tests on "micro-samples." Today's blood gas machines can perform a

complete analysis on less then 0.2 cc of blood (less than 1/10 of a teaspoon).

The "lightbox" is the traditional tool for viewing X-rays. Essentially, it's just a

big metal frame with backlights and a translucent plastic face. X-rays are

clipped onto the front of the lightbox and can then be viewed and interpreted by

transmitted light.

In the modern, digital era, films are read on-line and the images can be

manipulated through software to aid interpretation -- the contrast and brightness

can be manipulated, the image can be flipped or rotated, edges can be

enhanced, areas of interest can be enlarged, old images can be retrieved from

disk storage and compared with the new images, etc. Most importantly, an

image can be viewed in more than one place at a time, the neonatologist does

not need to wait for film to be "developed," and each image is stored and

backed up electronically so it cannot be misplaced in the radiology file room or

borrowed and lost.

A transport incubator is used when a sick or premature baby is moved from one

hospital to another -- for example, from a community hospital to a larger

medical center that has a neonatal intensive care unit. In fact, a transport

incubator is like a little self-contained intensive care unit on wheels. It usually

has a miniature ventilator (respirator), cardio-respiratory monitor, IV pump,

pulse oximeter, and oxygen supply built right into its frame. A specially-trained

physician, nurse, and respiratory therapist typically accompany the baby

fhroughout the trip.

A defibrillator is used to "shock" the heart from an abnormal rhythm pattern

back into a normal rhythm. Every neonatal ICU has one of these devices, but

they are rarely used there. Abnormal heart rhythms are quite unusual in babies,

even those babies with several cardiac abnormalities -- arrhythmias are more

typical of aged patients with damaged heart muscle or conduction pathways.