Nursing Care of extremely preterm babies in NICU

2. Neonatal Nursing -
Care of the Extreme Preterm
Dr Padmesh V
DM Neonatology

4. • Agenda for today’s talk:
• 1. Introduction
• 2. Resuscitation & Transport
• 3. NICU Care
– Maintenance of Temperature
– Asepsis in NICU
– Glucose monitoring
– Venous access & sampling
– Bundles – IVH , VAP , CLABSI
– Care of a baby on CPAP
– Feeding of an extremely preterm
– Developmentally Supportive Care (DSC)
• 4. Miscellaneous topics

5. • Agenda for today’s talk:
• 1. Introduction
• 2. Resuscitation & Transport
• 3. NICU Care
– Maintenance of Temperature
– Asepsis in NICU
– Glucose monitoring
– Venous access & sampling
– Bundles – IVH , VAP , CLABSI
– Care of a baby on CPAP
– Feeding of an extremely preterm
– Developmentally Supportive Care (DSC)
• 4. Miscellaneous topics

6. • 1. INTRODUCTION
• Why is a neonate different?
• 1. First Cry
• 2. Lungs & Surfactant
• 3. Heart – Transition & PDA
• 4. Developing Brain
• 5. Immature Kidneys
• 6. Intestines – Feed intolerence
• 7. Congenital problems

7. • 1. INTRODUCTION
• Definitions
• PRETERM < 37 WEEKS
• LATE PRETERM 34-37 WEEKS
• EXTREME PRETERM <28 WEEKS
• LOW BIRTH WEIGHT < 2.5 KG
• VLBW < 1.5 KG
• ELBW < 1 KG

8. • 1. INTRODUCTION
• Extreme Preterm – In-utero vs Ex-utero:
FACTOR IN-UTERO EX-UTERO

9. • 1. INTRODUCTION
• ENVIRONMENT:
• LIGHT
FACTOR IN-UTERO EX-UTERO

10. • 1. INTRODUCTION
• ENVIRONMENT:
• SOUND
FACTOR IN-UTERO EX-UTERO

11. • 1. INTRODUCTION
• ENVIRONMENT:
• PAIN
FACTOR IN-UTERO EX-UTERO

12. • Agenda for today’s talk:
• 1. Introduction
• 2. Resuscitation & Transport
• 3. NICU Care
– Maintenance of Temperature
– Asepsis in NICU
– Glucose monitoring
– Venous access & sampling
– Bundles – IVH , VAP , CLABSI
– Care of a baby on CPAP
– Feeding of an extremely preterm
– Developmentally Supportive Care (DSC)
• 4. Miscellaneous topics

13. • Agenda for today’s talk:
• 1. Introduction
• 2. Resuscitation & Transport
• 3. NICU Care
– Maintenance of Temperature
– Asepsis in NICU
– Glucose monitoring
– Venous access & sampling
– Bundles – IVH , VAP , CLABSI
– Care of a baby on CPAP
– Feeding of an extremely preterm
– Developmentally Supportive Care (DSC)
• 4. Miscellaneous topics

14. • 2. Resuscitation & Transport:
• 1. EQUIPMENT CHECKLIST
• 2. TEAM / CALL FOR HELP
• 3. DELAYED CORD CLAMPING
• 4. T  A  B  C

15. • 2. Resuscitation & Transport:

16. • 2. Resuscitation & Transport:

17. • 2. Resuscitation & Transport:

18. • 2. Resuscitation & Transport:

19. • 2. Resuscitation & Transport:

20. • 2. Resuscitation & Transport:

21. • 2. Resuscitation & Transport:

22. • 2. Resuscitation & Transport:
2.5, 3.5, 5

23. • 2. Resuscitation & Transport:

24. • 2. Resuscitation & Transport:
• Delivery Room CPAP

25. • 2. Resuscitation & Transport:
• Transport Incubator

26. • 2. Resuscitation & Transport:

27. • Agenda for today’s talk:
• 1. Introduction
• 2. Resuscitation & Transport
• 3. NICU Care
– Maintenance of Temperature
– Asepsis in NICU
– Glucose monitoring
– Venous access & sampling
– Bundles – IVH , VAP , CLABSI
– Care of a baby on CPAP
– Feeding of an extremely preterm
– Developmentally Supportive Care (DSC)
• 4. Miscellaneous topics

28. • Agenda for today’s talk:
• 1. Introduction
• 2. Resuscitation & Transport
• 3. NICU Care
– Maintenance of Temperature
– Asepsis in NICU
– Glucose monitoring
– Venous access & sampling
– Bundles – IVH , VAP , CLABSI
– Care of a baby on CPAP
– Feeding of an extremely preterm
– Developmentally Supportive Care (DSC)
• 4. Miscellaneous topics

29. • 5. NICU CARE
– Maintenance of Temperature
– Asepsis in NICU
– Glucose monitoring
– Venous access & sampling
– Bundles – IVH , VAP , CLABSI
– Care of a baby on CPAP
– Feeding of an extremely preterm
– Developmentally Supportive Care (DSC)

30. • 5. NICU CARE
– Maintenance of Temperature
– Asepsis in NICU
– Glucose monitoring
– Venous access & sampling
– Bundles – IVH , VAP , CLABSI
– Care of a baby on CPAP
– Feeding of an extremely preterm
– Developmentally Supportive Care (DSC)

31. • 5. NICU CARE: Maintenance of Temperature
• EUTHERMIA: AXILLARY TEMPERATURE : 36.5-37.5 deg C
SKIN TEMPERATURE : 36-36.5 deg C
• HYPOTHERMIA: AXILLARY TEMPERATURE : < 36.5 C
SKIN TEMPERATURE : < 36 deg C
AAP Guidelines:
NICU Room air temperature: 22 to 26 °C
Humidity: 30%–60%

32. • 5. NICU CARE: Maintenance of Temperature
• Ways of Heat Loss

33. • 5. NICU CARE: Maintenance of Temperature
• Ways of Heat Loss : CONDUCTION

34. • 5. NICU CARE: Maintenance of Temperature
• Ways of Heat Loss : CONVECTION

35. • 5. NICU CARE: Maintenance of Temperature
• Ways of Heat Loss : RADIATION

36. • 5. NICU CARE: Maintenance of Temperature
• Ways of Heat Loss : EVAPORATION

37. • 5. NICU CARE: Maintenance of Temperature

38. • 5. NICU CARE: Maintenance of Temperature

39. • 5. NICU CARE: Maintenance of Temperature

40. • 5. NICU CARE: Maintenance of Temperature

41. • 5. NICU CARE: Maintenance of Temperature

42. • 5. NICU CARE
– Maintenance of Temperature
– Asepsis in NICU
– Glucose monitoring
– Venous access & sampling
– Bundles – IVH , VAP , CLABSI
– Care of a baby on CPAP
– Feeding of an extremely preterm
– Developmentally Supportive Care (DSC)

43. • 5. NICU CARE
– Maintenance of Temperature
– Asepsis in NICU
– Glucose monitoring
– Venous access & sampling
– Bundles – IVH , VAP , CLABSI
– Care of a baby on CPAP
– Feeding of an extremely preterm
– Developmentally Supportive Care (DSC)

44. • 5. NICU CARE: Asepsis in NICU

45. • 5. NICU CARE: Asepsis in NICU

46. • 5. NICU CARE: Asepsis in NICU

47. • 5. NICU CARE: Asepsis in NICU
• SKIN CARE BEFORE CANNULATION / PRICKING
• 1. Hand Wash
• 2. Sterile Gloves
• 3. Skin Preparation
DRY DRY
Spirit Povidone Iodine Spirit

48. • 5. NICU CARE: Asepsis in NICU
• There are 3 main skin disinfectants used in neonates
– Chlorhexidine gluconate
– Povidone iodine (Betadine)
– Isopropyl alcohol
• Can cause chemical burns.
• Allow disinfectants to dry for proper action

49. • 5. NICU CARE: Asepsis in NICU
• PRESSURE INJURIES:
• Use hydrocolloid dressing
• Use cotton beneath probes
• Rotate CPAP mask and prongs
• Change pulse oximeter probe regularly
• Avoid leaving BP cuffs on infants

50. • 5. NICU CARE: Asepsis in NICU
• Adhesive Injuries
• Use smallest amount of tape
• Use transparent film when possible
• Use hydrocolloids under tape
• Avoid use of Band-Aids for heelsticks
• While peeling, hold skin surface next to adhesive
• Peel adhesives parallel to the skin instead of straight up

51. • 5. NICU CARE: Asepsis in NICU
• SAFE & ASEPTIC INFUSIONS
• 1. Separate IV bottles for each baby
• 2. Prepare IV Fluids/Parenteral Nutrition under Laminar
Flow
• 3. Use separate peripheral lines for antibiotics/drugs
rather than using central lines (Don’t break the line)
• 4. Scrub the hub with alcohol/povidone iodine
• 5. No unnecessary pricks
• 6. No unnecessary IV lines
• 7. Remove lines at the earliest

52. • 5. NICU CARE: Asepsis in NICU
• SAFE & ASEPTIC INFUSIONS

53. • 5. NICU CARE: Asepsis in NICU
• CLEANING THE ENVIRONMENT

54. • 5. NICU CARE: Asepsis in NICU
• CLEANING THE ENVIRONMENT

57. • 5. NICU CARE
– Maintenance of Temperature
– Asepsis in NICU
– Glucose monitoring
– Venous access & sampling
– Bundles – IVH , VAP , CLABSI
– Care of a baby on CPAP
– Feeding of an extremely preterm
– Developmental Supportive Care (DSC)

58. • 5. NICU CARE
– Maintenance of Temperature
– Asepsis in NICU
– Glucose monitoring
– Venous access & sampling
– Bundles – IVH , VAP , CLABSI
– Care of a baby on CPAP
– Feeding of an extremely preterm
– Developmental Supportive Care (DSC)

59. • 5. NICU CARE: Glucose monitoring

60. • 5. NICU CARE
– Maintenance of Temperature
– Asepsis in NICU
– Glucose monitoring
– Venous access & sampling
– Bundles – IVH , VAP , CLABSI
– Care of a baby on CPAP
– Feeding of an extremely preterm
– Developmental Supportive Care (DSC)

61. • 5. NICU CARE
– Maintenance of Temperature
– Asepsis in NICU
– Glucose monitoring
– Venous access & sampling
– Bundles – IVH , VAP , CLABSI
– Care of a baby on CPAP
– Feeding of an extremely preterm
– Developmental Supportive Care (DSC)

62. • 5. NICU CARE: Sampling
• 1. Use Small veins for sampling
• 2. Plan and club sampling procedures
• 3. Do not break needles for sampling
• 4. Do not apply plaster after sampling
• 5. Umbilical artery line for frequent sampling

63. • 5. NICU CARE: Venous Access- Cannulation
• 1. Spend time in selecting a good vein
• 2. Use Vein Finder /Transilluminator
• 3. No more than 2 pricks at a time  Take a break
• 4. Point of entry into skin should be visible
• 5. Umbilical Venous Catheter – Till 14 days
• 6. PICC Line
• 7. Document time of insertion
• 8. Hub care
• 9. Signs of extravasation

64. • 5. NICU CARE: Venous Access- Cannulation

65. • 5. NICU CARE: Venous Access- Cannulation

66. • 5. NICU CARE
– Maintenance of Temperature
– Asepsis in NICU
– Glucose monitoring
– Venous access & sampling
– Bundles – IVH , VAP , CLABSI
– Care of a baby on CPAP
– Feeding of an extremely preterm
– Developmental Supportive Care (DSC)

67. • 5. NICU CARE
– Maintenance of Temperature
– Asepsis in NICU
– Glucose monitoring
– Venous access & sampling
– Bundles – IVH , VAP , CLABSI
– Care of a baby on CPAP
– Feeding of an extremely preterm
– Developmental Supportive Care (DSC)

68. • 5. NICU CARE: IVH BUNDLE

69. • 5. NICU CARE: IVH BUNDLE
25% of IVH by 6 hours of life.
50% of IVH by 24 hours of life.
Only < 5% IVH after 4 days

70. • 5. NICU CARE: IVH BUNDLE
• 1. Prevent Hypothermia
• 2. Keep head midline for 72 hours
• 3. Head-end raised at 15-25 deg
• 4. Avoid rapid push/flush/pull of samples
• 5. Gentle ventilation
• 6. Minimal Handling/Stimulation

71. • 5. NICU CARE: VAP BUNDLE

72. • 5. NICU CARE: VAP BUNDLE
• 1. Hand Hygiene
• 2. Elevate head-end of bed
• 3. Drain condensate in circuits away from baby
• 4. In-line suction
• 5. Oral care – colostrum swabbing
• 6. Daily evaluation of readiness for extubation

73. • 5. NICU CARE: VAP BUNDLE

74. • 5. NICU CARE: CLABSI BUNDLE

75. • 5. NICU CARE: CLABSI BUNDLE

76. • 5. NICU CARE: CLABSI BUNDLE

77. • 5. NICU CARE: CLABSI BUNDLE

78. • 5. NICU CARE
– Maintenance of Temperature
– Asepsis in NICU
– Glucose monitoring
– Venous access & sampling
– Bundles – IVH , VAP , CLABSI
– Care of a baby on CPAP
– Feeding of an extremely preterm
– Developmental Supportive Care (DSC)

79. • 5. NICU CARE
– Maintenance of Temperature
– Asepsis in NICU
– Glucose monitoring
– Venous access & sampling
– Bundles – IVH , VAP , CLABSI
– Care of a baby on CPAP
– Feeding of an extremely preterm
– Developmental Supportive Care (DSC)

80. • 5. NICU CARE
• CARE OF A BABY ON CPAP:

81. • 5. NICU CARE
• CARE OF A BABY ON CPAP:
• 1. Water level in Water chamber
• 2. Water level in Humidifier
• 3. Probe connections of Humidifier
• 4. Temperature of Humidifier
• 5. Bubbling in Water Chamber

82. • 5. NICU CARE
• CARE OF A BABY ON CPAP:
1. Leaks
2. Condensates
Heated wire circuit

83. • 5. NICU CARE
• CARE OF A BABY ON CPAP:
1. Leak around the interface
2. Retractions
3. Auscultate for bubbling
sounds
4. Nasal injury prevention
5. CPAP Belly prevention

84. • 5. NICU CARE
• CARE OF A BABY ON CPAP:

85. • 5. NICU CARE
• CARE OF A BABY ON CPAP:

86. • 5. NICU CARE
• CARE OF A BABY ON CPAP:
Prevention of Nasal Injury

87. • 5. NICU CARE
– Maintenance of Temperature
– Asepsis in NICU
– Glucose monitoring
– Venous access & sampling
– Bundles – IVH , VAP , CLABSI
– Care of a baby on CPAP
– Feeding of an extremely preterm
– Developmentally Supportive Care (DSC)

88. • 5. NICU CARE
– Maintenance of Temperature
– Asepsis in NICU
– Glucose monitoring
– Venous access & sampling
– Bundles – IVH , VAP , CLABSI
– Care of a baby on CPAP
– Feeding of an extremely preterm
– Developmentally Supportive Care (DSC)

89. • 5. NICU CARE: Feeding of an extremely preterm

90. • TROPHIC FEEDS:
• Trophic feeds are defined as minimal volumes of milk
feeds (10–15 mL/kg/day).
• Start trophic feeds preferably within 24 h of life.
• Exercise caution in extremely preterm, extremely low
birth weight (ELBW), or growth-restricted infants.
• Asphyxia, respiratory distress, sepsis, hypotension, glucose
disturbances, ventilation, and umbilical lines are not
contraindications for trophic feeds.

91. • FEED INTOLERANCE:
• Do not check gastric residuals routinely.
• Isolated green or yellow residuals are unimportant.
• Green residuals could be due to duodenogastric reflux or
overzealous aspiration, which could suck back duodenal
contents .
• Hemorrhagic residuals are significant.
• Abdominal girth is not a reliable measure of feed
tolerance.
• Stool occult blood positive – Not reliable

92. • NUTRITIONAL FEEDS:
• In babies weighing <1 kg at birth,
– Start nutritional feeds at 15–20 mL/kg/day
– Increase by 15–20 mL/kg/day.
• For babies weighing ≥1 kg at birth,
– Start nutritional feeds at 30 mL/kg/day
– Increase by 30 mL/kg/day.
• Aim to reach full enteral feeding (~150–180 mL/kg/day)
– by about 2 weeks in babies weighing <1000 g at birth
– by about 1 week in babies weighing 1000–1500 g

93. • FEED ADMINISTRATION:
Tube Feeds
Paladai/Spoon Feeds
DBF + Paladai Feeds

94. • 5. NICU CARE
– Maintenance of Temperature
– Asepsis in NICU
– Glucose monitoring
– Venous access & sampling
– Bundles – IVH , VAP , CLABSI
– Care of a baby on CPAP
– Feeding of an extremely preterm
– Developmentally Supportive Care (DSC)

95. • 5. NICU CARE
– Maintenance of Temperature
– Asepsis in NICU
– Glucose monitoring
– Venous access & sampling
– Bundles – IVH , VAP , CLABSI
– Care of a baby on CPAP
– Feeding of an extremely preterm
– Developmentally Supportive Care (DSC)

96. • 5. NICU CARE: Developmentally Supportive Care
(DSC)
• ‘Evidence-based interventions that promote newborn
brain and neurobehavior development’
• Main aim: Minimise stress, provide conducive
environment for healing & development.
• Minimise pain

97. • 5. NICU CARE: Developmentally Supportive Care
(DSC)
• 5 CORE MEASURES:
• 1. PROTECTED SLEEP
• 2. PAIN & STRESS ASSESSMENT/MANAGEMENT
• 3. DEVELOPMENTAL ACTIVITIES OF DAILY LIVING:
POSITIONING, FEEDING, SKIN CARE
• 4. FAMILY CENTERED CARE
• 5. HEALING ENVIRONMENT

98. • 5. NICU CARE: Developmentally Supportive Care
(DSC)
• 5 CORE MEASURES:

99. • 5. NICU CARE: Developmentally Supportive Care
(DSC)
• 5 CORE MEASURES:

100. • 5. NICU CARE: Developmentally Supportive Care
(DSC)
• 5 CORE MEASURES:

101. • 5. NICU CARE: Developmentally Supportive Care
(DSC)
• 5 CORE MEASURES:

102. • 5. NICU CARE: Developmentally Supportive Care
(DSC)
• 5 CORE MEASURES:

103. • 5. NICU CARE: Developmentally Supportive Care
(DSC)

104. • Agenda for today’s talk:
• 1. Introduction
• 2. Resuscitation & Transport
• 3. NICU Care
– Maintenance of Temperature
– Asepsis in NICU
– Glucose monitoring
– Venous access & sampling
– Bundles – IVH , VAP , CLABSI
– Care of a baby on CPAP
– Feeding of an extremely preterm
– Developmentally Supportive Care (DSC)
• 4. Miscellaneous topics

105. • Agenda for today’s talk:
• 1. Introduction
• 2. Resuscitation & Transport
• 3. NICU Care
– Maintenance of Temperature
– Asepsis in NICU
– Glucose monitoring
– Venous access & sampling
– Bundles – IVH , VAP , CLABSI
– Care of a baby on CPAP
– Feeding of an extremely preterm
– Developmentally Supportive Care (DSC)
• 4. Miscellaneous topics

106. • 6. MISCELLANEOUS TOPICS:
• PREVENTION OF IATROGENIC ANEMIA:

107. • 6. MISCELLANEOUS TOPICS:
• PREVENTION OF IATROGENIC ANEMIA:

108. • 6. MISCELLANEOUS TOPICS:
• PREVENTION OF FLUID OVERLOAD:
• Subtract Blood products from daily fluid requirement.
• Subtract antibiotics from daily fluid requirement.
• As minimum dilution as needed.
• Dilution in 5% D rather than NS if compatible.
• Calories are more important than volume.
• GIR of 6 mg/kg/min
• Daily monitoring of urine output (Diaper weighing)

109. • 6. MISCELLANEOUS TOPICS:
• ACUTE DESATURATION ON RESPIRATORY SUPPORT:
• D - DISPLACEMENT
• O - OBSTRUCTION
• P - PNEUMOTHORAX
• E - EQUIPMENT FAILURE

110. • 6. MISCELLANEOUS TOPICS:
• COMMONEST DRUG USED IN NICU?

111. • 6. MISCELLANEOUS TOPICS:
• PREVENTING BURNS DUE TO PULSE OXIMETER PROBE

112. • 6. MISCELLANEOUS TOPICS:
• ANTHROPOMETRY MONITORING:

113. • 6. MISCELLANEOUS TOPICS:
• APP FOR EASY USE:

114. • TAKE HOME MESSAGE: