Types of Ventilators and Respiratory Support

There are many different modalities of ventilators and respiratory devices in the NICU setting. The risks and benefits should be discussed with your neonatologist, as well as the indication for use on your baby. NICU nurses HEAVILY RELY on our respiratory therapists, since they are the ones who literally “eat, sleep, and breathe” all things related to preemie lungs! Here is my short and hopefully helpful description of the various types of NICU respiratory support:

1. HFOV (High Frequency Oscillator Ventilator) — Provides smaller, faster, but shorter bursts of breaths which may be less damaging to the preemie’s fragile lungs. This type of ventilator helps to reduce the chronic respiratory problems experienced by babies born prematurely by improving carbon dioxide elimination.

2. Various Mechanical Ventilators (Conventional, Drager, etc.) — A machine that helps the baby breathe (via breathing for the baby) when the baby is unable to breathe on his/her own.

3. HFJV (High Frequency Jet Ventilator, “Jet”) — High-frequency ventilators are often used for very small, very sick, extremely premature babies. They breathe much faster than conventional ventilators.

4. CPAP (Continuous Positive Airway Pressure) — A mode of ventilator assistance in which positive pressure is delivered to the airway throughout the respiratory cycle. Constant air pressure is transmitted down into the baby’s lungs, helping them to stay inflated (distended) and eliminating alveolar collapse.

5. SiPAP — A type of non-invasive ventilatory support used in preemies. It provides bi-level nasal CPAP for the spontaneously breathing neonate through the delivery of sighs above a baseline CPAP pressure. These sighs may be timed, at a rate specified by clinicians, or “triggered” by the baby’s own inspiratory efforts. This mode is also used when extubating patients and helps to maintain functional residual capacity, reduce work of breathing, and stimulate the respiratory center.

6. HFNC (High Flow Nasal Cannula) — This is a small plastic tube that goes into the baby’s nose and is humidified with increased oxygen/air potential. The air-oxygen flow (via blender) ranges from 1-6 L/minute. Minimal oxygen support is provided with high pressure.

7. RAM Cannula — A “newer” oxygen delivery device that can be used as an alternative approach to delivering positive pressure. By providing a continuous distending pressure and intermittent breaths, this mode improves tidal volumes, reduces work of breathing, improves oxygenation, and increases carbon dioxide elimination. Due to the increased diameter of the inner nasal prongs, a decrease in airflow resistance is allowed when compared to a traditional nasal cannula.

8. iNO (Inhaled Nitric Oxide) — Improves gas exchange in infants with chronic respiratory failure (persistent pulmonary hypertension of the newborn “PPHN”) through enhanced ventilation-perfusion matching and/or a reversal or extrapulmonary shunting.

9. Oxygen blenders allow the fraction of inspired O2 concentration to be adjusted between 21% and 100%

NICU RTs & RNs… Am I missing anything from the list? What are your thoughts, comments, suggestions, questions, etc.? Isn’t it so incredible how the loud, scary, bulky, ancient ventilators that existed when dinosaurs roamed the earth are the ones that are the most gentle, successful, and effective on the preemie’s tiny, fragile lungs?

Retinopathy of Prematurity (ROP)

Retinopathy of prematurity (ROP) is a potentially blinding disease caused by abnormal development of retinal blood vessels in premature infants. The retina is the innermost layer of the eye that receives light and turns it into visual messages that are sent to the brain. When a baby is born prematurely, their eyes are also underdeveloped. As a result, the retinal blood vessels can grow abnormally. Most ROP cases resolve on their own, however; in severe cases, this can cause the retina to pull away or completely detach from the wall of the eye and possibly cause blindness. 

Out of all the infants born in the U.S. each year, about 14,000 are affected by ROP. Birth weight and gestational age are the most important risk factors for its development. Babies </=1250 grams and </= 31 weeks gestation are at highest risk.

Other factors associated with ROP include anemia, poor weight gain, blood transfusion, respiratory distress, breathing difficulties and the overall health of the infant. Current research suggests that ROP is a complex disease with multifactorial causes including genetic and environmental factors. 

Let’s start from the beginning...

The eye starts to develop at about 16 weeks, when the blood vessels of the retina begin to form at the optic nerve in the back of the eye. The preterm infant’s retina is partially vascularized at about 22 weeks. Ongoing retinal vascular development occurs by angiogenesis (the extension of existing blood vessels by proliferation and migration of endothelial cells). The blood vessels grow gradually toward the edges of the developing retina, supplying oxygen and nutrients. During the last trimester, the eye develops rapidly. When a baby is born full-term, the retinal blood vessel growth is mostly complete (the retina of an infant is not fully vascularized until about 40 weeks). However, if a baby is born prematurely before these blood vessels have reached the edges of the retina, normal vessel growth may stop. The edges of the retina—the periphery—may not get enough oxygen and nutrients.

ROP and Supplemental Oxygen:

Supplemental oxygen used to treat respiratory distress syndrome of prematurity has long been associated with ROP. When ROP was first discovered, the technology to monitor/regulate oxygen did not exist. Throughout the years, technological and medical advances have made it possible to regulate oxygen and detect early forms of ROP. 

Oxygen stresses, such as uncontrolled supplemental oxygen and major oxygen fluctuations can delay vascular development. In ROP, delayed retinal vascularization increases the area of avascular retina and increases retinal hypoxia due to a lack of blood vessels and blood flow. 

HOW IS ROP DIAGNOSED?

Pediatric ophthalmologists diagnose ROP by performing routine bedside eye examinations. They examine the eyes after the RN dilates the pupils with Cyclomydril drops. Tetracaine is administered by the MD as a topical local anesthetic to numb the eyes and prevent pain during the procedure. 

ROP is described by its location in the eye (the zone), by the severity of the disease (the stage) and by the appearance of the retinal vessels (plus disease). 

Stage 0 — normal eye.

Stage 1 — a demarcation line that separates normal from premature retina. 

Stage 2 — a ridge which has height and width. 

Stage 3 — growth of fragile new abnormal blood vessels. 

Stage 4 — partially detached retina.

Stage 5 — completely detached retina and the end stage of the disease.

As ROP progresses the blood vessels may engorge and become tortuous (plus disease).

WHO REQUIRES TREATMENT?

When ROP reaches a certain level of severity, the potential for retinal detachment (and blindness) becomes great enough to warrant consideration of laser treatment. 

Once it is determined that treatment is necessary, there are typically two options:

1. The first method is laser ablation which is applied to the immature portion of the retina. This is the oldest and most common method of treatment. 

2. The second method involves an injection of medication into the eye. These medications may be used as an alternative to, or in addition to, laser treatment. This is a newer treatment and while results have been encouraging, further research is being done to help determine long term side effects and rate of ROP recurrence.

Eyes with retinal detachment caused by ROP generally have a poor visual prognosis. Retinal detachment can be treated with vitrectomy and/or scleral buckling procedure. Despite optimal treatment, some eyes with ROP progress to permanent and severe vision loss.

NICU A-Z Terminology

When I was a new NICU nurse, I was so overwhelmed by the amount of medical "jargon" I needed to learn. And for parents, it can be especially intimidating and confusing. Here is a list of the most common terms used daily in the NICU setting and a short but (hopefully) helpful definition of each.

ABDOMINAL ULTRASOUND

Sound waves are used to produce a picture of the GI tract. The test is simple and painless and is often ordered to get more information about the liver or kidneys.

ALVEOLI

Tiny sacs in the lungs where oxygen and carbon dioxide from the air are exchanged in the bloodstream.

ANEMIA

A condition that occurs when there are less than the normal number of red blood cells in the blood.

ANTIBIOTICS

Medication that kills bacteria and stops/prevents an infection. Commonly used antibiotics in the NICU include ampicillin, gentamicin, ceftazidime, and vancomycin. 

AORTA

The artery (large vessel) leading from the heart that moves oxygenated blood to the body.

ARTERY

Any blood vessel that leads away from the heart and carries oxygenated blood to the body.

APNEA & BRADYCARDIA

Apnea - The cessation of breathing for a short period of time (<20 seconds). This stop in breathing is often linked to a slower than normal heart rate AKA Bradycardia - heart rate <100 beats per minute.

ASPHYXIA

A condition where there has been a lack of sufficient oxygen to the tissues of the body. The brain and the kidneys are the most sensitive organs to a lack of oxygen.

ASPIRATION

Breathing/inhaling a foreign material (such as formula, breastmilk, stomach fluids, meconium, amniotic fluid, etc.) into the lungs.

BACTERIA

A one-celled organism that can use infections in the bloodstream, urine, spinal fluid, lungs, or intestines. 

BAGGING

Filling the lungs with air or oxygen by squeezing a bag which is connected to an endotracheal tube or attached to a mask fitted over the face. This allows us to breathe for the baby when his own breaths are not enough.

BILI LIGHTS (Phototherapy)

Special lights used in the treatment of jaundice; see “Phototherapy and Hyperbilirubinemia”.

BILIRUBIN

A breakdown product of red blood cells. This is a test to check for jaundice by looking at the level of bilirubin in the blood. See “Phototherapy and Hyperbilirubinemia.”

BLOOD GASES (EPOC)

A test that measures the amount of oxygen, carbon dioxide and degree of acidity in the blood. A small amount of blood is taken from the heel (by heel stick), umbilical catheter or from the artery near the wrist where your pulse is felt to test for these levels. This helps assess how well the baby is breathing with or without oxygen support and indicates if any adjustments need to be made.

BLOOD PRESSURE (BP)

The pressure of the blood in the arteries with each pulsation of the heart. It measures the pressure the blood exerts against the walls of the blood vessels. This pressure causes blood to flow through the veins. It is measured in two numbers: systolic and diastolic.

BLOOD TRANSFUSION

This procedure puts blood or blood products from a donor into your baby’s blood. The donor blood comes from a blood bank and has been tested to make sure it is as safe as possible for your baby. The most common reason that a baby may need a blood transfusion is due to anemia. The neonatologist will discuss the procedure with you first and obtain consent before starting any blood products.

BRADYCARDIA

An abnormally slow heart rate.

BRONCHOPULMONARY DYSPLASIA (BPD)

Also known as chronic lung disease. This is lung damage in a baby who is treated with oxygen and mechanical ventilation for a long period of time.

CAPILLARIES

Tiny blood vessels that come into close contact with the body’s cells and supply the cells with oxygen and nutrients.

CARBON DIOXIDE (CO2)

A waste product (not used by the body) created by breathing air. Carbon dioxide is carried by the blood to the lungs, where it is exhaled. 

CARDIOPULMONARY/CARDIORESPIRATORY (CP/CR) MONITOR

A device that tracks your baby’s heart rate and breathing rate. The monitor is connected to your baby with electrodes or leads (sticky pads placed on your baby’s chest and abdomen, or sometimes limbs).

CBC (Complete Blood Count)

A count of the various types of cells present in the blood and helps to identify if a baby has an infection. Red cells (for carrying oxygen), white cells (for fighting infection), and platelets (for prevention of bleeding).

CCS (California Children's Services)

A state agency, operating by county, which assists with medical benefits and ongoing therapies for infants and children who meet certain diagnostic criteria.

CHEM PANEL (BMP, CMP)

A test to measure the levels of different electrolytes in the blood.

CHEMSTRIP

AKA Blood glucose check. This is a test in which a drop of the baby's blood is placed on a strip of special paper to determine the amount of sugar in the blood.

CHEST TUBE

A small plastic tube placed through the chest wall into the space between the lung and chest wall, or between the ribs and lungs. The tube drains extra fluid or air out of the chest to allow the baby’s lungs to expand so that he/she can breathe better. 

CHEST X-RAY (CXR)

A painless way to take a picture of the inside of your baby’s chest allowing doctors to see the heart and lungs to help determine the cause of breathing problems.

CHRONOLOGIC AGE

A baby’s age based on his/her actual birthday. 

CIRCUMCISION

A surgical procedure done to remove the foreskin of the penis. Usually done just before the baby goes home and only on request.

COLOSTRUM

The breast milk produced in the first few days after having a baby. This milk is especially rich in nutrients and antibodies.

CONGENITAL

Existing at the time of birth.

CORRECTED AGE

A baby’s age based on his/her gestation.

CPAP (Continuous Positive Airway Pressure)

A form of ventilator assistance which helps to keep the baby's lungs properly expanded as he/she breathes. CPAP does not breathe for the baby, but allows the baby to breathe into a "wind." This is pressurized air, delivered by a mask or nasal prongs, with or without extra oxygen. 

C-Reactive Protein (CRP)

A protein that is higher when inflammation (swelling) is found in the body. A high level may be suggestive of an infection.

CT SCAN (of the head)

Computerized x-rays which show the size and position of many parts of the brain. A CT scan also can be done on other parts of the body. The baby must go to another area of the hospital to have a CT scan. A series of X-rays are taken from different angles and used by a computer to create detailed images.

CULTURE (Cx)

A laboratory test of blood, spinal fluid, urine, or other specimens which shows if germs are present and which ones they are. This helps to detect the location of an infection. 

CYANOSIS

Blue color of the skin that occurs when there is not enough oxygen in the blood.

DESATURATION

A low level of oxygen in the blood, usually caused by an A/B spell.

DIFFERENTIAL

A test which divides the white blood cell count (from the CBC) into several categories, chiefly: "polys" (short for polymorphonuclear leukocytes), "bands" (immature "polys"), "lymphs" (lymphocytes), "monos" (monocytes), "cos" (eosinophils), "basos" (basophils). The percentages of each cell type may vary in different kinds of infections; for example, polys and bands usually will predominate in bacterial infections, while the number of lymphs usually will increase in viral infections.

DYSPNEA

Difficulty breathing.

ECHOCARDIOGRAM (ECHO)

A test performed to look at the heart using soundwaves through the chest wall. This is much like an ultrasound done during pregnancy and is neither harmful nor painful. This is used to identify heart defects and show how the heart is working.

EDEMA

Fluid retention/buildup in the body tissues that causes puffiness or swelling.

ENDOTRACHEAL TUBE (ETT)

A thin, plastic tube which goes from the baby's nose or mouth past the vocal cords and into the upper trachea (windpipe). This tube allows a breathing machine to directly deliver air and/or oxygen into the lungs.

EXCHANGE TRANSFUSION

A treatment which removes the baby's blood in small quantities and replaces it with donor blood. This procedure is used most frequently to lower the level of bilirubin in the baby's blood. (See also “Phototherapy and Hyperbilirubinemia.”) It also may be used to raise or lower the number of red blood cells, and improve the ability of the blood to clot.

EXTUBATION

The removal of a tube which has been placed through the nose or mouth into the trachea; see ENDOTRACHEAL TUBE.

FEEDING TUBE (NG/OG/GT)

Feedings that are given through a tube that passes through the nose or mouth to reach the stomach. Medications can also be delivered through the tube. A GT (gastrostomy tube) is placed directly into the stomach and sits on top of the baby’s abdomen.

FUNDOPLICATION

A surgery to wrap the upper part of the baby’s stomach around the lower part of the esophagus. This helps to reduce reflux if a baby is having constant emesis. This surgery is permanent and irreversible. 

GASTROESOPHAGEAL REFLUX DISEASE

Occurs when milk is forced up backwards into the baby’s esophagus instead of down into the intestines. This can lead to choking from vomiting or spit-up, apnea and bradycardia, or even an oral aversion due to a negative association with bottle feeding. Treatment may include medication or possibly surgical correction. 

GAVAGE FEEDINGS

Feedings delivered by a small plastic tube placed through the nose or mouth and down into the stomach when the baby is too weak or too premature to suck and swallow from a bottle.

GLUCOSE

The type of sugar that circulates in the blood and is used by the body for energy. A baby’s glucose level should not get too low (hypoglycemia) or too high (hyperglycemia) and will be monitored by the care team.

GRAM

A unit of measurement or a way to measure weight. Your nurse will typically tell you your baby’s weight in grams or kilograms. 454 grams equal one pound, and 1 kilogram equals 1000 grams.

HEEL STICK

A quick prick of the heel with a sterile instrument (much like a finger prick) to obtain small blood samples for tests.

HEMATOCRIT (crit)

A test done to determine if the amount of red blood cells in the blood is adequate.

HIGH FREQUENCY OSCILLATORY VENTILATOR (HFOV)

A special ventilator capable of breathing for your baby at higher rates than a normal ventilator, typically used if a baby requires more help than a typical ventilator can provide.

HYDROCEPHALUS

An abnormal accumulation of cerebrospinal fluid (the normal fluid which bathes the brain and spinal cord) in the ventricles of the brain. This can cause increased pressure inside the baby’s head indicative of a sharp-pitched cry (“neuro cry”).

HYPOGLYCEMIA

A low amount of sugar (glucose) in the blood.

HYPOTENSION

When a baby’s blood pressure is low. Medications may or may not be necessary to treat the low blood pressure.

I:E RATIO

Inspiratory/expiratory ratio. The ratio of the length of the forced breath provided by a ventilator to the length of the time between two breaths.

INFILTRATION (IV Infiltrate)

The slipping of an IV needle out of a vein, allowing IV fluid to accumulate in the surrounding tissues.

INFUSION PUMP

A pump attached to an intravenous (IV) line that provides fluids/nutrition to your baby in measured amounts. The pump can also be attached to a feeding tube that provides milk to your baby.

INTRAVENOUS (IV)

A small plastic tube or hollow metal needle placed into one of the baby's veins, through which fluids, sugar, and minerals can be given when the baby cannot take all of his nourishment by feedings.

INSPIRATORY TIME (IT)

The length of a forced breath provided to the baby by a ventilator.

INTRAVENTRICULAR HEMORRHAGE (IVH)

A collection of blood in and around the ventricles (hollow portions) of the brain. Bleeding inside or around the ventricles in the brain can lead to brain damage. There are four grades (levels) of IVH:

1. Grade 1 - bleeding confined to the tiny area where it first begins

2. Grade 2 - blood is also within the ventricles

3. Grade 3 - more blood in the ventricles, usually with the ventricles increasing in size

4. Grade 4 - a collection of blood has moved within the brain tissue

INTUBATION

The process of inserting an endotracheal tube in the baby's trachea (windpipe). See Endotracheal Tube.

IUGR (INTRAUTERINE GROWTH RESTRICTION)

A phrase used to describe babies who are smaller than they should be for their gestational age. This is usually caused by very low levels of amniotic fluid in utero (oligohydramnios). 

JAUNDICE

A yellow coloration of the skin and eyes caused by increased amounts of bilirubin in the blood. Bilirubin is a break-down product of red blood cells; it is processed and excreted by the liver. It is a common problem in newborn infants and usually occurs during the first week of life. Most cases are mild and may not require treatment. Treatment for jaundice includes phototherapy ("bili lights") and (rarely) exchange transfusion. See also “Phototherapy and Hyperbilirubinemia.”

KUB (Abdominal X-ray)

Stands for Kidney, Ureter, Bladder. This is a painless way to take a picture of the inside of your baby’s abdomen. This allows doctors to see the bowels to help determine the cause of feeding problems. 

LABS

Most babies receive many blood or lab tests while in the NICU. These tests provide the care team with vital information about your baby’s condition. Most tests are performed using a heel stick, meaning your baby’s heel will be pricked with a small needle (lancet). Some specific labs require the nurse to draw blood from a vein in your baby’s arm, hand, scalp, foot, or leg.

LANUGO

The fine, downy, sometimes dark hair that covers the body of the fetus (baby before birth) from about the fourth or fifth month in the womb. This type of hair disappears as a baby reaches full term but is often present in preemies. 

LUMBAR PUNCTURE ("Spinal Tap")

A procedure that tests for an infection in the spinal fluid or to measure the amount of pressure in the spinal canal. A small needle is carefully placed in the small of the back, between the vertebrae (back bones), to obtain spinal fluid for bacterial cultures and other tests.

MECONIUM

The first bowel movements that a baby has which are thick, sticky, tarry, and dark green-to-black in color.

MAS (Meconium Aspiration Syndrome)

The inhalation of meconium into the lungs. If a baby stools in the womb and the stool contaminates the amniotic fluid, the meconium may be inhaled into the lungs, causing significant problems with breathing after the baby is born. 

MENINGITIS

Infection of the fluid that cushions and surrounds the brain and spinal cord.

MRI (Magnetic Resonance Imaging)

A machine that uses a large magnet, radio frequencies, and a computer to create very detailed pictures of your baby’s brain. All metal must be removed from around the baby. The baby must go to another area of the hospital to have an MRI. Sedation may be needed prior because your baby must stay completely still during the test. It provides a more detailed picture than a head ultrasound. 

MURMUR

An extra heart sound that may (or may not) be a sign of heart problems. A murmur is often heard with a patent—or open—ductus arteriosus (PDA). However, some murmurs are normal. A murmur is typically heard with a stethoscope

NASAL CANNULA

A soft, clear, plastic tube which passes under the nose to provide supplemental oxygen/air.

NECROTIZING ENTEROCOLITIS (NEC)

An infection of the wall of the intestines, which may spread to the blood. Premature babies are particularly vulnerable to this disease. NEC is a very serious condition that can be life threatening. Surgery is sometimes necessary to remove damaged intestines, and the baby may need prolonged feeding by vein until he recovers. 

NEONATOLOGY

The medical specialty concerned with diseases of newborn infants (neonates). Neonatologists are pediatricians who have received several years of additional training.

NEWBORN SCREEN (NBS)

A screening for specific genetic diseases in the following groups: metabolic, endocrine, hemoglobin, or other genetic diseases. It is performed within the first three days of the baby’s life, and is MANDATED by the state!

NPO

Nothing by mouth is a term meaning to withhold food and fluids. It is also known as nil per os, a Latin phrase that literally translates to English as "nothing through the mouth.”

OXYGEN SATURATION MONITOR (AKA Pulse Oximetry)

A small probe placed on the finger, hand, wrist, toe, or foot of your baby that painlessly measures the oxygen level in the blood.

PAIN MEDICATION

Your baby’s care team is closely watching for signs and symptoms of pain. If they believe your baby is in pain, they will start with nonpharmacologic measures first to comfort them; these include rocking, holding, swaddling, repositioning, distracting (mobile or music box), or giving your baby a pacifier. Examples of pain medications commonly given in the NICU include morphine, methadone, fentanyl, ativan, and versed. 

PARENTERAL NUTRITION (TPN)

AKA Total Parenteral Nutrition. This is a fluid that contains protein and sometimes fats (lipids) given along with sugars and salts by vein when the baby cannot tolerate complete feedings by nipple or gavage.

PATENT DUCTUS ARTERIOSUS (PDA)

A small vessel which allows blood to bypass the lungs. This vessel is open while the baby is in the womb, but normally closes shortly after delivery. If the vessel fails to close on its own, special medication or surgery may be needed. If it stays patent, it can cause stress to the baby’s heart and lungs over time. See also “Let’s Talk: PDA.”

PEAK INSPIRATORY PRESSURE (PIP)

The highest pressure that is delivered to the baby by the ventilator during a forced breath.

PERIVENTRICULAR LEUKOMALACIA (PVL)

Injury to the white matter (inner part of the brain), usually caused by infection, low oxygen levels, or low blood pressures. This can lead to cerebral palsy and other problems.

PHOTOTHERAPY

A treatment in which the baby is placed under bright lights (frequently blue in color) or on a special light blanket which helps bilirubin to be excreted into the intestine. The light breaks down the bilirubin in the blood so it’s easier for your baby’s body to get rid of it. The nurse will cover the baby’s eyes with a mask to protect them from the bright lights. See also “Phototherapy and Hyperbilirubinemia.”

PICC LINE

A type of central line/central catheter that stands for Peripherally Inserted Central Catheter. A thin, flexible tube is placed in a large vein to deliver medications or necessary fluids and nutrients to the body. PICC lines are usually threaded through a vein in the arm to the vena cava. These types of catheters are indicated when IV therapy, antibiotics, or TPN/Lipids are administered for a long period of time OR if your baby is a really hard stick (has fragile veins that collapse) and a peripheral IV is unable to be inserted.

PKU (Phenylketonuria)

A rare disorder in which one of the amino acids (a building block of protein) cannot be handled normally by the baby, leading to elevated levels in the blood. Babies with PKU require a special diet. All babies are routinely tested for PKU, as well as several other disorders, before going home from the nursery. This test is required by law.

PNEUMOMEDIASTINUM

Leakage of air from the normal passageways of the lung into the space surrounding the heart inside the chest. A pneumomediastinum is usually harmless in itself, but is often associated with a pneumothorax (which can be life-threatening if large). See PNEUMOTHORAX.

PNEUMOTHORAX

Leakage of air from the normal passageways of the lung and is trapped in the space surrounding the lung inside the chest wall, causing a partial or complete collapse of the lung. This condition may require a chest tube. 

POSITIVE END-EXPIRATORY PRESSURE (PEEP)

The lowest pressure that is delivered by the ventilator to the baby between forced breaths.

PROGNOSIS

The outcome that is expected in the future.

PULMONARY HYPERTENSION

Caused when the baby has difficulty pumping blood to the lungs. This limits oxygen entering the baby’s bloodstream and causes the heart to work harder.

PULMONARY INTERSTITIAL EMPHYSEMA (PIE):

Caused when pressure from a ventilator leaks air from the lungs, creating tiny air bubbles that get trapped between the layers of the lungs.

RED BLOOD CELLS (RBCs)

The cells in the blood which carry oxygen.

REFLUX

A return or backward flow; gastroesophageal (GE) reflux occurs when portions of feedings or other stomach contents flow back up into the esophagus. See also: “GASTROINTESTINAL REFLUX DISEASE.”

REGIONAL CENTER

One of a network of state-funded agencies which helps to coordinate community services and resources to infants at risk of having a developmental delay; also provides services and coordination of resources to children and adults with specific developmental disabilities.

RESIDUAL

The contents left inside a baby’s stomach at the starting of the next feeding.

RESPIRATORY DISTRESS SYNDROME (RDS)

A common breathing problem of premature infants caused by insufficient surfactant (a lubricating fluid) in the baby's lung. This results in an excessive stiffness of the baby's lungs and difficulty breathing.

RETINOPATHY OF PREMATURITY (ROP)

A condition of the eye that causes blood vessels to grow abnormally in the retina. Vessels that help the retina develop are one of the last parts of the eye to mature (several weeks after the baby’s due date). Supplemental oxygenation over a long period of time can increase the baby’s risk of developing ROP. Severe cases can lead to significant vision loss, detachment of the retina or blindness. See also “Retinopathy of Prematurity.”

RETRACTIONS

A sign of respiratory distress and that your baby is having trouble breathing. This appears when the chest wall pulls in as the baby uses muscles to breathe. It is often associated with grunting, nasal flaring, and head bobbing.

SEDATION

A medication given to help a baby remain calm, quiet, relaxed, or immobile. Babies may require sedation if they are on a ventilator, have a chest tube, are going for a procedure, have a possible brain injury, etc. They will be gradually weaned off the medication as their condition permits.

SEIZURE

A "short circuiting" of the electrical activity in the brain, sometimes causing involuntary muscle activity or stiffening. There are many causes of seizures. If your child has a seizure, speak with your baby's doctor about this condition and its implications.

SEPSIS

Infection of the blood that affects the baby’s whole body. Sepsis is treated with antibiotics and can be life-threatening if not treated early.

SEPTIC WORKUP

An assortment of tests performed on an infant who is suspected of having an infection. This may include a chest x-ray and/or abdominal x-ray, as well as blood, urine, and spinal fluid cultures. Because infections in babies can progress very rapidly, the baby is frequently started on antibiotics until the results of the cultures are known.

SUCTIONING

The process of removing mucus out of the baby’s mouth, nose, or endotracheal tube through the use of a suction catheter (small tube), neosucker (suction device), or bulb syringe.

SURFACTANT

A material secreted by special cells within the alveoli (air sacs) of the lung, which makes the lung flexible and helps to keep the lung from collapsing. Deficiency of surfactant is the main problem in RDS. Commercial products are available which can be put into the lungs through the tube in the windpipe. These products frequently are very helpful to the premature baby with RDS.

SWALLOW STUDY

A test used to see if the baby can swallow safely and effectively.

SYNCHRONIZED INSPIRATORY POSITIVE AIRWAY PRESSURE (SIPAP)

CPAP with additional higher pressure settings for babies who need more help and support than CPAP can offer. 

TACHYCARDIA

An abnormally fast heart rate that is greater than 180 beats per minute.

TACHYPNEA

An abnormally fast rate of breathing (respiratory rate) that is greater than 60 breaths per minute.

TERM INFANT (Full-Term Infant)

A baby born between 37 and 42 weeks gestation.

TRACHEOSTOMY

A surgical opening in the trachea, below the larynx (voice box) to allow air to enter the lungs; usually done to by-pass a narrowing in the area immediately below the larynx.

TRANSFUSION

Giving donated blood to the baby by vein or artery.

ULTRASOUND OF THE HEAD (Cerebral Ultrasound)

A test performed using soundwaves which shows an image of the brain. The test is not harmful or painful to the baby and may be done at the bedside.

UMBILICAL CATHETER

A small, flexible, plastic tube placed in one of the umbilical (belly button) blood vessels (either an artery or a vein).

VEIN

A blood vessel leading to the heart that carries non-oxygenated blood from the body.

VENTILATOR

Sometimes referred to as a breathing machine or respirator. A special machine connected to an endotracheal tube to help your baby breath by giving breaths and oxygen.

VENTRICULAR SEPTAL DEFECT (VSD)

A hole between the two lower chambers (ventricles) of the heart

VITAL SIGNS

A set of numbers that are obtained every hour in the NICU. These include temperature, breathing rate, heart rate, blood pressure, and oxygen saturation. Nurses are constantly monitoring these numbers and assessing trends. If any become abnormal they will intervene accordingly and take the appropriate/necessary steps. 

WEANING

To take away gradually, often used to describe the process of removing a baby from a ventilator or incubator, or from specific medications (for drips, it may be referred to as titrating).

Who's Who in the NICU?

There are many people involved in the care of your baby. To name a few, your interdisciplinary healthcare team consists of:

Parents — We encourage you to be involved in family-centered care. We believe that you are a critical part of your baby’s health and healing. We encourage you to visit frequently and call often for updates.

Neonatologists — AKA a “NICU doctor” or “Neo.” They are board-certified pediatricians trained to care for newborns who are ill and need special care. They make daily rounds to review your baby’s condition, record information in your baby’s chart and make any necessary changes in their medical care. Your neo may change throughout your baby’s stay to better provide service to and care for your baby.

Pediatric Residents — A medical doctor receiving special training to become a pediatrician. Residents are supervised by senior physicians, like a neonatologist. A residency program is usually three years long. First year residents are sometimes referred to as interns. Third year residents are sometimes called senior residents.

Fellow (in Neonatology) — A trained pediatrician who is receiving additional specialized training in the care of sick newborns.

Neonatal Nurse Practitioners (NNP) — A registered nurse with special training and an advanced degree in the care of newborn babies, especially ill, premature or high-risk newborns.

Registered Nurses (RN) — A licensed healthcare professional who has completed a nursing program. A NICU nurse has specific education and training in the care of premature and sick newborns.

Respiratory Care Practitioners/Respiratory Therapists (RCP/RT) — A licensed healthcare professional who has completed a respiratory care program. NICU RCPs are trained to care for premature and sick infants. 

Lactation (or Breastfeeding) Consultants — An expert who educates and supports patient families and hospital staff related to all things pumping and breastfeeding.

Nursing Assistants (CNAs) — Provides patient care such as recording vital signs, feeding, bathing, changing diapers, and holding babies as directed and delegated by a licensed provider.

Transport Team — A team of RNs and RCPs specifically trained to safely transfer infants from one facility to another by air or ground transportation (ambulance).

Occupational Therapy (OT) — A licensed professional with special training in the care of NICU babies. An OT will help you and your baby with feeding readiness, movement patterns, development, and other sensory and motor skills. They mainly focus on the small/fine muscle groups.

Physical Therapists (PT) — A licensed professional with special training in the care of NICU babies. They will help your baby improve control of his/her large muscles and help with your baby’s developmental needs.

Dietitians (RD/RDN) — A healthcare professional with special knowledge about the nutrients needed for an infant’s healthy growth and development. Dietitians work with the doctor to ensure that your baby is getting sufficient nutrition and is not being over/undernourished. 

Speech-Language Pathologists/Speech Therapists (SLP/ST) — A licensed professional who works to prevent, assess, diagnose, and treat speech, language, social communication, cognitive-communication and swallowing disorders in children.

Social Workers — A licensed professional who specializes in helping you and your family cope with the emotional effects of your baby’s stay in the NICU. Social workers can help with financial resources and home support issues and help you plan for discharge.

Case Managers — Collaborates with the healthcare team and uses available resources to ensure that the care provided meets the desired patient outcome. Case managers also coordinate access to medical equipment, home health nurses, and supplies upon discharge. They interact with insurance agencies regarding medical necessity and length of stay and make referrals to CCS for eligible infants. 

Pharmacist — A specialist who prepares and delivers medications. 

NICU Cuddler — A volunteer who helps by holding your baby when you cannot be here. Cuddlers complete special training to learn how to safely hold your baby. 

Parent Representatives — Promotes family-centered care practices by facilitating family support times, coordinating educational activities, serving as a liaison with community-based referrals and collaborating with the healthcare team to ensure that the needs of parents and families are met.

Radiology Technicians — A specially trained staff member who uses various pieces of equipment to safely take images of your baby for diagnostic purposes.

Radiologist — A doctor with specialized training who interprets and dictates the images taken by the radiology tech to diagnose and treat your baby.

Milk Technicians — A trained staff member who handles and prepares breast and donor milk for infants in the unit.

Healthcare Unit Coordinator (HUC) — Organizes non-patient care activities, provides clerical/secretarial support for the unit and manages patient medical records.

Other specialists that may be on your baby’s care team during his/her stay in the NICU:

ATTENDING PHYSICIAN

A doctor who has the primary responsibility for coordinating the medical care for a patient. In the NICU this will generally be the neonatologist.

CARDIOLOGIST

A medical doctor who specializes in the heart and circulation.

GENETICIST

Physician that deals with heredity, the variation of individuals, prognosis for development and function, and risks of recurrence of genetic conditions.

NEPHROLOGIST

A medical doctor who specializes in disorders of the kidneys.

NEUROLOGIST

A medical doctor who specializes in the brain and nervous system.

OPHTHALMOLOGIST

A medical doctor who specializes in disorders of the eye. He/she will perform ROP exams regularly to screen for, detect, and treat your baby for eye problems.

OTOLARYNGOLOGIST

A medical doctor who specializes in the ear, nose, and throat.

PEDIATRICIAN

A medical doctor who specializes in infants and children.

Phototherapy and Hyperbilirubinemia

Hyperbilirubinemia AKA “neonatal jaundice” is defined as the clinical manifestation in skin and sclera (eyes) of elevated serum concentrations of bilirubin. It is a very common condition and develops in 60-80% of all infants born in the U.S. each year. Usually it manifests during the first week of life. Some cases are mild and may not need any treatment.

Treatment is based on weight and serum bilirubin level and can include:

• Phototherapy (single, double, triple, etc.)

• IV fluids for hydration

• Exchange transfusion (rarely) as indicated

What is jaundice?

A yellow coloration caused by increased amounts of bilirubin in the blood. Bilirubin is a break-down product of red blood cells; it is processed and excreted by the liver. 

What is phototherapy?

AKA “bili lights”, this is a treatment in which the baby is placed under bright blue lights which helps bilirubin to get excreted into the intestines. The light breaks down the bilirubin in the blood so that it’s easier for your baby’s body to get rid of it. The nurse will cover the baby’s eyes with a mask/shield to protect them from the bright lights. The more skin (surface area) exposed to the lights, the more effective the treatment will be. That said, kangaroo care and breastfeeding may be discouraged temporarily in order to avoid removing the baby from the lights until the bili level reaches a normal value.

What is an exchange transfusion?

A treatment which removes the baby's blood in small quantities and replaces it with donor blood. It is indicated in severe cases of elevated bilirubin in order to prevent bilirubin encephalopathy (BE).

Bilirubin encephalopathy is a rare neurological condition that occurs in some newborns with severe jaundice. If the level of bilirubin is very high and not treated, the substance will move out of the blood and collect in the brain tissue if it is not bound to albumin (protein) in the blood. This can lead to serious problems such as brain damage and hearing loss. The term "kernicterus" refers to the yellow staining caused by bilirubin that can be seen in parts of the brain on autopsy.

CCHD Screening

What’s the difference between CHD & CCHD?

Congenital heart disease (CHD) is a problem with the structure of your baby’s heart that is present at birth. It is a very common birth defect. CHD can affect normal blood flow to the heart. Critical Congenital Heart Disease (CCHD) represents a group of severe heart defects that can cause potentially fatal, life-threatening symptoms. This is much more rare and affects approximately 18 out of every 10,000 newborn babies.

What are some signs & symptoms of CCHD?

Although babies with CCHD may appear healthy for the first few hours/days of life, signs and symptoms soon become apparent. These include:

• Pale or blue skin (cyanosis)

• Tachypnea/tachycardia

• Heart murmur

• Fatigues easily

• Sweats

• Fussy and difficult to console 

What is pulse oximetry?

A simple test can help identify if your baby may be affected with CCHD before he is discharged home. This test measures how much oxygen is in your baby’s blood. A baby has to be at least 24-hours old in order for the results to be accurate. 

How is it performed?

This test is completely painless and only takes a couple of minutes. It is performed by placing a probe/sensor on your baby’s right hand (preductal) and either of his/her feet (postductal). The pulse oximeter reads the amount of oxygen in the blood right away.

What if the test is abnormal?

A normal reading equals >95% oxygenation with a difference of <3% between the hand and foot. This is considered “NEGATIVE” for CCHD. An abnormal reading is where the oxygen is <90% with a difference of >3% between the hand and foot. This is considered “POSITIVE” for CCHD and further testing and examining is required.

More information can be found at:

https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/PEHDIC/Pages/Newborn-Screening-for-CCHD.aspx

The Golden Hour

The "Golden Hour" of neonatal life refers to the first hour of postnatal life in both preterm and term infants. This concept includes practicing all of the evidence-based interventions in the initial sixty minutes of life in order to produce better long-term outcomes for the baby.

Neonatologists around the globe stress the importance and benefit of the “Golden Hour” concept in order to significantly reduce hypothermia, hypoglycemia, intraventricular hemorrhage (IVH), bronchopulmonary dysplasia (BPD), and retinopathy of prematurity (ROP) in the preemie population.

NICU nurses have many roles and responsibilities during this critical time window. Here are some examples of the NICU nurse’s bedside tasks during “Golden Hour”:

1. Prepare the bed (isolette or warming table depending on age/weight)

   • Use humidity as necessary per protocol 

2. Turn on and preheat warmer

3. Attach temp probe

4. Place electrodes & pulse oximeter probes

5. Take temp (maintain infant’s temp 36.5-37.5 C)

6. Measurements (head circumference, chest, girth, length, weight) 

7. Suction available (oral & nasal)

8. Oxygenate as needed to maintain sats within target range

9. Intubation supplies (if necessary)

   • Consider surfactant administration if infant requires intubation

10. Obtain a set of vital signs (HR, RR, BP, oxygen sat)

11. Head-to-toe assessment

12. Sacral dimple & skin check

13. Maintain neutral head position of the neonate

14. Collect labs (CBC, type & Cross, MRSA, blood cultures, CBG, glucose)

15. Perform diagnostic images (CXR, echo, etc.)

16. Establish IV access (UVC/UAC)

17. Avoid procedures in the first 72 hours (LP, PICC placement, IV sticks, heel pokes)

18. MD performs neuro exam and checks reflexes 

19. Start antibiotic administration

20. Orient family to the unit as available

21. Eyes & Thighs! (Erythromycin ointment & Vitamin K injection) 

22. Obtain orders

23. CHART!!!

Fellow NICU RNs, am I missing anything from the list? LMK!

MR. SOPA

I am sure you ALL have heard this acronym with your Neonatal Resuscitation Program (NRP) course! NRP emphasizes that when the baby isn’t responding to your resuscitation efforts, use MR. SOPA as your corrective steps for Positive Pressure Ventilation (PPV):

M — Mask Adjustment — Reapply the mask using the 2-hand technique. Ensure it is the right size and fit

R — Reposition airway — Place head neutral or slightly extended 

S — Suction mouth and nose — Use a bulb syringe or suction catheter

O — Open mouth — Open the mouth and lift the jaw forward when bagging

P — Pressure increase — Increase pressure gradually in 5-10 cm H2O increments until visible chest rise is noted, max PIP of 40.

A — Alternative Airway — If all else fails, place an ETT or LMA as your final intervention

Pacifiers: Good or Bad?

The decision whether or not to use a pacifier (AKA paci, soothie, binky, chupi, chupon) is a very controversial topic. Ultimately, the decision is up to you. As a parent, it’s important to make an informed decision by understanding the risks and benefits associated with pacifier use as well as important safety tips.

Most babies have a strong sucking reflex. Sucking on hands and digits is an innate behavior seen both in the fetus and neonate. This non-nutritive sucking (NNS) is now considered part of routine developmental care of the preterm infant. Beyond nutrition, sucking has a soothing, calming effect. And for some babies, pacifiers are the key to contentment between feedings. That's why many parents rank pacifiers as must-haves!

Consider the PROS:

• Soothes a fussy baby. If you have a fussy/colicky baby, sometimes a paci can be a “godsend” lifesaver!

• Offers temporary distraction. A paci may come in handy during and after shots, blood tests or other painful/uncomfortable/stressful procedures.

• Helps a baby fall asleep

• Eases discomfort during flights. Babies can't intentionally "pop" their ears by swallowing or yawning to relieve ear pain caused by air pressure changes.

• Helps to reduce the risk of sudden infant death syndrome (SIDS). NNS at nap time and bedtime may reduce the risk of SIDS.

Consider the CONS:

• Might interfere with breast-feeding. Sucking on a breast is different than sucking on a pacifier or bottle, and some babies are sensitive to those differences. This can lead to nipple confusion.

• Might become dependent. If your baby uses a pacifier to sleep, you might face frequent middle-of-the-night crying spells when the pacifier falls out of your baby's mouth.

• May increase risk of infection. A paci should be cleaned and sterilized on a regular basis because it is placed directly into your baby's mouth. Pacifiers are constantly falling on the floor and getting dirty, which means they are often colonized with bacteria and can cause oral candidiasis.

• Might increase the risk of middle ear infections. AKA otitis media. However, rates of middle ear infections are generally lowest from birth to age 6 months—when the risk of SIDS is the highest and your baby might be most interested in a pacifier.

• Prolonged use might lead to dental problems. Prolonged use might cause a child's teeth to be misaligned or not come in properly, or can cause dental caries (cavities).

Information retrieved from: https://www.mayoclinic.org/healthy-lifestyle/infant-and-toddler-health/in-depth/pacifiers/art-20048140

Car Seat Safety!

Car seat safety is SO important because vehicle crashes are the leading cause of death for children in the U.S. As NICU RNs, one of our jobs is to educate families about how an infant should be properly secured in a car seat. We also check all car seats for expiration dates. YES! Car seats expire! If your car seat has been passed down or has previously been used by an older sibling or family member, there is a chance that it’s expired! And insurance is not going to cover you if “heaven forbid” you were to get in an accident. Also, car seats have a minimum & maximum weight limit, so we make sure that it is the proper fit for each baby before they are discharged.

California State law requires that all parents or legal guardians who are driving with their children must make sure they are safe and secure in an approved child passenger safety seat, booster seat, or safety belt.

NEW: Effective January 1, 2017, California law requires that children ride rear facing until age 2 OR 40 pounds OR 40 inches tall. Rear-facing is FIVE TIMES safer than forward-facing! The AAP recommends that children ride rear-facing until the highest weight or height allowed by the car seat manufacturer.

~Note: You do not need to purchase the most expensive, fanciest, super luxurious, top-of-the line car seat! Anything that is user friendly will suffice :) Some of my favorite brands include Graco and Evenflo!~

What should the infant look like in the car seat?

• The very first thing we tell parents to do is READ THE MANUAL! Parents must always read the car seat manufacturer’s instructions prior to use.

• Place the infant all the way back into the seat, with no excess clothing and no added blankets under the infant.

• The harness should be AT or BELOW the infant’s shoulders when rear facing.

• The harness should be tight, and should not allow any slack. You should NOT be able to pinch excess webbing at the shoulder or hips once the harness is buckled.

• Harness retainer clip should be at armpit level.

• Base of car seat should be secured so that it will NOT move more than 1 inch side to side when checked at the belt path.

• If it did not come with the car seat, do not add it!

• PARENTS SHOULD DEMONSTRATE THE ABOVE STEPS ON THEIR OWN. Nurses are NOT required to place an infant in his/her car seat due to legality reasons. We are not responsible for the failure of the car seat or for improper installation/securement.

Alcohol and Breastfeeding

A very common question that NICU nurses are asked is, “Is it safe to breastfeed my baby if I’ve consumed any alcohol?”

Well, it depends. Not drinking alcohol is clearly the safest option for breastfeeding mothers. In general, though, moderate alcohol consumption (up to 1 standard drink per day) is not known to be harmful to the infant, especially if the mother waits at least 2 hours after drinking before nursing. Drinking alcoholic beverages is not an indication to stop breastfeeding; however, consuming more than one drink per day is not recommended. Alcohol levels are usually highest in breast milk 30-60 minutes after consumption and can be generally detected in breast milk for about 2-3 hours afterward. A good rule of thumb is that if you are sober enough to drive, you are sober enough to breastfeed!

Exposure to alcohol ABOVE moderate levels through breast milk can be damaging to an infant’s development, growth, and sleep pattern. In addition, higher alcohol levels may also impair a mother’s judgment and ability to safely care for her child. Excessive alcohol consumption can interfere with the milk ejection reflex (letdown) and over time, could lead to shortened breastfeeding duration due to decreased milk production.

The alcohol level in breast milk is essentially the same as the alcohol level in a mother’s bloodstream. As the mother’s alcohol blood level falls, the level of alcohol in her breast milk will also decrease. A mother may choose to “pump & dump” milk after consuming alcohol to ease her physical discomfort or adhere to her milk expression schedule, but it will not reduce the amount of alcohol present in her milk any quicker.

What is considered a standard drink?

The Dietary Guidelines for Americans defines a standard drink as:

• 12oz of 5% beer

• 8oz of 7% malt liquor

• 5oz of 12% wine

• 1.5oz of 40% (80 proof) liquor

[All of these drinks contain the same amount of alcohol (14 g or 0.6 oz)]

Cue-Based Feedings

What are Cue-Based Feeds?

Feedings offered by mouth based on your baby’s cues (signs) that he/she is ready and interested in bottle feeding. It is infant driven, flexible, safe, and emphasizes quality over quantity. Feeding readiness is determined by your baby’s hunger and stress behavior and how your baby sucks on the nipple. The goal is to lessen and prevent your baby’s stress while PO feeding. Babies need to learn how to coordinate sucking, swallowing, and breathing, which takes a lot of practice and patience. This typically starts around 32-34 weeks gestation. Cue-based feedings follow the developmental progression of oral motor and sensory skills. Nurses and therapists will work with parents to learn their baby’s hunger signs, stress cues, and techniques to properly and safely feed their baby. 

Common Hunger Signs:

• Bringing their hand(s) to their mouth

• Sucking on their fingers or pacifier

• Being alert, crying and fussing

• Rooting (turning head side-to-side to find the nipple)

• Having good muscle tone

• Opening their mouth (“ooh” face)

Common Stress Cues:

• Crying during the feed

• Yawning often

• Gaze aversion (avoiding eye contact)

• A change in muscle tone (limp and floppy)

• Splayed fingers or “stop sign” hands

• Arching or pulling away from the bottle

• Apnea and/or bradycardia 

• Breathing too fast or too slow

• Facial grimacing

• Gagging/coughing/retching

• Spitting out the milk excessively

• Vomiting

• A change in coordination

• Falling asleep

Newborn Hearing Screen

A newborn hearing screen is a test used as a screening tool for the early identification of hearing loss. This test helps to ensure that all babies who are deaf or hard of hearing (HOH) are identified as soon as possible. HOH infants need the right support, care, and resources to promote healthy development because if it’s not diagnosed early, it may negatively impact the child's academic achievement and social-emotional development.

California State Law requires EVERY baby to have a hearing screen before they are discharged home from the hospital. This includes every NICU and non-NICU baby. Each hospital calls a hearing screen by a different name, and some of these names may include:

1. ALGO — which is the brand name of the machine used 

2. AABR — “Automated Auditory Brainstem Response” assessment

3. OAE — “otoacoustic emissions” exam

Regardless of what it’s called, the screen is performed the exact same way and measures how the hearing nerve & brain respond to different sounds, clicks, and tones. It is completely painless, quick and easy. Different sounds are played through soft earphones that are placed into the baby's ears. The device measures the sound that comes back and the results are displayed on the screen. 

If the device detects a response, the results are displayed as "Pass." If no response is detected, the result is displayed as “Refer.” If a baby refers on one or both ears, the exam can be repeated again and does NOT necessarily mean that hearing loss is present. If the baby refers a second time, this won’t prevent the baby from going home but will require further follow-up and testing with audiology outpatient. 

There are some factors that can cause a false positive for hearing loss. These include:

Vernix in the ear canal

Excessive background noise

Fluid in the middle ear

Improper/poor fit of the ear piece

Movement or crying during the exam

In addition, some medications that are given to babies can cause hearing loss; these include:

NSAIDs such as ibuprofen

Large quantities of aspirin

Loop diuretics intended for heart problems or blood pressure

Certain antibiotics used to treat kidney disease — AKA the “aminoglycoside” group (gentamicin, tobramycin, etc.)

NICU babies are at an increased risk for hearing loss, especially if they have been diagnosed with an infection such as meningitis or congenital herpes, a head injury, or have been exposed to damaging levels of loud noise or secondhand smoke. Hearing is important for a baby’s speech + learning development, which is why early detection & intervention can make a HUGE difference in their communication + language development!

Now take a guess: do you think babies like or hate this little test? Drop your guess in the comments below!

Sudden Infant Death Syndrome (SIDS)

Sudden Infant Death Syndrome (SIDS) is a very scary term and is defined as the death of an infant under one year of age that occurs suddenly and unexpectedly without explanation. SIDS is the leading cause of death among babies between one month old and one year of age. Here we will discuss potential factors that can increase your baby’s risk for SIDS as well as the recommended practices to reduce your baby’s risk for SIDS.

Identified risk factors for SIDS include:

• Prone sleep position

• Sleeping on a soft surface

• Co-sleeping or bed sharing (including co-bedding of twins)

• Maternal smoking during pregnancy

• Second hand smoke exposure

• Overheating

• Limited-to-no prenatal care

• Young maternal age or advanced maternal age

• Preterm birth and/or low birth weight

• Toys, loose bedding, other objects and pillows in the crib

• Formula-fed infant

• Male gender of the infant

• Being African American, American Indian, or Alaskan Native

Safe to Sleep Practices:

• Bed should be flat and mattress should be firm

• Place infant on their back to sleep (tummy time only when awake & supervised)

• Keep soft objects (stuffed animals) and loose bedding, blankets, pillows, etc. out of crib

• Do not use crib bumpers

• Infant should not be swaddled in his sleep area 

• Do not smoke or let anyone smoke around your baby

• Baby should sleep alone in his own crib

Learn more here! https://safetosleep.nichd.nih.gov 

Different Levels of NICU Care

Did you know? 

There are various levels of NICU care! The American Academy of Pediatrics​ categorizes hospitals into four levels based on the care a facility can provide to newborns. The definition of each may vary from state to state or by hospital, but here is a general breakdown of the different levels!

Level I

This type of care is designated for healthy newborns AKA the well newborn nursery. These facilities have the capability to provide neonatal resuscitation at every delivery; evaluate and provide postnatal care to healthy newborn infants; stabilize and provide care for infants born at 35-37 weeks gestation who remain physiologically stable; and stabilize newborn infants who are ill and those born less than 35 weeks gestation until transfer to a facility that can provide the appropriate level of neonatal care. Most neonatal nurses do not have a long career in Level I, as newborn infants often stay in the same room with their mother. Some NICU nurses start out here to learn the fundamentals of a healthy newborn and then transition to a higher level of care.

Level II

This is a special care nursery. This unit can care for babies born at 32 weeks gestation or older (often referred to as moderately preterm) and weigh more than or equal to 1,500 grams. They can stabilize infants born earlier than 32 weeks and those weighing less than 1,500 grams until they can be transferred to a higher level facility. 

These babies have physiologic immaturity or can be moderately ill with problems that are expected to resolve rapidly and are not anticipated to need subspecialty services on an urgent basis. Sometimes babies admitted to this unit are full-term but require close monitoring or intravenous antibiotics after birth.

This level is reserved for newborns delivered prematurely or those with illness, requiring immediate care. These newborns commonly need specialized care due to their prematurity such as intravenous fluid administration, specialized feeding, phototherapy, help with thermoregulation, oxygen therapy, and medications. They usually need time to mature and grow prior to discharge.

Special care (level 2) nurseries may be broken down into:

• Level 2A nurseries which do not provide respiratory assistance

• Level 2B nurseries which provide some respiratory assistance such as continuous positive airway pressure

Level III NICU

A Level 3 NICU can provide intensive care for babies born at almost any gestational age, from "very premature"—babies born at 27 to 30 weeks, and above. All Level 3 NICUs can care for babies born at more than 28 weeks, are able to provide respiratory support for babies who are having trouble breathing and can deliver intravenous fluids to babies who cannot take breast milk feedings. This includes conventional and/or high-frequency ventilation and inhaled nitric oxide. 

Neonatal nurses in this level render care to very sick newborns, often with complex congenital problems. Newborns may need much intense care, such as incubators, ventilators, surgery, and other support equipment. This level of care can provide sustained life support as well as equipment and machinery necessary to care for infants born at all gestational ages and birth weights. In addition, level III NICUs can perform advanced imaging, with interpretation on an urgent basis, including computed tomography, MRI and echocardiography. 

Level IV NICU

This is the highest NICU level, and this unit is well-equipped to care for the most complex and tiniest babies as young as 22 to 24 weeks gestational age. The term "micro preemies" is used to describe babies born between 22-26 weeks of gestation or smaller than 1 pound 13 ounces. Level 4 NICUs can provide very sophisticated types of respiratory support for very sick babies, including extracorporeal mechanical oxygenation (ECMO), surgical interventions, consultations, referrals, and specialties. 

Typically, these NICUs are referral centers. They offer all of the above PLUS surgical interventions, ECMO (heart and lung bypass), and require subspecialty care. This includes consults from various departments such as Cardiology, Cardiothoracic surgery, ENT, Plastics, Genetics, Neurosurgery, Infectious Disease, General Peds Surgery, Pulmonology, Speech/Language/Feeding specialists, etc. In addition, they have the capability of facilitating transport and providing outreach education. 

Retrieved from https://www.floyd.org/medical-services/maternity/NICU/Pages/Levels-of-Neonatal-Care.aspx 

What Does a NICU Nurse Do?

WHAT DOES A NICU NURSE DO?

1. Administers medications that have been prescribed by neonatologists (IV, PO, PR, IM, SQ)

2. Coordinates the plan of care through assessment, diagnosis, planning, implementation, and evaluation of nursing interventions that lead to the established outcomes.

3. Collaborates with ALL ancillary staff and team members assigned to the patient

4. Assists with diagnostic imaging (CXR, ECHO, ultrasounds, etc.)

5. Manages medical treatment at the bedside (phototherapy, silos, pavlik harnesses, etc.)

6. Assists with central line placements and dressing changes

7. Assists with bedside procedures (LPs, intubations, extubations, chest tube placement, etc.)

8. Starts IVs and draws their own labs! (UACs, PICC, venous draws, heel sticks)

9. Manages care of central lines (sterile cap and line changes)

10. Places and manages enteral feeding tubes (NG, OG, etc.)

11. Monitors UOP/Is & Os and inserts and manages urinary catheters as needed (in-n-out cathing, foley catheters)

12. Provides pre-op and post-op care to the infant...Our babies leave directly from & return directly to the NICU before/after surgery.

13. Cares for new surgical sites (tracheostomies, gastrostomy tubes, ostomies, etc.)

14. Serves as the patient’s and parents’ advocate & voices concerns to the respective personnel 

15. Performs all of their own ADLs, assessments, vital signs (feeds, diaper changes, etc.)

16. Supports and encourages mothers with breastfeeding and pumping

17. Educates parents on EVERYTHING and provides emotional support PRN

18. Serves on the forefront of family-centered care by providing ongoing education DAILY and actively involving families in the care of the neonate.

19. Ensures patients and parents are ready for discharge by performing routine vaccine administration (shots! shots! shots!), car seat challenges, medication education, formula/fortification teaching, etc.

Fellow NICU RNs, am I missing anything from the list?!?! LMK!

The "F" Word... Floating!

One of the things I love most about nursing is that there is always variety. Nurses can work in multiple settings and specialties. If you are a new grad or any RN considering what kind of nursing job to pursue, what shift you want to work, or what specialty you are interested in, a position to think about is becoming a float nurse. 

In nursing, “floating” refers to moving from one unit to another. In some cases, nurses who are permanently assigned to a specific unit may be asked to float to another unit because of staffing needs. However, some facilities establish a float pool. In these facilities, nurses are hired specifically to float from unit to unit as staff needs require. Float nurses are utilized on an as-needed or PRN basis in many cases. This makes these positions great for nurses looking for a lot of flexibility; they also are great for new grads not wanting to “lose their skills!”

For nurses, being sent to work on another unit where patient needs are totally different than those usually encountered on their home unit can evoke stress, anxiety, fear, and frustration. Working with an unfamiliar patient population can ultimately threaten patient safety. Interventions may be within the nurse's scope of practice, but not within his or her acquired skill set.

A fantastic benefit of being a float nurse is that you will gather a variety of clinical experiences. Float nurses have the opportunity to work in multiple specialty areas and care for different kinds of patients each day. This helps to develop invaluable clinical assessment skills as well as sharpen skills in communication and teamwork. Float nurses work with a variety of colleagues and grow relationships with fellow staff members all over the facility. If you are a person that likes each day to be different and challenging, being a float nurse is definitely a job to consider!

When even highly competent, experienced nurses are asked to float to a new unit, their anxiety and uncertainty gets communicated to patients nonverbally. In an unfamiliar setting, even a simple task such as gathering supplies may become time-consuming, taking focus away from the patient and conveying disorganization. This directly affects face-to-face contact with the patient, which can in turn compromise quality nursing care. Nurses who lack unit-specific knowledge may not be able to answer patient questions or address patient concerns effectively, which also compromises their credibility and reflects poorly on them and the hospital. Even finding the correct person to ask can be difficult for the float nurse. If patients pick up on the nurse's struggle to adapt to an unfamiliar situation, they may feel unsafe, undermining the nurse–patient relationship. Prioritizing becomes a challenge and the nurse may become consumed with concern about making mistakes.

RNs have the professional right to reject or refuse any patient assignment that puts patients or themselves at serious risk for harm. When an RN is asked to float, that unit must be similar to his or her own and the nurse must demonstrate competencies specific to that unit. Placing float nurses in inappropriate assignments can put patients and healthcare organizations at risk and seriously compromise patient safety and outcomes. Ultimately, it’s your @$$ and your license on the line if you were to make a mistake. Do your behind a favor and CYA!!!

In general, units try their best to orient the float nurse, partner the float nurse with another experienced nurse to serve as his/her resource, and provide verbal and written information on the unit’s policies and workflow. From personal experience, I have found it extremely beneficial to ask the NOC nurse handing off report to me or any nurse for that matter helpful questions such as the location of equipment, healthcare team contact numbers, shift routines, codes to locked doors, specific required unit documentation, safety procedures, and unit-specific protocols. This helps me to feel more confident and less anxious, because there’s nothing scarier than feeling like a fish out of water!

Let's Talk: VSD

What is a VSD?

A ventricular septal defect is a hole in the ventricular septum (muscular wall that separates the right and left ventricles). This opening shunts blood between the ventricles of the heart. Most commonly, oxygenated blood from the left moves to the right because there is greater pressure on the left & the resistance in the lungs is significantly lower than that of the body (systemic resistance). VSDs are the most common form of congenital heart disease. They may be single or multiple, can vary in sizes, and may occur anywhere on the ventricular septum. The severity of the symptoms depends on all of those factors! 

What are the effects of a VSD?

In left-to-right shunting, blood that just came from the lungs (oxygenated) crosses the VSD and returns to the lungs again. This causes increased pulmonary blood flow. A murmur can be heard d/t turbulent blood flow crossing the hole. The smaller the hole, the louder the murmur. 

The following are some examples of signs and symptoms that you may see in an infant with EITHER an ASD or VSD due to increased blood flow, fluid overload, or congestive heart failure:

• Brisk pulses 

• RDS

• Murmur

• Edema 

• Poor growth & development

• Tachypnea and/or tachycardia

• Increased WOB and fatigue

• Sweating

• Restlessness and look of panic 

How is it treated?

Babies can be treated with diuretics such as Lasix and Aldactone. These medications help to reduce the volume of fluid traveling to the lungs, making it easier for the infant to breathe. Blood pressure medications may also be prescribed to help the left ventricle with pumping blood out the aorta in order to reduce blood flow to the lungs. Surgery may also be required to close the VSD. This involves patching or suturing during open heart surgery. 

Necrotizing Enterocolitis (NEC)

Necrotizing enterocolitis (NEC) is a devastating disease that affects the intestine of premature infants. The wall of the intestine is invaded by bacteria, which causes local infection and inflammation that can ultimately destroy the wall of the bowel. This can lead to perforation or rupture of the intestine and spillage of stool into the infant’s abdomen, which can result in an overwhelming infection (sepsis) and death.

Unfortunately, its cause is completely unknown and multifactorial. It is the most common serious surgical disorder among infants in the NICU and is a significant cause of neonatal morbidity & mortality.

Overall, NEC affects between 1-5% of NICU admissions and occurs in nearly 10% of preemies. It affects 1 out of every 2,000-4,000 births. The premature infant has immature lungs and immature intestines. Therefore, any decrease in oxygen delivery to the intestines—because the lungs cannot oxygenate the blood adequately—will damage the lining of the intestinal wall.

One of the first signs of NEC is feeding intolerance. This is often associated with abdominal distention (bloating), discolored belly, bowel loops, bloody stools, and vomiting bile (green). Other clinical manifestations include lethargy, apnea/bradycardia spells, hypotension, & temp instability. The diagnosis of NEC is usually confirmed by the presence of gas or air bubbles in the wall of the intestine on an abdominal X-ray. Dilated bowel and pneumatosis may also be visible. It is most commonly found in infants who are fed formula versus breastmilk.

Initial treatment of NEC consists of:

• Discontinue the feedings and place patient NPO

• Insert an OG tube or NG tube to suction to decompress stomach

• Administer IV fluids for hydration

• Antibiotics

• Perform frequent, serial X-rays of the abdomen

• Infants who respond to this treatment often can resume feeds when signs of the infection have disappeared. This may take one to two weeks. Infants who have more severe disease may require a longer period for the return of bowel function. Infants who do not respond to medical treatment and develop worsening condition or bowel perforation will require surgery.

How is the surgery performed?

At the time of surgery, the surgeon may find portions of the intestine that is frankly necrotic (dead) or perforated. The operation consists of removing the piece of ruptured intestine, and the surgeon tries very hard to preserve as much intestine as possible by removing only the segments absolutely necessary. 

Prognosis:

Most infants who develop NEC recover fully and do not have further problems/complications. A potential residual problem may be malabsorption; there are some infants who lose so much intestine from the infection that they do not have enough intestine left to survive (AKA “short gut”).

Treatment/Prevention:

This includes the administration of probiotic bacteria (lactobacillus) to counteract the effects of the pathogenic bacteria that cause the infection.

Referenced from: https://www.chla.org/necrotizing-enterocolitis

Fetal Circulation

It is important to understand fetal circulation before you can begin to learn about the various complex heart defects that preemies and neonates can be born with.

Here is a quick (and hopefully helpful) description of the Fetal Cardiovascular System:

The blood from the placenta that has been enriched with oxygen and nutrients gets passed via the umbilical vein to the liver. Some of this blood flows through it and some bypasses it via the ductus venosus and travels to the inferior vena cava and then the right atrium (RA) of the heart.

The blood flowing from the superior vena cava into the RA is partially mixed with the oxygen-rich blood from the placenta.

The largest part of the blood from the RA bypasses the right ventricle (RV) and instead flows through the foramen ovale into the left atrium (LA) and then down through the mitral/bicuspid valve into the left ventricle (LV). From the LV, the blood goes into the aorta and into the right and left pulmonary artery (aortic arch), then the descending part of the aorta, and then to systemic circulation. This blood gets returned back to the placenta via the umbilical arteries for gas exchange, waste removal, and nutrients. 

The remaining part of the blood travels from the RA into the RV via the tricuspid valve and into the pulmonary artery (PA). Due to the high pressure in the lungs (vasoconstriction of the pulmonary bed), a large part flows through the ductus arteriosus and goes into the descending aorta and directly into the large systemic circulation. 

Neonatal Cardiac Circulation:

Oxygen-poor blood enters the RA and passes through the tricuspid valve into the RV where it is pumped through the PA to the lungs. As the oxygen flows through the lungs, it gives up carbon dioxide and gains oxygen. Oxygen-rich blood returns from the lungs through the pulmonary veins. It enters the LA and then passes through the mitral valve into the LV, which pumps it through the aortic valve and into the aorta.

PVR decreases and SVR increases:

When the baby takes his first breath, the arterial PO2 increases. Oxygen dilates the pulmonary vasculature causing pulmonary resistance to fall. When the cord is clamped and the placenta is removed, this results in increased systemic vascular resistance. 

Clear? Questions? Comments? Concerns?