Neonatal Intensive Care an update

Dr.S.Boopathi MD, DNB Paediatrics(AIIMS), MRCPCH(UK)Fellow Neonatal Medicine, University Hospital Wales, UK

Evolution of Neonatal care and NICU1900s- IMR 250-300/1000 live birth

1950s :More insight into newborn physiology and the normals

1970 s :Antenatal steroids; 1980 :Use of surfactants

Applying technology to save lives- Advanced Ventilators, Drug delivery devices, Monitors, point of care investigations, microsampling and assay techniques etc etc

1990s The Decade of Microprimies

•Protocol based NEONATAL care. Structured and mandatory training in Newborn resuscitation, and other key areas, Specialized nurses trained in Newborn care

2000s to present

•In utero transfer and centralized care for sick infants, Dedicated Newborn and Paediatric retrieval and transport services, Concept of golden hour in primies care

•Recent developments- probiotics in NEC, Therapeutic cooling for HIE, Parentral nutrition, Improved aseptics

Preterm birth the growing problem

Preterm newborn(≥ 23 weeks- <37 weeks)

Not normal

Immature lungs

Immature kidneys

Immature brain

Poor reserves- Fat, protein and glycogen

Immature thermoregulatory mechanisms

Immature or poorly developed Immune systems

Lack of bonding with parents

Preterm Birth- Common problems

EPICURE 2 Study Arch Dis Child Fetal Neonatal 2014

Managing a Preterm BirthGOLDEN HOUR IN PRETERM BIRTH < 32 weeks

Day 1 most dangerous Period of life for a preterm infant

BE GENTLE

Complete the following within first 1 hour after birth Admit to NICU Normal temperature Stabilise the infant on CPAP/Mechanical ventilation Secure the vascular access including UVC and UAC x-ray- Confirm all line and tube positions on Perform first

blood gas Record vital signs Commence IV fluids and starter TPN. Administer medications including vitamin K, first dose of

antibiotics, and caffeine where applicable.

Improves survival rates and incidence of other complications

Hypothermia and Thermal control of newborn

Kangaroo mother careClosed Incubator

Open care warmer

Embrace warmer with PCMFood grade plastic wrap <30 weeks

Sepsis Common cause of neonatal mortality

30-50% of Neonatal deaths

Wide prevalance of Gram negative multidrug resistant organisms in India

Risks- Maternal sepsis, PROM, Multiple PV examinations, Perinatal asphyxia, Poor hygiene and asepsis routines, Overcrowded and poorly staffed NICU

Management

Prevention-Hand washing is the most effective way to prevent infection, Strict infection control policies

Prophylactic antibiotics in c/o risk factors

Judicial use of antibiotics based on cultures

Meticulous care with lines

Training of nurses and DrS, SOP in the unit

Respiratory distress syndrome of preterm or SDLD or Hyaline membrane disease

Chronic lung disease of prematurity/Bronchopulmonary dysplasia Continued Need of O2/Respiratory support at

Day 28 or at 36 Weeks GA

Risk Factors GA <30 weeks, B Wt<1500 gms, HMD, Patent Ductus arteriosus, Maternal infection, Mechanical Ventilation, Excess O2 use, Fluid overload

Old BPD - Presurfactant era- mean B wt – 2000 gm, GA 33 weeks

Vs New BPD-Mean GA 28 weeks, B wt <1000 gm

Treatment

Lung protective strategies from hour 0

Nutritional support

Steroids, Bronchodilators, Diuretics,Treatment of PDA, immunization(Routine +Flu+RSV)

Intracranial(Intraventricular) Haemorrhage and Periventricular leucomalacia/White matter Injury

Intracranial(Intraventricular) Haemorrhage and Periventricular leucomalacia/White matter Injury Common in <32 weeks GA.

Primary reason for neurodevelopmental problem in infants <32 weeks

Fragile subependymal germinal matrix and watershed areas of blood supply

Risks

Maternal infection, Lack of antenatal steroids, Aggressive handling at delivery, Haemodynamic disturbances, Hypocarbia, Hypoxia, Increase in Intrathoracic pressure, coagulation disorders etc

Presentation

Usually asymptomatic at onset.

Grade 3, 4 IVH and Severe PVL – Poor prognosis

Diagnosis and Treatment

By Bedside Ultrasound imaging

Prevention must be the aim

Managing hydrocephalous, CP etc.

Necrotizing Enterocolitis

Most Common GI emergency In a neonateIncidence 0.3- 2.4/1000 live birthRisk factors

PrematurityHypoxic or Hemodynamic insult for the babyLack of breast milkH2 Blockers(?), Blood transfusion(?)

Prevention

Exclusive Breast milkCautious enteral feeding

ProbioticsMinimise hypoxic insult to the gut

Bell staging criteriasuspected(I), Definite(II), Advanced(III)

TreatmentNil by Mouth, IV antibiotics, surgical intervention if needed

Nutrition

Nutrition

Retinopathy of prematurity

Vasoproliferative disorder of retina in preterm infants due to excess O2.

Results in Blindness and Vision problems

Seen in 20-30% of at risk infants

At risk group <32 weeks <1500 gms B Wt ≥32 weeks – If Critcally sick and on

Prolonged O2 RX

Keep O2 saturation at 90-93%(Alarm limits 88 & 95%)

Screening at 4weeks/ 32 weeks

Treatment Laser photocoagulation Anti VEGF A-Bevacizumab(Avastin).

Patent Ductus Arteriosus(PDA)

Incidence 15- 40 % <1500 gm, <1000 gms- 50-65%

Functional closure in term infants by 12 -24 hrs

Hemodynamic problems, Difficult ventilation Myocardial strain

L to R shunt

Ductal steel, Risk of NEC

Diagnosis- ECHO

Treatment

Medical- Fluid restriction, Diuretics,

Ibuprofen, Indomethacin, Paracetamol

Surgical – Duct ligation

Birth Asphyxia or Hypoxic Ischemic encephalopathy Responsible for 28% of all neonatal deaths

Treatment Maintain TABC, Normal Blood sugars, Na, K, Ca, Mg Treat Seizures

Therapeutic Hypothermia(33-34°C for 72 hours) a promising treatment in newborns with mild to moderate

• pH < 7.0 or base deficit of -12 mmol/l or more

• Ongoing resuscitation requirement including positive pressure ventilation after 10 mins

• Apgar score < 6 at 10 mins

• Clinical signs of encephalopathy

• Abnormal EEG

• Commenced ASAP or within 6 hours of birth

Meconium aspiration Syndrome

Passage of meconium inutero due to Acute/chronic Hypoxia, Infection

Meconium stained Amniotic fluid(MSAF) Incidence 8-25%, MAS develops in 5% of MSAF

Care at birth- No need for perineal suction○ If baby vigorous- Routine Care, ○ Baby not vigorous- Suction of oropharynx under direct vision and continue with

resuscitation

Causes varying degrees of respiratory distress

30-50% of cases develop Persistent Pulmonary hypertension(PPHN)

Treatment

Antibiotics, CPAP, Mechanical ventilation

PPHN- iNo, IV sildenafil, ionotropes, ECMO.

Managing a surgical Infant

Bowel problems- Atresia, Malrotation, Hernia, Gastrochisis, Omphalocele, Necrotising Enterocolitis, Bowel perforation

Congenital diaphragmatic hernia

Imperforate anus

Lung malformations- CCAM, Lung Cysts etc

Tracheooesophageal fistula with OA

Neural tube defects- Meningocele, Meningomyelocele etc

Fetal Cardiac defects

• Antenatal Ultrasound and MRI helps in planning pregnancy and prognostication

• Surgery followed by postoperative care in ICU- – Pain control, fluid and electrolyte management, Nutrition and monitor for complications.

1.Unchanging/increasing premature delivery rate with significant associated mortality and morbidity

2.New technology gains, and their safe clinical application

1.Question of "how small is too small" and how this care will be paid for

2.Advancement in Fetal diagnostics and Therapeutics

3.Inutero transfer of high risk pregnancies and centralization of care

4.MAKE IN INDIA and MADE IN INDIA

Future challenges