REVISION SESSION

Question 1

What is neonatology?

Answer 1

Subspecialty of paediatrics
It specifically deals with the medical care of newborn infants, in particular premature or ill newborn infants
It is usually practiced in the NICU by neonatologists

Question 2

What is the differences between premature neonates and paediatric patients in terms anatomy, physiology and treatment?

Answer 2

A premature neonate does not have the anatomy/physiology function that is expected of a paediatric patient.
Further complexity introduced where illness is additional factor
Infants physiology continues to change and develop with time
Ineffective treatments
Environmental exposure to the infant is far greater significance that the paediatric or adult

Question 3

What is the medical equipment used to maintain the environment of the neonate?

Answer 3

Neonatal incubator, transport incubator

Question 4

What is the medical equipment used to monitor the neonates vital signs?

Answer 4

Vital signs monitor, oxygen saturation monitor, apnoea monitor, glucose monitor

Question 5

What is the medical equipment used to maintain the environment of the neonate?

Answer 5

Infusion pumps, ventilators, phototherapy equipment

Question 6

What is the medical equipment used in neonatal care for diagnostics?

Answer 6

Ultrasounds, X-ray machines, blood analysers

Question 7

What elements and environments are important to control and take care with for the neonate to have a good development?

Answer 7

Healing environment - touch, light, taste, sound, light
Partnering with families, positioning & handling, safeguarding sleep, minimising stress & pain, protecting the skin, optimising nutrition

Question 8

What types of things are needed to be considered for the NICU environment?

Answer 8

Open plan or private room design: advantages to both, open plan is easier for patient care and private rooms give a better parent experience.

Infrastructure: a lot of equipment needs to be stored close at hand ‘ready to go’ - medical gases, suction (vacuum), plenty of accessible power, quiet, awareness of the effect of room heating on neonate - included direct sunlight, parent experience

Question 9

Name the risks and preventions of preterm birth, what are the influences?

Answer 9

Care of infections - infections
Healthy lifestyles - stress, smoking, alcohol, obesity, drugs, excessive physical work, undernutrition
Preconception & antenatal care - genetic predisposition, conception by in-vitro fertilisation, shorter inter - pregnancy intervals, multiple pregnancies, maternal age less than 18 and above 35 years, low economic status
Care of chronic diseases - maternal diseases eg. High blood pressure, diabetes

Question 10

What percentage of preterm births, the actual cause of early delivery as well as possibilities of prevention remain unknown?

Answer 10

50%

Question 11

Name the levels of neonatal care units

Answer 11

Special care baby unit (SCBU)
Local Neonatal Unit (LNU)
Neonatal Intensive Care Unit (NICU)
Transition Care (TC)

Question 12

For the SPCU, what care does this include?

Answer 12

Monitoring their breathing or heart rate
Giving them more oxygen
Treating low body temperature
Treating low blood sugar
Helping them feed, sometimes by using a tube
Helping babies who become too unwell soon after

Question 13

For the LNU, what care is provided?

Answer 13

Breathing support given through their windpipe
Short term intensive care
CPAP or high flow therapy for breathing support
Feeding through a drip in their vein
Cooling treatment for babies who have had difficult births or are unwell soon after birth ( before being transferred to NICU)
Helping babies who become unwell soon after birth

Question 14

For the NICU, what care do they provide?

Answer 14

Care for babies with the highest need for support
Need breathing support given through their windpipe
Have severe disease affecting their breathing (respiratory disease)
Need or have just had surgery

Question 15

For TC, what does care is provided?

Answer 15

Mother and baby stay together in hospital whilst the team care for the baby
Some babies born between 32 and 37 weeks of gestation
Babies with mild jaundice or feeding problems

Question 16

Neonatal care is family centred, what elements are important to ensure this is the priority through the chain of care?

Answer 16

Capacity and patient flow, repatriation, discharge planning and outreach, follow-ups

National guidance and pathways, data and audits, health information, research and innovation, education and workforce

Equity, well-being, quality improvement

Question 17

What are the key areas for neonatal technology development?

Answer 17

Resuscitation and stabilisation equipment
Monitoring systems, wearable tech, AI integrated monitoring
Thermoregulation
Infusion and delivery systems
Diagnostic tools
Telemedicine solutions

Question 18

What is jaundice a symptom of?

Answer 18

High bilirubin levels in the blood

Question 19

What causes jaundice?

Answer 19

Accumulation of bilirubin in the skin and sclera, resulting in yellow discolouration

Question 20

What happens when there is too much bilirubin?

Answer 20

Orange-yellow pigment formed by the breakdown of haemoglobin

Question 21

Why is bilirubin needed?

Answer 21

It’s a normal catabolic pathway which is necessary for the clearance of waste products

Question 22

What percentage of term babies get hyperbilirubinaemia?

Answer 22

60%

Question 23

What percentage of preterm babies get hyperbilirubinaemia?

Answer 23

80%

Question 24

Explain the process of bilirubin creation

Answer 24

Reticuloendothelial cells maintain the red blood cells levels by destroying abnormal and old red blood cells by breaking it down into haem and globin groups.

Globin is further broken down into amino acids and recycled

Haem is further broken down into iron and biliverdin. The iron is recycled and the biliverdin is reduced to create unconjugated bilirubin

Question 25

Name the types of bilirubin and what they are also known as

Answer 25

Unconjugated - indirect Conjugated - direct

Question 26

Explain the process where conjugated bilirubin is formed from unconjugated bilirubin

Answer 26

In the bloodstream, unconjugated bilirubin bins to albumin and is transported to the liver In the liver, the enzyme GLUCURONYL TRANSFERASE adds GLUCURONIC ACID to unconjugated bilirubin and it’s converted to conjugated bilirubin Conjugated bilirubin is water soluble and can be excreted into the duodenum in bile

Question 27

What is urobilinogen? What does it do?

Answer 27

A colourless byproduct of the breakdown of bilirubin in the intestines. Formed by gut bacteria on conjugated bilirubin. Is it either reabsorbed into the bloodstream and excreted in urine as urobilin, giving urine its yellow colour, or it remains in the intestines and is converted to stercobilin, which gives stool its brown colour. Monitoring urobilingoen levels in the urine can be helpful in diagnosing liver and blood disorders

Question 28

What is the treatment used for jaundice? How does it work?

Answer 28

Phototherapy is the use of light to lower the serum bilirubin levels It transforms bilirubin into water soluble without conjugation in the liver Light waves absorbed by the skin and the blood and unconjugated bilirubin molecules are converted into water soluble isomers, which are forms of bilirubin that can be easily excreted in the urine without the liver having to process them

Question 29

What light is the most effective for phototherapy?

Answer 29

Blue green light with a range of 460-490nm

Question 30

What phototherapy treatment for jaundice can be used? State the benefits and limitations

Answer 30

Fluorescent tubes Halogen spotlights These produce considerable heat which can be placed close to the infant Fibre optic blankets - limited exposure area LEDs - low heat production Gallium nitric LEDs - produce a high intensity wavelength light

Question 31

*What does irradiance mean?*

Answer 31

Defined as power per unit area on a surface, given in W/m2

Question 32

*When is irradiance maximised? Explain*

Answer 32

When the surface is perpendicular to the beam The power of the light source and angle at which the light hits is important The irradiance is maximised when the light is directly received by the surface E (degree sign) = E x cos(degree sign) Increasing the angle decreases the irradiance

Question 33

Explain the make up of a fluorescent lamp for blue light delivery

Answer 33

Sealed glass tube, inside which is a little mercury and an inert gas (usually argon) under low pressure Inside surface of glass is coated with phosphor powder An electrode at either end of the tube with a high potential difference

Question 34

*how does a fluorescent lamp actually work? Explain*

Answer 34

When current is applied, electrons flow from negative to positive electrode This energy changes the liquid mercury to a gaseous form As the electrons collide with the gaseous mercury atoms, energy is transferred to the electrons of the mercury atoms, moving them to a higher energy shell The electrons drop down to their previous level, losing energy as they do so in the form of UV light photons

Question 35

For fluorescent lamps, explain exactly what happens in the energy shells for them to produce the UV light

Answer 35

Electrons orbit in distinct energy shells: 2, 8, 8 The closer the energy shell is to the nucleus, the tighter it is bound to the electron The free electrons interact with the outer shell electrons of the gaseous mercury atoms Electrons are given sufficient energy to promote higher energy orbit Electrons instantaneously lose energy, returning to their former position and emitting light The amount of light emitted is determined by the energy shell differences in mercury

Question 36

How does the phosphor powder impact the UV transmission from the fluorescent lamp? How does it create the visible light?

Answer 36

When the UV light strikes the coating, an outer energy shell of the powder is given energy, promoted to a higher energy shell and returns to its former position losing energy in the form of visible light Light is emitted in all directions

Question 37

How is blue light produced? What is it made of?

Answer 37

LEDs Semiconductor, which, under the right conditions, allows the flow of electron-hole pairs to produce visible light

Question 38

*Explain the process of LEDs*

Answer 38

So you have p type and n type (positive and negative) in a semiconductor. the p type is a side of excess holes (where electrons are missing which act like positively charged particles) the n type is the side with an excess of electrons (negatively charged particles) When a voltage is applied across the LED, the n type side moves towards the p type side and recombines with the holes They release energy in the form of photons - light The region where the electron-hole recombination occurs is called the depletion zone/junction, this is like an insulating layer

Question 39

*What is doping?*

Answer 39

Process of adding small amounts of impurities to a semiconductor to alter its electrical properties P type doping would be adding more holes N type doping would be adding more electrons Essentially creating more PN junctions

Question 40

*What is the conductor material for LEDs?*

Answer 40

Aluminium Gallium (AlGaAs)

Question 41

*How does LEDs create light?*

Answer 41

Free electrons have more energy than those that fall into the holes These are bound to an atom in an outer energy shell When this free electron falls into a hole, it loses energy in the form of light

Question 42

*How can the desired wavelength for an LED be achieved?*

Answer 42

By using the correct combination of materials

Question 43

*The Control of Artificial Optical Radiation at Work Regulations 2010 was put in place to minimise the risks of exposure to artificial light sources, why is this necessary? Why are control measures needed? What should be done to minimise the risks?*

Answer 43

Prolonged exposure to blue light can damage retinal cells, causing vision problems such as age related macular degeneration Has also been linked with cataracts and eye cancer Control measures are needed to ensure irradiance exposure to staff is as low as reasonably practicable (ALARP) The variability in the manufacturer spectra means that is not possible to state that this application is harmless to staff A risk assessment should be completed, protective eyewear may be indicated An understanding of clinical practise is required

Question 44

* What are the 4 ways heat is exchange between a neonate and environment? Explain*

Answer 44

Evaporation - when water is lost from the skin Conduction - direct contact with a surface with a different temperature Convection - air currents carry heat away from the body surface Radiation - temperature of the surfaces surrounding the infant but not in direct contact with the infant

Question 45

What is the temperature range for the rectum?

Answer 45

36.5 to 37.5 degrees Celsius

Question 46

What is the temperature range for axillary?

Answer 46

0.5 degrees Celsius or lower

Question 47

What is the temperature range for abdominal skin?

Answer 47

36.2 to 37.2 degrees Celsius

Question 48

WHO have classified hypothermia temperatures into mild, moderate and severe, what are the temperature ranges of each category?

Answer 48

Mild: 36 to 36.4 degrees Celsius Moderate: 32 to 35.9 degrees Celsius Severe: less than 32 degrees Celsius

Question 49

What is the definition of a thermoneutral zone?

Answer 49

An environment in which a neonate maintains a normal body temperature while minimising energy expenditure and oxygen consumption

Question 50

What are the outcomes for a neonate who has thermal stability within the thermoneutral environment? (TNE)

Answer 50

Enhanced growth Decreased respiratory support Decreased oxygen requirements Increased glucose stability Reduced mortality Reduced morbidities associated with hyper and hypothermia

Question 51

*Preterm neonates find it very hard to have thermal regulation, why is this?*

Answer 51

Low body mass ratio Minimal muscular activity Subcutaneous fat insulation is not there High ratio of surface area to body mass

Question 52

*What advantages does skin to skin care provide for the neonate?*

Answer 52

Thermoregulation Improved weight gain Reduced risk of infection Greater haemodynamic stability - improvement of body circulatory system: heart rate, blood flow etc Blood sugar stability Decreased stress ProMotion of bonding

Question 53

*what areas of advancements in technology have been made for neonatal care?*

Answer 53

Delivery room advancement Wireless monitoring equipment Respiratory function monitoring Neuromonitoring

Question 54

*what is wireless monitoring equipment? What is crucial for this? What types of parameters can they have?*

Answer 54

Small, wearable and non invasive allowing unrestricted parental care in a more natural and stress free environment All must have safety with no discomfort, skin changes or local rise in temperature Accuracy, reliable and efficacy Single and multiple parameters for displays

Question 55

*What is telemedicine?*

Answer 55

The delivery of health care services by all health care professionals using information and communication tech for the exchange of valid info for the diagnosis, treatment, and prevention of disease, and injury, research and evaluation ,and continuing education of health care professionals

Question 56

*What are the critical components of telemedicine?*

Answer 56

Provision of clinical support (range of services and assistance etc) Purpose to overcome geographic barriers The use of a variety of info and communication technology The objective of improving population health

Question 57

*why do we need incubators?*

Answer 57

Used to establish and maintain an environment suitable for a neonate Usually preterm babies but also ill full term

Question 58

*What is the back story to incubators?* When was it first developed, why, how, the beginning

Answer 58

Paris in 1880 hypothermia was known to be the primary cause of death for premature infants French obstetrician Stephane Tarniers first design housed several infants heated over a hot water reservoir A redefined design followed, a single occupancy incubator heated via hot water- water bottles replaced manually every 3 hours

Question 59

*what are the key design considerations for an incubator?*

Answer 59

Precise control over the environment - temperature, humidity A quiet environment for the patient - 60dBA within the incubator Loud noises have been linked with apnoea, hypoxaemia, reduced oxygen saturation, elevated heart and respiratory rates, among other things Safe for patients - good design, warning alarms, battery backup etc

Question 60

In terms of temperature control, how does the incubator work? What does the heating system consist of?

Answer 60

Electrical element under the incubator compartment Heat is provided by convection - air is passed through the heating element by a fan Temperature can be set within a range, varies typically 28 to 40C which is the air temperature, this is a clinical decision

Question 61

*How does the temperature control work in an incubator?*

Answer 61

The unit is required to maintain a constant temperature Can be achieved by a negative feedback control loop Temperature measurements made using one or more air temperature sensors

Question 62

What are the design variations for temperature control?

Answer 62

Single air temperature sensor is a simple, effective design Uniformity of temp, multiple air temp sensors can provide a more accurate indication, or fans ensures uniformity of air temperature Patient skin temperature for the value to be compared with the reference (operator set) temp, requires body temperature to be used on the patient Equilibrium temperature is reached when the patient reaches the reference (operator set) temperature

Question 63

*Temperature control can be hard to maintain, what are the external influences for this?* Heating Why is this an issue?

Answer 63

There are other sources of heating for the incubator: Sunlight Heat lamps Spot lamps Electric cushions Whilst the negative feedback loop will correct, as these are unexpected and unpredictable, variations will increase

Question 64

For temperature control, how does the safety features work?

Answer 64

A redundant system (extra backups) takes the absolute measured temperature and initiates an external audible and visible alarm if this is not within the range. Good as it prevents significant risks to the patient The system an automatically switch off heating element if the temp is too high At first switch on, the temp may take more than half an hour to reach the ref temp

Question 65

What are the typical values for humidity control levels in a percentage?

Answer 65

70-80%

Question 66

Humidity is important to control for an incubator, why is it important to control?

Answer 66

The heated air in the incubator will become very dry therefore the patient will experience increased heat loss due to evaporation, this can lead to them becoming hypothermic regardless of the incubator air temp

Question 67

The desired humidity level is a clinical decision, what impacts this?

Answer 67

Patient gestational period Patient sodium level

Question 68

*what happens to the leakage current in the incubator? what is touch leakage current? How would you measure this?*

Answer 68

Leakage current - unintended flow of electrical current that does not follow the intended path. Unwanted flow of current from the device to the ground, which could indicate an issue with insulating or grounding. Instead of flowing in through the normal circuit, this takes the path of least resistance and flows from the device to the earth. To measure this, can use a leakage current clamp ammeter or multimeter Touch leakage current is basically the same but current from a poorly grounded device that would flow through someone touch in the device casing

Question 69

*How does the battery back up work? why is it important?*

Answer 69

Hospitals are designed such that a loss of mains power to critical equipment is compensated for by power generated by on site diesel generators It is unlikely that the battery would be relied on for long Electrical infrastructure companies always prioritise hospitals Any failure of mains power would result in the loss of the ability to maintain the environment. Loss of temp could have a significant clinical detriment Battery can maintain the environment for hours

Question 70

*why is it important to have warnings and alarms on the incubator?*

Answer 70

A failure of any feature on the incubator operation could have a negative clinical effect on the patient

Question 71

*how does the warnings and alarms work for the incubator? What things can be triggered?*

Answer 71

Failure of an essential function will trigger a continuous tone alarm Malfunction of the incubator control module Mains failure Air temp sensor failure Fan failure Anything not working should be reported immediately to staff

Question 72

*how are incubators tested? What parameters can it measure?*

Answer 72

Using an incubator testing device Air temperature Skin temperature Temperature uniformity Humidity Airflow Sound

Question 73

*List the stages of the development of the respiratory structure and the weeks of their development

Answer 73

Embryonic - 0 to 7 pseudoglandular 7 to 17 canalicular 17 to 27 saccular 27 to 36 alveolar 36 to 2 years

Question 74

* what respiratory complications can happen during to prematurity?*

Answer 74

Respiratory distress syndrome (RDS) Apnoea of prematurity Bronchopulmonary dysplasia

Question 75

*What are the goals of respiratory support?*

Answer 75

Maintain oxygenation Effective ventilation Minimise work of breathing Avoid complications- short and long term

Question 76

*What are the non invasive methods for neonatal respiration?*

Answer 76

Nasal cannula - blended oxygen delivered through prongs in the nose at low flow rates HFNC/HFOT - humidified, blended oxygen delivered through prongs in the nose at higher flow rates CPAP - humidified, blended oxygen driven by CPAP to prevent alveolar collapse. Delivered through prongs in the nose or by mask BiPAP: Biphasic CPAP NIPPV NIV NAVA: Neural adjustment ventilatory assist

Question 77

*What is the invasive way for neonatal respiratory care?*

Answer 77

Mechanical ventilation

Question 78

*What are the hybrid way for respiratory care of neonates?*

Answer 78

SIMV/SIPPV + VG PSV + VG SIMV + PS

Question 79

*Explain the chain for mechanical ventilation*

Answer 79

Mechanical ventilation splits to positive and negative and then positive splits to conventional ventilator and high frequency ventilation

Question 80

*How many patient transfers does the Scottish neonatal transport service make each year?*

Answer 80

1200

Question 81

*what members make up the transfer team?*

Answer 81

Ambulances and crews from the Scottish ambulance service (SAS)

Question 82

*Why are standard incubators unsuitable for use for transport?*

Answer 82

Their batteries are not designed for it Functionality may be excessive such a blue light They are not built to maintain activity over long periods of time, they must be plugged in. They reply only temporarily a battery power They require emergency power sources to keep it running properly, but there may be a delay in these systems

Question 83

*what are the key functionalities for design considerations?*

Answer 83

Minimum functionality Heating and humidity Same provision and function as for standard incubators Similar ranges available Similar controls (skin temperature), alarms and safety systems Note that the environment is harder to control - transfer outside to ambulance/aircraft, ambient vehicle temperature Minimum power supply - in the UK, able to provide 230V mains A/C and 12/24V DC power provided in the ambulance Battery life of the power supply - very variable by make and model 2-4 hours claimed for a single battery Many manufacturers off an option of a dual battery pack, doubling battery Full functionality generally requires use of manufacturers proprietary batter

Question 84

Transport incubators have a specific construction, what must be considered? What do manufacturers offer?

Answer 84

The use of lighter materials - carbon fibre Fixing - must be securely affixed to the trolley it comes with Offer design that is compatible with the securing mechanisms found in routinely available ambulances IEC standard requires the means of affixing be described in the user manual Limiting patients movements via Velcro straps Easy access - increased ease to full infant bed, bed pulls out of side door or entire top lifts off, for initiating fast CPR when necessary Vibration - more of an issue with transport incubators, creates noise with risks exceeding 60dB within the compartment, good design incorporates use of seals etc Stability - need to be stable when tilted 10 degrees normal use and 20 degrees during transportation Test conditions mandate all moving parts - doors drawers mattress to be the most disadvantageous during testing Medical gases - means of stowing cylinders of any necessary medical gases it’s important, need to comply with standards

Question 85

What are the design variations for the transport incubator?

Answer 85

Shown far from clinical disadvantage - patient must be transferred from a standard incubator, which could be clinically significant for a very ill patient A ew design of shuttle device removes this requirement An add on device for standard incubators that creates a transport incubator

Question 86

What electrical components should the transport incubator have to be approved?

Answer 86

2-4 sealed units 12volts, 20/42 amp hour Temperatures monitored via thermostat Universal power module - charges batteries, monitors input/output and battery condition, switches between A/C and DC battery Sockets - to power peripheral devices attached to the standard incubator

Question 87

What warning signs should the incubator for transport have?

Answer 87

Locking mechanism - mechanical switches indicating poor connection with legs of standard incubator LED lighting red and not red Interference condition - mechanical switches activated by body of standard incubator (height issues) Battery runtime estimate - lcd screen estimate, led lights 1-5 Battery charging and status - overload condition, too much power drawn