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Neonatal Intensive Care > REVISION SESSION > Flashcards

REVISION SESSION Flashcards

1
Q

What is neonatology?

A

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

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2
Q

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

A

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

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3
Q

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

A

Neonatal incubator, transport incubator

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4
Q

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

A

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

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5
Q

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

A

Infusion pumps, ventilators, phototherapy equipment

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6
Q

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

A

Ultrasounds, X-ray machines, blood analysers

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7
Q

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

A

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

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8
Q

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

A

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

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9
Q

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

A

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

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10
Q

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

A

50%

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11
Q

Name the levels of neonatal care units

A

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

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12
Q

For the SPCU, what care does this include?

A

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

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13
Q

For the LNU, what care is provided?

A

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

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14
Q

For the NICU, what care do they provide?

A

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

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15
Q

For TC, what does care is provided?

A

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

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16
Q

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

A

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

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17
Q

What are the key areas for neonatal technology development?

A

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

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18
Q

What is jaundice a symptom of?

A

High bilirubin levels in the blood

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19
Q

What causes jaundice?

A

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

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20
Q

What happens when there is too much bilirubin?

A

Orange-yellow pigment formed by the breakdown of haemoglobin

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21
Q

Why is bilirubin needed?

A

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

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22
Q

What percentage of term babies get hyperbilirubinaemia?

A

60%

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23
Q

What percentage of preterm babies get hyperbilirubinaemia?

A

80%

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24
Q

Explain the process of bilirubin creation

A

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

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25
Q

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

A

Unconjugated - indirect

Conjugated - direct

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26
Q

Explain the process where conjugated bilirubin is formed from unconjugated bilirubin

A

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

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27
Q

What is urobilinogen? What does it do?

A

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

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28
Q

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

A

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

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29
Q

What light is the most effective for phototherapy?

A

Blue green light with a range of 460-490nm

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30
Q

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

A

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

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31
Q

What does irradiance mean?

A

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

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32
Q

When is irradiance maximised? Explain

A

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

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33
Q

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

A

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

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34
Q

how does a fluorescent lamp actually work? Explain

A

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

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35
Q

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

A

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

36
Q

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

A

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

37
Q

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

A

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

38
Q

Explain the process of LEDs

A

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

39
Q

What is doping?

A

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

40
Q

What is the conductor material for LEDs?

A

Aluminium Gallium (AlGaAs)

41
Q

How does LEDs create light?

A

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

42
Q

How can the desired wavelength for an LED be achieved?

A

By using the correct combination of materials

43
Q

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?

A

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

44
Q
  • What are the 4 ways heat is exchange between a neonate and environment? Explain*
A

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

45
Q

What is the temperature range for the rectum?

A

36.5 to 37.5 degrees Celsius

46
Q

What is the temperature range for axillary?

A

0.5 degrees Celsius or lower

47
Q

What is the temperature range for abdominal skin?

A

36.2 to 37.2 degrees Celsius

48
Q

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

A

Mild: 36 to 36.4 degrees Celsius

Moderate: 32 to 35.9 degrees Celsius

Severe: less than 32 degrees Celsius

49
Q

What is the definition of a thermoneutral zone?

A

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

50
Q

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

A

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

51
Q

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

A

Low body mass ratio

Minimal muscular activity

Subcutaneous fat insulation is not there

High ratio of surface area to body mass

52
Q

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

A

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

53
Q

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

A

Delivery room advancement

Wireless monitoring equipment

Respiratory function monitoring

Neuromonitoring

54
Q

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

A

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

55
Q

What is telemedicine?

A

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

56
Q

What are the critical components of telemedicine?

A

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

57
Q

why do we need incubators?

A

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

58
Q

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

A

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

59
Q

what are the key design considerations for an incubator?

A

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

60
Q

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

A

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

61
Q

How does the temperature control work in an incubator?

A

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

62
Q

What are the design variations for temperature control?

A

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

63
Q

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

A

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

64
Q

For temperature control, how does the safety features work?

A

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

65
Q

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

A

70-80%

66
Q

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

A

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

67
Q

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

A

Patient gestational period

Patient sodium level

68
Q

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

A

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

69
Q

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

A

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

70
Q

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

A

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

71
Q

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

A

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

72
Q

how are incubators tested? What parameters can it measure?

A

Using an incubator testing device

Air temperature
Skin temperature
Temperature uniformity
Humidity
Airflow
Sound

73
Q

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

A

Embryonic - 0 to 7

pseudoglandular 7 to 17

canalicular 17 to 27

saccular 27 to 36

alveolar 36 to 2 years

74
Q
  • what respiratory complications can happen during to prematurity?*
A

Respiratory distress syndrome (RDS)

Apnoea of prematurity

Bronchopulmonary dysplasia

75
Q

What are the goals of respiratory support?

A

Maintain oxygenation

Effective ventilation

Minimise work of breathing

Avoid complications- short and long term

76
Q

What are the non invasive methods for neonatal respiration?

A

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

77
Q

What is the invasive way for neonatal respiratory care?

A

Mechanical ventilation

78
Q

What are the hybrid way for respiratory care of neonates?

A

SIMV/SIPPV + VG
PSV + VG
SIMV + PS

79
Q

Explain the chain for mechanical ventilation

A

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

80
Q

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

A

1200

81
Q

what members make up the transfer team?

A

Ambulances and crews from the Scottish ambulance service (SAS)

82
Q

Why are standard incubators unsuitable for use for transport?

A

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

83
Q

what are the key functionalities for design considerations?

A

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

84
Q

Transport incubators have a specific construction, what must be considered?

What do manufacturers offer?

A

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

85
Q

What are the design variations for the transport incubator?

A

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

86
Q

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

A

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

87
Q

What warning signs should the incubator for transport have?

A

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

Neonatal Intensive Care (10 decks)

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