Nicu Protocols
Melvina Kryder
The Iowa Neonatology Handbook is an ongoing effort by the Division of Neonatology at the University of Iowa Stead Family Children's Hospital to provide physicians, nurses, and medical students who care for newborn infants a collection of protocols outlining rational approaches to the care of critically ill neonates. This document is not intended to be a comprehensive review of the field of neonatology, nor is it implied that the therapeutic approaches outlined in this book are established policies or standards of care. Rather, they represent a compilation of the experience and clinical styles of the members of our division and are intended only as a guide to therapy.
This monograph should be regarded as an educational document. Some of the information provided will be outdated by the time you discover it; other information is subject to controversy. The Handbook is designed only to supplement and not to replace the education gained from the teaching of the faculty and fellows and the experience of taking care of infants in the neonatal ICU.
The Handbook was added to the Virtual Hospital site in 2003 so that it would be more widely available and could be updated by section as needed. The material contained in the first on-line draft was taken from the 1995 printed edition. The date of the last revision is shown on each page. The Handbook is a document that has evolved over many years, since the first edition appeared in the early 1980s. The current product, which continues to evolve, has been built upon the efforts of many present and former faculty members and fellows, as well as nurses and residents who wrote, reviewed or edited sections of this book. The transition from printed to on-line format could not have been accomplished without the technical contributions of Nola Riley and Mark Hart.
The contents of this website are for information purposes only and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not rely on the information provided for medical decision making and should direct all questions regarding medical matters to their physician or other health care provider. Use of this information does not create an express or implied physician-patient relationship.
Newborn care is one of the vital sectors to be looked into in order to reduce neonatal mortality and morbidity. Infection is a great area of concern, especially for preterm babies. We are losing many babies, because of sepsis in resource limited settings. While it is difficult to treat neonatal sepsis, it is rather easier to prevent infections. Recommendations for prevention of neonatal sepsis is presented, with special reference to the rural Indian scenario. The approach towards the prevention of neonatal sepsis is multi-disciplinary, comprising of neonatologists, hospital administrators, nursing staff and engineers. Thus making implementations easy. If the equipment and other consumables are manufactured indigenously in bulk, and in large quantities, the cost is bound to come down significantly. Thus, reducing the financial burden on the hospitals and the health-care cost of the country
i. Location of NICU: The NICU has a distinct area with controlled access. Each infant space has a minimum of 120 sq ft clear floor space excluding the hand washing areas and corridors. There should be a minimum of 4 ft between two infant beds.
ii. Airoborne infection isolation room: An airborne infection isolation room should be available. A hands free hand washing station for hand hygiene and areas for gowning and storage of clean material should be provided near the entrance to the room. Ventilation has negative air pressure with exhaust to the exterior. When not used for isolation, these rooms may be used for care of noninfectious infants. Relative humidity should be 30- 60% Humidity> 60% may promote growth of micro organisms. According to American Institute of Architecture (AIA) guideline, the NICU should have a minimum of 6 Air change per Hour (ACH) and 12 ACH for isolation room.
iii. Hand washing station: Every infant bed should be within 20 feet of a hands free hand washing station. The hand washing sink should be large enough to control splashing. Pictorial hand washing instruction should be provided. Non absorbent wall material should be used around the sink to prevent the growth of mould on cellulose materials. There should be space for soap and towel dispensers.
Alcohol-based hand rubs can be used as hand hygiene agents if hands are not visibly dirty or contaminated. They are proven to be more effective than standard hand washing. Alcohol rubs may be used in between patient examination. At least 2-3 ml hand rub should be applied to all over surface of palm and fingers. ABHR are not useful after touching an infected patient or when the hands are soiled.
Usually microbes enter into NICU through personnel who enter into NICU and hence restriction of entry is a must. People with active infection (Respiratory, muco-cutaneous and gastrointestinal) and children should not be allowed inside NICU. Infected and out born infants should be managed in the isolation room. NICU should be a cell phone free zone.
Studies have shown no reduction of infection during gowning period as compared to no gowning period. The focus should be on adequate hand washing by all hospital personnel and visitors before handling neonate.
Consensus recommendations are that health care workers should not wear artificial fingernails or extenders when having direct contact with patients and natural nails should be kept short (0.5 cm long or approximately inch long)
Good housekeeping routines are helpful in reducing the proliferation of microbes, thus preventing and curtailing spread of infection. Avoid wet areas inside the NICU. Dry and clean NICU is unlikely to harbor microbes. The details of the housekeeping routines and the waste disposal are described in a tabular form.
This is the most important step in preventing the spread of microbes from proliferative sites to baby and from one baby to another baby (Cross Contamination). The following steps are important in this regard.
All units undertaking neonatal intensive and high-dependency care should have appropriate number of neonatal nurses. Recommended ratio is 1:1 if baby has multidrug resistant microbes, 1:2 if babies are having similar organism or susceptible organism, 1:3 if babies are already on adequate antibiotics cover.
To break the journey of microbes, ample disposables are needed. A baby kit containing stethoscope, measuring tape, thermometer and a torch in a sterile container should be available at each bed. There should be separate syringe for each medication and for each baby. Each time, a fresh suction catheter should be used for endotracheal suction.. For each baby separate gloves, antibiotics vials, disposable respiratory support circuits, should be used. Do not keep formites e.g. files, x-ray films, and pens on the baby cot. For flushing of catheter, stock solution should not be used. Epidemic of Enterobactor cloacae in the NICU with use of multi dose antibiotic vials has been reported.1
Cord infections can be prevented through promoting clean cord care and reducing harmful cord applications. The WHO currently recommends dry cord care in developing countries and the use of soap and water solution to clean the cord if visibly soiled
Skin injury should be prevented by applying less adhesive tape, using Tegaderm between skin and adhesive, precaution during adhesive removal and by using skin friendly Duropore instead of Dynaplast and Micropore. Bath should be avoided in hospitals, instead sponiging may be done.
Current evidence does not support the use of IVIG and GM-CSF for prevention of nosocomial infections The role of probiotics is promising but the right choice, the right dose and the right patient is still under review.
Antifungal prophylaxis is recommended for all Extreme Low Birth Weight babies. The Cochrane meta-analysis suggests that there will be one fewer death in every nine infants treated with this intervention but 95% confidence interval around this estimate of effect is wide. Future large Randomized controlled trials are needed.
Prevention of nosocomial infections is the prime responsibility of all individuals. Everyone must work cooperating with each other in order to reduce the risk of infection for patients and staff. Therefore, infection control protocols should be in place.
The role is to establish a multidisciplinary infection Control committee who can use appropriate resources and methods to monitor and prevent infections, ensure education and training and participate in outbreak investigation. The physician, microbiologist, nursing manager, resident nurses and housekeeping staff must play their role in infection surveillance and prevention of infection outbreaks in NICU.
vi. Restrict the use of broad spectrum antibiotics, for empiric therapy Narrow spectrum antibiotics should be chose, CRP should not be a guide for antibiotic therapy. Shorten the duration of antibiotic administration, whenever possible.
vii. Use of cephalosporins, quinolones and carbapenems should be restricted to microbes resistant to aminoglycosides of penicillins. In a recent study, cephalosporian restriction reduces the incidence of ESBL producing bacteria from 46.8% to 19.5%.9
The morbidity and mortality of neonate can be significantly reduced by instituting strict infection control strategies. Prevention of entry of microbes to NICU can be achieved by clean environment, hand hygiene and conducive infrastructure. Curtailing proliferation of microbes in NICU can be successful by daily and weekly maintenance of equipments like incubators, warmers, syringe pumps, ventilator filters, circuits, bag and mask. Efficient bio-medical waste disposal is very important. Cord care, skin care and precautions during various procedures like venepuncture, endotracheal intubation and umbilical catheterization are important. Early breast feeding, use of colostrums and early discharge play an important role in prevention of neonatal morbidity. The role of hospital management and a robust infection control committee play an important role in prevention of infection related neonatal morbidity and mortality.
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