Podcast Episode 5
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The first time you see your baby in the NICU can be incredibly intimidating and frightening. I know even with my years of NICU experience, when I first saw my son lying there with an endotracheal tube in place, a UAC line, a phototherapy light, eye shields and so much more, I was taken aback. There really is no preparation for NICU parents – after all, this is your child! After this episode, I hope you have a better grasp on all of the many different wires and tubes that are on your baby, what their purpose is, what pieces of equipment they are hooked up to, and how it relates to your baby’s plan of care.
I know that I am a very visual person and something may not make sense to me until I actually see it or a drawing related to it, so please click on the link to get the free pdf that correlates with this episode. Even if you do not finish the podcast episode, at the very least, go and grab your free pdf that is essential for every NICU parent.
Today, we are going to systematically discuss from head to toe some of the common equipment used in the NICU. Whether it is physically attached to your baby, or a machine that is hooked up to a tube or wire on your baby, after this episode, you will know what it is for and how it is helping the care team in caring for your infant. Now that you have your image downloaded, you can follow along in the picture (assuming that you are not driving of course!).
Radiant Warmer/Isolette
From the top! Once infants are admitted to the NICU, they are placed in either a radiant warmer or an isolette. In our drawing, we have a radiant warmer. Radiant warmers, keep your infant warm through radiant heat. The temperature probe that you see labeled in the drawing, comes from the radiant warmer and it is placed on your infant to an exposed area and secured with a foiled-back sticker.
Especially when your infant is first born, the radiant warmer is set to Servo Control or set on a particular temperature. Servo Control is an electronic feedback system that maintains a constant temperature wherever the probe is placed – meaning, the warmer or isolette will adjust the amount of heat generated to maintain the pre-set temperature. The goal for your baby’s care team is to provide a thermoneutral environment for your infant.
It is important for your infant to remain in a thermoneutral environment, to minimize their energy expenditures and to decrease the amount of calories they burn to maintain normal body temperature. It also prevents them from cold stress and also from overheating.
Isolettes also use Servo Control to maintain your infant’s temperature. Both isolettes and radiant warmers also monitor and display what your baby’s temperature is as well. Many isolettes and radiant warmers have a built-in scale as well so the care team can easily weigh your baby right on the warmer or isolette by simply lifting your infant up.
Phototherapy Lights
Radiant warmers and isolettes may also have phototherapy lights attached to them. Phototherapy appears as a blue light and may be provided to your infant either as an overhead light or by a bilirubin blanket placed under them. Phototherapy is used to treat hyperbilirubinemia or elevated bilirubin levels. Elevated bilirubin levels are common in preterm infants, but it may also occur in term infants due to physiologic jaundice, hemolysis due to a blood type incompatibility, poor liver function due to an infection or other causes including breast milk jaundice, slow feeding advancement, or from birth trauma.
Phototherapy eye shields as pictured in the image are necessary for infants who are receiving phototherapy either overhead or via a bili blanket. Phototherapy can cause degeneration of the retina with prolonged, unprotected exposure, so eye shields have become a standard of care for any infant receiving phototherapy.
Endotracheal Tube and Ventilator
An endotracheal tube is a tube that is inserted into your infant’s trachea to assist with their breathing. The ideal tip position of the endotracheal tube is in the mid-trachea just above the carina or the point that the trachea divides into the left and right bronchi. The endotracheal tube is secured to your baby’s face or cheek area with either tape or a NeoBar. The only way to 100% confirm correct ETT position, is with an X-Ray.
There are different sizes of endotracheal tubes, and your baby’s weight will determine what size of endotracheal tube is appropriate for them. The endotracheal tube is connected directly to the ventilator.
The ventilator is the machine that artificially moves air in and out of the lungs if your infant needs assistance with oxygenation and/or ventilation. The need for a ventilator and assistance with breathing is due to several factors including but not limited to respiratory distress commonly due to prematurity, meconium-aspiration syndrome, PPHN, or BPD. Your infant may also need assistance from a ventilator due to complications from labor and delivery, cardiac defects, congenital defects, or if your infant has required surgical intervention.
There are many different brands and types of ventilators. And each ventilator has the ability to provide your infant with many different modes of ventilation based on what your baby needs. The NICU providers in collaboration with the respiratory therapists manage the ventilators and make changes based on your baby’s clinical condition and blood gases.
Not pictured in our image, but also very common, are nasal cannulas. Nasal cannulas may be used once your infant no longer needs an endotracheal tube, or they may never need an endotracheal tube, but perhaps they need another mode of respiratory support. Non-invasive ventilation is just that ventilation provided to your infant in a less invasive way – through a nasal cannula as opposed to an endotracheal tube. CPAP, or continuous positive airway pressure is a common form of respiratory support used in the NICU that can be delivered via a nasal cannula, nasal prongs, or a facemask. High flow and low flow oxygen are also common treatments used in the NICU and the oxygen is also delivered via a nasal cannula.
Nasogastric or Orogastric tube
Moving along our image, is the ng (nasogastric) or og (orogastric) tube. Most infants in the NICU will have an ng or og placed at some point. The ng or og tube originates from the baby’s nare or nostril for nasogastric or mouth for orogastric; it travels down the esophagus to the stomach. It will be secured to your baby’s cheek or chin with tape. Confirmation of correct placement of the ng or og tube is done by X-ray, but there are a few other techniques the nursing staff may perform to verify daily placement.
For premature infants, they are fed through the ng or og tube up until they reach the gestational age when they can begin to try to orally feed either with a bottle or nursing – usually around 33-34 weeks. Again, due to their immaturity, their suck, swallow, and breathing coordination is just beginning to develop at this age. But it may take them several weeks to fully be able to orally feed before the ng or og tube can be removed.
Term infants may also need an ng or og tube for feeding if they are intubated or require respiratory support. The ng or og tube may also be used to vent air from your baby’s stomach or at times a different tube can be placed called a replogle tube which can be used for intermittent suctioning if needed for certain clinical conditions.
ECG Leads, Cardiopulmonary and B/P Monitor
In addition to the temperature probe being on your infant’s abdomen, they will have three ECG stickers placed on them that are connected to the cardiopulmonary monitor to monitor their heart rate and rhythm as well as their respiratory rate.
Your infant’s heart rate will be displayed on the monitor. It provides reliable and accurate monitoring of your infant’s heart rate and rhythm with the assumption that the leads are well-attached and as long as your infant is not moving too much.
The QRS complex will be visible on the monitor with each beat. The heart rate monitor will alarm if your infant’s heart rate is too slow or if they are bradycardic or if their heart rate becomes too fast or tachycardic as well. The normal heart rate for infants can vary, but it is typically in the range of 100-160 beats per minute. Some term infants may have a low resting heart rate around 80 bpm or if your infant is crying, in pain or possibly during cares, their heart rate can get as high as 200 bpm, but it should not stay up that high for an extended period of time.
The ECG leads also detect your infant’s respiratory rate or how fast they are breathing. The respiratory rate on the monitor is affected by your infant’s movement and activity as well. So if your infant is squirming, crying, or if it is in the middle of their cares, the number displayed will not be accurate. The typical respiratory rate for an infant is around 40-60 breaths per minute. Some infants with respiratory distress or other clinical conditions may have an increased respiratory rate or be what is called tachypneic. The care team will closely watch for tachypnea and the monitor may alarm if their respiratory rate is above the normal limits set on the monitor.
Your infant’s blood pressure is also measured on this monitor. The blood pressure may be monitored by a blood pressure cuff similar to what they use on you….except much, much smaller. The cuff is typically placed on one of your infant’s legs. Again, if your infant is very active and moving alot at that moment in time when the b/p is attempting to be taken, it may not read the value appropriately.
Your infant’s blood pressure may also be monitored continuously if they have an umbilical arterial catheter (UAC) in place. With an umbilical arterial catheter, the line is placed in one the arteries in the umbilicus and secured, so it can continuously monitor your baby’s blood pressure. The other way your infant’s blood pressure may be monitored continuously is if they have a radial arterial line. The radial arterial line is used for frequent lab draws, but if it is in the proper position, it will also provide the care team with a continuous value of your baby’s blood pressure.
Many cardiopulmonary monitors also display your baby’s oxygen saturations, but for our purposes, we have placed it on a separate monitor in our drawing.
PICC line, UVC, and UAC
Next on our image is the PICC line. PICC lines are peripherally inserted central catheters. Just as it says, a PICC line is placed peripherally or away from the center of the body, but the goal is for the tip to be in a central location. PICC lines are typically inserted by a member of the PICC line team or one of the nurse practitioners. They are used for long-term IV nutrition or for IV medications. PICC lines are often placed via a vein on your infant’s arm or leg. Some infants may have it placed in their head as well.
PICC lines are inserted with an introducer through a vein and threaded so the tip is just outside the heart in the superior vena cava or the inferior vena cava. The only way to 100% confirm placement of a PICC line is with an X-Ray. PICC lines may stay in place for several weeks or months if needed.
PICC lines can be used in place of a UVC an umbilical venous catheter or once the UVC is removed around 5-7 days of age. Or, a PICC line may be placed rather than a UVC if they are unable to place a UVC centrally or depending on your baby’s clinical condition and what their needs are. PICC lines and UVCs are used for IV solutions and IV medications.
UVCs are often inserted if your baby was born prematurely for central and stable IV access, or for infants with hypoglycemia or low blood sugars who need central access to accomodate a higher percentage of dextrose in their IV fluids, or for surgical infants or those with complications during labor and delivery that need prolonged IV therapy with IV solutions or medications.
In your infant’s umbilicus, there are 2 arteries and one vein. The umbilical venous catheter is inserted into the vein and threaded up to a central location just outside the heart. The only way to 100% confirm correct placement is with an X-Ray. On average, most NICUs only leave a UVC line in place for around 5-7 days. If your baby needs additional days of IV fluids as they are working up on feedings or for further treatment with IV medications, at that point a PICC line would be placed or perhaps a surgical line if needed.
Also as mentioned previously, in your infant’s umbilicus there are 2 arteries along with the vein. At times, your infant may have a UAC placed or an umbilical artery catheter. Using one of the small arteries, a catheter is inserted and threaded up to just outside the heart. As previously mentioned, UACs allow the care team to continuously monitor your infant’s blood pressure. They also allow for a way to access blood for close monitoring of lab values or arterial blood gases which help with managing your infant’s care. UAC lines will have clear fluids slowly infusing via the IV pump at a set rate. Some units may use the UAC line for limited IV access if they are unable to place a UVC or PICC line right away. UAC lines are typically only left in place for 5 days.
IV Solutions and IV Pumps
Your infant, especially in the first few days will typically require IV fluids. They may only have clear fluids infusing with some dextrose in it, and/or some saline and electrolytes. The type of IV solution depends on your baby’s clinical condition, plan of care, and what line or access point the fluids are infusing into.
The brown bag on the right in the image is the TPN or total parenteral nutrition – meaning it is nutrition given intravenously or through an IV. For infants with slow initiation and advancement of feedings, TPN is used to supplement your infant’s nutrition and electrolytes. The Neonatologist, NNP, or Dietician will order TPN with very specific ingredients each day based on your baby’s labs. The inpatient pharmacist will oversee and fulfill the order. TPN is covered in a brown bag because light exposure to TPN has shown to cause formation of peroxides and other degradation products that can be harmful to your baby.
Infants may also have intralipids infusing through their IV which is a 20% intravenous fat emulsion used routinely in the NICU as a source of fat and calories for infants who require parenteral nutrition.
The flow rate of IV solutions whether TPN, intralipids, clear fluids, or medications need to be regulated before they infuse into your baby, so they are connected to an IV pump. There are several different brands of IV pumps, but the nurse programs how much volume of each solution was ordered to infuse over a certain period of time or as ml/hr and the pump infuses that exact amount. Some IV pumps are dual and can have 2 different IV solutions in one pump.
Oxygen Saturation Monitor and Pulse Oximeter
Your baby’s arterial oxygen saturations are detected by a pulse oximeter that can be placed on either your infant’s wrists or feet. The number you see displayed is the fraction of oxygen-saturated hemoglobin relative to the total hemoglobin in your baby’s blood or in more simple terms, the extent to which your infant’s hemoglobin is saturated with oxygen. Depending on your infant’s gestational age or clinical condition, the saturation goal varies, but we typically like it to be around 90-100%. The number fluctuates minute to minute and there are many factors that affect your baby’s oxygen saturations.
If your baby is requiring respiratory support, the care team may need to give supplemental oxygen to keep their oxygen saturations within the appropriate range. The FiO2, (fraction of inspired oxygen) or concentration of oxygen in the gas mixture may need to be adjusted from 21% up to 100% based on your baby’s needs. The concentration of oxygen at room air (what most of us breathe) is 21%. Your baby’s oxygen saturation value helps to drive the clinical decision of how much FiO2 they may require or need throughout the day. If your infant is intubated and needs to be suctioned with an inline suction catheter, it does briefly occlude their airway and may cause them to desaturate.
There are many other clinical conditions that affect your baby’s oxygen saturations including but not limited to meconium-aspiration syndrome, respiratory distress, PPHN, a PDA, cardiac conditions or defects, congenital defects, and BPD.
At times, while your infant is receiving cares with diaper changes or position changes, their oxygen saturations may briefly decrease and they may require a temporary, but minimal increase in their FiO2. Remember, something as simple as gently wiping their mouth or a bright light in their eyes can affect them clinically, especially for our micropreemies.
For certain infants, as their ng (nasogastric) or og (orogastric) feedings are infusing, it may cause them to have intermittent desaturations. The length of time their feedings are infused over may need to be extended to prevent extensive desaturations. Also, when your infant begins to nurse or bottle feed, they will likely need their feedings to be paced because of the higher likelihood that they may experience some oxygen desaturations due to their immature suck, swallow, and breathing coordination and/or resolving respiratory issues.
You may also hear reference to pre-ductal and post-ductal saturations. If the clinical team wants a pre-ductal saturation, the pulse oximeter needs to be on the right upper extremity. For post-ductal saturations, the pulse oximeter can be placed on any of the other extremities. We will dive into this topic in much more detail in the future.
Closing
We hope you gained some value reading about the common pieces of equipment used in the NICU and for your baby. Every NICU is different, so some of the common pieces of equipment or treatment practices may vary wherever your infant is being treated. As always, ask your baby’s NICU care team questions to get a better understanding of the plan of care for your infant which includes a basic understanding of the equipment being used as well as it’s purpose. If you need to ask multiple times to understand something, that is also completely normal and expected.
Remember, it is normal to feel overwhelmed when you see your baby with wires attached to them and hooked up to several different machines. Although seeing them that way may leave you feeling apprehensive, just know that everything has a purpose and is either helping to monitor or treat your baby so they can get home to you that much sooner!
If you have not done so already, go and grab your free image that correlates with this post. It will make it all come together and you will walk away with a much better understanding of the equipment commonly used in the NICU and possibly on your own baby. As always, if you know of someone who would benefit from hearing the podcast episode, from reading our post, or who would like to receive the free image, please share it with them!
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