LoveTheNICU

Working as a Neonatal NP in a level 4 NICU, I've had several... But one of the worst by far was during my last pregnancy. Anyone in NICU can tell you that the worst time of our own pregnancies are 23-25 weeks, when the parents are given an option to try resuscitation if their child delivers, but the outcomes are often exceedingly poor. Opinions on what is right, moral or ethical abound, and everyone THINKS they know what they would do. I personally have always coped with those "what if" weeks by burying my head in the sand, ostrich-style, and praying until my own children were solidly in the land of the viable fetuses. Except this time. This time, I cared for a lovely little fellow, who forced me to face my own worst fears. He delivered at 23 5/7 weeks to a set of loving parents who desperately wanted him. They'd had difficulty conceiving, but had no indication of trouble with this pregnancy until the night she precipitously delivered. They were shocked and stunned, surrounded by concerned family, as the NICU team discussed the realities of his care- oscillating ventilators, brain bleeds, sepsis, chronic lung disease, NEC- all possibilities for him. Unfortunately, this conversation happens almost daily where I work. What made this different? This tiny child and my own tiny child shared, to the day, a due date. I scoured that chart, trying to find something, ANYTHING, that would make this mother different from me- some sort of proof that this couldn't, wouldn't happen to me! There wasn't any. They were "normal", doing everything right... And yet here they were. I sat with the family and care team when the results of his second head sono came back- devastating, irreversible bleeding that would virtually ensure no chance at a normal life. We presented options- continue aggressive treatment, or withdraw support and allow him to die peacefully. They requested time to think. Shortly thereafter, his nurse found me. The family had questions. They wanted brutal truth- what would happen, how would it look, sound, feel- if they chose to withdraw. I talked them through the process, carefully and honestly. I fielded questions from all the grandparents and friends holding this couple up, doing my best to address their fears and concerns. At one point, a grandfather grasped my arm tightly and said, "You're doing a good job. How many times have you had this conversation?" Too many. Way, way, too many. "I don't know how you can do this, especially like that," he said sadly, gesturing toward my belly, which I had been trying so desperately to conceal in oversized scrubs, hoping to spare the mother further pain. At that moment, I wasn't so sure about my job, either. After a few minutes of privacy, the parents had made up their mind- they were going to let him go. However, in a twist from the usual, they decided against staying with him while he was passing. They wanted to hold him, love him, bathe him and then let him go- and let us extubate him once they were gone. They requested that I hold him, in their place, since we had been together since his admission. What could I say? Of course I would do this for them. My coworkers reassured me I didn't have to- how would the family know, since they would be gone? But I couldn't betray a mother's trust like that. So in the stillness of his room, now empty of the many people who had loved him, I held that baby, rocked him and sang to him. I held him as his heart rate slowed and he became still, in striking dichotomy to the tiny active life inside my body... So much the same, and yet so very different. I cried on the top of his tiny, perfectly round head for the life he would not have, and prayed for both him and my own child, for the blessing of a healthy pregnancy, for deliverance from the pain his mother was feeling that day. When it was over, and the bedside nurses took over his postmortem care, I called the family per their request, with a time of death. The grandfather who answered the phone said only, "Thanks you. Really. We just couldn't..." before the line went dead. Unlike many families who lose children in our unit, I never heard from them again. He was certainly not the first, and also not the last, child I've been with through their end of life- nor even that I've held in the place of their parents. However, I will never be able to forget that baby, and that mother, who so very easily could have been me.

Dr. Leak- Urologist!!!

As a newer NNP, I came into a practice where the "more experienced" NNPs tended to restrain the infants hand and foot and give sucrose for PICC insertions. A few of the newer girls and I have adopted an approach that includes swaddling the infant with only the necessary extremity left out, as well as sucrose administration and Fentanyl if the infant requires it. If I can fairly confidently say that I will be able to insert the PICC with one stick, I may forgo the Fentanyl if the infant is otherwise calm and contained by the swaddling, however I tend to err on the side of giving the dose rather than witholding it. I have also occasionally given oral or intranasal Versed to an infant lacking other IV access. On a side note- some of the "more experienced" NNPs can't figure out why we have a higher percentage of successful insertions, and can perform them more quickly... Hmmm....

I don't think the results are in yet, as she was still working on the research this spring and with the time between research and publishing, I can't imagine we will see them any time soon. However, her name is Karen D'Apolito, and she has been published frequently in Neonatal literature regarding withdrawal in neonates. If you do a CINAHL or Medline search I'm certain you can find her work, as well as the new topics once they are published. I do not know what her results have been, since I graduated and we are no longer in touch!

Spacey, I will see about getting some contact information for you- if she doesn't mind, of course- and getting better answers for your questions if at all possible. I don't know if I will have a chance to do so this week, as our NICU reunion picnic is this weekend and I'm sure that is our support person's priority now, as she organizes the whole shindig. I'll be in touch! -LovetheNICU

We do have a designated support person, who has been working for our unit just over two years on a grant-type arrangement. She has a social work/counseling background of some sort, but is not a practicing social worker. She conducts support groups and checks with NICU families on a regular basis to act as a sounding board and liason for any type of concerns they have, and also attends interdisciplinary care conferences, etc to act as a family advocate. She is a dedicated member of our NICU staff and as far as I'm concerned, indispensible in situations such as poor prognoses or withdrawal of care. She is wonderful at diffusing situations with agitated or upset families. I'm hoping her funding continues, as I'm not sure what we'd do without her!! As an aside, we do have a dedicated social worker for our unit, who assists in such things as funding/housing issues, legal issues, child protective services, vouchers for travel, etc.

All the way back to your original question- I think the reason you may see NNP positions listed as "MSN preferred" is because not so long ago, you could become an NNP as a certificate-type program if you were a BSN prepared RN. There was definitely advanced education, but simply not within the confines of an MSN program. When the newer national guidelines required an MSN, these NNPs were "grandfathered in". Since some of them had been practicing for 20 years or more, it would have been quite the hardship to ask them all to return to school to obtain an MSN. However, any new NNP is required to have an MSN. The BSN/certificate prepared NNP could still apply for an NNP position, on the basis of experience and prior education, but most hospitals prefer their NNPs have a MSN, and encourage them to return to school to obtain one. I personally ran into this issue, as I am almost finished with my NNP degree. When I was doing precepted clinical hours in the NICU, I could only be there if there was an MSN NNP on staff that day, due to my university's requirements. We still have 3-4 (out of 12) NNPs that have their certificate only, so I had to make sure to schedule around them. I was kind of disappointed, as I felt these practitioners would have a significant amount to teach me, given that they have worked there since the 70s! However, they have often mentioned the difficulty they would have getting a position elsewhere without their MSN. Hope this helps!

I would think along the lines of a "risk for" diagnosis if you cannot find anything in his assessment to support a problem. Or if you feel mom is not understanding the infant's true condition, what about an education/knowledge diagnosis? Think it through and let us know what you come up with!!

This is one of those questions that plauges the NICU, so it's completely normal to be confused by this! The overriding thing that I try to remember in this situation is that in GENERAL, too much oxygen is much more harmful than too little, especially when dealing with the tiny micros. I read some research recently that said even in babies allowed to have SpO2s in the 70s for 10-20 minutes at a time, the risk of CP or developmental delays did not increase. However, spending relatively little time with high SpO2s (>95%) was certainly associated with an increased risk of ROP and CLD. I will try to find and post the link to that study if I can. The other piece of research out of that study was that the rapid swings in FiO2 needs are more damaging than a few minutes of decreased sats- meaning it is better to leave the kiddo to recover on their own than crank them up right away. The other concept that is difficult to understand in relation to this is what your pulse oximeter is really telling you. In the case of lower saturation, your SpO2 will do a fairly good job of reflecting a decrease in your PaO2 (should you get a blood gas). However, a baby whose SpO2 is 100% could have a PaO2 of 85, or of 150! The pulse oximeter cannot determine that, and it is as the PaO2 rises that your oxygen associated complications increase. Make sense? You are doing the right thing by going to the bedside and assessing your baby, making sure there isn't something besides "normal preemie" that is causing him to desaturate, such as kinked tubing. I know that it is hard to stand back and wait, especially with parents near by or that blasted alarm sounding. Unfortunately, there is no set time limit for how long to wait- it would be awesome if they did a study and said, "Oh, yes, it is safe to increase the FiO2 after 2.37 minutes..." but that will never happen. Instead, look at the baby and the monitor. Is the child agitated? Could some gentle containment help? Is he becoming dusky or working harder to breathe? Is bradycardia beginning? Are his saturations continuing to decrease, or have they stabilized at a lower number and begun to slowly come back up? All of these things play into your decision to increase the FiO2. When you do decide, after some careful assessment, that he could use a little bump, go s-l-o-w-l-y. My NNP professors recommend 2-5% to begin. Then wait again, and assess. If after another couple minutes (literally, minutes) he needs more O2, do another small bump. Remember, too, to turn the baby back down slowly after they have recovered, as well- those big swings are killers! You are doing the right thing by trying to care for him in a efficient and calm manner (such as with diaper changes), but keep in mind that often these little guys just don't have the capacity to have their care clustered as much as we would like. If he is ok for the first part of your hands on cares, then kinda freaks and desats, maybe he needs a 10 minute break or so. Stop, chart what you've already done, and let him recover.Then, once he is comfortable again, you can finish what you need to do, and THEN leave him undisturbed for as long as possible. It is awesome to know that you are thinking about this in your patients. You will see the nurses- every unit has them- that have worked there long enough to remember when every baby was placed in 100% FiO2. When their baby desats, they hop on over and crank them up a good 30-50%, or worse, hit the dreaded "suction" button on the vent that automatically gives 100% FiO2. It is the way they were trained, and often, even with education, old habits die hard. It is hard, too, as a new grad, when you feel like you aren't DOING anything to help the baby in front of you- I understand. But know in your heart that waiting is helping, and be prepared to explain this to families or even other nurses who say, "Why aren't you DOING something?" Reassure moms that a few minutes of desats will not brain damage their child, and that minimizing FiO2 changes will improve their long term outcomes. Talk to your unit educator or former preceptor if you need some back up on that. Finally, in terms of taking care of a 24 weeker. Make sure the environment in his bed is comfortable and he is positioned well (extremities brough to midline, head neutral, shoulders and hips rounded, good boundaries). Keep it dark and quiet in his area. If going from prone to supine for cares, turn him slowly and support his head well. All of these little things may help improve on the number of desaturations he has, and the "shock" of hands on cares. Encourage kangaroo time with mom, as allowed in your unit. And know that as a new grad, this is very, very hard, and it sounds like you are doing a great job!!

I don't know the weights of the babies at this point, but in my NICU, we follow a protocol that any baby less than 1500g has an OG regardless of NC or CPAP. This is based on research regarding nasal/sinus deformities in VLBW kids and the whole "obligate nose breather" thing. We have found that it doesn't appear to make much difference in the baby's ability to nipple, but of course that is entirely anecdotal. I know different units have different policies, perhaps this NICU has similar protocols to mine.

The problem with the "risk for pulmonary embolism" diagnosis is that it is not actually a nursing diagnosis. But you are on the right track. What nursing diagnosis would a pulmonary embolism cause?

When I think about PPHN, it helps me to think about it's other name- persistent fetal circulation- because that really does describe what is going on. In utero, the baby's blood supply comes in through their umbilical vein, up to their right atrium, and the majority goes through the foramen ovale, into the left atrium and out to the body through the ductus arteriosus. After the ductus, the blood circulates out to the body and back to the mother via the umbilical artery. Very little blood flows to the lungs via the pulmonary artery because the pressure in the artery as well as pulmonary vascular resistence is very high. So more simply, the blood comes in, bypasses the lungs, goes out to the body and back out to the placenta- round and round and round. When a baby is in utero, this is no big deal because the placenta does the oxygenating for the baby. This is another reason the pO2 of a fetus is so very low- like 20-25. PPHN occurs when the baby's body doesn't figure out it has to switch from being a fetus to being a "big kid" now. Normally, with the first few breaths, the pulmonary vascular resistance (higher blood pressure in lungs) goes down, and the systemic vascular resistance (blood pressure in the body) goes up. When the higher blood pressure in the lungs goes down, blood can flow to the lungs easily and be oxygenated there. This change, as well as the raising of the systemic pressure helps close the foramen ovale and ductus arteriosus, so blood flows through the heart in what we think of as a normal pattern- right atrium to right ventricle, out to lungs via pulmonary artery, back to left atrium via pulmonary vein, to left ventricle and out to body via aorta. Several things cause the changes in blood pressure I talked about- the raising of the baby's pO2, the mechanical forces of the first breaths, the loss of certain substances from the placenta, even fluid shifts in the body- all normal processes at birth. When the newborn's body does not undergo this transition- boom! You have PPHN. Babies in certain situations are more likely to have PPHN- those with hypoplastic lungs, meconium aspiration, hypoxia/asphyxia at birth, sepsis, diaphagmatic hernia all come to mind. This is because there are already factors impairing their oxygenation/ventilation/acid base status, etc, so their normal transition does not occur. Books will tell you the signs and symptoms of PPHN include cyanosis, tachypnea, low pO2 with normal-ish pCO2, possible cardiac murmur, and often a notable difference in their preductal (right hand) SpO2 and their post ductal (either foot) SpO2. From practice, I can say that these kids are often the term/near term kids that were born through mec, normal appearing for the first few hours. Then they seem to crash and burn, requiring way more O2 per hood or cannula, etc. than you would expect for their GA. Their work of breathing increases significantly and they just look crappy! Treatment often includes placement of UA/UV for good access and careful BP/ABG monitoring- you often end up with multiple drips (sedation, pressors, etc) to run on these kiddos- as well as intubation and ventilation with an oscillator for oxygenation and to help reduce CO2 retention. Nitric oxide, a pulmonary vasodilator, is often used to help promote relaxation of the pulmonary vessels. Minimal stimulation is recommended, with carefully controlled light/sound and sedation, as a stressed or struggling infant can reverse any progress that is being made in relaxing those vessels. We always treat with antibiotics to rule out any possible septic causes. Occasionally, these infants need ECMO to provide their oxygenation until their own body can adapt to the task- finally switching from fetal to regular newborn circulation. I hope this makes sense! If it doesn't, please PM me and I'll try to help you. I'm doing a study on PPHN for my NNP program right now, so this is a favorite topic of mine.

I am working on finishing my NNP, and one of my professors is very heavily involved in a study right now that is comparing the effects of buprenorphine and methadone. They have studied over 800 infants born to mothers whose addiction was either treated with methadone or Subutex throughout their pregnancies, with a focus on the severity and length of withdrawal symptoms in those babies. Their hypothesis is that the Subutex will less severe symptoms and shorter withdrawal periods after birth, and their preliminary research evidently supported this. However, since the study is double-blind, there is no way to know for sure what they are finding now until the study is completed. I do know that if they find their hypothesis is correct, they plan on petitioning the FDA to change their recommendation to Subutex instead of methadone to treat addiction in pregnancy. I think it is unfair of the doctors to give Subutex to mothers instead of methadone under the pretense that it will not cause ANY withdrawal symptoms in their infants, when there is clearly research otherwise. Even if the study is successful, no one is suggesting that these infants don't withdraw, just that it may be easier on them. THAT is the information that should be given to moms, and the babies should be screened and treated as appropriate after they are born!

We most certainly do have rehab people involved in our NICU. Physical therapy, occupational therapy and speech/language pathologists all are involved in the care of some of our infants. Specifically, speech language pathologists come to work on feeding therapy with infants who are having difficulty acquiring bottle-feeding skills. Since these therapists are specialists in how the lips, tongue and jaw move, they can be very helpful in this! They are also involved in performing swallowing studies, which determine if a baby is at risk for inhaling fluids into their lungs when they eat. This helps us decide whether a baby needs their milk thickened. PT is used a little less often, usually with infants who have been there long term- think a 24 week infant who is now 3-4 months old. These babies need help maintaining their range of motion and developmental milestones such as holding their head up, etc. since they have often been on a ventilator long term or had other treatment related things that have impaired their normal abilities. PT is also involved with babies that have a specific condition limiting their range of motion- for instance, today I was caring for an itty-bitty boy that has some necrosis of his fingers and toes related to a central line placement. Because those necrotic areas do not move normally, PT is helping him maintain whatever function he can in those extremities. OT is probably the most rarely used rehab service in our NICU. They will sometimes be involved in caring for our long term babies, like mentioned above, and I have seen them work on skills such as learning to feed from a spoon. That baby had been in the NICU for about 9 months when they attempted that, however. Just today, in caring for my tiny man, OT was consulted to help work on hand movements, since fine motor rehab is a skill they frequently use in the adult population. In terms of how much time the therapists spend in the NICU, I would say that at any given time, 5-10 of our 50-60 patients are being seen by one rehab service or another. I probably see a therapist each shift I work, but not necessarily one from each discipline. However, I work in a children's hospital, so the therapists also cover general pediatrics, PICU, PICU/NICU stepdown units and outpatient rehab for kids in the community, so I suspect they stay very busy. I would say, if you feel your interests lie in caring for NICU kids, go for it! Attempt to arrange a shadowing opportunity with a therapist, or see if a local NICU has volunteer opportunities, just to see if NICU could really be your thing. Good luck!:)

Our NNPs have recently started putting these dual lumen PICCs in some of our larger babies- not sure why they are choosing just the bigger ones, I haven't seen P/P on them at all yet. Mostly, they are wonderful, in that you don't have to stop your TPN to run a med and such. They have proven especially helpful with our pre-op cardiac kids, who are often lacking reliable access and have several drips going at once. One problem we have noted is that the babies have a tendency to be able to twist the lines and cause an occlusion of the flow- somehow they can move enough to bend or tangle the line between where it comes out from under the occlusive dressing and where it attaches to the actual IV tubing, if that makes any sense. Then your pump alarms and you have to go untwist the darn thing. We've been devising creative taping methods in addition to the regular central line dressing to try and prevent this problem, LOL. However, it is a small price to pay to gain twice the access of our previous PICCs.