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 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 33  |  Issue : 3  |  Page : 744-749

Updated management protocols of common situations in neonatal intensive care units


Department of Pediatrics, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission10-Jan-2019
Date of Decision19-Feb-2019
Date of Acceptance02-Mar-2019
Date of Web Publication30-Sep-2020

Correspondence Address:
Mohammad H. A. Shahin
Shibin El-Kom City, Menoufia Governorate
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_10_19

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  Abstract 


Objective
To review the updated management protocols of common situations in the neonatal intensive care unit (NICU).
Data sources
A systematic search of MEDLINE (PubMed, Medscape, ScienceDirect, EMF-Portal) and Internet was conducted on all articles published from 2000 to 2018.
Study selection
English-language reports of the updated management protocols of common situations in the NICU. The initial search presented 160 articles where 23 had inclusion criteria.
Data extraction
Articles not reporting on updated management protocols of common situations in the NICU in the title or abstract were not included. Fifteen independent investigators extracted data on the methods.
Data synthesis
Comparisons were made by a structured review with the results tabulated. Seven authors emphasized on the new approaches for managing neonatal hypoglycemia, 16 about the management of neonatal hyperthermia, seizures, and transport.
Findings
Dextrose gel is safe and has the potential to decrease health-care costs and other risks related to the treatment of hypoglycemia. Antiepileptic drugs are then administered according to clinical preference, independent of the seizure cause. It should only be initiated once seizure activity is confirmed, due to a lack of evidence for any positive outcomes if they are administered in the absence of seizures. As a mobile ICU, transport vehicles, equipment, and supplies must reflect the needs of the patient population.
Conclusion
Further phrasing of guidelines to cover all aspects of neonatal care in the NICU, following the application of the set protocols in the practical field. Detecting improvement or deterioration of the outcome after applying these protocols to have an 'evidence-based' judgment over these selected guidelines.

Keywords: hyperthermia, hypoglycemia, management protocols, seizures, transport


How to cite this article:
El-Mashad GM, El Said HM, Shahin MH. Updated management protocols of common situations in neonatal intensive care units. Menoufia Med J 2020;33:744-9

How to cite this URL:
El-Mashad GM, El Said HM, Shahin MH. Updated management protocols of common situations in neonatal intensive care units. Menoufia Med J [serial online] 2020 [cited 2020 Oct 29];33:744-9. Available from: http://www.mmj.eg.net/text.asp?2020/33/3/744/296645




  Introduction Top


The neonatal intensive care unit (NICU) is a therapeutic environment, a collection of equipment, and a qualified team that is guided by a wise leadership and by a body of scientific knowledge [1]. All good neonatal units follow a protocol-based management of sick neonates for uniform standard clinical care [2]. Consenting to follow the agreed protocols serves as a catalyst for new ideas to improve clinical care. These protocols however must be viewed as generic in nature [3]. Suitable adaptation may be done at individual centers through the process of consultation with other team members [4]. As new evidence emerges, and one's own experience becomes richer, the protocols will need to be updated and revised [5]. Neonatologists in developed countries accommodate the continuous development and change in the knowledge and policy guiding the management of different situations in the NICU. For that there is a wide gap between developed countries and developing countries as regards neonatal morbidity and mortality and the main reason for that gapping is not only lack of resources, but also lack of a system and protocols for the management of the most common situations in the NICU which guarantee better care and better outcome in our units [6]. Therefore, the aim of this study was to review the updated management protocols of common situations in NICU.


  Materials and Methods Top


Data sources

A systematic search on the updated management protocols of common situations in NICU. Using MEDLINE (PubMed, Medscape, ScienceDirect, EMF-Portal), and Internet was conducted on all articles published from 2000 to 2018. During the research that focused on new approaches for managing neonatal hypoglycemia, management of neonatal hyperthermia, seizures, and transport were used as searching terms. Additional records were identified by reference lists in retrieved articles. The search was established in the electronic databases from 2000 to 2018.

Study selection

Eligible articles were published in peer-reviewed journals and were written in English. Articles not reporting updated management protocols of common situations in NICU in the title or abstract were not included. Full-text articles were screened, and the final inclusion decisions were made according to the following criteria: original studies, systematic reviews, or meta-analyses; primary or first-line treatment; and, if necessary, secondary treatment was described, and treatment success, complications, and side-effects were described.

Data extraction

Articles not reporting on updated management protocols of common situations in NICU in the title or abstract were not included. Thirteen independent investigators extracted data on methods, health outcomes, and traditional protocol. Surveys about symptoms and health without exposure assessment, report without peer review, not within the national research program, letters/comments/editorials/news, and studies not focused on exposure from the prevalence of nocturnal enuresis.

The analyzed publications were evaluated according to the evidence-based medicine (EBM) criteria using the classification of the US Preventive Services Task Force and UK National Health Service protocol for EBM in addition to the evidence pyramid [7].

US Preventive Services Task Force [7]:

  1. Level I: evidence obtained from at least one properly designed randomized controlled trial
  2. Level II-1: evidence obtained from well-designed controlled trials without randomization
  3. Level II-2: evidence obtained from well-designed cohort or case–control analytic studies, preferably from more than one center or research group
  4. Level II-3: evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled trials might also be regarded as this type of evidence
  5. Level III: opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.


Study quality assessment

Quality of all the studies was assessed. Important factors included study design, ethical approval, calculation of evidence power, specified eligibility criteria, appropriate controls, adequate information, and specified assessment measures. It was expected that confounding factors would be reported and controlled for and appropriate data analysis made in addition to an explanation of missing data.

Data synthesis

A structured, systematic review was done with the results tabulated. Seven authors emphasized on the new approaches for managing neonatal hypoglycemia, eight about the the management of neonatal hyperthermia, and eight about the management of neonatal seizures and transport.


  Results Top


Study selection and characteristics

A systematic search on updated management protocols of common situations in NICU using MEDLINE (PubMed, Medscape, ScienceDirect, EMF-Portal) and internet was conducted on all articles published from 2000 to 2018. Articles not reporting on new approaches for managing neonatal hypoglycemia, management of neonatal hyperthermia, seizures, and transport in the title or abstract were not included. Fifteen independent investigators extracted data on the methods, health outcomes, and traditional protocol. Potentially relevant publications were identified, 137 articles were excluded as they are away from our inclusion criteria. Twenty-three studies were reviewed as they met the inclusion criteria. Seven authors emphasized on new approaches for managing neonatal hypoglycemia, eight about the management of neonatal hyperthermia, and eight about the management of neonatal seizures and transport.

Regarding these studies there were two cohort studies [8],[9] that falls under the second level regarding the pyramid of EBM; it is reported that neonatal hyperglycemia is one of the most common metabolic abnormalities encountered in preterm and critically ill newborns. Also, three prospective studies [2],[3],[10] comes to level II-2 or (level B) and reported that prevention of neonatal hypoglycemia includes prompt identification of at-risk neonates, initiation of early feeding, and provision of breastfeeding support. In addition, observation of symptoms attributable to hypoglycemia should prompt an urgent evaluation and the initiation of treatment to prevent the central nervous system effects of hypoglycemia. The dextrose gel (200 mg/kg) was massaged into the infant's dried buccal mucosa and the infant was encouraged to feed. The treatment with gel continued for a total of six doses over 48 h in addition to, two randomized control studies [4],[11] come to level I or (level A) reported that dextrose gel is safe, and has the potential to decrease health-care costs and other risks related to the treatment of hypoglycemia, including decreased breastfeeding. One important observation is that many episodes of hypoglycemia, documented by both blood obtained per their low glucose concentration screening protocol and continuous glucose monitoring (CGMS) measurements, resolved spontaneously, and were not associated with bedside nursing observations of clinical signs that might be interpreted as symptoms of hypoglycemia [Table 1].
Table 1: New approaches for managing neonatal hypoglycemia

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Regarding management of neonatal hyperthermia, two case analyses [12],[13] fall under the second level regarding the pyramid of EBM. It has been reported that hyperthermia is defined as a temperature that is greater than the normal core temperature of 37.5°C. Infection should always be suspected first, unless there are very obvious external reasons for the baby becoming overheated, while three randomized case–control studies [14],[15],[16] come to level I or (level A) and showed every birth should be attended by at least one person who can perform the initial steps of newborn resuscitation and positive pressure ventilation (PPV), and whose only responsibility is care of the newborn. It is important that the baby be breastfed more frequently to replace fluids. If the baby cannot be breastfed extra fluids should be given intravenously or by tube. Also, three prospective studies [17],[18],[19] come to level II-2 or (level B) found that the baby can be given a bath. The water should be warm. If it is possible to measure the water temperature, it should be about 2°C lower than the baby's body temperature. Using cooler or cold water is dangerous. It may not achieve the desired effect and the baby may very quickly become hypothermic. Acetaminophen (5–10 mg/kg per dose, orally or rectally, every 4 h) [Table 2] was given.
Table 2: Management of neonatal hyperthermia

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Regarding management of neonatal seizures and transport, there were two prospective studies [4],[20] come to level I or (level A) and they showed that neonatal seizures are paroxysmal, repetitive, and stereotypical events, mostly clinically subtle, inconspicuous, and very difficult to recognize. Very high level of experience is necessary to differentiate neonatal seizures from the normal behaviors of the inter-ictal periods or physiological phenomena. Neonatal seizures do not present with clear clinically recognizable post-ictal state, while four randomized case–control studies [6],[15],[21],[22] come to level I or (level A). It has been reported that conventional video-electroencephalography is the gold standard for neonatal seizure detection and is critical for studies that attempt to quantify seizure burden and/or treatment responses. Antiepileptic drugs (AEDs) are then administered according to clinical preference, independent of seizure cause. AEDs should only be initiated once seizure activity is confirmed, due to a lack of evidence for any positive outcomes if they are administered in the absence of seizures. Also, two cohort studies [23],[24] fall under the second level regarding the pyramid of EBM and reported that there is no evidence that choosing one professional group over another will provide a more effective transport service. Instead, it is critical that transport services are planned with training as a central activity, both for new staff joining the service and continuing education for the existing staff [Table 3].
Table 3: Management of neonatal seizures and transport

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  Discussion Top


Neonatal hyperglycemia is one of the most common metabolic abnormalities encountered in preterm and critically ill newborns. Although the definition varies, a blood glucose concentration greater than 125 mg/dl (6.9 mmol/l) or a plasma or serum glucose concentration greater than 150 mg/dl (8.3 mmol/l) regardless of gestational age is often used [8],[9]. Prevention of neonatal hypoglycemia includes prompt identification of at-risk neonates, initiation of early feeding, and provision of breastfeeding support. In addition, observation of symptoms attributable to hypoglycemia should prompt an urgent evaluation and the initiation of treatment to prevent the central nervous system effects of hypoglycemia [2]. The dextrose gel (200 mg/kg) was massaged into the infant's dried buccal mucosa and the infant was encouraged to feed. If the baby still had a low glucose concentration 30 min after gel administration, or if the baby developed recurrent hypoglycemia, the treatment with gel continued for a total of six doses over 48 h [10]. In these newborns, dextrose gel decreased the number of episodes of hypoglycemia, decreased the recurrence rate of hypoglycemia, increased exclusive breastfeeding rates at discharge, and decreased the need for admission to the NICU to treat hypoglycemia [3]. In summary, dextrose gel is safe, and has the potential to decrease health-care costs and other risks related to the treatment of hypoglycemia, including decreased breastfeeding [11]. Another interesting feature of the dextrose gel study is the use of CGMS to continuously monitor interstitial glucose concentrations. One important observation is that many episodes of hypoglycemia, documented by both blood obtained per their low glucose concentration screening protocol and CGMS measurements, resolved spontaneously, and were not associated with bedside nursing observations of clinical signs that might be interpreted as symptoms of hypoglycemia [4].

Hyperthermia is defined as a temperature that is greater than the normal core temperature of 37.5°C [12]. However, it is not possible to distinguish between fever and hyperthermia by measuring the body temperature or by clinical signs, and when the newborn has a raised temperature it is important to consider both causes. Infection should always be suspected first, unless there are very obvious external reasons for the baby becoming overheated [13]. Every birth should be attended by at least one person who can perform the initial steps of newborn resuscitation and PPV, and whose only responsibility is care of the newborn [14]. Defining the cause of the elevated body temperature is the most important initial issue. Determine whether the elevated temperature is the result of a hot environment or increased endogenous production, such as is seen with infections [15]. The baby should be moved away from the source of heat, and undressed partially or fully, if necessary. If the baby is in an incubator, the air temperature should be lowered [13]. It is important that the baby be breastfed more frequently to replace fluids. If the baby cannot be breastfed extra fluids should be given intravenously or by tube [16]. The baby can be given a bath. The water should be warm. If it is possible to measure the water temperature, it should be about 2°C lower than the baby's body temperature. Using cooler or cold water is dangerous. It may not achieve the desired effect and the baby may very quickly become hypothermic [17]. Acetaminophen (5–10 mg/kg per dose, orally or rectally, every 4 h) is given [18]. In hyperthermia due to environmental overheating, antipyretics are ineffective, and newborns are appropriately managed by reducing the environmental heat exposure [19].

Neonatal seizures are paroxysmal, repetitive, and stereotypical events, mostly clinically subtle, inconspicuous, and very difficult to recognize. Very high level of experience is necessary to differentiate neonatal seizures from the normal behaviors of the inter-ictal periods or physiological phenomena. Neonatal seizures do not present with clear clinically recognizable post-ictal state [20]. Conventional video-electroencephalography is the gold standard for neonatal seizure detection and is critical for studies that attempt to quantify seizure burden and/or treatment responses [21]. Once neonatal seizures are suspected, the neonate should be rapidly assessed for treatable underlying causes, such as hypoglycemia or electrolyte disturbances. AEDs are then administered according to clinical preference, independent of the seizure cause. AEDs should only be initiated once seizure activity is confirmed, due to a lack of evidence for any positive outcomes if they are administered in the absence of seizures [6]. Providers of neonatal transport services can make choices on the composition of transport teams on the basis of staff supply, transport demand, budget, and other local factors. There is no evidence that choosing one professional group over another will provide a more effective transport service. Instead, it is critical that transport services are planned with training as a central activity, both for new staff joining the service and continuing education for existing staff [23]. Neonatal transfers generally require more interventions and involve more complications when compared with other populations. In one study of 295 neonatal transfers, 19.8% of the neonates required intubation, compared with 7.5% of infants and 4.9% children; almost half of transport complications in neonates were airway related [15]. A very high level of expertise is necessary because practical procedures may be needed in the transfer environment [22]. As a mobile ICU, transport vehicles, equipment, and supplies must reflect the needs of the patient population. The weight and bulk of equipment must not exceed the standards for the occupational health and safety of crew members. Recent recommendations require all equipment to be fixed and crash-tested before use in air or land vehicles [24].


  Conclusion Top


This review found that further phrasing of guidelines to cover all aspects of neonatal care in NICU is necessary. Routine revision and updating of protocols every 2 years are required, following the application of the set protocols in the practical field. Detecting improvement or deterioration of the outcome after applying these protocols is necessary to have an 'evidence-based' judgment over these selected guidelines.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3]



 

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