Your SlideShare is downloading. ×

03 advances in neonatal care june2010


Published on

Published in: Health & Medicine, Education
  • Be the first to comment

  • Be the first to like this

No Downloads
Total Views
On Slideshare
From Embeds
Number of Embeds
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

No notes for slide


  • 1. Egyptian_Pediatric yahoo group Egyptian_Pediatric yahoo group egyptian_pediatric/ egyptian_pediatric/
  • 2. Don’t Put Off Your EducationCatherine L. WittT he question of educational preparation for practitioners who must consider returning to school nursing practice is not new. Forty-five years to obtain a doctorate of nursing practice and nurses ago in 1965, the American Nurses Association who must consider earning a baccalaureate degree.published a position paper calling for the baccalau- There are certainly many practicing nurses who doreate degree as the minimum requirement for entry not have a baccalaureate degree and provide safe,into professional nursing practice.1 It is interesting effective care to their patients. They have a wealth ofthat nearly a half century later, we are no closer to experience that is invaluable. They may reasonablyachieving this standard. Many components of the question the value of returning to school in the mid-debate have not changed. Healthcare continues to dle of a satisfying career. One author looked at bar-become increasingly complex. The amount of knowl- riers that prevented nurses from pursuing a BSNedge required to provide safe patient care has degree.6 Incentives included increased options inincreased substantially. Nurses are also required to their career, including improved mobility and oppor-have an in-depth knowledge of healthcare systems, tunities. The possibility of pursuing an advancedinformation technology, and research methodology. degree that would allow for advanced practice nurs-An increasing number of studies have shown that ing, management opportunities, or teaching careersthere is a connection between baccalaureate nursing was another incentive. Barriers included not enougheducation and lower mortality rates.2-4 time, lack of confidence, and lack of recognition by Despite this evidence, in 2004, only 47.2% of RNs employers. Previous negative experiences in schoolcurrently working have a baccalaureate or graduate were also noted as a Fifty-one percent of RNs currently working Employers can do more to encourage their staff tohave an associate degree or a diploma in nursing.5 This return to school. Tuition reimbursement and studentis in contrast to other healthcare professionals with loan forgiveness programs can help. Pay differentialswhom patients interact. Physical therapists, occupa- that reward education and requiring a BSN degree fortional therapists, pharmacists, social workers, audiolo- leadership positions can also provide incentives.gists, and speech therapists have not only a baccalau- Changing state or certification requirements havereate degree but also graduate degrees. This argument proved to be a big incentive for advanced practicehas been used to justify requiring nurse practitioners to nurses. Schools of nursing can help by recognizing andhave a doctoral degree but should illustrate the need giving credit for educational and work experiences.for a baccalaureate degree (BSN) as a minimum entry- Easy transfer of credits from associate degree pro-level educational criterion for nurses. grams to 4-year schools should be made standard. There are many other arguments for increasing the Increased federal funding of nursing education at therequirement for entry into practice. Unfortunately, baccalaureate and graduate levels should be a priority.despite 45 years of debate, we have not made much However, waiting for someone to make you pur-progress as a system. Human nature being what it is, sue a degree is not very proactive. The desire tomany will put off pursuing this degree until it is increase one’s professional credibility and careerrequired. I would ask you to consider this waiting options should be a driving force. In fact, states, hos-until someone makes you do something, meaning pitals, and certification boards can change rules andthat you might put it off until it is too late. Some nurse requirements for various positions with little warning,practitioners have learned this to their detriment. meaning that by the time someone makes you get aWhile most states have “grandfathered” those practi- degree, you will not have adequate time to make ittioners who do not have a master’s degree, changing happen. Also, if you are waiting until you have time,rules requiring certification, prescriptive authority, or consider that you will likely never have unlimitedother factors have limited the ability of a few to prac- free time in which to pursue a degree unhindered.tice. It is possible that future changes in nurse prac- You have to make available the time. There are nowtice acts will limit the practice of those who do not more options than ever: online programs, acceler-have the necessary education. This applies to nurse ated programs, traditional classroom programs, andAdvances in Neonatal Care • Vol. 10, No. 3 • pp. 105-106 105
  • 3. 106 Witteven on-site work programs in collaboration with 2. Aiken LH, Clarke SP, Cheung RB, Sloane DM, Silber JH. Educational levels of hospital nurses and surgical patient mortality. JAMA. 2003;290:1617-1623.hospitals and universities. Don’t wait until it is too 3. Aiken LH, Clarke SP, Sloane DM, Lake ET, Cheney T. Effects of hospital carelate. There is no time like the present. environment on patient mortality and nurse outcomes. J Nurs Adm. 2008;38:223-229. 4. Estabrooks CA, Midodzi WK, Cummings CG, Ricker KL, Giovanetti P. The impact of hospital nursing characteristics on 30-day mortality. Nurs Res.References 2005;54,72-84.1. Nelson MA. Education for professional nursing practice: looking backward 5. American Association of Colleges of Nursing. Fact Sheet: creating a more into the future. Online J Issues Nurs. 2002;7:3. Manuscript No. 3. highly qualified nursing work force. pdf/nursingworkforce.pdf. Accessed March 14, 2010. ANAPeriodicals/OJIN/TableofContents/Volume72002/No2May2002/ 6. Megginson LA. RN—BSN education: 21st century barriers and incentives. EducationforProfessionalNursingPractice.aspx. Accessed March 14, 2010. J Nurs Manag. 2008;16:47-55.
  • 4. LAURA A. STOKOWSKI, RN, MS • Section EditorHospital Stay for Healthy Parents’ MedicationTerm Newborns Administration ErrorsT B he American Academy of Pediatrics has pub- efore discharge, nurses often teach parents how lished a revised policy statement, “Hospital to draw up and administer oral medications that Stay for Healthy Term Newborns.” It is the the parents need to administer to their infants atfirst revision in 15 years and contains many evidence- home. Although we may send home an oral syringe orbased updates. Here are a few of the updates; for all two for this purpose, who really knows how parentsdischarge-readiness criteria and the complete set of are measuring these medications after they go home?changes, please see the policy statement.1 A simple, yet practical, study1 recently assessed the ability of 302 parents to measure liquid medications • Along with stable vital signs, newborns should in 6 different commonly available measuring instru- have no signs of respiratory distress. ments (2 types of dosing cups, a dosing spoon, a cal- • Infants should complete 2 successful consecutive ibrated dropper, and 2 types of oral syringes). The feedings. volume of these instruments ranged from 5 to 30 mL. • Clinical risk of development of subsequent Participants were asked to measure a test medica- hyperbilirubinemia has been assessed, and tion in each of the 6 methods presented. An error was appropriate management or follow-up plans or generously defined as 20% or more than 20% over or both have been instituted. under the intended dose. The actual dose measured • Evaluation and monitoring for sepsis on the by participants was determined by weighing the basis of maternal risk factors. measured sample and subtracting the weight of the • Screening tests in accordance with state regula- measuring instrument. In addition, the investigators tions includes a test for human immunodefi- examined the potential role of health literacy in the ciency virus. parents’ ability to accurately measure medications. • Newborn hearing screenings have been Health literacy was assessed with the Newest Vital completed. Sign Test, which classifies health literacy as limited, • Mothers’ infant-feeding techniques are assessed possibly limited, or adequate. by trained staff. Errors were alarmingly frequent with some meas- • Along with safety in the home, a smoke-free uring instruments, and almost all errors were over- environment and room sharing are emphasized. doses. Errors were most frequent and most significant • The presence of communicable illness in the with the 2 dosing cups, and least frequent with oral home is assessed. syringes. Only 30% of parents measured the test dose • Continuing care after discharge includes identi- accurately with a dosing cup that had printed cali- fication of a medical home for the infant. bration marks, and 50% measured accurately with a • Barriers to adequate follow-up are identified dosing cup that had etched calibration marks. The and assistance is given as appropriate (trans- most accurate instrument was the standard oral portation, translators) syringe, with which 91% of parents measured the test dose within 20% of the intended dose. The updated policy statement also describes the Both instrument type and health literacy had inde-purpose and requirements of the first newborn fol- pendent effects on the rate of error. Dosing cups werelow-up visit. associated with large overdosing errors, and parentsReference who had low health literacy were most at risk of mak-1. American Academy of Pediatrics, Committee on Fetus and Newborn. Policy ing an error. Part of the discharge teaching with respect statement: hospital stay for healthy term newborns. Pediatrics. 2010;125: to oral medications should include the importance of 405-409. continuing to use an oral syringe to measure liquid medications, and cautioning parents about using dos-Address correspondence to Laura A. Stowkowski, RN, MS; ing cups to measure their infant’s medication Affiliation: Inova Fairfax Hospital for Children, FallsChurch, Virginia. Reference 1. Yin HS, Mendelsohn AL, Wolf MS, et al. Parents’ medication errors: role ofCopyright © 2010 by the National Association of dosing instruments and health literacy. Arch Pediatr Adolesc Med. 2010;Neonatal Nurses. 164:181-186.Advances in Neonatal Care • Vol. 10, No. 3 • pp. 107-109 107
  • 5. 108 Stokowski oration or critical illness at a later age, premedicationSevere Combined Immunodeficiency should be used for all endotracheal intubations inAdded to Uniform Newborn newborns. Medications with rapid onset and short duration of action are preferable. RecommendationsScreening Panel for premedication include the following:A historic unanimous vote early this year by • analgesic agents or anesthetic dose of a hypnotic the Secretary’s Advisory Committee for drug should be given (fentanyl, remifentanil, Heritable Disorders in Newborns and and morphine);Children paves the way for severe combined immun- • vagolytic agents and rapid-onset muscleodeficiency (SCID) to be the latest addition to the relaxants should be considered (atropine,uniform newborn screening panel performed by state glycopyrrolate);public health programs. • use of sedatives alone, such as benzodiazepines The SCID is a rare group of generic disorders with (midazolam) without analgesic agents, shouldan estimated incidence of 1 in 40,000—100,000 new- be avoided;borns, and perhaps higher as a result of undiagnosed • a muscle relaxant should not be used without ancases.1 The SCID is a lethal disorder of adaptive analgesic (pancuronium, vecuronium, etc);immunity, characterized by the absence of T-lym- andphocytes. With essentially nonfunctional immune • each NICU should develop protocols andsystems, infants with SCID are at the mercy of their lists of preferred medications to improve com-surroundings and must live in protected environ- pliance and minimize medication errors andments (eg, “boy in the plastic bubble”) where expo- adverse effects.sure to infectious agents can be minimized. Without treatment, recurrent opportunistic infections A full table of medications, doses, and routes ofare eventually fatal. However, because SCID has no administration can be found in the article.1overt signs or symptoms, the only way to save affectednewborns is to identify them with universal newborn Referencescreening and perform early stem cell transplantation. 1. Kumar P, Denson SE, Mancuso TJ; Committee on Fetus and Newborn, Section on Anesthesiology and Pain Medicine. Premedication for non- In 2005, the Advisory Committee for Heritable emergency endotracheal intubation in the neonate. Pediatrics. 2010;Disorders in Newborns and Children adopted a list 125:608-615.of 29 conditions recommended for newborn screen-ing. Since that time, only 6 conditions (Fabry disease,Krabbe disease, Niemann-Pick disease, Pompe dis- Sepsis in Late Preterm Infantsease, spinal muscular atrophy, and SCID) have been Ibrought to the committee for consideration of inclu- t is now well known that late preterm infantssion in the uniform newborn screening panel. The (born with estimated gestational ages of 34-36 wk)SCID is the first condition to be added to the manda- are at high risk for numerous problems, such astory newborn screening panel since 2005. hyperbilirubinemia, hypoglycemia, and respiratory distress. Early- and late-onset sepsis and sepsis-Reference related mortality are also believed to occur more fre-1. National Human Genome Research Institute. Severe combined immunod- quently in this gestational age group. eficiency. Accessed March 19, 2010. In the largest observational study conducted to date, Cohen-Wolkowiez and colleagues1 prospec- tively collected data from 119,130 late pretermPremedication for Nonemergency infants admitted to 248 NICUs to determine specificIntubation in the Neonate infection rates, pathogen distribution, and mortality associated with early- and late-onset sepsis. A bloodA recent evidence-based review of premedica- culture was obtained from most (69%) of these new- tion for nonemergent intubation in the borns within the first 3 postnatal days. Whether these neonate was published by the American blood cultures were prompted by clinical signs ofAcademy of Pediatrics Committee on Fetus and sepsis or premature birth is unclear.Newborn.1 An ideal strategy for premedication for A total of 531 episodes of early-onset sepsis (EOS)intubation eliminates the pain, discomfort, and phys- were documented for a cumulative incidence of 4.42iologic abnormalities of the procedure; helps to carry per 1,000 admissions. The highest rate of EOSout intubation expeditiously; minimizes the chances occurred in Hispanic infants, who had a frequency offor traumatic injury to the newborn; and has no 20%. Gram-positive organisms caused most episodesadverse effects. of EOS (66.4%, 353/531), gram-negative organisms Except for emergent intubation during resuscita- accounted for 27.3% of EOS, and yeast for 0.8%.tion either in the delivery room or after acute deteri- Group B strep, Escherichia coli, and Staphylococcus
  • 6. Noteworthy Professional News 109aureus accounted for most EOS episodes within this The high proportion of infants evaluated with agroup of infants. blood culture and the small number of infection Late-onset sepsis (LOS) episodes numbered 803 episodes suggest that the yield from sepsis evalua-for a cumulative incidence of 6.30 per 1,000 admis- tions in most late preterm infants is low.sions. Like EOS, most LOS episodes were caused bygram-positive organisms (59.4%), followed by gram- Referencenegative organisms (30.7%), and yeast (7.7%). The 1. Cohen-Wolkowiez M, Moran C, Benjamin DK, et al. Early and latehighest mortality was associated with LOS and onset sepsis in late preterm infants. Pediatr Infect Dis J. 2009;28:1052-gram-negative rods. 1056.Advances in Neonatal Care • Vol. 10, No. 3
  • 7. REGINA GRAZEL, MSN, RN, BC, APN-C • Section Editor Board Member of National Association of Neonatal NursesUPDATES ON NANN’S CONFERENCE,PRODUCTS, AND ADVOCACY INITIATIVESLAS VEGAS, BABY!NANN’s annual educational conference “Embracingthe Power of Change: Advancing, Leading, andLearning” will be held on September 19 to 22 in excit-ing Las Vegas. This nationally renowned conferencewill feature • an opening keynote address by John Nance, pi- lot, safety expert, and author of Why Hospitals Should Fly; • an in-depth symposium on the “Golden Hour” by Robin Bissinger, PhD, RN, NNP-BC, high- lighting important nursing interventions for the critical first hour of life; • sessions on core content for certification; • a stimulating lineup of sessions in RN, manage- ment, advanced practice, and review tracks; • preconference workshops on NICU certification review, the S.T.A.B.L.E. Cardiac Module, pallia- tive care, pharmacology, and the late preterm infant; • a procedural skills laboratory (back by popular demand)—a hands-on learning experience for ad- vanced practice nurses, to include umbilical arte- rial catheter insertion, chest tube placement, and lumbar puncture; • the Faces of Neonatal Nursing Photo Contest; and • a closing keynote address by Rick Kirschner— G REAT N EW P RODUCTS F ROM NANN “Bringing Out the Best in People (Even at Their Worst).” Transport Guideline Also, Vegas offers something for every taste. Get Rapid advances in neonatal care, technologies, andready for fun! For more information, visit www.nann. regionalization of neonatal services have improvedorg. care and outcomes for at-risk newborns. Access to ter- tiary care is available, made possible through the efforts of neonatal transport teams that facilitate inter- hospital transfer of critically ill newborns. NeonatalAddress correspondence to Barbara Hofmaier, MAT, National transport medicine has evolved in recent decades, andAssociation of Neonatal Nurses, 4700 W Lake Ave, Glenview, neonatal transport teams need up-to-date informationIL 60025. on evidence-based clinical care practices and ways toNo grant funding was involved in the production of this article. ensure patient safety throughout the transport process.Copyright © 2010 by The National Association of Research from related areas and best practicesNeonatal Nurses established by experts in the field of neonatal110 Advances in Neonatal Care • Vol. 10, No. 3 • pp. 110-111
  • 8. Grazel 111transport were used to create a new guideline, only a physician can direct respiratory care services.Neonatal Nursing Transport Standards: Guideline for Although this rule allows advanced practice regis-Practice, being released by NANN in 2010. This is a tered nurses (APRNs) in all specialties to write respi-must-have resource for all nurses involved in neona- ratory care orders, it also mandates that the “respon-tal transport. For information on how to get your sible doctor of medicine or osteopathy must cosigncopy of this vital new publication from NANN, visit the order.” For APRNs in the 15 states that still re-our Web site at quire a physician—APRN relationship of “supervi- sion or collaboration,” this requirement presents aOther Valuable Resources Coming significant impediment to providing prompt and ap-From NANN in 2010 propriate care. For the NNPs practicing in those • RNC (registered nurse, certified) review course— states, this ruling causes significant duplication of An Internet-based, modular, comprehensive work, complicated workflows, and unnecessary re- review course. dundancy. The NNPs caring for critically ill infants • Understanding Clinical Research: A Guide for the in the NICU can write hundreds of respiratory or- New Researcher—An introductory guide to review- ders a day, depending on the size of the unit and the ing, evaluating, and conducting research that in- acuity level of the patients. Following The Joint cludes material on literature evaluation and a Commission’s support of this requirement, the com- continuing education component. mittee made this issue a priority. A sample letter of • Competencies and Orientation Tool Kit for Neonatal concern was sent to NANN’s advocacy e-mail dis- Nurse Practitioners—A valuable tool kit that will cussion group, along with information about where help neonatal nurse practitioners (NNPs) to assess to send letters of concern. their practice and identify their own learning The committee has also initiated grassroots cam- needs and will help preceptors and staff educators paigns in response to several US House and Senate both to determine the learning needs of NNP stu- bills introduced this session, including bills about dents and new NNPs and to evaluate the contin- fighting antimicrobial resistance, researching ued competence of experienced NNPs. endocrine disrupters, and establishing an Office of • Resource Guide for Cardiac Care in the NICU and the National Nurse. For more information about accompanying quick reference guide—A handy these “calls to action,” please visit the NANN Web resource that includes common medications, site and click on the Advocacy button on the right dosages, and tips on bedside care. side. Visit for product-ordering information. State LiaisonsH EALTH POLICY AND ADVOCACY We are in the process of identifying a NANN or NANNP member from each state to serve as a liaisonThe Health Policy and Advocacy Committee of to our committee. The state liaison (SL) is a volunteerNANN and NANNP has been extremely busy during who has a strong interest in advocacy, health policy,the 111th US Congress. Although it sometimes seems and legislative issues. The SL will monitor and sharethat global healthcare reform is the only item on the information about current or pending legislation of in-congressional agenda, other issues that affect neonatal terest at the state level and act as liaison to the Healthnursing practice and neonates have arisen at both state Policy and Advocacy Committee. The SL need notand federal levels. have previous experience in health policy and advoca- cy. For more information about this role or to expressIssues of Interest your interest, please contact committee membersThe committee is responding to the Centers for Joyce Stein ( or Katie MalinMedicare & Medicaid Services requirement that ( in Neonatal Care • Vol. 10, No. 3
  • 9. NANN Position Statement 3049112 Advances in Neonatal Care • Vol. 10, No. 3 • pp. 112-118
  • 10. NANN Position Statement 3049 113Advances in Neonatal Care • Vol. 10, No. 3
  • 11. 114 NANN Position Statement 3049
  • 12. NANN Position Statement 3049 115Advances in Neonatal Care • Vol. 10, No. 3
  • 13. 116 NANN Position Statement 3049
  • 14. NANN Position Statement 3049 117Advances in Neonatal Care • Vol. 10, No. 3
  • 15. 118 NANN Position Statement 3049
  • 16. LINDA IKUTA, RN, MN, CCNS, PHN • Section EditorUse of a Vacuum-Assisted Device in aNeonate With a Giant Omphalocele Susan L. Wilcinski, MS, RN, NNP-BC ABSTRACT Wound healing is a complex process that can be even more challenging in neonatal and pediatric patients. Infants and children have special characteristics such as skin immaturity, a high body surface to weight ratio, sensitivity to pain, increased potential for percutaneous absorption of medication, and an immature immune system that adds to the com- plexity of treating their wounds. The use of controlled topical negative pressure across a wound surface has been used in adults and children since 1995. Recently, the use of this device has been reported in neonates. This article discusses the normal process of wound healing and describes the use of this device in an infant with a giant omphalocele. KEY WORDS: giant omphalocele, Vacuum-Assisted Closure, wound healing and her pregnancy was complicated by an abnor-T he care and treatment of large chronic wounds in neonatal and pediatric Z can be very chal- mal 2-hour glucose tolerance test and pregnancy- lenging. Since 1995, Vacuum-Assisted Closure® induced hypertension.Therapy (V.A.C.®; Kinetic Concepts, Inc [KCI] San The infant was delivered vaginally underAntonio, Texas) has been a useful therapy in the epidural anesthesia and her Apgar scores were 7 atmanagement of complex wounds in adults and chil- 1 minute and 8 at 5 minutes. She weighed 3320 g.dren. Little has been published regarding its use in Resuscitation included oral and gastric suctioning,full-term and premature infants. The V.A.C.® device stimulation, and blow by oxygen. A giant omphalo-uses the application of controlled topical negative cele, measuring 10 12 cm, was noted at the timepressure across a wound surface in a manner that of delivery, which was not diagnosed antenatally.produces rapid wound healing. This case presenta- The defect was wrapped with sterile normal saline–tion describes the use of this device in a full-term soaked gauze and Kerlix (Kendall Brands, now partbaby with a giant omphalocele who had difficult of Coviden, Mansfield, Massachusetts). A Reploglewound healing and reviews normal wound healing. tube was also passed to decompress her stomach and bowel.CASE PRESENTATION Shortly after delivery, IZ developed increased work of breathing with mild to moderate subcostalBaby girl IZ was born at 38-week gestation to a retractions and tachypnea because of the large size of24-year-old, gravida 3, para 1 mother at a local the defect that limited her lung expansion, and shereferring hospital. Her mother was negative for was placed into a 40% oxygen hood with good oxy-hepatitis B and HIV, her rapid plasma reagin test gen saturation levels achieved. A blood culture waswas negative for syphilis, and her blood type was A obtained and a peripheral intravenous catheter wasnegative. Her mother received early prenatal care placed for antibiotics (ampicillin and gentamicin) and hydration. She was transported to a regional referral center for surgical repair and ongoing care.Address correspondence to Susan L. Wilcinski, MS, RN, Initially, the pediatric surgeon thought she wouldNNP-BC, Presbyterian St Luke’s Medical Center, 1719 E, require a staged closure that involves placing a silo19th Ave, Denver, CO 80218; but a primary repair was achieved on day 1. DuringAuthor Affiliation: Presbyterian St Luke’s Medical Center, surgery, the omphalocele was excised and the liver,Denver, Colorado. spleen, and the majority of bowel were extruded,Copyright © 2010 by the National Association of the sac was completely excised, and the umbilicalNeonatal Nurses. cord structures were ligated. The defect was closedAdvances in Neonatal Care • Vol. 10, No. 3 • pp. 119-126 119
  • 17. 120 Wilcinskiusing a Surgisis graft (Cook Medical Products,Bloomington, Indiana) that was placed over the defect FIGURE 1.attaching circumferentially to the fascia. The skin wasthen closed over the Surgisis graft. The repair wascompleted without evidence of significant abdominalcompartment syndrome. A Broviac central venouscatheter was also placed at the time of surgery. Shereceived perioperative antibiotics, which werecontinued for 5 days. Six days postoperatively, a patch of wound openedexposing the Surgisis mesh graft. The antibioticsamikacin and vancomycin were started as well asnormal saline wet-to-dry dressing changes 3 times aday. Five days later, on day 11, the wound was mal-odorous and acetic acid wet-to-dry dressing changeswere begun twice a day. On day 14, healing of the Postoperative wound prior to application of thewound was improved, the wet-to-dry dressing V.A.C.® therapy. Photograph courtesy of Presbyterian/changes were stopped, and a nonocclusive dressing St. Luke’s Medical Center, Denver, Colorado.was placed over the wound that has little granulation Reprinted with permission.tissue over the mesh graft. Silvadene (silver sulfadi-azine) was used topically daily beginning on day 17for increased wound breakdown. During this time, IZreceived 2 more courses of antibiotics. Over the next embryonic disk. Migration and fusion of the cranial,3 days, progressive wound breakdown developed caudal, and lateral folds normally result in an intactand the decision was made to consult the wound care umbilical ring by 5-week gestation.1 Partial or com-team located at the hospital. A wound punch biopsy plete arrest of this process results in an omphalocele,was done and showed a full-thickness wound with with insertion of the umbilical cord onto the centralchronic infection of the SurgiSIS graft mesh. omphalocele sac with a surrounding facial defect.Silvadene was stopped and Silvasorb was placed over The size of the defect may vary with large defects ofthe wound twice a day. the entire midgut as well as the stomach, liver, and On day 47, IZ was taken to the operating room spleen. In 50% of cases, the liver, spleen, and ovarieswhere the wound was debrided and 90% of the or testes accompany the midgut.1 The abdominalSurgisis graft mesh was excised. It was necessary to cavity remains small with the absence of the viscera.leave a portion of the graft mesh in place because the One in 5000 babies has an omphalocele that involvesmajority of the graft was adherent to the liver that the bowel only.1 Only 1 in 10 000 infants have a giantmade cautery dissection difficult. The fascial edges omphalocele that involves the liver.1were joined by bolster sutures and the defect was Fetal omphalocele may occur in conjunction withclosed. Postoperatively, the incision was cleaned with other conditions, such as cardiac or genitourinaryhalf-strength hydrogen peroxide and triple antibioticointment and she received 1-week dose of amikacinand vancomycin. Wound culture specimens that FIGURE 2.were taken intraoperatively were growing methi-cillin-sensitive Staphylococcus aureus and Escherichiacoli. One week postoperatively, the skin broke downaround the retention sutures. Once again, Silvasorbwas used to treat the open wound. Progressive dehis-cence developed, and 9 days postdebridement, theopen wound measured 5 2 cm and contained fas-cia and Surgisis (Figure 1). At this time, the decisionwas made to apply a V.A.C.® Therapy device (KCI)(Figure 2).GIANT OMPHALOCELEAbdominal wall defects in infants have 3 subtypes: Device used for wound vacuum assisted closureomphalocele, gastroschisis, and hernia of the cord. therapy, V.A.C.®, Kinetic Concepts, Inc (San Antonio,Closure of the fetal abdominal wall depends upon Texas). Reprinted with permission.appropriate craniocaudal and lateral infolding of the
  • 18. Use of a V.A.C.® Device in a Neonate With an Omphalocele 121abnormalities, neural tube defects, and the genetic which collagen fibers are deposited, mature, anddefects trisomy 13 or 18. In addition, omphalocele strengthen. This gel-like substance keeps the woundmay be associated with Beckwith–Wiedemann moist, which facilitates healing.6 Vitamin C, zinc,Syndrome or pentalogy of Cantrell. oxygen, and iron are required for this process. Granulation occurs when collagen, capillaries, andNORMAL WOUND HEALING cells begin to fill the wound space with new connec- tive tissue. Granulation tissue is red and bumpy withWound healing is an ever-changing and delicate a meaty appearance. The wound contracts as myofi-process that at times is taken for granted. The process broblasts align along the lines of contraction. This isis an overlapping series of events, beginning with a unified process requiring cell-to-cell and cell-to-injury to eventual repair. Normally, rapid wound matrix communication. The effect of contraction is tohealing occurs in infants and pediatric patients but decrease the area to be filled in with granulation tis-healing can be delayed by a number of reasons sue. Reepithelialization begins as epithelial cellsincluding impaired perfusion, infection, prolonged migrate from surrounding skin. Epithelial cells needpressure, poor nutrition, edema, and the wound envi- a viable wound edge and a moist wound surface toronment. Neonatal and pediatric wound care requires migrate across a wound bed.7 These cells eventuallyspecial expertise and precise management. Infants begin to differentiate into various layers of the der-and children have special characteristics such as skin mis. The initial scar is bright red, thick, and blanchesimmaturity, a high body surface to weight ratio, sen- with pressure.sitivity to pain, increased potential for percutaneous In the fourth stage, remodeling of the scar contin-absorption of medication, and an immature immune ues for about 1 year. Scar tissue regains about two-system that adds to the complexity of treating their thirds of its original strength and is never as strong aswounds.2,3 Effective wound management is depend- the normal tissue and never fully retains tensileent upon an understanding both of the normal repair strength.4 Wounds slow down or stop their healingprocess and of factors affecting this process and inter- process because of numerous factors. Tissue hypoxiaventions that can impact the ultimate outcome. There is an important cause. Tissue hypoxia decreasesare 4 phases of wound healing. resistance of the wound to infection by interfering The first stage includes a vascular response, so with phagocytosis. Hypoxia impairs collagen synthe-within seconds of an injury, blood vessels constrict to sis and increases collagen lysis as well as decreasesstop any bleeding and to limit exposure to bacteria. epithelial proliferation and migration.8,9 A balancedPlatelets cluster together to form a clot, which is the nutrition is also very important for wound healing. Aresult of conversion of thrombin to fibrinogen and neonate should optimally be in a good anabolic stateultimately to fibrin.4 The second stage involves an with good protein intake. Some centers measureinflammatory response, which is the body’s first albumin and prealbumin levels and consider themdefense system against bacterial invasion. Neutrophils markers of optimal protein intake during their man-along with macrophages arrive and ingest bacteria. agement of chronic wounds.2 Full formula or breastMonocytes, which play a critical role in the healing milk feedings should provide enough protein to opti-process, arrive later. They phagocytose bacteria along mize wound healing. If oral feedings are not toler-with damaged tissue, engulfing and destroying microbes ated, total parenteral nutrition with adequate protein,present there. Macrophages secrete angiogenesis glucose, and fat along with vitamins and trace miner-factor, which stimulates the formation of new blood als should be provided.vessels.4,5 Ischemic cells release the vasoactive sub- Wounds that are chronically infected are very slowstances bradykinin, histamine, and prostaglandin. to heal. Infection prolongs the inflammatory phase ofVessels start to dilate, permeability increases, and healing, resulting in diminished levels of oxygen influid begins to leak into the wound. Inflammation is a the tissue, with decreased fibroblast production andsign of healing but prolonged inflammation due to diminished collagen formation. Many chronicnecrotic, infected tissue or foreign bodies slows the wounds require surgical debridement before they canhealing process and can lead to chronic wounds. begin the healing process. The proliferative phase is the third stage of healing The use of corticosteroids can inhibit the inflam-and involves intense multiplication of cells. matory response and phagocytosis, interfering withAngiogenesis, collagen synthesis, contraction, and healing. In addition, these medications decrease col-epithelialization are part of this phase.2 Angiogenesis lagen strength and can inhibit epithelial prolifera-is the growth of new capillaries by which local blood tion.4 A dry wound bed should be avoided becauseflow for healing is increased. Macrophages secrete this leads to slow healing.4 When a wound is dry,lactate and growth factors into the wound, which keratinocytes, which are the major cell type of thestimulate fibroblast proliferation. Fibroblasts secrete epidermis, to heal the wound, will need to burrowcollagen, which reconstructs connective tissue. down to a moist environment in the wound in orderCollagen is initially secreted as a gel matrix onto to secrete collagenase, which lifts the scab. TheseAdvances in Neonatal Care • Vol. 10, No. 3
  • 19. 122 Wilcinskicells later migrate, differentiate, and resurface the used for the treatment of acute and chronicwound. A dry wound bed will also interfere with wounds.10,11 Since its introduction more than aepithelial proliferation and migration. A very impor- decade ago, it was initially used in adult wound heal-tant goal of wound healing is to provide a moist ing and has been applied to the pediatric population.wound bed that stimulates the wound into its healing However, its use in neonates has been limited.cascade.4,7 V.A.C.® therapy uses the application of controlled Infants have multiple developmental considera- topical negative pressure across a wound surface in ations that place them at higher risk for skin injury and manner that produces rapid wound healing.10,12-14slower wound healing. During the last trimester of This negative pressure system creates an environ-pregnancy, collagen is deposited into the dermis. The ment within the wound bed that resists bacterialdermis of a full-term baby is 60% as thick as that of an growth, encourages capillary growth, and establishesadult.2 This lack of collagen places a neonate at microcirculation. Blood is drawn into the woundgreater risk of becoming edematous, making their bed and brings growth factor, neutrophils, andskin more susceptible to injury. Differences in skin macrophages to the area. Again, neutrophils are thepH place a neonate at greater risk of skin breakdown. first responders; they phagocytize bacteria andA full-term infant has an alkaline skin surface at birth. breakdown fibrin. These cells activate fibroblasts andWithin 4 days, the pH drops to less than 5, creating keratinocytes and attract macrophages to the “acid mantle.” An acidic skin surface protects These macrophages engulf large particles such asagainst bacterial invasion.8 Premature infants have an bacteria, yeast, and drying cells. They clean theimmature stratum corneum, which is the outer layer wound and secrete cytokines and growth factors.of the dermis, and overall underdeveloped skin struc- Cytokines and growth factors attract fibroblaststures, and they are at risk for skin disruption and tox- and endothelial cells, which convert oxygen toicity from topically applied substances. A number of superoxide. Superoxide serves as a natural antimicro-studies involving wound cleansers indicated that sev- bial agent, inhibiting infection in the wound.eral cleansers and disinfectants can destroy or dam- Keratinocytes migrate into the wound bed and beginage fibroblasts and granulation tissue in healing epithelialization, which, in turn, stimulates secretionwounds.8,9 These include Ivory Liqui-Gel, Dial of growth factors, cytokine activity, and angiogenesis.4,14Antibacterial Soap, and Hibiclens. These products Negative pressure increases local blood flow andwere at a 1/100,000 dilution to be considered non- decreases edema, which improves oxygen delivery totoxic.9 The skin and wound cleansers, povidone– the wound bed.12,14 Slough and loose necroticiodine surgical scrub (Betadine Surgical Scrub) and material are removed from the wound, cleaninghydrogen peroxide, were found to be nontoxic to the wound and improving the blood supply.fibroblasts at a 1/1000 dilution.9 Shur-Clens was Removing the necrotic tissue decreases bacterialnoted to be the least toxic to fibroblasts, requiring no colonization.12,14dilution to maintain viable cells, with SAF-Clens and A good blood supply and a clean wound promotesaline not far behind. Acetic acid, Biolex, Cara- the formation of granulation tissue, which encouragesKlenz, and Puri-Clens had a toxicity index of 10, cor- wound closure and ensures that white blood cells areresponding to a 1/10 dilution.9 This was an in vitro supplied with necessary oxygen while ensuring thatstudy and it is difficult to establish a direct correlation aerobic bacteria in the wound bed die. V.A.C.®of in vitro findings with in vivo results. There may not therapy provides a moist wound environment, whichbe issues with the efficacy of cleansing actions but is essential for healing, preventing further necrosisbenefits to tissue repair should be cautiously exam- and tissue loss.ined.9 It is possible that the use of hydrogen perox- V.A.C.® therapy is applied in a manner that waside and acetic acid on IZ’s wound added to its slow originally described in 1997, with clean wound tech-healing, but there were other significant factors nique predominantly used.13 The choice of foam isincluding chronic infection that added to nonhealing important. The black reticulated foam (GranuFoam™of her wound. Silvadene, in addition, is not recom- Dressing; KCI), is the most common dressing used. Itmended for use in babies younger than 3 months is hydrophobic and does not absorb fluid, but it willbecause of concern for absorption of silver.8 stay moist under the occlusive drape. This foam is the most effective at stimulating granulation tissue andPRINCIPLES OF MOIST WOUND HEALING wound contraction. This foam is cut to the exact size of the wound. The White Foam™ Dressing (KCI) isThe goal of wound healing is to accomplish all of the an alternative, but it is a denser sponge. It is premoist-principles listed with every wound. These include ened and nonadherent. It is more hydrophilic thanoxygenation and circulation, removal of necrotic tis- the Black Foam. It is used more commonly insue, control of exudates and infection, and provision wounds with exposed tendon, bone, organs, fistulas,of a clean, moist, and protective environment. or tunnels. It is used to pack tunnels because of itsVacuum-assisted closure V.A.C.® therapy has been higher tensile strength. A third type of foam,
  • 20. Use of a V.A.C.® Device in a Neonate With an Omphalocele 123GranuFoam Silver™ dressing, is also available. It is a (Johnson & Johnson, New Brunswick, New Jersey) orBlack Foam microbonded with silver that acts as an Mepitel (Molynlycke Health Care, Eddyston,effective barrier to bacterial penetration and may Pennsylvania) or applying a thin layer of a hydrogelhelp to reduce infection. Because the foam is kept to the wound base can be used to line the woundconstantly moist with the suction force of the pump, before the Black Foam is placed.13-15 With woundscare is needed not to overlap the intact skin because with extensive drainage, there is a collection canistermaceration of the wound edges can occur. In large that can accurately quantify the drainage.15,16wounds, multiple pieces of Black Foam can be used. The foam is placed into the wound without over- LITERATURE REVIEWlapping the edges and an occlusive drape dressing isplaced over the wound extending on to the intact Negative pressure therapy has been accepted as askin to create an airtight seal. A 2-cm hole is cut into valuable adjunct for wound closure in adults sincethe drape by pinching it over the foam. The 1993.13 Its use was originally reported for the treat-SensaT.R.A.C.™ (Therapeutic Regulated Accurate ment of deep chronic wounds with moderate to highCare; KCI) pad is placed directly over the hole in the exudate levels such as pressure ulcers, abscesses, anddrape and gentle pressure is applied. Then, the deep wounds secondary to trauma. A retrospectiveSensaT.R.A.C.™ pad tubing is connected to the canis- study reported experience in 42 patients from 1999ter tubing. The seal from the transparent drape needs to 2002 for conditions such as nonhealing sternal,to stay intact and occlusive for the therapy to be effec- spinal, and lower extremity wounds. The use of thetive since air leaks are common problems (Figure 3). V.A.C.® therapy provided faster wound healing,The V.A.C.® therapy unit is then programmed for a there were shorter hospital stays, and a reduction inspecific amount of suction-negative atmospheric overall cost.16pressure. For infants and children, there are no pub- Another study by Mooney et al17 reviewed 27lished recommendations. Typically, the lowest nega- pediatric patients with complex wounds, whichtive pressure of 50 mm Hg is chosen. The negative included open fractures, failed flap closure, abdomi-pressure settings vary from 50 to 200 mm Hg, admin- nal and sterna dehisced wounds, and spinal woundistered continuously or intermittently. Continuous infection. V.A.C.® therapy proved to be advanta-suction is typically used for the first 48 hours, later geous in this group, aiding in closure without need foradjusted to intermittent suction. Dressing changes are complex surgical interventions.17commonly performed at 48-hour intervals or 3 times A retrospective medical record review of childrena week.22 To prevent granulation tissue from growing and infants was conducted to evaluate the effective-into the foam, more frequent dressing changes should ness of V.A.C.® therapy at a large pediatric hospitalbe performed.22 To help minimize patient discomfort between January 2003 and 2005.18 Data were col-during dressing changes, the White nonadherent lected on wound type, treatment method and dura-foam or a nonadherent dressing layer of Adaptic tion, and complications. Sixty-eight patients with 82 wounds were identified. The mean age was 8.5 years and ranged from 7 days to 18 years. Twenty patients (29%), including 8 neonates, were 2 years or FIGURE 3. younger. Wound types identified were pressure ulcers, extremity wounds, dehisced surgical wounds, open sterna wounds, wounds with fistula, and com- plex abdominal wall defects. Following the use of negative pressure therapy, 93% of wounds decreased in volume. It was concluded that negative pressure therapy by using the V.A.C.® therapy system can be effectively used to manage a multitude of wounds in children and neonates. No major complications were identified.18 Another retrospective medical record review was conducted on 24 neonatal and pediatric patients who had received negative pressure wound therapy for their wounds from 1999 to 2004.19 Their ages ranged from 14 days to 18 years. The most common wound Example of patient with the V.A.C.® therapy device in type was traumatic, with exposed hardware and place. Photograph courtesy of Presbyterian/St. Luke’s bone. In a median time of 10 days, 11 wounds were Medical Center, Denver, Colorado. Reprinted with closed by flap, 3 by split-thickness skin graft, 4 sec- permission. ondarily, and 4 primarily. Results were promising. Complete closure was achieved in 22 of 24 patients.19Advances in Neonatal Care • Vol. 10, No. 3
  • 21. 124 Wilcinski A report in 2006 described V.A.C.® therapy of 3 bowel perforation secondary to necrotizing entero-infants with giant omphalocele from 2002 to 2004.20 colitis.21 She received total parenteral nutritionAll patients had undergone unsuccessful attempts at through a percutaneously placed central venousclosure by using other methods. The first patient was catheter through a saphenous vein that infiltrated,initially treated by staged silo reduction, which dis- and she developed on day 31 a 7 3.5-cm blister onrupted after 21 days. The large mass of the bowel and her lower back. There was extensive full-thicknessliver made primary or skin flap closure impossible. necrosis from the T8/9 region to L5/S1 over the pos-V.A.C.® therapy was applied for 45 days. The viscera terior torso and dehiscence of tissues between thewere subsequently covered with acellular dermal paraspinous muscles, involving the spinal laminaematrix (AlloDerm). The dermal matrix that failed to and epidural tissue. The dura was exposed but viable.integrate into the fascial rim was removed. The small Following intravenous antibiotic administration andremaining defect was covered with split-thickness debridement, a 7 10-cm defect remained on herskin graft at 3 months of age. In the second case, back. The V.A.C.® therapy system was applied ini-mesh placement was performed 5 months after birth, tially by using the White Foam at a negative pressurewith subsequent necrosis of the infant’s abdominal of 50 mm Hg. Within a week, this was changed to theskin within the immediate postoperative period. The Black Foam and the negative pressure was increasedmesh was removed and V.A.C.® therapy was applied to 75 mm Hg. The V.A.C.® therapy dressing wasfor 22 days. The infant subsequently underwent acel- changed every 3 to 4 days for 21 days. Mepitellular dermal matrix replacement of the fascial defect (Molylycke Health Care) was applied to the woundand full-thickness skin flap closure by tissue expan- and changed daily until the wound was completelysion. The third case was of a full-term infant with a 6- epithelialized 10 days following V.A.C.® therapycm omphalocele that was initially treated by staged removal.21silo reduction. After multiple suture line disruptions,the silo was removed and gross-type skin flaps were NURSING IMPLICATIONSused to cover the large defect. This procedure wascomplicated by an enterocutaneous fistula. The mesh When a V.A.C.® therapy device is applied, it is thewas removed and V.A.C.® therapy was applied for 36 responsibility of the nurse to maintain its functiondays. A healthy granulation bed developed and the and settings that are outlined by the wound careV.A.C.® therapy device was allowed for the treatment team. A team-centered approach should be used andof the fistula and coverage of the defect. This case a care plan for the V.A.C.® therapy changes shouldseries illustrated the challenges faced by pediatric sur- be instituted at the bedside.geons in the management of giant omphalocele and Maintenance of the V.A.C.® therapy system isdemonstrates the usefulness of V.A.C® therapy.20 important and careful assessment is vital to ensure In 2005, the V.A.C.® system was used in the care proper negative pressure. Air leaks from under theof 2 premature infants, weighing less than 1500 g, with occlusive dressing are common problems. An air leakextensive soft tissue defects.21 The first case involved can be identified when a hissing sound is heard;a former 23-week gestation infant who at 6 weeks of smaller leaks may be auscultated with the use of aage and 850 g was found to have an omphalomesen- stethoscope. An air leak would also be suspected whenteric duct fistula that became infected and ruptured the foam is observed to not being collapsed becauseinto the abdominal wall. At laparotomy, a 3-cm seg- the negative pressure has been lost. The pump will alsoment of ileum adjacent to the ruptured omphalome- alarm if negative pressure is lost. If an air leak devel-sentric duct was resected. An ileostomy and mucus ops, it can be patched with an additional drape.15fistula were placed but the patient had necrosis of the Pain assessment and treatment should be a prior-midline musculature and the closure was not accom- ity. Initially, continuous suction is typically used. Aplished. A bovine pericardial patch was used for tem- pain assessment scale should be put into practice andporary closure of the muscle defect, and the overly- a pain management plan instituted. Some patientsing necrotic skin was debrided. One week following experience pain during the dressing change when thesurgery, V.A.C.® therapy was applied. The White pump is initially turned on and the foam is com-Foam was placed over the defect and a negative pres- pressed. Pain medication should be given in 10 tosure of 75 mm Hg was applied. The dressings were 30 minutes, depending on the route of medicationchanged every 2 to 3 days for 43 days. V.A.C.® ther- before the dressing change. Most infants and childrenapy was discontinued when the wound was at the with moderate wounds tolerate device changes withlevel of the skin and the suction device was bigger oral pain medications. Typically, acetaminophen isthan the open wound. Later, wet-to-dry dressings used for pain control but with larger wounds, par-were used and the wound was completely epithelial- enteral pain medication or conscious intravenousized 14 days after V.A.C.® therapy removal.21 In the sedation may be needed.10 If pain or bleeding seemssecond case, the neonate was a former 27-week ges- excessive with V.A.C.® therapy dressing changes,tation infant, born weighing 800 g, who developed a one should assess for invasion or adherence of
  • 22. Use of a V.A.C.® Device in a Neonate With an Omphalocele 125granulation tissue to the Black Foam. Intermittent crib while the wound is healing. Range-of-motionsuction has been proven to accelerate the growth of exercises should also be considered as indicated.granulation tissue faster than continuous suction.23 Optimally, a developmental specialist should be aTherefore, switching to continuous suction may part of the care team.diminish rapid growth of granulation tissue and Wound healing can test family members to thedressing changes may be more comfortable. Lining limit of their endurance. A family may have tothe wound bed with a nonadherent, oil emulsion– endure multiple surgeries and a prolonged hospital-type dressing (eg, Adaptic; Johnson & Johnson) or a ization when healing is nonexistent or lining (Mepitel; Molynlcke Health Care) Frustration with the lack of progress in healing ismay disrupt adherence of the V.A.C. sponge.23 common. Doubts and fears should be treated withDecreasing the amount of suction used may also help respect. Depression can be avoided or improved withwith pain. More frequent dressing changes may also good psychological support. Information aboutdecrease the growth of granulation tissue into the wound healing and how a wound V.A.C. systemfoam. The manufacturer of the wound V.A.C. device works should be provided.recommends dressing changes every 48 hours formost wounds.15 Denuded wound margins are noted IZ’S OUTCOMEby older patients and researchers to be a commonsource of wound pain.23 To protect intact wound mar- Three days following the initial V.A.C.® therapy, IZ’sgins under the occlusive V.A.C.® therapy drape, the wound was showing some granulation tissue and wasV.A.C.® therapy sponge should be cut to the exact epithelializing along the wound edges. One week fol-size of the wound, avoiding overlapping of the lowing placement, there was marked improvement;sponge on to good skin or to apply a water-soluble the wound showed healthy granulation sealant (3M No Sting Barrier swab; 3M Fibrous tissue was noted to be present as well and thisHealthCare, St Paul, Minnesota) as primary preven- was treated with Accuzyme (DPT Laboratories, Ltd,tion. If periwound skin margins break down, one San Antonio, Texas) during dressing changes tosource recommends applying 1-in strips of thin debride this tissue (Figure 4). The wound washydrocolloid (Duoderm Thin; Convatec, Princeton, assessed and the V.A.C.® therapy device was reap-New Jersey) or thin adhesive form (Allevyn; Smith & plied every other day. Following 7 weeks of negativeNephew, Largo, Florida) to protect the areas that are pressure wound therapy, the wound was healedopen before applying the V.A.C.® therapy drape.23 enough to stop the V.A.C.® therapy.Include parents in comfort measures during and after IZ was discharged from the hospital at approxi-dressing changes. Offering an oral sucrose solution mately 5 months of age. In addition to the difficultmay also help with pain. wound-healing course, IZ had feeding difficulties Close monitoring of fluid loss from the wound into because of significant gastroesophageal reflux thatthe canister is extremely important, especially in was related to her large abdominal wall defect. Inhighly exuding wounds or large wounds in relation topatient size. Neonates in particular can lose a signifi-cant amount of extracellular fluid from the woundbed and are at risk for dehydration. Accurate meas- FIGURE 4.urement is required since fluid replacement mayneed to be instituted. Rapid contraction of the wound bed can occurshortly after placing the V.A.C® therapy on an infantwith a large abdominal wound at risk for respiratoryembarrassment. Care should be taken to follow theneonate’s work of breathing and oxygen requirementand to stabilize as needed. Developmental care issues need to be addressed.Depending upon the site of the wound, neonatesmay need to lie in a position that is not developmen-tally supportive. For instance, IZ could lie only onher back because of the limitation of her largewound and the V.A.C.® therapy device. However,positional supports and boundaries were provided tooptimize and facilitate appropriate postural align- Wound after 3 days of V.A.C® therapy. Photographment. Her mother could not provide kangaroo care. courtesy of Presbyterian/St. Luke’s Medical Center,Providing age-appropriate stimulation is important Denver, Colorado. Reprinted with permission.since infants can be spending significant time in theirAdvances in Neonatal Care • Vol. 10, No. 3
  • 23. 126 Wilcinski systems such as the V.A.C.® therapy system may be FIGURE 5. helpful in some infants. References 1. Magnuson DK, Parry RL, Chwals WJ. Abdominal wall defects. In: Martin RJ, Fanaroff AA, Walsh MC, eds. Fanaroff and Martin’s Neonatal-Perinatal Medicine, Diseases of the Fetus and Newborn. 8th ed. Philadelphia, PA: Mosby-Elsevier; 2006:1380-1386. 2. Lund, CH, Tucker JA. Adhesion and newborn skin. In: Hoath SB, Mailbach HI, eds. Neonatal Skin Structure and Function. 2nd ed.; pp. 299-324. New York, NY: Marcel Decker Inc; 2003. 3. Barharestani M, Pope E. Chronic wounds in neonates and children. In: Krasner D, Rodheaver GT, Sibbald RG, eds. Chronic Wound Care: A Clinical Source Book for Healthcare Professionals. 4th ed. Malvern, PA: HMP Communications; 2007:673- 693. 4. Strodtbeck F. Physiology of wound healing. Newborn Infant Nurs Rev. 2001;1:43-52. 5. Clark RAF. Wound repair: overview and general considerations. In: Clark RAF, ed. The Molecular and Cellular Biology of Wound Repair. 2nd ed. New York, NY: Plenum Press; 1995:3-50. 6. Flanigan KH. Nutritional aspects of wound healing. Adv Wound Care. 1997;10: 48-52. Wound after 2 months V.A.C® therapy. Photograph 7. Waldrop J, Doughty D. Wound healing physiology. In: Bryant RA, ed. Acute and courtesy of Presbyterian/St. Luke’s Medical Center, Chronic Wounds. Nursing Management. 2nd ed. St Louis, MO: Mosby; 1997:413-429. 8. Association of Women’s Health, Obstetric and Neonatal Nurses. Neonatal Skin Denver, Colorado. Reprinted with permission. Care, Evidenced Based Clinical Practice Guidelines. 2nd ed. Washington DC: AWONN; 2007. 9. Wilson J, Mills J, Prather I, Dimitrijevich SD. A toxicity index of skins and wound cleansers used on in vitro fibroblasts and keratinocytes. Adv Skin Wound Care. 2005;18:373-378. 10. Caniano DA, Teich S, Ruth B. Wound management with vacuum-assisted closure: experience in 51 pediatric patients. J Pediatr Surg. 2005;40:128-132.addition, coordination and stamina were issues for 11. Jerome D. Advances in negative pressure wound therapy. J Wound Ostomyher, which made nippling a challenge. She was dis- Continence Nurs. 2007;34:191-194. 12. Smith N. The benefits of VAC therapy in the management of pressure ulcers.charged from the hospital with an indwelling nasal Br J Nurs. 2004;13:1359-1365.gastric tube in place. She was not a candidate for sur- 13. Argenta L, Morykwas M. Vacuum-assisted closure: a new method for wound control and treatment. Annu Plast Surg. 38:563-576.gical treatment of her gastroesophageal reflux 14. Miller M, Glover D. Wound Management: Theory and Practice. London, England:because of previous multiple abdominal wall surger- The Friary Press; 1999. 15. KCI The Clinical Advantage. V.A.C. Therapy Clinical Guidelines: A Referenceies. She was nippling small volume of formula dur- Source for Clinicians; 2007. Accessed October 2008 from the day and was fed the remainder by her mother com/KCI1/vacapplicationsvideoswith gavage feedings. To improve growth, she was 16. Antony S, Terrazas S. A Retrospective study: clinical experience using vacuum assisted closure of the treatment of wounds. J Natl Med Assoc. 2004;96:1073-1077.discharged home on 27 cal/oz of formula and 17. Mooney JF, Argenta LC, Marks MW, et al. Treatment of soft tissue defects in pedi-received continuous-drip nighttime feedings. atric patients using the VAC system. Clin Orthop Relat Res. 2000;376:26-31. 18. McCord SS, Murphy K, Olutoyeo L, Naik-Mathuria B, Hollier L. Negative pressure Following discharge, she was followed by the wound therapy is effective to manage a variety of wounds in infants and chil-Wound Healing Center and pediatric surgeons. One dren. J Wound Ostomy Continence Nurs. 2007;34:573-574. 19. Baharestani M. Use of negative pressure wound therapy in the treatment ofweek following discharge, her wound began to break neonatal and pediatric wounds: a retrospective examination of clinical out-down once again (Figure 5). V.A.C.® therapy was reap- comes. Ostomy Wound Manage. 2007;53(6):75-85.plied and her mother was instructed on how to change 20. Kilbride K, Cooney D, Custer M. Vacuum-assisted closure: a new method for treating patients with giant omphalocele. J Pediatr Surg. 2006;41:212-215.the V.A.C.® therapy dressings. Three weeks later, the 21. Arca M, Somers K, Derks TE, et al. Use of vacuum assisted closure system in thewound was completely healed and V.A.C.® therapy management of complex wounds in the neonate. Pediatr Surg Int. 2005;21:532- 535.was discontinued. Her wound has remained closed. 22. Bookout K, McCord S, McLane K. Case studies of and infant, a toddler, and an Wound healing can be difficult in neonates, partic- adolescent with a negative pressure wound treatment system. J Wound Ostomy Continence Nurs. 2004;31:184-192.ularly those with large wounds or surgical sites. The 23. Krasner D. Managing wound pain in patients with vacuum assisted closureuse of controlled topical negative pressure with devices. Ostomy Wound Manage. 2002;48(5):38-43.
  • 24. CE TestUse of a Vacuum-Assisted Device in a Neonate With aGiant OmphaloceleInstructions: • Questions? Contact Lippincott Williams & Wilkins: The ANCC’s accreditation status of Lippincott Williams &• Read the article on page 119. 800-787-8985 Wilkins Department of Continuing Education refers only to• Take the test, recording your answers in the test its continuing nursing educational activities and does not answers section (Section B) of the CE enrollment form. Registration Deadline: June 30, 2012 imply Commission on Accreditation approval or Each question has only one correct answer. Provider Accreditation: endorsement of any commercial product.• Complete registration information (Section A) and course LWW, publisher of Advances in Neonatal Care, will award Disclosure Statement: The authors have disclosed that evaluation (Section C). 3.0 contact hours for this continuing nursing education they have no financial relationships related to this article.• Mail completed test with registration fee to: Lippincott activity. Williams & Wilkins, CE Group, 333 7th Avenue, This article has been approved by the National 19th Floor, New York, NY 10001. LWW is accredited as a provider of continuing nursing Association for Neonatal Nurses Certification Board for• Within 4-6 weeks after your CE enrollment form is education by the American Nurses Credentialing Center’s Category B credit toward recertification as an NNP. received, you will be notified of your test results. Commission on Accreditation.• If you pass, you will receive a certificate of earned This activity is also provider approved by the California Payment and Discounts: contact hours and answer key. If you fail, you have the Board of Registered Nursing, Provider Number CEP 11749 • The registration fee for this test is $17.95 for NANN option of taking the test again at no additional cost. for 3.0 contact hours. Lippincott Williams & Wilkins is also members and $24.95 for nonmembers.• A passing score for this test is 13 correct answers. • If you take two or more tests in any nursing journal pub- an approved provider of continuing nursing education by• Need CE STAT? Visit for imme- lished by LWW and send in your CE enrollment forms to- the District of Columbia and Florida #FBN2454. diate results, other CE activities, and your personalized gether, you may deduct $0.95 from the price of each test. CE planner tool. Your certificate is valid in all states. • We offer special discounts for as few as six tests and• No Internet access? Call 800-787-8985 for other rush institutional bulk discounts for multiple tests. Call 800- service options. 787-8985 for more information.CE TEST QUESTIONSGENERAL PURPOSE STATEMENT: To provide the registered 6. A wound’s resistance to infection is decreased byprofessional nurse with the use of vacuum assisted closure (VAC) device to a. tissue osmolality.assist wound healing in the neonate with a giant omphalocele. b. tissue hypoxia.LEARNING OBJECTIVES: After reading this article and taking this test, c. release of angiogenesis factor.the nurse will be able to: d. inhibition of bradykinin.1. Identify normal wound healing in neonates. 7. Which of the following leads to slow healing? a. a dry wound bed2. Describe wound VAC therapy in neonates with giant omphalocele. b. a wet wound bed 1. Following development of progressive dehiscence, a c. full formula feedings wound VAC device was applied on Baby Girl IZ at how d. breastmilk feedings many days post debridement? 8. A neonate is at greater risk of skin breakdown due to a. 3 days a. excessive collagen. b. 5 days b. a thick dermis. c. 7 days c. differences in skin pH. d. 9 days d. increased cardiac output. 2. Abdominal wall defects in infants include all of the 9. For Baby Girl IZ, use of which of the following wound following except : cleansers may have added to slow wound healing? a. hiatal hernia. a. hydrogen peroxide and acetic acid b. gastroschisis. b. antibacterial soap c. omphalocele. c. Shur-clens d. hernia of the cord. d. Hibiclens 3. Fetal omphalocele may occur in conjunction with 10. To produce rapid wound healing, VAC therapy uses the a. cystic fibrosis. application of controlled: b. neutral tube defects. a. topical negative pressure. c. Down syndrome. b. systemic negative pressure. d. fetal alcohol syndrome. c. topical positive pressure. 4. Which is a special characteristic that adds to the complex- d. systemic positive pressure. ity of treating neonatal wounds? 11. VAC therapy encourages rapid wound healing by a. a high body surface to weight ratio a. constricting blood flow into the area. b. a low body surface to weight ratio b. drawing blood into the area. c. decreased sensitivity to pain c. preventing angiogenesis. d. decreased potential for percutaneous absorption of medication d. limiting granulation. 5. Which stage of wound healing involves intense multiplica- 12. Which is the most common dressing used with wound tion of cells? VAC? a. first stage b. second stage a. black foam b. white foam c. third stage d. fourth stage c. silver foam d. gold foamAdvances in Neonatal Care • Vol. 10, No. 3 127
  • 25. 13. When using wound VAC therapy, the negative pressure 16. A priority of wound VAC therapy care is typically chosen for infants is a. pain management. a. 50 mmHg b. oxygen administration. b. 100 mmHg c. fluid administration. c. 150 mmHg d. antibiotic therapy. d. 200 mmHg 17. To protect intact wound margins under the occlusive VAC14. As described in this article, a retrospective chart review of drape, the VAC sponge should be 24 patients who received negative pressure wound therapy a. smaller than the wound. found that complete closure was obtained in b. larger than the wound. a. 12 of 24 patients. c. the exact size of the wound. b. 18 of 24 patients. d. overlap the wound. c. 22 of 24 patients. 18. Optimally, the team caring for the infant receiving wound d. all patients. VAC therapy should include15. Which is a common problem with wound VAC therapy? a. an infection control specialist. a. fluid leaks from under the occlusive dressing b. a developmental specialist. b. air leaks from under the occlusive dressing c. a neurologist. c. wound infection d. a cardiologist. d. wound fistula ANC0510CE Enrollment FormAdvances in Neonatal Care June 2010Use of a Vacuum-Assisted Device in a Neonate With a Giant Omphalocele A Registration Information: ❑ LPN ❑ RN ❑ CNS ❑ NP ❑ CRNA ❑ CNM ❑ other______________Last name______________________ First name____________________MI____ Job Title______________________Specialty_____________________________Address__________________________________________________________ Type of facility_____________________________________________________City_______________________________State_________________Zip_______ Are you certified? ❑ Yes ❑ NoTelephone___________________Fax______________email________________ Certified by_______________________________________________________Registration Deadline: June 30, 2012 State of License (1)__________License #________________________________Contact Hours: 3.0 State of License (2) __________License#________________________________Fee: NANN member: $17.95 ❑ Please check here if you do not wish us to send promotions to your email NANN Membership No. _______________________ address. ❑ Please check here if you do not wish us to release your name, address, email Nonmembers: $24.95 address to a third party vendor. B Test Answers: Darken one for your answer to each question. A B C D A B C D A B C D A B C D A B C D 1. ❍ ❍ ❍ ❍ 5. ❍ ❍ ❍ ❍ 9. ❍ ❍ ❍ ❍ 13. ❍ ❍ ❍ ❍ 17. ❍ ❍ ❍ ❍ 2. ❍ ❍ ❍ ❍ 6. ❍ ❍ ❍ ❍ 10. ❍ ❍ ❍ ❍ 14. ❍ ❍ ❍ ❍ 18. ❍ ❍ ❍ ❍ 3. ❍ ❍ ❍ ❍ 7. ❍ ❍ ❍ ❍ 11. ❍ ❍ ❍ ❍ 15. ❍ ❍ ❍ ❍ 4. ❍ ❍ ❍ ❍ 8. ❍ ❍ ❍ ❍ 12. ❍ ❍ ❍ ❍ 16. ❍ ❍ ❍ ❍ C Course Evaluation D Two Easy Ways to Pay: A B1. Did this CE activity’s learning objectives relate to its ❑ Yes ❑ No ❑ Check or money order enclosed general purpose? (Payable to Lippincott Williams & Wilkins)2. Was the journal home study format an effective way ❑ Yes ❑ No ❑ Charge my ❑ Mastercard ❑ Visa ❑ American Express to present the material?3. Was the content relevant to your nursing practice? ❑ Yes ❑ No Card #_____________________________________Exp. Date_________4. How long in minutes did it take you to read the article____study the Signature___________________________________________________ material____and take the test____?5. Suggestion for future topics_____________________________________ Need CE STAT? Visit for immediate results, other CE activities, and your personalized CE planner tool!128
  • 26. KSENIA ZUKOWSKY, PHD, APRN, NNP-BC • Section EditorRepositioning Techniques forMalpositioned Neonatal PeripherallyInserted Central Catheters Elizabeth L. Sharpe, MSN, ARNP, NNP-BC ABSTRACT The utilization of Peripherally Inserted Central Catheters (PICCs) has grown to become a common practice in neonatal care. Proper placement of the catheter in the superior vena cava (SVC) is essential to support safe delivery of care and minimize complications. This article describes three cases of patients whose catheters were malpositioned on initial place- ment or while in situ, that were successfully guided to appropriate tip location in the superior vena cava by implement- ing a combination of non-invasive catheter repositioning techniques. KEY WORDS: neonate, neonatal, PICC, malposition, migration, reposition, maneuvers, peripherally inserted central catheter, complication, central venous catheterP remature infants today face great challenges as catheter tip be placed in the lower half to one-third of they strive to survive. Only secondary to airway the SVC, sometimes delineated as T3—T5.4-7 Catheter is the urgent need for vascular access. The uti- malposition has been reported to occur as frequentlylization of peripherally inserted central catheters as 85.8% on initial insertion, accounting for 1.5%—3%(PICCs) has grown in practice and nearly become a of PICC complications.8,9 Catheters in situ can dis-standard of care as a reliable means of providing par- place because of hemodynamics and physical forcesenteral nutrition and medications. Appropriate posi- such as patient position, and especially if subjected totioning of the PICC is key to minimizing complica- external forces such as high-frequency ventilation.tions of care. A noncentral catheter tip—location thatis outside the superior vena cava (SVC) demonstrated CASE PRESENTATION 1a significantly increased likelihood of complications inpediatric patients.1 Catheter tips located outside the Baby H is a 25-week, 680-g infant who received umbil-SVC or in the proximal or upper portion of the SVC ical arterial and umbilical venous catheters uponhave been associated with a higher risk of thrombosis admission. By day 3 of life, the umbilical venousthan the distal or lower portion of the SVC.2,3 Current catheter became displaced and was removed. To pro-commonly referenced guidelines from the National vide vascular access, a 28-gauge polyurethane catheterAssociation of Neonatal Nurses and the Infusion was inserted via the right basilic vein without compli-Nurses Society reflect these findings and recommend cation. The initial chest x-ray film indicated that the tipfor an upper extremity or scalp insertion that the of the catheter appeared to be curled in a retrograde slightly superior direction just below the clavicle, and via consultation with the radiologist, determined that the tip had been malpositioned in the subclavian vein,Address correspondence to Elizabeth L. Sharpe, MSN, ARNP, a thyroid vein, the brachiocephalic vein, anterior jugu-NNP-BC, Pediatrix Medical Group, West Palm Beach, Florida; lar vein, or diverted retrograde superiorly into internal jugular vein (Figure 1). Retaining a catheterAuthor Affiliation: Pediatrix Medical Group, Wellington Florida. with its tip in suboptimal location has been associatedThe authors have disclosed that they have no outside with greater incidence of complications includingfinancial or commercial support related to this article. thrombosis and subdiaphragmatic palsy.1,10,11 LeavingCopyright © 2010 by the National Association of a coiled catheter within a confined vein lumen couldNeonatal Nurses. be particularly damaging to the tunica intima.Advances in Neonatal Care • Vol. 10, No. 3 • pp. 129-132 129
  • 27. 130 Sharpe mentation needs and medications. On day 19 of life, a FIGURE 1. 28-gauge polyurethane catheter was inserted via the right basilic vein without complication. Initial chest x-ray film showed catheter tip beyond the cavoatrial junction within the right atrium, and per digital annotator estimation, catheter was withdrawn 1.5 cm. Follow-up chest x-ray film showed tip of catheter across midline in the contralateral subclavian vein, rather than in the SVC, as might be expected (Figure 3). This illustrates that accurate correction cannot be pre- sumed and demonstrates the importance of obtaining radiographic reconfirmation after a catheter is adjusted in accordance with the Food and Drug Administration precautions.12 Management This patient was placed on the ipsilateral side as the catheter with the head of the bed elevated for approx- Peripherally inserted central catheter tip turns imately 20—30 minutes and catheter was flushed with superiorly toward right clavicle. A feeding tube and 1 mL of normal saline, and then continuous infusion umbilical arterial catheter are also in place. resumed. Follow-up anterior-posterior x-ray film, taken with patient in the supine position, showed that the catheter redirected into appropriate position inManagement the SVC, not in the right atrium. Incidentally, thisThis patient was supported to a sitting position briefly same malposition occurred to the patient described(approximately 1 minute), while catheter was flushed in case 1 on day 8 of dwell, and the catheter was suc-with 1 mL of normal saline, right upper extremity was cessfully repositioned in the SVC using the sameabducted and elbow extended, and then right upper techniques.extremity was adducted and elbow flexed. Follow-upx-ray film was taken with right upper extremity CASE PRESENTATION 3adducted and showed correction of the catheter tip toan appropriate location in the SVC, in central place- Baby N is a 26-week, 600-g infant, who on day 3 ofment (Figure 2). life underwent placement of a 28-gauge polyurethane catheter via the left axillary vein with the catheter tipCASE PRESENTATION 2Baby R is a 28-week, 750-g infant who required reli-able long-term vascular access for lingering hyperali- FIGURE 3. FIGURE 2. Peripherally inserted central catheter crosses midline Peripherally inserted central catheter in superior vena into contralateral subclavian vein. A feeding tube is cava. also in place.
  • 28. Repositioning Techniques for Neonatal PICCs 131 The repositioning maneuvers implemented in case FIGURE 4. 1 apply anatomical principles that recognize the role of soft tissue compression and its impact on the vessel’s anatomical pathway and eventual catheter tip position. With a catheter inserted in the basilic vein, abducting the upper extremity and extending the arm withdraws the catheter.17,18 Adducting the upper extremity and flexing the elbow then advances the catheter tip, driving it deeper into the chest.17,18 In addition, the injection of flush solution into the catheter produces movement at the distal tip of the catheter, that in combination with the patient’s hemodynamic flow returning to the heart successfully repositioned the catheter tip in the SVC.19 The strategies utilized to redirect the catheter tip in cases 2 and 3 apply the synergistic principles of the hemodynamics of blood flow, gravity, and the effects Peripherally inserted central catheter ascends into left of actively flushing fluid through the catheter, internal jugular vein. thereby mobilizing the catheter tip into the desired location in the SVC (Figure 5). Spontaneous correction of catheter tips has been noted in patients whose catheters were initially locatedadvanced to central placement. A chest x-ray film in vessels outside the SVC, suggesting that anothertaken 2 days later showed the catheter tip positioned strategy may be utilizing the catheter as a peripheralin the internal jugular vein, directed superiorly line during a period of 24 hours of observation, fol-(Figure 4). lowed by radiographic reevaluation of the catheter tip.15,16 Catheters recalcitrant to the strategiesManagement described may require replacement or interventionalThis patient was supported to a sitting position, with radiology catheter redirection via guidewire under flu-head midline in a neutral position, for approximately oroscopy, based upon the patient’s needs.1 minute, while catheter was flushed with 1-mL nor-mal saline. Follow-up x-ray film revealed that thecatheter tip had resumed its initial central position. FIGURE 5.DISCUSSIONCatheter malposition occurs when the catheter tip failsto reach optimal tip location in the SVC with reportedincidence rates ranging from 10% to 85.8%.9,13 Wheninitial placement does not achieve or the catheter doesnot maintain optimal tip location in the SVC, varyingoptions may be considered. The PICC placement maybe attempted at another site or catheter exchangethrough the same vein may be performed.14 Cathetershave been observed to self-correct but this cancontribute to doubt and delay in delivering the neces-sary therapy.15,16 The catheter could be withdrawn toa midline noncentral placement with its tip located inthe proximal portion of an extremity or above thelevel of the clavicle if in a scalp vein.4 Midline place-ment of the catheter sacrifices central tip location andits benefits of optimal hemodilution of infusates,thereby subjecting use of the catheter to peripheral Major veins of the head and chest. Commonly encoun-limitations.5 The association of increased complica- tered malpositioned catheters follow the anatomicaltions with noncentral tip location cannot be dismissed pathways to lodge in the contralateral subclavian veinin a pay-for-performance environment of care that or ipsilateral jugular vein. Reprinted with permission.emphasizes not only patient safety but also eliminating Copyright © Becton, Dickinson and Company.unnecessary procedures.1,3,13Advances in Neonatal Care • Vol. 10, No. 3
  • 29. 132 Sharpe 6. Association for Vascular Access. Position statement: tip location of peripherallyIMPLICATIONS FOR PRACTICE inserted central catheters. J Vasc Access Devices. vol 3. 1998:2-4. 7. Food and Drug Administration. Guidance on Premarket Notification. SubmissionThe combined approach of noninvasive strategies for Short-term and Long-term Intravascular Catheters. Silver Spring, MD: Food and Drug Administration; 1994. FDA notice 510-K.before other measures that directly manipulate the 8. Pettit J. Assessment of infants with peripherally inserted central catheters: Part 1.catheter can be invaluable in decreasing potential risk Detecting the most frequently occurring complications. Adv Neonatal Care. 2002;factors for catheter-associated bloodstream infection. 2(6):304-315. 9. Fricke BL, Racadio JM, Duckworth T, Donnelly LF, Tamer RM, Johnson ND.These techniques are cost-effective, can minimize the Placement of peripherally inserted central catheters without fluoroscopy inneed for additional and more complex procedures, children: initial catheter tip position. Radiology. 2005;234(3):887-892. 10. D’Netto M, Bender J, Brown R, Herson V. Unilateral diaphragmatic palsy in associ-and reduce undue stress to the fragile neonate. ation with a subclavian vein thrombus in a very-low-birth-weight infant. AmPurposeful repositioning maneuvers can successfully J Perinatol. 2001;18(8):459-463. 11. Pettit J. Assessment of infants with peripherally inserted central catheters: Part 2.accomplish optimal catheter tip location in the SVC. Detecting less frequently occurring complications. Adv Neonatal Care. 2003;3(1):Ensuring appropriate positioning of the PICC tip loca- 14-26. 12. Food and Drug Administration. Precautions necessary with central venous catheters.tion in the SVC is an achievable goal to support safe FDA Drug Bull. 1989;19: of therapy to our tiny patients. 13. Treretola S, Thompson S, Chittams J, Vierregger K. Analysis of tip malposition and correction in peripherally inserted central catheters placed at bedside by a dedicated nursing team. J Vasc Int Radiol. 2007;18:513-518. 14. Pettit J. Technological advances for PICC placement and management. Adv NeonatalReferences Care. 2007;7(3):122-131.1. Racadio J, Doellman D, Johnson N, Bean J, Jacobs B. Pediatric peripherally inserted 15. Rastogi S, Bhutada A, Sahni R, Berdon W, Wung JT. Spontaneous correction of the central catheters: complication rates related to catheter tip location. Pediatrics. malpositioned percutaneous central venous line in infants. Pediatr Radiol. 1998; 2001;107(2):e28. 28:694-696.2. Cadman A, Lawrance JA, Fitzsimmons L, Spencer-Shaw A, Swindell R. To clot or not 16. Tawil K, Eldemerdash A, Hathlol K, Laimoun B. Peripherally inserted central venous to clot? That is the question in central venous catheters. Clin Radiol. 2004;59(4): catheters in newborn infants: malpositioning and spontaneous correction of 349-355. catheter tips. Am J Perinatol. 2006;23(1):37-40.3. Kearns PJ, Coleman S, Wehner JH. Complications of long arm-catheters: a random- 17. Nadroo AM, Glass RB, Lin J, Green RS, Holzman IR. Changes in upper extremity ized trial of central vs peripheral tip location. JPEN J Parenter Enteral Nutr. position cause migration of peripherally inserted central catheters in neonates. 1996;20(1):20-24. Pediatrics. 2002;110(1, pt 1):131-136.4. Infusion Nurses Society. Infusion nursing standards of practice. J Infus Nurs. 18. Connolly B, Amaral J, Walsh S, Temple M, Chait P, Stephens D. Influence of arm 2006;29(1 suppl):S1-S92. movement on central tip location of peripherally inserted central catheters (PICCs).5. Pettit J, Wyckoff MM. Peripherally Inserted Central Catheters Guideline for Pediatr Radiol. 2006;36:845-850. Practice. 2nd ed. Glenview, IL: National Association of Neonatal Nurses; 19. Ragasa J, Shah N, Watson RC. Where antecubital catheters go: a study under 2007. fluoroscopic control. Anesthesiology. 1989;71(3):378-380.
  • 30. CHERYL KING, MS, CCRN • Section EditorPerinatal Germ Cell TumorsA Case Report of a Cervical Teratoma Sharon Fichera, MSN, RN, CNS, NNP-BC, Heather Hackett, BSN, RN, Rita Secola, MSN, RN, CPON ABSTRACT Teratomas belong to a class of tumors known as germ cell tumors. Cervical teratomas are rare and account for 1.5% to 5.5% of all pediatric teratomas. These types of tumors are the result of abnormal development of pluripotent cells. The following case study describes a 36-week male infant who was prenatally diagnosed with a large cervical mass. The neonate was delivered via the EXIT (ex utero intrapartum treatment) procedure, with expert teams present. After stabilization, the infant was transferred to the neonatal intensive care unit (NICU) at Childrens Hospital Los Angeles. The teratoma was removed on day of life 5. The pathology report indicated a malignant germ cell tumor. A chemotherapy regimen was developed for this critically ill neonate in the NICU. An interdisciplinary treatment approach allowed safe and optimal quality of care. Baby CM was discharged on day of life 88 without complications and continues to be cancer free and at home thriving. KEY WORDS: chemotherapy, EXIT procedure, malignant, teratomaT eratoma is a type of neoplasm or tumor. the cervical area, mediastinum, nasopharynx, and Teratomas belong to a class of tumors known retro peritoneum, do not usually contain malignant as germ cell tumors. These types of tumors are germ cell elements. Recurrence or metastasis is rarethe result of abnormal development of (a) pluripotent but may occur when immature elements are presentcells, which are stem cells that have the potential to or if surgical resection is incomplete.1,3-5 For the pur-differentiate into any of the 3 germ layers, endoderm pose of this article, a brief overview of the etiology,(interior stomach lining, gastrointestinal tract, the diagnosis, treatment, and prognosis of neonatal ter-lungs), mesoderm (muscle, bone, blood, urogenital), atomas and a neonatal case study are presented.or ectoderm (epidermal tissues and nervous system),and can give rise to any fetal or adult cell type; (b) ETIOLOGYgerm cells; and (c) embryonal cells. Teratomasderived from embryonal cells usually occur in the Teratomas are neoplasms that are derived from moremidline of the body. The most common embryonal than 1 of the embryologic germ cell lines. The wordteratomas are found in the sacrococcygeal region.1 neoplasm comes from the Greek word meaning newCervical teratomas are rare and account for 1.5% to growth and is the abnormal proliferation of cells in5.5% of all pediatric teratomas.2 They are usually his- tissue or organs that result in a neoplasm. When atologically benign but may be large in size and com- neoplasm forms a distinct mass, it is referred to as apromise the airway. Morbidity and mortality are tumor. These tumors can be benign or malignant.increased because of the high risk of airway compro- Teratomas derived from germ cells occur in the testesmise and a potentially life-threatening upper airway in males and ovaries in females. Teratomas derivedobstruction.2 In general, the sacrococcygeal tumors from embryonal cells usually occur in the midline ofhave the highest risk of malignancy; hence, those in the body. Embryonal teratomas most commonly occur in the sacrococcygeal region. Sacrococcygeal teratoma is the single-most common tumor found inAddress correspondence to Sharon Fichera, MSN, RN, CNS, the newborn.1 The incidence is 1 in 20,000 to 40,000NNP-BC, Childrens Hospital Los Angeles, 4650 Sunset Blvd births and is rarely malignant.1 A malignant cervical74, Los Angeles, CA 90027; teratoma is rare and usually presents as an enlargingAuthor Affiliation: Childrens Hospital Los Angeles, neck mass. After surgical excision is performed, anLos Angeles, California. initial diagnosis of immature extragonadal teratomaCopyright © 2010 by the National Association of is changed to malignant cervical teratoma afterNeonatal Nurses. confirmation of cervical metastasis and an elevatedAdvances in Neonatal Care • Vol. 10, No. 3 • pp. 133-139 133
  • 31. 134 Fichera et al -fetoprotein (AFP) level.6 Fetuses with teratomas ment approaches germ cell tumors include cisplatin,detected antenatally have 3 times the mortality rate etoposide, and bleomycin (Table 1). These agents arecompared with postnatally diagnosed neonates.7 usually given via intravenous administration, one fol- lowing the other as 1 dose for 4 to 6 cycles on a monthly basis. Cisplatin is classified as a heavy-DIAGNOSIS metal, platinum-based alkylating agent that inhibits DNA synthesis of the cell cycle. Etoposide is classi-Teratomas are thought to be present at birth but are fied as a plant alkaloid, specifically in a group ofoften not diagnosed until much later in life. Fetal and epipodophyllotoxins that inhibits the late S or earlyneonatal teratomas have been reported on fetal ultra- G phase of the cell cycle. Bleomycin is classified as ansound studies. Teratomas are considered the most antitumor antibiotic that mostly interferes with the G2controversial of the germ cell tumors and are classi- or mitosis phase of the cell cycle. These agentsfied as benign mature or malignant immature tumor require strict monitoring of intake and output, bloodtypes.8 These tumors may present as an enlarging pressure, electrolytes, and potential allergic reactions.neck mass and usually are benign. The tumor mark- The use of platinum-based combination chemother-ers AFP and -human chorionic gonadotropin are of apy has significantly improved the survival rate ofcritical importance in the diagnosis of all types of infants with advanced malignant germ cell tumors.7germ cell tumors. The elevation in the levels of these Safe dosing of chemotherapy in the very young childclinical markers can confirm the presence of malig- is administered according to the weight in kilogramsnant disease and determine response to treatment. of the patient.The peak concentration of AFP is at 12 to 14 weeks’gestation and reaches adult normal level of 10 ng/mLby 1 year of age.8 Elevated serum AFP levels indicate PROGNOSISthe presence of malignant endodermal sinus tumor in The site, stage, and AFP level have prognostic signif-extracervical teratomas.9 A normal level of -human icance for all germ cell tumors. Survival for extrago-chorionic gonadotropin in a healthy, nonpregnant nadal sites for stages I and II is approximately 90%adult woman is less than 5 IU/mL.8 There are other and for stages III and IV 75%.10 Patients with stage IIIconditions that may cause elevation of these markers; or IV disease are considered at high risk. In additiontherefore, there is ongoing research that is focused on to increasing the chance of long-term, event-free sur-identifying additional markers that may have diag- vival for these infants with appropriate cytotoxic reg-nostic and prognostic value for these infants. Because imens, decreasing acute toxicities and long-termof their immature physiological state, great caution is effects is of outmost importance. For the neonate whoexercised to implement a necessary cytotoxic treat- has undergone cytotoxic therapy, long-term follow-ment plan to minimize short- and long-term effects. up is mandated because these infants will be at riskIn addition to the location of the tumor in the infant, for developing secondary malignancies later in theirpathological review is also vital to confirm a malig- childhood or adulthood. It is also vital to providenant or benign tumor and to determine the exact ongoing assessment of any potential long-term seque-classification of the germ cell tumor. This information lae such as developmental or growth delay,is essential to determine an appropriate treatment endocrine dysfunction, or other long-term pul-plan. monary or cardiac dysfunction that may inhibit their long-term survival and quality of life.11TREATMENT Neonates with congenital cervical teratomas are associated with a high rate of perinatal mortalityLife-threatening airway obstruction at birth is com- because of airway obstruction.12 Perinatal asphyxia ismon in infants who have cervicofacial teratomas.9 usually considered as the likely cause of death.13 ThePrenatal diagnosis is feasible, reliable, and essential to mode of delivery for these neonates is problematic.facilitate individualized treatment modalities neces- The establishment of the airway should optimally besary for the germ cell tumors that can arise in infancy. performed while still attached to placental circula-Surgical resection is the initial treatment of choice, tion.14,15 The ex utero intrapartum treatment (EXIT)providing vital structures and organs remain intact; procedure was originally developed to reverse theotherwise, a biopsy of or debulking the tumor is temporary tracheal occlusion (tracheal clip) in fetusesappropriate. If the teratoma has a malignant com- with congenital diaphragmatic hernia. The tempo-ponent, then surgical resection alone is not suffi- rary occlusion of the trachea must then be removedcient. Once malignant confirmation is obtained, at the time of delivery while the neonate remains onchemotherapy is given after recovery from postsur- placental circulation. The EXIT procedure has cur-gical resection in the hope to eradicate any remain- rently been shown to be useful for the managementing tumor or microscopic disease. Common of other causes of fetal airway obstruction.15,16 In onechemotherapeutic agents utilized in standard treat- study, a retrospective review of 52 patients who
  • 32. Perinatal Germ Cell Tumors 135 TABLE 1. Common Chemotherapy Agents Utilized for the Treatment of Germ Cell Tumorsa Drug Classification Route(s) Adverse Effects Special Considerations Cisplatin Alkylating agent, Intravenous Nausea, vomiting, bone Antiemetic regimen prior to (Platinol) cell-cycle marrow suppression, and throughout days of nonspecific hypomagnesemia, therapy alopecia, hearing loss, Strict intake and output and renal toxicity electrolyte monitoring Rare: peripheral Administer mannitol/diuretics neuropathy, seizure, as needed secondary malignancy Caution simultaneous use of aminoglycosides Etoposide (VP-16, Plant derivative, Intravenous Nausea, vomiting, bone Avoid rapid infusions to Vespid) cell-cycle specific oral marrow suppression prevent hypotension Rare: hypotension, Blood pressure monitoring anaphylaxis, rash, during infusions stomatitis, secondary Instability of drug if malignancy concentrations 0.4 mg/mL Oral drug must be refrigerated Bleomycin Antitumor antibiotic, Intravenous Occasional: high fever few Have emergency (Blenoxane) cell-cycle Intramuscular hours after infusion medication/equipment for nonspecific Subcutaneous allergic reaction at bedside Rare: anaphylaxis, skin Test dose by subcutaneous or rash, late pulmonary intramuscular route given fibrosis, renal failure 1 h before remaining dose Baseline and routine pulmonary function tests performed a Adapted from Frederick18 and CHLA (Children’s Hospital Los Angeles) Pediatric Formulary, 2009.underwent the EXIT procedure showed that 5 EXIT procedure (Figure 1). CM was born atpatients underwent the EXIT procedure for neck 36 weeks’ gestation to a 34-year-old gravida 2, paramasses. Tracheostomy was performed in 3 of these 2 mother with a history of Crohn disease. The preg-patients, 1 patient was successfully intubated, and 1 nancy was uneventful until 20 weeks’ gestation whenpatient underwent resection of the neck mass while a large fetal cervical mass measuring 9 9 cm wason placental support. The authors of this study found detected on ultrasonography. The diagnosis wasthe EXIT procedure to be an excellent strategy for confirmed with a fetal magnetic resonance imaging.establishing an airway in a controlled manner.16 In Plans were made to deliver the baby via EXIT pro-another study, endotracheal intubation was initially cedure, with the NICU and otolaryngology teamsattempted in 6 infants prenatally diagnosed with air- present at delivery.way obstruction.14 Only in those airways that werenot amenable to endotracheal intubation, tra- EXIT Procedurecheostomy was performed. In both of these studies, The mother was placed under general anesthesia forthe EXIT procedure team consisted of a high-risk cesarean delivery. Promptly after delivery, CM wasobstetrician, a neonatologist, a pediatric otolaryngol- placed on the abdomen of his mother and was intu-ogist, a pediatric surgeon, and an anesthestist.14,17 bated by endotracheal method prior to his removal from placental circulation. He was then removedNEONATAL CASE REPORT from placental circulation and transferred to a radi- ant warmer for resuscitation and stabilization. CM’sThe following case study describes a male neonate birth weight was 3015 g; Apgar scores of 1 at(CM) diagnosed in utero with a cervical teratoma 1 minute, 1 at 5 minutes, 4 at 10 minutes, and 6 atwho was delivered by cesarean delivery via the 15 minutes, respectively, although these scores mayAdvances in Neonatal Care • Vol. 10, No. 3
  • 33. 136 Fichera et al intermittent atelectasis of the left lung, most likely FIGURE 1. because of his positioning, his blood gases remained within acceptable levels, with carbon dioxide levels in the 35 to 50 ranges. CM continued to show signs of hemodynamic instability and remained on a dopamine drip through the postdelivery period. He required prolonged fluid resuscitation, multiple blood products, albumin, and normal saline adminis- trations. Echocardiography and cranial ultrasonogra- phy were performed and the findings were reported to be normal. A presurgical magnetic resonance imaging was performed on day 4 to assist the surgical team in planning for excision of the teratoma. Findings revealed that the teratoma was compressing the tra- chea and vasculature of the neck but was not encas- ing or involving the structures of the head, neck, or CM at birth illustrating cervical tumor and airway chest. Because of CM’s compromised respiratory sta- compromise. Photo used with permission. tus and hemodynamic instability, surgery was sched- uled for the next day. During the 5-hour surgery, the encapsulated tumor was removed in its adversely affected by anesthesia administered to Bleeding was significant, with an estimated blood lossthe mother before and during delivery. Umbilical of 350 mL. CM was transfused with multiple units ofcatheters were placed and CM received epinephrine, donor-directed red blood cells, plasma, and platelets.tromethamine, and multiple normal saline boluses to The left carotid artery, vagus nerve, and left internalincrease perfusion. Significant airway compression jugular vein were all identified and preserved. Thefrom the mass caused extreme difficulty in adequately excess skin surrounding the teratoma was resectedventilating the infant. Because of marked respiratory and a 5-French Blake drain was inserted prior to clo-acidosis, CM was placed on a high-frequency oscilla- sure of the wound. The incision, which was madetory ventilator. He was then urgently transported to under the chin from ear to ear, was covered with athe NICU at Childrens Hospital Los Angeles. gauze dressing. The patient was transferred to the NICU for recovery. Figure 2 shows CM postsurgicalNeonate Status Post-EXIT Procedure removal of teratoma.Upon arrival in the NICU, CM’s birth weight was The tumor specimen was sent to pathology depart-3015 g with a length of 52 cm; head circumference was ment for analysis. The pathology report indicatednot measured since the head, neck, or shoulders could that the tumor was an extragonadal grade III malig-not be moved. CM was pale with poor perfusion and nant germ cell tumor. Survival rates for stages III andhad minimal chest expansion. Initial arterial blood gas IV extragonadal germ cell tumor sites are approxi-values were as follows: pH 7.12, PCO2 96 mmHg, mately 75%.18 Because of the rarity and controversiesPO2 37 mmHG, and Base Excess 0.6. The surgical in diagnosing this type of tumor in neonates, an out-team was urgently notified to discuss using extracor- side laboratory confirmed the diagnosis.poreal membrane oxygenation as a bridge to surgi- Swelling of CM’s airway and surgical site resolvedcal repair. However, extracorporeal membrane oxy- within several weeks. CM was extubated and placedgenation would not be possible because of the size on oxygen therapy. Direct laryngoscopy and bron-and position of the cervical teratoma. choscopy were performed following extubation and Chest radiograph showed the endotracheal tube to revealed left vocal cord paralysis with a functioningbe in a good position but appeared to be compressed airway. A nasogastric tube was inserted to adminis-by the weight of the teratoma. The endotracheal tube ter continuous breast milk feedings. During this time,was pulled back to be above the area of compression, the hematology/oncology team was consultedand CM was placed in an extreme left-side lying posi- regarding the pathology results and an elevated AFPtion to allow the weight of the teratoma to fall for- level of 48,300. A computed tomographic scanward off the airway. Despite the high position of the showed possible regrowth of the tumor in the neck.endotracheal tube, this method proved effective with A chemotherapy regimen was promptly devised.a repeat blood gas values of pH 7.40, PCO2 38 The chemotherapy regimen consisted of 4 plannedmmHG, PO2 55 mmHg, and HC03 24/Base Excess doses of cisplatin and etoposide by intravenous 1.1. CM was given a medication for muscle relax- administration. Because of CM’s vulnerable clinicalation and placed on synchronized intermittent status, the oncology primary attending physicianmechanical ventilation. Although he experienced elected to eliminate bleomycin from the regimen
  • 34. Perinatal Germ Cell Tumors 137 FIGURE 2. CM postsurgical removal of tumor.because of its risk of allergic and long-term pul- oncology clinical manager received all necessarymonary adverse effects. information and chemotherapy orders for CM. As a Since CM continued to require neonatal intensive collaborative effort, the oncology clinical managercare, it was decided that he would need to receive his communicated with an oncology pharmacist, thechemotherapy in the NICU. A collaborative team NICU clinical manager, and the primary nurse ofapproach was initiated for CM to support him and his CM to establish a plan for education and administra-family through this intense hospitalization. The tion of chemotherapy, required patient monitoring,Advances in Neonatal Care • Vol. 10, No. 3
  • 35. 138 Fichera et al tent and confident in caring for CM, managed with a FIGURE 3. central venous catheter, at home. CM was discharged home with his parents on day of life 88. CM returned to the outpatient hematology oncology day hospital for the fourth and final dose of chemotherapy, with no complications or concerns from his parents. He continues to be cancer free and thriving at home and remains in routine follow-up with outpatient hema- tology oncology team. Figure 3 shows CM at 2 years of age and cancer free. SUMMARY This case highlights a 36-week gestational age male infant who was diagnosed with a cervical neck mass by fetal ultrasonography prior to birth. At the time of delivery, the infant was endotracheally intubated while on placental circulation. The infant was stabi- lized and underwent excision of the mass on day of life 5. The pathology report indicated that the mass was a malignant germ cell tumor. A chemotherapy regimen was initially administered while the infant was in the NICU. Overall, CM tolerated therapy and was discharged home with adequate nutritional intake and infant activity. CM will remain in short- and long-term follow-up with multiple specialties CM at 1 year old. He is still cancer free at 2 years of because he will be at risk of delay in reaching devel- age. Photo used with permission. opmental milestones, relapse of disease, or secondary malignancy.staff safety, and infection control precautions. All Quality and safety of patient care is a high nationalnecessary education was provided to the NICU nurs- priority. This case study illustrates that in rare anding team caring for CM and a concise reminder and complex clinical conditions of vulnerable patientinformational sheet was created and remained in populations, it is critical for expert multidisciplinaryCM’s bedside chart for easy access for all NICU staff. team’s participation to ensure accurate diagnosis,The oncology clinical manager administered the first delivery of care, and follow-up required for theand second doses of CM’s chemotherapy in the patient and the family.NICU. The oncology clinical manager communi-cated daily with the designated pharmacist and ReferencesNICU bedside RN prior to each chemotherapy 1. Mignon L, Matthay K. Congenital malignant disorders. In: Taeusch W, Ballard R,administration to ensure clear communication and eds. Avery’s Diseases of the Newborn. 8th ed. St Louis, MO: Elsevier Saunders Publishers; administration and monitoring of CM through- 2. Sayan A, Karacay S, Bayol U, Arikan A. Management of a rare cause of neonatalout his treatments. The oncology clinical manager airway obstruction: cervical teratoma. J Perinat Med. 2007;35(3):255-256.was also able to spend time with parents and NICU 3. April MM, Ward RF, Garelick JM. Diagnosis, management, and follow-up of con- genital head and neck teratomas. Laryngoscope. 1998;108(9):1398-1401.nurses to offer education and support on a daily basis. 4. Carr MM, Thorner P, Phillips JH. Congenital teratomas of the head and neck. After the first dose of chemotherapy, CM experi- J Otolaryngol. 1997;26(4):246-252. 5. Wakhlu A, Wakhlu AK. Head and neck teratomas in children. Pediatr Surg Int.enced vomiting, abdominal distention, and dilated 2000;16(5-6):333-337.bowel loops. After a period of bowel rest, feedings 6. Muscatello L, Giudice M, Feltri M. Malignant cervical teratoma: report of a case in a newborn. Eur Arch Otorhinolaryngol. 2005;262(11):899-904.with Elacare formula were resumed. He had no other 7. Isaacs H. Perinatal (fetal and neonatal) germ cell tumors. J Pediatr Surg.significant adverse effects or signs of infection during 2004;39(7):1003-1013. 8. Brace O’Neill J. Rare tumors. In: Baggot CR, Kelly KP, Fochtman D, Foley GV, eds.hospitalization. A barium swallow was performed Nursing Care of Children and Adolescents With Cancer. 3rd ed. Glenview, IL:and showed no signs of aspiration. CM’s parents, Association of Pediatric Hematology Oncology Nurses; 2002:598-615.nurses, and occupational therapy team were able to 9. Azizkhan RG, Haase GM, Applebaum H, et al. Diagnosis, management and out- come of cervicofacial teratoma in neonates: a childrens cancer group study.teach CM to nipple feed. His AFP levels dropped J Pediatr Surg. 1995;30(2):312-316.after the initiation of chemotherapy and a repeat 10. Thomas L. Rare tumors of childhood. In: Kline N, ed. Essentials of Pediatric Oncology Nursing: A Core Curriculum. 2nd ed. Glenview, IL: Association ofcomputed tomographic scan was negative for tumor. Pediatric Hematology Oncology Nurses; 2004:58-60. CM was transferred to the oncology unit for the 11. Anderson PJ, David DJ. Teratomas of the head and neck region. J Craniomaxillofac Surg. 2003;31(6):369-377.third dose of chemotherapy, which he tolerated well. 12. Green JS, Dickinson FL, Rickett A, Moir A. MRI in the assessment of a newbornAfter thorough instruction, his mother was compe- with cervical teratoma. Pediatr Radiol. 1998;28(9):709-710.
  • 36. Perinatal Germ Cell Tumors 13913. Kamil D, Tepelmann J, Berg C, et al. Spectrum and outcome of prenatally diag- 16. Hirose S, Farmer DL, Lee H, Nobuhara KK, Harrison MR. The ex utero intrapartum nosed fetal tumors. Ultrasound Obstet Gynecol. 2008;31(3):296-302. treatment procedure: looking back at the EXIT. J Pediatr Surg. 2004;39(3):375-380.14. Raveh E, Papsin BC, Farine D, Kelly EN, Forte V. The outcome after perinatal manage- 17. Hirose S, Harrison MR. The ex utero intrapartum treatment (EXIT) procedure. ment of infants with potential airway obstruction. Int J Pediatr Otorhinolaryngol. Semin Neonatol. 2003;8(3):207-214. 1998;46(3):207-214. 18. Frederick ES. Rare tumors of childhood. In: Kline N, Hobbie W, Hooke MC, Rodgers15. Castillo F, Peiro JL, Carreras E, et al. The exit procedure (ex-utero intrapartum C, O’Brien-Shea J, eds. Essentials of Pediatric Hematology/Oncology Nursing: A treatment): management of giant fetal cervical teratoma. J Perinat Med. 2007; Core Curriculum. 3rd ed. Glenview, IL: Association of Pediatric Hematology 35(6):553-555. Oncology Nurses; 2008:54-56.Advances in Neonatal Care • Vol. 10, No. 3
  • 37. ANITA CATLIN, DNSC, FNP, FAAN • Section EditorHope and Parents of theCritically Ill NewbornA Concept Analysis Barbara Amendolia, NNP, APN-BC ABSTRACT Hope is a human phenomenon that is observed repeatedly in the neonatal intensive care unit setting. There have been few studies specifically examining the concept of hope in this population. The purpose of this article is to examine the concept of hope in parents of critically ill newborns. Uses of the concept will be investigated. Critical defining attributes will be provided. Antecedents and consequences of hope will be investigated. An overview of the empirical referents of hope will be presented. KEY WORDS: concept, hope, hopelessness, neonatal, newborn, neonatal intensive care unit effort to care holistically for their patients. Hope isH ope has been conceptualized and measured as a construct in nursing.1 The phenomenon considered a basic human response, essential for and of hope is observed repeatedly in the neona- associated with life meaning and quality of life.3tal intensive care unit (NICU) setting where critically Psychologists contend that hope levels can changeill newborns cling to life. Parents of critically ill new- over time through interventions such as counselingborns have expressed a sense of powerlessness and and education.4 Hope-inspiring strategies have beenexacerbation of the negative aspects of NICU expe- extrapolated from qualitative studies that have iden-riences when there is a loss of hope.2 Loss of hope tified stages of hope and behavioral signs related tomay also affect how well parents of gravely ill new- the process of hope.5 A better understanding of hopeborns cope with the stress of the situation. Hope is will help nurses devise appropriate interventions toimportant in the NICU setting and may be helpful to support parents of sick neonates.parents in need of strength and resilience when fac-ing the many challenges in dealing with a critically ill METHODSbaby.2 Exploration of the concept of hope withregards to implications for practice in the NICU set- The method utilized in this article is the Walker andting may prove beneficial to healthcare providers Avant6 method of concept analysis. The first stepcommitted to optimal care for this population. involves a thorough investigation into all possible uses of the concept. Critical attributes are then iden- tified. Exemplar cases are then constructed. TheseBACKGROUND include the model case, the borderline case, a relatedHope is a human phenomenon that warrants further case and a contrary case, an invented case, and aninvestigation and clarification. Because they work illegitimate case. The invented and illegitimate caseswith human responses, nurses need to broaden their were not included in this analysis. Antecedents andbody of knowledge about the concept of hope in an consequences of the concept are then identified and empirical referents defined (Table 1).6Address correspondence to Barbara Amendolia, NNP, APN-BC, Data Sources19 Golf Dr, Hammonton, NJ 08037; A review of the literature was conducted utilizingAuthor Affiliation: Drexel University, Philadelphia, Pennsylvania. search engines CINAHL, MEDLINE, and PsycLIT.Copyright © 2010 by the National Association of Articles were limited to the English language,Neonatal Nurses. research, and peer review. Key words included hope,140 Advances in Neonatal Care • Vol. 10, No. 3 • p. 140-144
  • 38. Hope and Parents of the Critically Ill Newborn 141 TABLE 1. Antecedents, Critical Attributes, and Consequences of Hope Critical Attributes Antecedents Consequences Future orientation Negative or stressful stimuli Ability to cope Goal-setting Suffering or loss Certainty Realism Predicament or threat Improved health Energy or activity processing Improved quality of life Uncertainty Peace Positive feeling or optimism New perspective Strength Empowermenthopelessness, concept, neonatal, newborn, and action-oriented expectation that a positive future goalNICU. Databases were searched for the period or outcome is possible.”10(p217) Hope is a process-between 1975 and 2009 to allow for a historical per- oriented complex of many thoughts, feelings, andspective. The criterion for inclusion was the appear- actions that change over time. Hope encompassesance of the words hope or hopeless combined with many manifestations and dimensions.10neonatal or newborn population as a focus for the The field of psychology focuses on prevention ofstudy. A total of 21 articles were retrieved initially. psychopathology and has identified hope as a psy-Two of the articles used an adolescent-specific popu- chological strength that may foster healthy develop-lation and were excluded. The remaining 19 articles ment.4 A longitudinal study in 20064 involving ado-were included in the review. lescent participants from 3 public middle schools analyzed the cognitive—motivational construct ofUses of the Concept hope as a psychological strength in adolescents.According to Webster’s New World Dictionary (1974), These researchers found that those participants whohope can be defined as a noun or a verb. Hope as a reported higher initial levels of hope were morenoun can be defined as “a feeling that what is wanted likely to report higher levels of global life satisfactionwill happen, desire accompanied by expectation or a year later. The study also supported the theory thatthe thing that one has a hope for.” As a verb, it is individuals higher in hope are better able to envisiondefined as “to want very much, to trust or rely and to and undertake adaptive coping strategies when facedexpect.”7 with significant life stress. The study also supported Hope has been described as an emotion, as an the hypothesis that hope levels function as a moder-experience, or as a need.8 There exists a distinction ator of the relationship between stressful or negativebetween generalized and particularized hope. Hope life events and mental health outcomes. Hope wasis described in very positive terms; however, descrip- found to be a protective or buffering factor in certaintions may be unclear and vague. Some definitions contexts.4can be ambiguous or even contradictory.8 Hope has been defined by as “a response to a threat RELATED CONCEPTSthat results in the setting of a desired goal; the aware-ness of the cost of not achieving the goal; the planning Concepts related to hope have been identified in theto make the goal a reality, the assessment, selection, review of the literature. These include endurance,and use of all internal and external resources and sup- uncertainty, and suffering.11 Self-transcendence,ports that will assist in achieving the goal; and the acceptance, coping, and spiritual perspective havereevaluation and revision of the plan while enduring, been found to have interrelationships with hope.12working, and striving to reach the desired goal.”5(p281) Social support and interconnectedness with othersA similar definition of hope has been developed that are related concepts that have been described ininvolves multiple dimensions.9 Other authors define development of interventions to foster and maintainhope as a “multidimensional dynamic life force char- hope.11acterized by a confident yet uncertain expectationof achieving a future good which, to the hoping per- DEFINING ATTRIBUTESson, is realistically possible and personally signifi-cant.”9(p381) One conceptual definition of hope is “an A review of the literature allows for synthesis of theenergized mental state involving feelings of uneasi- terms that act as defining attributes. The literature hasness or uncertainty and characterized by a cognitive, yielded 6 central defining attributes that includeAdvances in Neonatal Care • Vol. 10, No. 3
  • 39. 142 Amendolia(1) future orientation; (2) goal-setting; (3) realism; of the concept being examined.6 The following is an(4) energy or activity processing; (5) uncertainty; and (6) example of a model case.a positive feeling or optimism.1,3,5,13-15 Other attributes Gabrielle was born 3 months premature withrelated to hope have been described, including power, severe respiratory distress syndrome. She is nowmeaningful, internal, and essential for life in addition to 6 weeks old and has been having difficulty toleratingglobal, process, desire, and intentionality (Table 1). her feedings. Her parents visit her in the NICU every day. Mom brings her pumped breast milk and hap-THEORETICAL BASIS pily gives it to the nurse as she expresses how excited she is that Gabrielle will be resuming feedings today.There have been 2 major frameworks that use hope She tells the nurse that she understands that the feed-as a conceptual model. The Hope Process ings might need to be stopped again if the biliousFramework was developed by Farran et al13 in 1990. residuals come back but is glad to think that if she canThis framework is based on 4 central attributes of tolerate the 1 mL every 3 hours for 2 days, she canhope: experiential process, spiritual or transcenden- advance to 2 mL every 3 hours and so forth.tal process, rational thought process, and relational Watching her progress slowly with the feedings andprocess.16 The framework was developed from data weight gain has been difficult, but both parentson hope from philosophy, theology, nursing, medi- remain optimistic and believe that their baby will becine, psychology, and sociology. The framework has coming home by the time her due date arrives. Theybeen utilized in the development and implementa- set goals for her weight gain and believe that she cantion of a hope intervention program.16 achieve them. Other authors have developed a conceptual model Gabrielle’s case can be used as the model caseof hope that includes 7 components.5 The first com- example. This case includes all of the critical attrib-ponent suggests that hope involves a realistic assess- utes of hope: goal-setting, future orientation, realism,ment of a threat that results in envisioning of alterna- energy, uncertainty, and optimism.tive goals. These goals include negative outcomes.The decision of the goals is an active process. The BORDERLINE CASEactive process is the second component. The thirdcomponent is revision of hope goals and this may The borderline case contains some, or perhaps all, ofinvolve what these authors cite as “bracing for nega- the critical attributes but differs substantially in onetive outcomes.”5(p284) The inference is that hope of them.6 The following is an example of a border-remains important in the face of a negative outcome. line case.The fourth component of the model involves a real- Sammy was born 3 months prematurely and hasity assessment with regards to selecting and augment- had a difficult clinical course. His parents visit himing goals. The fifth component emphasizes social every day and watch as the nurse cares for, sustaining relationships, and interconnect- They are not very optimistic that he will improveedness with others as invaluable contributions to soon but visit him daily because they believe thatthe development and maintenance of hope. this is their duty. The mother brings her pumpedReinforcement of goals, revision of goals, and contin- breast milk in and hands it to the nurse to place inued evaluation is component number 6, and the last the freezer. He is not eating yet but Mom believesfactor involves determination to endure. These that feeds will be resumed soon. She cries almostresearchers believe setting and attainment of goals to every day when she thinks he may never tolerate hisbe the work of the patient. The model was developed feeds and may even an effort to better understand the role of hope in The story of Sammy is a borderline case. The bor-the illness experience and enhance hope in the clini- derline case of Sammy has some of the definingcal setting. Nurses working with critically ill new- attributes of hope, such as uncertainty, realism, andborns can utilize Morse and Doberneck’s model to activity possessing, but it is not future oriented anddevelop and implement a plan for fostering and does not include goal-setting.maintaining hope in the parents of these fragileinfants.5 Together with the parents, nurses can set and RELATED CASErevise goals, evaluate and reinforce needs of socialsupport and sustaining relationships and intercon- According to Walker and Avant,6 a related concept isnectedness, and explore personal strengths to help similar to the main concept but does not contain theparents endure and cope with the critical situation. critical attributes. One concept that has an interrela- tionship with hope is spirituality.17 The following isMODEL CASE an example of a related case. Nicole was born in the middle of the night onThe model case is one that includes all of the critical April 4. Weighing in at only 489 g, this baby girl,attributes and is considered to be a perfect example born at just 23 weeks’ gestation, is what the world of
  • 40. Hope and Parents of the Critically Ill Newborn 143neonatology would call a micropreemie. The NICU Threats to Hopeteam resuscitated because her parents wanted every- Threats to hope include pain, uncontrolled symp-thing done for her. Their decision was made after toms, spiritual distress, fatigue, anxiety, social isola-they had been given all of the grim facts regarding tion, loneliness, and hopelessness from powerful oth-what this infant might have to endure after being ers such as the healthcare team.12 The goal of theborn so early. They were told that her chance of sur- practitioner caring for patients struggling with suffer-vival was less than 50%. They were also told that if ing, loss, or a stressful life event, such as the birth ofshe survived, she would have a 90% chance of having an extremely premature or critically ill newborn, is toserious problems including cerebral palsy, deafness, limit or minimize threats to hope and promote hope-blindness, and mental retardation. Still, they made inspiring strategies.the decision to have everything possible done for her.Mom said they would “take whatever God gave Consequences of Hopethem.” Both parents voiced their belief that the fate Consequences of hope as identified in the review ofof this baby was in His hands. the literature include ability to cope, certainty, The story of Nicole is a related case and an exam- improved health, better quality of life, andple of the concept “spirituality.”18 Additional con- peace.1,5,13-15 New perspective, strength, and empow-cepts found to have interrelationships with hope erment have also been identified as consequences orinclude endurance, uncertainty, and suffering.9 outcomes of hope.3CONTRARY CASE EMPIRICAL REFERENTSThe contrary case is a clear example of what the con- Hope can be measured using a variety of scales withcept is not.6 The following is an example of a contrary proven reliability and validity. The Herth Hopecase. Scale (HHS), the Hope Index Scale, the Childrens’ Janice has just delivered an extremely premature Hope Scale, the Stoner Hope Scale, the Miller Hopeinfant at 22 weeks’ gestation. The baby was brought Scale, and the Nowotny Hope Scale address multipleto the NICU and Janice is waiting with her parents in dimensions of hope, including the interpersonal ele-the labor room suite. Janice’s father asks her whether ment, the time-oriented future focus, and the goal-she is happy that the baby is a girl. Janice expresses achievement expectation of hope.20her sadness over having such a sick baby. She admits The HHS incorporates all of the critical elementsthat she does not believe the infant will survive and of hope and also includes other related elements. Theis frightened to visit her and become attached if she HHS is a 30-item, 4-point scale based on 6 dimen-is going to die anyway. sions of hope. The Herth Hope Index is a 12-item The story of Janice is an example of hopelessness adapted version of the HHS used to assess hope inand despair. The contrary case is an example of the adults in clinical settings.19opposite of the main concept. The contrary case The Children’ Hope Scale was created to measurehelps in understanding the concept by providing a goal-related hopeful thinking in children and adoles-contrasting example of what the main concept clearly cents aged 8-16 years.4 The scale contains 6 itemsis not. Neonatal nurses often see parents who do not ranked on a 6-point scale. The scale could be helpfulwish to hold or touch their very ill infants because in adolescent pregnancy situations in which thethey are afraid to have hope. mother of the premature baby is in reality at the developmental stage of a child.ANTECEDENTS OF HOPE The Miller Hope Scale was developed utilizing the critical dimensions identified for the concept of hope.1Antecedents of hope involve negative or stressful Interventions to inspire hope were also derived fromstimuli such as pivotal life events or situations that the framework. The dimensions of hope that weremight include presence of loss,1 difficult decisions,5 identified include mutual affinity or interpersonal rela-uncertainty,13 suffering,14 hardship,15 or a tempta- tions characterized by caring, sharing, and a sense oftion to despair.17 Hope commonly involves suffer- the possible; avoidance of despairing effects of a futileing, captivity, or a sense of trial.12 Additional attitude; looking forward to a future; expectations of aantecedents retrieved from the literature search positive outcome; and establishment of goals.include a predicament or threat.5 The birth of a The Hope Assessment Guide was developed tocritically sick baby represents an example of a aid nurses in assessing the subjective and objectivemajor stressful life event encompassing uncer- behavioral cues that indicate the progression andtainty, suffering, potential for loss, and a tempta- development of hope.9 These authors presented ation to despair. The event of a premature birth and clinical application of the framework of Morse andthese antecedents might well activate hope in the Doberneck’s conceptual model of hope.5 The guideperson and the family. utilizes the 6 components of the framework andAdvances in Neonatal Care • Vol. 10, No. 3
  • 41. 144 Amendoliaintegrates nursing assessment in these areas by iden- of fostering hope. Recognizing the important roletifying behavioral signs that suggest which stage of hope plays in the day-to-day experiences of familieshope the individual is moving through. Specific in this setting can improve the overall experience atstrategies are recommended for clinical guidance at such a stressful crossroad in their lives. Fostering andeach of the stages of hope. maintaining hope should be a priority for those entrusted in the care of the critically ill newborn.Gaps in the LiteratureOf the total 21 articles retrieved in the literature Referencesreview, only 2 involved the neonatal population as 1. Miller JF. Hope: a construct central to nursing. Nurs Forum. 2007;42:12-19.the focus of the study. The NICU literature is sparse 2. Charchuk M, Simpson C. Loyalty and hope: keys to parenting in the NICU.on the role of hope from the parent’s perspective of Neonatal Netw. 2003;22:39-45. 3. Stephenson C. The concept of hope revisited for nursing. J Adv Nurs.having a critically ill newborn. Qualitative studies 1991;16:1456-1461.investigating the impact of hope on the overall 4. Valle MF, Huebner ES, Suldo SM. An analysis of hope as a psychological strength.NICU experience are needed for a better under- J Sch Psychol. 2006;44:393-406. 5. Morse JM, Doberneck B. Delineating the concept of hope. Image J Nurs Sch.standing and assessment of needs of parents of these 1995;27:277-285.babies. End-of-life decision making for this popula- 6. Walker LD, Avant KC. Strategies for Theory Construction in Nursing. Norwalk, CT: Appleton and Lang; 1995.tion is another area of needed investigation. For 7. Websters New World Dictionary. William Collins and World, Cleveland, 1974.example, in the case of a dying infant, hope for relief 8. Kylma J, Vehvilainen-Julkunen K. Hope in nursing research: a meta-analysis of the ontological and epistemological foundations of research on hope. J Adv Nurs.of suffering, love, and caring can be promoted by the 1997;25:364-371.bedside nurse.21 Decisions surrounding transforma- 9. Dufault K, Martocchio BC. Hope: its spheres and dimensions. Nurs Clin North Am.tion from hope for survival to hope for a peaceful 1985;20:379-391. 10. Rodgers BL, Knafl KA. Concept Development in Nursing: Foundations,and meaningful death can be facilitated by the car- Techniques, and Applications. 2nd ed. Philadelphia, PA: Saunders; nurse.19 11. Morse JM, Penrod J. Clinical scholarship. Linking concepts of enduring, uncer- tainty, suffering, and hope. Image J Nurs Sch. 1999;31:145-150. 12. Miller JF. Inspiring hope. Am J Nurs. 1985;85:22-25.CONCLUSION 13. Farran CJ, Wilken C, Popovich JM. Clinical assessment of hope. Issues Ment Health Nurs. 1992;13:129-138. 14. Cutcliffe JR, Herth KA. The concept of hope in nursing 5: hope and critical careThe concept of hope has been identified as an impor- nursing. Br J Nurs. 2002;11:1190-1195. 15. Benzein E, Saveman BI. One step towards the understanding of hope: a concepttant phenomenon rooted in the NICU setting that analysis. Int J Nurs Stud. 1998;35:322-329.warrants further investigation. An increased under- 16. Herth KA, Cutcliffe JR. The concept of hope in nursing 6: research/education/policy/standing of the concept of hope would help develop practice. Br J Nurs. 2002;11:1404-1411. 17. Bassett H, Lloyd C, Tse S. Approaching in the right spirit: spirituality and hope inspecific interventions that could be utilized by the recovery from mental health problems. Int J Ther Rehabil. 2008; team working with the neonatal popula- 18. Lipscomb M. Maintaining patient hopefulness: a critique. Nurs Inq. 2007;14:335- 342.tion. Neonatal nurses have the potential to inspire, 19. Herth K. Fostering hope in terminally-ill people. J Adv Nurs. 1990;15:1250-1259.enable, enhance, and foster hope. Nurses at the bed- 20. Herth K. Abbreviated instrument to measure hope: development and psychome- tric evaluation ... the Herth Hope Index. J Adv Nurs. 1992;17:1251-1259.side, specifically in the NICU setting, have the ability 21. Baergen R. How hopeful is too hopeful? Responding to unreasonably optimisticto include parents in the care of their baby as one way parents. Pediatr Nurs. 2006;32:482-486.
  • 42. Moral Distress in Neonatal IntensiveCare Unit RNs Terri A. Cavaliere, DNP, RN, NNP-BC, Barbara Daly, PhD, RN, FAAN, Donna Dowling, PhD, RN, NNP-BC, Kathleen Montgomery, MS, RN ABSTRACT BACKGROUND: Moral distress is a significant problem for nurses (RNs). It has physical, emotional, and psychological sequelae and a negative impact on the quality, quantity, and cost of patient care. Moral distress leads to loss of moral integrity and job dissatisfaction and is a major cause of burnout and RNs leaving the profession. The majority of research has been carried out with RNs working in acute care, adult inpatient settings, especially critical care areas. Neonatal inten- sive care unit (NICU) RNs confront ethically and morally challenging situations on a regular basis. There are limited data clarifying their moral distress. AIMS: The purpose of this study was to describe the moral distress of RNs working in NICUs and to identify the situa- tions that are associated with their moral distress. RESEARCH QUESTIONS: What are the intensity and frequency of moral distress in NICU RNs, what situations are asso- ciated with moral distress in NICU RNs, and what personal characteristics are correlated with moral distress in NICU RNs? DESIGN AND METHODS: This descriptive, correlational study was conducted with RNs in the level III NICUs of a health- care system in the northeastern United States. Participation was voluntary and anonymous. A convenience sample of RNs completed a demographic data sheet and the Moral Distress Scale Neonatal—Pediatric Version. Data were collected dur- ing October 2008. Ninety-four of 196 eligible RNs (48%) participated in the study. FINDINGS: As a whole, the subjects did not perceive that the situations described in the instrument occurred frequently and did not cause great distress. Subjects’ individual scores displayed wide variations for all dimensions of moral distress ranging from low to high, indicating that individual RNs may be experiencing moral distress. The situations receiving the highest scores are comparable with the areas that are problematic for other critical care nurses as described in the literature. In this study, 4 RN characteristics were significantly related to moral distress: the desire to leave their current position, lack of spirituality, altered approach to patient care, and considering but not leav- ing a previous job because of moral distress. CONCLUSIONS: The results of this study add to the understanding of the moral distress in NICU RNs. The data will pro- vide evidence for eventual psychometric testing and factor analysis of the Moral Distress Scale Neonatal—Pediatric Version. KEY WORDS: ethical dilemmas, moral distress, NICU nurses, registered nursesT he increasing complexity of healthcare has led ble-edged sword challenging both practitioners and to unforeseen problems that have serious con- patients with difficult choices and decisions. Issues of sequences for consumers and healthcare short staffing and inadequate resources impede theproviders alike. Technologic advancement is a dou- provision of appropriate patient care. The situation is further complicated by managed care directives, healthcare regulations, and organizational expecta-Address correspondence to Terri A. Cavaliere, DNP, RN, NNP-BC, tions.1 Moral distress, pervasive and seldom recog-40 Jamaica Ave, Plainview, NY 11803; nized, impedes the ability of healthcare professionalsAuthor Affiliations: Schneider Children’s Hospital at North to deliver optimal care. Although the seminal work2Shore, Manhasset, New York (Dr Cavaliere); State University and the majority of research have been done in nurs-of New York, Stony Brook (Dr Cavaliere); and Frances ing, moral distress is not unique to nurses. EvidencePayne Bolton School of Nursing, Case Western Reserve has emerged revealing moral distress in other health-University, Cleveland, Ohio (Drs Daly, Dowling, and care disciplines.3-7Professor Montgomery). Nurses are particularly vulnerable to moral distressCopyright © 2010 by the National Association of because of the nature of nursing as a moral endeavor,Neonatal Nurses. the intimacy of the nurse—patient relationship, and theAdvances in Neonatal Care • Vol. 10, No. 3 • pp. 145-156 145
  • 43. 146 Cavaliere et alrole of nurses.6,8,9 Moral distress exacts a heavy toll on uations in which a nurse is aware of a moral problem,nurses and impacts the quality, quantity, and cost of accepts moral responsibility, and makes a moralnursing care.10-14 Nevertheless, moral distress remains judgment regarding the correct course of action.poorly understood and seldom acknowledged in clin- However, because of real or perceived constraints, heical practice. or she participates, by either act or omission, in a The majority of research on moral distress has manner perceived to be morally wrong.22been conducted with nurses working in acute adultinpatient settings, especially critical care areas. Three BACKGROUNDstudies that included small numbers of NICU nursesexist,15-17 but there are limited discussion and data In the first published reference to moral distress,clarifying the presence and effects of moral distress in Jameton2 observed that RNs experienced stress andneonatal nurses.18 This is unfortunate because the anger in an attempt to reconcile professional and per-NICU is an emotionally and ethically sensitive area sonal values with the realities of healthcare. Sincewhere nurses are faced with ethically and morally Jameton’s original work, many authors have added tochallenging clinical situations on a regular basis.18,19 the body of knowledge on the topic.4,23-26 Causes of Neonatology is a type of critical care and thus moral distress identified in the literature includeNICU nurses may experience moral distress in the issues surrounding end-of-life care,27-30 as well assame way as nurses in adult critical care settings. On futile, aggressive care without perceived patient ben-the other hand, the moral distress of neonatal nurses efit.1,4,16,31,32 Patient harms resulting from pain and suf-might be unique to the practice setting. Neonates rep- fering,14,33,34 depersonalizing patients when meetingresent a vulnerable population; caring for them institutional requirements,35 constraints caused bymight add a different dimension to their nurses’ health policies and managed care directives,36 inade-moral distress. Therefore, studying moral distress in quate staffing,20 working with incompetent col-this clinical area can increase the understanding of leagues,27 and the effects of cost containment34 areand generate information about the concept in gen- other situations that can cause moral distress. In fact,eral. It can also facilitate the identification of moral anything that interferes with a nurse’s ability to pro-distress in NICU nurses and enhance the develop- vide optimal patient care has the potential to createment of strategies to ameliorate its effects. moral distress. The purpose of this study was to describe the moral Moral distress has a negative effect on nursing prac-distress of RNs working in the NICUs at the flagship tice and, in some cases, on patient outcome.25 It canhospitals of a large healthcare system in the northeast- influence the quality, quantity, and cost of nursingern United States and to identify clinical situations care,1,35 contribute to feelings of frustration and pow-leading to their moral distress. The study was designed erlessness,18,37,38 lead to loss of moral integrity,22,25 andto describe the frequency and intensity of moral dis- create dissatisfaction with the work environment.39tress in neonatal nurses, to explore the situations asso- Nurses can lose the capacity to care, fail to provideciated with moral distress in neonatal nurses, and to good care, avoid patient contact, become emotionallyexamine which, if any, demographic factors are asso- aloof, deny their emotional pain, and become cynicalciated with moral distress in neonatal nurses. and sarcastic.14,20,26,32,35,36,40 Ultimately, moral distress may lead to burnout16,22,35,41 and eventually to nursesTHEORETICAL FRAMEWORK leaving the work setting and the profession.10,20,35,42-45 Those nurses who continue in clinical practice in theThe theoretical framework for this study was Corley’s face of moral distress experience stress-induced phys-proposed theory of moral distress.20 Corley states that ical, emotional, and psychological pain andmany moral concepts in nursing have been identified anguish.32,35,39,46and defined. These concepts are moral: commitment, There is little documentation in the literature ofsensitivity, autonomy, sense making, judgment, con- moral distress experienced by NICU RNs. Oneflict, competency, certainty, intent to act, courage, group of researchers studied perinatal and neonatalresidue, heroism, comportment, and outrage. The RNs and pediatric and obstetric residents to deter-relationships among these concepts had been mine the frequency of moral distress and to identifyexplored by others; however, the concept of moral associated factors.15 These investigators defineddistress had not yet been included in these relation- moral distress as the confrontation of ethically trou-ships. In her theory, Corley defined these moral con- bling situations. However, moral distress is morecepts, demonstrated the connections between them, than the mere confrontation of ethically challengingand illustrated how they impact and contribute to situations. The use of this inaccurate definition of themoral distress or comfort.21 concept gives the results of this study limited value in For this study, moral distress was defined as the describing the moral distress of NICU RNs. Thephysical and psychological pain and disturbed inter- small number of NICU nurses (n 8) in the secondpersonal relationships resulting from patient care sit- study limits its generalizability.16
  • 44. Moral Distress in NICU RNs 147 Hefferman and Heilig14 surveyed NICU staff of effect size. Furthermore, because the other studiesregarding the ethical dilemmas they faced in their of moral distress in nurses did not include informa-practice. Twenty-four RNs responded to the first sur- tion on effect size, the literature did not provide guid-vey; the subsequent survey consisted of 67 RNs who ance for selection of effect size in this current study.did not participate in the initial study. Subjects were Therefore, an effect size of 0.3 was chosen.47asked to list the ethical dilemmas they encountered Power analysis conducted prior to data collectionand to describe the impact the dilemmas had on revealed that to investigate whether NICU RNs whotheir care or their self-perceptions as healthcare are considering leaving their current positions willproviders.14 The primary concern of the nurses, and have higher levels of moral distress than those whothe only situation discussed by the authors, was the are not considering leaving their current positions,resuscitation and treatment of infants born at 23 to 24 approximately 64 subjects would be needed toweeks’ gestation. achieve a power of 0.8 when using a moderate effect In summary, research to date confirms the exis- size of 0.3 on a 1-tailed t test with a significance leveltence of moral distress in nurses in clinical practice. set at 0.05.48 Ninety-four responses were collected;The most stressing situations for nurses were working therefore, the sample size for this study was adequatewith inadequate staffing and issues regarding end-of- for statistical analysislife decisions. In the majority of these studies, moraldistress was influenced by many factors but was not Data Collection Proceduressignificantly related to demographic variables of the After obtaining approval from the appropriate insti-subjects. Moral distress has been associated with tutional review boards, the study was announced viaadverse effects on nurses and also with burnout and written notices attached to the nurses’ paychecksnurses leaving their practice settings. Many of these and by signs posted in the NICUs at each site.studies included small numbers of nurses and the Participation was voluntary. The participants weremajority involved nurses who worked in critical care not personally recruited by the investigators.with adult patients. There has been limited research Study material was distributed 2 weeks after thein neonatal units; thus, there is a need for studies announcement.examining moral distress in this setting. The results of The study packet contained a cover letter detailingthis study may be used to design strategies to assist the purpose of the study. Formal signed consent wasNICU RNs in dealing with their moral distress, not obtained because this was an anonymous study;achieving moral comfort.24 This, in turn, could return of completed material implied consent.improve the quality of nursing care, prevent burnout, Names or other identifying data were not collected,and improve retention. so information could not be linked back to partici- pants. Approximately 15 minutes were necessary toMETHODS complete the study.Design and Setting InstrumentsThis was a descriptive correlational study conducted The Moral Distress Scale Neonatal—Pediatricin the NICUs of the 2 flagship hospitals of a large Version (MDSNPV) measured moral distress as thehealthcare system in the northeastern United States. dimensions of frequency and intensity. This tool wasBoth units are level III NICUs that provide acute and developed by M. Corley, PhD, RN (written personalchronic care to high-risk neonates and are regional communication, 2007). The MDSNPV is a Likert-perinatal transport centers. Although the neonatolo- type scale containing 20 clinical situations that weregists, neonatal fellows, and pediatric residents rotate scored from 0 (none) to 4 (very frequent) for frequencybetween both sites, the nursing staffs are separate. and 0 (none) to 4 (great extent) for intensity. This wasData were collected in October 2008. considered a single scale, although each item, repre- senting a potentially distressing situation, was ratedSample for the dimensions of frequency and intensity.The target population consisted of the RNs working Subjects were instructed to respond to each situa-in the NICUs at each of the 2 institutions. A conven- tion by checking the appropriate column for eachience sample was used for this study. There were 196 dimensions: frequency (how often did a particular sit-RNs eligible to participate. RNs who worked full- or uation occur in the course of practice) and intensitypart-time in the NICU and provided direct patient (how much distress did each situation cause). The fre-care as staff nurses were eligible to participate. quency score was multiplied by the intensity score toOrientees, agency, and float nurses, as well as nurses create a composite score for each situation. The com-who did not provide direct patient care as staff posite score was the level of moral distress. Therefore,nurses, were excluded. levels of moral distress for each situation could range There were no published studies of the moral dis- from 0 (low) to 16 (high). Use of the level of moral dis-tress of NICU nurses on which to base the estimation tress allows comparison of different populations ofAdvances in Neonatal Care • Vol. 10, No. 3
  • 45. 148 Cavaliere et alNICU nurses and correlations of moral distress with To assess which situations were associated withcharacteristics/demographic data. In addition, by moral distress, the 20 situations were placed in rankemploying a scoring scheme of 0 to 4 for the Likert- order according to mean scores for frequency, inten-type scale and multiplying to obtain a composite sity, and level of moral distress.score, all items marked as “never experienced” or“causing no distress” would have a “level” score of 0, RESULTSaccurately reflecting the moral distress of the subjects(M. Corley, PhD, RN, written personal communica- Subject Characteristicstion, February 2, 2009). Ninety-four RNs (48%) returned the study material. The second instrument used in this study was the The responses were evenly divided; 48 and 46 RNsDemographic Data Sheet created by the investigators responded at each site. Information about genderto collect subjects’ characteristics such as age, was not requested to safeguard the anonymity of therace/ethnicity, religion, education level, marital sta- 2 male nurses in the population.tus, years in nursing, and whether the subjects had Table 1 presents the subjects’ characteristics;resigned a prior position because of moral distress Table 2 provides a list of the correlations between(see the Appendix). The question regarding subjects’ major characteristics and the level of moral distress.intentions to leave their current nursing positions As shown in Table 1, the majority of the subjectsallowed assessment of the difference in the level of were married (72.4%), white (68.1%), Catholicmoral distress between those nurses who were con- (60.6%), and females who stated that they were some-sidering or would consider leaving their current posi- what religious (60.6%) and somewhat spiritualtions and those who were not considering leaving. (55.3%). They worked between 31 and 40 hours per The MDSNPV was a new instrument based on the week (72.3%) on the day shift (53.2%). Most receivedoriginal Moral Distress Scale created by Corley et al25 their basic nursing education in baccalaureate orand used with permission (M. Corley, PhD, RN, writ- higher programs (76.6%), were between 41 andten personal communication, December 26, 2007). It 50 years of age (33.3%), worked as RNs for 1 towas submitted to 3 doctorally prepared nursing experts 10 years (38.3%), and were in their current NICUwith experience in neonatal and pediatric patient care, positions between 1 and 10 years (51.1%). A total ofethics, and research. Eighteen situations on the original 57.4% were familiar with the term moral distress,scale were deemed not pertinent to the practice of 27.7% had participated in support groups to deal withneonatal and pediatric nurses and were deleted. The moral distress, and 84.6% of these nurses found theremaining 20 situations were considered “quite rele- groups to be helpful.vant” or “very relevant” to neonatal and pediatric nurs- Subjects were asked whether they had altered theiring. There was 100% agreement among the experts on approach to patient care because of disturbing clini-all 20 situations. The data from this study will be added cal situations. For example, had they withheld infor-to a larger database on moral distress for establishing mation when parents asked because they werereliability and performing factor analysis. ordered not to reveal aspects of patients’ conditions or had they failed to report a problematic situationAnalysis because of fear of “getting into trouble”? A total ofThe Statistical Package for the Social Sciences, 42.6% replied in the affirmative. Moral distress wasVersion 17.0, was used to analyze the data. To assess the reason given by 4.3% of RNs for leaving their pre-the frequency of moral distress, individual analysis vious positions, whereas 30.9% said that they hadwas performed on the dimension of frequency for considered leaving but did not do so. Finally 10.6%each of the 20 situations on the study instrument. A revealed that they were considering leaving their cur-mean score was calculated for each situation; higher rent jobs because of moral distress.mean scores indicated greater frequency of moral dis-tress. Analysis was performed on the dimension of Frequency, Intensity, and Levelintensity for each of the 20 situations on the instru- of Moral Distressment. Mean intensity score was calculated for each The mean scores for dimensions of frequency, inten-situation. As with frequency, higher scores indicated sity, and level of moral distress (frequency multipliedgreater intensity of distress. The intensity score was by intensity) were calculated for each of the 20 situa-multiplied by the frequency score for each situation tions and for each create a composite score, the level of moral dis-tress. A total scale score for the level of moral distress Mean Frequency, Intensity, and Level for Itemswas also calculated for each subject. Subsequently, The scores for subjects for each situation were totaleddepending on the type of data (ordinal, nominal), a and then divided by 94 (n) to produce the mean score2-tailed t test, Pearson correlation, or analysis of vari- for frequency, intensity, and level of moral distress.ance was performed to examine associations between These results were arranged in rank order and the top-the moral distress level and subjects’ characteristics. 10 items for each dimension are listed in Tables 3 to 5.
  • 46. Moral Distress in NICU RNs 149 TABLE 1. Sample Characteristics (Continued) TABLE 1. Sample Characteristics Sample Characteristics n (%) Sample Characteristics n (%) Years as an RN Age, y 1—10 36 (38.3) 21—30 23 (24.7) 11—20 31 (33.3) 31—40 22 (23.7) 21—30 16 (17.2) 41—50 31 (33.3) 31—40 10 (10.8) 51—60 17 (18.3) Missing 1 Missing 1 Years in current position Race 1—10 47 (51.1) White 64 (68.1) 11—20 28 (30.4) Black 7 (7.4) 21—30 13 (14.1) Hispanic 5 (5.3) 31—40 4 (4.3) Asian 14 (14.9) Missing 2 Other 4 (4.3) Educational level Marital status Diploma or associate 22 (23.4) Married 69 (73.4) Baccalaureate or higher 72 (76.6) Domestic partner 2 (2.1) Familiar with term moral distress Single 20 (21.3) Yes 54 (57.4) Other 3 (3.2) No 40 (46.2) Religion Participated in support groups Catholic 57 (60.6) Yes 26 (27.7) Protestant 21 (22.3) No 68 (72.3) None 3 (3.2) Support groups helpful Other 13 (12.8) Yes 22 (84.6) Religious Undecided 4 (15.4) Very religious 23 (24.5) Altered approach to care Somewhat religious 57 (60.6) Yes 40 (42.6) Not religious 14 (14.9) No 54 (57.4) Spiritual Left previous job Very spiritual 35 (37.2) Yes 4 (4.3) Somewhat spiritual 52 (55.3) Considered but did not leave 29 (30.9) Not spiritual 7 (7.4) No 61 (64.9) Shift Leave present job due to moral distress Days 50 (53.2) Yes 10 (10.6) Evenings 2 (2.1) No 84 (89.4) Nights 36 (38.3) Leave present job for other reasons Rotating 6 (6.4) Yes 16 (17) Hours worked (weekly) No 78 (83) 10—20 1 (1.1) 21—30 19 (20.2) The mean frequency score was 1.34, with a range 31—40 68 (72.3) of 0.4 to 2.88. The situation with the highest mean 40 6 (6.4) score was “following the family’s wishes to continue (continues) life support even though it was not in the best interests of the child.” Mean frequency scores for the top-10Advances in Neonatal Care • Vol. 10, No. 3
  • 47. 150 Cavaliere et al as competent as the patient care required; consider- TABLE 2. Level of Moral Distress ing themselves incompetent to care for certain According to RN Characteristics patients; and preparing an anoxic, ventilator- dependent child for gastrostomy tube insertion Variable (%) Mean r P (range 0.66-1.54). Agea ... 0.095 .372 The mean levels of moral distress for the situations b ranged from 0.35 to 9.16, with an overall scale mean Race ... ... .895 of 3.96. Continuing life support when it is not in the Marital statusb ... ... .263 patient’s best interests received the highest moral dis- Religion b ... ... .888 tress level score. Mean levels for the top-10 items, as Shift worked b ... ... .283 listed in Table 5, ranged from 2.77 to 9.16. Situations with lower levels of moral distress were similar to Hours workeda ... 0.002 .985 those assigned for frequency and intensity: withhold- Years in nursing ... 0.125 .24 ing information from parents; working with nursing Leaving current position c .025 assistants, support personnel, and nonlicensed per- Yes (10.6) 5.592a ... sonnel who are not as competent as the patient care required; or considering themselves incompetent to No (89.4) 3.820 ... care for certain patients (range 0.29-2.39). Altered approach to carec .017 Yes (42.6) 4.662 a ... Mean Frequency, Intensity, and No (57.4) 3.512 ... Level for Subjects The frequency, intensity, and level scores for the sit- Spiritualb .025 uations were totaled and divided by 20, producing Very (37.2) 4.454 ... mean scores for each subject for each dimension. Somewhat (55.4) 3.430 ... Mean frequency scores for the subjects ranged from Not at all (7.4) 6.030c ... 0.4 to 3.5, mean intensity scores from 0.35 to 3.6, and mean levels of moral distress from 0.05 to Left previous jobb .048 11.35. Yes (4.3) 3.600 ... Considered but did Characteristics and Levels not leave (30.9) 4.896c ... of Moral Distress Neither considered Table 2 shows the results of the analysis of subjects’ nor left (64.8) 3.612 ... characteristics and level of moral distress. There were significantly higher levels of moral distress in a Pearson correlation. those RNs who (1) altered their approach to patient b Analysis of variance; post hoc (Scheffe) P .05. care in response to moral distress, (2) considered c Two-tailed t test; P .05. leaving their previous jobs but did not, (3) were con- sidering leaving their current positions, and (4) indi- cated that they were not spiritual. Analyses (t tests,situations are listed in Table 3. For the remaining Pearson correlation, and analysis of variance) were10 situations, the lowest mean frequency scores were performed to determine whether any other demo-assigned to withholding information from parents; graphic data were responsible for the associationsworking with other RNs, nursing assistants, support between each of these 4 variables and the level ofpersonnel, or nonlicensed personnel who are not as moral distress. No other associations were identified.competent as the patient care required; and consider- For example, there was no significant correlationing themselves incompetent to care for certain between spirituality and subjects’ ages, experiencepatients (range 0.44-1.38). level, and education. The mean intensity score was 1.73, with a range of Age, educational level, years of experience in0.66 to 3.18. The situation with the highest score was nursing, years in current NICU position, religion,also “following the family’s wishes to continue life religiosity, marital status, previous knowledge ofsupport even though it was not in the best interests moral distress, participation in support groups, andof the child.” Mean intensity scores for the top-10 sit- whether the groups were deemed helpful were notuations (listed in Table 4) ranged from 1.71 to 3.18. correlated with the level of moral distress of the sub-For the remaining 10 situations, the lowest mean jects. However, there was a modest correlationintensity scores were similar to those in the dimen- between age, years in nursing, and years in the NICUsion of frequency: withholding information from and frequency or intensity of moral distress forparents; working with nursing assistants, support selected items on the MDSNPV. These are shown inpersonnel, and nonlicensed personnel who are not Table 6.
  • 48. Moral Distress in NICU RNs 151 TABLE 3. Top-10 Items—Frequency of Moral Distress Rank Item Mean Frequencya 1 Follow the family’s wishes to continue life support, even though it is not in the 2.88 best interest of the child 2 Participate in care of vent dependent child when no one will decide to stop 2.40 3 Initiate extensive life-saving actions when I think it only prolongs dying 2.34 4 Carry out physician’s orders for unnecessary tests and treatments for a terminally ill child 2.05 5 Work with levels of nurse staffing that I consider unsafe 1.96 6 Work with physicians who are not as competent as the patient care requires 1.83 7 Follow the family’s wishes for the child’s care when I do not agree with them but 1.66 do so because hospital administration fears a lawsuit 8 Carry out a physician’s order for unnecessary tests and treatments 1.62 9 Provide care that does not relieve the child’s suffering because physician fears that 1.61 increasing dose of pain medication will cause death 10 Prepare an anoxic, ventilator-dependent child for insertion of a gastrostomy tube 1.53 a Range 0-4.DISCUSSION for all dimensions of frequency, intensity, and level of moral distress ranging from low to high. For example,Overall Frequency and Intensity 12 subjects’ mean frequency scores were above 2,of Moral Distress indicating that troubling situations, for some RNs,The mean frequency, intensity, and level scores for occurred often. Likewise, 23 RNs had mean intensitythis group of subjects were low to moderate, based on scores more than 2, signifying that some RNs weremaximum frequency and intensity scores of 4 and greatly disturbed by the situations. This confirms thatmaximum level score of 16. These findings indicate moral distress is a subjective experience.11 Despite thethat as a whole, the subjects did not perceive that the overall low to moderate scores for the group as asituations described in the instrument occurred fre- whole, certain RNs in the NICUs may be experienc-quently and did not cause great distress. However, the ing troubling effects of moral distress and it would besubjects’ individual scores displayed wide variations beneficial to assist them in dealing with this distress. TABLE 4. Top-10 Items—Intensity of Moral Distress Rank Item Mean Intensitya 1 Follow the family’s wishes to continue life support, even though it is not in the best interest of the child 3.18 2 Initiate extensive life-saving actions when I think it only prolongs dying 2.90 3 Participate in care of vent dependent child when no one will decide to stop 2.85 4 Work with physicians who are not as competent as the patient care requires 2.75 5 Work with levels of nurse staffing that I consider unsafe 2.53 6 Carry out physician’s orders for unnecessary tests and treatments of a terminally ill child 2.37 7 Provide care that does not relieve the child’s suffering because physician fears that increasing dose of pain medication will cause death 2.33 8 Work with nurses who are not as competent as the patient care requires 2.33 9 Follow the family’s wishes for the child’s care when I do not agree with them but do so because hospital administration fears a lawsuit 2.03 10 Carry out a physician’s order for unnecessary tests and treatments 1.71 a Range 0-4.Advances in Neonatal Care • Vol. 10, No. 3
  • 49. 152 Cavaliere et al TABLE 5. Top-10 Items—Level of Moral Distress (Frequency Intensity) Mean Level Rank Item (Frequency Intensity)a 1 Follow the family’s wishes to continue life support, even though it is not in the best interest of the child 9.16 2 Participate in care of ventilator-dependent child when no one will decide to stop 6.84 3 Initiate extensive life-saving actions when I think it only prolongs dying 6.79 4 Work with physicians who are not as competent as the patient care requires 5.03 5 Work with levels of nurse staffing that I consider unsafe 4.96 6 Carry out physician’s orders for unnecessary tests and treatments for a terminally ill child 4.86 7 Provide care that does not relieve the child’s suffering because physician fears that increasing dose of pain medication will cause death 3.75 8 Follow the family’s wishes for the child’s care when I do not agree with them but do so because hospital administration fears a lawsuit 3.37 9 Work with nurses who are not as competent as the patient care requires 3.22 10 Prepare anoxic, ventilator-dependent child for gastrostomy tube insertion 2.36 a Range 0-16.Situations Associated With Moral Distress care nurses as described in the literature.4,30,31 Thus,The situations receiving the highest scores for all the futile, aggressive care without perceived benefit,dimensions of moral distress (refer to Tables 2-4) are patient harms from pain and suffering, unnecessarysimilar to those that are problematic for other critical treatments, inadequate staffing, and working with TABLE 6. Correlations Between Either Frequency or Intensity of Selected Scale Items and Subjects’ Characteristics Item Demographic Frequency, r/P Intensity, r/P Carry out physician’s orders for unnecessary tests Years as RN ... 0.214/.044 and treatments Years in NICU 0.211/.044 0.216/.043 Educational level 0.229/.030 ... Initiate extensive life-saving actions when I think it Hours worked ... 0.215/.045 only prolongs dying Participate in care of ventilator-dependent child Age 0.225/.030 ... when no one will decide to stop Follow orders not to tell truth if parents ask Hours worked 0.236/.022 ... Prepare anoxic, ventilator-dependent child for Years in NICU 0.249/.017 ... gastrostomy tube insertion Follow orders not to discuss code status with parents Age 0.218/.040 Nursing assistants not as competent as patient Age ... 0.239/.024 care requires Years in NICU 0.269/.010 0.336/.001 MDs not as competent as patient care requires Age ... 0.228/.031 Years as RN ... 0.219/.038 Years in NICU ... 0.221/.037 Support personnel not as competent as patient Years as RN 0.209/.047 0.236/.028 care requires Years in NICU 0.271/.010 0.236/.014
  • 50. Moral Distress in NICU RNs 153colleagues who are deemed incompetent for the level ciated with futile care escalated with time spent prac-of care required cause moral distress in NICU RNs. ticing in the critical care environment. The reason for All items share the common feature of acts that are the associations between RNs’ characteristics andperceived as not being in the patients’ best interests.25 moral distress discovered in this study is unknown atThere are myriad causes for RNs to act in ways they this time and there are not enough data available tofeel are contrary to the patients’ best interests: institu- speculate on a cause. Further study in this populationtional constraints, personal inhibitions, fear of retalia- of NICU RNs, using Corley’s proposed theory ontion (whistleblowing), professional blunting, burnout, moral distress as a framework, may reveal otheror some other as yet unidentified reason. The primary moral concepts (sensitivity, competence, etc) thatcommitment of the RN is to the patient, but RNs are affect the experience of their moral distress.20frequently in situations in which the values of andresponsibilities to patients, families, physicians, insti- Limitations of the Studytutions, employers, self, society, and the profession There are 2 limitations involving the instrument andare competing.49 Thus, nurses may feel compelled to the subjects. Because the MDSNPV is a new instru-act in ways they perceive are not in the patients’ best ment, there are no data against which to compare theinterests. In violating their personal and professional current results. However, the data generated fromvalues, they experience moral distress. this study will be used to establish psychometric data A recurring theme in the acute care literature is the for the scale. The subjects in this study are predomi-association of moral distress with nurses’ feelings of nately married, white, Catholic, and female and thuspowerlessness to assist patients.18 Nurses are taught may not represent views of males and NICU RNs ofthat they have moral responsibility for care, yet, at other religions and races.the same time, they often find themselves powerlessand without the ability to raise objections or alter the Significance of the Studytherapeutic regimen.35,50 Nurses are expected to carry Moral distress has a negative impact on nurses andout physicians’ orders and to comply with adminis- affects the quantity and quality of patient care. It is atrative policies. They often lack the authority com- major cause of burnout and of nurses leaving theirmensurate with their responsibility and feel inca- jobs and the profession. Adequate staffing is anpable of pursuing what has previously been deemed important issue in the NICUs where this study wasto be the correct action. This predisposes them to conducted. Therefore, the finding that 10% of theexperience moral distress.25 RNs would consider leaving their current jobs is especially troubling.Subject Characteristics and Moral Distress Turnover of nursing staff is very costly. It has beenThe majority of researchers have reported that there estimated that the cost of replacing medical-surgicalwas no relationship between characteristics such as and specialty nurses was more than $92,000 andage, religion, level of education, and marital status, $145,000, respectively.51 Acknowledging theand the experience of moral distress.23,27 In this study, expenses involved in replacing nurses at the bedside,4 characteristics were significantly related to moral the Joint Commission on Accreditation of Healthcaredistress. Those nurses who considered leaving their Organizations encouraged nursing leaders to considerprevious jobs but did not leave had significantly strategies to promote nurse retention.52higher levels of moral distress than those nurses who It is an unfortunate reality in healthcare today thateither left the previous job because of moral distress moral distress is unavoidable and nurses are espe-or did not feel a need to leave. cially vulnerable to moral distress.8 In light of the cur- Similarly, RNs who reported that they changed their rent nursing shortage, the profession can ill afford toapproach to patient care had significantly higher levels lose nurses or to have them suffering from the conse-of moral distress than those who did not. Nurses who quences of moral distress. This will serve only to exac-were not spiritual had significantly higher levels of erbate the degree of moral distress and present furthermoral distress than those who were very or somewhat challenges to the delivery of optimal healthcare.spiritual. The finding that nurses who were considering The identification of moral distress is a prerequi-leaving their current positions had significantly higher site to the development of strategies to ameliorate itslevels of moral distress is particularly concerning. It also effects. Given the nature of practice in the NICU, itconfirms the results of other researchers that moral dis- is unlikely that it will be eliminated. Therefore, it istress may lead to job resignations.1,20 important to assist RNs in achieving moral comfort.24 In considering subjects’ characteristics and either Strategies include the following: (1) developing moralfrequency or intensity of moral distress associated sensitivity20; RNs must recognize the experience ofwith certain situations on the MDSNPV, there were moral distress; (2) acquiring knowledge about thesome weak yet significant correlations. A similar find- concept and its consequences53; and (3) acting toing was reported by only 1 group of researchers. change the work environment to safeguard personalMobley et al30 discovered that the moral distress asso- values and integrity.54Advances in Neonatal Care • Vol. 10, No. 3
  • 51. 154 Cavaliere et al Institutions share the responsibility to identify and 14. Hefferman P, Heilig S. Giving “moral distress” a voice; ethical concerns among neonatal intensive care unit personnel. Camb Q Healthc Ethics. 1999;8:173-address moral distress. Mechanisms to achieve moral 178.comfort include the following: (1) unit-based, interdisci- 15. Janvier A, Nadeau S, Deschenes M, Couture E, Barrington KJ. Moral distress in the neonatal intensive care unit: caregiver’s experience. J Perinatol. 2007;27:203-208.plinary councils in which patient goals and diverse opin- 16. Zuzelo PR. Exploring the moral distress of registered nurses. Nurs Ethics.ions are discussed openly and respectfully; (2) availabil- 2007;14:344-359. 17. Yam BM, Rossiter JC, Cheung KY. Caring for dying infants: experiences of neona-ity of social workers, chaplains, grief counselors, and/or tal intensive care nurses in Hong Kong. J Clin Nurs. 2001;10:651-659.employee assistance personnel to interact with staff dur- 18. Kain VJ. Moral distress and providing care to dying babies in neonatal and after stressful situations; (3) unrestricted access Int J Nurs Palliat Nurs. 2007;13:243-248. 19. Rogers S, Bagbi A, Gomez C. Educational interventions in end-of-life care, partto ethics committees that include nursing representa- I: an educational intervention responding to the moral distress on NICU nursestives; and (4) educational sessions and training to man- provided by an ethics consultation team. Adv Neonatal Care. 2008;8:56-65. 20. Corley M. Nurse moral distress: a proposed theory and research agenda. Nursage and decreases moral distress.53,54 Ethics. 2002;9:636-650. 21. Walker LO, Avant KC. Strategies for Theory Construction in Nursing. 4th ed. Upper Saddle River, NJ: Pearson(Prentice Hall; 2005.CONCLUSION 22. Nathaniel A. Moral reckoning in nursing. West J Nurs Res. 2006;28:419-438. 23. Webster GC, Baylis FE. Moral residue. In: Rubin SB, Zoloth L, eds. Margin of Error: The Ethics of Mistakes in the Practice of Medicine. Hagerstown, MD: UniversityThis study adds to the understanding of moral dis- Publishing Group; 2000:217-230.tress in NICU RNs and the situations that cause it. It 24. Corley M, Minick P. Moral distress or moral comfort. Bioethics Forum. 2002;18:7-14.represents the initial work in moral distress in this 25. Corley M, Elswick M, Gorman M, Clor T. Development and evaluation of a moral distress scale. J Adv Nurs. 2001;33:250-256.nursing specialty and is the first study to use the 26. Hanna DR. Moral distress: the state of the science. Res Theory Nurs Pract: Int J.MDSNPV, providing information for eventual psy- 2004;18:21. 27. Corley M, Minick P, Elswick RK, Jacobs M. Nurse moral distress and ethical workchometric testing and factor analysis. The data environment. Nurs Ethics. 2005;12:381-390.demonstrate that although the overall scores for MD 28. Oberle K, Hughes D. Doctors’ and nurses’ perceptions of ethical problems in end- of-life decisions. J Adv Nurs. 2001;33:707-715.frequency, intensity, and level are low in the sample 29. Ferrell BR. Understanding the moral distress of nurses witnessing medically futilestudied, some NICU RNS have high levels. care. Oncol Nurs Forum. 2006;33:922-930. Further study is needed of both neonatal and 30. Mobley MJ, Rady MY, Verheijde JL, Patel B, Larson JS. The relationship between moral distress and perception of futile care in the critical care unit. Intensive Critpediatric nurses using this new tool. Replicating the Care Nurs. 2007; with male subjects among a more culturally 31. Catlin A, Volat D, Hadley MA, et al. Conscientious objection: a potential neona- tal nursing response to care orders that cause suffering at the end of life? Thediverse nursing population would increase general- study of a concept. Neonatal Netw. 2008;27:101-116.izability of the findings. It would also be helpful to 32. Corley M. Moral distress of critical care nurses. Am J Crit Care. 1995;4:280-285. 33. Omery A, Henneman E, Billet B, Luna-Raines M, Brown-Saltzman K. Ethical issuesidentify which, if any, moral concepts described by in hospital-based nursing practice. Cardiovasc Nurs. 1995;9:43-53.Corley20 are involved in moral distress and what 34. Raines M. Ethical decision making in nurses: relationships among moral reason- ing, coping style, and ethics stress. JONAS Healthc Law Ethics Regul. 2000;2:29-41.strategies are needed to assist NICU RNs in dealing 35. Wilkinson JM. Moral distress in nursing practice: experience and effect. Nurswith their distress. Forum. 1987-1988;23:16-29. 36. Redman BK, Fry ST. Nurses’ ethical conflicts: what is really known about them? Nurs Ethics. 2000;7:360-366.Acknowledgments 37. Rodney P, Starzomski R. Constraints on the moral agency of nurses. Can Nurse. 1993;89:23-26.This original research was performed at Schneider 38. Laabs CA. Moral problems and distress among nurse practitioners in primary care.Children’s Hospital at North Shore, Manhasset, New J Am Acad Nurse Pract. 2005;17:76-84.York, and Schneider Children’s Hospital, New Hyde 39. Elpern EH, Covert B, Kleinpell R. Moral distress of staff nurses in a medical inten- sive care unit. Am J Crit Care. 2005;14:8.Park, New York. 40. Millette BE. Using Gilligan’s framework to analyze nurses’ stories of moral choices. West J Nurs Res. 1994;16:660-674. 41. Sumner J, Townsend-Rocchiccioli J. Why are nurses leaving nursing? Nurs AdmReferences Q. 2003;27:164-171. 1. Pendry PS. Moral distress: recognizing it to retain nurses. Nurs Econ. 42. Kelly B. Preserving moral integrity: a follow-up study with new graduate nurses. 2007;25:217-221. J Adv Nurs. 1998;28:1134-1145. 2. Jameton A. Nursing Practice: The Ethical Issues. Englewood Cliffs, NJ: Prentice 43. Gutierrez KM. Critical care nurses’ perceptions of and responses to moral distress. Hall; 1984. Dimens Crit Care Nurs. 2005;24:229-241. 3. Chen PW. When doctors and nurses can’t do the right thing. The New York Times. 44. Meltzer LS, Huckabay LM. Critical care nurses’ perceptions of futile care and its 2009. Accessed March 10, 2009 from effect on burnout. Am J Crit Care. 2004;13:7. health/05chen.html?_r 45. Redman BK, Hill M. Studies of ethical conflicts by nursing practice settings or 4. Hamric AB, Blackhall LJ. Nurse—physician perspectives on the care of dying roles. West J Nurs Res. 1997;19:243-250. patients in intensive care units: collaboration, moral distress, and ethical climate. 46. Tiedje LB. Moral distress in perinatal nursing. J Perinat Neonatal Nurs. 2000; Crit Care Med. 2007;35:422-429. 14(2):36-43. 5. Sporrong SK, Hoglund AT, Arnetz B. Measuring moral distress in pharmacy and 47. Cohen J. A power primer. Quant Methods Psychol. 1992;112:155-159. clinical practice. Nurs Ethics. 2006;13:416-427. 48. Faul F, Erdfelder E, Lang AG, Buchner A. G*Power 3: a flexible statistical power 6. Austin W, Lemermeyer G, Goldberg L, Bergum V, Johnson MS. Moral distress in analysis program for the social, behavioral, and biomedical sciences. Behav Res healthcare practice: the situation of nurses. HEC Forum. 2005;17:33-48. Methods. 2007;39:175-191. 7. Hilliard RI, Harrison C, Madden S. Ethical conflicts and moral distress experienced 49. Hamric AB. Reflections on being in the middle. Nurs Outlook. 2001;49:254-257. by paediatric residents during their training. Paediatr Child Health. 2007;12:29-35. 50. Jameton A. Dilemmas of moral distress: moral responsibility and nursing prac- 8. Peter E, Liaschenko J. Perils of proximity: a spatiotemporal analysis of moral dis- tice. AWHONNS Clin Issues Perinat Womens Health Nurs. 1993;4(4):542-551. tress and moral ambiguity. Nurs Inq. 2004;11(4):218-225. 51. Hatcher BJ, Bleich MR, Connolly C, Davis K, O’Neill Hewlett P, Hill KS. Retaining 9. Nightingale F. Notes on Nursing: What It Is and What It Is Not. New York, NY: older nurses in bedside practice. Nurse Educ. 2006;31:206. Dover Publications Inc; 1969. Originally published in 1859. 52. Joint Commission on Accreditation of Healthcare Organizations. Healthcare at10. Sundin-Huard D, Fahy K. Moral distress, advocacy and burnout: theorising the the Crossroads: Strategies for Addressing the Evolving Nursing Crisis. Oakbrook relationships. Int J Nurs Pract. 1999;5:8-13. Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations; 2002.11. Hamric AB. Moral distress in everyday ethics. Nurs Outlook. 2000;48:199-201. 53. American Association of Critical-Care Nurses. Position Statement: Moral Distress.12. Erlen JA. Moral distress: a pervasive problem. Orthop Nurs. 2001;20:5. Aliso Viejo, CA: American Association of Critical-Care Nurses; 2006:1-3.13. Hardingham LB. Integrity and moral residue: nurses as participants in a moral 54. Rushton CH. Defining and addressing moral distress: tools for critical care nurs- community. Nurs Philos. 2004;5:127-134. ing leaders. AACN Adv Crit Care. 2006;17:161-168.
  • 52. Moral Distress in NICU RNs 155 APPENDIX DEMOGRAPHIC INFORMATION SHEET MORAL DISTRESS IN NICU NURSES Please participate in this study only if you are working full- or part-time and you are involved in direct patient care in the NICU as a staff RN. Please answer the following questions: 1. What shift/shifts are you working? ____ Days ____ Evenings ____ Nights ____ Rotating shifts 2. What is the number of hours worked per week? ____ hours 3. What is your marital status? ____ Married ____ Domestic partner ____ Single ____ Other 4. What is your race/ethnicity? ____ White ____ Black ____ Hispanic-white ____ Hispanic black ____ Asian ____ Native American/Native Alaskan ____ Hawaiian ____ Other 5. What is your religion? ____ Catholic ____ Protestant ____ Christian ____ Jewish ____ Muslim ____ Hindu ____ Buddhist ____ None/atheist ____ Other/pagan/earth religion 6. Do you consider yourself to be religious? ____ I am very religious ____ I am somewhat religious ____ I am not at all religious 7. Do you consider yourself to be spiritual? ____ I am very spiritual ____ I am somewhat spiritual ____ I am not at all spiritual 8. What is your age in years? ____ Years old on last birthday 9. How many years have you been working as an RN? ____ YearsAdvances in Neonatal Care • Vol. 10, No. 3
  • 53. 156 Cavaliere et al 10. How many years have you been working in your current position as an NICU nurse? ____ Years 11. How many years of formal education have you had in nursing? ____ Years 12. What is your educational level in nursing? ____ Diploma program ____ Associate degree ____ Baccalaureate degree ____ Master’s degree ____ PhD or DNP 13. Prior to this study have you ever heard of the term moral distress? ____ Yes ____ No 14. Have you ever participated in support groups and/or debriefing sessions to deal with moral distress or disturbing clinical situations? ____ Yes ____ No 15. If the answer to question 14 is YES, were the sessions helpful? ____ Yes ____ No ____ Undecided 16. Have you ever altered your approach to patient care or your practice because of disturbing clinical situations? (eg, Withheld information when parents asked because you were ordered not to reveal aspects of patient’s condition; failed to report a problematic situation because of fear of “getting into trouble”) ____ Yes ____ No 17. Have you ever left or considered quitting a clinical position because of discomfort with the way patient care was handled in the NICU or because of moral distress? ____ Yes, I left a position ____ Yes, I considered leaving but did not do so ____ No, I neither left nor considered leaving 18. Are you considering leaving your present NICU position because of discomfort with the way patient care is handled or because of moral distress? ____ Yes, I am considering leaving ____ No, I am neither considering nor would I leave because of discomfort with the way patient care was handled or because of moral distress? 19. Are you considering leaving your present NICU position for any other reason? ____ Yes, I am considering leaving ____ No, I am not considering leaving Please review this form to be certain all questions are answered. This information is important to the analysis of the study data. It is anonymous and will be kept confidential. Please enter this study only once. Thank you for taking the time to participate!
  • 54. JACQUELINE MCGRATH, PHD, RN, FNAP, FAAN • Section EditorReducing Gastroesophageal Reflux inPreterm Infants Whitney Hardy, BS, RN fewer episodes of acid GER detected by pH monitor-B oth full-term and preterm infants experience gastroesophageal reflux (GER) following gav- ing in these positions, with prone position demon- age feeding, breastfeeding, and bottle feeding. strating the least occurrences of GER.Gastroesophageal reflux occurs when stomach con- During the study, the researchers divided the timetents cross the lower esophageal sphincter and enter following a feeding into 2 postprandial periods. Theythe esophagus. It is well documented that as many as found that during the first postprandial period, the90% of preterm infants experience some degree of refluxate was less acidic than during the second post-GER. In preterm infants, GER can lead to postpran- prandial period. They found that during the first post-dial apnea, bradycardia, desaturations, emesis, and prandial period, the time the esophagus was exposedaspiration.1 In the NICU, positioning is often used to to acidic refluxate was shorter when the infant waspromote better sleep patterns, improve breathing, placed in the left-side position. However, during theand provide developmentally appropriate care. This second postprandial period, the exposure was lessstudy, using the CINAHL database, examined post- when the infant was placed in the prone position.prandial positioning as a way to decrease the num- Anatomy offers an explanation for these findings.ber of postprandial GER episodes experienced by When infants are placed in the prone position, thepreterm infants. Is there a specific way for nurses to stomach contents are not close to the lowerposition preterm infants that will decrease postpran- esophageal sphincter and therefore they do not tra-dial GER? verse it and enter the esophagus as easily as in other Corvaglia et al2 examined in a randomized, positions. When infants are placed in the left-sidecrossover design with infants serving as their own position, the stomach contents pool in the body andcontrol how positioning contributed to GER. The greater curvature of the stomach and do not travelstudy2 included 22 premature infants born between toward the lower esophageal sphincter easily.24 and 32 weeks who had experienced documented Developing a protocol for positioning the pretermsymptomatic GER. During the 24 hours of the study, infant following feedings could decrease the numberinfants were placed in 1 of 4 positions—supine, of GER events. Given these findings, if infants areprone, right side, and left side—for 6 hours at a time placed in the prone or left-side position following auntil each infant had been in each position once. feeding, they are more likely to experience fewerThis time frame allowed for 2 feedings during each events of GER. Since GER is often an antecedent toposition. The order of the positions for each infant apnea, bradycardia, and desaturations, using thesewas random. The researchers utilized pH monitor- positions has the potential to also lead to a decreaseing and intraluminal impedance to determine when in the number of these experiences in this vulnerableeither an acid GER event or a nonacid GER event population. In addition, the frequency and volume ofoccurred. They found that infants showed fewer emesis will potentially decrease along with the inci-episodes of nonacid GER when placed in the prone dence of aspiration following emesis. Given the Backand left-side lying positions. The infants also had to Sleep guidelines for positioning recommended by the American Academy of Pediatrics, further research is needed to determine when and how best to teachAddress correspondence to Whitney Hardy, BS, RN, CJW parents to manage GER following discharge.Medical Center, Chippenham Campus, Richmond, VA, 23225; ReferencesAuthor Affiliation: CJW Medical Center, Chippenham 1. Wheatley E, Kennedy KA. Cross-over trial of treatment for bradycardia attributedCampus, Richmond, Virginia. to gastroesophageal reflux in preterm infants. J Pediatr. 2009;155(4):516-521. 2. Corvaglia L, Rotatori R, Ferlini M, Aceti A, Ancora G, Faldella G. The effect of bodyCopyright © 2010 by the National Association of positioning on gastroesophageal reflux in premature infants: evaluation byNeonatal Nurses. combined impedance and pH monitoring. J Pediatr. 2007;151(6):591-596.Advances in Neonatal Care • Vol. 10, No. 3 • p. 157 157
  • 55. DONNA DOWLING, PHD, RN • Section EditorPreterm Infants’ Sympathetic Arousaland Associated Behavioral Responses toSound Stimuli in the Neonatal IntensiveCare Unit Arash Salavitabar, BS, Kim Kopenhaver Haidet, PhD, NNP-BC, Cherie S. Adkins, PhD, RN Elizabeth J. Susman, PhD, Charles Palmer, MB, ChB, Hanne Storm, MD, PhD ABSTRACT PURPOSE: To evaluate the utility of skin conductance (SC) as a measure of autonomic arousal to sound stimuli in preterm infants. DESIGN: A pilot cross-sectional, correlations study. SUBJECTS: Eleven preterm infants with a mean gestational age of 31.6 weeks without anomalies or conditions associ- ated with neurodevelopmental delay composed the sample. METHODS: On days 5-7 of life, the following infant responses were simultaneously recorded in response to naturally occurring sound stimuli in the NICU: real-time measurements of heart rate, respiratory rate, and oxygen saturations; sym- pathetic-mediated sweating via SC; and behavioral responses using the Newborn Individualized Developmental Care and Assessment Program naturalistic observation. Baseline sound levels (BSL, 55 dBA) and high sound levels (HSL, 65 dBA) were measured to index patterns of response during a nonhandling period preceding care. RESULTS: Mean heart rate during precare was directly associated with higher SC increases to sound stimuli (r[10] 0.697, P .017). The SC during HSL was significantly higher than that during BSL (P .0001). Males demonstrated higher SC increases to sound stimuli than females (P .030). Changes in SC induced by increases in sound intensity were asso- ciated with lower attention responses (r[10] 0.92, P .0001) and lower summated behavioral responses (r[10] 0.59, P .054). CONCLUSION: SC provides a noninvasive, sensitive measure of sympathetic arousal that may not be apparent in behav- ioral cues or states, or determined by standard physiological responses alone. KEY WORDS: behavorial responses; preterm infants; sound stimuli; skin conductance; sympathetic arousalI ntensive care for preterm infants necessitates an vide the highest quality of care for infants and their environment designed to support the use of families. However, growing evidence indicates that sophisticated technologies to provide life-saving these activities, namely the level of sound they gener-interventions and to facilitate interdisciplinary team ate, may be detrimental to the health of pretermcommunication. These activities are essential to pro- infants. The focus of this study was to characterize preterm infants’ stress response patterns to high sound levels (HSL) within the neonatal intensive care unit (NICU) using physiological and behavioralAddress correspondence to Kim Kopenhaver Haidet, PhD, measures.NNP-BC, The Pennsylvania State University, 1300 Academic Sound is measured according to acoustic loudnessSupport Bldg, Hershey, PA 17033; or intensity via a logarithmic scale unit, the decibel,Author Affiliations: College of Medicine (Mr Salavitabar and using a sound meter. The standard range ofDr Haidet and Palmer), School of Nursing (Drs Haidet and sound intensity is a minimum of 0 dB and a maxi-Adkins), Departments of Pediatrics (Drs Haidet and Palmer) mum of 140 dB.1 Observing various sound types asCollege of Health and Human Development (Dr Susman), The well as measuring sound intensity are effective meansPennsylvania State University, Hershey; and University of of assessing the acoustic climate within a NICU.Oslo, Oslo, Norway (Dr Storm). Sources of sound can be caused by routine care, com-Copyright © 2010 by the National Association of munication among staff, and use of equipment andNeonatal Nurses. supplies.2-4 Despite a policy statement set forth a158 Advances in Neonatal Care • Vol. 10, No. 3 • pp. 158-166
  • 56. Preterm Infants’ Sympathetic Arousal and Associated Behavioral Responses to Sound Stimuli 159decade ago by the American Academy of Pediatrics cent single isolation rooms and 2 lower acuity care(AAP) on guidelines to prevent hearing loss in rooms nearby (which accommodate 4 isolettes each).neonates, excess sound levels persist in contempo- There is equal space in square feet between care unitsrary NICU environments.3,5-9 The use of a sound per recommended standards.17 The NICU’s struc-meter is one way to determine whether a NICU tural elements include nonrubberized, hard-surfacemeets the recommendations of the AAP and the flooring and standard ceiling materials, which lackSeventh Consensus Conference on Newborn ICU acoustical features to buffer sound.Design of limiting average sound exposures to lessthan 45 dB.5,10 This decibel level reflects the US Subjects/RecruitmentEnvironmental Protection Agency’s acceptable The sample comprised 11 preterm (29-33 weeks’ ges-daytime average sound level for hospitals.11 tational age) infants admitted within 6 hours of birth Ambient as well as loud, intermittent auditory from May 1, 2007, through August 30, 2007.stimuli in the NICU have been known to provoke Exclusion criteria were infants born to mothers whopain-like stress responses8 and standard physiologic reported using illicit drugs or alcohol or both orchanges in preterm infants.12-14 Palmar or plantar infants having anomalies or conditions known tosweating reflecting sympathetic nervous system affect developmental outcomes. These exclusion cri-response to a stressor also occurs as a result of sensory teria were set to ensure a normoresponsive auto-stimulation.15 With sympathetic arousal, acetyl- nomic system. The study protocol was approved bycholine acts on muscarinic receptors in postsynaptic the institutional review board and consent wassynapses, resulting in sweat gland filling and a spon- obtained from parents of infant subjects beforetaneous wave of electrodermal activity measured at enrollment.the skin surface as conductance.16 During arousal,there are quantifiable increases in the number and Measuresamplitude of waves from baseline, known as electro- Study variables, operational definitions, and devicesdermal responses (EDRs).16 Skin conductance (SC) are listed in Table 1.documents the sympathetic nervous system responseto stress in real time. Sound level measurement The uniqueness of this study is predicated on the A calibrated SoundPro DLX sound level meterrelatively new technology of SC in complementing (Quest Technologies Inc, Oconomowoc, Wisconsin)behavioral and standard physiological observations was used to measure 10-second Leq for averageof preterm infants as an innovative method of detect- sound level and Lmax for maximum sound level ining arousal. The primary objective of this study was each of the intervals using A-weighted (dBA), slow-to demonstrate the relationships among measured response settings in the area of the infant’s isolette.sound intensities in a NICU and preterm infants’ The threshold range of sound detection for thereal-time physiological and behavioral responses to SoundPro DLX is 0-140 dB. The meter detects thethat auditory stimulation. The a priori hypotheses octave spectra of 31.5 Hz-8 kHz and has an uncer-were that there would be (1) significant SC responses tainty of ±1.4%, estimated at a 95% confidence levelto sound stimuli; (2) an association between SC and (k 2). The sound level data were recorded contin-standard physiological measures in response to uously throughout the observation period and weresound; and (3) an association between SC and behav- later transferred to the QuestSuite Professional IIioral responses to sound. Multimodal measures are software for data storage, retrieval, and analysis.useful for evaluating comprehensive and unique Lmax was selected as the best representation forpatterns of autonomic response to sound stimuli in the measurement of the highest sound levels in thepreterm infants. Understanding these patterns is NICU.2 Frequently occurring sound sources that con-necessary to evaluate intervention strategies for stress tributed to HSLs included equipment alarms, verbalreduction in preterm infants. communication among staff members, communica- tion devices, water running, and infants crying. SoundMETHODS levels were sorted into baseline sound level (BSL) and HSL data segments for each infant. The BSL consistedStudy Design of periods of sound below 55 dB, whereas the HSLThis study was a pilot, cross-sectional correlations consisted of periods with sound measured to be 65 dBstudy. or higher. Although both standards are above the AAP-recommended maximum sound level of 45 dB,Setting 65 dB has been used as a standard for harmful noiseThe setting was a level III-C tertiary referral NICU levels in previous studies7,18-20 and is the currentlocated within an academic medical center in south recommended standard for limiting transient soundcentral Pennsylvania. The physical layout includes a exposure in the NICU setting.10 This study used 65 dB22-bed, open-bay, higher acuity care area with 2 adja- to represent significantly higher sounds that couldAdvances in Neonatal Care • Vol. 10, No. 3
  • 57. 160 Salavitabar et al TABLE 1. Description of Measures Variable Operational Definition Unit of Measure Monitoring Method Sound stimuli BSL, 55 dBA dBA A-weighted, slow Sound Pro DLX sound HSL, 65 dBA response sound level level meter in decibels Heart rate Change in mean heart rate Beats per minute Continuous electrocardiogram Drager monitor Respiratory rate Change in mean respiratory rate Breaths per minute Direct observation Oxygen saturation 90% saturation Percentage Continuous plethysmography Skin conductance Mean basal skin conductance Microsiemens Continuous SC EDR EDR per second Med Storm Innovation Infant Stress Monitor Frequency in fluctuation in EDR per second EDR per unit time Mean amplitude (mean of peaks) Microsiemens EDR per second difference score EDR per second Change in response to sound stimuli from BSL to HSL Behavioral stress Newborn Individualized Frequency Direct observation responses Developmental Care and Assessment Program domains Motor (Facial) Visceral Attention/interactional Total stress responses Sum of all frequencies Abbreviations: BSL, baseline sound level; EDR, electrodermal response; HSL, high sound level.cause potential stress for the infant and 55 dB to The standard measure of EDR per second wasapproximate the baseline range of sound for an active used as the best representative index of SC inNICU environment during morning medical rounds response to sound stimuli.21 The SC data segmentswhen the observations occurred.11,18,19 during the immediate BSL and HSL periods were selected during, and for 20-30 seconds, after the highSkin conductance sound stimulus to represent immediate and sustainedThe SC of infants was obtained noninvasively using SC responses related to high dBA levels. Sets of fluc-measurement apparatus and software developed by tuations that had less than a 20-second intervalMed-Storm Innovation, Oslo, Norway, product between peaks and valleys were isolated to capturenumber 060895, in accordance with safety regula- the fluctuations that were temporally associated withtions set by the International Electrotechnical sound stimuli. Infants’ behavioral sleep/awake stateCommission, Standard 60601.21 and type of sound stimuli (eg, alarms, staff talking, The SC data obtained via the acquisition system and equipment noises) as well as extraneous environ-were analyzed using Med-Storm Innovation soft- mental stressors were recorded. This information wasware.21 The software was used to determine mean useful to select periods of time for analysis during theabsolute SC, number of fluctuations (EDR per sec- precare phase for which sound occurrences were pre-ond), and amplitude (mean of peaks) in SC (Figure 1) described elsewhere.21 To eliminate “electronicnoise” and focus on significant amplitude fluctua- Behavioral responsestions, the sensitivity for minimum amplitude detec- The Newborn Individualized Developmental Caretion was set at 0.05 microsiemens per manufacturer and Assessment Program (NIDCAP) was used as arecommendations for this setting. framework for the naturalistic observation and
  • 58. Preterm Infants’ Sympathetic Arousal and Associated Behavioral Responses to Sound Stimuli 161 FIGURE 1. Graphic representation of skin conductance measures (Med-Storm Innovation).coding of behavioral responses to stimuli.22 A NID- ProcedureCAP-certified single observer recorded the pres- The Score for Neonatal Acute Physiology, a measureence or absence of 85 behaviors comprising motor, of severity of illness, was used to rate infants’ level ofstate/interactional, and self-regulatory systems.22 stability at 48 hours of age.23 On days 5-7 of life, aThis observer has demonstrated intra- and inter- prescheduled observation, including SC, sound levelrater agreement of greater than 0.85 with an inter- measurements, environmental observations, stan-national NIDCAP-certified trainer. Using the NID- dard physiological monitoring, and ratings of infantCAP protocol, behaviors were observed stress behaviors, was conducted. In the days leadingcontinuously and recorded on the behavioral check- up to and the morning of the observation, infantslist.22 Behaviors were later quantified for total fre- were carefully screened to ensure their medical sta-quency per domain with attention to the following bility and absence of sedative/narcotic intake sincespecific behaviors: facial activity and twitch/startle birth. Also, immediately before the observation, the(motor), cry/fuss (interactional/attentional), and medical team was consulted to confirm that neithersucking, bracing, and hands-to-mouth (self-regula- invasive procedures nor handling had been per-tory). These real-time behavioral data were formed within 2 hours of the scheduled observation.recorded continuously while also simultaneously Observations (7-11 AM) occurred before scheduledmeasuring physiological (SC, heart rate [HR], respi- nursing care. The infants’ cardiorespiratory monitor,ratory rate, and O2 saturation) parameters to char- oxygen saturation, the laptop computer for SC acqui-acterize individual patterns of stress response and sition, and the sound level meter were synchronizeddetermine the linkages between preterm infants’ before the initiation of data collection. The soundphysiological and behavioral responses and sound level meter was placed adjacent to and at the heightstimuli. The absence of other confounding factors of the infant’s isolette, in a location and position that(eg, handling) during this precare period allowed for would prevent any vibrations, impact, or extraneousan accurate window into the preterm infant’s indi- sounds that would negatively affect the sound levelvidual stress response system. readings. Neonatal surface electrodes (ConMed,Advances in Neonatal Care • Vol. 10, No. 3
  • 59. 162 Salavitabar et alUtica, New York) were applied to the skin of the liers. Relationships between continuous variables ofinfants as a 3-electrode system, consisting of a meas- interest (physiological and behavioral) were esti-uring electrode (M), a counter current electrode (C), mated using Pearson product moment correlationsand a reference electrode (R).21 The M electrode was with 2-sided significance levels. Serial changes inplaced on the palmar surface of the hand approach- EDR per second between BSL and HSL measure-ing the hypothenar eminence, the C electrode was ments were analyzed using paired samples t tests andplaced on the dorsum of the hand, and the R elec- analysis of variance for repeated measures. For alltrode was placed on the lateral surface of the leg. analyses, the value of alpha was set at .05.Before electrode placement, skin surfaces were gen-tly cleansed with alcohol for 30 seconds. Accuracy of RESULTSreadings was ensured before and after measurementsby microphone calibration using a Quest Sample and Environment CharacteristicsTechnologies QC-10 Calibrator. Data validity was The sample characteristics are presented in Table 2.ensured by requiring that the skin surface electrodes The predominately white sample consisted of 11 lowwere properly positioned, the infant had been left birth-weight (M 1607 g) preterm infants. Low mor-undisturbed for a minimum of 2 minutes, sharp fluc- bidity index (score for neonatal acute physiology)tuations in SC had ceased, and normative patterns of scores (M 4.82) were observed at M 32.4 weeks’SC were consistently noted on the SCA On-line gestation.acquisition software program (Med-Storm Innovation, The range of 10-second Lmax sound levelOslo, Norway). The SC and sound meter data were detected in the NICU during the precare periods wascollected and monitored by the same group member between 41.1 dBA and 81.5 dBA. The descriptives offor all subjects to ensure consistency and synchro- sound occurrences, most notably caused by voicesnization between measures. and alarms, are depicted in Table 3.Statistical Analysis Hypothesis 1: There Will Be SignificantFor each interval of baseline and high sound data, SC Responses to Sound Stimulisimultaneously recorded SC data were analyzed using The SC values are represented in Table 4. EDRthe SCA Off-Line analysis software program (Med- per second to high sound stimuli was significantlyStorm Innovation, Oslo, Norway). From these seg- higher than the responses to baseline sound stim-mental analyses, the median EDR per second value uli (P .0001). In fact, the majority of infants hadwas determined for both the BSL and HSL measure- no detectable fluctuations in EDR per second dur-ment periods to represent that infant’s responses to ing BSL periods. Male infants showed greaterperiods of baseline and high sound levels. An EDR per increases in SC in response to sound stimuli thansecond difference score (difference in EDR per second female infants (P .03) (Figure 2). Male andin response to BSL vs HSL) was calculated as an index female groups were otherwise equivalent as inde-of responsivity to sound stimuli. pendent samples t tests demonstrated that there SPSS for Windows (version 14.0, Chicago, Illinois) were no significant differences regarding birthwas used for data entry and analyses. Distributions of weight, gestational age, or postnatal age at the timethe variables were checked for normality and out- of the SC measurement. TABLE 2. Sample Characteristics Variables N Minimum Maximum Mean SD Frequency % GA on admission 11 29.3 32.6 31.55 1.048 … … Birth weight, g 11 1327 1898 1607.45 230.506 … … Score for neonatal acute physiology 11 2.0 9.0 4.818 2.562 … … GA at observation 11 30.3 33.5 32.41 1.042 … … Ethnicity (per maternal racial identity) White … … … … … 9 82 Black … … … … … 1 9 Asian … … … … … 1 9 Gender, Female … … … … … 6 55 Abbreviation: GA, gestational age.
  • 60. Preterm Infants’ Sympathetic Arousal and Associated Behavioral Responses to Sound Stimuli 163 TABLE 3. Alarm Occurrences and Sound Descriptives Subject No. of Voice No. of Alarm Duration Length of BSL, Length of HSL, Location or Laughter Events Precare, min No. of BSL s (M SD) No. of HSL s (M SD) 1-H 32 28 29.0 10 39 21.3 4 45 44.4 2-L 32 8 12.0 3 136.7 150.1 2 110 42.4 3-H 63 88 27.0 10 50 47.1 4 35 31.1 4-H 110 121 39.0 7 20 11.6 8 22.5 15.8 5-H 54 60 22.0 11 50 25.7 2 25 21.2 6-H 30 19 22.0 5 28 4.5 3 13.33 5.8 7-L 34 14 44.0 15 149.3 139.2 1 20 8-H 57 42 33.0 16 41.3 16.3 5 12 4.5 9-H 35 23 20.0 14 37.9 26.7 4 15 5.8 10-H 62 26 35.0 11 37.3 17.9 5 58 78.2 11-H 43 34 33.0 9 32.2 20.5 8 26.3 15.1 Abbreviations: BSL, baseline sound level; H, higher acuity care area; HSL High Sound Level; L, lower acuity care area.Hypothesis 2: There Will Be an relation with EDR difference score approaching sig-Association Between SC and Standard nificance (P .054).Physiological Measures in Responseto Sound DISCUSSIONThe following relationships were demonstratedbetween SC measures and standard physiological While standard physiological and behavioralvariables (Table 5). The mean HR during the precare responses to noxious stimuli have been studied,24-30phase was positively associated with the EDR differ- their correlation to SC in response to sound is lim-ence score (P .05), reflecting a direct relationship ited. Excessive sound is sufficient to cause a sympa-between HR and SC, each representing physiologi- thetic response,14 reflected in SC measurement.16 Ourcal arousal. There were no associations found findings revealed that there was a significant SCbetween SC and respiratory rate fluctuations or SC response to sound in support of the first hypothesis.and changes in O2 saturation. In addition, the results demonstrated that male preterm infants manifested a higher SC response toHypothesis 3: There Will Be an sound stimuli than female infants matched for gesta-Association Between SC and Behavioral tional age and acuity of illness. The higher SC reac-Responses to Sound tivity of the male infants in our study is an interestingThere were moderate, negative correlations between finding. This suggests a potential early vulnerabilityall the observed behavioral cues (motor, attention, in male infants to consequences of repeated noiseand total stress) and the EDR difference score during exposures during the postnatal period. However, thisthe precare phase (Table 6). Attention cues (cry, fuss, sex difference is a novel finding that should be repli-or whimper) were negatively correlated with EDR cated in a larger sample of preterm infants.difference score, showing that despite EDR fluctua- We found a positive relationship between SC andtions (sympathetic arousal), there were few attention HR as predicted in the second hypothesis; however,behaviors. Total number of stress behaviors (facial, there were no relationships between SC and respira-visceral, motor, and attention) showed a negative cor- tory rate or SC and O2 saturation. Consistent with TABLE 4. Characteristics of Skin Conductance Variables N Minimum Maximum Mean SD Mean basal level 11 20.84 46.78 29.92 11.16 Mean peak amplitude 11 0.10 0.49 0.2100 0.1267 Electrodermal response/s 11 0.0172 0.1925 0.0807 0.0526Advances in Neonatal Care • Vol. 10, No. 3
  • 61. 164 Salavitabar et al term cortisol levels31 seen in such children, as well as FIGURE 2. leading to a socially anxious childhood and adoles- cence in some children.31,32 Moreover, there is evi- dence that extremely preterm infants exhibit more behavioral inhibition during adolescence than those who were born at term.33 The behavioral inhibition observed in the preterm infants during exposure to HSL in our study may be related to basal stress arousal and greater internalizing, consistent with recent evidence that neonatal exposures to stressors may lead to higher cortisol levels later in infancy.34 These patterns of behavior, if identified early in psy- chosocial development, may guide the choice of intervention strategies. Specifically, using a slow approach to interaction with a single sensory input at a time may be better tolerated in these infants. Previous studies have reported a lack of direct cor- Precare electrodermal response/second to sound relation between standard physiological responses stimuli. Abbreviation: EDR, electrodermal response. and behaviors in preterm infants.26,28 Infant charac- teristics, exclusion criteria, and behavioral and stan- dard physiological measures used by these investiga-our findings, other investigators have noted that HR tors were similar to those used in our study. Inis a sensitive measure of arousal while O2 desatura- contrast, our study isolated sound as the only majortion, although changing significantly in response to stimulus during precare. Our findings, therefore,noxious stimuli, was not a consistent measure of pain have more applicability to studying the effects of non-or arousal.24,28 noxious stimuli on preterm infant arousal. In support of the third hypothesis, we found that The lack of organization and facility in behavioralnegative correlations between EDR per second and state transitions in preterm infants, particularly underbehavioral responses were associated with sound stress, has been well-documented20,35 and found tostimuli (HSL) in the precare phase of observation. result in a decreased ability of the infants to adjust toStudy infants demonstrated sympathetic arousal by environmental stimuli.26,36 Our findings of negativeSC without attention (cry, fuss) responses. While correlations between SC and attention and total stresssome infants had clear physiological (SC and HR) behavioral cues are novel. To date, there are virtuallyreactivity to sound, they demonstrated minimal no other studies with which to compare our findingsbehavioral responses and limited facial expressivity. in preterm infants. However, in school-aged children,Physiological responses without recognized behav- linkages have been reported between SC and behav-ioral distress patterns may be secondary to the lim- ioral responses to interadult argument and the inter-ited repertoire of facial expressivity in the preterm actions of those measures with parent dysphoria.32infant. Children with high SC reactivity had increased inter- An alternate plausible explanation is that the pat- nalizing problems, which were associated withterns of high physiological arousal and low attention parental depressive symptoms.32responses identified in our sample represent anintraperson dimension of behavioral inhibition to LIMITATIONSauditory stimuli, characterized by “fearfulness” or“watchfulness.” Behavioral inhibition has been used A potential limitation of this study is that the rangesto explain fearfulness in toddlers and higher long- set for BSL ( 55 dBA) and HSL ( 65 dBA) were TABLE 5. Physiological Measures and Electrodermal Response Difference Score Relationship Correlation Coefficient, r P (2-tailed) Mean heart rate → EDR difference score 0.697 .017 Mean respiratory rate → EDR difference score 0.328 NS O2 desaturations → EDR difference score 0.325 NS Abbreviations: EDR, electrodermal response, NS, non significant; r, Pearson product moment correlation.
  • 62. Preterm Infants’ Sympathetic Arousal and Associated Behavioral Responses to Sound Stimuli 165 TABLE 6. Behavioral Measures and Electrodermal Response Difference Score Relationship Correlation Coefficient, r P (2-tailed) Motor cues → EDR difference score 0.333 NS Attention cues → EDR difference score 0.920 .0001 Total stress behaviors → EDR difference score 0.594 .054 Abbreviations: NS, non significant; r Pearson product moment correlation.narrow. However, investigators have reported that that arousal in preterm infants can be detected usingwhen a nonlinear scale is used to detect sound (as a multimodal measurement system: SC, standardused in this study), a mere 6 dBA increase represents physiologic parameters, and behavioral cues. SC pro-a perceived doubling of loudness.20,24 In practical vides a noninvasive, yet sensitive method of detect-terms, this means that the minimum difference (10 ing sympathetic arousal that may not be apparent indBA) between BSL and HSL translates into at least a behavioral cues or states, or determined by standarddoubling of the perceived loudness during the 2 physiological responses alone. Unraveling the inte-sound level periods. gral patterns of biobehavioral responses in preterm infants is a critical first step to our understanding ofCLINICAL IMPLICATIONS linkages between intraperson characteristics and early environmental contexts. Understanding these unique,When sound levels are detected above the recom- but complex vulnerabilities can facilitate opportuni-mended standards for safety, as in this study, it is ties for successful interactions between infants andimperative that strategies for sound reduction be caregivers, which will promote positive infant healthemployed. These recommendations include utilizing outcomes.sound detectors with a multicolor light-response sys-tem, incubators with increased sound-protection Acknowledgementsdesigns, and protective coverings (eg, infant ear- The research reported here was supported by grantsmuffs) during periods of increased sound levels.14,37 from Johnson & Johnson Consumer and PersonalOther modifications involve a variety of options for Products: Health Behaviors and the Quality of Life,changing the physical layout of the NICU (eg, indi- Research Innovation Grant 2006-2007 and Thevidual rooms) to control sound levels according to Children’s Miracle Network. Thanks are extended toindividual infant’s developmental and physiologic Scott Brandeburg, MS for assisting with numerousneeds.17 More modest strategies to reduce sound lev- aspects of the project and Kim Walker and Emilyels may also be employed, for example, adding or Swanger for assistance with the manuscript. Theupgrading acoustical features of ceilings and authors would also like to thank the nurses and physi-floors.38,39 cians at Penn State Children’s Hospital, NICU for In addition, practice standards should be adopted assistance with recruitment and the parents who gen-to reduce sound levels in the NICU. These interven- erously allowed their infants to participate in thetions require an assessment of the location and research.sources of HSLs and a willingness of staff to alterpractice accordingly.40 This may include reducing Referencesequipment alarm settings, limiting conversations to 1. Gray L. Properties of sound. J Perinatol. 2000;20:S6-S11. 2. Gray L, Philbin MK. The acoustic environment of hospital nurseries: measuringlocations away from crib side,41 and banning music sound in hospital nurseries. J Perinatol. 2000;19:S100-S104.from care areas.18 Sound-reduction strategies are 3. Brandon DH, Ryan DJ, Barnes AH. Effect of environmental changes on noise in the NICU. Neonatal Netw. 2007;26(4):213-218.paramount to enhance stability in preterm infants 4. Trapanotto M, Benini F, Gobber D, Magnavita V, Zacchello F. Behavioural andand provide a supportive environment necessary to physiological reactivity to noise in the newborn. J Paediatr Child Health. 2004;40:275-281.foster growth and development.42 In addition, such 5. American Academy of Pediatrics, Committee on Environmental Health. Noise: astrategies have been found to be helpful in optimiz- hazard for the fetus and newborn. Pediatrics. 1997;100(4) the work environment, performance, and health 6. Byers JF, Waugh WR, Lowman LB. Sound level exposure of high-risk infants in different environmental conditions. Neonatal Netw. 2006;25(1):25-32.of NICU staff.43 7. Chang YJ, Pan YJ, Lin YJ, Chang YZ, Lin CH. A noise-sensor light alarm reduces noise in the newborn intensive care unit. Am J Perinatol. 2006;23(5):265- 271.CONCLUSIONS 8. Ahn Y, Jun Y. Measurement of pain-like response to various NICU stimulants for high-risk infants. Early Hum Dev. 2007;83:255-262.The current study is unique, given its comprehensive 9. Williams AL, van Drongelen W, Lasky RE. Noise in contemporary neonatal inten- sive care. J Acoust Soc Am. 2007;121(5):2681-2690.approach to exploring relationships among varied 10. Report of the Seventh Consensus Conference Newborn ICU Design. http://www.arousal-response indicators. Our findings indicate Published February 1, 2007. Accessed March 22, 2009.Advances in Neonatal Care • Vol. 10, No. 3
  • 63. 166 Salavitabar et al11. Environmental Protection Agency, Office of Noise Abatement and Control. 28. Johnston CC, Stevens BJ, Yang F, Horton L. Differential response to pain by very Information on Levels of Environmental Noise Requisite to Protect Public Health premature neonates. Pain. 1995;61(3):471-479. and Welfare With an Adequate Margin of Safety. Washington, DC: Government 29. Eriksson M, Storm H, Fremming A, Schollin J. Skin conductance compared to a Printing Office; 1974. Report 5509-74-004. combined behavioural and physiological pain measure in newborn infants. Acta12. Slevin M, Farrington N, Duffy G, Daly L, Murphy JFA. Altering the NICU and meas- Paediatr. 2008;97(1):27-30. uring infants’ responses. Acta Paediatr. 2000;89(5):577-581. 30. Holsti L, Grunau RE, Oberlander TF, Osiovich H. Is it painful or not? Discriminant13. Morris BH, Philbin MK, Bose C. Physiological effects of sound on the newborn. J validity of the Behavioral Indicators of Infant Pain (BIIP) scale. Clin J Pain. 2008; Perinatol. 2000;20(8, pt 2):S55-S60. 24(1):83-88.14. Zahr LK, Balian S. Responses of premature infants to routing nursing interven- 31. Goldsmith HH, Lemery KS. Linking temperamental fearfulness and anxiety tions and noise in the NICU. Nurs Res. 1995;44(3):179-185. symptoms: a behavior-genetic perspective. Biol Psychiatry. 2000;48(12):1199-15. Hellerud BC, Storm H. Skin conductance and behaviour during sensory stimula- 1209. tion of preterm and term infants. Early Hum Dev. 2002;70:35-46. 32. Cummings EM, El-Sheikh M, Kouros CD, Keller PS. Children’s skin conductance16. Storm H. Skin conductance and the stress response from heel stick in preterm reactivity as a mechanism of risk in the context of parental depressive symptoms. infants. Arch Dis Child Fetal Neonatal Ed. 2000;83:143-147. J Child Psychol Psychiatry. 2007;48(5):436-445.17. White RD. Individual rooms in the NICU: an evolving concept. J Perinatol. 33. Levy-Shiff R, Einat G, Mogilner MB, Lerman M, Krikler R. Biological and environ- 2003;23:S22-S24. mental correlates of developmental outcome of prematurely born infants in18. Graven SN. Sound and the developing infant in the NICU: conclusions and rec- early adolescence. J Pediatr Psychol. 1994;19(1):63-78. ommendations for care. J Perinatol. 2000;20(8, pt 2):S88-S93. 34. Grunau RE, Haley DW, Whitfield MF, Weinberg J, Yu W, Thiessen P. Altered basal19. Krueger C, Wall S, Parker L, Nealis R. Elevated sound levels within a busy NICU. cortisol levels at 3, 6, 8 and 18 months in infants born at extremely low gesta- Neonatal Netw. 2005;24(6):33-37. tional age. J Pediatr. 2007;150(2):151-156.20. Philbin MK, Klaas P. Evaluating studies of the behavioral effects of sound on 35. Anand KJS, Scalzo FM. Can adverse neonatal experiences alter brain development newborns. J Perinatol. 2000;20(8, pt 2):S61-S67. and subsequent behavior? Biol Neonate. 2000;77(2):69-82.21. Storm H. The development of a software program for analyzing skin conductance 36. Stevens BJ, Riddell RRP, Oberlander TE, Gibbons S. Assessment of pain in changes in preterm infants. Clin Neurophysiol. 2001;112:1562-1568. neonates and infants. In: Anand KJS, Stevens BJ, McGrath PJ, eds. Pain in22. Als H. A synactive model of neonatal behavioral organization: framework for the Neonates and Infants. Philadelphia, PA: Elsevier; 2007:67-90. assessment of neurobehavioral development in the premature infant and for 37. Zahr LK, Traversay J. Premature infant responses to noise reduction by earmuffs. support of infants and parents in the NICU environment. Phys Occup Ther J Perinatol. 1995;15(6):448-455. Pediatr. 1986;6(3):3-53. 38. Brown P, Taquino LT. Designing and delivering neonatal care in single rooms. J23. Richardson DK, Gray JE, McCormick MC, Workman K, Goldmann DA. Score for Perinat Neonatal Nurs. 2001;15(1):68-83. neonatal acute physiology: a physiologic severity index for neonatal intensive 39. White RD. Flooring choices for newborn ICUs. J Perinatol. 2007;27:S29-S31. care. Pediatrics. 1993;91(3):617-623. 40. Hendricks-Munoz KD, Prendergast CC. Barriers to provision of developmental24. Philbin MK. The influence of auditory experience on the behavior of preterm care in the neonatal intensive care unit: neonatal nursing perceptions. Am J newborns. J Perinatol. 2000;20(8, pt 2):S77-S87. Perinatol. 2007;24(2):71-77.25. Warnock F, Lander J. Foundations of knowledge about neonatal pain. J Pain 41. Philbin MK. Planning the acoustic environment of a neonatal intensive care unit. Symptom Manage. 2004;27(2):170-179. Clin Perinatol. 2004;31:331-352.26. Stevens BJ, Johnston CC. Physiological responses of premature infants to a 42. Witt CL. Addressing noise in the NICU. Adv Neonatal Care. 2008;8:S2 painful stimulus. Nurs Res. 1994;43(4):226-231. 43. Thomas KA, Martin PA. The acoustic environment of hospital nurseries: NICU27. Philbin MK, Klaas P. Hearing and behavioral responses to sound in full-term sound environment and the potential problems for caregivers. J Perinatol. newborns. J Perinatol. 2000;20(8, pt 2):S68-S76. 2000;20:S93-S98.