The document describes about the differnce and major guidelines between NICU and PICU.

1. Modernize setup of
NICU & PICU
Dr.Rajathisakthivel R.NM, M.Phil., Ph.D.
Vice-Principal/ HOD Child Health Nursing
Hindu Mission College of Nursing
West Tambaram, Chennai

2. At the end of this session, the participants will be able to,
 define ICU / NICU / PICU
 find out the difference between NICU / PICU
 identify the need for NICU / PICU
 list out the objectives of NICU / PICU
 enlist the category of NICU / PICU care
 follow guidelines to modernize setup of NICU / PICU
 recognize the innovative equipment in NICU / PICU
 explain the strategies followed by NICU / PICU Nurses.
 enhance the knowledge through case scenario related to the preparation of the
unit and the arrival of a newborn to NICU / child to PICU.
LEARNINGOBJECTIVES

3.  ICU - Intensive Care Unit (ICU) highly specified and
specialized area for extremely sick patients who needs
to maintain hemodynamic stability.
 Great demand - costs three times more than a day
than an acute medical ward.
 Technology - Personnel needs more education and
training to use/handle equipment & follow significant
safety features for managing critically ill patients.
 Past 10-15 years, ICU has become well established
and has progressed to have a reputable subspecialty in
Intensive care of sick patients.
Introduction
Top-notch Monitoring & Maintain Quality Standards

4. Definition
 NICU – Neonatal Intensive Care Unit Care for
medically unstable and critically ill newborns
requiring constant monitoring, continual respiratory
support, or other intensive interventions.
 PICU - Pediatric Intensive Care Unit receives the
highest level of Quality medical care and support with
close monitoring of sick children.
 ICU – Intensive Care Unit is a separate, self-
contained area equipped with high-tech specialized
medical facilities designed for close monitoring,
rapid intervention with acute organ dysfunction.

5. Difference between NICU/PICU
Major Difference - AGE
Criteria NICU
Meaning Newborn babies who need
intensive medical attention
and Quality of care
Age Up to 1 month
Illness Newborn babies with health
complications or those who
require extra medical care
are treated.
PICU
Designed for older kids/Children
who need intensive medical attention
and Quality of care
> 4 weeks old till 14 -18 years
Severe illness that requires close
monitoring and medications

6. NICU/ PICU– causes for admission
NICU
 Preterm Gestation < 37 weeks
 Low birth weight < 2.5 kg
 APGAR score < 7
 Baby who did not cry at birth or has delayed
 Requiring ventilator therapy
 Infections - Meningitis
 Hypoglycemia or hypocalcaemia
 Neonatal seizure
 New born Jaundice > 20mg/dl
 Genetic syndromes & structural disorders
 Inborn errors of metabolism
PICU
Congenital abnormalities
Autoimmune disorders
Complex surgery
Severe infection
Physical trauma
Medication overdose
Food poisoning
Organ failure
Cancer
Epilepsy
Suicide /Homicide

7. Need of NICU/PICU – Background
Global Analysis - WHO 2018
 Global - 2.3 million children died in the first
month of life in 2021 i.e., approximately 6,400
neonatal deaths every day.
 India, nearly 0.9 million, mortalities of newborn
per year i.e., 30% of global neonatal mortalities
(2019).
Mortality 1990 2021 Percentage
NMR 5.2 million 2.3 million 51% (36.6 /1000 live
births to 18 in 2021)
Under five 12.8million 5 million 59% ( 93 death per 1000
live births to 38 in 2021)
Global Analysis - WHO 2022

8. Days in life
Percentage
Distribution of Neonatal Mortalities- Day wise
NEEDFOR NICU

9. P
e
r
c
e
n
t
a
g
e
Weeks
Distribution of Neonatal Mortalities- Week wise
NMR
NEEDFOR NICU

10.  Global (2021) – 1,03,407 Number of Mortality for
adolescents aged 15–19 years: i.e., 62.2 %
 Overall risk of death for teenagers (average annual
death rate)- 49.5 / 100,000 population.
 Homicide, suicide, Accidents (unintentional
injuries), cancer, and heart disease make up the
five leading causes of death for teenagers.
NEEDFOR PICU
Source: National Crime Records Bureau -2
 National Top causes - Self-harm close to
60,000 deaths annually (15- 18 years).

11. Current Neonatal Mortality Rate (NMR)
 Global - 18 / 1000 live births (WHO - 2018)
 National - 19.1 / 1000 live births (UNICEF- 2021)
SDG -3 - Good Health & Wellbeing Target – 2030
Global
< 10 / /1000 livebirths
National/ INAP
12 /1000 livebirths
NEED FOR Modernize setup of NICU/ PICU ….
 Standards for improving the quality of care for children and young
adolescents to reduce the mortality rate from 62 % (15-19 years)
Innovations & transformations of advanced technology to care for
neonates & Children for enhanced Survival in the last 2 to 3 Decades

12. Establishment of satisfactory feeding regimen
Secondary
OBJECTIVES OF NICU/ PICU
Primary - To enhance survival, augment recovery, minimize pain &
mitigate any risk of disability.

13. Level of care category-wise in NICU/ PICU
Aim: Provides high-quality skilled care to critically ill neonates /child by offering
facilities for continuous clinical, biochemical, and radiological monitoring and use of
life support systems for improving the survival of babies.
Category NICU
( Gestational maturity and Weight)
Level I Normal Neonatal Care - less than 2000
grams between 35th - 37th gestational week
Level - ll Special care- weight less than 1500 g and
greater than 30 weeks gestation - oxygen
support
Level -III Intensive care - weight less than 1200 grams
or gestational maturity of fewer than 30 weeks.
Level IV Specialized Care of a Level III - Offers
facilities like extracorporeal membrane
oxygenation (ECMO), after surgical correction
for CD.
PICU
Just for observation after any surgery
Level 2 Care (Step down/High
Dependency) more than 50% oxygen
to maintain saturation
Level 3 care - Tertiary level All
patients requiring mechanical
ventilation

14.  The organization setup follows the three aspects of
1. GENERAL PREPARATION
2. PHYSICAL SETUP
3. ADMINISTRATIVE SETUP
Guidelines to Modernize NICU/ PICU
1988 - The Society of CCM (Critical Care Medicine)
developed the guidelines to design of ICU.
 The field of Intensive Care is rapidly growing in India.
 2004 – Updated guidelines for NICU / PICU
admission, level of care. transfer and discharge,
(AAP - American Academy of Pediatrics followed by
approval of IAP - Indian Academy of Paediatrics /
ISCCM-Indian Society for Critical Care Medicine)

15. Guidelines to Modernize NICU/ PICU…
AIM: To provide a detailed clinical observation, focused interventions to facilitate
the care of critically ill pediatric patients over an indefinite period of time.
1. GENERAL PREPARATION
 Notify the doctor and nurse in charge
 Warmer & incubator.
 Oxygen and suction apparatus as
available in the unit - Oxygen line
connected to the oxygen flow meter.
 Vital signs monitor to get ready
 Resuscitation & treatment trolly stocked
 Check the infant identification label
 Quickly examine the infant from head to
toe for obvious abnormalities
 Explain to parents.
 Transfer to a warm environment.
 Previous & Current maternal History
 Birth history - Done in the labor ward
 APGAR score and examination of the
newborn
 History, continuation sheet, treatment & diet
sheet, problem list, and flow charts.
 Start simultaneous appropriate management

16. Criteria NICU PICU
Location Possible to labor rooms &
obstetric OT
Near to lift or Emergency room
H.washing &
gowning room
 Located at the entrance & Self- closing doors
 Distance 20 feet from bed & each bed have a separate disposable hand rup.
Space &
facilities
 Minimum area of 100 sq. ft
 Baby beds should be located
4 feet away
 At least 2 feet away from the
wall and windows
 6 feet distance between
incubators ( 120 sq.ft )
 150 to 200 sq ft. in a cubicle.
 Minimum area should be 200 to 250 sq. ft
(for isolation unit )
 Beds must have a railing
 Each bed should have an emergency alarm
button
 Six to ten beds are desirable.
Nurses station  Central station should provide visibility to all patient areas
 Patient records should be easily available.
 Adequate space for telephone lines, computers, printers, and central monitor is
essential.
Guidelines to Modernize NICU/ PICU…..
2. PHYSICAL SETUP

17. Criteria NICU PICU
Utility  Storing clean utility items and sterile disposables
 For disposal of dirty linen and contaminated disposables.
Ventilation &
Lighting
 Effective air ventilation - white fluorescent tubes
 Minimum of 6 air changes, 2 fresh air changes should be outside
for filtering the inner air & add Provision of exhaust fan( reduction
of HAI)
 Noise kept well below 60 decibels. (keep level continuous < 45 dB and
transient < 60 dB )
Temperature and
Humidity
 26-28°C in order to minimize the effect of thermal stress
 Humidity should be kept at 30–60%
Diagnostic
facilities
 24x7 laboratory facilities , Mobile X-ray, ECG, EEG and Scanning
room available in side the Cabin
Guidelines to Modernize NICU/ PICU
2. PHYSICAL SETUP

18. Guidelines to Modernize NICU/ PICU…..
2. PHYSICAL SETUP- BIO MEDICAL WASTE MANAGEMENT

19. Criteria NICU PICU
Personnel
Nurse
 Mechanical ventilation support, nurse: baby
ratio should be 1:1-2 per shift. Availability of
a sufficient number of adequately trained
personnel
 Nursing staff 1:1
Doctor  Resident doctor available for 24hrs
 1:5 ratio of neonatologist
 specialist team of intensivists/
 critical care consultant
Para medical
personnel
 Respiratory therapist,
 Lab technician
 Social worker attached to NICU care
 Respiratory therapist
 Dietician
 Lab technician
 Social worker
 Speech and Language
Therapist
 Occupational therapist
Biomedical Engineering
(Healthcare Technology/Clinical Engineering and Medical Physics)
Guidelines to Modernize NICU/ PICU…..
3. Administrative SETUP

20. .
Guidelines to Modernize NICU…..

21. Guidelines to Modernize NICU…..
Additional facilities
 Feeding room
 Milk bank
 Counselling room
 Conference room
 Entry of
attendees at the
separate gate

22. Guidelines to Modernize PICU…..
Layout - PICU Physical setup

23.  Direct Ophthalmoscope
 Mobile X-Ray
 ECG unit, 3 channel, portable
 Low Cost Glucometer
 Blood Gas Analyzer
 Transilluminator Cold Light Source
 CPAP
 Intensive Care Ventilator (Neonatal and Pediatric)
 Transport Ventilator (Neonatal and Pediatric)
 Defibrillator
 Nebulizer (Electric)
 Syring Pump
 Infusion Pump-Volumetric
 Suction Pump, Portable, Electronic
 Mobile EEG
Equipment’s using in NICU/PICU
 Self-inflating reservoir bag
 Laryngoscope
 Oxygen Hood
 Oxygen Concentrator
 Radiant Warmer
 Phototherapy Unit
 Transport Incubator
 Thermometer, Digital
 B.P. Instrument Aneroid
 Pulse OximeterLine Powered
 Monitor
 Electric Baby Weighing Scale
 Breast Pump
 Examination Treatment Light
Crash cart - Drugs and portable defibrillator should be readily accessible.

24. Recommended
Disposable Mucus Extractors
1. Assessment of Breathing(Cried well - No need for suction)
Mucus Extractor -De Lee suction
device,
 Mechanical equipment to
generate negative pressure for
suction.
 should not exceed 100 mmHg
(130 cm water).
 Size 10 - 12F and have side holes
at the tip.
 Do suction Mouth & Nose
 Depth < 5 cm < 2cm
 Time < 10-15 seconds
Modernize setup of NICU

25.  Rooming in (Skin-to-skin
contact)
 Breast feeding
 Bathing postponed
 Appropriate clothing
 Warm transportation
2. Thermoregulation - WARM CHAIN
Thermal shield
Modernize setup of NICU…..

26. 3. Laminar Air Flow System
Modernize setup of NICU / PICU
 It circulates unidirectional airflow with little or
no turbulence providing an aseptic
environment to perform any procedure.
High Efficiency Particulate Air Filter (HEPA)
 The laminar flow - open unit and facilitates
access to care providers and family, less
magnetic rays.
 HEPA- To provide controlled total body
hypothermia, which is not possible with either of
the other two units even warmer & incubator

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To address the Transition of feeding from Tube / gavage to nipple
feeds, syringe feeding was conceptualized
4. Exclusive Breast Milk
Modernize setup of NICU…..

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4. Exclusive Breast Milk – Milk bank
CDC -2022
Modernize setup of NICU…..

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5.Oxygen Saturation by ‘Signal Extraction Technology’
 Conventional and infrared signals-
advanced techniques including radio
frequency and light-shielded optical
sensors, digital signal processing, and
adaptive filtration, to measure Spo2
accurately during challenging clinical
conditions and poor tissue perfusion.
 To separate the arterial signal from sources
of noise ( Including the venous signal) to
measure SPO2 and pulse rate accurately.
Modernize setup of NICU / PICU

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6.Newer Therapeutic Equpiments
BASICS Trolley - ‘Bedside
Assessment, Stabilization and Initial
Cardiorespiratory Support’ within a
50 cm radius from the mother's uterus.
Independent, portable, neonatal CPAP -
to provide breathing support to critically ill
neonates with Respiratory Distress
Syndrome (RDS) in resource-poor settings
and during transportation.
Modernize setup of NICU…..

31. Biliprobe Transcutaneous Jaundice
Detector
7.Bilirubinometer
Modernize setup of NICU…..

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8. Fibre Optic Blanket Phototherapy
 It’s consist of an LED (Light Emiting Diode) pad
for the treatment of neonatal jaundice
(hyperbilirubinemia) in the home.
 It’s wrapped around the baby and a pad of
woven fibers is used to transport the baby.
 Light emitted from a Biliblanket is used to break
up bilirubin in the baby’s blood, reducing the
yellowing effect in the baby’s skin.
 Advantage
Does not need to have eye protection when using a
biliblanket. Another advantage of the biliblanket is
that it can be used at home.
Modernize setup of NICU…..

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9. Non-invasive Administration of Surfactant
a.
b.
Devices for surfactant instillation by the standard and the less invasive surfactant
administration method.
a. Endotracheal tube size 2.5 (outer diameter 4.1mm)
b.Soft suction catheter 5 French (outer diameter 1.7mm)
Modernize setup of NICU
 Low Invasive Surfactant Administration
(LISA)using a thin catheter, to the exact site,
Laryngeal mask airway.
 Surfactant spreads easily when administered in
thin and large airways.
 Reduced ETT-associated risk of death or BPD,
less intubation in the first 72 hours, Reduced
incidence of major complications and in-
hospital mortality.

34.  Footprint recognition - newborn
personal authentication
 Male child - Right and Female
child from left leg and thump
impression from mother are taken
& recorded.
BioBaby – Infant Protect System
 BioEnable - Infant footprint
scanner and software
 Create a biometric birth record.
10.Safety and Security
Modernize setup of NICU …..

35. 10. Safety and security….
 RFID-Radio-Frequency Identification
 Staff ties RFID band around the hand of
baby, and RFID ID card with tag - mother
and attender.
 All information stored on a tag and
sensor fixed in all main entries.
 A tag can be read from up to several feet
away and does not need to be within
direct line-of-sight of the reader to be
tracked.
 RFID and tag removed- Before discharge
the baby
Modernize setup of NICU …..

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11.Inhaled Nitric Oxide Therapy for PPHN
 Persistent Pulmonary Hypertension
(PPHN) in neonates can lead to life-
threatening circulatory failure.
 Inhaled Nitric Oxide (iNO) is a potent
vasodilator used to treat pulmonary
hypertension in newborns.
 In ventilator circuit, it dilates the
pulmonary vasculature. It is inactivated
instantly in blood, by reacting with
hemoglobin.
 No action on the systemic blood
pressure.
 It has proved to improve oxygenation
and reduce the need for ECMO for the
neonates.
Modernize setup of NICU/PICU

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Innovations in Technology-Based Advanced Neonatal Care
12. Non- Invasive Ventilators (NIV) with Synchronization…..
Nasal CPAP has gradually emerged as the first
choice of respiratory support in preterm neonates
and BPD
CPAP - Introduction of neonatal ventilators along
with Intermittent Mandatory Ventilation (IMV) In
the last three decades,
 Bubble CPAP method shows more effective
 High-Frequency Ventilation (HFV).
 Optimal Humidity and natural pressure
oscillations, provide a protective, safe, and
effective method to initiate spontaneous
respiration among neonates.

38. 13. EXTRACORPOREAL LIFE SUPPORT (ECLS)
 ECLS - is an advanced life support system modified
form of heart-lung bypass facilitating the support of
neonates and children with severe respiratory or
cardiorespiratory failure.
 2005 - Extracorporeal Life Support Organization
(ELSO) started the ECLS program to support a
critically ill associated preterm with pulmonary
malfunction.
 ELSO guidelines are utilized for training ECLS
specialists and competency enhanced professionals
Modernize setup of NICU / PICU

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14. Telemedicine - Remote monitoring and ROP
 With tele consults, can relax with the baby at
comfort and discuss queries about the child’s
health.
 Remote monitoring involves keeping tabs on
patients & irrespective of the doctor’s place of
consulting, the baby can get the best care
possible. It saves up on travel costs and time.
 Screening for ROP is effective and cost-
effective, but in many areas, access to skilled
Remote screening with retinal photography is
an alternative strategy that may allow for
improved ROP care.
 Check for retinoblastoma & other eye
complaints in the neonate.
NICU care providers
take photos of a
premature baby's
retinas in the
telemedicine for ROP
screening
Modernize setup of NICU/PICU

40. 7/31/2023 40
15. Artificial Intelligence (AI)
 Current AI approaches - disease prediction and risk
stratification, neurological diagnostic support, and
novel image recognition technologies.
 AI can be used to identify high-risk babies for
timely targeted treatment and predict responses
to treatment provided.
 AI application will support the diagnosis of newborn
conditions and reduce 30% of antibiotic use.
 Support healthcare professionals in providing
personalized efficient newborn care and shared
clinical decision-making with parents, besides
reducing avoidable errors
Modernize setup of NICU / PICU
Digitalization

41. 16. Family- Centered Care - EBP
Modernize setup of NICU / PICU
 FCC- a crucial part of creating a healing
environment for sick newborns is emerging
as a paradigmatic shift in the practice
Transforming a provider-centered model /
client-centered to building a new
therapeutic alliance.
Cornerstone of the continuum of care,
imparting competencies to parents
/caregivers both within institutions as well
as after the discharge.
Source: Europe PMC 2016

42. NICUand PICUNurse - Strategies
 A subspecialty of children’s nursing that
requires additional skills and knowledge to care for
critically ill children and their families.
 Need requisite education and training to support
nurses in specialty roles.
 PICU Nurses are in charge of assessing, treating,
and monitoring young patients 18 years or younger
suffering from acute, life-threatening illnesses.
 PICU Nurses collaborate with other healthcare
professionals to provide age-appropriate care
Improve quality and can efficiently treat severe
consequences of high-burden diseases.


43.  Assessment
 Monitoring physiological data around
clock
 Safety measures
 Respiratory support
 Thermoregulation
 Protection from infection
 Hydration & Elimination
Nurses in the NICU and PICU play one of the most
critical roles in our healthcare system.
Responsibilities of NICUand PICUNurse
 Skin care
 Nutrition Feeding resistance
 Administration of medications
 Facilitating parent-infant relationship
 Discharge planning and home care
 Timely and appropriate referrals
 Documentation - Digitalization

44. 13 months in the facility’s neonatal intensive care unit, and on “multiple
treatments and machines” for survival discharged at a far
healthier weight of 6.3 kilograms (13.9 pounds).,
44
World’s smallest baby at birth, who weighed 7.5 ounces, leaves
hospital (August10, 2021)
Singapore’s National University Hospital
Effect of Modern NICU

45. Conclusion
INAP : Single Digit NMR – 2030 & Enhance the Quality of Survival
 Hospitals around the country are making strides in
modernizing and expanding these essential units, and
initiating majority of Nurses in contributing critical
roles to care for sick people.
 Organization of a good quality NICU/ PICU unit is
essential for reducing neonatal mortality and
improving the quality of life of the pediatric population.
 Technology - Innovations and Quality improvement
strategies aimed towards excellent outcomes.
 Discharge from NICU / PICU is an important milestone
of a baby on the road to recovery.