It's all about the lungs . . .

Hi all.  I have been silent on my blog for quite awhile.  I got busy with life (and kids), plus I did not think anyone was really reading.  From looking at statistics, I may not have regular followers, but I have had quite a few more blog visits since I stopped writing, so maybe it's time to try and pick it up again.  :-)

Some changes in where I work and what population I care for have happened in the last few years.  I moved from California to the mid-west and from a Children's hospital to a local large hospital system.  This means less chance to encounter congenital malformations, cardiac, and/or surgical conditions first hand.  However, I still can write about my knowledge and experiences with these different encounters, I will most likely focus on prematurity and it's complications.

The main issue in my line of work is respiratory issues, hence the title.  The lungs are one of the last organs to develop in the infant, and continue to develop into our 30s!  That is one of the reasons that top marathoners tend to be in the late 20s, early 30s.  The human body continually amazes me.

The earliest babies that can be saved when born are in the 23-25 week gestation age.  This is about 6 months into pregnancy (which is really 10 lunar months, which is close to 9 calendar months, but not exactly).  This means that these babies are born 3-4 months before they are supposed to be.  At this point the air sacs where oxygen exchange takes place are still barely formed and not optimal for gas exchange.  Amazingly, some infants at this age are still able to survive and develop usually with the help of artificial ventilation.  Very occasionally, I have seen some infants close to 25 weeks who are able to breathe with the help of CPAP rather than a ventilator.  Amazingly strong little babies.

I will go further into ventilation and CPAP on a further blog post, but for now just know the lungs are usually the body system that give us the most difficulty early in life.

Prematurity Awareness Month

November is Prematurity awareness month. So, it is fitting for me to talk a little bit about that and the organization that helps to bring awareness to prematurity all the time - the March of Dimes.

The March of Dimes is a national organization that helps to raise money for research and programs supporting premature babies, babies with birth defects, and their families. They have educational programs to help mothers have full-term pregnancies and resources for parents of premature babies along with some research that has resulted in wonderful products to help premature babies all over the world. I love the March of Dimes and raise money each year for the organization through the Walk for Babies in April and donate on my own throughout the year when I can. Plus, each day when I go to work, I put in my best effort to help the premature babies under my care and provide support and education to their families. March of Dimes uses 77% of all donations directly for research and programs that support preemies and those born with birth defects. This is huge! The rest goes towards marketing and support staff to help raise money for those beautiful babies.

Two of the greatest accomplishments that March of Dimes has achieved is folic acid and surfactant. Decades ago it was discovered that folic acid supplementation taken before and during pregnancy can help the mother avoid spinal defects in her unborn child. March of Dimes spent lots of time and money to get the knowledge out to the public and help greatly reduce the number of babies born with spinal defects. March of Dimes also did much research to help produce surfactant to help premature babies' lungs. With this, we have been able to save younger babies and get them through their NICU stay with less lung damage.

One in eight babies in this country is born prematurely! All over the world, approximately thirteen million babies are born prematurely - 13 million! Also, the rates of premature birth are rising in countries all over the world at an alarming rate! Many of this babies become angels too early or leave the NICU with on-going health problems that require a lot of care and resources, along with time and money. Prematurity is a huge problem in health care and can cost a huge amount. As we know from current politics - health care costs are rising all over and we may run low on resources at some point in the future. Not all premature births can be prevented, but there are many things that can be done and I believe that in the future medicine will better be able to treat premature babies, and prevent more premature birth.

Please go look at the March of Dimes website and consider donating even a small amount to this wonderful organization. Premature babies all over will thank you.

How premature is that?

Normal gestation (pregnancy) is 40 weeks long, which is actually 10 4-week lunar months, not 9 as is the common thought. Sorry ladies, you are actually supposed to be pregnant a little longer than 9 months for a full-term healthy newborn. A premature baby is any baby that is born before 37 weeks of gestation. Why 37? At that point all the baby's systems are basically fully developed and they are able to breathe, eat, and function basically on their own without any problems.

For the NICU, our cut-off point for general prematurity is 35 weeks. Anyone born younger than than 35 weeks will automatically be admitted to the NICU for our extra care and support during their last weeks of development. At 35 weeks, we often come to the delivery to evaluate the infant and if there is any question in their ability to transition to extra-uterine life, they come to the NICU. Of course, we do get 'older' babies born at 'term' for different reasons that we'll discuss later.
A 25-week baby on a ventilator

The edge of viability for current medical advances is about 23 weeks of gestation. Mind you this is just a little under 6 months of pregnancy. At this point most mothers are just really starting to look "pregnant" and developing their tell-tale pregnant belly. These babies will have a lot of problems to overcome and will likely be given a lot of outside support by NICU staff. Also, it is very likely that they will spend at a minimum 3-4 months in the NICU before being able to go home. Most of the infants born this early actually spend even longer in the NICU - so expect a stay more like 4-5 months with lots of hurdles to overcome also. (we'll talk more about why later on as well). These babies are often less than 2 lbs and may be no 'taller' than a pen. Their limbs are tiny and thin and you can see every bone in their little bodies. Their skin is very thin, moist, and easily torn - we must take great care to keep their skin moist, healthy, and take very delicate care of them. Before 25 weeks gestation, their eyes are usually still fused together, and the skin of their eyelids is very thin - therefore they are very sensitive to light and we must keep their beds dark and cover their eyes from any outside light to protect their developing eyes. They cannot eat by bottle and need a tube placed to their stomach through which we place mother's breastmilk or formula. Every system is still developing and they need a lot of support.

The mid-range preemies are about 28 weeks until about 31 weeks. At this point in development they still have a ways to go, but they likely make it through their NICU stay and leave us just around when their birthday was supposed to be and may leave with some long-term medical needs. These babies are usually born aournd 1-3 lbs or more. Their skin is still thin and they need help to stay warm and not loose too much moisture through evaporating. Their eyes are open but still sensitive to light and we still must keep their bed dark and try to keep lights dim or cover their eyes when we need bright lights. They will likely need some help breathing and will need to be fed through a tube until they can learn to eat by bottle.
A 28 week baby on BiPap (a machine providing a small amount of positive pressure to the lungs)

The later-term preemies are about 32-35 weeks. These babies may need some respiratory support and will need help learning to eat by bottle or breast, but hopefully will not have too many other issues to overcome. They usually spend a much shorter time in our NICU and have few long-term medical complications. These babies are usually 3, 4, and 5 lbs or more. They may need a little short-term help breathing, but can usually breath on their own after a few days or a week. They will need a little help feeding through a tube but usually learn to eat by bottle pretty quickly. They need a little help staying warm and somewhat dimmer lights, but can be in a crib quickly and have less light sensitivity.

Modern NICUs have many great treatments and equipment to help these little babies develop and get the chance to do lots of teaching to the parents. The job is tough, but extremely rewarding and I love it!

(Note: the pictures above were found on google images or permission was given by the parents)

Primaries and Associates

In the NICU there are many nurses and many babies. Each night one comes to work, they get assigned different patients depending on how sick the infants are and where the managers need different nurses based also on skills and experience. One thing that has been in place in both NICUs I have worked in is a program or policy for continuity of care - primaries or associates. This is where nurses volunteer to care for certain infants throughout their stay in the NICU. There are different reasons that nurses sign-up to be a primary nurse for an infant but often there is a an attachment to the infant and hopefully the family as well.

During my time as a NICU nurse, I have had several primaries and loved each one in my own way. They all had different lengths of stay in the NICU, but all have been premature. They all came from very different families and each one was special. Each NICU nurse has his/her own reasons for choosing to bring a baby into their hearts as their primary but each time it enriches your life. Sometimes it is a long road with many trials and bumps but we always learn from our little babies.

When a nurse becomes a primary for an infant, we learn the infant's personality, likes, dislikes, and very importantly - the history of the infant and all of his/her problems, diseases, treatments, medications, etc. As the primary, you often become the advocate for your patient and help to become a part of the team making medical decisions for your patient as well as the one to communicate all the nuances to other nurses caring for your primary.

There are other areas of the hospital that allow a nurse to take on a primary however often our patients have a longer average length of stay which allows us to build relationships with our patients and their families. The wonderful enriching thing is helping that family to learn to care for their infant and hear updates on our special patients.

I think I will always have a handful of primaries throughout the year as long as I work in the NICU and each one will make a mark on my heart and teach me new things about the work I love. Currently I am caring for my seventh primary and who knows how many more there will be.

NEC

NEC stands for necrotizing enterocolitis which basically is death of intestinal tissue. It is a very scary and unpredictable preemie problem. One of the scary things with NEC is that we do not know exactly what causes it or how to prevent it in preemies. It appears to be related to feedings and ischemic injury (lack of blood flow to an area).

While in the NICU, we try to give preemies feedings as early as possible once they are fairly stable to help the gut begin to work as it should. Normally in development there will be no food entering the digestive system, although now that they are outside the womb, preemies must continue development in a different environment and there will be a whole host of other problems if we delay feedings too long unnecessarily.

Often preemies breath sporadically and have small pauses in their breathing. This can cause a drop in the oxygen concentration of their blood for a short time. If the pause is too long - there is a chance for injury to happen to different body tissues due to lack of oxygenation. Neonatologists feel that this may be part of the cause of NEC.

There are different types of NEC and different ways of treating it depending on the type and seevarity. Medical NEC is often treated with antibiotics and resting the gut i.e. holding regular feedings. There is also NEC that needs to be treated surgically to remove the dead tissue and attempt to save the tissue that remains alive within the infant.

Amazingly many preemies who develop NEC can go from normal to very sick within a few hours and sometimes they die within a few hours of developing intestinal issues. Usually we are able to provide some treatment and can help to save much of the intestines. Thankfully many of the babies that now develop NEC do improve and eventually go home.

Still, it remains to be a major problem for our patients and we continue to try and do our best to first prevent and then treat NEC.

NANN & ANN & CoCANN oh my!

This one is for my fellow NICU nurses - I'd like to talk a little bit about the professional organizations in our field - NANN and ANN. In case you do not know NANN is the National Association of Neonatal Nurses and ANN is the Academy of Neonatal Nursing. These two organizations strive to help improve the care of neonates across the US (and the world). They each have a publication with specific neonatal topics and at least one article with CEUs each journal. They each hold national conferences with great speakers and strive to educate and improve our practice.

I feel it is important to belong to either one or both of these organizations in order to further your own neonatal practice and keep the field growing strong. It is important for us to be accountable for keeping the profession moving forward and bringing new ideas to your units. Great care is a matter of culture within each NICU and it is up to all of us to help create the culture and keep it moving forward into the 21st century to provide the best care for our precious patients!

The wonderful thing is that there are also local chapters of the organization to help build community, support one another, and provide a little social activity to get together and network. We are all neonatal nurses with our patients at the heart of what we do. I belong to both NANN and the local chapter - CoCANN. CoCANN is a newer local chapter attempting to provide a bridge between LA and Orange Counties. If you live closer to San Diego or Inland Counties there are SCANN and ICANN respectively. These local chapters have regular meetings to discuss upcoming events and educational conferences as well. CoCANN is holding a day long educational conference in February and an upcoming holiday party in December. Check the website below for more information!

Join your national and local chapters to help build and strength the field and your own practice!
Click the links below to bring you to the professional sites:

NANN
ANN
CoCANN

NICU Nurse notes

Hi. My name is Victoria and I'm a NICU nurse at a children's hospital in Southern California. I have been a NICU nurse for three years and love what I do. I love to participate in the March of Dimes walk for babies to help raise money and awareness for prematurity, however I realized there is another way to do so - write a blog about it! So here I am beginning my journey blogging about what I do and what I love.

In case your new to it - NICU stands for Neonatal Intensive Care Unit. This is the area in the hospital that cares for neonates (new babies) that are either premature or sick. It may also be called the Infant Special Care Unit (ISCU). It is a very specialized form of medicine that has it's own set of problems and ways to treat these special patients.

Here I plan to mix a little about common preemie problems, NICU experiences, procedures, and (with permission from their parents of course) perhaps even some personal stories of preemies I have cared for (perhaps even updates on their lives). Send any questions my way and I'll try to find you the answer in a blog post. :-)

Thanks for reading.
Victoria, NICU RN
viccar82@gmail.com