Neonatal Incubator Related terms: Neonates, Medical Device, Prematurity, Incubator View all Topics > 4, Download as PDF QQ Set alert @ About this page Perinatology Vinnie DeFrancesco, in Clinical Engineering Handbook, 2004 Incubators Infant incubators provide thermal support for the neonate (Perlstein and Atherton, 1988). Most incubators also incorporate means for controlling oxygen levels and relative humidity of the air the infant breathes. Microprocessors incorporated in most modern incubators assist in the accurate control of temperature, humidity, and oxygen levels while enabling such features as graphical data trending of the critical parameters controlled by the incubator. An incubator PM program should take into account the manufacturer's recommendations and should include measurement of sound levels, operating temperatures of humidifiers, and oxygen sensors. Servo- controlled oxygen and humidity delivery systems typically require unique calibrations to be preformed during PM. In addition to calibration, humidifiers require periodic replacement of the air-intake filter. Inadequate maintenance can result in incubators that are hazardous to the infant. Incubators are used for many years, during which time they are subjected to appreciable shock and vibration because most are mounted on casters and are moved about for cleaning and storage. In the past, mechanical stress has damaged temperature control mechanisms, which, in turn, have overheated infants, causing brain damage or death. Old incubators that have been relegated to storage can be placed back into service during a high census period (Figure 93-4). These semiretired incubators might lack necessary safety features and manufacturer-recommended upgrades or modifications and can pose serious risks to neonates. For example, on some older models, a missing heat shield can permit an infant to crawl over a hot air vent and thus suffer severe burns. Lack of maintenance results in the use of incubators with high ambient-noise levels originating from defective or misaligned air-circulating fans, which can cause hearing loss. Defective door latches can enable an infant to crawl out of an incubator and fall to the floor (Dyro, 1977). Older incubators used mercury-based temperature sensors, which often broke, thus ‘exposing the infant to hazardous mercury vapors (Dyro, 1981). It was not uncommon to observe a pool of mercury from broken thermometers and mercury switches on the floor of the heating compartment directly beneath the infant mattress.Neonatology Philip Roth MD, PhD, in Pediatric Secrets (Fifth Edition), 2011 38 What techniques are available to keep preterm infants warm in the delivery room? Methods used in the delivery room to keep infants warm have included occlusive wrapping, heated mattresses, land kangaroo cate (skin-to-skin contact). A number of studies have compared placement immediately after birth of preterm infants in a reclosable polyethylene bag without drying with standard drying after birth. A significantly higher neonatal intensive care unit (NICU) admission rectal temperature was observed in infants managed in this way, especially in those younger than 30 weeks’ gestational age. A large multicenter trial is under way to confirm these results. ‘Watkinson M: Temperature control of preterm infants in the delivery room, Chin Perinatol 33:43-53, 2006. Finer NN and the SUPPORT Study group Early CPAP versus surfactant in extremely premature infants, N Engl J Med 362:2024-2026, 2010. Pediatric Equipment Richard H. Blum, Charles J. Coté, in A Practice of Anesthesia for Infants and Children (Fourth Edition), 2009 Heating and Cooling Systems ‘The operating room, which is comparable to a large infant incubator, provides the physical environment for the conduct of anesthesia, Readily controlled heating and cooling systems are crucial for thermal stability of the child, that is, control of the external environment. The neonate or small infant requires a warmer room temperature than an adult and should be considered poikilothermic particulary if preterm, critically ill, or stressed. With approximately 40% of heat loss by radiation and 35% by convection, increasing the operating room temperature warms the walls, which decreases radiation heat loss, and warms the air, which decreases convection heat loss (see Chapters 25, 35, and 36). Exposure to a cool room temperature during induction of anesthesia and surgical preparation may cause significant thermal stress, particularly in the preterm neonate and young infant, Mild to moderate hypothermia may cause acidosis and apnea in infants, alter the pharmacokinetics of medications, cause difficulty in antagonizing the neuromuscular blockade, and increase oxygen consumption with shivering.' Once the child is prepared and draped, the operating room temperature may be reduced to a more comfortable level. Clinical Engineering Advocacy Thomas J. O'Dea, in Clinical Engineering Handbook, 2004 Patient Safety Patient safety requires knowledgeable professionals in technical areas for the discovery, evaluation, and mitigationof patient risk. The author's work (O'Dea et al, 1998) on the interaction of infant warmers and bilirubin lights with the regulation of temperature of newborn infants is an example of an unexpected safety issue discovered during the ordinary duties of a clinical engineer. The nurses in the Neonatal Intensive Care Unit (NICU) experienced problems with using infant incubators in the servo-controlled temperature mode on some neonates. The manual mode triggered an audible alarm every few minutes, which added to the already high sound level in the NICU. In looking at the entire situation, interaction between the infant warmer and the bilirubin lights used simultaneously on low weight newborns prevented effective control of body temperature, since the uncontrolled energy delivered by the broad spectrum bilirubin lamps was significant compared to that delivered by the incubator. Once the cause of the problem was determined, operational changes in the simultaneous use of the two devices allowed effective care. ‘An example of combining the disciplines of clinical engineering and medical physics is quantification of patient skin radiation dose during neurointerventional procedures (O'Dea et al., 1999). This study determined the probability of patient skin injury due to radiation received during such procedures as cerebral angiograms and embolizations. Using the data from this study, a method of estimating the probability of patient injury was proposed, using fluoroscopy time and the number of digital angiographic images, both easily obtained from the radiographic equipment. Some neurointerventional procedures had a small likelihood of patient injury, and might be omitted from an elaborate monitoring program, while others had a higher likelihood of injury, and should be part of such a program. Another collaboration effort with a medical physicist yielded a quality control system for automated dosimetry and the estimation and mitigation of error (Li et al., 1999). Neonatal Anesthesia Rita Agarwal MD, Jennifer F. Brunworth MD, in Anesthesia Secrets (Fourth Edition), 2011 8 What special preparations are needed before anesthetizing a neonate? The room should be warmed at least 1 hour before the start ofthe procedure to minimize radiant heat loss. A warming blanket and warming lights also help to decrease heat loss. Covering the infant with plastic decreases evaporative losses. Forced-air warming blankets have been shown to be very efficient at keeping infants warm. They work equally well if the infant is placed on them or ifthe blanket is placed on the infant. Temperature should be monitored carefully because itis easy to overheat a small infant. = Routine monitors in a variety of appropriately small sizes should be available. At least two pulse oximeter probes are helpful in measuring preductal and postductal saturation. '= Listening to heart and breath sounds with a precordial or esophageal stethoscope is invaluable. = Calculate estimated blood volume, maintenance, and maximal acceptable blood loss. = Placing 25 to 50 ml of balanced salt solution in a buretrol prevents inadvertent administration of large amounts of fluid = Five percent albumin and blood should be readily available. Medical Device TroubleshootingJoseph F. Dyro, Robert L. Mortis, in Clinical Engineering Handbook, 2004 Listen, Look, Smell, and Feel Your senses and brain make up the best and most flexible test and analysis system in the world. Listen to the operator or user, and to the device for normal and abnormal sounds such as: + Information as to the conditions and symptoms of failure from the operator. + Rattles, squeaks, buzzes. These can indicate wear or lack of lubrication or motion. + Sizzling or humming, Either can indicate a short circuit, arcing, high-voltage corona, and excessive loading of transformers. + Excessive loudness or silence. Each can indicate a broken or defective part such as a cooling fan. Look for the following: ‘+ Physical damage and wear. (Figure 96-7 shows a bent knob on the front panel of an infant incubator.) + Loose, inadequate, incorrect, or incompatible connections or connectors. Figure 96-8 shows two connectors ‘on a pressure transducer cable, both of which have bent pins. Investigation revealed that the operator was attempting to connect the cable to the incorrect receptacle on the blood pressure monitor. + Dirt, dust, lint, corrosion, leaks, or vermin. (Figure 96-9 shows lint accumulation about temperature-control ‘elements in an infant incubator, Signs of fluid staining also can be seen. Figure 96-10 shows a printed circuit board infested with red ants. The ants apparently were attracted by the tempting odors emanating from the board at the site of power transistor mountings. + Burned, charred, or discolored insulation, components, circuit cards, or chassis. Figure 96-11 shows a hole and scorch marks produced by electricity from a power cord passing through the chassis of height-adjusting control unit of parallel bars. The cord was inadequately protected with grommet and strain relief. + Physical relationships-use these to build a mental image of the functional relationships + Proper mechanical operation-no binding or jerking + Ways to disassemble the device or module Smell for the following: + Ovetheated transformers. This can indicate a defect in the transformer, an external short, excessive load, or a cooling failure. + Burned resistors or resistors where you cannot read the color code. These can be caused by reduced value due to age effects, failure of another component or function, or cooling failure. + Burned or charred insulation. This can be caused by a short circuit, excessive current flow, or an overheated nearby component. Feel for the following: + Hot spots. Be careful not to get burned or shocked. + Rough edges or worn spots. These can indicate such things as mechanical wear, incorrect alignment or assembly, or broken parts. + Smooth operation. Few devices are designed to function in a jerky or irregular manner. Do not look at schematics or begin taking measurements until you have exhausted the preceding process. Most (nearly 80%) instrument system problems can be solved by using your general and specific understanding of instruments and systems and the knowledge to be gained through a careful utilization of your senses of sight,hearing, smell, and touch. ‘Temperature Regulation of the Premature Neonate Stephen Baumgart, Sudhish Chandra, in Avery’s Diseases of the Newborn (Ninth Edition), 2012 Giraffe Omnibed As a radiant warmer, the Giraffe OmniBed (General Electric, Ohmeda Division, Laurel, Maryland) evenly heats the infant's mattress with a curved reflector surface designed to distribute heat to the baby and its bed surface without, overwarming bedside caregivers. Babies are warmed uniformly, regardless of their position on the bed platform surface, which can be rotated 360 degrees, accommodating intravenous and ventilator tubing and attached wire leads. The same platform tilts up to 12 degrees i access from drop-down walls in the radiant warmer mode facilitates procedures such as diaper and bedding changes, blood sampling, starting intravenous lines, performing tracheal intubation, administering medications, Trendelenburg or reverse Trendelenburg positions. Three-sided creating radiographs, and conducting ultrasound examinations without interrupting warming. A stable thermal environment in either the incubator or radiant warmer mode eliminates the stress of moving premature babies, such as when performing chest tube insertion or other surgical procedures performed in the NICU and outside the operating room. In one of several industry sponsored studies, Leef et al (2001) reported that infants were handled significantly less with the Giraffe OmniBed, especially when converted to incubator mode (from 6.9 handling events per hour maximum on a standard radiant warmer bed device to 1.6 times per hour on an (OmniBed-closed), These authors concluded that the OmniBed is conducive to providing developmentally appropriate care—that is, medically fragile newborns are not exposed to a variety of visual, auditory, and tactile stimuli that would not occur otherwise within the mother's womb. Consequences of such stimulation are unknown, although it seems reasonable to avoid excessive handling and inappropriate touches because of documented physiologic effects of procedural handling (Gressens et al, 2002). Ina second industry-sponsored study (Gaylord et al, 2001), there were no differences found in mean skin ‘temperature among the four tested conditions in premature neonates (R = radiant warmer configuration of OmniBed; transition R to C = convection-warmed closed OmniBeed and transition C to R). Mean heart rate, respiratory rate, blood pressure, and oxygen saturation were not statistically different among the four test conditions. These authors conclude that the Giraffe OmniBed provided thermal and physiologic stability across bed states, eliminating the risk of infant mishap as a result of bed transfer. When transforming the Giraffe OmniBed from incubator to warmer bed and back, the closed-convection heat partition adapts to form a uniform open-radiant heating configuration with sequential alterations of air warming temperature, fan power, and radiant heat delivered while displaying all equipment and baby parameters in one control panel. For example, when returning to the closed-convection mode, the retracting radiant warmer pylon immediately disconnects electrical power to the warming element and opens a mechanical air vent to cool the reflector hood, avoiding overheating the infant upon descent. In closed-convection configuration, bidirectional airflow through a double wall construction provides a stably enclosed thermal environment. When either door port is opened, an air curtain minimizes infant heat loss. Light and sound levels are carefully controlled within the OmniBed to promote infant health and development (Lynam, 2003). An alarm light easily visible to caregivers remains out of infant's view. The WhisperQuiet mode limits sound to create the most quiet and soothing environment possible. Alarm speakers are deflected to minimize any noise experienced by the baby. An in-bed scale further reduces infant handling. In addition. servo-reeulated humidification is sunnlied within the elased-incubator condition and can be set toadetermined relative humidity between 70% and 80%, which is optimal to avoid excessive insensible water loss and electrolyte disturbances often experienced by premature neonates with extremely low birthweight in the first week oflife when incubated dry. One recent non-industry-sponsored report ofa clinical series compared the use of initial stabilization of babies with extremely low birthweight (<1000 g) under a radiant warmer followed by conventional incubation—dry versus use of humidity control in OmiBeds. The authors demonstrated that humidification improved care by decreasing fluid intake, with more stable electrolyte balance, and growth velocity (Kim et al, 2010). The authors did not address the risk-benefit issue of humidification and infection. ‘The Giraffe Humidifier immerses a heating element in a reservoir of sterile, distilled water. Water temperature at equilibrium ranges 52° to 58° C, which is bactericidal to most organisms thriving at temperatures of 20 to 45° C (most human pathogens). As an added safety measure against reservoir contamination, water is boiled off the immersion element as the humidified air is passed inside the infant's compartment. Sterile humidity is created in a vapor state, with no airborne droplets. In a third industry-sponsored study by Lynam and Biagotti (2002), humidified OmniBeds (in vitro, air control mode at 35° C, and humidified to 659 relative humidity) were cultured after investigator inoculation with reservoir contamination with four waterborne pathogens over a 4-week incubating period. No infant environment culture revealed growth of any pathogen. The authors concluded that there is no concern for an increased risk of infection to an infant when the reservoir is filled daily with sterile distilled water and the bed is routinely cleaned, according to their protocol.