The NICU

We don't get very much exposure to the neonatal intensive care unit (NICU) on our general pediatrics rotation. During my week in nursery, I got a little introduction to common problems seen in premature infants, surgical conditions, and the sepsis workup. It's a completely different world than well-baby nursery. Babies are in incubators, hooked up to ventilators, monitored around the clock. Everything is incredibly detail-oriented; even simple things like fluids matter a lot. A change of a few milliliters/hour of fluids in a baby weighing 500 grams (just over one pound) is critical. They have so many difficulties with respiration, immune function, temperature regulation, and other homeostatic mechanisms.

I saw one newborn resuscitation. This was a baby at 34 weeks with known severe polycystic kidney disease. His kidneys were not only poorly functional, but also complicated the growth of his lungs (there was almost no amniotic fluid). The assessment by the neonatologist suggested that he might have a 50% or less chance of surviving his first few days of life. Unfortunately, the mother went into preterm labor. We were called to the delivery of this baby. This was so much different than the deliveries I had been at on my obstetrics rotation. The baby came out limp, blue-gray, and not moving. The neonatology fellow directed the resuscitation. With some warming, drying, and stimulation, he began to breathe spontaneously; his heart rate was around 80 (normal is well above 100). We then intubated him, putting a tube down his throat to assist breathing. We needed to secure access to blood and the residents began cannulating the umbilical artery and vein. Meanwhile, a respiratory therapist began bagging (hand-pumping) oxygen to the baby. He began to pink and his heart rate picked up. After getting access to the umbilical cord vessels, we drew up blood and handed it to the laboratory tech who was there (I was impressed by the team we could assemble at 10pm). He ran the samples on a portable analyzer in the room for arterial blood gases, blood count, and chemistry panel.

We then gave some surfactant down the endotracheal tube to help the baby's lungs open up. Things began to look pretty stable and we were preparing for transport to the ICU when the baby stopped ventilating. He began to turn blue, his oxygen saturation dropped from the 90s to the 80s to the 70s, and finally his heart rate dropped. Nobody panicked. The attending calmly took control of the situation. We began chest compressions, called a code (we realized we needed more nursing support), and the attending managed the airway. The fellow began listing the medications we wanted: epinephrine, THAM, fluids, blood. After suctioning a mucus plug from the airway, the attending reintubated the newborn and his oxygen saturation picked up. After ascertaining that he was stable, we transferred him to the intensive care unit.

This was the first time I'd seen an infant code. It's very scary and a little traumatizing. But I was impressed by the leadership of the neonatology team who seamlessly directed the resuscitation.

Image shown under GNU Free Documentation License, from Wikipedia.