Neonatal Network
July/August 2006
Vol. 25, No. 4

ABSTRACTS

Neonatal ECMO: Current Controversies and Trends
Jesse W. Ford, RNC, MSN, NNP

Extracorporeal membrane oxygenation (ECMO), a technique for providing life support to patients with cardiac and/or respiratory dysfunction, allows the heart and lungs to "rest." the neonatal respiratory population has been a major benefactor of ECMO since 1982. its use for neonatal respiratory disease increased dramatically until the past few years, when the number of neonatal respiratory ECMO cases began a downward trend. Fewer patients with persistent pulmonary hypertension of the newborn (PPHN), meconium aspiration syndrome, respiratory distress syndrome, or sepsis are requiring ECMO support as frequently as in the past. Many attribute this decline to the newer respiratory therapies-mainly, surfactant, high-frequency oscillatory ventilation, and inhaled nitric oxide. Neonates who continue to require ECMO today are sicker than the historic norm and have more complicated and lengthy ECMO runs. Patients with congenital diaphragmatic hernia, PPHN, and sepsis remain the most consistent in their representation among ECMO recipients within this author's institution, suggesting that the newer respiratory therapies have not had the same impact on these patients' needs for ECMO support. Better guidelines for determining which patients would benefit from earlier initiation of ECMO are needed.

Congenital Diaphragmatic Hernia: Two Case Studies with Atypical Presentations
Barbara Puckett, RN, BScN, MS/NNP

Congenital diaphragmatic hernia (CDH) affects 1 in every 2,000 to 4,000 live births. Many infants with this condition are diagnosed antenatally through routine ultrasound screening. Nearly 90 percent present at delivery with severe respiratory distress requiring intubation. Many of these infants develop persistent pulmonary hypertension of the newborn due to hypoplasia of the affected lung. The survival of infants with CDH is limited by the degree of pulmonary hypoplasia and requires sophisticated medical technology such as high-frequency ventilation and inhaled nitric oxide. Some infants also require treatment with extracoporeal membrane oxygenation. This article gives details of two cases of CDH in which the presentation was atypical. The more subtle presentation is discussed, as well as the embryology and pathophysiology of CDH and the possibility of associated anomalies. Clinical management and impact on the family are outlined.

Optimizing the Neonatal Thermal Environment
Tami Irwin Sherman, RN, BSN, MBA
Jay S. Greenspan, MD
Nancy St. Clair, RN, BSN
Suzanne M. Touch, MD
Thomas H. Shaffer, PhD

Devices used to maintain thermal stability in preterm infants have advanced over time from the first incubator reported by Jean-louis-Paul Denuce in 1857 to the latest Versalet incuwarmer and Giraffe omnibed devices today. Optimizing the thermal environment has proven significant for improving the chances of survival for small infants. Understanding the basic physiologic principles and current methodology of thermoregulation is important in the clinical care of these tiny infants. This article highlights principles of thermoregulation and the technologic advances that provide thermal support to our vulnerable neonatal population.

A Protocol for the Use of Amorphous Hydrogel to Support Wound Healing in Neonatal Patients: An Adjunct to Nursing Skin Care
Lorna Cisler-Cahill, RN, MS

The care registered nurses offer makes a critical difference in the quality and cost-effectiveness of patient outcomes. The prevention and treatment of alterations in skin integrity remain primary nurse-sensitive quality indicators. Although wound prevention is a primary goal for nurses, iatrogenic wounds do occur. Neonatal patients are at greater risk for alterations in skin integrity because of the fragile nature of their skin. When skin breakdown occurs, nurses must have knowledge of effective treatment alternatives. The purpose of this article is to describe the use of a collaborative practice protocol to introduce and document patient outcomes with the use of amorphous hydrogel as a treatment modality for iatrogenic neonatal wounds. All hospitals collect data on the quality of patient care, and it has been known for some time that registered nurses can make a critical difference in the quality of patient care and the effectiveness of patient outcomes. The american nurses association has identified ten specific quality measures that are impacted by nursing care. Referred to as nurse-sensitive quality indicators, these measures include the maintenance of skin integrity.1

Evidence-Based Review of Oral Sucrose Administration to Decrease the Pain Response in Newborn Infants
Kathleen H. Leef, RNC, MSN, NNP

Pain assessment and management are important issues for the neonatal nurse today. Clinicians have gradually come to acknowledge that newborn infants (term and preterm) are capable of responding to painful stimuli. This article reviews the evidence regarding the safety and efficacy of oral sucrose administration, to help answer the clinical question of how to manage an infant's pain response to minor invasive procedures that are everyday occurrences in the NICU. This review included information on 1,077 infants enrolled in 16 studies. The evidence presented in the 16 studies reviewed here shows the safety and efficacy of sucrose in decreasing term infants' pain response to a single procedure. In regard to preterm infants, there is insufficient evidence to recommend the use of sucrose as a routine comfort measure. More research is needed to determine the safety and efficacy of repeated doses of oral sucrose given for multiple procedures in preterm infants.