1. Clinical Monitoring of
Hospitalized New Born
Dr. L S Deshmukh
MD,Dip.NB,DM (Neonatology)
Heinz Fellow,
Royal College of Pediatrics &
Child Health, London,
eMail
:lsdesmukh@indiatimes.com
2. Importance of Neonatal Monitoring
• A neonate cannot complain
• Adaptation to extrauterine life may be
difficult.
• Illnesses quite common
• If not detected in time, may be fatal /
brain damage
• Adequate monitoring – first step
toward improved survival without
morbidity
3. Objectives of neonatal monitoring
• Evaluate the status of neonate at birth
• Categorize degree of risk to the baby
• Anticipate and detect early signs of
illness
• Assess the progress of illness
• Monitor adequacy of nutritional intake
and growth.
4. What should be monitored ?
• Vital signs
• Signs and severity of illness
• Biochemical and biophysical monitoring
depending upon the illness.
• Drug administration and side effects of
drugs.
• Nutritional intake and growth
• Effective functioning of the equipment
used in neonatal care.
5. Who should monitor ?
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Trained nurse (Adequate number essential)
Doctors (senior / junior)
During transport, nurse / doctor
Role of mother - supportive
6. Frequency of clinical monitoring
• Decided by degree of risk & of sickness
• Continuous electronic monitoring for very high-risk NB
• During first 8 – 12 hrs. in all babies
- Two hourly vital signs till stabilized
- Note feed/fluid intake
• Low-risk baby
- Vital signs 12 hrly.
- Daily weight, feeding, bowel, urination.
• High-risk baby
- Every 2 hrs. in first 24 hrs. (May be longer if unstable)
- Every 4 hrs – on stabilization
• During transport
- Every 15-30 min.
7. Whom to monitor ?
* Some monitoring for all
neonates
* During first 8 hours
(transition), in all babies.
* For longer period in high
risk neonates.
10. “The eye of the master will do
more work than both his hands”
- Benjamin Franklin
11. Eyes, ears, nose and palpating
fingers are crucial for clinical
monitoring with intact analytical
brain, an essential attribute
12. Clinical Monitoring – Vital Signs
Temperature :
• Monitor environmental as well as baby’s temperature.
• Methods :
- Mercury –in- glass thermometer
- Probe – Type electronic thermometer
- Infrared thermometer
• Hand touch is most useful for monitoring at any level.
• Sites : Axillary, Rectal, Skin surface,
- Aural / Esophageal, Sublingual
• Intermittent rather than continuous monitoring
13. Site for Temperature Monitoring
Site
Surface
1. Abdomen
2. Axillary
Rate [°C]
Application
36.0-36.5
36.5-37.0
Servo control
Noninvasive
Approx of core temp
Core
1. Sublingual 36.5-37.5
2.
Esophageal 36.5-37.5
3.
Rectal
36.5-37.5
Quick reflection of
body change
Reliable reflection of
Changes
Slow reflection of
Changes
14. Core-Peripheral Temp. Gradient
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Often used to assess state of peripheral perfusion
Large gradient = hypo volemia
A gradient may indicate thermal stress
May be affected by thermal environment,
phototherapy.
• Gradient > 3.2°C, may be a sign of sepsis
(Bhandari et al, Indian Pediatr, 1992)
• Usually inaccurate in pre terms (immature autonomous
control)
• Optimum sites & reference ranges not well studied.
15. Clinical Monitoring – Vital Signs
Heart Rate :
• Varies widely with state
• Resting HR most consistent
• Preterms have higher HR
• Recorded by precordial
palpation, peripheral pulses
• Easiest way by auscultation
• Bradycardia < 100 bpm
• Tachydardia > 160 bpm
16. Clinical Monitoring – Vital
Signs :
Respiration
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RR must be counted for full one
minute in a quiet infant
RR x TV = MV
RR affected by various factors
RR slightly more on listening with
stethoscope than observation.
Normal range – 30-60 BPM
In addition, look for retractions,
grunting / moaning, apnea
17. Clinical Monitoring – Vital Signs
Blood Pressure
• Various techniques
• Invasive / noninvasive
• Flush blood pressure
- Gives mean pressure
- Lower than direct
• Important elements for accuracy
1. Quiet infant
2. Proper cuff size (50-67% of arm
length)
•
Small cuff – BP higher, Large cuff –
BP lower
18. Clinical Monitoring – Vital Signs
Blood pressure (Contd..)
• Note pulse pressure (25-30 mmHg in term, 15-25
mmHg in preterm).
• Limitations of flush method – Continuous
monitoring not feasible, not practical,
inaccurate, does not given systolic and
diastolic BP.
• Normal values for BP vary with GA, PNA,
method as well as site.
• For normal values, use Nomogram / chart.
20. Capillary Refill Time (CRT)
• Widely used as a guide to peripheral
perfusion.
• Upper limit of normal less than 3 seconds.
• Values from center of chest and forehead
more reliable (Strozik et al, Arch Dis Child, 1997).
• Limitations :
- Large inter observer variation.
- Fallacious on babies in incubators or
radiant warmers.
- Does not always correlate with BP/Cardiac
index
21. Clinical Monitoring – Vital Signs
Activity :
• Good – reassuring
• Lethargic / irritable – Search for cause
• Seizure activity – CNS disorder
Important : State of the baby and feeding
23. Pulse Oximetry
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Considered as “Fifth vital sign”
Part of clinical monitoring
Normal range – 92+3% (room air)
Advantages :
- Noninvasive
- No patient preparation
- Rapid response time
- Useful on different patient population.
Limitations :
- Decreased accuracy < 65%
- Not sensitive for hyperoxemia
- Affected by type of Hb (F/A)
- Nor reliable with low pulse volume
24. Intake / Output Record
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Record fluid intake ml to ml
•
Record feed volume & type
accurately
Record accurately
- Stool – frequency, type
- Vomiting – frequency, color,
content
- Gastric residuals – volume, color,
content.
Urine – volume (accurately) or
frequency (stable NB)
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(including boluses & flushes)
27. Weight Monitoring
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Most important parameter of growth
Monitoring intake-output balance
Record with a sensitive weighing scale
Check daily till weight gain stabilized
Plot daily weight on a chart
Monitor rate of weight gain / loss
In addition, record, length and head
circumference weekly.
31. Role of Mother
(In a Hospitalised Baby)
• Nursing shortage – chronic problem
• An educated mother can monitor
almost all vital signs (except HR and
CRT)
• Monitor IV leakage, milk intake
• Uneducated mother may be trained to
monitor
• Need to supervised, educated and
monitored.