STANDARD RADIANT WARMER PROTOCOL

                      

THE EFFECTIVENESS OF STANDARD RADIANT WARMER PROTOCOL ON SELECTED PARAMETERS AMONG LOW BIRTH WEIGHT BABIES IN NICU

Key: Radiant warmer, Low birth weight babies, Neonatal intensive care unit (NICU), Parameters, and Protocol

Introduction:

Overhead Radiant Warmers is valuable forms of treatment which are used frequently in the care of low-birth-weight infants. It is powerful and efficient source of heat serving to warm the cold-stressed infant acutely and to provide uninterrupted maintenance of body temperature despite a multiplicity of nursing, medical, and surgical procedures required to care for the critically ill premature newborn in today's intensive care nursery. The clinician caring for the infant is faced with the difficult problem of fluid and electrolyte balance, which requires vigilant monitoring of all parameters of fluid homeostasis. Compounding these difficulties, other portions of the electromagnetic spectrum (for example, phototherapy) may affect an infant's fluid metabolism by mechanisms that are not well understood. The heat output of these devices is usually regulated by servo control to keep the skin temperature constant at a site on the abdomen where a thermostat probe is attached. The major advantage of the radiant warmer is the easy access it provides to critically-ill infants without disturbing the thermal environment. Its major disadvantage is the increase in insensible water loss produced by the radiant warmer. Most infants can be safely and adequately cared for in either incubator or radiant warmer bed. It has shown to increase insensible water loss in term and premature infants.  The purpose of this study is to determine whether the implementation of standard warmer protocol causes a greater influence in maintenance of normal physical parameter of the Low Birth weight babies.

Title: A experimental study to assess the effectiveness of standard radiant warmer protocol on selected parameters among low birth weight babies in NICU, Tayma General Hospital, Tabuk region, Saudi Arabia.

Objective of the study:

·         To develop and implement standard warmer protocol for low birth weight babies in NICU

·         To assess the physiological parameter before implementing warmer protocol for low birth weight babies in NICU

·         To determine the effectiveness of standard warmer protocol on the selected parameters among low birth weight babies in NICU.

·         To associate between the post test scores of selected parameters with selected demographic variables among low birth weight babies in NICU.

Method:

 A quantitative approach with quasi experimental research design one group pre  - post test only design was adopted for this study. The population of the study is low birth weight babies weighing between 1000 to 2500g and accessible population were 60 low birth weight babies who was admitted in Tayma general hospital during the study period. Non probability convenient sampling technique was adopted. After the extensive review of literatures the standard protocol where developed, and implemented (table -1). Tools consist of 2 sections. Section I was  demographic variables such as age in days, sex, apgar score at birth weight, gestational week of the baby  and mode of delivery, and section II consist of  physiological parameters such as temperature, heart rate, respiration, oxygen saturation, activity, appearance/colour , fluid status, feeding capacity/24hrs were monitored (table-2). A total score of 8 marks were scored as follows: physiological parameter Maintained within normal limit- 6 to 8, moderately maintained – 3 to 5, not maintained within normal limit – 0 to 2.  The data were collected over 3 months by Bio-physiological method (in-vivo). Descriptive and inferential statistics were used to analyse the date.

Standard warmer protocol (Table -1)

S. No

Warmer protocol

1. 2. 3. 4. 5. 6. 7. 8. 9. 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

Perform hand hygiene before initiating new contact with infant and after each contact with the infant. Place the infant under pre warmed radiant warmer. Keep the baby under warmer in servo control mode. .Maintain thermoregulation according to the weight of the baby. <1.0 kg     -   36.9 degree centigrade 1.0-2.0      -   36.7 1.5-2.0      -   36.5 2.0-2.5      -   36.3 Number of feeds given per 24 hours are      6-10       -   at 1st week,      6-8       -   at 2week-1 month.  Place servo temperature probe to the area of trunk or abdomen, and avoid on bony prominences. Verify probe temperature with electronic thermometer every 2-4 hours. Change temperature probe site every 12-24 hours. Adjust warmer temperature 1 – 1.5°C higher than infant’s temperature, or assure/place in NTE (Not To Exceed) range, or use skin control mode. Assess if warmer temperature is within NTE range.  If higher, decrease to appropriate range by reducing isolette temperature by 1-1.5°C. A Check the temperature of the baby every 30 min under axilla. Maintain the abdominal temperature at the rate of 36.5 to 37degree centigrade Does not cover the baby while the baby under warmer. Ensure heat emitted to the baby does not exceed to more than 45degree centigrade Monitor the vital signs of the baby every 1 hour. Obtain the daily weight. Monitor the fluid status of the baby Maintain adequate hydration Observe for signs of redness or irritation. Place the baby in a comfortable position and turn every 1 hour. Maintain distance between mattress and bottom surface is within 850mm. Maintain dry linens and diapers Place the warmer in draft free area and away from cold wall Minimize the number of entries into the isolate. Apply sterile liquid paraffin or non irritating oil on the skin to reduce evaporative losses from skin. Use a warmed, humidified environment for increased insensible water loss. Postpone weaning for 24 hours if axillary temperature is less than 36.4°C at two consecutive readings. Notify physician/practitioner of temperature instability of infant, extreme fluctuation of isolette temperature or out of not to exceed range if using skin control, hypo or hyperthermia, or inadequate growth pattern.

Physiological check list for assessing parameters of LBW babies under warmer (table-2)

S.NO	CRITERIA	YE (score-  1)	NO (score-0)
1. 2. 3. 4. 5. 6. 7. 8.	Temperature Heart rate Respiration Oxygen saturation Activity Appearance / colour Fluid status Feeding capacity	36.5-37 o C 120-150 beats/min 30-60 breaths/min 95-100% Normal activity     Pink Moist/ Elastic Normal	<36.5 or >37o C <100 or >150 beats/min <30 or >60 breaths/min < 95% Decreased Activity Pale, blue. Dry and scaly Decreased

Result:

It was found that not even single LBW babies were well maintained normal physiological parameter without warmer, were as 23 % of LBW babies were able to maintain moderately, the mean pre test score was 3.7 with SD of 0.257 and majority (77%) of LBW babies were unable to maintain physiological parameter, the mean pre test score was 1.3 with SD of 0.49 and it was found that after implementation of an standard warmer protocol, around  42(70%) low birth weight babies were able to maintain normal physiological parameter, the  mean post test score was 6.95 with SD of 0.75, were as 18 (30%) Low birth weight babies were able to maintain physiological parameter slightly less than normal limit, the mean pre test score was 4.5 with SD of 0.60. And it was found that no one was poor in maintaining physiological parameter within normal limit. (Refer Table-3)

Frequency and percentage distribution of Pre and Post test scores of physiological parameters of babies (Table-3)

S.No	Interpretation and Score	Pre test Frequency	Percentage	Post Test Frequency	Percentage
1.	Thermoregulation and physiological parameter Maintained  [ 6-8]	0	0%	42	70 %
2.	Thermoregulation and physiological parameter Moderately  maintained   [3-5]	14	23%	18	30 %
3.	Not  maintained   [0-2]	46	77%	0	0 %

It also found that there is a significant association exit between age, Apgar score at birth, weight of the baby, and gestational week of the baby. There is no association exist between sex and mode of delivery with maintenance of physiological variables.   Association was tested with chi square test, with 5% level of significant.

Conclusion:  It was found that standard warmer protocol is effective in maintaining normal physiological parameter of LBW babies in NICU. The results indicate benefits for the use of the standard warmer protocol for LBW babies. Insensible fluid loss is more through radiant warmer, so fluid requirements were higher in the radiant warmer

 Reference:

1.      Maayan-Metzger,  Yosipovitch, Hadad  and  Sirota  ^‘Effect of Radiant Warmer on Transepidermal Water Loss (TEWL) and Skin Hydration in Preterm Infants”,  Journal of Perinatology (2004) 24, 372–375. \

2.      Kanya Mukhopadyay et al., (2005), post discharge feeding practices in very Low Birth Weight Infants, “Journal of neonatology”, volume. 19. pp 46-49

3.      Michael  and Geoff  “Admission temperatures following radiant warmer or incubator transport for preterm infants <28 weeks: a randomised study”, Arch Dis Child Fetal Neonatal Ed. 2007 Jul; 92(4): F295–F297.

4.      Mukesh Gupat et. al (2007) Kangaroo Mother Care in LBW infants “Indian Journal of Pediatrics”. Volume.74. pp 88-89

5.      M. Mona war Hosain et. al., (2005), Factors associated with Low Birth Weight “Journal pediatrics”, Volume.52. p 59.

6.      Denoraj K. Steward et. al., (2002), Growth patterns of Extremely Low birth weight Hospitalized pre-term Infants, JOGNN Pediatric journal.’’

7.      Edward “servocontrol: incubator and radiant warmer” univeristy of lowa children’s hospital, Iowa City, IA 52242