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

stem cell therapy

                                                                              S.K.MOHANASUNDHARI  M.SC PEDIATRIC NURSING

AIIMS RISHIKESH

COLLEGE OF NURSING

UTTARAKANDAM

STEM CELL THERAPY

Introduction:

During 1990 the concept of stem cell therapy was introduced. Blood stem cells were the first stem cells to be identified. Their discovery in the 1960s marked the beginning of stem cell research. Stem cell therapy is likely to have the greatest success with diseases that are caused by single gene defects. Only genetic diseases caused by errors in a single recessive gene are being considered for treatment, since the insertion of a normal dominant gene should override the effect of the abnormal gene.

Definition of stem cell therapy

Stem cell therapy is a set of experimental techniques which involves introducing a healthy copy of the new gene for correcting defective gene or inactivating the improperly functioning mutated gene or replacing a mutated gene that are responsible for causing diseases.

Purposes of stem cell therapy:

·         Stem cell therapy for correcting defecting gene,

·         Stem cell therapy Inactivating or knocking out improperly functioning mutated gene

·         Stem cell therapy replacing a improperly functioning mutated gene (most common type)

The goal of stem cell therapy

·         to replace unhealthy cells with healthy ones and to do so efficiently,

·         allowing proper cell functioning in the human body

Diseases on which research studies are undertaken for evaluation of stem cell therapy includes:

Haemophilia, leukemia, aplastic anaemia, burns(new skin cell grafting) Parkinson's disease,  Amyotrophic lateral sclerosis, Alzheimer, Stroke, Spinal Cord Injury, retinal diseases, Multiple Sclerosis, Radiation Induced Intestinal Injury, Inflammatory Bowel Disease, Liver Disease, Duchenne Muscular Dystrophy, Diabetes, Heart Disease, Severe combined immune deficiencies Bone Disease, Renal Disease, Chronic Wounds, Graft-Versus-Host Disease, Sepsis and Respiratory diseases.

Types of Stem Cell Therapy

There are a number of stem cell therapies that are currently being investigated or used to treat a range of diseases. These are:

1)      Germ line gene therapy

Germ line gene therapy involves the modification of germ cells (gametes) that will pass the change on to the next generation. Gives permanent changes and eliminating some diseases from a particular family with germ line therapy genes could be corrected in the egg or the sperm that is being used to conceive. The child that results would be spared certain genetic problems that might otherwise have occurred

Steps of procedure:

1.      Remove the man’s sperm producing cells that contain a defective gene.

2.      A healthy gene is added to each cell to replace the defective gene

3.      The cells are put into mouse testes

4.      They mature inside the mouse and start producing healthy human sperms

5.      Those sperms once tested are used to fertilize women’s eggs in a laboratory dish.

6.      The resulting embryos are placed in a women’s womb.

7.      She gives birth to a child whose genes are free from the father’s disease.

2)      Somatic gene therapy

Somatic cell gene therapy changes/fixes/replaces genes in just one person. The targeted cells are the only ones affected; the changes are not passed on to that person's offspring. Short lived because the cells of the most tissues ultimately die and are replaced by new cells.

 It has two types includes invivo (genes are changed in the cells when cells are still inside the body), exvivo (cells are modified outside the body and then transplanted back again),

Steps of procedure for exvivo:

1.      Cells are removed from the patient

2.      In the laboratory a virus is altered so that it can’t reproduce.

3.      A gene is inserted in to the virus

4.      The altered virus is mixed with cells from the patient

5.      The cells from the patient are genetically altered.

6.      The altered cells is injected into the patient

7.      The genetically altered cells produce the desired protein or hormones.  

3)      Adult stem cell transplants using bone marrow stem cells.

A bone marrow stem cell transplant uses stem cells derived from bone marrow to provide a fresh and healthy source of new blood cells which in turn, allows for a patient to receive higher doses of chemotherapy to treat certain types of cancer such as leukaemia. The bone marrow stem cells may be allogeneic and therefore donated by a family member of stranger, or they may be autologous, which utilizes a patient's own stem cells.

4)      Adult stem cell transplants using peripheral stem cells  (Now most commonly used)

A peripheral blood stem cell harvest is a technique used to restore a person's blood cells after they have been damaged by chemotherapy or radiation.  Peripheral stem cell may be Autologous or Allogeneic or Syngeneic: a patient receives stem cells from an identical twin.

Steps of procedure:

1.      One week before a donor receives drugs to increase the number of stem cells in his or her bloodstream

2.      The donor's blood is removed,

3.      it flows through a machine that removes the stem cells.

4.      The blood then flows back to the donor

5.      The extracted stem cells are then frozen until they are transferred to the recipient.

6.      After the stem cells are transplanted into the patient, they move from the bloodstream to the bone marrow.

7.      It is here that they produce healthy white blood cells, red blood cells and platelets. (Engraftment)

8.      Engraftment generally occurs over the two to four weeks following stem cell transplantation.

5)      Stem cell transplants using umbilical cord blood

After a baby is born, cord blood is left in the umbilical cord and placenta. It is relatively easy to collect, with no risk to the mother or baby. It contains haematopoietic (blood) stem cells: rare cells normally found in the bone marrow. Is used to treat children with leukaemia, or genetic blood diseases like Fanconi anaemia. The cord blood is transplanted into the patient, where the HSCs can make new, healthy blood cells to replace those damaged by the patient’s disease or by a medical treatment such as chemotherapy for cancer.

6)      Therapeutic cloning:

Therapeutic cloning is another phrase for a procedure known as somatic cell nuclear transfer. A major benefit of therapeutic cloning is that the cells removed are pluripotent. Pluripotent Cells can give rise to all cells in the body with the exception of the embryo. This means that pluripotent cells can potentially treat diseases in any body organ or tissue by replacing damaged and dysfunctional cells. Another distinct advantage to this type of therapy is that the risk of immunological rejection is alleviated because the patient's own genetic material is used

Steps of procedure:

1.      A scientist extracts the nucleus from an egg

2.      The nucleus holds the genetic material for a human or laboratory animal

3.      The scientist then takes a somatic cell from a patient, which is any body cell other than an egg or sperm, and also extract the nucleus from this cell

4.      The nucleus that is extracted from the somatic cell in the patient is then inserted into the egg, which had its nucleus previously removed

5.      In a very basic sense, it's a procedure of substitution. The egg now contains the patient's genetic material, or instructions

6.      It is stimulated to divide and shortly thereafter forms a cluster of cells known as a blastocyst

7.      This blastocyst has both an outer and inner layer of cells and it is the inner layer, called the inner cell mass that is rich in stem cells.

8.      The cells in the inner cell mass are isolated and then utilised to create embryonic stem cell lines.

9.      Which are infused into the patient where they are ideally integrated into the tissues, imparting structure and function as needed.

A tool used to deliver a genetic material into the cells includes:

Viral method (transduction)

Non viral method

1.      Adenovirus ·         Infects many cell types ·         Does not integrate into host genome and can be lost. 2.      Retrovirus ·         Integrates into host genome and cannot be lost ·         Integrates into host genome and can cause cancer 3.      Adeno-Associated Virus (AAV) ·         Integrates into host genome and cannot be lost ·         Difficult to work with. 4.      Herpes Simplex Virus (HSV) ·         DNA stays in nucleus without integrating into host genome. ·         Only infects cells of the nervous system.

1.      Physical method (carrier free gene deliver) Employes a physical force that permits the cell  membrane and feacilitates intracellular gene transfer ·         Needle injection ·         Electroporation ·         gene gun ·         Ultrasound ·         hydrodynamic delivery 2.      Chemical method: (synthetic vector based gene delivery) DNA must be protected from damage and its entry into the cell by covering the plasmid DNA with lipid. ·          Lipoplexes ·         Poly plexes

To design and carry out a stem cell therapy treatment, a researcher must:

1. Identify the gene(s) responsible for the disorder.
2. Make copies of the normal gene.
3. Insert the copies into vectors.
4. “Infect” the affected cells with the vectors.
5. Activate the gene so that transcription and translation take place.

Challenges of Stem Cell Therapy

1.      Identifying stem cells within an actual tissue culture

2.      Isolating specific cell types from tissue culture

3.      Finding appropriate solutions to trigger these cells to grow into the desired cell types.

4.      Acceptance of implanted stem cell with native body cell of the patient. For example, if cardiac cells are implanted, they must be able to beat in sync with the patient's own heart cells. 

5.      Triggering of an immune reaction that result in rejection of the new cells.

6.      Finding a balance between directing cell growth into specialized tissues that can replace damaged ones, and also ensuring that cells don't excessively grow and become cancer cells.

Risk of stem cell therapy

• Damage to organs or blood vessels
• Graft versus host disease
• Death
• Risk of abortion if prenatal test regarding baby with genetic diseases.

Stem cell Therapy Disappointments

• In 1999 a boy died due to an immune response to an adenovirus gene therapy vector.
• Four children have developed cancer due to a retrovirus gene therapy vector
• The cost is very high

Reference:

1.      Larijani, Esfahan, Amine, Nikbin, Alimoghaddam et all. , “A Stem cell therapy in treatment of different diseases’ Acta Med Iran. 2012; 50(2):79-96.

2.      Yann barrandon, what diseases and conditions can be treated with stem cells? Euro stem cell organization. http://www.eurostemcell.org

3.              Jo Johnson, “MS and Stem Cells”explore stew cell - Updated: 12 May 2014,  

4.      Rajeev gupta, Blood stem cells: the pioneers of stem cell research. Cord blood stem cells: current uses and future challenges last updated: 19 Dec 2012,

5.              Kathi, Hanna,’ advancing human health through genomics research” national human genome research institute’ march 2006.  

6.               Murnaghan Peripheral “Blood Stem Cell Harvest” Explore Stem Cell.  - Updated: 22 July 2014,

7.              Murnaghan” Therapeutic Cloning”  “” Explore Stem Cell.  - Updated: 24 may 2015,

8.              Murnaghan” Bone Marrow Stem Cell Harvest”  “” Explore Stem Cell.  - Updated: 13 may 2015.