Neonatal Intensive Care Unit (Nicu)

NEONATAL INTENSIVE CARE UNIT (NICU)

Introduction: NICU is a very specialized unit where critically ill neonatal cared to reduce the neonatal morbidity and mortality. The admission to neonatal special care unit or intensive care unit has some can. If the child is neonatal in the critical condition, the neonate needs the care of interer unit. Mostly from the labour wards, operation theatre and hospital or any other referred they will be send to intensive care unit (ICU)

CRITIRIA FOR ADMISSION IN NICU: Indications for admission to the neonatal intensive care unit are as follow.  Low birth weight(2000gm)  Large babies(more than or equal to 4kg)  Birth asphyxia(apgar score less than or equal to 6)  Meconium aspiration syndrome. If symptomatic/ thick meconium seen in lab  Sever jaundice  Infants of diabetic mother  Neonatal sepsis/meningitis  Neonatal convulsions  Severe congenital malformation/cyanotic congenital heart disease 

O2 therapy/parentral nutrition

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Immediate after surgery/cardiological investigayion

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Cardio respiratory monitoring, if heart Rate and respiratory rate are unstable

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Exchange blood transfusion

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PROM/foul smelling liquor

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Mother of hepatitis ‘B’ carrier

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Injured neonate

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Intensive care needs highly trained personnel including the intensive care specialist,and nurses and techniques. Sophisticated equipment for the monitoring and if vital functions and the availability for continuous laboratory support are in the intensive care.

AIMS/GOALS OF NEONATAL INTENSIVE CARE UNIT The goals of a neonatal intensive care unit are: To improve the condition of the critically ill neonates keeping in mind the survival of neonate so as to reduce the neonatal morbidity and mortality.  To provide continuing inservice training to medicine and nursing personnel in the care of the new born.  To maintain the function of the pulmonary, cardio-vascular, renal and nervous system.  To monitor the heart rate, body temperature, blood pressure, central venous pressure and blood by non-invasive techniques.  To measure the oxygen concentration of the blood is by oxygen analyzers.  To check/observe alarms systems signal, to find out the changes beyond certain fixed limits set on the monitors.  To administer precise amounts of fluids and minute quantities of drugs through I.V. infusion pumps.

PREPARATION OF NICU

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Warm (33-36°C) incubator Adequate light source Resuscitation and treatment trolly stocked. History, continuation sheet treatment and diet sheet, problem list

and flow charts.  Oxygen air and suction apparatus (as available in the unit).  Oxygen line connected to oxygen and air flow meter.  Suction - complete suction unit tubing and various sizes of suction catheters. Ventilation bag and mask of appropriate sizes,  Vital signs monitors.  Specific equipment as indicated by diagnosis. ADMISSION PROCEDURE IN NICU All babies admitted to the neonatal unit . Should have the following data recue carefully within 24 hours of admission (if possible much sooner).

History and examination  Maternal history  Paternal history  Previous obstetric history  Details of present pregnancy  Labour.  Delivery  Apgar score

On admission  Notify the doctor and the nurse in charge.  Resuscitate infant as necessary and maintain warmth.  Check infant identification label.  Quickly examine the infant from head to toe for obvious abnormalities condition permits.  Record Weight, length and head circumference as soon as possible.  Transfer to warm environment as soon as. Possible.

 Cornrnonest observations are :(a) Temperature - Infant normal temperature range 36°C to 37°C - Environment - See natural thermal environment charts. (b) Heart rate. (c) Respiration (d) Colour, (e) Activity. - Explain to parents - Hand over from transferring unit staff

Record keeping: - Birth history : Done in labour ward. History A. Ward history contains - Apgar score and examination of new born infant, sheet. - Neonatal weight and feed sheet, progress chart. B. Compiled history contains - Patient registration form. - Progress 'sheet. - intra uterine growth chart. - 02 flow sheets, fluid balance sheet etc.

LIFETHREATENING CONDITIONS WHICH REQUIRE NICU The following are the life threatening conditions in neonates : - Apnea - Baby with respiratory distress - Birth asphyxia. - Convulsions. - Low birth weight babies (less than 1500 gm requiring intensive care.)

- Neonatal jaundice requiring exchange blood transfusion. - Sepsis and meningitis.

HOW TO MAKE ROUND WITH THE CONSULTANT IN NICU The nurse should have the following recording and reporting while round with consultant. A. Examine and evaluate assigned patients (neonate) each day. B. Record keeping. 1) Progress notes - it should reflect present status of infants and new or ongoing problems 2) Problem list - a coniplete problem list is kept at the front of the progress notes. - This must be kept current, new problems listed and resolved problem also noted. - The number of the problems in the progress chart should be consistent with the problem list. - Only active problem needs to be discussed. The problems should be collected from following areas :a. general status :- Better ? Worse ? No change ? - Pertinent physical findings. b. nutrition ;- Weight, change appropriate ?, inappropriate - Caloric status, source. - Plan of nutrition (feeding) c. Respiratory problems :- Present status, pertinent physical findings, laboratory findings. d. infection :-

- If suspected or present, pertinent findings. - cultural• results. - Plan of therapy e.g., how long antibiotic treatment is planned ? e. Apnea :- Number and severity of apneas/bradycardia. - Treatment (ventilation), - Caffeine or theophyline levels. f. Cardiovascular - Physical findings - Blood pressure - Results of test such as echo, - Treatment plans g. Fluids and electrolytes :- Intake and output, electrolytes - Problems and plan, h. Metabolic :- Glucose, calcium, phosphorusim balance or any problems - Assessment and plan. i. Neurological :- Problems, changes, meditation, plans. - Seizures, medications, blood levels, ECG results. j. Hematological :- Anemia/coagulopathy, neutropenia etc. - Transfusions and plans. k. Hepatic l. Renal problems m. Eyes when examined and results (3) Discharge - Summaries/transfer summaries must be done prior to discharge patient.

INSTRUMENTS AND FACILITIES IN NICU Apex institution or regional perinatal centre must be equipped with centralization supply, suction facilities, incubators/open care system, vital signs and transcutans ventilators and infusion pumps, which are mandatory to provide intensive neonatal care. Physical facilities The neonatologist and the nurse in charge must be involve while planning the unit. The intensive care area should be localized preferably next labour ward and delivery rooms. For economizing the costs it would be preferably to it combined with level II facilities, through both the areas there must have separate adequate staff and a single administrative control. Temperature of the unit: In the case of controlling the environmental temperature, the NICU should not - be located on the top floor, but there must be adequate sunlight for illumination. The unit must have a fair degree or ventilation of fresh air through central air conditioning is a must. The temperature inside the unit should be maintained at 282 4. 2gC while the humidity must be above 50%. In case the unit is responsible for picking up babies, referred from the regional hospitals, it Should be within easy access for the ambulance entrance and should have a separate elevator.

Physical set up:• The NICU can be-irt a single area or it can be in multiple rooms with a capacity Of 2-4: infants each.

Bed strength of NICU One intensive care bed is generally required for -100 deliveries provided the prematurity ratio is around 8% and, hence for a population of one million, 30 intensive care beds would be required for our country. These figures would

require modification based on the growth rate, number of premature deliveries and the toad of high risk population drains since the supportive services to be provided for it would be uneconomical to have a NICU of less than 6-8 bed.

ASPECTS OF NICU: Two main important aspects-in NICU 1) Physical ,set up 2) Administrative set up Categories of NICU: There are three categories: 1) First level (mild) 2) Second level (moderate) 3) Third level (critical).

PHYSICAL SET UP Space between the patients - For the patient care, 100 square feet is required for each baby as it is true for any adult bed. - There should be a gap of about 6 feet between two incubators for adequate circulation and keep the essential lifesaving equipment’s, space needed about 120 square feet. - Each patient station should have 12-16 central voltage stabilized

electric outlets. - 2 to 3 oxygen outlets. - 2 compressed air outlets. - 2 to 3 suction outlets. - Additional power plug point would be required for the portable x-ray

machine close to the patient care area. Water Hand washing

- The unit must have an uninterrupted clean water supply and each patient care area must also have a wash basin with foot or elbow operated tapes. Near wash basin, placing paper towel and receptacle. - The unit should be equipped with laminar air flow system, however alternate air conditioned with multipore filters and fresh air exchange of 12 per hour should be provided. Colour: The walls of the whole unit should be washable and have a white slightly off white colour for better colour appreciation of the neonates. Lighting: The lighting arrangement should -provide uniform, shadow illumination of WO foot candles at the baby's level. in addition, spot illumination should be available for each baby for any procedure. A generator back up is mandatory where there are frequent power fluctuations power failures. Sounds The Acoustic characteristics should be such that the intensity of noise kept well below 75 decibels. The unit should also have an intercom and a direct outside telephone line so that parent of the patient can have an easy acess to the medical personnels in case of emergency. Rooms Apart from patient care area including rooms for isolation and procedure there is need of space for certain essential functions, like a room for scrubbing and gown near the entrance, a side laboratory, mothers room, adequate stores for keep consumable and non-consumable articles. - A room for keeping the x-ray and ultra sound machines. - One or two rooms each would be needed for doctors and nurses on day

night duties. - There is a space available for a biomedical engineer to provide essential period preventive maintenance of the costly equipment. - Additional space will be required for educational activities and storing of database Ventilation: Minimum of six air changes, 2 air changes should be outside filtering the inner air. - Effective air ventilation of nursery is essential to reduce nosocomial infection - The air conditioning ducts must be provided with rnillipore filters- (0.5H) to restrict the passage of microbes. Exaster: Keep away from the baby. Ventilated air: - A simple method to achieve satisfactory ventilation consists of vision of exhaust fan in a reverse direction near the ceiling for input of fresh contarninated air fixation of other exhaust fan in the conventional manner near the r for air exit.

Infection control measures :- Hand Washing Facilities - Each room should have a separate basin facilities, it can be used for children. - Sinks are regularly cleaned by disinfection.

ADMINISTRATIVE SET UP Medical staff: The unit should be headed by a director who is full time neonatologist with special qualification and training in neonatal medicine. - He should be responsible for maintenance of standard of patient care. - Development of the operating budget. - Equipment evaluation and purchase. - Planning and development of education programme. - Evaluation of effectiveness of perinatal care in the area.

- He should devote time to patient care services, research and teaching as well as co-ordinate with level I and level II hospital in the area.

Staff Requirements - Neonatal physician 6-12 patient in the continuing care, inter mediate care and intensive: care areas. - He should be available on 24 hours bases for consultation. - A ratio of one physician in training to every 4-5 patient who requires intensive care ideal round the clock. - Services of other specialists like microbiologist, hematologist, radiologist, and cardiologist and should be available on call. - An anesthetist capable of administering anesthesia to neonate. 15addiatric surgeon and pediatric pathologists should be available.

Nurses Ratio 1) Nurse patient ratio of 1:1 maintained throughout day and night. 2) A ratio of one nurse for two sick babies not requiring ventilator support may be adequate. - For an ideal nurse patient ratio, four trained nurses per intensive care bed are needed. - Additional head nurse who is the overall incharge. - In addition to basic nursing training for level II care, tertiary care require dedicated, committed and trained staff of the highest, qualify, - Their training must include training in handling equipment, use of ventilator and use of mask resuscitations and even endotracheal intubation, arterial sampling and so on.

Experience: - The staff nurse must have a minimum of 3 years work experience in special neonatal care unit in addition to having 3 months hands on training in a intensive neonatal care unit.

Other staff - There is a special need of motivated staff responsible for upkeep and cleanlin of the unit, - Special attention must also be made to train and educate Other persons their role in the patient care. - One sweeper should be available round the clock. - Laboratory technician. - Public health nurse/social workers. - Respiratory therapist. - Biomedical engineer. - Ward clerk can help in keeping track of the stores.

EQUIPMENTS FOR NICU - Equipment and supports should include all that is necessary to resuscitation and intermediate care areas. - Supply should be kept close to the patient station so that nurse does not ha to go away from the neonate unnecessarily and nurses time and skills are u efficiently. - There should be servo controlled incubators and open air system for provide adequate warmth. - Two-third of the bed strength should be of open care system. - When every incubators are being used, heat shields used inside the,incubato would be useful to further decrease the insensible water loses. - Adequate number of infusion pumps for giving fluid (minimum 2 pint parenteral nutrition solutions and drugs should be available.

- Infant ventilators capable of giving the pressure ventilation and various cardiopulmonary monitor.

Equipment required for any neonatal ICU and the quantity required for 6 patient - Resuscitation set -6 - Open care system 4 - incubators -2 - infusion pumps -12 - +ve pressure ventilators -6 - o2 hoods, 02 analyzers -6 - Heart rate apnea monitors without scope-6 - Phototherapy unit-6 - Electronic weighing scale-12 - Pulse oxygmetres -6 - Transcutaneous PO, and PCO2monitors 2-3. - Noninvasive B.P. monitors 4-2. - Invasive RP. monitors 1-2 - ECG monitor without defibrillator -1 - Intracranial pressure monitors -1.

Disposable Articles Required for the NICU IV catheter' IV. sets, bacterial filters, feeding tubes, endotracheal tubes, suction catheters, three way adopters, umbilical arterial and venous catheters, syringes, needles ventilator tubing’s, trocar and canula, pressure transducers for invasive blood pressure

LABORATORY FOR NICU - A micro chemistry laboratory attached to the unit and providing round the clock service, in preferable through under indian conditions, this may not be mandatory. - This should be well-equipped to provide quick and reliable hematocrit, blood glucose and total serum bilirubin. - Facilities for total leukocytes counts and microscopic examination of peripheral blood films for evidence of infection. - Equipment for measure of specific gravity of urine and calcium should be available. - House X-ray machine and an ultrasound machine should be mandatory for modern day neonatal care units.

NURSING STATION

GROWING NURSERY

INFANT VIEWING

Fig: layout map for a single corridor special neonatal intensive care unit for 24 infants

CLEANING AREA

PROCEDURE ROOM

FUMIGATIO N CHAMBER

ISOLATION ROOM

LAB

MINIMAL CARE ROOM

SPECIAL CARE ROOM

SCRUB GOWN

NURSES ROOM

DOCTORS ROOM

CONFERENCE ROOM

FORMULA ROOM

STORE ROOM

X-RAY ROOM

WAITING AREA

DOCUMENTATIONS IN NICU - The unit should have printed problem oriented stationary for maintaining records, admission and discharge slips etc. - Records of all admission should be maintained in a register or on a computer. - The information should be analyzed and discussed at least once a month to improve the effectiveness of the NICU in providing the services.

EDUCATION PROGRAMME AT NICU - There should be continuing medical education programmes for physicians and nurses in the form of lecturers, demonstrations and group discussions. - this should cover important issues like resuscitation, sterilization to be maintained for critically ill babies, putting in arterial catheters, conducting exchange transfusion, maintenance of ventilators etc. - Educational programmes covering the nurses and physician in the community should be developed. - There should be regular meetings with the obstetrician to discuss the perinatal condition and care. - Individual high risk cases. - Education and follow up is necessary.

PAEDIATRIC INTENSIVE CARE UNIT (PICU) Introduction: Pediatric intensive care unit where critically ill children are cared reduce the child mortality. Advances in the understanding of pathophysiology and management of complex life threatening processes, such as respiratory failure, shock,

trauma, and increased intracranial pressure and availability of electronic monitoring and life sustaining procedures such as mechanical ventilators have dramatically improved the level of care that can be offered to seriously ill children. Efforts to deliver this highly sophisticated health care in an organized manner have led to evolution of a new sub specialty intensive care unit. Pediatric intensive care units for the critically ill are found in many children hospitals and the large pediatric departments in general hospitals. In some states, care of the high risk. Children takes place in regional centers equipped for this purpose. Children who are critically ill are transported from local hospitals to these centers for care. Development of separate pediatric intensive care units is only logical in this process, physiological need and disease patterns of young and infants and children are distinct from adults.

CONDITIONS REQUIRE PAEDIATRIC INTENSIVE CARE UNIT PICU is an internal part of the healt4 care services being afforded in a particular up, an assessment of its need should primarily be based, on the existing patient load and type Of illnesses cared for, conditions regarding pediatric intensive care are following Raised intracranial pressure - Acute meningitis - Encephalitis - Intracranial hemorrhage - Encephalopathy - Severe head injury Shock: - Hypovolemic - Septic shock - Severe burns

Acute respiratory failure: - Severe pneumonia - Severe status asthmatics - Severe upper airway obstruction - Diphtheria - Organophosphate poisoning. Acute hepatic failure: - Fulminant viral hepatitis - Poisoning (paracetamol, sodium valporate). - Metabolic disorders (Wilson’s disease). Acute renal failure - Hemolytic uremic syndrome - Acute tubular necrosis. Fulminant metabolic : - Metabolic Acidosis disease. Availability of committed and appropriately trained staff and adequate resources are other important considerations, An institution providing paediatric intensive care should be capable of providing hours accessibility to abroad range of paediatric sub-specialties As these are essential for optimum care.

PHYSICAL SET UP OF PICU 1. Size: - The ideal size is not known as there is no clear standard or method determine its size. It is felt that a multi-specialty hospital requires about 5% of beds for care, out of which 1% should be in ICU, A unit smaller than 6 beds risks in efficiency and units larger than 16 beds may be manage. In other country 'like Britain, there are 6 beds in PICU 2. Location: location of PISU should be such that there should

be no traffic passing the area and transport of patients and from

the Unit for diagnostic and aphetic procedure is minimized. PICU should be located within direct access to paediatric emergency room, children , radiology department and operating and recovery rooms. It is also desirable units to be close to each other. 3. Space :Adequate provision of space is essential for the patient care, area should proximately 20 m2, space available per patient with 3-3.5 rn2 separating each patient. There must be provision for enough floor space around the head end of the bed to

Me necessary personnel and equipment for

resuscitation In addition, space should be provided for nursing and clinical activity, equipment, eidoctors duty room, nurses locker room, conference room, toilets, offices of nursing rvision and consultant physicians, laboratory, storage area for supplies, linen and entbelongings and a clean and separate work room. An intermediate care area to allow for continuing care patients and waiting room hinnies should also be provided immediately adjacent to the unit. The total area needed is about 3 times the size needed for beds alone. 4. Design/lay out - In the design of patient care area is a provision for adequacy of observation and easy access to the patients. - A central station for observation, record keeping and charting, preparation o medications and other functions are necessary. - The patient care area may have an open ward design or multiple enclosed room design (each room serving 1-2 patient). Both of their designs have advantages. In our set up with shortage of nurses, it is better to adopt for an open ward design. - For a 6-8 bed unit, a big room serving 4-6 patients and two smaller rooms (25- 30 m2) serving 1-2 patients are adequate.

- These rooms are required for isolation and dialysis. An area for intermediate care may be designed within PICU, to look after patients who require intensive tribnitoring but are not on life supporting therapeutic intervention. - Each room should have adequate shelf space (cabinet) at growing and hand washing facility presence of glass covered windows is helpful in providing adequate light and for patients to maintain

day

light. Attractive colour

designs - on walls and ceiling may be helpful. - Each must be provided, with appropriate electrical sockets, illumination, suction, air and oxygen outlets. - Appropriate air conditioning heating, ventilation plumbing and safety must he observed. REQUIREMENT FOR A PICU I.

Electrical requirement

A. Electrical outlets 1648 per bed. - For spot light - Call bell alarms - Monitoring equipments - Vacuum, exhaust fan. - Air conditioning - Television. B. Special outlet - For ventilator - Portable x-ray machines. C. Earthling all the outlet : Must be properly earthed and have earthling circu breakers to protect against electrocution. D. Voltage stabilization for all the inlets, voltage fluctuations may damage sensitive monitoring equipment.

II.

Illumination (lighting) a) Back ground lighting - Low intensity lighting below the patient's bed level keep a minimum illumination at all times. b) General and additional illumination - During active patient care for procedure needing extra brightness additional lights are needed. Full size florescent tube light fixed in ceilings, 4 per patients, 2 for general and 2 for additional illumination is minim requirement. c) One spot light to give high level illumination for procedures, examination treatment. This may be fixed in ceiling or may be a portable one.

III.

Compressed Air :- One outlet per bed, provision of double filtered airat a pressure of 50-55 psi.

IV.

Oxygen outlets :- Two per bed, supplied from a central source should have dis colour identification, alarm for low pressure and shut off value between the main the outlet to close the flow if needed.

V.

Suction vacuum :- Two per bed, minimum a third outlet may be desirable. pressure should be adjustable for patient's needs such as nasogastric suction, tracheostomies tube drainage, endotracheal suction etc.

VI.

Physical environment - Temperature adjustment between 25°-20°C. - Relative humidity 30-60% - Positive air pressure inside as compared to adjacent area - Air conditioning system must allow for the above requirement for air exchange and filtration. - Air exchanges at least 12 tithes per day.

STAFFING PATTERN OF PICU 1. Medical director/consultant in-charge. The medical director or consultant in- Age should have special training and experience in the care of critically ill children ding advance skill in monitoring and life support techniques. He/she must be available full time for clinical, administrative and educational ties of the unit. These activities include following: - Supervision - Regular care - Resuscitation - Life support measures to all patients - Quality control and appropriateness of care. - Co-ordination of multiple subspecialty services. - Maintenance - Condemnation and replacement of equipment’s. -

Organization of educational and research activities.

- Staff development and improvement on standard of care. - Collection of statistical data necessary for evaluation of the unit effectiveness. - Implementation of policies and procedures. It is desirable that the PICU consultant maintains regular participation in continuing programme in the field.

2. House Staff (Residents) Twenty hours presence of a qualified doctor in the PICU is necessary. The doctor should be exclusively designated for the PICU and should e covering other areas such as the emergency department or other wards mutinously.

He must be trained in cardio-pulmonary resuscitation and intubations.

3. Nurses : Nurses are the most important staff in any PICU for actual delivery of care. It is essential t6 have high quality, specially trained nurses to provide 24 hours coverage. - A kit containing education programme for nurses must be developed within the unit. - A common problem in our hospital is frequent change of nursing staff that should be avoided. - The in charge of PICU must take up the issues with the concerned administrative authority to ensure undisturbed availability of trained and experienced nurses. - The ideal nurse patient ratio is 1:1, the minimum is one nurse per three patients in the unit at all times. - The nurse should have basic understanding of commonly emergency clinical, condition and should be trained in Resuscitation techniques, electronic monitoring and use of PICU equipment.

The nurse should be able to recognize and interpret changes in patient monitoring date, and results of common laboratory samples, perform venipuncture’s to obtain blood - Establish an IV lines. - Administer drugs and parental fluids. - It is helpful to have protocol for nursing care.

4. Respiratory therapists :A person trained in respiratory, care with knowledge ventilation equipment and basic life support has become an important part of PICU team in the developed countries. 5. Other staff - A biomedical and a laboratory technician - A unit of clerk to handle patient and administrative paper work - Physiotherapist - Nutritionist - A social worker

EQUIPMENT NEEDED FOR PICU Equipment required for any pediatric intensive care unit and quantity required 6 patient beds:- Open care system -4 - Resuscitation set -6 - Positive pressure ventilators -6 - Infusion pump 5-12 - Electronic weighing scale 1-2 - 0, hood, 02 Analysis -6 - Heart rate apnea monitor with scope-6 - Transcutaneous P02 and PCO2 monitors-2-3. Pulse oximeter-6 - Intracranial pressure monitors-1 - ECG monitor without defibrillator4 - Invasive B.P. monitors -1-2. - Noninvasive B.P. monitors -1-2.

Disposable articles :- Required disposable articles for PICU are Intravenous catheter - Intravenous sets - Bacterial filters. - Feeding tubes - Endotracheal tubes - Suction catheters - Three way4doptors - umbilical arterial and venous catheters. - syringes - needles - ventilator tubings, - trocar and canula - pressure transducers for invasive blood pressure.

SERVICES THAT SHOULD BE AVAILABLE IN PICU A. monitoring services 1. cardiac and haemodynamic devices  heart rate and rhythm ECG  blood pressure  CVP and pulmonary artery pressure  Cardiac output. 2. Respiratory functions  Respiratory rate.  Oxygen saturation of Hb(Sa02).  -Blood gases  Inspired oxygen and end tidal CO,.

 Monitoring for ventilated children

3. Temperature 4. Cerebral functions  Intracranial pressure  electroencephalogram  cerebral blood flow. B. Therapeutic or Diagnostic Services  Emergency resuscitation  respiratory support.  cardiac support  Defibrillation;

Temporary cardiac pacing. 5. Infusion pumps and pressure infusion devices. 6. dialysis peritoneal/ Hemodialysis.  Supportive services for P I C U      

Radio diagnosis and imaging facility. 24 hours coverage for portable x-rays of chest, abdomen Ultra sound, CT. scan. ECHO Angiography, lung scan.

2. Laboratory services:-. 24 hours availability  Hematocrit, Hb, blood units.  Blood glucose urea and electrolytes  Prothrombine time, platelet counts.  Body fluid analysis (C.S.F. urinalysis)  Arterial blood gases,  Microbiology.  Blood bio-chemistry  Toxicology and drug levels measurements.

3. Centralized 02, supply, compressed air and suction facility. 4. Blood Bank services. 5. Physiotherapy and occupational therapy services. 6. Transport services: An ambulance team with a resident trained in circulation and stabilization of critically ill patient and resuscitation, equipment, drugs and b monitor equipment’s.

(D) Auxiliary services  House keeping related to cleaning, HP, electrician, air conditioner line cleaning, CSSD,  Communication with PICU and outside through telephone, paging and intercogn system.  Computerized record keeping.  Social services

EQUIPMENT MAINTENANCE AND CARE Services of bio-medical engineer/technician should be available for regular frequent servicing of equipment’s to keep it in good working order.

EDUCATIONAL PROGRAMMES AT PICU  In PICU, there should be continuing education programme for physician and nurses in the form of lectures, demonstrations, and group discussions.  The education programme should cover, important issues like resuscitate sterilization of critically ill children’s, putting in an arterial catheters, conducting exchange transfusion, maintenance of ventilators etc.  Educational programmes covering the nurses and physician in the communication should be developed

 There should be regular meeting with the pediatricians and obstetrician to discuss about individual high risk child  Educational programme should be followed regularly.

PROCEDURE ROOM

GROWING NURSERY

WAITING AREA

ROOM-1

ROOM-2

ROOM-3

CLEANING AREA

LAB

ROOM-4

ROOM-5

ROOM-6

FUMIGATION CHAMBER

NURSES ROOM

NURSING STATION SCRUB GOWN

FORMULA ROOM

DOCTORS ROOM

CONFERENCE ROOM STORE ROOM

X-RAY ROOM

Fig: layout map of a 6-room pediatric intensive care unit