ICU and You · Mind Map Series · Number 31
Essentials of neonatal intensive care
Written for regional practice — the newborn you will actually meet
We are not a neonatal intensive care unit, and this map does not pretend otherwise.
What we are is the department that receives the precipitate delivery in the resuscitation bay at two in the morning, the baby brought back at eleven days old who has gone grey on the bedroom floor, and the birth that went wrong in a hospital without a paediatric registrar rostered overnight. Those babies are stabilised by whoever is present. Then a retrieval team arrives and takes over. The interval in between is short, it is entirely ours, and almost everything that determines the outcome happens inside it.
So this is not a NICU curriculum. There is nothing here about surfactant trials or retinopathy screening. It is the physiology that makes a newborn behave unlike any patient you routinely manage, the resuscitation that is respiratory rather than cardiac, the golden hour, the handful of diagnoses that kill a well-looking baby within hours, and what the retrieval service needs from you when you telephone.
ICU AND YOU · MIND MAP SERIES · No. 31 Essentials of neonatal intensive care BEFORE ANYTHING ELSE Not a small adult HEAT LEAVES FAST Large surface area, thin skin, no shivering, wet at birth Radiation, evaporation, conduction, convection — all four Cold means acidosis, hypoglycaemia, apnoea, coagulopathy Target 36.5–37.5 °C. Every degree lost costs you something A CIRCULATION MID-CHANGE Pulmonary vascular resistance is falling, hour by hour The duct and foramen ovale may still be open — or closing Hypoxia and acidosis reopen the fetal pattern (PPHN) Cardiac output is rate-dependent: bradycardia is the arrest NO RESERVE Small glycogen store — hypoglycaemia within hours Low FRC, high oxygen consumption — desaturation is fast Compliant chest wall, horizontal ribs, diaphragm-dependent Immune naivety: sepsis presents as 'just not right' THE AIRWAY IS DIFFERENT Obligate nasal breather — choanal atresia, or just secretions Large occiput flexes the neck: a shoulder roll, neutral position Short trachea — right main bronchus intubation is easy to do Large tongue, anterior larynx, floppy epiglottis MINUTE ZERO The first breaths IT IS ALMOST ALWAYS RESPIRATORY Newborn arrest is hypoxic, not cardiac — inflate the lungs Dry, stimulate, warm, position; assess breathing and heart rate No breathing or heart rate under 100: start positive pressure Inflation pressure ~30 cmH₂O at term, 20–25 preterm, PEEP 5 Rate 40–60 per minute. The chest should move, and the rate rise HEART RATE IS THE SIGNAL Rising heart rate is the single best sign it is working Not rising? MR SOPA — Mask, Reposition, Suction, Open mouth, Pressure up, Airway alternative Under 60 despite effective ventilation: compressions 3:1, 120 events a minute, two thumbs encircling OXYGEN, MEASURED Start in air at term; 21–30% under 32 weeks Probe on the right hand — preductal — and titrate to target Hyperoxia is an injury, not a safety margin Delayed cord clamping at least 60 seconds if vigorous WHEN IT IS STILL NOT ENOUGH Adrenaline 10–30 µg/kg IV (0.1–0.3 mL/kg of 1:10 000) Umbilical venous catheter: 4–5 cm, until blood draws freely Volume only if blood loss suspected — 10 mL/kg, not 20 Think pneumothorax, hypovolaemia, and the undiagnosed lesion PREDUCTAL SATURATION TARGETS — THE NUMBERS THAT STOP OVER-OXYGENATION 1 min 60–70% · 2 min 65–85% · 3 min 70–90% · 4 min 75–90% · 5 min 80–90% · 10 min 85–90% A pink baby at two minutes of age has been given too much oxygen. Climb the ladder; do not jump to the top of it. THE FIRST SIXTY MINUTES The golden hour — S.T.A.B.L.E. SUGAR, TEMPERATURE, AIRWAY Sugar: keep above 2.6 mmol/L. 2 mL/kg of 10% dextrose, then an infusion — check again in thirty minutes Temperature: hat, warmer, plastic wrap under 32 weeks, room at 23–25 °C, and the doors shut Airway: secure it before the retrieval team arrives, not during BLOOD PRESSURE, LABS, EMOTION Blood pressure: perfusion, lactate and capillary refill first; mean arterial pressure roughly the gestational age in weeks Labs: gas, glucose, lactate, cultures, FBC, and a group Emotional support: the parents are also your patients, and this is the hour they will remember for the rest of their lives COOLING — DECIDE EARLY OR NOT AT ALL Moderate to severe hypoxic-ischaemic encephalopathy, 35 weeks or more, within six hours of birth: therapeutic hypothermia to 33–34 °C. The window is short and it does not reopen. If the birth was difficult and the baby is encephalopathic, telephone the retrieval service before you are certain — passive cooling begins with turning the warmer off, and that decision cannot be made retrospectively. DAY TWO TO DAY FOURTEEN The baby who comes back THE DUCT CLOSING Sudden collapse in a baby who was discharged home well Absent or weak femorals; pre- and post-ductal saturation gap Prostaglandin E1 from 10 ng/kg/min — but a grey baby whose duct has already closed may need 50 or more, titrated to response Apnoea is frequent: have the airway ready before you start Oxygen is not always the friend here: it closes the duct SEPSIS, AND ITS DISGUISES Group B streptococcus, E. coli, Listeria; HSV if seizures or vesicles or maternal history — add aciclovir Signs are non-specific: poor feeding, temperature instability, tachypnoea, mottling, 'not right' according to the mother Benzylpenicillin and gentamicin; take the cultures, do not wait METABOLIC AND ENDOCRINE Inborn errors: encephalopathy, acidosis, ammonia above 100 Stop feeds, give 10% dextrose, send ammonia early Congenital adrenal hyperplasia: hyponatraemia, hyperkalaemia, shock in the second week, sometimes ambiguous genitalia Hydrocortisone before the diagnosis is confirmed if shocked THE ONE NOBODY WANTS TO NAME Abusive head trauma presents as apnoea, seizures, or collapse No history of trauma is offered, because none will be Retinal haemorrhage, bruising in a baby who cannot yet roll Examine fully, photograph, document, escalate — and do not let discomfort make the diagnosis disappear LISTEN TO THE MOTHER In almost every retrospective review of a missed neonatal deterioration, the parent said something before the observations changed. "He is not feeding like he was." "She has gone quiet." That is data. Treat it as an observation, and chart it as one. BEFORE THE TEAM ARRIVES Stabilise, then hand over WHAT THE RETRIEVAL SERVICE NEEDS Weight — everything downstream is calculated from it Gestation, birth history, Apgars, what you have already given Gas, glucose, and the trend rather than a single number NETS NSW 1300 36 2500 — call early, call uncertain, call anyway THE NUMBERS TO HAVE WRITTEN DOWN ETT: 2.5 under 1 kg · 3.0 at 1–2 kg · 3.5 at 2–3 kg · 3.5–4.0 above Depth at the lip in centimetres = weight in kg + 6 Fluid bolus 10 mL/kg · dextrose 2 mL/kg of 10% Maintenance day one 60 mL/kg/day · blood 10–20 mL/kg THROUGHOUT The family in the corridor You will meet a critically unwell newborn rarely, and you will remember every one of them. So will the parents — with a clarity that does not fade, and in language they will repeat for decades. Name the baby. Say what you are doing and why. Let someone stay in the room if they want to. None of that competes with the resuscitation; it is part of it. The clinical work has a retrieval team coming to finish it. The other work does not. Warm, pink, sweet, and someone holding the parents. Everything else is detail — but the detail is what this map is for.
On a phone: turn it sideways, or scroll the map across. Pinch to zoom on any section.
Your challenge this week
One sentence, back to me: what would you want within arm's reach if a newborn arrived in your resuscitation bay in the next ten minutes? Equipment, a phone number, a chart on the wall, a person — anything at all.
I am asking because the answers tend to be specific, practical and immediately actionable, and because most of them describe something we could simply go and put there.
And an optional reflection: have you been part of a neonatal resuscitation outside a maternity unit? What did you wish you had known beforehand? Those are the answers that teach.
Send your response
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