(Received March 22; revision accepted for publication July 9, 1968.)
This work was supported by grants from the Swedish Medical ReSearcll Council and the Association for the Aid of Crippled Children, New York.
R.C. is Bursar, Council for Scientific and Industrial Research, Pretoria, South Africa. TO. is SUp1)Orted
by Swedish Council for Applied Research.
ADDRESS: (R.C.) Department of Child Health, University of Cape Town, Medical School,
Observa-tory, Cape, South Africa.
INTENSIVE
CARE
Roy Cooke, M.B.Ch.B., Harry Larsson, M.D., Torsten Olsson, M.Sc., Lars Victorin, M.D., and Petter Karlberg, M.D.
Department of Pediatrics, Unieersity of Goteborg, and Chalmers Institute of Technology,
Goteborg, Sweden
ABSTRACT. Recent advances in neonatal intensive
care have introduced many practical difficulties. A multiple-purpose crib and incubator combination is
described which facilitates the introduction (with
fluoroscopy) and aftercare of umbilical catheters. A method for fixation of respirator tubing during
in-termittent positive pressure ventilation to allow
regular postural drainage and to avoid accidental
extubation of the endotracheal tube has been
de-veloped. Radiography, in three planes, is possible
with less risk to tile infant and surrounding
equip-ment. Intensive care equipment can be
incorpo-rated into this incubator-crib combination with the
maintenance of good observation and an
unob-structed access to the infant. Pediatrics, 42:928,
1968, NEWBORN INFANT, INTENSIVE CARE, PLASTIC
CRIB, UMBILICAL VESSELS, ARTIFICIAL RESPIRATION, RADIOGRAPHY, FLUOROSCOPY.
N INFANT CB for the care of the new-born during and after treatment with intermittent positive pressure ventilation was described in previous reports.12 This crib afforded more satisfactory attachment of respirator tubing to the nasotracheal tube, regular postural drainage, and efficient nursing care due to a more controlled com-plex technical environment. Radiologic
ex-amination of the chest in the anteropos-tenor position was facilitated with less dis-turbance to the infant. Fixation of the
in-fant for umbilical vessel catheterization and exchange transfusion was another practical
feature of the crib. Further experience has enabled us to develop a more versatile model.#{176} The all important principle from the outset in setting up a complex intensive
care environment is to maintain good obser-vation and an unobstructed and rapid
ac-cess to the infant and surrounding equip-ment. This principle has been applied in this incubator-crib combination.
* Obtainable from Dameca, 211 Islevdalvej, 2610
R#{216}dovre, Copenhagen, Denmark.
DESCRIPTION
The Main Body
(
A, Fig. 1)
is 37 cm long, 20 cm wide, and 8 cm high. Notable features are: (1) holes in the side and end-wall forfixation of the hands and legs with bands
(B, Fig. 1); (2) two slits in the base of the crib 22 cm X 2 cm for the insertion of the
x-ray plate during lateral projections (C, Fig. 1); (3) the side-walls of the crib,
along-side the slits mentioned above, can be opened downwards (D, Fig. 1).
The Head of the Crib (E, Fig. 1, and A,
Fig. 2) is 14 cm X 17 cm and 11 cm at its
highest point. The features here are: (1) a series of holes for fixation of the respirator tube holding brackets (F, Fig. 1, and B, Fig. 2); (2) a hole for arm fixation above the head (G, Fig. 1, and C, Fig. 2).
The Support for the X-ray Plate is
de-signed as a removable drawer on the
under-side of the crib (H, Fig. 1). A 6 cm perspex
layer separates the film from the infant. Rotation of the Crib is facilitated by a
ARTICLES
support may be removed if lateral rotation is
not required.
An Oxygen Hood is made to fit over the
head-end of the crib. Apertures are pro-vided for oxygen inlet and for an oxygen analyzer (Fig. 3). The hood can be placed in position when the holding brackets for
the respirator tubes are attached to the head of the crib. A disposable plastic sheet fits
over the front of the hood.
A Stop-Cock, Exchange Transfusion, or
Syringe Tray/Table can be slid over the
end of the crib (K, Fig. 1). There are holes for fixation of a stop-cock attached to an umbilical vein or artery catheter (L, Fig. 1). A table is more suitable for larger infants
(M, Fig. 1).
Holding brackets for Respirator Tubes.
Two spring-metal holding brackets may be fastened to the head of the crib (D, Fig. 2).
The fixation method allows a satisfactory range of movement of the holding brackets.
A nylon strap passed through holes in the
brackets is fastened around the respirator
tubes.f
COMM ENTS The Incubator-Crib Combination
The crib is designed to accommodate in-fants up to 3 kg in weight. The infant, lying on a linen bed within the crib, has been nursed inside the Air Shields C-86 Isolette
and Intensive Care Model incubators4 An Armstrong isolation-type incubator (Model 190 A
)
has also been used. However, smallNylon strap No. LST-2, Panduit Corporation,
17301 Ridgeland Avenue, Tinley Park, Illinois
60477.
t Air-Shields, Inc., Hatboro, Pennsylvania 19040. Ohio Medical Products, 1400 East Washington
Avenue, Madison, Wisconsin 53701.
Ftc. 1. The multiple-purpose crib showing the main body (A), holes in the
side and end-wall for limb fixation (B), slit for x-ray plate during lateral
pro-jection (C), downward moving side flap for lateral radiography and
intra-thoracic drains (D), head-end of crib (E), holes for fixation of respirator
tube holding brackets (F), hole for arm fixation above head (C), sliding
drawer for placement of x-ray plate during anteropostenior radiography (H),
crib support for lateral rotation (J), sliding table for placement of
stop-cock on umbilical vessel catheters or for use (luring exchange transfusion
(K), holes for stop-cock placement (L), and table (M) with same purpose as
Fic. 2. Section to show head-end of crib (A), with holes for fixation of respirator tube holding brackets
(B), hole for arm fixation above head (C), and
res-pirator tube holding brackets (D).
alterations are required to the hoods of these incubators when they are used as an intensive care incubator incorporating the
crib. We selected and adapted an Air
Shields C-86 Isolette incubator hoodt to
suit our intensive care requirements. Two
extra ports of entry, one at each end, and
an additional height of 6 cm have been added (Fig. 4). This incubator-crib combi-nation allows both technical access and in-tensive nursing management.
In an emergency situation, such as re-in-tubation of the tracheal tube, the hood of the incubator is opened so that the
proce-dure can take place with the infant lying inside the crib, who at the same time re-mains attached to the monitoring equip-ment (Fig. 5). The holding brackets for the respirator tubing may be moved to allow an unobstructed access to the airway.
The Oxygen Hood
The hood, with the oxygen electrode placed inside it, allows a more accurately controlled oxygen environment.3’4 Rapid
changes in the oxygen concentration are
possible and higher concentrations than the
incubator is designed to give are readily
achieved. The oxygen hood is also a
valu-able aid during weaning the infant from the respirator before extubation.’
The Stop-Cock, Exchange Transfusion, and Syringe Tray/Table
Umbilical vessel catheterization is now a common neonatal procedure. During the
monitoring of the intra-arterial blood pres-sure a short catheter, with a small dead
space, is preferable. The stop-cock connec-tion between the arterial catheter and the
pressure transducer catheter, now situated
inside the incubator, is open to contamina-tion. The stop-cock tray has been used to fix
the stop-cock and to keep it free from con-tamination
(
Fig. 5).
It also facilitates ex-change transfusion of the sick newbornin-fant in an intensive care situation.
Holding Brackets for Respirator Tubes
This particular design has been
devel-oped for nasotracheal intubation which is
proving satisfactory for some neonatal con-ditions, and for our particular respirator
equipment.1 These holding brackets should be easily adaptable to other respirator cir-cuits as well as to the management of res-pirator tubes leading to a tracheostomy. The advantages of these holding brackets over other means of tube fixation’ are listed
elsewhere.2
Rotation of the Crib
In the previous communication we
de-scribed the techniques and advantages of the crib. One advantage is regular postural drainage in combination with physiother-apy, during and after intermittent positive pressure ventilation. The Trendelenburg and Fowler’s positions offered by the base plate of the incubator supplement the lat-eral rotation of the crib. Of course, there are limitations to its efficiency for postural
B
ARTICLES
of the infant and attached equipment as
one unit, provided the head of the infant is controlled within the crib as described.2
Radiography and Fluoroscopy
Devices have been described for the im-mobilization of the infant during
radiologi-cal procedures.8’ The radiological examina-lion of the sick infant, however, can be
haz-ardous since oxygen concentrations are rap-idly lost unless the due precautions are taken, while the positioning of the x-ray plate, which disturbs the exhausted infant,
may cause rapid collapse. Radiography is easy, less time consuming, and of less risk to the infant when using this crib inside the incubator. The x-ray plate can be placed under the undisturbed infant with or
with-out the crib support. The x-ray plate
(
N,Fig. 1) for anteroposterior radiographs may be placed at any desired position, e.g., thorax, abdomen, and so forth. Left and right oblique radiographs are obtainable by
placing the film on the x-ray plate support and rotating the crib laterally to the desired
position using the crib support. The 6 mm perspex between the film and the infant does not make any appreciable difference to the quality of the radiograph.
Lateral radiographs of the thorax and ab-domen are possible from both sides of the incubator under our conditions. The x-ray plate is placed in the slits shown in C, Fig-ure 1, and the side-walls of the crib on both sides are moved downwards (D, Fig. 1).
The procedure is performed with the crib and x-ray plate support, the latter to pre-vent the laterally placed film from falling through the slit.
We have used the crib on a specially de-signed catheterization table using a Philips II
BV 20S image intensffication unit and TV.5
It has proved most useful during umbilical vessel catheterization and could find further application in neonatal cardiovascular in-vestigations. In infants requiring additional oxygen during the procedure, we have used
IlNorth American Philips Compan\, Inc., 100
East 42nd Street, New York, New York, 10017.
the oxygen hood with the crib. The crib support may also be useful, allowing angu-lation without disturbing the infant during fluoroscopy and angiography. Again, even with the use of the crib support, only 6 mm
perspex comes between the roentgen source and the camera; this does not alter the image appreciably. The support for the
x-ray plate is removed during fluoroscopy.
FIG. 3. head-end of crib showing perspex oxygen hood that fits over it, with oxygen inlet (A) and
C
Fic. 4. Modified plastic hood for combination witil nlultiple-purpose crib.
Standard Air Shield entry ports are at the head-
(
A) and tail-end(
B)
ofincubator ( measurements in centimeters ). Other modifications are an
addi-tional 6 cm to height of hood (C) and slits for entry of accessory tubing (D).
Other Neonatal Intensive Care Situations
The presence of an intrathracic drain is a common situation in the neonatal intensive
care unit. The side-wall of the crib (D, Fig. 1) is moved downward to accommodate
the drain. Regular and easily performed postural drainage in such a situation and in tile routine postoperative care of the new-born is an advantage.
Electrocardiographic, respiratory, oxy-gen, and temperature monitoring equip-ment is incorporated into this incubator-crib combination without interference to
the routine clinical and nursing care of the infant.
SUMMARY
A multiple-purpose crib and incubator combination has been developed for the
FIG. 5. Infant lying in the crib showing easy nursing
management and observation. Note limb fixation,
stop-cock tray for care of catheters between arterial
blood sampling, during blood pressure
measure-ment, and during exchange transfusion. Electrodes
on the infant’s chest are for respiration and ileart
care of the sick neonate. Nursing care,
oh-servation, and clinical assessment is greatly facilitated for infants who require intensive care in an often complex technical
environ-ment. Catheterization of the umbilical
ves-sels and the aftercare of the indwelling
catheters is made practically easy. These latter advantages also make the crib useful during exchange transfusion. Improved management of the infant during
intermit-tent positive pressure ventilation, with par-ticular reference to respirator tube fixation and postural drainage, is a further feature of the crib-incubator combination. Antero-posterior, oblique, and lateral radiographs may be taken without disturbing the infant or the attached equipment. The crib is ideal
for infant placement during fluoroscopy for neonatal cardiovascular investigation.
REFERENCES
1. Cooke, R., Lunding, M., Lomholt, N. F., Yssing,
M., Zachau-Christiansen, B., and
Friis-Han-sen, B.: Respiratory failure in the newborn.
The techniques and results of intermittent
positive pressure ventilation. Acta Pediat.
Scand., 56:498, 1967.
2. Cooke, R., Friis-Hansen, B., and Lunding, M.:
Endotracheal tube fixation and postural
drainage in prolonged artificial ventilation of
the newborn. Acta Pediat. Scand., 56:509, 1967.
3. Kistler, G. S., Caldweil, P. R. B., and Wiebel, E. R. : Development of fine structural damage
to alveolar and capillary lining cells in
oxygen-poisoned rat lungs. J. Cell Biol.,
33:605, 1967.
4. Premature infants in Priestley’s pure air. New
Eng. J. Med., 277:878, 1967.
5. Cooke, R., Kjellmer, I., Larsson, II., Olsson, T.,
and Victorin, L.: A contribution to umbilical
artery and vein catheterization. Unpublished manuscript.
6. Rees, C. J., and Owen-Thomas, J. B.: A
tech-nique of pulmonary ventilation witll a
naso-tracheal tube. Brit. J. Anaesth., 38:901, 1966.
7. Harrison, V., Heese, H. de V., Klein, M., and
Malan, A. F.: Prolonged endotracheal
intuba-tion in the newborn infant. Brit. J. Anaesth.,
39:645, 1967.
8. Davis, L. A.: Standard roentgen examinations in
newborns, infants and children: Techniques,
“portable” films, immobilization devices and
fluoroscopy. In Kaufmann, H. J., ed.: Progress
in Pediatric Radiology, Vol. 1, Basel/New
York: Karger, pp. 3-17, 1967.
9. Fendel, H.: Radiation problems in roentgen
ex-animations of the chest. in Kaufmann, H. j.,
ed: Progress in Pediatric Radiology, Vol. 1.
Basel/New York: Karger, pp. 18-32, 1967.
Acknowledgment
This infant crib is the end result of ideas put
forward by many colleagues to whom we are most
grateful. We are also indebted to Mr. C. R. Mac
Innes of Air-Shields, Inc., Hatboro, Pennsylvania
19040, for his cooperation in providing the Isolette
