Atlas of Procedures in Neonatology, 4th Edition


It has been over a quarter of a century since the first edition of the Atlas of Procedures in Neonatology was published. The basic philosophy and purpose of the Atlas, as reflected in the preface to editions one through three, has not changed as the field of neonatal-perinatal medicine has matured.

This fourth edition has undergone a significant facelift, and the majority of illustrations are now in color. Color photographs of procedure complications proved comparatively difficult to obtain; it is tempting to hope that this reflects a decline in their incidence. The new, fold-over cover continues to allow the book to open flat and also offers easy identification on a bookshelf.

In the preface of the third edition, we noted that some promising technologies, such as transcutaneous bilirubin measurement, required further field testing. A chapter on transcutaneous bilirubin measurement has been added in this edition, plus one on auditory screening, and three other new chapters.

With the exception of Aseptic Preparation, the procedures included on the DVD fall into two categories:

  • Commonly performed procedures, such as peripheral and umbilical line placement and endotracheal intubation.
  • Vital emergency procedures that trainees may have infrequent opportunity to perform, such as chest aspiration/placement of a thoracostomy tube, or rare opportunity to perform, such as exchange transfusion.

Particularly in the case of exchange transfusion, there is now a generation of neonatologists who have graduated from training with limited practical experience of the procedure but who now have the responsibility to teach it to trainees. We hope that the video—animation will prove a valuable teaching resource.

Mhairi G. MacDonald MBChB, FRCPE, FRCPCH, DCH

Jayashree Ramasethu MD, FAAP

Editors: MacDonald, Mhairi G.; Ramasethu, Jayashree

Title: Atlas of Procedures in Neonatology, 4th Edition

Copyright ©2007 Lippincott Williams & Wilkins

> Front of Book > Preface to the Third Edition

Preface to the Third Edition

Almost two decades have passed since the publication of the first edition of Atlas of Procedures in Neonatology. We have seen our patients become progressively smaller, less mature, and more susceptible to iatrogenic morbidity. The increasing fragility of our patient population and the escalating complexity of care continue to make neonatology challenging. These challenges have necessitated not only innovations in technology and equipment but also increased familiarity with and proficiency in procedures.

This revised edition of Atlas of Procedures in Neonatology reflects changes that have come about in the management of neonates since the second edition was published in 1993. Reliable monitoring techniques and therapeutic modalities have been developed or refined since then for some aspects of care; however, other promising technologies, such as noninvasive transcutaneous bilirubin monitoring, require additional field testing and validation.

The passing of the era of the mercury thermometer deserves special note. The prototype of the widely used clinical mercury thermometer was designed over 130 years ago, an admirable track record for a medical device. Technical advances in thermometry have rendered the risk of mercury toxicity from broken thermometers unacceptable. As a result, in July 2001, the Committee on Environmental Health of the American Academy of Pediatrics recommended that mercury thermometers no longer be used for pediatric patients.

Advances in the prevention and intrauterine management of alloimmune hemolytic disease, along with the liberal use of phototherapy, have resulted in a significant decrease in the need for postnatal exchange transfusions—to the point that fellows in neonatal–perinatal medicine now occasionally complete training programs without ever performing the procedure. The reappearance of kernicterus in well full-term neonates underscores the importance of retaining the chapter on exchange transfusions in this edition. Cryotherapy for retinopathy of prematurity has been replaced by laser therapy. A chapter on ostomy care has been added. Expanded chapters on the management of extravasation injuries and vascular spasm and thrombosis are acknowledgments of the all-too-common iatrogenic problems in neonatal intensive care. A new chapter on perimortem sampling provides guidelines for testing in the event of sudden or unexpected death.

Updated information regarding the complications of each procedure is provided to facilitate risk-versus-benefit considerations and the informed consent process. Complications are listed whenever possible in order of frequency of occurrence or of importance.

At the request of those who used the previous editions of Atlas of Procedures in Neonatology, we have modified the binding to allow the book to lie flat when open. As in previous editions, commercial products listed in the text are intended for illustrative purposes only; no endorsement is implied. Commercial availability of some equipment may change subsequent to the publication of this edition.

Acknowledgment of the fact that invasive procedures are currently unavoidable in the care of sick neonates must come with the recognition that there is responsibility to reduce potential iatrogenic morbidity to the minimum possible. The latter may be achieved by strict adherence to basic principles of asepsis, careful monitoring and maintenance of patient homeostasis, and by ensuring that procedures are performed or supervised by those with the requisite expertise.

Mhairi G. MacDonald MBChB, FRCP(E), DCH

Jayashree Ramasethu MD

Editors: MacDonald, Mhairi G.; Ramasethu, Jayashree

Title: Atlas of Procedures in Neonatology, 4th Edition

Copyright ©2007 Lippincott Williams & Wilkins

> Front of Book > Preface to the Second Edition

Preface to the Second Edition

There is nothing more gratifying to editors than to see their book lying open and dog-eared during a bedside visit to another facility. We have been pleased to find the first edition of the Atlas of Procedures in Neonatology used not only by trainees and staff in neonatology but also by other members of the neonatal–perinatal health care team, including radiologists and respiratory therapists.

The primary purpose of the Atlas is to provide a detailed, step-by-step approach to procedures, most of which are performed by neonatologists, pediatricians, and nurses within the nursery. Some procedures—such as extracorporeal membrane oxygenation cannulation, operative tracheotomy, gastrostomy, and cryotherapy—are usually performed by surgical specialists but are included to promote understanding by those who are responsible for the perioperative care of the neonate.

On the advice of our readers, we have selected a binding that will allow the book to open flat so as to facilitate bedside use during procedures. The organizational format of the first edition remains. We recommend studying an entire procedure before starting it, not only to review the technique but also to better weigh benefits against risks by understanding the complications and precautions. As in the first edition, we have emphasized the anatomical differences between the neonate and older patients that influence the performance of certain procedures. After every procedure, we have attempted to include a comprehensive list of complications in order to heighten awareness of their potential impact on both morbidity and mortality. The order of listing does not necessarily reflect the frequency or severity of any single complication.

It is sobering to observe that a significant number of complications, some of them not previously recognized, continue to be reported for procedures that have been standard in neonatal nurseries for more than two decades. For example, since the first edition of the Atlas was published, reports in the literature on complications of umbilical artery catheterization have approximately tripled. With every new procedure there is a learning curve, but one would expect the incidence of complications to decrease as experience and expertise increase. Clearly, the number of reported complications does not represent their true incidence. An optimistic view might be that increased reporting of complications reflects a more universal respect for the possibility of their occurrence and attempts to find ways of preventing or minimizing them.

When any procedure is applied to smaller and more immature infants, it is not only technically more difficult but also more likely to be accompanied by side effects or complications. For all procedures performed in the newborn there is a baseline morbidity; no procedure will be absent complications. For example, placement of a peripheral intravenous line is a basic procedure essential for the survival of sick newborn babies. There have been significant improvements in the size and quality of i.v. cannulas and pumps specifically to allow for pressure obstruction alarms, low flow rates, and so forth. However, no matter how good the care of the infant and the i.v., there will always be incidents of infiltration and chemical skin burns. It behooves each clinician to carefully weigh the risks versus the benefits of every procedure before beginning it, while any piece of equipment remains in place, and even in the months and years after completion.

One cannot possibly practice good medicine and not understand the fundamentals underlying therapy. Few if any rules for therapy are more than 90% correct. If one does not understand the fundamentals, one does more harm in the 10% of instances to which the rules do not apply than one does good in the 90% to which they do apply.

—Fuller Albright

Mary Ann Fletcher MD

Mhairi G. MacDonald MBChB, FRCP(E), DCH

Editors: MacDonald, Mhairi G.; Ramasethu, Jayashree

Title: Atlas of Procedures in Neonatology, 4th Edition

Copyright ©2007 Lippincott Williams & Wilkins

> Front of Book > Preface to the First Edition

Preface to the First Edition

The rapid advances in neonatology in the last 15 years have brought with them a welter of special procedures. The tiny, premature, and the critically ill term neonate is attached to a tangle of intravenous lines, tubes, and monitoring leads. As a result, more and more procedures are done at the bedside in the intensive-care nursery, rather than in a procedure room or operating room. With these technical advances has come the opportunity for more vigorous physiologic support and monitoring. With them also has come a whole new gamut of side-effects and complications. The old dictum to leave the fragile premature undisturbed is largely ignored. It is therefore the responsibility of those who care for sick newborns to understand the complications as well as the benefits of new procedures and to make systematic observations of their impact on both morbidity and mortality. Unfortunately, the literature on outcome and complications of procedures is widely scattered and difficult to access. Manuals that give directions for neonatal procedures are generally deficient in illustrations giving anatomic detail and are often cursory.

We are offering Atlas of Procedures in Neonatology to meet some of these needs. A step-by-step, practical approach is taken, with telegraphic prose and outline form. Drawings and photographs are used to illustrate anatomic landmarks and details of the procedures. In several instances, more than one alternative procedure is presented. Discussion of controversial points is included, and copious literature citations are provided to lead the interested reader to source material. A uniform order of presentation has been adhered to wherever appropriate. Thus, most chapters include indications, contraindications, precautions, equipment, technique, and complications, in that order.

The scope of procedures covered includes nearly all those that can be performed at the bedside in an intensive-care nursery. Some are within the traditional province of the neonatologist or even the pediatric house officer. Others, such as gastrostomy and tracheostomy, require skills of a qualified surgeon. Responsibility for procedures such as placement of chest tubes and performance of vascular cutdowns will vary from nursery to nursery. However, some details of surgical technique are supplied for even the most invasive procedures to promote their understanding by those who are responsible for sick neonates. We hope this will help neonatologists to be more knowledgeable partners in caring for babies and will not be interpreted as a license to perform procedures by those who are not adequately qualified.

The book is organized into major parts (e.g., “Vascular Access,” “Tube Placement,” “Respiratory Care”), each of which contains several chapters. Most chapters are relatively self-contained and can be referred to when approaching a particular task. However, Part I, “Preparation and Support,” is basic to all procedures. Occasional cross referencing has been used to avoid repetitions of the same text material. References appear at the end of each part.

Many persons have contributed to the preparation of this atlas, and we are grateful to them all. Some are listed under Acknowledgments, and others have contributed anonymously out of their generosity and good will. Special thanks is due to Bill Burgower, who first thought of making such an atlas and who has been gracious in his support throughout this project.

If this atlas proves useful to some who care for sick newborns, our efforts will have been well repaid. Neonatology is a taxing field: strenuous, demanding, confusing, heartbreaking, rewarding, stimulating, scientific, personal, philosophical, cooperative, logical, illogical, and always changing. The procedures described in this atlas will eventually be replaced by others, hopefully more effective and less noxious. In the meantime, perhaps the care of some babies will be assisted.