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The first 24 hours
Complications during Chandi’s birth are first detected with a non-reassuring category II fetal heart rate tracing during birth. Upon delivery she does not begin breathing on her own and requires extensive resuscitation. Eventually, her breathing does recover and she initiates her own first breaths. However, Chandi remains unresponsive, floppy, and with marked respiratory distress. Her cord blood gas reading is pH 6.9 and base deficit 18.
These symptoms are indicative of neonatal encephalopathy. Chandi is moved to the NICU and evaluated for a range of causes of brain injury including hypoxic-ischemic, infection, and metabolic disorders. After evaluation, her doctors determine that hypoxic ischemia is the most likely cause of her symptoms and she starts brain cooling treatment, as well as continued respiratory and seizure monitoring.
24 hours & after
During cooling, two forms of monitoring are used to monitor breathing quality and watch for potential ischemic threats. Capnography is used for early identification of overventilation, as low CO2 levels cause a rapid decrease in blood flow to the brain, potentially compounding existing brain injury with further ischemia. This enables more precise ventilator management and alerts the neonatologist that Chandi needs an urgent change in her respiratory support.
A second layer of monitoring provided by near-infrared spectroscopy (NIRS) enables tissue-specific monitoring of cerebral and renal perfusion, allowing early identification of hypoxia and a window for intervention and also provides an additional set of data to help determine the severity of brain injury. After the third day of cooling and limited interaction to prevent further brain injury, Chandi is warmed. As she re-warms, she becomes more agitated and experiences seizures, both of which increase the risk of extubation, so her nurse begins monitoring tube movement with the SonarMed™ airway monitoring system
After her brain MRI, which confirms the presence of brain injury consistent with the diagnosis of HIE, the neonatologist combines all the previous NIRS data with the new MRI data to assess severity of HIE and communicate an ongoing plan of support with the family to ensure the best quality of life for them and Chandi. Before she can go home, a tracheostomy tube is placed to manage persistent airway protection and secretion management difficulties that increase the risk for pneumonia.
Therapeutic hypothermia is a treatment that, in some cases, can prevent or minimize permanent brain damage caused by hypoxic-ischemic encephalopathy (HIE). But timing is critical, and therapy must be given within hours of the baby's birth.
Chandi is showing signs of HIE post-resuscitation after delivery. She is immediately moved to the NICU for cooling. To ensure proper oxygen and respiratory management at low body temperatures1, her NICU care team continuously monitors her ventilation status with Capnostream™ 35 portable respiratory monitor and a Microstream™ advance filter line — which provide continuous capnography for intubated and nonintubated patients.
Microstream™ has the flexibility to be used for long-term and short-term, intubated and non-intubated patients. With special design considerations for neonates, its lightweight (3.8g) design reduces additional weight on the endotracheal tube (ETT). The ability to use Microstream™ sampling lines in one area of care and transfer to another area, allows for continuous capnography monitoring from labor and delivery to the NICU.
Reliable access to respiratory status is vital to providing comprehensive care. The Capnostream™ 35 portable respiratory monitor delivers real-time, continuous monitoring of your patient’s respiratory status by measuring etCO2, SpO2, respiration rate, and pulse rate. All so you can respond earlier and intervene sooner if your patient is showing signs of respiratory compromise.
The Microstream™ capnography monitoring system should not be used as the sole basis for diagnosis or therapy and in intended only as an adjunct in patient assessment.
Hypoxic-ischemic encephalopathy (HIE) is a type of newborn brain damage caused by oxygen deprivation and limited blood flow.
Chandi’s cerebral oxygen saturation is monitored with the non-invasive INVOS™ regional oximetry system. A higher-than-expected or fast increase in cerebral rSO2 after a hypoxic-ischemic event can indicate the severity of the brain injury — a lower than expected cerebral rSO2 can also suggest over extraction of oxygen, inadequate cardiovascular support and risk for further ischemia. Because outcomes after a brain injury are difficult to predict, the unknown can become a major source of stress for families affected by HIE. It helps the care team properly communicate with the family if they have as much data as possible to inform those difficult discussions.
The INVOS™ 7100 regional oximetry system is designed to help quickly identify desaturation events and improve the clinician’s ability to intervene sooner. Because seconds matter.
INVOS™ 7100 regional oximetry system
A soft, small sensor designed for fragile neonatal skin for use anywhere on the body. INVOS™ infant regional saturation sensors are applied to the skin’s surface, and are user and patient friendly, making monitoring of ischemic threats to the brain and body possible. By reporting venous weighted regional hemoglobin oxygen saturation (rSO2) in tissue directly beneath the sensor, the INVOS™ technology reflects oxygen remaining after tissue demand has been met.
The INVOS™ 7100 regional oximetry system should not be used as the sole basis for diagnosis or therapy and is intended only as an adjunct in patient assessment.
If an infant with HIE cannot breathe completely on their own, mechanical ventilation may be required.
Chandi’s breathing is unstable after birth and she is supported with mechanical ventilation using the Puritan Bennett™ 980 ventilator. The Puritan Bennett™ 980 ventilator’s NeoMode 2.0 software is designed to ensure accurate and safe neonate breath delivery.
A multipurpose ventilator for noninvasive and invasive ventilation to help clinicians manage neonatal respiratory care:
Puritan Bennett™ 980 ventilator
Helps clinicians provide ventilatory support to neonates weighing as little as 300 grams by delivering tidal volumes as small as 2 mL. The NeoMode 2.0 software was developed specifically for neonates to address and improve some of the issues critical to their care and safety, such as accurate breath delivery, responsive triggering, lower elevated oxygen preset for procedures, effective alarm management, and automatic leak compensation.
Please refer to the instructions for use for the indications, contraindications, warnings, risks, and precautions associated with the Puritan Bennett™ 980 ventilator and software referenced in these materials.
For neonates requiring long-term mechanical ventilation, it is important to use products designed for their anatomy to mitigate risks of unplanned extubation (UEs) and airway trauma.
We offer a range of DEHP free neonatal and pediatric cuffless endotracheal tubes made with plastic that does not contain phthalates.
Shiley™ neonatal and pediatric tracheostomy solutions incorporate a wide range of simple and smart design advances for the distinct anatomy of neonate and pediatric airways.
The SonarMed™ airway monitoring system should not be used as the sole basis for diagnosis or therapy and is intended only as an adjunct in patient assessment.
“Wires, monitors, smells, sights and sounds in the NICU can be trauma-inducing for families. For them, having confidence in their child’s quality of care and the people and products providing that care — keeping their child alive, delivering therapeutics, and hopefully getting them to a healthy place — is paramount.
In the face of all these stressors, families share that the NICU is also a place where trusting relationships form, trauma decreases, and connections to resources create a halo of support around them.“
– Betsy Pilon, Executive Director at Hope for HIE
Support & partnerships
The NICU team is more than just a group of highly trained and specialized medical professionals. It’s a genuine smile at the sight of a milestone achieved. It’s an emotional and sometimes heartbreaking end to a shift. It’s a supportive shoulder and life coach to a concerned parent struggling with their new reality. It is a family. At Medtronic we strive to be more than just a medical technology company; we aim to be a supportive member of that family.
† These narratives feature fictional patients, based on real clinical scenarios and product use. At all times, it is the professional responsibility of the practitioner to exercise independent clinical judgment in a particular situation. Changes in a patient’s disease and/or medications may alter the efficacy of the therapy, or product features. Results may vary.
Afzal B, Chandrasekharan P, Tancredi D. Monitoring gas exchange during hypothermia for hypoxic-ischemic encephalopathy. Pediatr Crit Care Med. 2019; 20(2): 166-171. doi:10.1097/PCC.0000000000001799.
Mehta H, Kashyap R, Trivedi S. Correlation of end tidal and arterial carbon dioxide levels in critically ill neonates and children. Indian J Crit Care Med. 2014;18(6):348-353. doi:10.4103/0972-5229.133874.
Keszler M. Mechanical ventilation strategies. Seminars in Fetal and Neonatal Medicine. 2017;22(4):267-274.
Dargaville PA, Tingay DG. Lung protective ventilation in extremely preterm infants. Journal of Pediatrics and Child Health. 2012:48(9): 740-746.
Puritan Bennett™ 980 ventilator operations manual.
Roddy DJ, Spaeder MC, Pastor W, Stockwell DC, Klugman D. UEs in children: Impact on hospital cost and length of stay. Pediatr Crit Care Med. 2015;16(6):572-575.
Galiote JP, Ridoré M, Carman J, et al. Reduction in unintended extubations in a level IV neonatal intensive care unit. Pediatrics. May 2019;143(5):e20180897.
Alitimier L, Phillips R. The neonatal integrative developmental care model: advanced clinical applications of the seven core measures for neuroprotective family-centered developmental care. Newborn and Infant Nursing Reviews. 2016:16:230–244.
Internal bench testing. Comparative fluid seal test performed using the Shiley™ 4.0PCF and 6.5PLCF pediatric tracheostomy tubes with taper-shaped cuff versus predicate Shiley™ 4.0PDC and 6.5PLC pediatric tracheostomy tubes with barrel-shaped cuff.
Internal bench testing. Comparative ventilator air leak test performed using the Shiley™ 4.0PCF and 6.5PLCF pediatric tracheostomy tubes with taper-shaped cuff versus predicate Shiley™ 4.0 PDC and 6.5PLC pediatric tracheostomy tubes with barrel-shaped cuff.
Internal bench testing. Comparative removal force test performed using the Shiley™ 4.0PCF and 6.5PLCF Pediatric Tracheostomy Tubes with taper-shaped cuff versus the predicate Shiley™ 4.0PDC and 6.5PLC pediatric tracheostomy tubes with barrel-shaped cuff.