Buyers Guide

The Protective Warmth

The significance of incubators in a neonatal intensive care unit (NICU) is characterised with their ability to provide a clean and warm environment to a newborn. Sonal Shukla takes a look at their functioning and utility.

Picture Courtesy: Phoenix Medical Systems Pvt Ltd

The most important component for a newborn's survival is the body temperature regulation, which forms the basis of the invention of neonatal incubators. It is a device with an enclosure intended to contain a baby and have transparent section(s) which allow(s) view of the baby. It provides with means to control the environment of the baby, primarily by heated air within the enclosure. They provide an environment, where the temperature and humidity can be controlled and oxygen can be supplied, if necessary. The microprocessor-based technology used in it gives accuracy and near perfect control. Incubators also allow isolation from other unwell babies in the NICU.

Mechanism

The device may include an AC-powered heater, a fan to circulate the warm air, a container for water to add humidity and a control valve through which oxygen may also be added. It may also contain a servo-control to help regulate incubator air temperature and adjust the heat, according to the needs of the baby. The servo-control uses a temperature sensing thermistor, which is taped to the child's abdomen. "Incubators can be single walled or double walled. The double walled incubator has greater ability to maintain a uniform temperature than the single-walled unit," explains Dr Rahul Verma, Pediatrician and Neonatologist, Department of Neonatology, Bombay Hospital, Mumbai.

The top of an incubator is made of acrylic or perspex sheets with multiple ports to access the baby. One long side of this incubator can be completely opened for moving the baby in and out. The wall usually contains a slot for a temperature sensor to monitor the air temperature within.

Types of Incubators

"The disadvantage of close incubators is that they are more expensive and the running costs are high" - Dr KP Sanghvi Neonatal Pediatrician Jaslok Hospital, Mumbai

There are two types of devices used to maintain the temperature of newborns, open care systems and closed care systems or incubators, the difference being one is a closed box, the other is an open cot with overhead radiant warmer. Both the systems are usually servo-controlled and essentially provide the same function.

Closed incubators: They are the incubators in the proverbial sense and are used worldwide for the care of very small and/or sick newborns. The closed incubator is preferable for very pre-term babies, specially those weighing less than one kilogram or with less than 28 weeks of gestation. "The disadvantage of these incubators is that they are more expensive and the running costs are high. Furthermore, if they are not used and maintained correctly, they may be more of a hazard than a benefit to the newborn," opines Dr KP Sanghvi, Neonatal Pediatrician, Jaslok Hospital, Mumbai. According to him, closed incubators need to be cleaned and disinfected regularly. They also create a barrier between mother and baby, which delays bonding and makes breast-feeding difficult. As in any other fields, with the advent of newer technologies, newer trends are set. The lack of proper trained nursing staff lead to the limitations to maintain a highly sterile environment in the NICU. "Professionals started to realise that incubators being closed areas, proper and thorough sterility of the incubators in the existing working conditions is difficult. This was when the concept of open care incubators started to become popular," states Abhay Tokekar, Marketing Executive, Shreeyash Electro Medicals, one of the manufacturers of a variety of incubators in India.

"The open care system provides easier access to the baby and better visibility of the baby" - Dr Manish Malik Consultant Neonatologist Max Super Speciality Hospital, New Delhi

Open Care Radiant warmers: The open system uses radiant warmers, which have overhead heating elements that provide warmth locally. "The open care system provides easier access to the baby and better visibility of the baby. It is easier to maintain and is associated with less risk of infection as compared to closed incubator," explains Dr Manish Malik, Consultant Neonatologist, Max Super Speciality Hospital, New Delhi. The disadvantage of this system is that the babies tend to lose a lot of water through their skin, as there is no control over humidity levels. As a result, the baby needs a closer monitoring of fluid and electrolyte balance. The equipment can have both manual and servo-controlled temperature regulation.

The system has a bed with a heating arm situated approximately 18-24 inches above it. There is no humidifying system incorporated in this unit. Some open care systems have accessories like a phototherapy unit, a halogen spot light, suction and CPAP units incorporated in them. The open care systems do not have enclosed areas, but allow access to the baby from at least three sides. Open care system is more commonly used in India when compared to the closed system as the former is less expensive in terms of costs and maintenance. It is also easier to clean.

The Chosen One

The choice of incubators is determined by the baby's conditions and the advantages and disadvantages of the types of incubators. According to Dr Manimala Rao, Chief Intensivist, Yashoda Hospital, Hyderabad, the open care system gives a better outcome on babies who have undergone surgeries, whereas for the pre-mature ones, the close incubators is a better choice with their good temperature control.

Dr Malik feels that in a country like India, the doctor's penchant to a certain extent is for open care systems as there is a less fear of infection for the baby than when the baby is inside the closed box. "In close incubators, water circulates in the system to provide humidity. That water is a very potent source for bacteria and fungus to multiply. This risk is not there in the open care system,” he adds. In open care system, there is a better visualisation, for example, the breathing and activity of the baby can be closely monitored, besides providing easy access to the baby for providing nursing care and doing procedures.

According to Shailesh Patel, Director, Zeal Medical, Mumbai the demand for closed incubators would rise as the actual water loss of infant is minimal in close care incubators, as well as very tiny infants require close incubator care rather than open care warmer.

Likewise, cost is also one determinant why the open care systems are more preferred than the close incubators, which are more costly. Close incubators cost anywhere between Rs 7 to Rs 8 lakh. Open care incubators, depending on the model ranges from Rs 40,000 to Rs 3 lakh. "I would not say the technology of close incubators is fading away. But it is more matter of personal choice and experience. If somebody has been using a closed incubator and not having any problems with infection control, then they will continue to use it," adds Dr Malik.

Technological Advances

Neonatal incubators have transformed into sophisticated devices from simple structures. Over the years, incubators have evolved from wooden boxes with heating elements to manually and servo-controlled transparent light weighted equipment. They have evolved from single walled to double walled incubators to prevent heat loss by radiation, convection and conduction. The temperature in the early incubators was controlled by simple thermostats. Modern incubators use microprocessors to control the humidity and temperature. The thermister (sensor of the temperature) can be put in the air mode or in the baby mode which controls the temperature automatically. Air mode and baby mode are options on both closed and open incubators. In baby mode, one sets the baby's temperature, and then the device tries to maintain it by varying the heater output. Baby mode is preferred by the doctors as it is vital to maintain the baby's skin temperature at 36.5 C. In air mode, one sets the temperature of the air around the baby, while in baby mode one can set the temperature of the baby as wanted.

According to Dr Row, the baby mode is today more preferred as it is attached to the baby's body and manages the temperature more accurately than the former.

To avoid heat loss by opening doors, current incubators have windows. Some incubators are now available with an inbuilt weighing scale so that the infant is not disturbed even for daily weight checks. Says Dr Malik, "The basic technology remains the same—to keep the baby warm at a set temperature decided by the treating physician. However, the look and sturdiness of the equipment have improved over the time. Also, there is facility to slide a cassette underneath the mattress for taking an X-ray instead of lifting the baby."

Some also have adjustable height and features to lift the head of the baby. Few models have a rotating base to allow the baby to be turned in a particular direction, which is useful for doing procedures like intubation and IV lines.

This type is a completely automated device that maintains its internal environmental temperature to a decimal fraction. The structure now is more rounded and the perspex cover is smoother, alcohol resistant, larger and has clarity of vision. The double-walled incubator maintains and conserves heat more efficiently. There are usually six port holes for access and an efficient oxygen delivery system for the baby. Some of the newer systems have ventilators and infusion systems and various monitoring systems incorporated within them, making them efficient transport systems.

Issues and Concerns

There are quite a few problems associated with the practical usage of incubators. For instance, availability of biomedical engineers for servicing as well as regular calibration. "In smaller nursing homes and hospitals, many a times there is an absence of a biomedical engineer to monitor the problems with the equipment," states Dr Malik.

The temperature probes are also quite flimsy and tend to come off the patient easily. Experts feel that even though the utility of incubators has advanced many folds with the advent of computerisation, training of the personnel working in the NICU should not be overlooked.

"Monitoring is not easy as the baby is isolated. We have to be very vigilant in picking up early signs of illness. Nursing staff has to be well trained for this," opines Dr Anjali Kulkarni, Consultant Neonatologist, Indraprastha Apollo Hospital, New Delhi.

Access to the baby for performing procedures is limited. Also, there is a potential risk of increased incidence of infection through the water kept for humidification.

"Improvement at various levels probably are ongoing, but a system of incorporating bacterial filters to ensure sterile oxygen and humidification like in ventilation systems would be very helpful," opines Dr Verma.

Future at a Glance

Experts believe that incubators are indispensable in any neonatal unit. The latest advancement is that of an open care system that can be converted to a closed incubator when required. "It has a mobile cover which can be lifted up to expose the baby, quite like opening the hood of a convertible car," explains Dr Malik. This model is not yet manufactured in India.

Servo-controlled computerised incubators in which the weight and gestational age of the newborn will be entered and the computer will control the temperature and humidity to maintain neutral thermal environment, according to the gestational age and weight is also in the offing. Also, in the pipeline is disinfecting incubators. The future of neonatal incubators is believed to be a full fledged neonatal work station, where inbuilt weighing, monitoring parameter of infant like Spo2, Pulse, Nibp, ECG waveforms etc will be included in the main unit.

sonal.shukla@expressindia.com

Phoenix Medical Systems Pvt Ltd	Draeger Medical India Pvt Ltd	Shreeyash Electro Medicals
NEONATAL OPEN CARE SYSTEM NOC 100A Control panel. Oval shaped baby bed with side panel. Probe a) Interchangeable and no field calibration required. Thermistar sensor for quick response. b) Wires are easy to clean, lasting, teflon coated with silicon rubber sleeve. c) Safe, efficient, splash-proof heater unit. d) Swivels away from bed to make room for an X-ray unit. Alarm System a) Clear visual and acoustic alarms for complete patient safety. b) Separate electronic to monitor system failure and heater failure. Castors a) Effortless mobility on 4 smooth-running swivel castors. b) Integral brakes & low centre of gravity ensures optimal stability & no movement during procedures. Handle: Conveniently positioned to move the equipment. Resuscitation unit with hand operated port (optional) or CPAP unit (optional, safer and more reliable, easy to use and autoclavable. Suction unit (optional) Oxygen powered, no need for electricity (electrical unit optional). Photo therapy unit (optional)-modular. -3 halogen lamps on each side angled for effective treatment. IV stand (optional on both sides). Dimensions: Length: 116.84 cm. Width: 81.28 cm. Minimum Height: 195.58 cm. Operating temperature range: 20 OC to 33OC. Storage temperature range: 25OC to 60OC. Phoenix Medical Systems Pvt Ltd No.32/4, Jawaharlal Nehru Salai Ekkattuthangal PO Box 3205 Chennai - 600 97, India Tel: 91-44-2225 1177, 2225 1178 Fax: 91-44-2225 0194 Email: phoenixmedical@vsnl.net www.phoenixmedicalsystems.com	CALEO CLOSE CARE SYSTEM PARAMETERS Mode of operations Temperature (air or skin mode). Humidification (servo controlled). Oxygen concentration (servo controlled). Functionality Physical durability and robustness Easy access via new Jumboports. Self explained easy operation. Ergonomic design. CleanSwitch- self cleaning mode. Developmental care aspects Kangaroo mode during kangarooing. Direct access X-Ray tray. Quiet operation. Smart alarms. Electronic bed tilt. Co-bedding possible for twins. Draeger Medical India Pvt Ltd Goldline Business Centre Next to Chincoli Bunder Fire Station Link Road, Malad - West Mumbai - 400 101, INDIA Fax: +91 - 022 28712311 Mobile: +91 - 9867885564 Email: prathiksha.b@draeger-medical.co.in www.draeger.com	MODEL: SP 41 Mode of Operation: Air mode / skin mode servo controlled. Power Source: 230 V 50 Hz. AC / 12 V DC with inverter. Heating & Cooling Mechanism: Yes. Air Controlled versus Baby Controlled: Yes. Supplementary Gas Connectors: Yes (Standard). Accuracy: ± 0.2ºC. Rise Time: 25 minutes (When ambient temperature is 38OC). Variability: None. Under shoot / over shoot: None. Flow Rates: 14 air changes per minute. Electrical: Only ISI grade spares used. Restraints: Only in transport incubators (With high quality velcrow straps). Alarms: 0.5ºC lower than set, 0.5ºC higher than set, over temperature, 2nd safety active, 3rd safety active. Sensors: Extra large, special uni-directional sensor. Temperature sensing surface made of silver. Military grade connector used. Shreeyash Electro Medicals Sr no 49, Plot no 22 Shri Sai Industrial Estate Gujarwadi Phata Katraj, Pune- 411046 Tel: 26959683, 26959188 E-mail: semneont@vsnl.com www.shreeyashnicu.com

Nice Neotech Medical Systems Pvt Ltd	V-Care Medical Systems Pvt Ltd	Phoenix Medical Systems Pvt lTD	Zeal Medical Pvt Ltd
NICE 3010H BABY INCUBATOR Mode of Operation: Micro controller controled air / skin modes of operation. Power Source: 230v AC or 110v AC, 3A. Heating & Cooling Mechanism: Infra red heater with centrifual blower. Air Controlled Vs Baby Controlled: Has both servo aircontrolled and servo baby controlled modes of operation. Has 4 display windows, 1 each for air temperature, set air temperautre, baby temperature and set baby temperature, which are displayed all the time, irrespective of the mode of operation. Supplementary gas connectors: Oxygen flow meter inbuilt in the machine and hence independent from the wall flow meter. Centrigual blower ensures fresh air for the baby, always. Temperature Control: Servo controlled for both air and baby modes. Accuracy: +/- 0.2OC. Rise Time: 10OC in 20 minutes at room temperature of 25 Deg. C. Variability: 0.1OC. Undershoot: 0.5OC. Overshoot: 0.5OC. Air Flow Velocity: Less than 25 centimetre/ second. Flow Rates: Air intake rate with filter 25 l/min. Safety Features Weight Capacity: Can support babies upto 6 kgs. Machine Weight: 110 kgs. Electrical: IEC 60601-1 certified for electrical safety. Alarms Skin temperature low/ligh. Air temperature low/ high. Air failure (fan failure). Air flow failure due to blocked filter or mechanical struck fan. Heator failure. Air / skin probe failure. Temperature > 39OC in any mode. Power failure. Circuit fault. Sensors: Two probes, one each for air and baby. Each probe has two sensor (dual sensor technology) and are thermister based. Nice Neotech Medical Systems Pvt. Ltd 85, Krishna Indl Estate, Vannagaram Mettukuppam, Chennai 600095 Tel: (044) 24762594/24764608 Mobile: 09444010704 Mobile: 09444976019 Email: marketing@niceneotech.com www.niceneotech.com	INTENSIVE CARE BABY INCUBATOR: "V-150" The controller is based on Micro computerised system. Large bright displays are easy to monitor and for viewing from a distance. Digital display system provided to measure the Infant temperature. Air temperature and to set the required temperature. Feather touch keys provided for easy operation. Bar graph LED system provided to indicate the heater output. BABY PROBE / AIR PROBE Baby probe / Air probe is made of highly sensitive sensor and interchangeable, field calibrations taken care of by software. The probe is made up silicon sheathed cable, which allows easy cleaning. OTHER FACILITIES IV stand provided. Storage drawers provided. PHYSICAL PARAMETERS Height : 1425 mm. Depth : 585 mm. Width : 945 mm. Working level from the ground : 900 mm. Baby tray tilt angle on either side: +/- 8 max. Weight : 60 kg (Approx). Castors: 125 mm with 2 brake wheels and 2 non-brake wheels. RECOMMENDED ENVIRONMENTAL SPECIFICATIONS Operating temperature range: 200-330 C. Storage temperature range: 250-600 C. Operating humidity range : 0 to 100 per cent RH. SKIN TEMPERATURE PROBE Range: 28OC-38OC. Accuracy: +/- 0.2OC within range. Resolution: 0.1OC. Probe interchangeability: +/- 0.2OC (Servo). AIR TEMPERATURE PROBE Range: 28OC to 38OC. Accuracy: +/- 0.2OC within range. Resolution: 0.1OC. Probe Interchangeability: +/- 0.2OC (Servo). V-Care Medical Systems Pvt Ltd No. 30/2, SV Complex, Magadi Main Road, Vijayanagar, Bangalore - 560 040 Tel.: 080 23110651 / 52 Fax: 080 2311 0645 Contact Person: Kumar Mobile: 0 9342536117 Email: sales@vacremed.com www.vcaremed.com	NEONATAL INTENSIVE CARE INCUBATOR INC 100 Features: 1.Elbow-operated ports allow immediate access & eliminates cross infection. 2.Large front: Provides direct access for major procedures and easy removal of baby. Externally-operated trendle and towler positioning. (Maximum of 8 on both sides). Easy to pull out baby tray with X-Ray cassette compartment. Self supporting tube & lead a pertures (made from autoclavable silicone. Easy & safe to insert tube and cords. Easy-to-ready and touch operated. DIMENSIONS Width - 70 cm. n Length - 94.5 cm. Height with Castors - 136.5 cm. Castors 4" diameter, 2 locking and 2 non-locking. Electrical Power Requirements: Voltage rating - 230Vn Power rating - 350w n Current rating - 3.1A Frequency - 50Hz n Leakage current - 0.5 mA n Power factor - 1.000 Electronics: Microprocessor-based servo control system. Heater Element: Encapsulated heater with aluminum fins. n Probe: Thermistor based interchangeable probe. n Probe Calibration: not required. Patient Temperature Range: 32OC to 38OC. Air Temperature Range: 20OC to 38O C. Accuracy: -+ 0.2OC, Resolution: 0.1OC. Power : 220V to 250V at 50Hz 500W. Performance Specifications: Temperature rise time: 20-30 minimum per 10OC, temperature variability: 0.2OC, temperature overshoot: 0.5OC, air velocity over mattress: 10 cm sec, noise level within mattress: 10 cm sec. Operational Environment: Operating temperature range - 20OC to 30OC, storage temperature range - 25OC to 60OC, operating humidity range - 0 to 95 per cent. Humidity: Water Capacity - 1000 ml Humidification upto 50 per cent -/+ 10 per cent, Humidity control range - 40 to 90 +/- 5 per cent, Humidity display resolution -/+ 5 per cent. Alarms: Patient Temperature (More than 0.5OC difference), air temperature (more than 0.5OC difference), temperature probe failure/ disconnect, system failure, heater failure, air flow failure, too much weight, power fail. Phoenix Medical Systems Pvt Ltd PO Box 3205, Chennai - 600 97 Tel.:91-44-2225 1177, 2225 1178 Fax : 91-44-2225 0194 Email: phoenixmedical@vsnl.net www.phoenixmedicalsystems.com	INFANT INCUBATOR (CLOSE CARE SYSTEM) MODEL INC 1001A   n Power source : 220 to 240 Volts, AC, 50 Hz. Heating & Cooling Mechanism : Air heater and blower fan continuously suppling heated air into baby care area of acrylic canopy. There is no cooling system provided. Air Controlled Versus Baby Controlled Air Controlled - This system maintain desired air temperature surrounding to baby as per setting done by operator. Periodic checking of baby's temp. is essential to understand baby's body temp.maintenance, if baby's does not maintain the body temp. the setting of air temp. requirement is to be alter periodically. Baby Controlled - In this mode the sensor attached to baby detects the body temp., send it to the processor, which in turn adjust the power of heater and accordingly maintain. The baby's temp. as per requirement. 100 per cent maintenance of baby's temp. is possible with this type of control system. Supplementary gas connectors: The system is having inlet provision of O2. Temperature control Accuracy: +/- 0.2OC. Rise Time : Air Temp. 45 min.for10 OC.- Baby temp 15 minfor 1OC. Variability : Maintain as per set temp. Undershoot/ Overshoot : Air temp. +/ - 0.5OC. Baby temp. + /- 0.2OC. Air Flow Velocity & Flow rates : Data not available. Safety features Electrical : Spike suppressor, proper opto isolatror provides 100 % electrical safety. Restraints Alarms : High/ low of set temperature and over / under temperature alarm in both mode, air as well as baby control. Sensor failure, heater failure, air flow failure, power control system failure and power failure. Sensors : Detachable type air as well as Skin sensor. Zeal Medical Pvt Ltd 4/19A, Piramal Estate SV Road, Goregoan (West) Mumbai- 400062 Tel: 91 22 2876 0274 Fax: 91 22.vsnl.net.in2876 19 05 Email: zealmedi@bom3 www.zealmedical.com