Neonatal stabilization and

transport

Santi Punnahitananda M.D.,M.Sc.(Clinical Epidemiology)

Department of Pediatrics,

Faculty of Medicine

Chulalongkorn University

NEONATAL TRANSPORT

HISTORY:

THE SAFEST AND BEST WAY TO TRANSFER

Interhospital neonatal transport

• in utero transfer has better clinical

outcomes for mother and infant than

transfer after birth

• In utero transfer is not always possible

Reasons for transferring infants

between hospitals

• No appropriate local facilities

• No cots available locally

• Insufficient appropriate staffs available

locally e.g. pediatric surgeon, cardiologist

• Unexpected delivery far from home

• Transfer back to local facility

Neonatal transport :ideal

• A dedicated transport team consisting of

Ambulance personnel, Paediatrician Respiratory

therapist, Neonatal Nurse

• Adequate equipment dedicated for the transport

of the infant only.

• Governmental and private medical facilities

agreeing upon a fixed set of transport guidelines

that are on par with the rest of the world.

If not,

• Medical and nursing staff from either

referring or receiving units undertake the

transport on an ad hoc basis.

Limitation

• Variable experience in neonatal transport

and the equipment used

• The vehicle may not be dedicated for

neonatal use

Neonatal transport: present

• We all know about receiving a baby that is

e.g. cold, faulty equipment, and more

unstable than when it left the transferring

hospital…

• Not enough qualified personnel and

equipment within the different departments

transporting neonates.

Safe transport of the preterm infant

• Early anticipating the need for transfer

• Appropriate preparation for transfer

• Ongoing high quality care during transfer

Anticipation

• An opportunity to seek advice

• Gathering staff with the right skills

• Preparation of appropriate equipment

• Direct communication between senior staff

in the two involved centers

Principles of safe transport

• Team composition

• Communication

• Preparation / planning

• Stabilization

• Documentation

• Prepare for worst case scenario

• Maintenance of equipment

• Safe delivery of the patient

Principles of safe transport

Stabilization

Specific treatments should be considered :

• antibiotic treatment

• surfactant replacement

• volume support or inotrope support

• analgesia, sedation, paralysis

• anticonvulsant treatment

• nitric oxide

Stabilization before transfer

• Any remedial action should be taken before

moving the baby and not during the transport.

• the infant should be in as good a clinical

condition as possible before setting off

• the decision to stabilise the infant further or

institute specific treatments must be weighed

against a delay in transfer

The S.T.A.B.L.E. Mnemonic

S ugar

T emperature

A rtificial/Assisted breathing

B lood pressure

L ab work

E motional support© S.T.A.B.L.E.

®

2001

The Basics Come First!

S.T.A.B.L.E.A B C

© S.T.A.B.L.E.®

2001

Sugar

• Initial IV therapy

– Fluid rates and calculations

• Glucose monitoring

– Hypoglycemia assessment and interventions

• Umbilical catheters

– Placement and safe use

Sugar Summary

Suspect hypoglycemia in SGA, LGA, IDM, sick, or stressed infants

Avoid enteral feedings (PO or NG)

D10W IV fluids at 80 ml/kg/day

Maintain the blood sugar > 50 mg/dl (> 2.8 mmol/L) and monitor frequently

© S.T.A.B.L.E.®

2001

Umbilical Vein Catheter (UVC)

• Placed in the IVC above the

diaphragm at the RA junction

– Don’t leave in the portal system, ductus

venosus, or deep right atrium

• Low placement — below the liver —

appropriate for emergencies until other

IV access established

© S.T.A.B.L.E.®

2001

T12

11

10

9

8

7

6

5

4

3

2

T1

UVC tip in acceptable position in

low right atrium

Optimal location is at IVC/RA

junction

© S.T.A.B.L.E.®

2001

Umbilical Artery Catheter (UAC)

• High lines

– Tip is located between T6 and T9

• Low lines

– Tip is located between L3 and L4

• Confirm placement with x-ray

© S.T.A.B.L.E.®

2001

UAC high line –tip in good position at T9

T12

11

10

9

8

7

T6

© S.T.A.B.L.E.®

2001

Temperature

• Detrimental effects of cold stress

• Vulnerable infants

• How body heat is lost

• Pulmonary vasoconstriction and

shunting

• Warming severely hypothermic infants

Temperature

• Keeping healthy babies warm is an instinctual behavior for caregivers

• Preventing cold stress in sick or small infants can be challenging

© S.T.A.B.L.E.®

2001

Hypothermia

• Extremely vulnerable

infants include:

– Low birth weight

– Those requiring prolonged

resuscitation

© S.T.A.B.L.E.®

2001

Resuscitation and Cold Stress

• Dry quickly — remove wet linens

• Use warm blankets

• Provide radiant warmer heat

– Place infant on ISC/servo control

• Use heated, humidified O2 as soon as

possible

– Remember: cold gas (O2) in, warm exhaled gases

out

© S.T.A.B.L.E.®

2001

Artificial/Assisted Breathing

• Evaluating respiratory distress

• Indications for positive pressure ventilation and endotracheal intubation

• Assisting with intubation

– ET tube sizes

– Securing tubes

– Location on chest x-ray

• Evaluating for pneumothorax

Blood Pressure

• Types and signs of shock

• Treatment of shock

– Hypovolemic

– Cardiogenic

– Septic

• Dopamine infusion

– Calculations and safe use

Blood Pressure Summary

Organ dysfunction results from inadequate perfusion and oxygenation

Evaluate for underlying problems and treat aggressively

Base decision to treat with volume and/or medications on the physical assessment and history, not just the blood pressure

© S.T.A.B.L.E.®

2001

Lab Work

• Initial lab evaluation

• Clinical signs of sepsis

• CBC interpretation

– ANC, I/T ratio, and platelet evaluation

• Antibiotic therapy

Lab Work the 4 B’s

Blood Count

Blood Culture

Blood Sugar

Blood Gas

CBC with differential

Obtain before starting antibiotics

Check early and be vigilant

If respiratory distress or shock suspected© S.T.A.B.L.E.

®

2001

Lab Work Summary

• Review maternal and neonatal history for risk factors for infection

• Watch for signs and symptoms of infection

• Be suspicious even if symptoms are subtle

• Draw a blood culture and start antibiotics promptly© S.T.A.B.L.E.

®

2001

Emotional Support

• Understand how the family may

react during the crisis

• Understand ways health care

providers can support families of

sick infants

Infant care during the journey

• Minimal active intervention should be

needed during the transfer

• The infant's temperature should be

maintained during any journey

• When possible, the environmental

temperature of the vehicle should be

raised.

Minimising heat loss from the infant

during transport

• Raise the environmental temperature of the

vehicle if possible

• Ensure doors of vehicle are closed

• Ensure doors of transport incubator are closed

• Use a heated gel mattress (also helps absorb

vibration and improve general comfort for the

infant)

During transport

• Connect to ambulance power supply if

possible and use ambulance O2

• Incubator and all equipment securely

fixed

• Monitor power and gas supplies

• Do not open portholes unless its

necessary

• Assess baby continuously

• Never perform emergency procedures in

a moving ambulance

• Keep a clear, concise record of events

• On arrival help with stabilization and give

a thorough handover

• Back at base – clean, re-charge, replace,

check (integrity / expiry dates)

During transport

Problems during transport

• Spontaneous clinical deterioration i.e.

pneumothorax

• Equipment i.e. endotracheal tubes and

intravenous lines dislodge

• Equipment to deal with such situations

must be carried.

Communication and documentation

• verbal and written communication

• Use of clinical guidelines, operational

policies, and checklists

• Parents also informed about plans for their

baby's care

• The transport team should meet the

parents when possible

• In some settings informed consent is

needed for transport and care.

• If parents are not travelling in the

ambulance with their infant, they may

need to know how to get to the destination

hospital and what facilities will be available

for them when they arrive.

Communication and documentation

MODE OF TRANSPORT

• Road

• Fixed wing

aircraft

• Helicopter

Choice of vehicle

The mode of transport depends on :

• Resource availability

• Geography

• Clinical pathology,urgency of the situation

• Experience of the staff.

Criteria for deciding which method

• Distance between hospitals

• Traffic density

• Buildings in town or city – hazard for

helicopters

• Weather

Air tranfer

Air transfers

• Needs more organization than road transfers.

• requires specialist training and skills from staffs

• Important physiological effects of flying must be taken into account.– Hypoxia

– barometric pressure drop

– thermal change

– Dehydration

– gravitational forces

– noise, vibration, and fatigue

Transport equipment

• Incubator

• Ventilator

• Gases

• Suction

• Monitors

• Infusion pumps

• Transport bag

Transport equipment

• Equipment for intubation, IV access, chest tube placement

• Drugs

• Portable blood gas analyzer

• Portable blood glucose analyzer

Equipment

• incubator fixed to a transport trolley with

integrated ventilator, monitor, intravenous

pump, and medical gas supply

Transport equipment

• The equipment should be designed to

function while in motion

• all equipment should be run from the

transport vehicle's power supply if possible

• Medical gases sourced from the transport

vehicle should be used whenever

possible.

Personnel and training

• All staff involved (M.D.,RN,paramedics)

should have competency in

– appropriate training in neonatal transport

medicine

– local organizational procedures

– Operation of transport equipment.

Hazards of transportation

• Heavy equipment – E.U. directive =

140kgs

• Noise / vibration

• Road safety - normal driving speeds best

• Traffic Accidents

• Altitude