ACEM 201_Neonatal transport and stabilization santi

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For ACEM 2011 participation : Critical Care transfer

Text of ACEM 201_Neonatal transport and stabilization santi

  • 1. Neonatal stabilization and transport Santi Punnahitananda M.D.,M.Sc.(Clinical Epidemiology) Department of Pediatrics, Faculty of Medicine Chulalongkorn University

2. NEONATAL TRANSPORT HISTORY: 3. THE SAFEST AND BEST WAY TO TRANSFER 4. Interhospital neonatal transport in utero transfer has better clinicaloutcomes for mother and infant thantransfer after birth In utero transfer is not always possible 5. Reasons for transferring infants between hospitals No appropriate local facilities No cots available locally Insufficient appropriate staffs availablelocally e.g. pediatric surgeon, cardiologist Unexpected delivery far from home Transfer back to local facility 6. Neonatal transport :ideal A dedicated transport team consisting ofAmbulance personnel, Paediatrician Respiratorytherapist, Neonatal Nurse Adequate equipment dedicated for the transportof the infant only. Governmental and private medical facilitiesagreeing upon a fixed set of transport guidelinesthat are on par with the rest of the world. 7. If not, Medical and nursing staff from eitherreferring or receiving units undertake thetransport on an ad hoc basis. 8. Limitation Variable experience in neonatal transportand the equipment used The vehicle may not be dedicated forneonatal use 9. Neonatal transport: present We all know about receiving a baby that ise.g. cold, faulty equipment, and moreunstable than when it left the transferringhospital Not enough qualified personnel andequipment within the different departmentstransporting neonates. 10. Safe transport of the preterm infant Early anticipating the need for transfer Appropriate preparation for transfer Ongoing high quality care during transfer 11. Anticipation An opportunity to seek advice Gathering staff with the right skills Preparation of appropriate equipment Direct communication between senior staffin the two involved centers 12. Principles of safe transport Team composition Communication Preparation / planning Stabilization 13. Principles of safe transport Documentation Prepare for worst case scenario Maintenance of equipment Safe delivery of the patient 14. StabilizationSpecific treatments should be considered : antibiotic treatment surfactant replacement volume support or inotrope support analgesia, sedation, paralysis anticonvulsant treatment nitric oxide 15. Stabilization before transfer Any remedial action should be taken beforemoving the baby and not during the transport. the infant should be in as good a clinicalcondition as possible before setting off the decision to stabilise the infant further orinstitute specific treatments must be weighedagainst a delay in transfer 16. The S.T.A.B.L.E. Mnemonic S ugar T emperature A rtificial/Assisted breathing B lood pressure L ab work S.T.A.B.L.E. E motional support2001 17. The Basics Come First! ABC S.T.A.B.L.E. S.T.A.B.L.E.2001 18. Sugar Initial IV therapy Fluid rates and calculations Glucose monitoring Hypoglycemia assessment and interventions Umbilical catheters Placement and safe use 19. Sugar Summary Suspecthypoglycemia 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 20. Umbilical Vein Catheter (UVC) Placed in the IVC above the diaphragm at the RA junction Dont 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 21. T1 UVC tip in 2acceptable 3 position in 4low right5atrium67Optimal 8location is 9at IVC/RA 10junction11 T12 S.T.A.B.L.E.2001 22. 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 23. T6789UAC 10high line 11 tip in good T12 position at T9 S.T.A.B.L.E.2001 24. Temperature Detrimental effects of cold stress Vulnerable infants How body heat is lost Pulmonary vasoconstriction andshunting Warming severely hypothermic infants 25. 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 26. Hypothermia Extremely vulnerableinfants include: Low birth weight Those requiring prolongedresuscitation S.T.A.B.L.E.2001 27. 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 28. Artificial/Assisted Breathing Evaluating respiratory distress Indications for positive pressureventilation and endotracheal intubation Assisting with intubation ET tube sizes Securing tubes Location on chest x-ray Evaluating for pneumothorax 29. Blood Pressure Types and signs of shock Treatment of shock Hypovolemic Cardiogenic Septic Dopamine infusion Calculations and safe use 30. 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 31. Lab Work Initial lab evaluation Clinical signs of sepsis CBC interpretation ANC, I/T ratio, and platelet evaluation Antibiotic therapy 32. Lab Work the 4 Bs Blood Count CBC with differential Blood Culture Obtain before starting antibiotics Blood Sugar Check early and be vigilant Blood Gas If respiratory distress or shock S.T.A.B.L.E. suspected2001 33. 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 S.T.A.B.L.E. antibiotics promptly2001 34. Emotional Support Understand how the family mayreact during the crisis Understand ways health careproviders can support families ofsick infants 35. Infant care during the journey Minimal active intervention should beneeded during the transfer The infants temperature should bemaintained during any journey When possible, the environmentaltemperature of the vehicle should beraised. 36. Minimising heat loss from the infant during transport Raise the environmental temperature of thevehicle if possible Ensure doors of vehicle are closed Ensure doors of transport incubator are closed Use a heated gel mattress (also helps absorbvibration and improve general comfort for theinfant) 37. During transport Connect to ambulance power supply ifpossible and use ambulance O2 Incubator and all equipment securelyfixed Monitor power and gas supplies Do not open portholes unless itsnecessary 38. During transport Assess baby continuously Never perform emergency procedures ina moving ambulance Keep a clear, concise record of events On arrival help with stabilization and givea thorough handover Back at base clean, re-charge, replace,check (integrity / expiry dates) 39. Problems during transport Spontaneous clinical deterioration i.e.pneumothorax Equipment i.e. endotracheal tubes andintravenous lines dislodge Equipment to deal with such situationsmust be carried. 40. Communication and documentation verbal and written communication Use of clinical guidelines, operationalpolicies, and checklists Parents also informed about plans for theirbabys care The transport team should meet theparents when possible 41. Communication and documentation In some settings informed consent isneeded for transport and care. If parents are not travelling in theambulance with their infant, they mayneed to know how to get to the destinationhospital and what facilities will be availablefor them when they arrive. 42. MODE OF TRANSPORT Road Fixed wingaircraft Helicopter 43. Choice of vehicleThe mode of transport depends on : Resource availability Geography Clinical pathology,urgency of the situation Experience of the staff. 44. Criteria for deciding whichmethod Distance between hospitals Traffic density Buildings in town or city hazard forhelicopters Weather 45. Air tranfer 46. Air transfers Needs more organization than road transfers. requires specialist training and skills from staffs Important physiological effects of flying must betaken into account. Hypoxia barometric pressure drop thermal change Dehydration gravitational forces noise, vibration, and fatigue 47. Transport equipment Incubator Ventilator Gases Suction Monitors Infusion pumps Transport bag 48. Transport equipment Equipment for intubation, IV access, chesttube placement Drugs Portable blood gas analyzer Portable blood glucose analyzer 49. Equipment incubator fixed to a transport trolley withintegrated ventilator, monitor, intravenouspump, and medical gas supply 50. Transport equipment The equipment should be designed tofunction while in motion all equipment should be run from thetransport vehicles power supply if possible Medical gases sourced from the transportvehicle should be used wheneverpossible. 51. Personnel and training All staff involved (M.D.,RN,paramedics)should have competency in appropriate training in neonatal transportmedicine local organizational procedures Operation of transport equipment. 52. Hazards of transportation Heavy equipment E.U. directive =140kgs Noise / vibration Road safety - normal driving speeds best Traffic Accidents Altitude