Transport of Sick Newborn

1. Transport of Sick Newborn

6. Successful high quality care Very Expensive (( Costly)) Require not only excellence from physicians, nurses, and other health professional But also A System of organization that permits the health professionals to function as cohesive team within community

7. Organizing Regional PrenatalSevices Perinatal-neonatal leaders in SA have been addressing perceived concerns relating to the quality of care for years Significant hospital-specific variations in the quality of perinatal & neonatal care

8. Topics To Be Discussed Regionalization Roles of a neonatal transport service Transport process Guidelines of stabilization Equipment and drugs Follow up Examples of sick newborn transport Study 1900 the development of first mobile incubator Chicago 1950 the first report of an organized transport progrm in US in 2 years period more than 1,209 pts 16% <1000gm transported. 1970 perinatal care regionalization1900 the development of first mobile incubator Chicago 1950 the first report of an organized transport progrm in US in 2 years period more than 1,209 pts 16% <1000gm transported. 1970 perinatal care regionalization

9. Beginning Late 1950�s and early 1960�s NICUs� became available

11. Regionalization In early 1970�s, Classification of nursery care into levels Primary I, Secondary II and Tertiary III Organized integrated guidelines between these levels of care established for better care Decreased neonatal mortality

13. Level I Nurseries Routine well newborn care To stabilize high-risk newborn Level II Nurseries Level I + support to smaller sicker infants Healthy growing premature IV support Oxyhood No prolonged ventilation

15. Maternal transport results in improved neonatal outcomes when compared with neonatal transport (Arch Gynecol Obstet 2001 Aug;265(3):113-8 ) Safe transfer of these mothers and infants to Level III is an important part of care Early Hum Dev 2001 Jun;63(1):1-7

16. Maternal Transportation After regionalization of prenatal care Are neonatal transport services needed?

17. Do We Need Neonatal Transport Service ? All hospitals require some transportation facilities Transporting from one city to another or simply within the hospital 30% or more of neonatal problems are identified after birth in Level I or II centers

20. Transport Process Communication The success or failure of many transport programs depends on the quality of communication system that supports the program. Toll-Free hot line Access for the physician referring a patient Coordinate the activities of the transport team Control NICU beds Sophisticated computerized communications network

21. Transport Process Information important for each consultation to the HOTLINE: 1) Neonatal Data 2) Paternal Data 3) Perinatal history 4) Diagnosis And reason for transfer

22. Disease entities Medical Respiratory distress MAS with PPHN Birth complications Inborn Error of met. Apnea, not doing well etc ... Surgical CDH CHD TOF NEC Abdominal wall defect

23. Personnel for Transport Service Consultant Neonatologist Physician, fellows, specialist, resident (Senior) Nursing staff with formal training program NNP Respiratory therapists Administrative assistant Secretarial services

24. Transport Equipment Two sets to be ready Safety regulations to be followed Replacement and maintenance

25. Transport Equipment Transport incubator equipped with Ventilator & Monitors (HR, RR, O2 sat, PB, Temp. ) Suction device Infusion pumps Airway equipment ( bag& mask, Laryngoscope) Tanks of Oxygen and compressed air Stethoscope Chest tube tray Vascular catheters

27. Isoproterenol Dopamine Dobutamine Glucagon Prostaglandin E1 Furosemide Dexamethasone Fentanyl Surfactant

29. Technical problems Excessive Noise Vibration Improper lighting Variable ambient temperature and humidity Changes in barometric pressure Confined space Limited support services

30. How to minimize these problems? Prepare the transport vehicle Assess and stabilize the baby extensively before transport. Monitor electronically all possible physiological parameters. Anticipate deterioration

35. Wrong Baby Term baby born to 23ys Saudi mother By E C/S Good A/S 7 �8 -9 Immediately after birth, developed central cyanosis With O2 saturation 75% on 100% Oxygen Baby transported to us with a nurse No IV line On arrival Looks pink , Normal physical Exam CVS normal pulses Normal S1 & S2 No murmur Pulse ox meter 98% on room air

36. Un safe Transport Term newborn infant Borne NSVD with thick MSA, Developed Sever respiratory distress Intubated, Connected to CMV but continue to had sever hypoxia. Transported with physician and one nurse with out portable incubator or ventilator

38. Pneumothorax After chest drainage , Connected to HFOV, Received NO. After 5 days of stabilization baby Extubated and transfer back to referring Hospital

39. Objectives Evaluate the outcome of neonatal transport. Developed simple and practical system for assessing transport outcomes. Re-evaluate our documentations during and on arrival to tertiary center

40. Results A total 263 Neonatal transports to KKUH, NICU . 87 Neonates involved in the study 47 male : 40 female 65 / 87 (75%) were Saudi 26/87 (30%) were premature < 1500gm Mortality Rate of 24/87 (28 % ) 10/87 immediate (3days) deaths (11.5 %) NICU mortality (8%)

41. Excluded Neonates 107 No Documentation chart available 9 Neonates with AWD diagnosed as trisomy 18 60 social and financial reasons

42. Timing & Method of Transport Ground Transport Total 63 pt (72% ) Mean age 17 days + 3 Mortality (15/63) 24% All ventilated infants transported by inadequate equipments Air Transport Total 24 pt (28%) Mean age 6 days + 2 Mortality (13/24) 54% All ventilated infants by portable vent.

43. Diagnosis

44. Inborn Vs Out born Mortality

45. Complications

46. Other Complication Pneumothorax 16/87 (18%) Blocked Et tube 13 ( 15%) Collapse lung 11 (13%) Iv line infiltration 7 (8% )

47. Guidelines of Stabilization Stable newborn: Patent airway and adequate ventilation Pink skin and lips (O2 sat) Normal BP for size and age Normothermic ( 36.5�-37�C) Metabolic problems corrected - e.g.. hypoglycemia, acidosis, etc

48. Assisted Ventilation/Resuscitation Assisted ventilation may be required when respiratory distress occurs with any of the following: Bradycardia (heart rate less than 80/minute) PaCO2 greater than 65 mmHg Central cyanosis in 100% oxygen Persistent apnea PaO2 less than 50 mmHg in 100% oxygen

49. Management of Hypothermia 20 � 35% Among ELBW Eliminate source of heat loss Place the infant in an environment one degree above the neutral thermal environment (for age and weight). Temperatures should be taken before transport. Consider using: silver swaddle (foil, saran wrap) - these do not warm the infant, but prevent further radiant losses. heat shield (commercial shield or oxyhood) - place over the infant's body to prevent further radiant losses additional humidity

57. Follow-up Referring physician should call or visit the Level III nursery to know about the condition and progress of his infant Discharge summary to be sent to the referral hospital Long-term follow-up can be shared between the primary care facility and the tertiary care

58. Return Transport If intensive care is no longer needed - purposes: Facilitate parental contact Link the infant to local follow-up system in the community Decrease financial cost for family and system Increase contact between staff in different levels of the system

59. Outcome Of infants Transported Back Tertiary units are obliged to ensure that there are appropriately trained personnel and facilities Overall complication rate is low (7%) Major new health problems developed in 27% Criteria for reverse transfer

60. Summary Communication Preparation ( Equipments and Personals ) Stabilization Parents Communication Loading Return Transport