Neonatal Transport - Clinical Tree

KEY POINTS

1.
Transport is not a benign event for the neonate, the family, and the transport team.
2.
Transport is a significant transition in care and has risk and safety concerns beyond the physical movement of the neonate.
3.
Decompensation is not uncommon due to the movement, vibration, noise, and change in environment during transport and must be anticipated and addressed as needed.
4.
Neonatal transport is complex and labor and equipment intensive.
5.
Management may vary based on environment.

Introduction

Advances in neonatology and technology have led to increased survival rates of neonates, especially low birth weight infants. The neonatal period is defined as the first 4 weeks of life and is the period of greatest mortality in childhood. The mortality rate in infancy is 5.96 per 1000 infants, with a mortality rate during the neonatal period of 4.04 per 1000 neonates. Infants may be born outside a regional center and require transport to a neonatal intensive care unit due to low birth weight, congenital anomalies, or multisystem problems. Neonatal transport is a frequent, daily occurrence in which the process, workforce, resources, and quality of care may vary widely ( Box 5.1 ).

Box 5.1

Conditions Requiring Neonatal Transport

The primary reasons for neonatal transport often mirror the common causes of death in the neonatal period, followed by the need for subspecialty consultation, evaluation, and management.

1.
Prematurity and low birth weight
2.
Congenital and chromosomal anomalies
3.
Maternal complications (preeclampsia, maternal abruption, placenta previa, cord prolapse, or accidents)
4.
Sepsis
5.
Respiratory distress secondary to respiratory distress syndrome, transient tachypnea of the newborn (TTN), and metabolic derangements
6.
Necrotizing enterocolitis with or without bowel perforation
7.
Intrauterine hypoxia and birth asphyxia

Evaluation

Clinical Evaluation

When a referral is made for a neonatal transport, it is important and useful to make an initial brief assessment or brief clinical assessment and evaluation of the infant, his or her most likely diagnosis, and the urgency for the transport team to arrive at the referring facility. A transport referral or intake sheet is a tool commonly used by transport teams to obtain certain clinical data in order to better assess the acuity and potential urgency for transport. The personnel, equipment, and resources available at the referring facility may vary widely depending on the level of perinatal care designation and the services provided there. Assessment of this variability allows for triage and appropriate use of the transport team.

Initial Management Assessment

During the initial call, the accepting neonatologist or physician should make an initial management assessment and suggest any additional treatments to initiate while the team in en route. It is important to professionally suggest alternative therapies if an assessment is made for which initial management or therapies are not optimal.

Laboratory

If not already done, request that vital signs are assessed, including temperature, blood pressure of all four extremities, and respiratory rate. The initial laboratory evaluation will vary depending on the diagnosis but always should include a blood glucose level. If the glucose level is assessed by an automated bedside analyzer and is less than 50 to 110 mg/dL, recommend that a serum glucose sample be sent. Recommend immediate intravenous treatment if the blood glucose level is less than 50 to 110 mg/dL, depending on the clinical scenarios. A recommendation to obtain other laboratory analyses will depend on the suspected or confirmed diagnosis(es).

For respiratory symptoms, appropriate initial laboratory testing includes glucose, ABG/CBG, and serum electrolytes. For suspected infection, laboratory testing should include NEC, glucose, complete blood cell count (CBC), CRP if available, and a blood culture. An inquiry about history of maternal herpes simplex virus infection (HSV) should be made.

Imaging

Access to timely radiology testing can be a challenge at some facilities, but when available, a chest x-ray and/or an abdominal x-ray is recommended, depending on the presentation of the neonate. If the infant has been intubated, recommend a chest x-ray (with an orogastric tube in place before obtaining the film). Imaging for other less common diagnoses may be beyond the scope of this chapter but include a suspected subgaleal hematoma and thus an urgent need for further studies. Confirm endotracheal tube placement by at least two methods including chest x-ray, direct laryngoscopy, capnography, and auscultation.

Management

Temperature Regulation

One of the principles of a successful transition to extrauterine life is maintained thermoregulation. ^, Cold stress can mimic and indeed worsen other possible comorbidities such as hypoglycemia and respiratory distress syndrome and has been implicated in an increased risk factor for intraventricular hemorrhage and other long-term outcomes in the very low birth weight infant. The infant should be managed with appropriate support to ensure normothermia. The infant should be transported in a temperature-controlled isolette with additional thermal support when indicated, including but not limited to the use of a disposable, gel-filled warmer mattress, polyethylene bags, and blankets whenever cold stress is a concern during transport. ^,

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