Neonatal Land Transport-Juniper Publishers
Juniper Publishers-Journal of Pediatrics
Summary
Owing to good perinatal care (prenatal detection of
problems and timely transport of pregnant women), critically ill
newborns are usually delivered in large centres (with tertiary perinatal
care provided) where they can be given intensive care and therapy. When
this is not the case, a critically ill newborn must be transported to a
centre with a higher level of perinatal care. The less time it takes
from identifying a problem to transpor to a higher level centre, the
better the chances for a better outcome, even though the transport of
newborns is still tied to higher morbidity and mortality rates than in utero transport. This is especially the case with extremely preterm and very preterm neonates.
The successful medical transport of such high-risk
and sensitive population requires a highly specialized personnel and
appropriate equipment. In ideal conditions, the neonatal transport team
is a link in the system of neonatal care followed by an intensive care
unit where critically ill newborns are treated (with the right
personnel, equipment and subspecialists for diagnostics and therapy when
needed).
The composition of transport teams varies according
to the transport type (by land, air or water) and referral organization
(one way, two ways, medical teams specialized in neonatal transport);
however, education, competence and equipment including the necessary
medical supplies should be appropriate for the level of care. Also,
basic stabilization measures before transport and the necessary medical
and technical procedures before and during transport are the same in all
the types of transport mentioned. Special procedures (administration of
surfactants, 'cooling', administration of prostaglandins) should be
performed by an experienced team well familiar with the application
techniques, monitoring methods and possible complications (and how to
deal with them).
The peculiarity of neonatal transport are surgical
patients with congenital anomalies who require specific procedures (such
as gastric emptying, ventilation, certain body positioning etc). Any
transfer, as well as any medical procedure should be properly documented
(pretransport documentation, newborn's condition at the transport team
arrival, performed interventions, the course of transport, any
complications, transport time etc).
Assessing the right transport indications,
maintenance of competence and keeping the transport team properly
equiped make neonatal transport a significant segment of operations of
any healthcare facility.
Introduction
Away from the secure and well supplied neonatal
intensive care unit (NICU), with special equipment and limited
personnel, and often uncertain and unpredictable transport course, a
transport team works in conditions far from ideal. During transport, a
newborn is exposed to numerous harmful noxae - noise, vibrations,
acceleration or deceleration, temperature instability, all of which
could additionaly aggravate an already difficult condition. The
treatment outcome of the transported newborn depends on a number of
factors, some of which can be measured - acidosis levels, retained
carbon dioxided levels, blood pressure, glucose in blood levels, and
temperature. Maintaining the neonate's organism homeostasis is thus of
vital importance, but sometimes very difficult to achieve during
transport.
In view of all above mentioned factors, neonatal transport is a risk for a newborn as well as for a transport team [1-3].
The first transport incubator constructed for 'the care of weak and
premature infants' was used in 1900 by Dr. Joseph De Lee (Chicago
Lying-In Hospital). The incubator was used to transport 'these weak
children from remote parts of town and suburbs' [4].
The regionalization of perinatal care in the entire
world, which started during the 1970's, contributed to the agglomeration
of ill neonates in the centres that could provide diagnostics and
treatment for most of neonatal diseases. Directly resulting from
regionalization, the number of transports of critically ill neonates
increased, to centres where they are taken care of and diagnostical and
therapeutical procedures fully observed, either in utero, before
birth (applying corticosteroids, for instance), or during and directly
following birth (nCPAP, surfactant). Deregionalization that is under way
in developed countries implies creation of intensive care units in
various healthcare facilities (and ample investments into equipment and
personnel) with staff training and highly developed transport network.
The aim is to bring each and every newborn, should there be a need, to
tertiary care with appropriate diagnostics and treatment.
Transport could elevate the risk of mortality and
aggravate the newborn's illness. Ill neonates that are transported from a
lower to a higher level centre of perinatal care usually have a less
successful outcome that the ones born in a high level care centre; even
the newborns that are transported between the same high level care
centres have a worse outcome than the neonates that were not
transported. This is the reason why, when assessing potential neonatal
problems, in utero transport is the best solution [1,2].
Even though regionalization, deregionalization and
even grading of neonatal departments, that is a division of NICU into
different categories (primary, secondary, tertiary) have been carried
out, there is still a certain number of newborns in need of intensive
care and therapy that are born in primary and secondary care settings.
These are most often the reasons:
A. Unforeseen or unidentified perinatal circumstances that do not allow for the mother to be transported - no time for in utero transport;
B. Unidentified prenatal condition that is life threatening for a newborn;
C. The pregnant woman's (obstetrician's) wish to deliver the baby in a certain facility;
D. Some other reason;
E. Neonatal transport from secondary or tertiary care NICU to a higher level.
Modes of Neonatal Transport
Cocnerning the type of vehicle and other options, the
transport can be made by land or air, and also on water. Transport
vehicles used for land transport can be specialized emergency medical
vehicles, rarely standard emergency medical vehicles with the addition
of a mobile incubator; air transport implies the use of special
aeroplanes and helicopters for the transport of patients, but standard
aeroplanes and helicopters can be used as well with the additon of
mobile incubators. Waterway transport makes use of vessels that can be
fitted with an incubator. The advantages of land transport are as
follows:
A. The lowest cost
B. Mostly not affected by the weather conditions
C. Better fitted to patients
D. Vehicles interior can be customized (dedicated exclusively to neonatal transport)
E. Land transport allows (with appropriate equipment)
for the transport of several patients simultaneously (two mobile
incubators).
Shortcomings of land transport are:
A. Slowness
B. The need to secure the incubator stability and to bring in all the necessary equipment (2).
Generally speaking, critically ill neonatal transport
(apart from in utero transport and the so-called 'intra-hospital'
transport, which are segments in their own right) can be organized as
A. two ways transport and
B. one way transport.
These two transport types (mostly) differ according to who organizes and who performs the transport:
A. Two ways transport: usually organized and carried
out by a higher lever healthcare facility team. (It is a common practice
that teams from facilities with Illb or Illc perinatal care levels
organize two ways transport of critically ill newborns; the advantages
are the presence of competent personnel, appropriate equipment and the
immediate treatment).
B. One way transport: by a healthcare facility team
organizing the transport into a facility of a higher level care. (In
most cases, there is no specialized transport team, it is formed ad hoc
with basic transport equipment).
C. By a specialized team for neonatal transport: this
kind of transport is characteristic of countries with vast territories
and small population (such as Australia), where the predominant mode of
transport is by air. These teams are specially trained and supplied so
they can start and administer therapy en- route [5].
D. By teams for emergency medical assistance who
perform neonatal transport along their regular duties (critically ill
neonatal transport occurs sporadically) without the presence of a
neonatologist or specially trained neonatal transport physician on
board.
Two Ways Land Transport of Critically Ill Newborns
To ensure timely, safe and beneficial transport, the following conditions should be met:
A. Appropriate transport team composition;
B. Required competencies and skills of transport team members ;
C. Required transport equipment:
D. Required drugs and medical supplies;
E. Accurately assessed transport indications;
F. Choosing the optimal time (newborn's age and condition) for transport.
Concerning the composition of the critically ill neonatal transport team, its permanent members can be:
A. A physician, a nurse (compared to the modes of
transport, physicians and nurses can be specially trained for neonatal
transport or carrying out the transport by merely monitoring the
patient).
B. A registered nurse, a respiratory therapist (This
transport team composition is characteristic of countries where the
costs of transport are very high if a physician is on board, so it is
more cost effective having a respiratory therapist in the team - with a
physician 'on line'.
C. A nurse (trained to monitor vital parameters and
perform basic cardiopulmonary resuscitation (CPR), while consulting with
a physician 'on line' in case of any other problems).
D. Driver (In some countries drivers are also trained nurses).
In the case of land transport, the physician makes
the decision about the transport speed and whether to call for police
escort in order to ensure undisturbed ride without speeding or slowing
down. If the newborn is stabilized before transport, there is almost no
need for high speed driving. If it is possible to plan transport ahead,
it is best to avoid the time of traffic rush hour. Should the newborn's
condition worsen during transport or a certain medical procedure must be
performed (reintubation, tenting or mere auscultation), the transport
vehicle should be stopped so that the procedure can be properly
performed.
The transport of ill newborns is a demanding task
which requires specific equipment and competencies; each transport
should be planned so that the risk of complications en-route is
minimized ; it is much more difficult and involves higher risk to
intervene during transport (intravenuous cannula insertion, endotracheal
intubation) than performing these in a regional hospital. These are the
reasons why certain conditions and procedures must be met before
transport takes place [6,7].
Condtions and procedures before transport:
Stabilization of an Infant
Before each transport, the condition of the newborn must be stabilized as much as possible and the therapy administered [7,8]. Then the following measures are [5,9]:
Respiratory stabilization
Many diseases in newborns manifest through
respiratory problems, even in cases when the primary disease is not
respiratory. Neonatal respiratory reserves are relatively small and
without adequate control respiratory problems may become significant. It
is of vital importance to ensure enough oxygenation and ventilation
(with appropriate pCO2) before transport. If there is a need for
respiratory support by using nasal CPAP or for intubation and assisted
ventilation, respiratory support should be provided in such a way that
there is enough even in case of condition aggravation during the
transport. If it is uncertain that the newborn will be able to breathe
spontaneously, the infant should be intubed before transport and
adequate ventilation secured. Whenever it is possible, acid-base status
should be checked before transport.
Circulatory stabilization
Neonatal circulation is rather unstable and many
diseases due to which the newborns are transported are accompanied by
different digrees of circulatory insufficiency This is especially the
case with newborns having respiratory problems (Respiratory Distress
Syndrome, Meconium Aspiration Syndrome), heart diseases and serious
infections. Newborn's circulation state can be assessed by measuring
arterial blood pressure. Invasive blood pressure measurement is the
safest and most reliable option; it is also possible to use a cuff, but
it is less reliable. It is compulsory to check the blood pressure values
before transport and to compare them with normal values for that age
and gestational age. The occurence of metabolic acidosis refers to
circulatory insufficiency and must be treated before transport. Newborns
with unstable circulation, who are given intravenous therapy or
endotracheal intubation should have at least two vascular lines open [10].
Temperature stabilization
It is important for a newborn to have normal
temperature before and during transport. Hypothermia will increase
respiratory problems as well as the risk of other complications.
Overheating, especially of asphyctic newborns may increase the risk of
cerebral disease. (This is why therapeutic hypothermia is planned for
before transport).
Metabolic stabilization
It is necessary to start with dextrose infusion
before transport, and the enteral food should be evacuated (by emptying
the stomach) in order to prevent aspiration of gastric contents during
transport. Normal need for glucose is equal to the solution of 10%
dextrose with the volume of 3,6ml/kg/h (6mg/kg/min glucose).
Stabilization of the Central Nervous System (CNS)
Some severely ill newborns have convulsions. It is of
vital interest to secure metabolic needs of CNS before transport,
especially by avoiding hypoglycemia. It is necessary to stop the
seizures prior to transport. Some authors report higher grade and
frequency of ICH in transported neonates [11].
Infection treatment
At slightest suspicion, adequate antibiotics therapy
should be administered prior to transport. Obtaining samples for
microbiological analyses is beneficial before starting with
antimicrobial therapy [12,13].
Surfactants administration prior and during transport
Administration of surfactant prior the transport is
safe. The newborn should be given time to stabilize after surfactant was
administered. Administration of surfactant does not influence the
frequency of transport of low birth weight neonates into centres with
higher levels of care and treatments [14-17].
Administration of prostaglandins during transport
In spite of adverse effects of prostaglandins
(hypotension, vasodilatation, redness, heart rhythm disorder,
convulsions, apnea, hypoventilation, frequent bowel movement, diarrhoea,
pyrexia), its administration is not contraindicated to most congenital
heart defects (except for total anomalous pulmonary venous return). The
recommendation for patients who are administered prostaglandins during
transport is to be electively intubated for timely therapy of sudden
apnea. Every facility should have its own protocol or prostaglandins
administration during transport [18-21].
Cooling during transport
Therapeutic hypothermia that is started within six
hours after birth has as a result better neurodevelopmental outcomes at
term neonates with moderately severe and severe Hypoxic Ischemic
Encephalopathy. The largest number of these neonates are born in
facilities where NICU are not properly equipped for cooling; with the
addition of transport time, it is quite possible that therapy will start
late, so that neuroprotective effect of cooling should be initiated
even during transport, optionally by passive cooling. Every facility
that transports neonates should have its own protocol on this procedure
concerning the necessity of a systematic approach[22,23].
Communication with regional facilities, medical documentation etc
Prior to transpott a regional healthcare facility
should be contacted to ensure stabilization of the newborn (especially
in the case of surgical diseases, congenital defects, etc). One should
obtain a list of the required documents to be given to the transport
team (X-ray records, laboratory analyses results). It is important to
note whether it is necessary for mother's blood to be taken [23].
Transport team
The required competencies (theoretical and skills) of the transport team members:
A. Physician: Beside theoretical knowledge of
pediatrics- neonatology and perinatology, they must be skilled at:
nasogastric tube placement, catheterization of urinary bladder, rectal
tube placement, peripheral venuous cannulation, central venuous
cannulation (and of umbilical vein), endotracheal intubation, pleural
space drainage, surfactant administration, application of respirator,
aspirator and defibrillator. They should be excellent with techniques of
manual ventilation and CPR. Beside theoretical and practical knowledge,
they must be able to recognize and act immediately upon any change in
the neonate's condition during transport as well as anticipate potential
problems.
B. Nurse: Beside competence and skills, they are
responsible for all the apparatus to be in working order, they must know
in detail how to assemble all transport devices, check the contents of
transport medical supplies (expendable supplies and drugs). They are
skillful at performing CPR.
C. Driver: is responsible for the transport vehicle,
gas and power supply to all machines and devices. They should be trained
to repair any potential defects during transport and finds the best
transport route (through rush hour, extreme weather conditions).
Necessary equipment
1. Mobile incubator with a transport ventilator
2. Device for the applicatin of nitric oxide
3. Portable ecmo
4. Cooling device
5. Oxygen hood
6. Monitor (ECG, respiratory, pCO2, pO2)
7. Pulse oximeter
8. Body temperature measuring device
9. O2 concentration measuring device
10. Blood pressure measuring device (by cuff or artery blood pressure)
11. Reanimation balloon with masks (in different sizes)
12. Intubation equipment
13. Air way (different sizes)
14. Aspirator
15. Injectomats
16. Stethoscopes (for the physician and the nurse)
Before placing the equipment into the transport
vehicle, it must be inspected. Its working order and contents are
checked. Following the equipment, all connections are checked (power,
medical gases) and their state of operation. Drugs and expendable
medical supplies container is inspected before and after it was brought
into the vehicle. All the equipment used during transport must be
inspected and serviced timely and regularly. There has to be a nurse
responsible for releasing/taking complete and working equipment.
Medications that are prepared for transport have to be properly labeled
and packed, and there has to be a person responsible for this. Transport
equipment and applied medications and medical supplies should be
recorded in their own documents.
If any device is not working properly, it should be detected in time, duly noted and repaired [23].
lt is vital that transport team is very well familiar
with monitoring equipment and ablr to manage in situations when this
equipment is unreliable [12].
Medications that are required for transport (in
appropriate solution, with precisely stated concentration, i.e. the
amount of drug per unit of volume):
1. Adrenalin
2. Adenosine
3. Antibiotics
4. Aqua redestilata (pro injectione)
5. Bensedin
6. Calcium
7. Dexamethason
8. Dopamin
9. Dobutamin
10. Diuretics
11. Fentanyl
12. Flormidal (Midazolam)
13. Dextrose 10%, 5%, 12,5%, 50%
14. Glucagone
15. Heparin
16. Hydrocortison
17. Konakion (vitamin K)
18. Lidocaine
19. NaCl 0,9% , NaCl 3% normal saline, 3% saline
20. NaHCO3 8,4% bicarbonate
21. Phenobarbiton
22. Prostaglandin
23. Surfactant
Expendable medical supplies required for the transport (plastic and suture material).
Documentation
Accurate and proper record keeping is an important
segment of neonatal transport. If there is no possibility for a
telephone conversations to be recorded - and even if there is, a written
form should be filled, containing the following items [24-27]:
A. When, where from and who makes the call (name and surname of that person - physician or nurse)
B. General information about the patient to be transported (name and surname, sex, date and hour of birth, place of birth)
C. Discription of the disease along with therapy and diagnostic procedures results; current diagnosis
D. Assessment of the emergency of transport
E. Instructions to the caller - potential diagnostic and therapy procedures to be performed before the transport team arrives
F. Contact person's name and telephone number that transport team can contact if needed
G. Assessment of time from the moment of making the
telephone call to the transport team's arrival (which is told to the
person making the call).
Following the transport team arrival, the physician
(or nurse) who had made the call (or treated the newborn until the
transport team arrival) validates the medical documents stating the
patient's condition by signing them when the team has arrived. It is
useful to hand over to the transport team the copy of work-ups, X rays,
blood type of the newborn and mother, important information about
pregnancy - diseases, an antibody titer etc. Transport sheet should
contain the name and surname of the physician, the nurse and the driver
who carried out the transport [9,11].
Disinfection during transport
Disinfection during transport is very important in
order to prevent spreading multi-resistant germs from one facility to
another.
Parents' consent prior to transfer
Prior to transport parents must be fully acquainted
with the information of their child's condition and the purpose of
transfer. With different congenital malformations it is important to
explain to parents the type and kind of defect, the options of treatment
and the risks. One should be very careful about giving prognosis
concerning that transfer itself does not guarantee survival and healing.
Parents should sign a written consent for the transport and special
procedures (transfusion of blood products, or surgery if necessary) [28-30].
It is of great importance for parents to be able to
see and touch their child, and if possible, take photographs or get the
newborn's foot print before transport. If parents cannot be transported
together with their newborn, the regional hospital is obliged to give
them information about the place and possibilites of staying with their
child (accommodation for mothers, a hotel etc).
Most NICU that newborns are transferred to have
brochures with the information about the department, its address,
telephone number, that should be given to parents before transport.
Parents need to meet the people in charge of the transport (know the
name and surname of the physician and nurse). If it is assessed that the
newborn is critically ill with an unfavourable prognosis, the team may
talk to parents about potential naming and christening the child, etc [31-33].
For more articles in Academic Journal of
Pediatrics & Neonatology please click on:
https://juniperpublishers.com/ajpn/index.php
https://juniperpublishers.com/ajpn/index.php
Comments
Post a Comment