Stabilization of the Newborn for Transport Arlen Foulks, DO FAAP FACOP Medical Director, CCMH Level II NICU Medical Director, NeoFlight Assistant Professor of Pediatrics Neonatal Perinatal Medicine Section, Department of Pediatrics OU Health Sciences Center Relevant Disclosure Under Accreditation Council for Continuing Medical Education guidelines, disclosure must be made regarding relevant financial relationships with commercial interests within the last 12 months. I have no relevant financial relationships or affiliations with commercial interests to disclose Learning Objectives Upon completion of this session, participants will improve their competence and performance by being able to: Review the history of neonatal transport Explain why neonatal transports are necessary Identify common conditions and Discuss treatments prior to transport Review how to contact NeoFlight and arrange for a neonatal transport Describe what to expect when the NeoFlight team arrives 1
History 1834 first description of neonatal intubation 1853 to 1855 establishment of Children hospitals 1857 Jean Louis Paul Denuce (1824 1889) had concept of a incubator 1878 French obstetrician Stephane Tarnier developed the Tarnier Martin Couveuse incubator History 1899 First portable transportation incubator by Joseph Bolivar DeLee (1869 1942) 1948 First organized transportation program 1950 s & 60 s Silverman and associates proved the need for heat and humidity for premature survival in randomized controlled trials 1960 s & 70 s Hospital based neonatal transport programs were created Why transport??? Main reason to deliver a sick or at risk (preterm) neonate needing special care to a tertiary care center that offers subspecialties and optimal resources to provide intensive care that can not be provided at the referring hospital Studies have shown this improves overall outcome 2
Who should be transported??? Extreme premature newborns Newborns with malformations Newborns with surgical conditions Newborns with conditions that can not be managed locally due to constraints of resources and staff at that local facility Goal of preparation for transport STABILIZATION!!!! Stability of a baby s condition is far more important than speed of transport Care given in the first few hours after birth is just as important if not more important to a newborn s outcome as the care given days or weeks at a regional intensive care nursery Basic Preparation for Transport Check Vital signs Temp, Resp rate, Heart rate, and BP Lab tests Blood glucose, Hematocrit, Blood gas, other tests Establish an IV line Obtain x rays if warranted Prepare copies of charts and x rays 3
THINGS TO CONSIDER S. Sugar and Safe Care T. Temperature A. Airway B. Blood pressure L. Lab work E. Emotional support IV Fluids/Access Peripheral IV (PIV) or Umbilical lines (UAC arterial or UVC venous) will need to be placed Use D10W as your main fluid to maintain appropriate serum glucose levels and to avoid excessive electrolytes early on (usually since urine output may not have been established well yet) Normal Saline (NS) can be used for fluid resuscitation in cases of hypovolemia or initial blood loss If using an Umbilical line or Central line then make sure there is 0.5 to 1 unit of heparin per 1 ml of IV Fluid (IVF) to prevent the line from clotting Hypoglycemia Newborns at risk include: Preterm infants (<37 wks) Small for gestational age (SGA) infants Infants of diabetic mothers (IDM) Large for gestational age (LGA) infants Stressed, sick infants Infants exposed to certain maternal medications in utero 4
Hypoglycemia Signs/Symptoms of Hypoglycemia Weak, High pitched cry Poor feeding Hypothermia Tremors/Jitteriness Hypotonia/Lethargy Seizures Tachypnea Hypoglycemia Blood glucose level below 40 mg/dl If below this and baby is asymptomatic and not sick then allow to feed and check a postprandial glucose level 30 min after the feed If hypoglycemia persists then obtain IV access and give a 2 ml/kg IV bolus of D10W Glucose levels should be checked every 30 min until stable and then every 4 hrs Hypoglycemia In a sick baby then do NOT feed and instead just obtain IV access and give a 2 ml/kg bolus of D10W and start IVF of D10W (without electrolytes) at 80 ml/kg/day Maintain blood glucose levels between 40 120 mg/dl Continue to monitor blood glucose levels every 30 min until stable and then every 4 hrs 5
Temperature Normal core temperature between 36.5 and 37.5 C (97.7 99.5 F) Hypothermia Mild: 36 36.4 C (96.8 97.6 F) Moderate: 32 35.9 C (89.6 96.6 F) Severe: <32 C (<89.6 F) Deviations from normal core temperature range increases metabolic rate and oxygen consumption Temperature Newborns most vulnerable for hypothermia: Preterm (especially < 32 wks) Small for Gestational Age (SGA) Require prolong resuscitation Acutely ill newborns Newborns with open skin defects Temperature Mechanisms of Heat Loss Conduction protect the baby from contact with cold objects Convection protect from air currents and keep air warm (26 to 28 C or 78.8 to 82.4 F) Evaporation quickly dry the baby and remove wet linens (plastic bags help) Radiation Keep baby away from cold window or walls and place in an incubator 6
Airway Establishing a patent airway in a newborn is essential in newborn stabilization It is important that a newborn s lungs establishes the functional residual capacity (FRC) in a timely manner for gas exchange to occur Airway Insufficient breathing fails to force fluid from the lungs Lack of ventilation of the lungs results in sustained constriction of pulmonary arterioles, preventing blood oxygenation Hypoxia and ischemia can cause bradycardia resulting in systemic hypotension Airway Issues that hinder breathing Respiratory distress due to surfactant deficiency Secretions or meconium in the way Respiratory depression due to hypoxia ischemia Respiratory depression due to maternal drugs Excessive or deep suctioning by care providers 7
Airway Indications for positive pressure ventilation (PPV) Apnea/ gasping Heart rate less than 100 bpm, even if breathing Persistent central cyanosis despite 100% free flow oxygen Abnormal blood gas showing poor ventilation or oxygenation Airway Ways to provide PPV: Self inflating bag or Flow inflating bag T piece respirator Ventilator 8
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Airway Once an airway is secure then constant monitoring of the patient is needed Pulse oximeter Chest X ray (CXR) should be obtained Blood gas (preferably arterial at first in order to properly assess PaO2) to monitor ventilation Vitals assessed routinely Respiratory Issues Congenital Diaphragmatic Hernia (CDH): Decreased breath sounds on affected side Bowel sounds on the affected side Scaphoid abdomen If known or suspected do not give mask PPV or continuous positive airway pressure (CPAP), instead intubate immediately and administer PPV or CPAP Place orogastric (OG) or nasogastric (NG) tube and remove air from stomach to facilitate lung expansion Obtain CXR and blood gas 11
Respiratory Issues Pneumothorax: Presents with respiratory and cardiovascular deterioration Definitive diagnosis is with CXR but transillumination can help Treatment: Needle aspiration or chest tube placement Studies have not shown that Nitrogen washout promotes faster resolution compared to RA Respiratory Issues Meconium aspiration: New recommendations by Newborn Resuscitation Program (NRP) that even depressed infants do not have to be intubated and suctioned immediately Instead treat as a normally depressed infant and if intubation is warranted and there is obvious meconium in the airway or endotracheal tube (ETT) that is hindering effective ventilation then suction Respiratory Issues Tracheoesophageal Fistula/ Atresia: History of polyhydramnios Present with respiratory distress with excessive salivation and choking, coughing, and cyanosis with feeding Make NPO (nothing by mouth) and provide IVF hydration and nutrition Place replogle suction on low intermittent wall suction to esophageal pouch Obtain CXR after placement 12
Respiratory Issues Airway obstruction Nose provide oral airway Mouth place prone and/or nasopharyngeal (NP) tube Larynx or Trachea intubate if possible or try an laryngeal mask airway (LMA) Blood Pressure/Cardiac SHOCK Presents with tachypnea, pale skin, cyanosis, bradycardia, tachycardia, hypotension, weak pulses, poor perfusion (prolonged cap refill), poor urine output Once you have hypotension then you have begun uncompensated shock Blood Pressure/Cardiac Types of Shock: Hypovolemic volume loss Cardiogenic poor contractility Septic hypotension from vasodilation and loss of fluid (capillary leak) 13
Blood Pressure/Cardiac Lab tests helpful in Shock Blood gas to look for metabolic acidosis Blood lactate Complete blood count (CBC) and c reactive protein (CRP) Blood culture Coagulation studies Liver function tests Blood glucose level Electrolytes, blood urea nitrogen (BUN), Creatinine, Calcium Possibly cardiac enzymes Blood Pressure/Cardiac Treatment of shock: Identify the cause(s) Treat or correct the cause(s) Hypovolemia give NS 10 ml/kg IV over 15 to 30 minutes, may need blood transfusion too if suspected blood loss Cardiac correct hypoxia, hypoglycemia, hypotension, acidosis, arrhythmia, calcium, etc. Septic inotropes (dopamine) and fluid is usually needed Blood Pressure/Cardiac Congenital Heart Defects (CHD) If you suspect a CHD from physical exam or due to the newborn failing the CCHD screen then call the NeoFlight Access Center at OU Children s Hospital While on the phone a Pediatric Cardiologist may also be involved on the conversation and management options will be discussed ECHOs for CHD should always be read and interpreted by a PEDIATRIC Cardiologist per AAP guidelines 14
Hypoxic Ischemic Encephalopathy (HIE) Potential Acute Perinatal Events may include: Variable/late fetal HR decelerations Prolapsed/ruptured or tight nuchal cord Uterine rupture Maternal hemorrhage/placental abruption Maternal trauma or CPR Any event that contributes to asphyxia prior to, at, or following birth Hypoxic Ischemic Encephalopathy (HIE) Criteria: 35 weeks gestation and are 1800 grams Contraindications Known cardiac disease Imperforate anus Evidence of head trauma or skull fracture causing major intracranial hemorrhage Birth weight of less than 1,800 gm Major congenital malformations Must meet 1 criteria in Category 1 and 3 in Category 2 Hypoxic Ischemic Encephalopathy (HIE) Criteria: Have at least one criteria below Category 1 Cord gas or ABG 1 hour of life with a: ph 7.0 or Base Deficit 16 APGAR 5 at 10 minutes Continued need for PPV or intubated at 10 minutes of life, required chest compressions, or epinephrine 15
Hypoxic Ischemic Encephalopathy (HIE) Criteria: Have at least 3 criteria below or have Seizures Category 2 Decreased Level of consciousness Decreased Activity Abnormal Posture Decreased Tone Weak/Absent Reflexes Abnormal Autonomic System findings (Pupils, heart rate, apnea) Hypoxic Ischemic Encephalopathy (HIE) Time is of the essence since cooling needs to begin within 6 hours of birth Passive cooling can and should begin at referring facility (prior to NeoFlight team s arrival) NEVER cool with ice packs PASSIVE Cooling Turn off radiant warmer (DO NOT Cool with cooling or ice packs) Monitor RECTAL temp every 15 minutes Goal Rectal Temperature: 34.4 C 35 C (93.92 F 95 F) If less <34 C (93.2 F), then turn on radiant warmer on Servo mode and set at 0.5 C higher than baby s current temp NEVER Rapidly COOL or REWARM a baby 16
PASSIVE Cooling Patient should be NPO and on D10W IVF at 60 ml/kg/day of total fluids Blood glucose needs to be monitored closely If SEIZURES are present then give loading dose of phenobarbital (20 mg/kg IV x1) Monitor vitals every 15 minutes with rectal temps Check blood gases per need of respiratory support, avoiding hyperventilation and hyperoxia Emotional Support Encourage emotional attachment between the parents and the newborn prior to transport Make sure the parent s have a clear understanding of their baby s condition and need for transport Offer up any other resources for support that the parents will need Consent for transport will need to be obtained Arranging Neonate Transport NeoFlight is a neonatal dedicated transport team based at OU Children s hospital at OU Medical Center Call 1 800 522 0212 or 405 271 7700 Prompted to press 1 for a neonate transfer Access center will connect you with NeoFlight team member and a Neonatologist 17
NeoFlight Transport After the referral call is made you will have an estimated time of arrival (ETA) NeoFlight team upon arriving at the facility will obtain more information on the patient s condition, review the chart, assess the patient, obtain any needed tests, and provide any treatment needed NeoFlight Transport NeoFlight is under medical control from a neonatologist at OU Medical Center, however the referring physician is in charge prior to the team leaving the facility The team will make sure prior to departure that the patient is stabilized to the fullest capacity for transport The team will need copies of the chart, results, and radiological studies to bring to the receiving facility Resources Karlsen, K. (2013). The S.T.A.B.L.E. Program pre transport post resuscitation stabilization care of sick infants: Guidelines for neonatal healthcare providers: Learner provider manual (6th ed.). Park City, UT: S.T.A.B.L.E. Program. 18