S f trip

Safe t i for
f newborn
b

Rinawati Rohsiswatmo
 Background
B k d

|T
|Transporting
ti sick
i k neonates
t isi nott an easy task.
t k
|Indeed, in cases of atrisk pregnancy , it is safer
to transport the mother prior to delivery than to
transfer the sick baby after birth( in-utero
transport ).

Indian Pediatr. 2008 Nov;45(11):920-2

transport premature infants of
very low
l birth
bi th weigh
i h
 The
Th goall off newborn
b transport
t t

|to improve the clinical status in a critically ill infant

who
h is
i distant
di from
f a hospital
h i l thath provides
id the h
required level of intensive care

|Stabilization before transport is of prime

importance to avoid deterioration in transit and also
to improve the outcome

Air Medical Journal Associates. 2010; 30:3

Wh is
Why i stabilisation
t bili ti important?
i t t?

|To optimise an infants outcome, it is the responsibility

of the healthcare team to deliver the most
comprehensive, anticipatory and appropriate care to
sick neonates.
|To morbidity and morbidity

STABLE

Neonatal pre-transport stabilisation caring for infants the STABLE way. Infant 1(1): 34-37.
Newborn
N b ttransportt

|Preparing everything (equipment and

personnel) still anticipating the unexpected
personnel),

|Working in a multidisciplinary field .

|Thinking out of the box

 T
Transport
t personnell

Neonatal transport is usually accomplished by a team of 2

or 3 health care pprofessionals,, which includes;;
| Physicians/ fellows/specialist/resident (senior)
| Nurse practitioners/ Nursing staff with formal training
Neonatal Nurse Practitioner (NNP) Program
| Ambulance driver
| Other health care providers

National Survey of Neonatal Transport Teams in the United States

 T
Transport
t personnell

|The NETS (Newborn Pediatric Emergency

Transport Service. Do we moving intensive care
for kids) team : a clinical nurse spesialist and
neonatal registrar or consultant.
consultant
|Highly skilled in all aspects of neonatal
management and transportincluding oxygenation,
oxygenation
ventilation, fluid and drug therapy, temperaature
regulation
g and clinical procedures.
p
WHILE
AWAITING
NETS
Continue
Continue observation
Keep the infant warm
Keep
Keep the infant pink
Keep the airway clear
Be
Be sure respiration is
adequate
Neonatal transport: skilled assistance

Skilled team
Not onlyy reduced the
Inadequate trained
mortaality and
staff with
morbidty
Inadequate facilities
1/3 reduction in
Increase the mortality
duration of
following the arrival
hospitalization
of cold hypoxic
yp
hypotensive infants

J. Pediatric 93:662,1978
 Transport
T t equipment
i t

Equipment provided for transport | Blood glucose meter

includes :
| Transport incubator with power
supply
supply.
| Supplies of oxygen and medical air | Equipement for intubation,
| Continuous monitors for temperature
, heart rate, and respiratory status
| Blood pressure manometer
| Pulse oximeter
| Ventilation equipment
| Suction apparatusa
| Medications of resuscitation
inserting a chest drain, umbilical
catheterization,, and other
procedures
| Camera to provide a photograph of
the infant for the parents
| Ultrasonography portable
Ventilation equipment (1)
providing CPAP
Ventilation equipment (2) providing CPAP
Ventilation equipment (3) providing NIV &
Invasif ventilation
Ventilation equipment (3)
Transport incubator
V til ti transport
Ventilation t t during
d i MRI
 Ultrasonography
d i transport
during t t

| can visualize the anatomic

position of the ETT position
| Can visualize Distance of
endotracheal tip to arch of aorta
| early ultrasound examinations
allow diagnosis of hemorrhagic
lesions, and later ultrasound
examinations can detect cystic
lesions or ventriculomegaly.
ventriculomegaly
| useful for the diagnosis of voiding
dysfunction in children with
abnormal urinary symptoms.

Paediatr Child Health. 2001 Jan; 6(1): Kidney Int. 1999 May;55(5):1920-6
3943
 Stabilization before transport:

Stabilization before transport can be considered in

th categories:
three t i
1. Attention which all babies require
2. Attention which some babies require attention
3. Conditions requiring specific management
Remember that unskilled attempts at procedures may
expose a sick infant to stresses that are more harmful
than the potential benefit of the procedure being
undertaken
1. Attention which all babies
require
i

| During transpor neonatal patient, the patient must have 6 stable

points verified by the responsible coordinating physcian:
1. Open airway and adequate ventilation
2. Skin and lips pink
3. Pulse rate 120-160 x/mim
4. Axilary temperature 36,5-37,3 Oc
5 Corrected
5. C d metabolic
b li problems
bl
6. Special problems managed
2. Attention which some babies
require attention

Attention to these problems may involve specialized skills

and knowledge
| Fluid and electrolyte therapy
| Acidosis
| Shock
| Infection
| Hypoglycemia
| seizures
3. Conditions requiring specific
managementt

| Choanal atresia
| Pierre Robin Syndrome
| Pneumothorax
| Diaphragmatic
p g hernia
| Gastroshisis
| Congenital cardiac defects
| Cardiac arrhythmias
| meningomylecele
St bili ti off some
Stabilization
specific problems
 Ch
Choanal
l atresia
t i

| Bilateral choanal atresia is a rare conditions recognized by the fact that the
infants becomes pink while crying, but still quiet becomes cyanotic, despite
good RR
| These infants must be provided with an oral airway and this is best done by
an oropharyngeal
p y g airwayy strapped
pp in pplace
| In the absence of an oropharyngeal airway, a finger in the mouth will create a
temporary airway
| Position
os o thee infant
a pprone
o e oor oon thee right
g sside
de w
with cchin sslightly
g y eelevated
eva ed
| Continuous observation of the pattern breathing is essential
| Early surgical evaluation and correction the CA is recommended
Ch
Choanal
l atresia
t i Management
M t

| The babyy was

stabilized, and airway
was maintained via a
soft rubber nipple.
| The tip of the nipple
was cut, and placed in
the neonate's mouth to
facilitate breathing.
| It was secured with tape
and thereby an airway
was created

( Department of Pediatrics and Child Health,

The Aga Khan University Hospital, Karachi. )
 Pi
Pierre - robin
bi syndrome
d

Diagnosis
| a small lower jawa usually accompanied by a cleft palate which results in
the tongue falling back into the pharnx to narrow or block the airway
| The best overcome by posturing the infant in prone position, with the
jjaw and tongue
g hanging
g g free,, if possibe,
p , the infant should also be
transported in this position
| Occasionally an OPA is useful
| Nasopharnyngeanl intubation may be attempted if an OPA is not
sufficient but the endotracheal intubation, even in very experienced hands
is very difficult
| A tongue stitch or clamp to pull the tongue forward may be effective
| Continuous observation of the pattern of RR and of colour is mandatory
Pi
Pierre - robin
bi syndrome
d managementt
 Di h
Diaphrgmatic
ti hernia
h i
Diagnosis
| RD related to hypoplastic lung and
presence of the bowel in the chest
| Severe cases severe asphyxia
| Dextrocardia or scaphoid abdomen
| Diagnostic procedure : x-ray, showing
loop of bowel in the thoracic cavity
| The most common on th left side due
to a defect in the left hemi-diaphragm ,
with
w t the
t e herniaton
e ato of o stomach
sto ac and
a d
bowel into the left hemithoraks
Management Diaphrgmatic
h
hernia
i

|intubated immediately to avoid bag-mask

ventilation and inflation of the bowel that has
herniated into the chest
|Minimal handling and disturbance the baby
from crying
|The ppassage
g of an 8 or 10 NGT mayy provide
p
some drainage of gas and should be aspirated
frequently
 P
Pneumothorax
th

Diagnosis
|Sudden unexplained deterioration (not due to
interruption of oxygen supply)
| chest movement and air entry (maybe
unilateral)
|Displacement of apex
ape beat
|Abdominal distention (variable sgin)
 Pneumothorax

Clinical Presentation
RD or sudden clinical deterioration with
alteration of VS and worsening of BGA
Cyanosis, bradycardia or tachycardia
Asymmetry of thorax is present in unilateral
cases.

The definitive diagnosis is made by an A-P and a

lateral CXR
Transillumination : for rapid detection
False (+) : skin edema, subcutaneous air,
pneumomediastinum, severe PIE
False (-) : thick chest wall, dark skin, room
too light, weak transiluminator
P
Pneumothorax
th

Neopix (pedialink.org)
 M
Management
t pneumothorax
th (1)

|Emergency decompression by insertion of a needle

eg
eg 21 gauge butterfly needle attached to a 3 way
stopcock an a 10 ml syringe
|Infants supine insert the needle into the pelural
space going directly over the top of the rib in the
2md and 3rd intercostal space in the midclavicular
line
|Avoid the nipple
|P i the
|Point h neddle
ddl inferiorly
i f i l
Management pneumothorax (2)

|Chest tube insertion in

neonate
 G t
Gastroschisis
hi i

|Infant with gastroschisis have major problems with

temperature control.
control
|Vast amounts of heat are lost from exposed gut by
evaporation
|To minimize heat and external fluid loss and protect
against
g infection the exposed
p area should be
covered with a clean plastic drape (sterility not
essential )
Management Eg plastic cling
wrap either as a
Gastroschisis sheet or a bag
securedd att the
th
neck
Routine
measures
should be
utilized
ili d to keep
k
the baby warm
 C
Congenital
it l cardiac
di defects
d f t

o Symptoms in the newborn period have a very high

probability of a ductus dependent defect,
defect this may
present
o Cyanosis in the case of ductus dependent pulmonary
circulation type of defect ed transposition of the great
artery
o With rapid omset CHF proceeding often to a state of
shock with poor or absent peripheral pulses- in the case
of ductus dependent systemic defects, coarctation of
the aorta,
aorta hypoplastic lung heart syndrome
 Management Congenital
cardiac defects

a. general supportive measures including: O2,

ventilation volume expansion
ventilation,
b. assessment and corection of acidosis
c. Support of hypotension with dibutamine or
p
dopamine
d. Imfusion of Prostaglandin E1
e Consult
e. Cons lt cardiologist
Important Thing in Transport of
Newborn
|Transport intrauterin
BEST
|Transport after the
baby is stable
|Refer newborn not
displaced
MORTALITY to the
other place
p
Step administration Nasal Prong
for CPAP

Sambungkan ETT yang

Potong ETT setinggi telah dipotong dengan
5 cm dari ujung connector

Masukkan ETT sampai

batas garis hitam
 NEST

Closed circuit system in the

central line of Peripherally
I
Inserted
t dC Central
t lCCatheter
th t
(PICC)

| Umbilical emergency
Key
K tto successful
f l ttransportt

|Properly assessing the infant

|Preventing stressors
|Properly intervening
|Knowing physiologic changes

Borroes. Pediatr Crit Care Med 2010

C
Conclusion
l i

| Neonatal transport nurses are an important part of a team

composition
| Family centered care should be a part of a services
| Proper fixation of the infant during transport need to be
mandatory
| High level hygiene standart is to be a part of transport
services guidelines
| Dont forget Endotracheal tube fixation during transport