Simulating whole-body vibration for neonatal patients on a tire-coupled road simulator

Exposure to excessive whole-body vibration is linked to health issues and may result in increased rates of mortality and morbidity in infants. Newborn infants requiring specialized treatment at neonatal intensive care units often require transportation by road ambulance to specialized care centers, exposing the infants to potentially harmful vibration and noise. A standardized Neonatal Patient Transport System (NPTS) has been deployed in Ontario, Canada, that provides life saving equipment to patients and safe operation for the clinical care staff. However, there is evidence that suggests patients may experience a higher amplitude of vibration at certain frequencies when compared with the vehicle vibration. In a multi-year collaborative project, we seek to create a standardized test procedure to evaluate the levels of vibration and the effectiveness of mitigation strategies. Previous studies have looked at laboratory vibration testing of a transport system or transport incubator and were limited to single degree of freedom excitation, neglecting the combined effects of rotational motion. This study considers laboratory testing of a full vehicle and patient transport system on an MTS Model 320 Tire-Coupled Road Simulator. The simulation of road profiles and discrete events on a tire-coupled road simulator allows for the evaluation of the vibration levels of the transport system and the exploration of mitigation strategies in a controlled setting. The tire-coupled simulator can excite six degrees-of-freedom motion of the transport system for vibration evaluation in three orthogonal directions including the contributions of the three rotational degrees of freedom. The vibration data measured on the transport system during the tire-coupled testing are compared to corresponding road test data to assess the accuracy of the vibration environment replication. Three runs of the same drive file were conducted during the laboratory testing, allowing the identification of anomalies and evaluation of the repeatability. The tire-coupled full vehicle testing revealed a high level of accuracy in re-creating the road sections and synthesized random profiles. The simulation of high amplitude discrete events, such as speed hump traverses, were highly repeatable, yet yielded less accurate results with respect to the peak amplitudes at the patient. The resulting accelerations collected at the input to the manikin (sensor located under the mattress) matched well between the real-world and road simulator. The sensors used during testing included series 3741B uni-axial and series 356A01 tri-axial accelerometers by PCB Piezotronics. These results indicate a tire-coupled road simulator can be used to accurately evaluate vibration levels and assess the benefits of future mitigation strategies in a controlled setting with a high level of repeatability.

Noise exposure exceeded safe limits during neonatal care and road transport but was reduced by active noise cancelling

AIM

Noise levels above 45 dB in a neonatal intensive care unit (NICU) and 60 dB during neonatal transport are recognised hazards, but protective equipment is not standard. We measured noise levels in both settings, with and without noise protection.

METHODS

Peak sound and equivalent continuous sound levels were measured in a NICU and during road transport, at a mannequin's ear and inside and outside the incubator. Recordings were made without protective earwear, with noise protecting earmuffs and with active noise cancelling headphones.

RESULTS

In the NICU, the peak levels at the ear, and inside and outside the incubator, were 61, 68 and 76 dB. The equivalent continuous sound levels were 45, 54 and 59 dB. During road transport, the respective levels were 70, 77 and 83 dB and 54, 62 and 68 dB. In the NICU, 80% of environmental peak noise reached the ear and this was reduced to 78% with earmuffs and 75% with active noise cancelling. The respective figures during transport were 87% without protection and 72% with active noise cancelling, with an unexpected increase for ear muffs.

CONCLUSION

Noise levels exceeded safe limits in the NICU and during transport, but active noise cancelling reduced exposure.

The impact of teleneonatology on the Transport Risk Index of Physiologic Stability score for outborn neonates: A prospective, observational study

INTRODUCTION

Teleneonatology (TN) allows neonatologists to use real-time, audio-video telemedicine to manage critically ill neonates located in community hospitals (CHs). The California Transport Risk Index of Physiologic Stability (Ca-TRIPS) score is a validated metric that predicts the risk of 7-day mortality for neonates undergoing medical transport. We hypothesized that neonates born in CHs who received TN consults would have lower (better) Ca-TRIPS scores upon arrival of the transport team than those who did not.

METHODS

Neonates born in CHs between 8 December 2018 and 31 July 2022 who were transported to the neonatal intensive care unit were screened for eligibility. TN was available at 50% (12/24) of CHs, where care teams decided when to activate the service. Study data were abstracted from the electronic health record and used to calculate Ca-TRIPS scores. Scores were evaluated using zero-inflated negative binomial regression.

RESULTS

Forty-two percent (161/385) of neonates received a TN consult. Neonates that received TN had lower birth weight, gestational age, and Apgar scores and were more often admitted with respiratory distress syndrome and respiratory failure. Neonates who received TN were less likely to have a Ca-TRIPS score of zero (odds ratio 0.51; 95% confidence interval 0.33, 0.78). When adjusted for baseline characteristics, this difference was no longer significant. Non-zero Ca-TRIPS scores were not different between groups.

DISCUSSION

In this observational study, neonates that received TN did not have lower (better) Ca-TRIPS scores. Findings may be limited by confounding bias given between-group differences in baseline patient characteristics. Randomized studies are needed to determine whether TN impacts the physiologic stability of neonates requiring medical transport.

Comparing Three Methods of Therapeutic Hypothermia Among Transported Neonates with Hypoxic-Ischemic Encephalopathy

Hypoxic-ischemic encephalopathy (HIE) and associated multiorgan injury are significant causes of morbidity and mortality in term and near-term neonates. Therapeutic hypothermia (TH) is the current standard of care for neuroprotection in neonates with HIE. In our experience, the majority of babies born with HIE were found in nontertiary care facilities in our region, where effective methods of cooling during transport to tertiary care centers are desirable. Most centers initiate passive TH at referral hospitals, while active cooling is typically initiated during transport. The objective of this study was to evaluate the effectiveness of three methods of cooling during transport of neonates with HIE in southern Alberta. In this prospective cohort study, 186 neonates with HIE were transported between January 2013 and December 2021. Among the 186 neonates, 47 were passively cooled, 36 actively cooled with gel packs, and 103 cooled with a servo-controlled cooling device. The clinical characteristics were comparable for the three groups, with no difference in adverse events. Fifteen neonates (8%) died and 54 neonates (29%) suffered radiologically determined brain injury. Servo-controlled cooling was found to be superior to other methods in maintaining a target temperature without significant fluctuation during transport and with temperature in the target range on arrival at tertiary care facilities. The rate of overcooling was also lower in the servo-controlled group compared with other groups. There were no statistically significant differences between the groups in relation to mortality and brain MRI changes associated with HIE. Adjusting for GA, 10-minute Apgar score, base excess, HIE stage, and need for intubation during transport, passive cooling increased the odds of temperature fluctuation outside the range by 12-fold and gel pack cooling by 13-fold compared with servo-controlled cooling. The use of servo-controlled TH devices should be the preferred practice wherever feasible. (REB17-1334_REN3).

Capnometry during neonatal transport-Mini review

AIM

The aim of this review was to give an overview of available data on end-tidal CO2 (etCO2 ) monitoring, also called capnometry, during neonatal transport.

METHODS

Pubmed/MEDLINE database was searched using research question (capno* OR etCO2 OR detCO2 OR (['end tidal' OR 'end-tidal'] AND [CO2 OR 'carbon dioxide']) AND (neonat* OR infant* OR newborn*) AND transport*). All articles relevant to the topic were reviewed and summarised.

RESULTS

The lack of studies relevant to neonatal transport prompted us to extend the search to capnometry in a neonatal intensive care setting. The published studies are showing conflicting results. The different study populations, technologies used to measure etCO2 , types of etCO2 sampling and the diverse sites of blood gas tests make the data unsuitable for systematic comparison.

CONCLUSION

Further research to obtain more data on capnometry during neonatal transport will be necessary to define precisely under what circumstances can end-tidal monitoring of CO2 be reliably used in neonates during transport and also how to interpret the measured values.

Cooling strategies during neonatal transport for hypoxic-ischaemic encephalopathy

AIM

We reviewed the literature on cooling methods during transport of newborn infants with hypoxic-ischaemic encephalopathy (HIE) born in a non-tertiary centre and transferred to a neonatal intensive care unit for therapeutic hypothermia.

METHODS

The electronic databases CENTRAL, MEDLINE, Embase, CINAHL, and Scopus were searched from inception up to 8 March 2022 for studies comparing cooling versus no cooling, active versus passive cooling, and servo-controlled versus non-servo-controlled cooling. Odds ratio and confidence of interval were calculated for dichotomous outcomes and mean difference and confidence interval for continuous outcomes.

RESULTS

The final analysis included 14 studies, 1 randomised and 13 non-randomised, involving 1098 newborn infants. Compared with the other cooling methods, servo-controlled active cooling was more likely to maintain body temperature within the target range of 33°C-34°C on arrival at a neonatal intensive care unit: odds ratio 13.58, 95% confidence interval 4.32-42.66, risk difference 0.33, 95% confidence interval 0.19-0.46; 224 participants; three studies; I² 0%. The certainty of evidence was low. Only five studies reported mortality rates.

CONCLUSION

Servo-controlled active cooling may be the preferred method during transport of newborn infants with HIE. A future area of focus should be long-term neurodevelopmental outcomes after servo-controlled active cooling.

Neonatal emergency transport teams and general emergency departments: Who will intubate the neonate?

OBJECTIVE

Confidence treating critically ill infants presenting to general ED may be limited by inexperience, with procedures deferred until specialised transport teams arrive.

METHODS

This retrospective cohort study analysed critical procedures performed by referring ED physicians, compared with a neonatal emergency transport service, on infants transferred over a 12-month period.

RESULTS

All 150 eligible infants were included, with median (interquartile range) age 28 (16-43) days. Forty critical procedures were performed in this cohort. Of 26 intubations, 17 (65%) were performed by local ED physicians.

CONCLUSION

Referring ED physicians perform the majority of critical procedures where infants require inter-hospital transfer by neonatal emergency transport service.

Effective Passive Cooling During Neonatal Transport

We retrospectively evaluated the rectal temperature of 297 hypoxic-ischemic encephalopathy (HIE) outborn newborns who were passive-cooling transported by Neonatal Emergency Transport Service (Genoa and Rome, Italy) at their arrival in Neonatal Intensive Care Unit. By a total of 1461 transports, 297 were for suspected HIE. Transferring suspected HIE newborn does not mean with certainty directing him/her to cooling treatment, but rather to monitoring and deepening in the hypothesis of starting hypothermia. This is the main reason why we have chosen 35°C (±0.5°C) as the temperature target to be maintained during transport. Our study demonstrated that 263/297 patients (88.55%) passively cooled during transport were within the target limit of 35°C (±0.5°C), whereas 15 newborns were at rectal temperature >35.5°C (5.05%) and 19 were <34.5°C (6.39%); no patients were <33°C. In our opinion, these are satisfactory results. Overcooling, failed temperature target, and unstable temperature values are the main problems claimed to occur during passive cooling in transport. We would like to conclude underlining that a well-experienced neonatal transport team can use passive cooling expecting appropriate performances.

Trends in respiratory management of transferred very preterm infants in the last two decades

BACKGROUND

Among infants needing urgent transfer after birth, very preterm infants are a high-risk sub-group requiring special attention. This study aimed to assess trends in early respiratory management in a large series of very preterm infants undergoing postnatal transfer.

METHODS

Trends in patient characteristics and early respiratory management were assessed in 798 very preterm infants who were transferred by the Eastern Veneto Neonatal Emergency Transport Service in 2000-2019. Trends were analyzed using joinpoint regression analysis and summarized as annual percentage changes (APCs).

RESULTS

Proportion of neonates with birth weight less than 1 kg decreased from 33% to 16% (APC -3.82%). Use of nasal-continuous-positive-airway pressure increased (at call: APC 15.39%; during transfer: APC 15.60%), while use of self-inflating bag (at call: APC -12.09%), oxygen therapy (at call: APC -13.00%; during transfer: APC -23.77%) and mechanical ventilation (at call: APC -2.71%; during transfer: APC -2.99%) decreased. Use of oxygen concentrations at 21% increased (at call: APC 6.26%; during transfer: APC 7.14%), while oxygen concentrations above 40% decreased (at call: APC -5.73%; at transfer APC -8.89%). Surfactant administration at call increased (APC 3%-10%), while surfactant administration when arriving at referring hospital remained around 7-11% (APC 2.55%).

CONCLUSION

Relevant trends toward "gentle" approaches in early respiratory management of very preterm infants undergoing postnatal transfer occurred during the last twenty years. In addition, the proportion of transferred extremely low birth weight infants halved. Clinicians and stakeholders should consider such information when allocating assets to both hospitals and transfer services and planning regional perinatal programs.

Kangaroo position during neonatal ground ambulance transport: Parents' experiences

BACKGROUND

Kangaroo mother care including skin-to-skin care aims to overcome the negative effects of separating parents and infants and to increase the quality of care for infants and parents in need of neonatal care. In most cases where inter-hospital transport is needed, the infant is placed in a transport incubator, which increases the risk of separation due to ambulance service restrictions that imply that parents are not allowed to accompany these transport trips.

AIM

To illuminate parents' experiences of holding their infant in a kangaroo position during neonatal ground ambulance transport.

STUDY DESIGN

A qualitative design with an inductive approach.

METHODS

A total of 11 open interviews with Swedish parents were conducted two to seven days after their infant had been transferred in a kangaroo position between hospitals. The transcribed interviews were analysed using qualitative content analysis.

RESULTS

The emerged overarching category was "an uninterrupted closeness chain." The parents experienced that holding their infant during the transport extended the time they were close to their infant. Using the kangaroo position during ground ambulance transport also created a feeling of being important as a parent, as their participation during transport was appreciated. Parents' experiences were allocated into three categories: "Strengthen the feeling of being important as a parent," "promote security and create a positive environment for the baby" and "the professionals' attitude promotes security."

CONCLUSION AND RELEVANCE FOR CLINICAL PRACTICE

This knowledge about parents' experiences is important in the continued work to develop interventions that focus on promoting zero separation in neonatal care. Using kangaroo position in a safety harness during ambulance transport enhances zero separation and closeness. To encourage the implementation of kangaroo position during ambulance transport, further research is needed to address parents' experiences of zero separation during transport of infants to a higher level of care.

Fifty Years of Progress in Neonatal and Maternal Transport for Specialty Care

Specialty care for preterm and critically ill infants has evolved over many years. Neonatal intensive care nurseries were developed, and physicians and nurses learned how to provide intensive care for these infants. Neonatal and maternal (in utero) transport to tertiary centers became common in regionalized systems of care to facilitate the specialized care of high-risk neonates when childbirth occurred in settings without specialized personnel or equipment. Annually, nearly 70,000 neonatal transports occur in the United States. Although specialty care helps reduce rates of neonatal mortality, racial disparities and disparities between urban and rural areas exist. The purpose of this article is to review the progress achieved in neonatal and maternal transport over the past 50 years. The knowledge developed can be used to improve the care provided to women, their fetuses, and infants.

Exploring physiological stability of infants in Kangaroo Mother Care position versus placed in transport incubator during neonatal ground ambulance transport in Sweden

BACKGROUND

The positive effects of Kangaroo mother care in NICU's are well documented but, to a lesser extent, explored during inter-hospital neonatal transport. Inter-hospital transport, with the infant placed in a transport incubator, increases the risk of separation while infants in Kangaroo mother care position implies that the parents accompany the transport. There exists limited knowledge if physiological stability differs when transported in Kangaroo mother care position compared to transport in a transport incubator.

AIMS

The aim of this study was to compare physiological stability of infants transported via ground ambulance in either Kangaroo mother care position or positioned in a transport incubator.

METHOD

In total, 24 infants were recruited to be transported between hospitals in either a Kangaroo mother care position (n = 16) or in a transport incubator (n = 8). Inclusion criteria were; current weight >1500 g; current gestational age above 31 ^{+ 0}  weeks; no central catheter; no respiratory support and no planed painful or distressing interventions during the 48-h follow-up period post-transport. Exclusion criteria were; infants whose parents did not speak or understand Swedish or English and infants with a current weight above 4500 g for the KMC group. Physiological stability was obtained during transport and for a 48-h follow-up period by measuring body temperature, respiratory and heart rate, oxygen saturation, pain score, transport risk assessment and number of interventions during transport and 48-h post-transport. Cost-effectiveness and adverse events were also evaluated.

RESULTS

Both groups had comparable background characteristics and physiological stability during transport and for the 48-h follow-up period after transport. Transporting in Kangaroo mother care position was more cost-effective.

STUDY LIMITATION

A small sample size in both groups.

CONCLUSION

Transporting an infant in Kangaroo mother care position can be regarded as a choice of transport mode when the infant fulfils the set criteria.

Smartphone monitoring of in-ambulance vibration and noise

Transferring sick premature infants between hospitals increases the risk of severe brain injury, potentially linked to the excessive exposure to noise, vibration and driving-related accelerations. One method of reducing these levels may be to travel along smoother and quieter roads at an optimal speed, however this requires mass data on the effect of roads on the environment within ambulances. An app for the Android operating system has been developed for the purpose of recording vibration, noise levels, location and speed data during ambulance journeys. Smartphone accelerometers were calibrated using sinusoidal excitation and the microphones using calibrated pink noise. Four smartphones were provided to the local neonatal transport team and mounted on their neonatal transport systems to collect data. Repeatability of app recordings was assessed by comparing 37 journeys, made during the study period, along an 8.5 km single carriageway. The smartphones were found to have an accelerometer accurate to 5% up to 55 Hz and microphone accurate to 0.8 dB up to 80 dB. Use of the app was readily adopted by the neonatal transport team, recording more than 97,000 km of journeys in 1 year. To enable comparison between journeys, the 8.5 km route was split into 10 m segments. Interquartile ranges for vehicle speed, vertical acceleration and maximum noise level were consistent across all segments (within 0.99 m . s^-1, 0.13 m · s^-2 and 1.4 dB, respectively). Vertical accelerations registered were representative of the road surface. Noise levels correlated with vehicle speed. Android smartphones are a viable method of accurate mass data collection for this application. We now propose to utilise this approach to reduce potential harmful exposure, from vibration and noise, by routing ambulances along the most comfortable roads.

Interfacility Neonatal Transport for Convalescent Care: Improving Regionalized Care

BACKGROUND

Transfer of infants who no longer need intensive or specialized care from tertiary to community hospitals or clinics contributes to efficient bed utilization in neonatal intensive care units (NICUs).

METHODS

We retrospectively analyzed the records of all 1,503 infants admitted to our NICU during the 6-year period from April 2013 through March 2019 to evaluate the impact of interfacility neonatal transport for convalescent care.

RESULTS

During the study period, our NICU accepted 33 infants from other tertiary NICUs and transferred 103 infants to other hospitals or clinics before their home discharge for convalescent care. Our NICU covered 39% of the total hospital days of infants accepted from other NICUs. Among infants transferred to other facilities, 81% born at our hospital were born to mothers transported to our obstetrics department as imminent high-risk deliveries; 94% of infants born at other hospitals were moved back to the referring facility.

CONCLUSIONS

Interfacility neonatal transport for accepting and transferring infants for convalescent care is now an integral part of NICU practice, to bridge gaps between higher-level care facilities and homes. Establishment of well-defined transfer criteria and appropriate allocation of medical and staff resources among relevant facilities are desirable.

Post-haemorrhagic hydrocephalus management: Delayed neonatal transport negatively affects outcome

BACKGROUND

Post-haemorrhagic ventricular dilatation (PHVD) still represents an important cause of brain injury in premature infants. Intervention for PHVD is recommended once Ventricular Index (VI) crosses the 97th percentile + 4 mm line according to Levene.

OBJECTIVES

We aimed to compare PHVD severity, timing of intervention, and outcome between outborn infants transferred to a level IV NICU in order to be treated for PHVD and a control population of inborn infants.

METHODS

Preterm infants with PHVD requiring treatment were divided into: outborn infants (transferred to our NICU in order to be treated for PHVD) and inborn infants (PHVD diagnosed at our NICU). Age at intervention, difference between VI and the 97th percentile according to postmenstrual age (VI-p97), permanent shunt rate, and developmental delay rate were compared between the two groups. Neurodevelopmental outcome was assessed using the Vineland Adaptive Behavior Scales II (VABS-II), a parental questionnaire investigating four domains of adaptive behaviour and overall adaptive functioning. Developmental delay was defined as a score <70 (-2 SD or less).

RESULTS

Twelve outborn and 15 inborn infants were included. Age at intervention (31.6 vs 17.4 days) and VI-p97 (left 10.0 vs 5.1 mm, right 7.7 vs 5.1 mm) were significantly higher among outborn infants. A permanent shunt was inserted in 66.7% of outborn and in 40.0% of inborn infants (p = 0.18). After excluding subjects with parenchymal lesions, a significantly higher rate of developmental delay was observed at 5 years in outborn patients compared to inborn patients (66.7% of outborn vs 18.2% of inborn patients with VABS-II composite score <70, p = 0.04).

CONCLUSIONS

Outborn infants reached a significantly more severe ventricular dilatation than inborn infants, largely exceeding the recommended cutoff for intervention. Our follow-up data showed a trend towards a higher rate of permanent shunt and developmental delay in outborn than in inborn patients. Infants requiring treatment should be timely transported to centres with adequate expertise in PHVD management.

The immediate efficacy of inhaled nitric oxide treatment in preterm infants with acute respiratory failure during neonatal transport

AIM

The aim of our review was to describe the clinical response to inhaled nitric oxide (iNO) in a series of preterm babies in respiratory failure during uplift transfers to a neonatal intensive care unit.

METHODS

We performed a retrospective review of critical newborns with gestational age <34⁺⁰  weeks transferred from January 2013 to December 2018. Data were extracted from our Clinical Information System for transport. The primary measure of this review was to assess whether a significant improvement in the oxygenation saturation index (OSI) occurred following the use of iNO.

RESULTS

Thirty preterm babies <34⁺⁰  weeks were included in our review. OSI, as a measure of oxygenation, did not statistically improve as an immediate response to iNO from referral to receiving hospital (17.1 vs 16.4; P = .7). We found that pH (7.15 vs 7.29; P = .004) and pCO2 (8.1 vs 6.3; P = .05) significantly improved probably based on ventilation management.

CONCLUSION

Following the recommendations of the American Academy of Paediatrics and other organizations, iNO should not routinely be used during the neonatal transfer of preterm babies <34⁺⁰ in respiratory failure. We need to conduct further studies to establish which selected preterm patients would benefit from being treated with iNO.

Neurocritical care of high-risk infants during inter-hospital transport

The centralisation of neonatal intensive care in recent years has improved mortality, particularly of extremely preterm infants, but similar improvements in morbidity, such as neurodevelopmental impairment, have not been seen. Integral to the success of centralisation are specialised neonatal transport teams who provide intensive care prior to and during retrieval of high-risk neonates when in-utero transfer has not been possible. Neonatal retrieval aims to stabilise the clinical condition and then transfer the neonate during a high-risk period for patient. Transport introduces the hazards of noise and vibration; acceleration and deceleration forces; additional handling and temperature fluctuations. The transport team must stabilise the infant fully prior to transport as when on the move they are limited by space and movement to effectively attend to clinical deterioration. Inborn infants have better neurodevelopmental outcome compared with the outborn and aetiology of this seems to be multifactorial with the impact of transport itself during critical illness, remaining unclear. To improve the neurological outcomes for transported infants, it seems imperative to integrate the advancing intensive care neuromonitoring tools into the transport milieu. This review examines current inter-hospital transport neuromonitoring and how new modalities might be applied to the neurocritical care delivered by specialist transport teams.

Lung ultrasound in the diagnosis of neonatal respiratory failure prior to patient transport

PURPOSE

Lung ultrasound (LUS) at the point-of-care is a new method that is increasingly used in neonatology. The aim of this study was to determine the utility of the addition of LUS prior to the interhospital transport of neonates with respiratory failure.

METHODS

LUS was performed on 50 newborns with respiratory failure prior to transport to a tertiary neonatal intensive care unit. We analyzed the performance of LUS for diagnosing the cause of respiratory failure, the concordance between LUS, chest X-ray (CXR) and final clinical diagnosis, and the impact of LUS on clinical decision making before transport.

RESULTS

LUS sensitivity for the diagnosis of respiratory distress syndrome was 91.3% (95%CI: 70.5-98.5%), and specificity was 92.6% (95%CI: 74.2-98.7%), whereas sensitivity and specificity of CXR were 69.6% (95%CI: 47.0-85.9%) and 81.5% (95%CI: 61.2-92.9%), respectively. For the recognition of pneumothorax (PTX) LUS had a sensitivity of 83.3% (95%CI: 36.5-99.1%) and a specificity of 100% (95%CI: 89.9-100%). For CXR, sensitivity was 16.7% (95%CI: 0.01-63.5%) and specificity was 97.7% (95%CI: 86.4-99.9%). The agreement between LUS and CXR in diagnosing the cause of respiratory failure was substantial (κ of 0.57 [95%CI: 0.40-0.74]) and the agreement between LUS and the final clinical diagnosis was very good (κ of 0.86 [95%CI: 0.74-0.98]). In 42% of the patients, a LUS examination prior to transport indicated the need for endotracheal tube repositioning or PTX decompression.

CONCLUSION

LUS may be a reliable imaging technique for differentiating the causes of respiratory failure before neonatal transport. Use of LUS may optimize the care of infants during transport.

Neonatal transport services, a cross-sectional study

Objective: To understand the process and challenges facing neonatal transport in Canada and to delineate their composition and working.Subjects and methodology: An online questionnaire was sent to all neonatal transport team directors/coordinators in Canada. The questionnaire covered different aspects of transport and was pilot tested prior to finalization. The responses were anonymous to the investigators.Results: All sixteen neonatal transport teams in Canada surveyed. Fifteen teams responded. Dedicated team as a model was adopted by 12 teams (80%). A combined Neonatal/pediatrics team, where the team could be assembled by either neonatal or pediatrics intensive care staff, adopted by two (13%). Team members were cross-trained in about quarter of the teams (four teams out of 15) with respiratory therapists and registered nurses performing each other's roles. Neonatal Resuscitation Program was mandatory for all teams that responded (15 teams) to become certified as a neonatal transport team member. Nine teams use a central dispatch phone call system.Conclusion: As the first to comprehensively describe the status of neonatal transport in Canada, our study shows that neonatal transport teams have similarities as well as differences. Regionalization and differences in referral practices, geography, provincial laws, and manpower are the main reasons why teams may have their individual variations in policies, protocols, and logistics. Our data can be utilized by health professionals and policy makers to improve neonatal transport logistics within their health care systems resulting in better outcomes of transported neonates.

Predicting Successful Neonatal Retro-Transfer to a Lower Level of Care

Up to 20% of newborn infants retro-transferred to a lower level of care require readmission to a higher-level facility. In this study, we developed and validated a prediction rule (The Rule for Elective Transfer between Units for Recovering Neonates [RETURN]) to identify clinical characteristics of infants at risk for failing retro-transfer.

Decreased oxygen exposure during transportation of newborns

Oxygen is the most common treatment for newborns in need of respiratory support. However, oxygen can cause tissue injury through reactive oxygen species formation, especially in premature infants with reduced antioxidant defences, and may result in short-term and long-term toxic effects in multiple organ systems. Although most hospitals have the capability to tightly control oxygen delivery to hospitalised neonates, in many circumstances, the need is overlooked during infant transport. Lack of awareness of harm or appropriate medical equipment invariably results in excessive oxygen exposure. We developed a quality improvement programme to decrease oxygen exposure to newborns during their transportation, thus improving patient safety and quality of care.

PDE3 inhibition with enoximone as first-line therapy for severe persistent pulmonary hypertension of the newborn during neonatal transport: a case report

Severe Persistent pulmonary hypertension of the newborn (PPHN) can be effectively treated with a PDE3 inhibitor as first‐line treatment during neonatal transport when iNO is not readily available. Starting iNO as soon as possible is strongly advised because of the complementary actions of both therapeutics.

Outcome of outborn infants at the borderline of viability in Western Australia: A retrospective cohort study

AIM

Preterm infants have a high risk of morbidity and mortality, which increases with decreasing gestational age. Inborn infants (infants born in tertiary perinatal centres) have higher survival and lower morbidity than outborn infants. We aimed to compare short-term and 1-year developmental outcomes of outborn infants at the borderline of viability (≥23 to ≤25 + 6 weeks gestation) with a similar cohort of inborn infants in the sole tertiary perinatal centre in Western Australia from 2001 to 2011.

METHODS

This was a retrospective cohort study. Outborn infants ≥23 to ≤25 + 6 weeks gestation who survived to be transported to the Neonatal Intensive Care Unit (NICU) in the perinatal centre were contemporaneously matched to the next inborn infant of comparable gestation and birth weight. We compared mortality, morbidity (including intraventricular haemorrhage, necrotising enterocolitis and chronic lung disease) and Griffiths General Quotient scores at 1-year corrected age.

RESULTS

There were 54 outborn and 519 inborn births in the gestational age range during the study period. Thirty-five (65%) outborn infants were transported to the NICU. Of the outborn infants, 21/54 (39%) survived to discharge compared with 375/519 (72%) inborn infants. For the 35 outborn infants transported to NICU, 14 (40%) died, compared with 6/35 (17%) of inborn infants. There were no differences in short-term and developmental outcomes in surviving infants.

CONCLUSIONS

Outborn extremely preterm infants <26 weeks gestation have higher mortality than inborn counterparts. However, those transported to a tertiary NICU have similar morbidity and developmental outcomes.

Nationwide survey of neonatal transportation practices in Japan

Rapid resuscitation and appropriate transportation of sick infants can greatly improve infant survival and neurological prognosis. To gain an understanding of the status of neonatal transport in Japan, we conducted a survey of neonatal transportation capabilities at perinatal medical centers across the country. Survey content included the number of neonatal transportation cases and the method of transportation. Twenty percent of infants admitted to neonatal intensive care units were transported to the medical centers from other institutions. Half of the level III perinatal medical centers owned an ambulance specialized for neonatal transport. A total of 36% of sick newborns, however, were transported by fire department ambulances that are ill-equipped to care for infants. Thirteen percent of centers reported problems with the emergency transportation of newborns in fire department ambulances. Centers lacked specialized ambulances primarily because of financial constraints. Adequate medical insurance coverage is needed to increase the number of specialized ambulances at perinatal medical centers.

Postresuscitation Care and Pretransport Stabilization of Newborns Using the Principles of STABLE Transport

The practice of perinatal regionalization is designed to ensure that newborns are born in facilities with a care level designation that is consistent with expected pregnancy outcomes. Regionalization practices have resulted in lower neonatal mortality and morbidity rates. However, despite regionalization efforts, approximately 10 percent of newborns will require some level assistance with breathing, and a few (<1 percent) will require resuscitation in the birthing room. After resuscitation, many of these newborns require acute transport to a different facility. This column provides an overview of principles from the STABLE Program, which guides clinicians in providing postresuscitation care and pretransport stabilization for compromised newborns.

Mild hypothermia and hemorrhagic lesions in neonates with hypoxic-ischemic encephalopathy: experience in an outborn center

OBJECTIVE

Therapeutic hypothermia (TH) started within six hours from birth has been shown to improve neurodevelopmental outcomes in newborns with moderate-to-severe hypoxic-ischemic encephalopathy.

METHODS

Twenty-nine consecutive newborns treated with whole body cooling at the Bambino Gesú Children's Hospital between March 2011 and December 2012 were included in this study. All infants were out-born neonates. Passive cooling was always started at the birth center and continued during transportation. Pre- and post-transport risk index of physiological stability (TRIPS) scores were calculated for each patient to evaluate the impact of the transportation. Magnetic resonance imaging (MRI) was performed within 10 days of life to investigate the presence of brain injury.

RESULTS

Among the 26 survivors, 14 had no detectable lesions and 12 presented with brain injury on MRI. Four babies presented with cerebral bleeding. Babies with cerebral hemorrhage had a worse pre-transport TRIPS score, but among these neonates no worsening between pre and post-transport score was registered.

CONCLUSION

The presence of cerebral hemorrhagic lesions seemed to be related to the initial clinical conditions of the baby rather than to the transport itself. Our data confirm that TH performed in an out-born center is efficient and safe.

Long-distance transport of neonates with transposition of the great arteries for the arterial switch operation: A 26-year Western Australian experience

AIM

There is evidence that outcomes of complex paediatric cardiac procedures including the arterial switch operation (ASO) for transposition of the great arteries (TGA) are improved when performed at higher volume centres. While in utero transport for surgery is considered ideal, antenatal detection rates of TGA are low. Long-distance transport of post-natally diagnosed neonates has the potential to destabilise the patient's clinical condition. Since 1986, many neonates with TGA have been transported interstate from Perth to Melbourne or Brisbane for ASO surgery. The aim of this study was to review the Western Australian experience of interstate transport of newborns with TGA for ASO, noting transport complications and comparing the early mortality of these patients with published outcomes of the ASO from Royal Children's Hospital (RCH), Melbourne.

METHOD

In this retrospective cohort study, we reviewed the neonatal and cardiology databases and medical records to identify infants with TGA born between 1986 and 2011 and requiring ASO surgery during the neonatal period.

RESULTS

Over 26 years, 80 neonates were transferred interstate for ASO surgery. Twelve infants required ventilation, 36 needed prostaglandin (prostaglandin E1) infusion and 3 inotropic support. There was no mortality during transport and there was a single early post-operative death. This early mortality of 1.2% compares favourably with the RCH mortality of 2.8% from a recently published review of early outcomes for ASO.

CONCLUSIONS

When in utero transport is not possible, long-distance transport of neonates with TGA can be safely undertaken, with no evidence of increased transport mortality/ major morbidity or higher early surgical mortality.

Neonatal carrier: An easy to make alternative device to costly transport chambers

The transport of sick neonates to the surgical centers or transportation within the center is an essential requirement of neonatal surgery. Neonatal transport incubators are costly, space occupying, and are not available at many places in the developing countries. We report here a cheap yet effective and easy to make, alternate neonatal carrier device.