Immediate Care and Transport of the Sick Newborn

The Transport Guidelines Committee of the West Virginia Perinatal Partnership gathered these guidelines in response to a need for them expressed by nurse managers from around the state.  Please direct comments to Ann Dacey.  These guidelines were last updated: 03/16/2010.

CONTENTS
General Considerations
Consultation and Transfer
Prior to Arranging a Transport
Transport Report for Receiving Hospital
    Transport to Cabell Huntington Hospital
    Transport to Charleston CAMC Women And Children’s Hospital
    Transport to WVU Children’s Hospital Morgantown
Neonatal Transport Log for Community Hospitals
Response Time of the Team
Transport Personnel and Equipment
What to Have Ready When The Team Arrives
Checklist for Neonatal Transport
Activity of the Team in the Referring Hospital
Parents
Basic Guidelines of Stabilization for All Infants
    Assisted Ventilation, Resuscitation and Oxygenation
    Temperature Control
    Glucose
    Acid-Base Status
    Shock
    Fluid And Electrolytes
    Infection
    Infection Prevention/Treatment
Special Stabilization Requirements
    Pneumothorax
    Diaphragmatic Hernia
    Esophageal Atresia/Tracheoesophageal Fistula
    Choanal Atresia
    Bowel Obstruction
    Omphalocele And Gastroschisis
    Follow-Up
Return Transport
Authors  

General Considerations

When the birth of a high risk newborn occurs at a community hospital, quick and organized transport to an NICU by skilled health providers is a necessity .  It is essential that the task of transporting high-risk infants be well planned so that optimal care of the newborn can be assured during transport. Initial stabilization is essential prior to transport.

The transportation decision should be made by the receiving NICU in collaboration with the referring physician based on clinical judgment, with careful consideration given to following questions:

  • How soon does the patient need to reach the referral center?
  • What are the weather/ground conditions that might inhibit air transport?
  • What are the transport times for ground versus air transport from the referring institution?
  • Are nursing and paramedic staff available for transport?

Back to Top Menu The Transport Process

Back to Top Menu  Consultation and Transfer

The decision to transport an infant from a community hospital depends upon a variety of factors including: availability of 24-hour skilled nursing, respiratory therapy, equipment, x-ray and laboratory support, as well as physician knowledge and time.

The following are examples of diseases or conditions that might be reasons for consultation or transport:

  • Respiratory distress from any cause (i.e., meconium aspiration, neonatal pneumonia, Infant respiratory distress syndrome) - without the capability to monitor oxygen therapy and arterial blood gases - without the capability to give ventilator assistance
  • Intravenous fluid requirements
  • Surgical conditions
  • Low birth weight infants
  • Suspected congenital heart disease
  • Significant birth complications
  • Severe neonatal depression
  • Unresponsiveness to resuscitation efforts
  • Infants of diabetic mothers
  • Neonatal seizures
  • Suspected infection (sepsis, meningitis)
  • Hemolytic disease
  • Apnea
  • Suspected shock
  • Persistent acidosis
  • Recurring hypoglycemia
  • Infants not doing well for unknown reasons
Back to Top Menu  Prior to Arranging a Transport

When calling to arrange transfer to one of West Virginia's three NICUs (Cabell Huntington, CAMC, WVUH) that accept infants for transport, it is important to have the following information readily available:

  • Patient's name and date of birth
  • Mother's and father's names
  • Details on prenatal history, labor and delivery, neonatal resuscitation
  • Apgar scores
  • Gestational and birthweight
  • Vital signs (temperature, heart rate, respiratory rate, blood pressure)
  • Oxygen/ventilatory support requirements
  • Laboratory data obtained (glucose, calcium, hematocrit, blood gas determinations)
  • Vascular access

See Transport Report for Receiving Hospital 

Back to Top Menu Transport to Cabell Huntington Hospital 

Neonatal Transport Phone Number: 877-531-2244 (Transfer Center - you will be patched through to NICU Transport RN)

Neonatal Transport Services Available:  Helicopter, fixed wing, ground, staffed by credentialed transport RNs who are employees of Cabell Huntington Hospital.

How to Initiate a Neonatal Transfer/Transfer process:

  1. Call Patient Transfer Center at 877-531-2244 to be patched through to NICU Transport RN.
  2. Transport RN takes information from referring physician and automatically accepts if bed is available.
  3. Referring physician is given opportunity to discuss patient with neonatologist.
  4. If NICU is on diversion, help is provided in placing patient at another institution.

Back to Top Menu Transport to Charleston Area Medical Center (CAMC) Women and Children’s Hospital

Neonatal Transport Phone Number: 877-Cam-Care (877-226-2273)

Neonatal Transport Services Available: Air and ground, staffed by neonatal nurses

How to Initiate a Neonatal Transfer/Transfer process:

  1. Call via Transport Hotline at 877-Cam-Care (877-226-2273)
  2. Neonatologist, Transport RN or Charge RN takes information from referring Physician and discusses bed availability with Neonatologist and decision in order to make transport decision.
  3. Receiving facility notifies referring facility of acceptance or deferral of patient.
  4. Receiving facility determines method of transport (air vs. ground), and arranges trasportation.

During this process Neonatologist may make stabilization/treatment recommendations to referring physician

Back to Top Menu Transport to WVU Children’s Hospital, WVU Hospitals, Inc. (WVUH) Morgantown

Neonatal Transport Phone Number – NICU: 304 598-4140

Neonatal Transport Services Available:  24 hours/day via ground or Healthnet helicopter.  Transport mode dependent on acuity of infant, length of transport, and availability of resources.  Transport team composed of neonatal nurse practitioner and/or a trained transport nurse as well as a respiratory therapist.

How to Initiate a Neonatal Transfer: 

  1. Call the NICU at 304 598-4140. 
  2. The neonatal nurse practitioner or the transport nurse will take the information.
  3. After evaluation and discussion with the attending physician, the neonatal nurse practitioner or the transport nurse will call with mode of transport and estimated time of arrival.
  4. When a baby has been accepted for transport, the WVU NICU will FAX a referral form to be filled out by the referring hospital.
  5. Transport initiation and or phone consultation with a WVU Children’s Hospital neonatologist may be obtained 24 hours a day by calling the toll free Medical Access and Referral number: 1-800-WVA-MARS (1-800-982-6277).
Back to Top Menu  Response Time of the Teams

The response time depends on distance and mode of transport.  You will be given estimated time of team’s arrival at your hospital at the time of call.

Back to Top Menu  Transport Personnel and Equipment

West Virginia transport personnel are trained in the care of high-risk newborns. The personnel usually include a specially trained transport nurse and respiratory therapist.  Equipment they bring with them usually includes :

  • Transport incubator
  • Monitors for:
    • heart rate
    • respiratory rate
    • temperature
    • arterial blood pressure
    • inspired oxygen concentration
    • oxygen saturation
  • Assisted ventilation equipment
  • Intravascular infusion equipment
  • Medications
  • Equipment for:
    • intubation
    • umbilical vessel cannulation
    • chest tube placement
  • Suction equipment
Back to Top Menu  What to Have Ready When the Team Arrives

Transport teams usually request the following (Items not available at time of transport should be FAXED ASAP to the receiving hospital):

  • Copy of infant's chart with completed nursing documentation (urine output, passage of stools, details of resuscitation, oxygen administration, vitamin K administration, eye prophylaxis, hepatitis vaccine, other medication administration)
  • Copy of maternal record including complete maternal history and labor and delivery records, including all medications received during labor.
  • All X-rays and other tests
Back to Top Menu  Activity of the Team When it gets to the Referring Hospital
  • The transport nurse will assess the infant's condition, review x-ray and/or laboratory results, and obtain vital signs and analysis of blood glucose and blood gases as appropriate.
  • A radiant warmer with servo control via skin probe should be used to maintain the infant's temperature during procedures.
  • The team may request additional tests so access to the laboratory and x-ray facilities will be required.
  • If the infant has unstable vital signs, the transport team will usually remain at the referring hospital until the baby is sufficiently stabilized to ensure a safe transport.
Back to Top Menu  Parents

The transport team will introduce themselves, discuss the infant's problems and plan of care, and seek to obtain written consent for transport and care. If the mother is unstable, a member of the immediate family should be available. If the mother cannot come to the nursery, the infant will be taken to her prior to transport.  The referring hospial may encourage the parents to visit the receiving hospital as soon as possible and participate in the care of their baby.

Back to Top Menu  Basic Guidelines for Stabilization for All Infants

The stable infant has:

  • Patent airway and adequate ventilation
  • Pink skin and lips
  • Heart rate of 120-160 BPM
  • Axillary temperature of 36.5-37°C (97.7-98.6°F)
  • Metabolic problems corrected
  • Special problems managed
Back to Top Menu  Assisted Ventilation, Resuscitation and Oxygenation

Supplemental oxygen should be monitored:

  • There are risks of too little or too much oxygen.
  • Preterm infants are at risk of ROP (Retinopathy of Prematurity) with high levels.
  • Term infants are at risk of pulmonary hypertension if hypoxemic.
Back to Top Menu  Monitoring Oxygen Administration

Pulse Oximetry (SpO2)

  • Any baby receiving oxygen therapy should have continuous pulse oximeter monitoring. These are very useful and easy to use.
  • Accuracy is about ± 2%. The therapeutic range is small. Remember the oxygen dissociation curve in interpreting the result.
Back to Top Menu  Assisted Ventilation/Resuscitation

Caveat: Although every provider should be certified, there should be at least one NRP certified provider in every delivery room and newborn nursery. The hospital should have at least one provider with the capabilities of intubating neonates of all sizes and weights.

Positive Pressure Ventilation (PPV) may be required when respiratory distress occurs with any of the following:

  • Neonatal heart rate less than 100/minute
  • PaCO2 greater than 65 mmHg
  • Central cyanosis in 100% oxygen
  • Persistent apnea
  • PaO2 less than 50 mmHg in 100% oxygen

Effectiveness of assisted ventilation

Increasing heart rate is the primary sign of effective ventilation during resuscitation. Other signs are:

  • Improving color
  • Spontaneous breathing
  • Improving muscle tone

Check the foregoing signs of improvement after 30 seconds of PPV. This requires the assistance of another person. Chest compressions should be administered if the heart rate is less than 60 BPM. Endotracheal intubation should be considered.

Endotracheal Tube Size Guide
Body Weight (grams) Tube (internal diameter in mm)
<1000 2.5
1000-2000 3.0
2000-3000 3.5
>3000 3.5 - 4.0
Back to Top Menu  Temperature Control

Normal core (rectal) range: 36.5–37.5 °C (97.7 – 99.9°F)

Hypothermia and hyperthermia may increase infant morbidity and mortality.

Hypothermia adversely affects oxygen consumption and glucose homeostasis and may result in initiation of hemorrhagic processes.

Hyperthermia also affects oxygen consumption and glucose homeostasis and, at extreme temperatures, may cause cerebral damage, dehydration, hypernatremia, and death.

World Health Organization Definitions of Hypothermia (1997):

  • Normal core (rectal) range: 36.5–37.5 °C (97.7 – 99.9°F)
  • Mild Hypothermia: 36.0–36.4°C (96.8 – 97.6°F)
  • Moderate hypothermia: 32.0–35.9° (89.6 –96.6°F)
  • Severe hypothermia: less than 32.0° (less than 89.6°F)

Preventing Hypothermia

  1. Immediately after delivery, place the infant under a prewarmed radiant heat source and dry him/her quickly. This act alone can cut heat loss in half.
  2. Radiant warmers may not produce adequate heat to keep the infant warm if contributing factors such as a cool or drafty room or wet skin are present.
  3. Cover scale with warm blanket.
  4. When using radiant warmer, use servo-control temperature probe over liver.
  5. Check the temperature every 15 – 30 minutes until it is within normal range and then every hour until infant is transported.
  6. Warm instruments and objects (such as stethoscopes) before contact with infant.
  7. If administering oxygen, use warm, humidified oxygen.
  8. Increase room temperature to 28°C (77 – 82.4°F).
  9. Carefully warm solutions that come in contact with infant but be careful not to over-warm.

Management of Hypothermia                                                         

  • Eliminate source of heat loss (cold drafts from windows blowing over the warmer or incubator, cold mist, cold mattress)
  • Re-warm the infant in an incubator or radiant warmer. An incubator allows more control of the re-warming rate and the radiant warmer increases the risk of rapid drop in blood pressure by causing blood vessels to dilate suddenly.
    • If using an incubator to re-warm the infant, set the air temperature 1 – 1.5°C above the infant’s core or rectal temperature. As the infant’s rectal temperature reaches the air temperature set point, and if the infant is not showing signs of deterioration, increase the air temperature again by 1 – 1.5°C above the infant’s core temperature in Celsius.
    • If using a radiant warmer to re-warm the infant, use the servo-control temperature probe over the liver set at 36.5°C and monitor closely.
  • Monitor the following during re-warming:
    • Core (rectal) temperatures should be taken as often as every 15 minutes during re-warming and every hour after stable until the transport team arrives. After temperature has stabilized, the axillary temperature may be monitored.
    • Heart rate and rhythm, blood Pressure, respiratory rate and effort
    • Oxygen saturation, acid-base balance
    • Blood Glucose
  • If the following signs of deterioration occur, the rate of re-warming may need to be slowed:
    • Tachycardia or cardiac arrhythmia
    • Hypotension
    • Hypoxemia- falling oxygen saturation levels
    • Worsening respiratory distress
    • Worsening acidosis
  • Consider using:
    • Silver swaddler foil or polyethylene (food grade plastic wrap) - these do not warm the infant, but prevent further radiant losses.
    • Heat shield (commercial shield or oxyhood) - place over the infant's body to prevent further radiant losses additional humidity
Back to Top Menu  Glucose

Glycogen, the storage form of glucose, increases in fetal tissues as term gestation approaches, and is essential to survival during labor and immediately following birth.  Any added stress to the newborn will rapidly deplete these stores.  Hypoglycemia is a serious problem in the neonate and, if left untreated, can result in varying degrees of damage to the central nervous system, or death.

The lower limit for blood glucose is 40 mg%.  A rapid semi-quantitative measurement of blood glucose can be obtained using glucose e strips (One Touch® or ccuCheck®) following the manufacturer's recommendations.

Infants at Risk for Hypoglycemia:

  • infants with birth asphyxia
  • infants with added stress (i.e., hypothermia, hyperthermia, respiratory distress)
  • premature infants
  • large for gestational age infants
  • small for gestational age infants
  • infants of diabetic mothers
  • erythroblastotic infants
  • infants with congenital heart disease
  • Infants exposed to certain maternal medications:
    • Beta-sympathomimetics for preterm labor such as terbutaline and ritodrine
    • Beta blockers for hypertension
    • Chlorpropamide used for Type 2 diabetes
    • Benzothiazide diuretics
    • Tricyclic antidepressants given in the third trimester

Symptoms of hypoglycemia:

Symptoms of hypoglycemia may be very subtle, and prognosis appears to be better if treatment is begun before the infant is symptomatic. The following symptoms may be seen:

  • tremors ("jitteriness")
  • cyanosis
  • convulsions
  • apnea or irregular respirations
  • lethargy
  • high-pitched or weak cry
  • hypotonia
  • poor feeding suck coordination
  • eye rolling
  • tachypnea

Any infant at risk for hypoglycemia may require glucose determinations as frequently as every 30 minutes until they are stabilized >50 mg/dl on at least two consecutive measurements.

Treatment of Hypoglycemia (from The S.T.A.B.L.E Program, 5TH Edition)

A semi-quantitative test for glucose below 50 mg/dl should be followed by a serum glucose measurement.  Do not delay treatment while waiting for results of serum glucose.

For an otherwise healthy infant who can tolerate oral feedings:

  1. Infants with low blood sugar who are otherwise healthy can usually tolerate oral feedings unless the blood sugar is very low in which case the infant may need IV therapy
  2. Repeat blood sugars every 30 minutes until they are stabilized >50 mg/dl on at least two consecutive measureme

For sick infants and those who are unable to tolerate oral feedings,  if blood glucose results are less than 50 mg/dl:

1.      Begin an IV infusion of D10W at 80 ml/kg/day (NOTE: Some NICUs in West Virginia may recommend D5W for infants less than 28 weeks or 1000 grams at 120 ml/kg/day. Check with your referral center.)

2.      Administer a bolus of 2 ml/kg body weight of D10W intravenously at a rate of 1 ml per minute

3.      Recheck the blood glucose within 15 to 30 minutes after any bolus or increase in IV rate

4.      If results are again less than or equal to 50 mg/dl, repeat the bolus of 2 ml/kg body weight of D10W

5.      If the blood glucose does not stabilize over 50 mg/dl, after two boluses, then repeat the bolus and increase the IV to 100 or 120 mls per kg per day or consider increasing the concentration if the infant is not a candidate to receive a higher fluid volume.

6.      Continue to evaluate the blood glucose every 30 – 60 minutes until stable >50mg/dl on at least two consecutive evaluations. Follow the trend in blood glucose screens and use clinical judgment to decide when blood glucose screening can be safely decreased

7.      If the blood glucose remains persistently low after these steps, call the attending physician or the transport control provider for additional advice.

Back to Top Menu  Acid-Base Status (from AAP, Neonatal Resuscitation textbook, 5th edition)

Experts differ on the use of sodium bicarbonate during resuscitation.   However, it may be helpful to correct metabolic acidosis that results from a buildup of lactic acid.

Caveat: Establishing and maintaining adequate ventilation and perfusion are much more important to a successful resuscitation than the vigorous use of alkali solution. In treating acidosis, it is necessary to decide whether the origin is respiratory or metabolic. Respiratory acidosis is due to inadequate ventilation, noted by an elevated PaCO2 and treated/corrected by improving ventilation.  Attempts at correction of a respiratory acidosis with alkali treatment may paradoxically worsen the acidosis since the liberated carbon dioxide can not be effectively removed.

Metabolic acidosis is due to inadequate tissue oxygenation and perfusion, noted by a low pH and a large base deficit. This is best corrected by improving tissue perfusion (administration of alkali is also used).

Administration of sodium bicarbonate is limited to situations where:

  • provision of adequate pulmonary ventilation has been assured
  • tissue oxygenation and perfusion are maximized and the pH remains <7.20 and base deficit>10
  • cardiopulmonary resuscitation when a documented or suspected metabolic acidosis is present

The dose of sodium bicarbonate is 2 mEq/kg given as a 4.2% solution (0.5 mEq/ml) at a rate no faster than 1 mEq/kg/min acording to the AAP, Neonatal Resusciation textbook, 5th edition. This dosage may be administered over 15-30 minutes.

Be aware of the concentration: sodium bicarbonate comes in a neonatal concentration of 0.5 mEq/mL. However, the adult concentration is 1 mEq/mL, which requires dilution with an equal volume of sterile water. Be aware of which formulation you have.

Emergency Administration

In emergency treatment of severe asphyxia or cardiac arrest where heart rate does respond to assisted ventilation, sodium bicarbonate can be given empirically in a dose of 2 mEq/kg infused at a rate no faster than 0.5 mEq/kg/minute.

Caveat: When ventilating an immature infant, be aware that over-ventilation with significant hypocapnia has been associated with later development of periventricular leukomalacia in very low birth weight infants. Prevention and/or correction of hypocapnia (PaCO2 <30 mmHg) in this population infants is recommended.

Back to Top Menu  Shock

"Shock" may be defined as inadequate tissue perfusion by oxygenated blood and should be suspected in infants who present with any of the following signs:

  • dusky, gray, pale, mottled skin color
  • slow capillary filling time (when skin in blanched with finger pressure)
  • hypotension (see Blood Pressure Chart)
  • decreased urine output (<1ml/kg/hour)
  • subnormal skin temperature
  • severe, persistent metabolic acidosis (pH <7.20 with base deficit>10)
  • tachycardia

Note:  Not all the above signs will necessarily be present or clinically apparent, and no one alone is indicative of shock.

Possible etiologies of shock include:

  • Hypovolemia because of:
    • placenta previa
    • placental abruption
    • rupture of maternal or fetal vessels
    • intracranial hemorrhage
    • intra-abdominal hemorrhage
    • fetal-maternal transfusion
    • twin-twin transfusion
    • trauma: cephalohematoma, caput succedaneum, subgaleal hemorrhage
  • Inadequate cardiac output secondary to asphyxia with normal blood volume
  • Sepsis

Blood Pressure Chart

Blood Pressure Chart
Adapted from: Bucci et al. Acta Pediatr. Scanda. (Suppl)229:1,page 8, 1972.

Treatment of Shock:

Volume expansion 10 mL/kg over 15-30 minutes.

Agents: Normal Saline, Lactated Ringers solution

Repeated doses may need to be given to maintain adequate pressure until the transport team arrives. You may want to consult the Hotline physician, if no response is noted after the first infusion.

Vasopressor drugs may be necessary (see Drug list for preparation and dose).

Be Aware:

  • A normal hematocrit does not rule out hypovolemia.
  • As blood pressure increases and fluid is pulled into the intravascular space, hematocrit will decrease and concurrent acidosis will begin to correct, causing vessels to dilate, resulting in a secondary hypotension.
  • Most episodes of hypotension are not caused by hypovolemia, and the automatic infusion of volume expanders is to be discouraged.
Back to Top Menu  Fluid and Electrolytes

Possible indications for initiation of intravenous infusion of 10% dextrose solution (some tertiary care centers in West Virginia recommend D5W for infants less than 1000 grams) prior to transport include:

  • fluid maintenance
  • access to vascular space for emergency drug and/or antibiotic administration

A constant infusion pump and volumetric chamber should be used to assure a constant rate of infusion and accurate measurement of fluid administered. A peripheral venous route is preferable. Umbilical arterial lines are not benign and in most cases should be used only during the critical phase of the illness for obtaining frequent blood gas samples.

The following guidelines are usually recommended for maintenance fluids: first 24 hours of life - 80 mL/kg/day 24 - 48 hours of age - 100 mL/kg/day over 48 hours of age - 100-120 mL/kg/day.

In the presence of hypoglycemia, dextrose solutions with concentrations greater than 10% should be used cautiously in peripheral veins. (Note: Some NICUs in West Virginia recommend D5W for infants less than 28 weeks or1000 grams at 120 ml/kg/day. Check with your referral center)

These solutions can be irritating to the tissue if infiltration occurs. During the first 24-48 hours of life, electrolytes do not usually need to be added to the IV solution.

Amounts of fluids administered should be documented hourly so adjustments can be made to insure proper amounts of infusion and to prevent fluid overload.

A urine bag placed on the infant allows accurate measurement of urine output.

Back to Top Menu  Infection

Diagnosis

Most infants with generalized infection present with vague, nonspecific signs and symptoms:

  • temperature instability (hypothermia, hyperthermia)
  • lethargy
  • respiratory changes (tachypnea, apnea)
  • cyanosis
  • feeding difficulty (vomiting, abdominal distension, diarrhea)
  • shock
  • acidosis
  • petechiae
  • infant appears "not right"

Evaluation

A complete history and physical examination in addition to clinical experience are useful in determining the extent of the evaluation. This may include:

  • blood culture
  • lumbar puncture (spinal tap) for CSF culture
  • aspiration of urine for culture
  • Complete Blood Count with platelet count and WBC differential
  • CRP
Back to Top Menu  Infection Prevention/Treatment

Sepsis may be present even if CBC is normal and may not be present if CBC is abnormal. It is very important that antibiotic treatment is initiated promptly because the neonate’s immune system is immature and places them at increased sick for acquiring infection which can be devastating.  Never withhold antibiotic treatment of an ill neonate who has respiratory distress on the basis of a normal CBC.

Prior to treatment, obtain an adequate volume blood culture

Intravenous antibiotics and dosages

Ampicillin 100mg/kg q 12 hours

For IV infusion, maximum concentration is 100 mg/ml, (over 3 – 5 minutes not faster than 100 mg per minute)

For IM injection, mix to a final concentration of 250 mg/ml

Use reconstituted solutions within one hour of mixing

Gentamicin 2.5mg/kg q 12 - 24 hours. 

IV over 30 minutes using infusion pump

Alternate Gentamicin dosing: 4-5 mg/kg per dose ranges between 24 and 48 hours depending on gestational age and renal function. Consult with tertiary center as needed

IV over 30 minutes using an infusion pump

Alternative Gentamicin route is IM if having difficulty establishing IV access

May give undiluted for a few doses.

Back to Top Menu  SPECIAL CONDITIONS REQUIRING STABILIZATING PROCEDURES

The conditions below require specific stabilizing procedures in addition to those previously discussed. These conditions in themselves are usually reason to arrange for transport.

Back to Top Menu  Pneumothorax

A pneumothorax may occur in an infant, cause no distress, and require no active treatment. If, however, the infant has significant respiratory distress, then the pneumothorax must be evacuated.

Signs may include:

  • respiratory distress
  • sudden deterioration in a previously stable infant

Diagnosis

Diagnosis is made by:

  • auscultation: breath sounds may be decreased or absent on affected side
  • chest x-ray
  • positive transillumination

Treatment

  1. Attach a syringe to a 3-way stopcock which is then connected to a 23 or 21 gauge butterfly needle.
  2. Place the infant in a supine position.
  3. AVOIDING THE NIPPLE, insert the needle into the pleural space superiorly directly over the top of the rib (avoiding vessels that run inferiorly under the ribs) at the anterior axillary line into the 4th or 5th intercostal space while withdrawing on the syringe. If air in the pleural space, the syringe will usually draw easily.
  4. When the syringe is filled, turn the stopcock off to the needle and expel the air through the stopcock.
  5. Continue to aspirate and expel until air is no longer retrieved.

aspiration of pneumothoraxIf reaccumulation of the pneumothorax occurs, the needle should be left in place and aspiration continued until a chest tube can be placed. A 18-gauge plastic catheter may be useful while waiting to place a chest tube. The catheter is pliable and may offer less chance of lung or vessel laceration which may occur as the lung re-expands. It is placed in the same way as a scalp vein needle.

Back to Top Menu  Diaphramatic Hernia

Signs may include:

  • immediate respiratory distress (due to the hypoplastic lung and presence of abdominal contents in the chest cavity)
  • scaphoid (concave) abdomen (not always present)
  • bowel sounds in the chest
  • heart sounds shifted to lateral chest (usually to the right chest)

Diagnosis

Chest x-ray reveals loops of bowel in the thoracic cavity.

Stabilization

  1. Do not ventilate the infant with bag and mask, as the proximal bowel will fill with air, further compromising ventilation.
  2. Intubate trachea immediately if oxygenation and ventilation are inadequate.
  3. Use orogastric tube for decompression of stomach to prevent air from entering the bowel (can cause further compression of lung).
  4. Place infant on affected side, allowing shift of mediastinum, thus improving expansion of unaffected lung.
  5. Place unclothed infant in an incubator for temperature maintenance and close observation.

A sudden deterioration during asisted ventilation is usually a sign of pneumothorax on the unaffacted side.  Be prepared to treat rapidly (see Pneumothorax treatment).

Back to Top Menu  Esophageal Artresia/Tracheosophageal Fistula

Signs may include:

  • polyhydramnios
  • regurgitation of saliva or the first feed out of the infant's mouth and nose
  • choking or gagging on secretions or feeds
  • abdominal distension is often present (occurs as inspired air enters the stomach through the fistula and distal esophagus)
  • respiratory distress

Diagnosis

  • The inability to pass a large (10F) catheter into the stomach. (Smaller flexible catheters may coil up in the pouch giving a misleading impression that they have advanced to the stomach. A radiopaque catheter is recommended).
  • Injection of 10 mL of air into the catheter while simultaneously taking an x-ray of the chest and abdomen. The air will outline the pouch if it is present. (Barium and other contrast materials are not necessary and are potentially dangerous because of the high risk of aspiration).

SURGICAL INTERVENTION IS INDICATED WHEN THE CONDITION OF THE INFANT IS STABLE.

Stabilization

  1. Gently place a 10F catheter into the pouch, connected to intermittent suction (or aspirate every 5 minutes with a syringe). Use of a Repogle tube is mandatory. The pouch fills with secretions which can overflow into the lungs if not continuously emptied.
  2. Place the infant at a 30 degree angle, head up position.
  3. Prevent the infant from crying if possible, as this causes air to be forced into the stomach through the fistula, causing distension that can result in reflux of air carrying gastric contents into the lung. Consider sedation if necessary (see Drug Dosages).
  4. Place unclothed infant in an incubator for temperature maintenance and close observation.
  5. Establish an IV for maintenance fluids (see Fluids and Electrolytes).
Back to Top Menu  Choanal Artesia

Chonal AtresiaBilateral choanal atresia is easily recognized immediately after birth.

Signs may include pink while crying, becoming cyanotic and struggling for air when quiet (even with good respiratory effort).

Inability to gently pass a small (3F) catheter through the nares into the pharynx suggests the diagnosis. Problems arise because infants usually breathe through their noses.

Unilateral choanal atresia may not be symptomatic, but checking for it is easily done. Signs may include inability to maintain oxygenation (noted by cyanosis when lips and unaffected nares is held closed). Diagnosis is made by the above examination and inability to pass small catheter on affected side.

Stabilization

  1. Place oral airway (size 0 or 00). (Be sure the airway does not go too far into the pharynx as it may enter the esophagus and occlude the airway).
  2. Tape oral airway into place to prevent dislodging.

Infants with choanal atresia require early evaluation and intervention.

Back to Top Menu  Bowel Obstruction

Signs may include

  • Abdominal distension (with low obstructions)
  • Failure to pass meconium in the first 24 hours of life
  • Vomiting with or without bile staining
  • Large gastric residuals at feeds

If a bowel obstruction is suspected or diagnosed, the following steps should be taken while awaiting arrival of the transport team.

Stabilization

  1. Place an orogastric tube (10F) to low intermittent suction (or aspirate with a syringe every 5 minutes). Use of a Repogle tube is suggested.
  2. Establish vascular access to administer fluids (see Fluid and Electrolytes)
  3. Place unclothed infant in an incubator for close observation and temperature maintenance.
  4. Obtain abdominal x-rays (including a lateral and upright view).
  5. Obtain blood for electrolyte determinations.

Frequently, these infants have associated problems of acidosis (see Acid-Base Status) and shock (see Shock).

Back to Top Menu  Omphalocele and Gastroschisis

Infants with these anomalies present problems similar to those with bowel obstruction. They also have problems with temperature regulation because of the large amount of heat loss from the exposed gut.

Stabilization

1.      Connect 10F orogastric tube to low intermittent suction (or aspirate with a syringe every 5 minutes).

2.      With Gastroschisis, evaluate appearance of exposed bowel for evidence of adequate perfusion. Bowel may have to be untwisted or abdominal defect may need to be enlarged if perfusion is poor.

3.      Place lower body of infant in bowel bag with opening of bag just at nipple line.

4.      Place in neutral thermal environment and check temperatures frequently.

5.      Establish vascular access for maintenance fluids (see Fluid and Electrolytes).

6.      Begin IV antibiotics (ampicillin and gentamicin) (see Drug Dosages).

 

Back to Top Menu  FOLLOW-UP

Referring physicians are encouraged to visit or phone the Neonatal Intensive Care Unit at any time to obtain information regarding the condition and progress of the infant. Infants may go directly home with the parents when ready for discharge or may return to the community hospital for convalescent care. When plans for discharge are being made, summaries that include all pertinent information related to the infant's hospital course will be sent to the physician.

Back to Top Menu  Return Transport

Infants who have recovered from the critical phase of their illness and no longer need the support offered by the Neonatal Intensive Care Unit may be candidates for return to the community hospital if the hospital has trained personnel and equipment necessary for the infant’s care.

Return of infants to the referring hospital serves many purposes:

Facilitates parental contact and increases their involvement in the infant's care. Links the infant to follow-up systems within the community. May diminish financial burden. Increases contact with community hospitals and facilitates communication between the referring hospital's staff and the tertiary center.

Back to Top Menu  Authors

Based on the manual prepared by Bethany L. Farris, R.N., N.N.P., and William E. Truog, M.D. for the Washington State Regional Perinatal Care Program.  Edited and adapted by Dennis E. Mayock, M.D.  Edited and adapted with permisiion by the West Virginia Perinatal Partnership, Neonatal Guidelines and Transport Committees.