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transfer of surgical neonates
1. TRANSFER OF A SURGICAL
NEONATE
-Dr. Roshan Chaudhary
PG II year
PAHS
-Moderator
Asst. Prof. Dr. Manish Pokhrel
Dr. Anu Maharjan
2. Introduction
• Neonatal surgery available in tertiary center
• Aim to improve short and long-term outcome for complex congenital
conditions
• Multidisciplinary team of experts
3. Introduction
• Management before and during transfer- important component of
the preoperative care of surgical neonates
• Major Complications before and during transport
• Aspiration of gastric contents
• Hypothermia
• Fluid and electrolyte imbalance
4. General principle of transfer
• Communication
• Pre-Transfer Stabilization
• Mode of transfer
• Care during transfer
• Parents
• Consent
5. Communication
• Early contact between medical staff at district hospitals and the
specialist center
• Lines of communication must be defined for quick and easily transfer
• Contact between nursing staff at the two hospitals
6. Pre-Transfer Stabilization
• Airway and Breathing
• Some conditions require specific considerations to stabilize A and B
• Circulation
• Has baby been adequately fluid resuscitated?
7. Pre-Transfer Stabilization
• 2 points of secure IV access or a double lumen UVC
• Maintenance fluids and replacement fluids for losses
• 10% glucose and 0.45% sodium chloride
• Do not infuse TPN during transfer
• If loss is greater than 20 ml/kg/24 hours consider replacing potassium (with 20mmol/l
KCL)
• Fluid boluses for hypovolemia
• 0.9% sodium chloride or
• 4.5% human albumin solution (babies will be losing protein-rich fluid from gut)
8. Pre-Transfer Stabilization
• Temperature
• Thermoneutral environment where possible
• Metabolic
• Electrolyte, glucose and acid-base balance should be optimized prior to
transfer ideally
• Infection
• Antibiotics either for treatment or prophylaxis with proper documentation
9. Pre-Transfer Stabilization
• Comfort
• Analgesia, considered or given prior to transfer with clear documentation
• Safety
• Check if all necessary equipment for transfer available and working?
• Baby identification
12. Mode of transfer
• Depends on
• Geography
• Weather
• Distance to travel and
• Condition of the infant
• Modes
• Road transfer
• By air
• Helicopter
• Fixed wing air craft
13. Mode of transfer
• Transport incubator
• High performance
respiratory support
• Optimal thermoregulation
• continuous monitoring
• Heart rate
• Blood pressure
• Oxygen saturation and
• Advanced ventilator
monitoring
14.
15. Care during transfer
• Clear airway and adequate ventilation
• Avoid hypothermia in all circumstances - minimum interference
reduces temperature stress on infant
• Continually assess circulatory status
• Consider further fluid boluses
• Consider inotropes
16. Parents
• One parent may be able to travel with their baby
• For mothers during transport:
- Discharged fully from in-patient maternal care
- At least 24 hours post vaginal delivery
- At least 72 hours post LSCS
- Physically able to walk and climb steps into ambulance independently
18. 1. Tracheo-oesophageal fistula /Oesophageal
atresia
• Avoid ventilation if possible
• Replogle tube (or gastric tube)
• On continuous drainage + aspirate and flush at least every 10 minutes
• Suction mouth with standard suction catheter
• Morphine infusion for sedation (If ventilated)
• During transfer: Baby to be nursed prone
19. Abdominal wall defect
• Rarely need intubation and ventilation
• First line antibiotics plus metronidazole
• Exposed viscera:
• Cover with plastic film
• Contra-indicated: cotton wool and sodium chloride soaks
• Omphalocele with intact sac:
• prevent rupture, avoid pressure and kinking, prevent stool contamination
• Ectopic bladder – gelaperm
• During transfer- Nurse baby on side
22. Congenital diaphragmatic hernia
• Usually antenatal diagnosed
• 8-10 g gastric tube- aspirate and leave on free drainage
• Intubate immediately after diagnosis-without using bag and mask
ventilation
• Ventilate in 100% O2 regardless of saturations
• May require nitric oxide for pulmonary hypertension
23. Pneumothorax / pneumomediastinum
• Tension pneumothorax- Needle thoracentesis , chest tube placement
• Non-tension pneumothorax:
• Chest tube placement is preferred
• Secure catheter with appropriate sized dressing
• Pneumomediastinum:
• Chest drain has very limited value
• ambient oxygen concentration of 100%
• During transfer: Chest drain catheter-securely fixed in position prior
to transfer - appropriate sized dressing
24. Neural tube defects
• Associated hydrocephalus and large head size
• airway positioning is important
• First line antibiotics
• Nurse infant in prone position
• Sterile dressing if sac is ruptured
• Cover back in plastic wrap to prevent stool contamination
29. Take home message
• Transfer- important component of the preoperative care of surgical
neonates
• Multidisciplinary team of experts
• Pre contact can make the process easier and effective
• Not all the case has similar approach
30. References
• Embrace Surgical Transfer Guidelines for Newborns, Cath
Harrison,October 2022
• Transfer of the Surgical Neonate, Christopher P. Driver, Rickham’s
Neonatal Surgery, https://doi.org/10.1007/978-1-4471-4721-3_7
• Transfer of the surgical newborn infant, David A. Lloyd, Semin
Neonatol 1996; 1: 241-248
Editor's Notes
Neutral ambient tempr24-36⁰c, WARMER,SKIN TO SKIN,PROPER CLOTHING AND BEDDING
WARMER,SKIN TO SKIN,PROPER CLOTHING AND BEDDING
sodium chloride soaks WHY?
Inc t=TC.dec hb intestinal damage and bleed,low plat d/t wide spread inf
first line antibiotics plus metronidazole (e.g. IV Amoxicillin + Gentamicin plus Metronidazole)
Pulmonary hypoplasia,risk of gastric distension,PAH
