A talk by Ian Braithwaite at TBS24

1. Precision in
Neonatal
Transport
Ian Braithwaite, TBS24

2. • Pic of dom

3. Intraventricular hemorrhage (IVH) of the newborn
Caro-Domínguez et al, 2021

4. • Pic of dom
Midline head position with elevation
Precise administration of medications
Slow arterial line sampling
Minimise stress and pain
Tight PaCO2 control
Tight oxygen saturation control

5. Precision and …
… ventilation management
… medication delivery
… the journey!

6. Precision and
ventilation management

7. National
mean
12.5%
% of transports with PaCO2 outside 4-7 kPa

8. 4
6
8
10
12
14
16
18
2016 2017 2018 2019 2020 2021 2022
Percentage
of
available
post-transfer
gases
% pCO2 < 4, or >7kPa with pH <7.2, by Year
National Mean Embrace
New
ventilators
% of transports with PaCO2 outside 4-7 kPa

9. Adult Deadspace
TV ~ 500 mL
Instrumental Deadspace = 10 to 20% of TV
8mL 10mL
60mL
7mL
=85mL

10. Neonatal Deadspace
TV = 5 to 8 mL/kg
Instrumental Deadspace = up to 100% of TV
1mL 2mL 1mL 1mL
=5mL

12. Accuracy of PaCO2
v
ETCO2
for 13 premature babies
End
Tidal
CO2
kPa

13. Transcutaneous Monitoring

15. Accuracy of PaCO2
v
ETCO2 (red)
v
tcPCO2 (blue)
for 13 premature babies
End
Tidal
CO2
(red)
and
Transcutaneous
CO2
(blue)
kPa

16. 4
6
8
10
12
14
16
18
2016 2017 2018 2019 2020 2021 2022
Percentage
of
available
post-transfer
gases
% pCO2 < 4, or >7kPa with pH <7.2, by Year
National Mean Embrace
New
ventilators
Transcutaneous
monitoring
What percentage of transports had PaCO2 outside the range 4-7 kPa on completion?

19. Precision and
medication delivery

20. 90 ml/kg/day
72 ml/day
Morphine 0.3 ml/hr
Atracurium 0.3 ml/hr
Arterial flush 0.5 ml/hr
Dopamine 0.4 ml/hr
Maintenance 1.5 ml/hr
{
3 ml/hr 3 ml/hr

21. Does static height difference matter?

22. Does static height difference matter?

23. Does relative static height difference matter?

24. Does lowering a pump matter?
Zahid et al 2020

25. Does lowering a pump matter?
Zahid et al 2020

26. Does raising a pump matter?
Zahid et al 2020

27. Does vibration matter?

28. Does vibration matter?
Time (seconds)
bubble
movement

29. Does the orientation of the pump matter?

30. Does the orientation of the pump matter?
Direction syringe is pointing
Time (seconds)
bubble
movement

33. Does syringe size matter?
* Syringe photos
Credit and thanks to the Nottingham Syringe Pump Stability Group
patrick.davies@nuh.nhs.uk

34. Precision and
the journey

35. By road:
50 miles
90 minutes
By air:
40 miles
20 minutes
Scarborough to Hull or James Cook

37. Defining the forces
Physical forces Definition
Example
(from road transport)

38. Defining the forces
Physical forces Definition
Example
(from road transport)
Shock
Short duration,
high amplitude discrete event
Driving over a bump

39. Defining the forces
Physical forces Definition
Example
(from road transport)
Shock
Short duration,
high amplitude discrete event
Driving over a bump
Acceleration
Change in velocity over
a period of time
Braking suddenly
or going round a roundabout

40. Defining the forces
Physical forces Definition
Example
(from road transport)
Shock
Short duration,
high amplitude discrete event
Driving over a bump
Acceleration
Change in velocity over
a period of time
Braking suddenly
or going round a roundabout
Vibration Sustained rhythmic accelerations
Engine, tyre and
road surface oscillations

42. Ambulance
Bouchet et al 2010
Helicopter

43. Ambulance
44 8
1 impulsive event per 11 minutes
1 impulsive event per 2 minutes
Helicopter
Bouchet et al 2010

44. Time-series vibration amplitudes
(200 minutes, Kyoto to Tokyo)
Shimizu et al 2018
flight flight
refuel ambulance
rooftop

45. A plot of possible driving
routes between two
English hospitals
Partridge et al 2020

48. References
• Bouchut, J.-C., Van Lancker, E., Chritin, V., &
Gueugniaud, P.-Y. (2011). Physical Stressors during
Neonatal Transport: Helicopter Compared with
Ground Ambulance. Air Medical Journal, 30(3),
134–139.
https://doi.org/10.1016/j.amj.2010.11.001
• Caro-Domínguez, P., Lecacheux, C., Hernandez-
Herrera, C., & Llorens-Salvador, R. (2021). Cranial
ultrasound for beginners. Translational Pediatrics,
10(4), 1117-1137. doi:10.21037/tp-20-399
• Hall, V. (2017). A study to investigate whether
speed and road conditions have an effect on the
physiological stability of sick and preterm babies
undergoing inter-hospital transfer by ambulance.
• Lei, Y. (2017). Medical ventilator system basics: A
clinical guide (1st edition). Oxford University Press.
• Partridge, T. (2020). Finding Comfortable Routes
for Ambulance Transfers of Newborn Infants*.
2020 42nd Annual International Conference of the
IEEE Engineering in Medicine & Biology Society
(EMBC), 5905–5908.
• Shimizu, N., Saito, O., & Nishimura, N. (2018).
Vibration risks during pediatric transport: A
comparison of the ambulance and the helicopter
(3). The Chiba Medical Society.
https://doi.org/10.20776/S03035476-94E-3-P33
• Yorkshire & Humber Pan-Network Neonatal Clinical
Guideline (2023) Evidence-based care bundle to
reduce intraventricular haemorrhage in preterm
neonates < 28 weeks’ gestation.
• Zahid, A., Raffaj, D., Wignell, A., & Davies, P. (2021).
Continuous Drug Delivery is Significantly Affected
by Relative Height Changes Between Patient and
Syringe Driver. Journal of Patient Safety, 17(1),
e15–e19.
https://doi.org/10.1097/PTS.0000000000000645