Control of Oxygenation during the Transport of Sick Neonates

(1)

Reprint requests to (R.I.C.) Department of Pediatrics, Mt Zion Medical Center, San Francisco, CA 94115.

American Academy of Pediatrics.

EXPERIENCE AND REASON 117

particularly to the apparent high risk during

in-fancy.

L. REBECCA CAMPBELL, MD

ARNOLD J. ZEDD, MD

RICHARD H. MICHAELS, MD

Department

of

Pediatrics

University of Pittsburgh School of Medicine

Children’s Hospital of Pittsburgh

Pittsburgh

REFERENCES

1. Tejani A, Dobias B, Nangia BS, et a!: Intrafamily spread of

Haemophilus type b infections. Am J Dis Child 131:778, 1977

2. Fiice GA, Andrews JS Jr, Hudgins MP, et a!: Spread of Haemophilus influenzae: Secondary illness in household contacts ofpatients with H. influenzae meningitis. Am JDiS

Child 132:757, 1978

3. Ward JI, Fraser DW, Baraff U, et al: Haemophilus influ. enzae meningitis: A national study of secondary spread in household contacts. N EngI JMed 301:122, 1979

4. Glode MP, Daum RS, Goldman DA, et al: Haemophilus influenzae type B meningitis: A contagious disease of chil-dren. Br Med J 1:899, 1980

5. Granoff DM, Basden M: Haemophiius influenzae infections in Fresno County, California: A prospective study of the effects of age, race, and contact with a case on incidence of

disease. J Infect Dis 141:40, 1980

6. Michaels RH, Norden CW: Pharyngeal colonization with

Haemophilus influenzae type b: A longitudinal study of

familjes with a child with meningitis or epiglottitis due to H

influenzae type b. J Infect Dis 136:222, 1977

7. Coulter D, Whisnant JK, Marks MI: Hemophilus influenzae

b meningitis in identical twins of a triplet sibship. Pediatrics 54:502, 1974

8. Whisnant JK, Rogentine GN, Gralmck MA, et a!: Host

factors and antibody response in Haemophilus influenzae

type b meningitis and epiglottitis. J Infect Dis 133:448, 1976 9. Yogev R, Lander HB, Davis AT: Effect of rifampin on

nasopharyngeal carriage of Haemophilus influenzae type b.

J Pediatr 94:840, 1979

10. Sinclair SE: H. influenzae type b in acute laryngitis with bacteremia. JAMA 117:170, 1941

11. Good PG, Fousek MD, Grossman MF, et al: A study of the

familial spread of H influenzae type b. Yale J Biol Med 15: 913, 1943

12. Addy MG, Ellis PDM, Turk DC: Haemophilus epiglottitis: Nine cases in Oxford. Br Med J 1:40, 1972

Control

of Oxygenation

during

the Transport

of Sick

Neonates

A safe neonatal transport system is an essential

component in the regionalization of perinatal care.

Despite efforts to provide continuous intensive care

to sick infants during transport,’5 several studies

have revealed an increased morbidity and mortality

among

infants

transported to newborn intensive

care units (NICU) compared with those infants

born at the NICU.6’7 There is little information

available

about

the

adequacy

of monitoring

and

maintaining oxygenation and

acid-base

status

dur-ing infant transport. In a preliminary study we

examined the ability of a neonatal transport team

to maintain an infant’s Pao2 (46 to 100 torr), pH

(7.25 to 7.55), and Paco2 (20 to 50 torr) in the

“physiologic” range during transport. We compared

the umbilical artery blood gases taken at departure

from the referring hospital and those taken on

arrival at the NICU in 58 infants. Of the newborns

85% (49) had blood gases that were in the

physio-logic

range

for

pH and Paco2 at these two times

during transport. However, 66% (38) were either

hyperoxic (> 100 torr) or hypoxic (< 46 torr) at the

times

the arterial

gases

were measured. The present

study is an attempt to examine in a prospective

manner the effectiveness of using a transcutaneous

TcPo2 monitor to maintain normoxia during the

transport

of sick newborns.

METHODS

Thirty-six newborn infants with respiratory

dis-tress

were transported

to

Mount Zion Medical

Cen-ter by fixed winged aircraft (pressurized to sea

bevel), or ambulance (equipped with Veriflow meter,

oxygen, and compressed air, and FIO2 analyzer).

Experienced neonatal fellows and NICU nurses

were used. All infants had umbilical artery catheters

inserted at the referring hospital and positioned at

L3-L4 for medical management. Arterial

blood

gases were drawn into heparinized glass syringes

and placed on ice during the transport until they

were analyzed.

Samples

of 0.3 ml were obtained at

departure from the referring hospital and at

30-minute intervals during the transport. These were

analyzed on a Corning 165

blood

gas analyzer at the

NICU within

three

hours

of collection.

In a preliminary study we found that the Pao2 of

blood gas samples handled in this manner was

within 5% of the Pao2 obtained when samples were

analyzed within 5 minutes following collection. An

infant was considered to have drifted out of the

at Viet Nam:AAP Sponsored on September 7, 2020

www.aappublications.org/news

(2)

* Groups compared using

x2

analysis, P < .01.

Corrective change

No change made

Change not

cor-recting Pao2

118 PEDIATRICS Vol. 66 No. 1 July 1980

TABLE 1. Characteristics of 32 Infants Who Required Changes in Ventilatory

Manage-ment to Maintain Pao2 in the Physiologic Range

Infant Transports

TcPo2 TcPo2

Not Monitored (%) Monitored (%)

(n=21) (n=11)

Birth weight (gm ± SEM) 1,750 ± 180 1,890 ± 226

Ventilatory Support:

Respirator 12 (57%) 4 (37%)

Continuous distending pressure 2 (10%) 2 (18%)

Hood 02 (FIO2 > 0.5) 2 (10%) 2 (18%)

Hood 02 (FIO2 < 0.5) 5 (23%) 3(27%)

Respiratory disease

IRDS 14 (67%) 8 (73%)

Other (meconium aspiration, bacte- 7 (33%) 3 (27%)

rial pneumonia, TTNB)

Transport time (mm) 108 ± 10 79 ± 14

No. of air transports 13 (62%) 5 (46%)

No. of blood samples for Pao2 per trans- 3.4 ± 0.2 3.4 ± 0.5

port

TABLE 2. Blood with Pao2 <46 or >

Gases During Transport of Infant’s

100 Torr

No. of Gases out of TcPo, Not Moni- TcPo, Monitored Physiologic Range tored (%) (n = 21) (%)* (n = 11)

:1 6 (30) 9 (80)

2 6 (30) 2 (20)

3 9 (40) 0 (0)

physiologic range during transport if the Pao2 of

any individual blood sample was less than 46 torr

or greater than 100 torr. A Litton transcutaneous

oxymonitor (TcPo2) (electrode placed on the

in-fant’s abdomen) was used during eleven transports;

its use during transport depended on its availability,

ie, whether it was being used on another sick infant

at the NICU. The correlation of TcPo2 with

simul-taneous arterial Pao2 has been previously

re-ported.8’9 Data were evaluated by a

x2

analysis or

unpaired

t-test.

RESULTS AND DISCUSSION

Of the 36 infants, 35 left the referring hospital

with the Pao2 in the physiologic range. Only four of

the 36 infants maintained their Pao2 in the

physio-logic range as determined by intermittent sampling

of arterial blood. These four infants required no

changes in ventilatory support (FIO2 or assisted

ventilation) during transport. Of the 32 infants who

required

alterations

in

ventilatory support to

main-tam

their Pao2 in the physiologic range, there were

no significant differences between infants who were

transported with or without the transcutaneous

monitor

in

birth weight, frequency of idiopathic

respiratory distress syndrome, type of ventilatory

support during transport, mean transport time, or

TABLE 3. Management Decisions for 32 Infants Who

Required Ventilatory Changes During Transport*

Management No. of Infant Transports

TcPo2 not Moni- TcPo Monitored

tored (%) (n = 21) (%) (n = 11)

4 (19) 8 (73)

12 (57) 1 (9)

5 (24) 2 (18)

* The group using the transcutaneous monitor had

sig-nificantly more corrective changes (changes in ventilatory

support that returned Pao2 to the physiologic range) than

did the group that did not have the monitor where either

no change or a change that did not bring the Pao2 into

the physiologic range was more likely to be made (P <

.01,

x2

analysis).

the frequency of air transports (Table 1). Table 2

demonstrates that the 1 1 infants who were

mom-tored with a transcutaneous oxygen monitor spent

less time (as determined by the number of arterial

blood samples) with their Pao2 out of the

physio-logic range. In addition, during transports in which

the transcutaneous monitor was used, physicians

were more likely to make changes in ventilatory

management that brought the infant’s Pao2 into the

physiologic range (Table 3).

Despite the fact that 35/36 infants left the

refer-ring

hospital

with

a

Pao2 in the physiologic range,

and that transports were conducted by skilled

neo-natal fellows with NICU nurses, 32 of the 36 infants

required alterations in ventilatory support to

main-tain their Pao2 in the physiologic range during

transport. The use of a portable transcutaneous

oxygen monitor enabled the physicians to limit the

periods of hyperoxia or hypoxia that occurred

dur-ing transport to the NICU.

(3)

Reprint requests to (J.S.) Department of Pediatrics, Post Office Box 3967, Duke University Medical Center, Durham, NC 27710.

American Academy of Pediatrics.

ACKNOWLEDGMENT REFERENCES

EXPERIENCE AND REASON 119

We would like to thank Ms Susan Axeirod for her help

in the preparation of this manuscript.

CAROL MILLER, MD

RONALD I. CLYMAN, MD

ROBERT S. ROTH, MD

SUSAN H. SNIDERMAN, MD

ROBERTA A. BALLARD, MD

DOUGLAS HENNING, MD

PHILIP RIEDEL, MD

ALAN ROSEN, MD

LiNDA BURDEN, MD

Department

of

Pediatrics

Mount Zion Hospital and Medical Center

San Francisco

1. Chance GW, O’Brien MJ, Swyer PR: Transportation of sick

neonates. Can Med Assoc J 109:847, 1973

2. Gunn T, Outerbridge EW: Effectiveness of neonatal tram-port.Can Med Assoc J 1 18:646, 1978

3. Hackel A: A medical transport system for the neonate.

Anesthesiology 43:258, 1975

4. Pettett G, Merenstein GB, Batt.agLia FC, et al: An analysis of air transport results in the sick newborn infant. I. The

transport team. Pediatrics 55:774, 1975

5. Cunningham MD, Smith FR Stabilization and transport of severely ill infants. Pediatr Clin North Am 20:359, 1973 6. Hirata T: Increased handicaps in transported very low

birth-weight infants. Clin Res 27:125A, 1979

7. Clark C, Lane B, Clyman R, et al: Decreased risk of intra-ventricular hemorrhage (P/H) for infants born in a perinatal center. C/in Res 27:123A, 1979

8. Huch R, Huch A, Albani M, et al: Transcutaneous Po, monitoring in routine management of infants and children with cardiorespiratory problems. Pediatrics 57:681, 1976 9. Huch R, Lubbers DW, Huch A: Reliability of transcutaneous

monitoring of arterial P0, in newborn infants. Arch Dis

Child 49:213, 1974

Infantile

Water

Intoxication

at

Home

Water intoxication in infants living at home has

been considered an unusual entity.’ This paper

describes two infants who were seen because of

seizures. It appears that the metabolic

derange-ments were a consequence ofparental error. In view

of the similarity between these and previously

re-ported cases,’4 including the context of parental

poverty,

the problem

and population at risk may be

more common than previously recognized.

CASE REPORTS

Case I

T.W. is a 5-month-old boy with no previously known

health problems. After being irritable for most of the

afternoon, he developed generalized seizures in the

eve-fling. His temperature was 97 F rectally, blood pressure

70 mm Hg by palpation, pulse rate was 132 beats per

minute, and respirations 20/mm. Measurements included

length 63.5 cm (25th percentile), weight 60 kg (third

percentile), and head circumference 40 cm (35th

percen-tile). He was actively convulsing at presentation. The

anterior fontanel was soft and flat. Transifiumination of

the skull was unremarkable. The optic fundi were normal.

The neck was supple. The skin had good turgor, there

were no lesions or edema. The remainder of the physical

examination was normal.

Blood glucose was 90 mg/100 ml. CSF showed no cells,

glucose was 60 mg/100 ml, protein 10 mg/100 ml, and

Gram stain and culture were negative. There was a mild

hypochromic, microcytic anemia. The white blood cell

count was unremarkable. The erythrocyte sedimentation

rate was 2 mm/hr. The serum electrolytes were: sodium

11 1 mEq/liter, potassium 3.8 mEq/Iiter, chloride 85 mEq/

liter, CO, 17 mm/liter, BUN 7 mg/100 ml, calcium 8.0

mg/100 ml, phosphorus 3.7 mg/100 ml, magnesium 1.5

mg/100 ml. Plasma osmolality was 230 mOsm/kg; urine

osmolality was 155 mOsm/kg; urine sodium was 47 mEq/

liter. Arterial blood gases on FIO 0.40 showed pH of

7.186, Pco2 38.3 mm Hg, Po, 199 mm Hg, and HCO, of 14

mm Hg.

Upon requestioning about the infant’s diet, the mother

confided that she ran out of whole milk, his usual major

nutritional source, on the day before admission. Tap

water was used as a substitute. At least 64 oz of water

was consumed on the day of admission, in addition to ‘/4

jar of commerically prepared strained fruit and /4 jar of

commercially prepared vegetable with ham dinner.

His seizures were unresponsive to the usual

pharma-cobogic management. When the serum sodium

concentra-tion became known, he was given NaHCO, cakulated to

raise the serum sodium by 10 mEq/liter and to

treat

the

metabolic acidosis. Serum sodium rose to 131 mEq/liter

within an hour, and his seizures abated.

Body weight decreased to 5.62 kg eight hours after

admission. Fluid output exceeded 670 ml. Serum electro-lytes were: sodium 138 mEq/liter, potassium 3.4 mEq/

liter, chloride 101 mEq/liter, and CO2 22 mm/liter. Fluid

restriction was discontinued at this time.

Case 2

RL is a 6-month-old (corrected for birth at 36 weeks

of gestation) boy who had a convulsion while awaiting a

(4)

1980;66;117

Pediatrics

Douglas Henning, Philip Riedel, Alan Rosen and Linda Burden

Carol Miller, Ronald I. Clyman, Robert S. Roth, Susan H. Sniderman, Roberta A. Ballard,

Control of Oxygenation during the Transport of Sick Neonates

Services

Updated Information &

http://pediatrics.aappublications.org/content/66/1/117

including high resolution figures, can be found at:

Permissions & Licensing

http://www.aappublications.org/site/misc/Permissions.xhtml

entirety can be found online at:

Information about reproducing this article in parts (figures, tables) or in its

Reprints

http://www.aappublications.org/site/misc/reprints.xhtml

Information about ordering reprints can be found online:

(5)