Chapter 120: Transport of the Critically Ill Newborn

Regionalized care · Levels of neonatal care · Stabilization · Transport team · ECMO transport · Reverse transport

🚑 Goal: Deliver VLBW infants to Level III+ centers · Healthy People 2020 target 83.7%

🚨 Neonatal Transport: Key Principles & Levels of Care

🏥 Level I (Basic)
Well newborn care, resuscitation, stabilization before transfer. Minimum for inpatient maternity.

🏥 Level II (Specialty)
Infants ≥32 wk or >1500 g, CPAP, short-term ventilation, stabilize <32 wk for transfer.

🏥 Level III (NICU)
Extremely preterm, advanced ventilation, subspecialists, surgery on-site or by agreement.

🏥 Level IV (Regional)
Highest acuity, ECMO, pediatric surgical subspecialties, transport team, outreach education.

👥 Transport team
RN + RT or paramedic; neonatologist or NNP for critical patients. Simulation training recommended.

❄️ Therapeutic hypothermia transport
Servo-controlled cooling device for HIE; maintain core 33.5°C, avoid overcooling.

📦 Equipment essentials: Incubator/warmer, O2 blender, pulse ox, ECG, ventilator/CPAP, iNO (if needed), medications (epinephrine, PGE1), chest tubes, ETTs, laryngoscope.

🔍 Approach to the critically ill neonate requiring transport

Recognize need for higher level of care – Extreme prematurity (<32 wk), respiratory failure requiring HFOV/iNO, surgical emergencies (CDH, gastroschisis), therapeutic hypothermia candidates, ECMO referral.

Pre-transport stabilization (ABCDE) – Secure airway (ETT if needed), optimize ventilation, obtain vascular access (UVC or peripheral), check glucose, treat pneumothorax, maintain normothermia.

Communication & consent – Discuss risks (decompensation, crash, vehicle accident) with parents. Send prenatal history, labs, imaging with team.

Mode of transport – Ground ambulance for short distance; helicopter/fixed-wing for long distance, traffic, or weather. Stability and travel time considered.

Special therapies during transport – iNO, hypothermia (servo-controlled device), PGE1 for ductal-dependent lesion, ECMO transport (specialist + perfusionist).

Reverse transport – Return to referring hospital after stabilization when intensive care no longer needed; improves bonding and resource utilization.

📋 Stepwise management: Pre-transport stabilization & en route care

Airway & breathing – Intubate if apnea, severe retractions, or need for sustained CPAP >8 cmH2O. Confirm ETT position (ETCO2, bilateral breath sounds). Provide warm humidified O2.

Circulation & access – Place umbilical venous catheter (UVC) for emergencies. Peripheral IV if UVC not possible. Inotropes (dopamine, epinephrine) if hypotension persists after volume.

Thermal control – Use transport incubator with servo-control; plastic wrap + hat for VLBW; aim for axillary temp 36.5-37.2°C.

Metabolic & hematologic – Check glucose (treat hypoglycemia), calcium. If suspected anemia/hemorrhage, cross-match blood. Vitamin K given.

Documentation & handoff – Provide transport note including vital signs, interventions, response, and time-stamped events. Use video telemedicine if available.

⚠️ ECMO transport considerations: Requires dedicated ECMO specialist/perfusionist, risk of decannulation, circuit clotting, bleeding. Ensure heparin protocol, backup plan.

🧠 Rapid reflex prompts – Newborn transport

📌 Which infants have lowest mortality when born at Level III?
VLBW (<1500 g) – meta-analysis: death 23% at Level III vs 38% at non-Level III.

📌 Medication needed for ductal-dependent lesion during transport?
Prostaglandin E1 (PGE1) 0.05-0.1 mcg/kg/min to maintain ductal patency.

📌 First step if infant deteriorates during transport?
Stop vehicle, assess ABC, provide bag-mask ventilation, consider tension pneumothorax, check ETT position.

📌 Minimum personnel for advanced neonatal transport?
At least 2 members (RN/RT/paramedic). For critical/ECMO, add neonatologist or NNP and ECMO specialist.

📌 Indication for reverse transport?
Infant stabilized, no longer needs Level III/IV resources (e.g., feeds well, room air, no drips).

📌 Equipment to provide for possible PPHN during transport?
Inhaled nitric oxide (iNO) device, high-frequency ventilator capability, sedation.