Transfer Guidelines for Surgical Newborns

Publication: 01/09/2003  --
Last review: 03/02/2014  
Next review: 02/02/2020  
Clinical Guideline
CURRENT 
ID: 278 
Approved By:  
Copyright© Leeds Teaching Hospitals NHS Trust 2014  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Transfer Guidelines for Surgical Newborns

I. General Stabilization Procedures
II. Special Conditions
     Oesophageal Atresia/Tracheo-Oesophageal Fistula
     Abdominal Wall Defects
     Abdominal Distention/Suspected Bowel Obstruction
     Necrotising -Entero-colitis
     Congenital Diaphragmatic Hernia
     Pneumothorax/Pneumomediastinum
     Choanal Atresia
     Pierre Robin/Micrognathia
     Neural Tube Defects

I. General Stabilization Procedures

Stabilise in same way as medical transfers as regards to ABCDE
(see Embrace Neonatal Stabilization Guidelines)

  • Pain Assessment
    Consider IV paracetamol or morphine infusion
  • Gastro-Intestinal problems
    keep nil by mouth
    indwelling 8 or 10g nasogastric or orogastric tube
    position confirmed by X-ray or acid positive  pH paper
    on free drainage
    frequent aspiration if large amounts
    If baby premature and small, consider smaller size ng tube if 8/10g too big
  • IV fluid management
    Remember maintenance fluids and replacement fluids for losses (ml for ml for gastric losses)
    Maintenance- 10% dextrose with additives or TPN
    The transport team do not use TPN during transfer but are happy to take unopened bags to accepting units for use.
     losses from ng tubes- replace with 0.45% saline with 20mmol
    KCl if greater than 20ml/kg loss over 24 hours 
    fluid boluses for hypovolaemia:  use saline or 4.5% human albumin solution if available (babies will be losing protein rich fluid from gut)
    beware of excessive fluid losses e.g. in gastroschisis, exomphalos and NEC
  • X-ray and diagnostics
    Xrays to be sent to accepting unit by PACS if possible
  • Drugs
    Morphine infusion preferred for sedation (or other opiate if Morphine not available)
    ensure Vitamin K has been given IM or IV prior to transfer in all surgical babies and documented
  • Parents
    • ensure clotted maternal blood is available for cross matching - EDTA bottle, fully labelled by hand (no sticky labels)
    • written consent will be obtained by Consultant Surgeon upon arrival at receiving Hospital - Consent will be taken by telephone in case parents not able to travel to receiving hospital
  • Communication by Referring Team
    • to contact Embrace to ascertain bed availability 0845 147 2472
      if cot available, Embrace will facilitate conference call with Embrace Consultant, referring doctor, and Surgical SpR/Consultant on call [Consultant Surgeon at receiving hospital MUST always be aware of transfer] to provide further stabilisation advice
    • if medical input required, or baby being admitted to NICU cot, discuss with Neonatologist on call.
    • If while waiting for Embrace Team to arrive: baby acutely deteriorates prior to transfer or has bowel perforation on X-ray
      Contact Embrace base 0845 147 2472 for urgent advice from Consultant Surgeon/ Neonataologist
  • Embrace Team
    It may not be possible to achieve total stability before transfer in critically ill infants. Resuscitation must take place, but if the baby cannot be stabilised without surgical intervention there may be occasions where it is better to transfer the baby urgently without achieving total stability. This is a difficult judgment and must be discussed with the Cons. Surgeon/Neonatologist at the receiving end.
  • During transfer
    • avoid hypothermia in all circumstances - minimum interference reduces temperature stress on infant
    • continually assess circulatory status
    • consider fluid boluses

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II. Special Conditions

Oesophageal Atresia/Tracheo-Oesophageal Fistula
Airway and Breathing

  • avoid ventilation if possible: inspiratory gases take path of least resistance (= through fistula) and may cause significant abdominal distension (or perforation)
  • if ventilation needed: urgent consultation with Consultant Neonatologist/ Surgeon on call
  • transfer as soon as possible to avoid prolonged ventilation prior to surgery

Circulation

  • 2 forms of venous access
  • continue maintenance fluids
  • Use 10g NG tube or Replogle tube if available
    • in pouch
    • on continuous drainage + aspirate at least every 10 minutes
      • to keep upper pouch empty and prevent overflow or tracheal compression
      • must be done, even if infant does not appear to have excess secretions
    • suction mouth with standard suction catheter if dribbly every 20-30 mins

Drugs

  • Start IV Amoxicillin + Gentamicin (or first line antibiotics)
  • If ventilated, commence morphine infusion for sedation and consider paralysis for transfer

During transfer

  • baby to be nursed prone with head up tilt, as far as practicable
  • try to keep infant contented (crying promotes gastric distension and subsequent regurgitation / aspiration)
  • attach Replogle tube to Atrium drain on continuous suction
  • if excess secretion may need to stop to flush tube with saline and using 'bulb' mechanism for further suction

Abdominal Wall Defects
Gastroschisis/Omphalocoele/Ectopic Bladder

Airway and Breathing:

  • these infants rarely need intubation and ventilation for transfer unless co-morbidities lead to respiratory compromise

Circulation:

  • 2 forms of venous access
  • continue maintenance fluids
  • nil by mouth
  • NG/OG tube, free drainage
  • Continual assessment of circulatory status- remember excessive fluid loss common
  • fluid boluses to give as 4.5% HAS if available- if not 0.9% saline

Drugs:

  • Start IV Amoxicillin + Gentamicin + Metronidazole  ( or first line antibiotics with metronidazole)

Exposed viscera

  • cover with plastic/cling-film (does not need to be sterile)
  • contra-indicated: cotton wool and saline soaks
  • exomphalos with intact sac must be handled with extreme care to prevent rupture - avoid pressure and kinking - prevent stool contamination of the defect
  • Ectopic bladder- gelaperm is more gentle

During transfer

  • nurse baby on side as this relieves tension on the mesentery
  • close observation of viscera - if circulation appears to be compromised, then reposition viscera in relation to infant (inspect base of viscera mass)
  • consider administration of fluid boluses
  • consider supplementary oxygen
  • regular temperature, pulse, respiration rate and BP monitoring

Abdominal Distention/Suspected Bowel Obstruction

Airway and Breathing:

  • Consider intubation and ventilation of abdominal distension compromising respiratory status
  • If ventilation problematic  and chest movement difficult to achieve despite high pressure, discuss with consultant Surgeon re abdominal drain

Circulation:

  • 2 forms of venous access
  • continue maintenance fluids
  • nil by mouth  
  • 8-10 F NG/OG tube
    • free drainage + intermittent gastric suction
    • record amount and type of fluid aspirated
    • if aspirates > 20 ml/kg: replace with normal saline and potassium (20mmol/500mls saline)
    • assess and correct shock with fliud boluses

Other 

  • AP and lateral shoot-through X-rays (lateral only if perforation suspected)
  • Do not instrument the anus (e.g. washouts, rectal thermometers) as this may obscure lower GI contrast appearances of Hirschsprung's

During transfer

  • nurse in supine position
  • if abdominal distension significant: close observation for hypoxia (splinting effect) and raise head of mattress to try and improve respiratory status

Necrotising -Entero-colitis

Airway and Breathing:

  • Ventilate if hypotensive or acidotic, according to Embrace Neonatal Stabilization Guidelines

Circulation:

  • 2 forms of venous access
  • continue maintenance fluids
    • nil by mouth
    • 8-10 g NG/OG tube
  • free drainage
    • Fluid boluses after assessment of circulatory status
    • Check clotting and consider administration of FFP/extra Vitamin K
    • If UAC in situ, then do not remove 

Drugs:

  • Start IV Amoxicillin + Gentamicin + Metronidazole (or first line antibiotics with metronidazole)
  • Remember pain relief- may need morphine bolus and then continuous infusion

Other:

  • AP and lateral shoot through X-rays

Congenital Diaphragmatic Hernia

Airway and Breathing:

  • Intubate as soon as diagnosis is made, without using bag and mask ventilation, using adequate sedation and paralysis
    • "gentle ventilation" to avoid barotrauma or pneumothorax (no hyperventilation). This technique will necessitate relatively higher COs levels to be tolerated
  • Surfactant not indicated, unless < or = 32 weeks
  •  ventilate in 100% O2 regardless of saturations

Circulation:

  • 2 forms of venous access  minimal
  • UVC and UAC desirable
  • continue maintenance fluids
    • nil by mouth
    • 8-10 g NG/OG tube
    • on continuous drainage
    • aspirate at least every 10 minutes to decompress stomach
    • Achieve good blood pressure with use of inotropes

Drugs:

  • Consider early use of inotropes- dopamine and dobutamine to support blood pressure
  • Commence on morphine infusion
  • Commence on atracurium infusion or regular pancuronium to achieve paralysis

During transfer

  • Consider nitric oxide
  • Keep baby sedated and paralysed
  • Maintain good BP- preferably with arterial monitoring
  • Adjust inotropes to achieve this
  • Carefully observe for the possible occurrence of pneumothorax (unaffected side)

Pneumothorax/Pneumomediastinum

Airway and Breathing:

  • Maintain airway patency and support respiratory drive prior to considering drainage unless under tension in which case the air leak must be drained first by needle thoracocentesis
    Pneumothorax which is not under tension and causing minimal symptoms
    • formal drainage must be done as risk of requiring drainage in transit is always real
    • use atrium drain in transit
  • Tension pneumothorax during transfer
    • = catastrophic event causing sudden and severe deterioration
    • perform needle aspiration immediately
  • Pneumomediastinum
    • chest drain has very limited value
    • place infant in ambient oxygen concentration of 100% to enhance absorption of gas collection if term.

Circulation:

  • 2 forms of venous access

Drugs:

  • remember analgesia for insertion and post insertion of drains

During transfer:

  • Chest drain must be securely fixed in position prior to transfer
  • Chest drain must be attached to an atrium drain for transport

Choanal Atresia

Airway and Breathing:

  • If bilateral, infant is unable to breathe through nose
    Oro-pharyngeal airway (appropriately sized Guedel) must be provided - secure in place with tape

Circulation:

  • 2 forms of venous access
  • Consider maintenance fluids
    Avoid feeding for at least 2 hours prior to transfer and elevate head of mattress slightly of reduce risk of vomiting

During transfer:

  • Close observation of breathing pattern during transfer is essential

Pierre Robin/Micrognathia

Airway and Breathing:

  • If significant respiratory distress then place oro-pharyngeal airway (appropriately sized Guedel) or consider naso-pharyngeal airway; secure for transfer
  • If endotracheal intubation is considered, this must be discussed with referring or receiving Consultant before any attempt is made to intubate. This can be extremely difficult, ask for help from experienced local anaesthetist

During transfer:

  • Nurse + transfer infant in prone position, as this usually improves airway patency

Neural Tube Defects
Meningocele, Encephalocele

Airway and Breathing:

  • Maintain open airway.
  • Ventilation not usually required
  • If associated hydrocephalus and large head size, airway positioning important.

Drugs:

  • Start IV Benzylpenicillin and Gentamicin ( or first line antibiotics)

Other:

  • Nurse infant in prone position to prevent pressure on lesion
  • Sterile dressing if sac is ruptured
  • Cover back in cling film - prevent stool contamination/can use Gelaperm/gauze and light bandage

During transfer:
          Nurse infant in prone position to prevent pressure on lesion

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Provenance

Record: 278
Objective:
Clinical condition:

Stabilisation of surgical neonates

Target patient group: Neonates in intensive care
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Adapted from:

N/A


Evidence base

Not supplied

Document history

LHP version 1.0

Related information

Not supplied

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