• Introduction
• The Transport Process
  • Consultation and Transfer
  • Arranging a Transport
  • Response Time of the Team
  • Transport Personnel and Equipment
  • Activity of the Team in the Referring Hospital
  • What to Have Ready When the Team Arrives
  • Parents
• Guidelines of Stabilization
  • Assisted Ventilation, Resuscitation
  • Oxygenation
  • Temperature Control
  • Glucose
  • Acid-Base Status
  • Shock
  • Fluid and Electrolytes
  • Infection
• Commonly Used Drugs
• Special Conditions
  • Pneumothorax
  • Diaphragmatic Hernia
  • Esophageal Atresia/Tracheoesophageal Fistula
  • Choanal Atresia
  • Bowel Obstruction
  • Omphalocele and Gastroschisis
• Follow-up
• Return Transport
• Authors

From the moment a perinatal problem is recognized to the point of its resolution, there is a continuum of care. A common feature of disease in the neonatal period is a rapidly progressive course. Use of special centers for the treatment of the sick newborn has been accompanied by improvement in survival, and the safe transfer of these infants to the center is an important part of their overall care. Appropriate stabilization, initiated on recognition of a problem, is necessary throughout the transfer process.

The ideal transport of a baby is done in utero. Unfortunately, not all problems can be identified in time to transfer the mother, and many emerge during or after birth. The purpose of this presentation is to aid the referring hospital staff in determining which infants need to be transported, in initiating the transport process, and adequately preparing the infant for transport.

Neonatal intensive care is provided at both University of Washington Medical Center and Children's Hospital and Regional Medical Center. Telephone consultation with a Neonatologist and arrangements for transfer can be made by calling:

Obstetrical, Perinatal, and Pediatric consultation (beyond the neonatal period) can also be accessed at the same telephone number.

The decision to transport an infant depends upon a variety of factors including: availability of 24-hour skilled nursing, respiratory therapy, equipment, x-ray and laboratory support, as well as physician knowledge and time.

The following are examples of disease entities or conditions that might be reasons for consultation or transport:

1. Respiratory distress from any cause (i.e., meconium aspiration, neonatal pneumonia, Infant respiratory distress syndrome) - without the capability to monitor oxygen therapy and arterial blood gases - without the capability to give ventilatory assistance
2. Intravenous fluid requirements
3. Surgical conditions
4. Low birth weight infants
5. Suspected congenital heart disease
6. Significant birth complications
7. Severe neonatal depression
8. Unresponsiveness to resuscitation efforts
9. Infants of diabetic mothers
10. Neonatal seizures
11. Suspected infection (sepsis, meningitis)
12. Hemolytic disease
13. Apnea
14. Suspected shock
15. Persistent acidosis
16. Recurring hypoglycemia
17. Infants not doing well for unknown reasons

The decision to transport an infant is made after consultation between the infant's physician and the neonatologist (NEONATAL MEDCON HOTLINE). If the decision is made to transport the infant, the HOTLINE physician will decide which hospital will receive the infant, depending on bed space availability, the infant's problem, and the wishes of the referring physician. The neonatologist then notifies the hospital which will receive the infant, and initiate arrangements for appropriate transport. The following information should be made available to the HOTLINE physician at the time of the consultation call:

1. Patient's name and date of birth
2. Mother's and father's names
3. Details on prenatal history, labor and delivery, neonatal resuscitation
4. Apgar scores
5. Gestational and birthweight
6. Vital signs (temperature, heart rate, respiratory rate, blood pressure)
7. Oxygen/ventilatory support requirements
8. Laboratory data obtained (glucose, calcium, hematocrit, blood gas determinations)
9. Vascular access

Ground Transport
The transport team and ambulance meet at Children's Hospital and Regional Medical Center and place the equipment in the ambulance prior to departure to the referring hospital. This requires approximately 30 minutes. Location of the referring hospital, road conditions, and traffic will all influence the time in route. The transport nurse will call the referring hospital when the team leaves, to give an estimated time of arrival and check on the condition of the infant.

Air Transport
The HOTLINE physician will contact the dispatcher at Airlift Northwest and initiate the transport process. The Airlift Northwest dispatcher will contact the referring hospital to give an estimated time of arrival and check on the condition of the infant.

Transport personnel are fully skilled in the care of high-risk newborns. The personnel include a specially trained transport nurse and respiratory therapist. Equipment they bring with them includes:

1. Transport incubator
2. Monitors for:
   • heart rate
   • respiratory rate
   • temperature
   • arterial blood pressure
   • inspired oxygen concentration
   • oxygen saturation
3. Assisted ventilation equipment
4. Intravascular infusion equipment
5. Medications
6. Equipment for:
   • intubation
   • umbilical vessel cannulation
   • chest tube placement
7. Suction equipment

Upon arrival, a member of the transport team will perform a physical examination, assess the infant's condition, review x-ray and/or laboratory results, and obtain vital signs and analysis of blood glucose and blood gases as appropriate.

If the infant has unstable vital signs, the transport team will remain at the referring hospital until the baby is sufficiently stabilized to ensure a safe transport. It is unsafe to transport an unstable infant, so the team may stay at the referring hospital for a prolonged time, depending on the infant's condition.

The transport team will rely upon the staff of the local hospital for maternal and infant history as well as information about laboratory tests and x-rays that have been done. A warming device to maintain the infant's temperature during procedures, and access to the laboratory and x-ray facilities may be required.

The following should be ready to send with the transport team:

1. Cord blood specimen
2. Maternal blood specimen (5-7 mL clotted)
3. Placenta
4. Copy of maternal record including complete maternal history and labor and delivery records
5. Copy of infant's chart with completed nursing documentation (urine output, passage of stools, vitamin K administration, eye prophylaxis, hepatitis vaccine, other medication administration)
6. All X-rays

After the infant has been placed in the transport incubator, he or she will be taken to the mother's room where both parents may see and touch their child. The transport team will introduce themselves, discuss the infant's problems and plan of care, and obtain written consent for transport and care. The parents are encouraged to visit the receiving hospital as soon as possible and participate in the care of their baby. A booklet will be given to the parents that explains the intensive care nursery, gives definitions of some of the terminology they may hear, and has numerous pictures and a map to the hospital. The names of the physicians who will be involved in the care of their infant and the telephone number of the nursery will also be given to them.

The following pages outline conditions requiring correction prior to transport. Appropriate treatment of these problems by the referring staff will aid in reducing the infant's morbidity and mortality.

The stable infant has:

• Patent airway and adequate ventilation
• Pink skin and lips
• Heart rate of 120-160 bpm
• Axillary temperature of 36.5-37^oC (97.7-98.6^oF)
• Metabolic problems corrected
• Special problems managed

Assisted ventilation may be required when respiratory distress occurs with any of the following:

• Bradycardia (heart rate less than 100/minute)
• PaCO₂ greater than 65 mmHg
• Central cyanosis in 100% oxygen
• Persistent apnea
• PaO₂ less than 50 mmHg in 100% oxygen

Assisted Ventilation with Bag and Mask

1. Suction nares and oral airway
2. Place head in neutral position (sniffing position), not overly flexed or hyperextended
3. Place the mask over the mouth and nose, pulling the jaw away from the throat and supporting the jaw against the mask
4. Ventilate with 100% oxygen at a rate of 40-60 breaths per minute. Use sufficient pressure to raise the chest and create breath sounds audible with a stethoscope over both lungs fields
5. Oral airway may be necessary to prevent the tongue from occluding the airway
6. If the infant's heart rate does not respond to effective bag/mask ventilation, the infant should have an endotracheal tube placed and receive continued assisted ventilation

Endotracheal Tube Size Guide

 Body Weight (grams)     Tube (internal diameter,mm)
           <1000                       2.5

         1000-2000                     3.0

         2000-3000                     3.5

           >3000                       3.5-4.0

Be Aware
Extremely immature infants are at risk of developing Retinopathy of Prematurity. One factor that increases this risk is hyperoxia. Therefore, ventilating premature infants of birth weight <1500 grams with oxygen concentrations greater than 21% (room air) for prolonged periods of time requires arterial blood tension measurements (see Oxygenation).

The risk of pneumothorax development is present - have equipment available for correction of this complication (see Pneumothorax).

Some equipment (self inflating ventilation bags) cannot deliver high concentrations of oxygen unless modifications are made.

Cardiac Compression

If the infant's heart rate does not respond to effective ventilation (remains <60/minute) or can not be detected, chest compressions should be initiated: Place thumbs over lower 1/3 of sternum. Wrap fingers around infant's chest, supporting spine with fingers. Compress 1/3 AP diameter of chest at a rate of 90/minute coordinating with ventilation. Ventilate after every 3rd compression. Stop momentarily every 30 seconds to check for improvement in heart rate.

The initial indication for oxygen administration is based on the presence of central cyanosis (blueness of the trunk, lips). Acrocyanosis (blueness of the feet, hands, and nailbeds), in the absence of central cyanosis, is not an indication for supplemental oxygen.

Administration of oxygen requires precise control of concentration, humidity, and temperature. Obtaining concentrations between 21% and 100% requires compressed air and oxygen which are connected by a mixing device (blender). Heating and humidification can be achieved by bubbling the gas mixture through water containing a heating coil or rod. Temperature of the heated air should be monitored continuously, and an alarm system should be set up in case overheating occurs. Oxygen concentration should be measured and recorded frequently. Calibration of the oxygen analyzer should be completed daily. Oxygen should be administered by percentage and not by flow per minute. Concentrations of oxygen less than 30% can be administered in the incubator while concentrations over 30% are best achieved using a head box with mixing, humidifying, and warming as mentioned above.

Hypoxia (inadequate oxygenation) can lead to brain damage and death. Hyperoxia (over-oxygenation) can damage the eyes in the premature infant. Optimal oxygenation lies between these two extremes.

The amount of oxygen the infant initially requires is based on relieving central cyanosis. Arterial blood samples should be obtained, maintaining arterial oxygen tension between 50-80 mmHg.

Assessment of Oxygenation

There are five common methods of assessing oxygenation which are listed below.
KNOW THE BENEFITS AND LIMITATIONS OF EACH METHOD.

1. Observation of the Infant's Color - The method should be used alone only when blood gas determinations are not available, and can be used for a short period in anticipation of transport. The infant should be given just enough oxygen to relieve central cyanosis (blueness of trunk and lips). Assessment of oxygenation needs to be done as frequently as every 10-15 minutes.
2. Arterial Blood Gas - This is the most accurate method and should be used whenever possible. Samples are obtained from an umbilical artery catheter or by percutaneous arterial puncture (radial, posterior tibial). Arterial oxygen tension should kept between 50-80 mmHg <1500 grams birth weight. Central cyanosis may occur when the PaO₂ falls substantially below 50 mmHg. However, a PaO₂ greater than 80 mmHg cannot be clinically detected. Thus, frequent measurements, sometimes as often every 15-30 minutes, are needed when oxygen is being delivered.
3. Capillary Blood Gas - A heelstick PO₂ always has a limited value, correlates poorly with arterial PaO₂, and should be used only for a short time when arterial samples cannot be obtained. Capillary pH and carbon dioxide tension values correlate fairly well with arterial values. Samples are obtained from a heel warmed (to 104^oF) for 5 minutes.
4. Transcutaneous Oxygen Measurements (PtcO₂) - This method of assessing oxygenation utilizes an electrode which is placed on the infant's trunk. An arterial blood sample is still required initially and periodically for correlation between the PO₂ recorded by the transcutaneous monitor and the PO₂ of arterial blood. Correlation during the first 24 hours of life appears to be poor.
5. Oxygen Saturation - This method utilizes fiber optic technology. Values should be kept in the 88-93% range in premature infants at risk for Retinopathy of Prematurity. Values of 88 to 100% can be used in term infants. It is important to remember that at high oxygen saturations (near 100%), the arterial oxygen tension may exceed toxic levels damaging to preterm infants (PaO₂ >80 mmHg). Saturation values need to be correlated with arterial oxygen tension values.

Norms:

• Axillary 36.5-37^oC (97.7-98.6^oF)
• Rectal 37^oC (98.6^oF)

Hypothermia and hyperthermia may increase infant morbidity and mortality.

Hypothermia adversely affects oxygen consumption and glucose homeostasis and may result in initiation of hemorrhagic processes.

Hyperthermia also affects oxygen consumption and glucose homeostasis and, at extreme temperatures, may cause cerebral damage, dehydration, hypernatremia, and death.

Immediately after delivery, place the infant under a radiant heat source and dry him/her quickly. This act alone can cut heat loss in half. Radiant warmers may not produce adequate heat to keep the infant warm if contributing factors such as a cool or drafty room or wet skin are present. After stabilization, the infant should be wrapped in warm blankets or commercially made silver swaddlers and taken to the nursery.

Management of Hypothermia

1. Eliminate source of heat loss (cold drafts from windows blowing over the warmer or incubator, cold mist)
2. Place the infant in an environment one degree above the neutral thermal environment (for age and weight). When a normal temperature is reached, place the infant into a neutral thermal environment (see Neutral Thermal Environment Temperature charts).
3. Temperatures should be taken as often as every 15 minutes during rewarming and every hour after stable until the transport team arrives.
4. Consider using:
   • silver swaddler (foil, saran wrap) - these do not warm the infant, but prevent further radiant losses.
   • heat shield (commercial shield or oxyhood) - place over the infant's body to prevent further radiant losses
   • chemical heating pad
   • additional humidity
5. Check blood glucose

Age and Weight                            Temperature
                                      Starting         Range
0-6 Hours                              oC    oF          oC
under 1200 grams                      35.0  95.0      34.0-35.4
1201-1500 grams                       34.1  93.4      33.9-34.4
1501-2500 grams                       33.4  92.1      32.8-33.8
over 2500 grams (and over 36 weeks)   32.9  91.2      32.0-33.8

6-12 Hours
under 1200 grams                      35.0  95.0      34.0-35.4
1201-1500 grams                       34.0  93.2      33.5-34.4
1501-2500 grams                       33.1  91.6      32.2-33.8
over 2500 grams (and over 36 weeks)   32.8  91.0      31.4-33.8

12-24 Hours
under 1200 grams                      34.0  93.2      34.0-35.4
1201-1500 grams                       33.8  92.8      33.3-34.3
1501-2500 grams                       32.8  91.0      31.8-33.8
over 2500 grams (and over 36 weeks)   32.4  90.3      31.0-33.7

24-36 Hours
under 1200 grams                      34.0  93.2      34.0-35.0
1201-1500 grams                       33.6  92.5      33.1-34.2
1501-2500 grams                       32.6  90.7      31.6-33.6
over 2500 grams (and over 36 weeks)   32.1  89.8      30.7-33.5

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Glycogen, the storage form of glucose, increases in fetal tissues as term gestation approaches, and is essential to survival during labor and immediately following birth. Any added stress to the newborn will rapidly deplete these stores. Hypoglycemia is a serious problem in the neonate and, if left untreated, can result in varying degrees of damage to the central nervous system, or death.

The lower limit for blood glucose is 40 mg%. A rapid semiquantitative measurement of blood glucose can be obtained using glucose oxidase strips (One Touch® or AccuCheck®) following the manufacturer's recommendations.

Infants at Risk for Hypoglycemia

• infants with birth asphyxia
• infants with added stress (i.e., hypothermia, hyperthermia, respiratory distress)
• premature infants
• large for gestational age infants
• small for gestational age infants
• infants of diabetic mothers
• erythroblastotic infants
• infants with congenital heart disease

Symptoms

Symptoms of hypoglycemia may be very subtle, and prognosis appears to be better if treatment is begun before the infant is symptomatic. The following symptoms may be seen:

• tremors ("jitteriness")
• cyanosis
• convulsions
• apnea or irregular respirations
• apathy
• high-pitched or weak cry
• hypotonia
• poor feeding
• eye rolling

Any infant at risk for hypoglycemia may require glucose determinations as frequently as every 30 minutes until they are stabilized on IV glucose infusion or on oral feedings.

Treatment

• A semiquantitative test for glucose below 45 mg% should be followed by a serum glucose measurement. If results are <40 mg%, the infant should immediately receive 2 mL/kg body weight of 10% dextrose in water (D10W) intravenously over 5 minutes followed by a continuous infusion of 10% glucose at 3-4 mL/kg/hour to prevent rebound hypoglycemia.
• Infants without respiratory distress who have a borderline low glucose levels (40-45 mg%) may be candidates for oral glucose water or formula feedings although data as to the safety and effectiveness of this treatment method are lacking.
• Any infant with a borderline low glucose who is at known risk for hypoglycemia should be treated.
• Treatment of hypoglycemia does not guarantee the infant has responded to the therapy. Blood glucose levels must be followed closely after treatment, to assure adequate response.

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Establishing and maintaining adequate ventilation and perfusion are much more important to a successful resuscitation than the vigorous use of alkali solution.

In treating acidosis, it is necessary to decide whether the origin is respiratory or metabolic.

Respiratory acidosis is due to inadequate ventilation, noted by an elevated PaCO₂ and treated/corrected by improving ventilation. Attempts at correction of a respiratory acidosis with alkali treatment may paradoxically worsen the acidosis since the liberated carbon dioxide can not be effectively removed.

Metabolic acidosis is due to inadequate tissue oxygenation and perfusion, noted by a low pH and a large base deficit. This is best corrected by improving tissue perfusion (administration of alkali is also used).

Administration of alkali is limited to situations where:

1. provision of adequate pulmonary ventilation has been assured
2. tissue oxygenation and perfusion are maximized and the pH remains <7.20 and base deficit>10
3. cardiopulmonary resuscitation when a documented or suspected metabolic acidosis is present

Calculation for dose of bicarbonate:

Be aware of the concentration: sodium bicarbonate comes in a neonatal concentration of 0.5 mEq/mL. However, the adult concentration is 1 mEq/mL, which requires dilution with an equal volume of sterile water. Be aware of which formulation you have.

Emergency Administration

In emergency treatment of severe asphyxia or cardiac arrest where heart rate does respond to assisted ventilation, sodium bicarbonate can be given empirically in a dose of 2 mEq/kg infused at a rate no faster than 0.5 mEq/kg/minute.

Caveat
When ventilating an immature infant, be aware that over-ventilation with significant hypocapnia has been associated with later development of periventricular leukomalacia in very low birth weight infants. Prevention and/or correction of hypocapnia (PaCO₂ <30 mmHg) in this population infants is recommended.

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"Shock" may be defined as inadequate tissue perfusion by oxygenated blood and should be suspected in infants who present with any of the following signs:

1. dusky, gray, pale, mottled skin color
2. slow capillary filling time (when skin in blanched with finger pressure)
3. hypotension (see Blood Pressure Chart)
4. decreased urine output (<1ml/kg/hour)
5. subnormal skin temperature
6. severe, persistent metabolic acidosis (pH <7.20 with base deficit>10)
7. tachycardia

Note: Not all the above signs will necessarily be present or clinically apparent, and no one alone is indicative of shock.

Possible etiologies of shock include:

1. Hypovolemia because of:
   • placenta previa
   • placental abruption
   • rupture of maternal or fetal vessels
   • intracranial hemorrhage
   • intraabdominal hemorrhage
   • fetal-maternal transfusion
   • twin-twin transfusion
   • trauma: cephalohematoma, caput succedaneum, subgaleal hemorrhage
2. Inadequate cardiac output secondary to asphyxia with normal blood volume
3. Sepsis

Treatment:

Volume expansion 10 mL/kg over 15-30 minutes.

Agents: Normal Saline, Lactated Ringers solution

Repeated doses may need to be given to maintain adequate pressure until the transport team arrives. You may want to consult the Hotline physician, if no response is noted after the first infusion.

Vasopressor drugs may be necessary (see Drug list for preparation and dose).

Be Aware

1. A normal hematocrit does not rule out hypovolemia.
2. As blood pressure increases and fluid is pulled into the intravascular space, hematocrit will decrease and concurrent acidosis will begin to correct, causing vessels to dilate, resulting in a secondary hypotension.
3. Most episodes of hypotension are not caused by hypovolemia, and the automatic infusion of volume expanders is to be discouraged.

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Possible indications for initiation of intravenous infusion of 10% dextrose solution prior to transport include:

1. fluid maintenance
2. access to vascular space for emergency drug and/or antibiotic administration

A constant infusion pump and volumetric chamber should be used to assure a constant rate of infusion and accurate measurement of fluid administered. A peripheral venous route is preferable. Umbilical arterial lines are not benign and in most cases should be used only during the critical phase of the illness for obtaining frequent blood gas samples.

We offer the following guidelines for maintenance fluids:
first 24 hours of life - 80 mL/kg/day
24 - 48 hours of age - 100 mL/kg/day
over 48 hours of age - 100-120 mL/kg/day

In the presence of hypoglycemia, dextrose solutions with concentrations greater than 10% should be used cautiously in peripheral veins. These solution can be irritating to the tissue if infiltration occurs. During the first 24-48 hours of life, electrolytes do not usually need to be added to the IV solution.

Amounts of fluids administered should be documented hourly so adjustments can be made to insure proper amounts of infusion and to prevent fluid overload.

A urine bag placed on the infant allows accurate measurement of urine output.

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Diagnosis

Most infants with generalized infection present with vague, nonspecific signs and symptoms.

Signs and Symptoms

1. temperature instability (hypothermia, hyperthermia)
2. lethargy
3. respiratory changes (tachypnea, apnea)
4. cyanosis
5. feeding difficulty (vomiting, abdominal distension, diarrhea)
6. shock
7. acidosis
8. petechiae
9. infant appears "not right"

Evaluation

A complete history and physical examination in addition to clinical experience are the best guides in determining the extent of the evaluation. This may include:

1. blood culture
2. lumbar puncture (spinal tap) for CSF culture
3. aspiration of urine for culture
4. Complete Blood Count with platelet count and WBC differential

Treatment

Intravenous antibiotics (Drug Dosages) and continued close observation.

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Dosages of drugs commonly used during the newborn period can be found by clicking here (Drugs)

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The conditions on the following pages require specific stabilizing procedures in addition to those previously discussed. These conditions in themselves are usually reason to arrange for transport.

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A pneumothorax may occur in an infant, cause no distress, and require no active treatment. If, however, the infant has significant respiratory distress, then the pneumothorax must be evacuated.

Signs may include

1. respiratory distress
2. sudden deterioration in a previously stable infant

Diagnosis

Diagnosis is made by

1. auscultation: breath sounds may be decreased or absent on affected side
2. chest x-ray
3. positive transillumination

Treatment

1. Attach a syringe to a 3-way stopcock which is then connected to a 23 or 21 gauge butterfly needle.
2. Place the infant in a supine position.
3. AVOIDING THE NIPPLE, insert the needle into the pleural space superiorly directly over the top of the rib (avoiding vessels that run inferiorly under the ribs) at the anterior axillary line into the 4th or 5th intercostal space while withdrawing on the syringe. If air in the pleural space, the syringe will usually draw easily.
4. When the syringe is filled, turn the stopcock off to the needle and expel the air through the stopcock.
5. Continue to aspirate and expel until air is no longer retrieved.

If reaccumulation of the pneumothorax occurs, the needle should be left in place and aspiration continued until a chest tube can be placed. A 18-gauge plastic catheter may be useful while waiting to place a chest tube. The catheter is pliable and may offer less chance of lung or vessel laceration which may occur as the lung re-expands. It is placed in the same way as a scalp vein needle.

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Signs may include

1. immediate respiratory distress (due to the hypoplastic lung and presence of abdominal contents in the chest cavity)
2. scaphoid (concave) abdomen (not always present)
3. bowel sounds in the chest
4. heart sounds shifted to lateral chest (usually to the right chest)

Diagnosis

Chest x-ray reveals loops of bowel in the thoracic cavity.

Stabilization

1. Do not ventilate the infant with bag and mask, as the proximal bowel will fill with air, further compromising ventilation.
2. Intubate trachea immediately if oxygenation and ventilation are inadequate.
3. Use orogastric tube for decompression of stomach to prevent air from entering the bowel (can cause further compression of lung).
4. Place infant on affected side, allowing shift of mediastinum, thus improving expansion of unaffected lung.
5. Place unclothed infant in an incubator for temperature maintenance and close observation.

A SUDDEN DETERIORATION DURING ASSISTED VENTILATION IS USUALLY A SIGN OF PNEUMOTHORAX ON THE UNAFFECTED SIDE. BE PREPARED TO TREAT RAPIDLY. (see Pneumothorax treatment).

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Signs may include

1. polyhydramnios
2. regurgitation of saliva or the first feed out of the infant's mouth and nose
3. choking or gagging on secretions or feeds
4. abdominal distension is often present (occurs as inspired air enters the stomach through the fistula and distal esophagus)
5. respiratory distress

Diagnosis is made by

1. The inability to pass a large (10F) catheter into the stomach. (Smaller flexible catheters may coil up in the pouch giving a misleading impression that they have advanced to the stomach. A radiopaque catheter is recommended).
2. Injection of 10 mL of air into the catheter while simultaneously taking an x-ray of the chest and abdomen. The air will outline the pouch if it is present. (Barium and other contrast materials are not necessary and are potentially dangerous because of the high risk of aspiration).

SURGICAL INTERVENTION IS INDICATED WHEN THE CONDITION OF THE INFANT IS STABLE.

Stabilization

1. Gently place a 10F catheter into the pouch, connected to intermittent suction (or aspirate every 5 minutes with a syringe). Use of a Repogle tube is mandatory. The pouch fills with secretions which can overflow into the lungs if not continuously emptied.
2. Place the infant at a 30 degree angle, head up position.
3. Prevent the infant from crying if possible, as this causes air to be forced into the stomach through the fistula, causing distension that can result in reflux of air carrying gastric contents into the lung. Consider sedation if necessary (see Drug Dosages).
4. Place unclothed infant in an incubator for temperature maintenance and close observation.
5. Establish an IV for maintenance fluids (see Fluids and Electrolytes).

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Bilateral choanal atresia is easily recognized immediately after birth.

Signs may include pink while crying, becoming cyanotic and struggling for air when quiet (even with good respiratory effort).

Unilateral choanal atresia may not be symptomatic, but checking for it is easily done. Signs may include inability to maintain oxygenation (noted by cyanosis when lips and unaffected naris is held closed). Diagnosis is made by the above examination and inability to pass small catheter on affected side.

Stabilization

1. Place oral airway (size 0 or 00). (Be sure the airway does not go too far into the pharynx as it may enter the esophagus and occlude the airway).
2. Tape oral airway into place to prevent dislodging.

INFANTS WITH CHOANAL ATRESIA REQUIRE EARLY EVALUATION AND INTERVENTION.

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Signs may include

1. Abdominal distension (with low obstructions)
2. Failure to pass meconium in the first 24 hours of life
3. Vomiting with or without bile staining
4. Large gastric residuals at feeds

If a bowel obstruction is suspected or diagnosed, the following steps should be taken while awaiting arrival of the transport team.

Stabilization

1. Place an orogastric tube (10F) to low intermittent suction (or aspirate with a syringe every 5 minutes). Use of a Repogle tube is suggested.
2. Establish vascular access to administer fluids (see Fluid and Electrolytes)
3. Place unclothed infant in an incubator for close observation and temperature maintenance.
4. Obtain abdominal x-rays (including a lateral and upright view).
5. Obtain blood for electrolyte determinations.

Frequently, these infants have associated problems of acidosis (see Acid-Base Status) and shock (see Shock).

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Infants with these anomalies present problems similar to those with bowel obstruction. They also have problems with temperature regulation because of the large amount of heat loss from the exposed gut.

Stabilization

1. Connect 10F orogastric tube (Repogle suggested) to low intermittent suction (or aspirate with a syringe every 5 minutes).
2. With gastroschisis, evaluate appearance of exposed bowel for evidence of adequate perfusion. Bowel may have to be untwisted or abdominal defect may need to be enlarged if perfusion is poor.
3. Place lower body of infant in bowel bag with opening of bag just at nipple line.
4. Place in neutral thermal environment and check temperatures frequently.
5. Establish vascular access for maintenance fluids (seeFluid and Electrolytes).
6. Begin IV antibiotics (ampicillin and gentamicin) (see Drug Dosages).

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Referring physicians are encouraged to visit or phone the Intensive Care Unit at any time to obtain information regarding the condition and progress of the infant. Infants may go directly home with the parents when ready for discharge or may return to the community hospital for convalescent care. When plans for discharge are being made, summaries that include all pertinent information related to the infant's hospital course will be sent to the physician.

Children's Hospital and Medical Center
206-987-2041

University of Washington Medical Center
206-598-4606

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Based on the manual prepared by Bethany L. Farris, R.N., N.N.P., and William E. Truog, M.D. for the Washington State Regional Perinatal Care Program. Edited and adapted for this Web site by Dennis E. Mayock, M.D.
EMAIL feedback to Web site author

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