Neonatal transport and retrieval — formative SAQs

SAQ 1 — Triaging the request and pretransport stabilisation (10 marks)

A general hospital calls the neonatal retrieval service about a 2-hour-old, 35-week infant with increasing respiratory distress, a temperature of 35.6 degrees and a glucose of 1.9 mmol per litre. The referring team asks how quickly the baby can be moved. [2] [3]

Questions

1. Take the referral call in a structured way, state how you would triage the urgency, and explain why the baby is not yet fit to move. (4 marks) [2] [5]
2. Outline the STABLE pretransport stabilisation you would perform at the referring hospital before the vehicle moves. (4 marks) [3] [5]
3. Give two reasons why a specialist neonatal transport team is preferred over an ad-hoc transfer, citing the evidence. (2 marks) [1]

Model answer

Referral and triage (4). Take the call using SBAR — situation, background, assessment, recommendation — capturing gestation, age, weight, the presenting problem, current observations, airway and access, drugs given, and what the baby needs, then read it back to prevent misheard doses or wrong bed bookings. This is an urgent (not yet time-critical) retrieval: respiratory distress needing a higher level of care, but no closing treatment window. The baby is not fit to move because the temperature (35.6 degrees) and glucose (1.9 mmol per litre) are both below safe thresholds, and the airway and vascular access must be confirmed — moving an unstabilised infant is the cardinal transport error. [2] [5]

STABLE stabilisation (4). Correct the glucose with a dextrose bolus and start a maintenance dextrose infusion (Sugar); actively rewarm to hold 36.5 to 37.5 degrees with a pre-warmed incubator, hat and warm blankets (Temperature); assess and secure the airway, intubating if the work of breathing is excessive (Airway); measure blood pressure and perfusion and support the circulation with fluid or inotropes if needed (Blood pressure); take a blood gas, septic screen and chest radiograph, and speak to the parents (Lab work); and check the transport equipment and escort before movement (Equipment). [3] [5]

Specialist team (2). The Cochrane review of specialist neonatal transport teams found that specialist teams reduce transport-related adverse events compared with non-specialist transfer, because they bring neonatal intensive care skill and purpose-built equipment to the bedside; this is the evidence base for regionalising retrieval rather than improvising it. [1]

SAQ 2 — Therapeutic hypothermia on transport (10 marks)

A term infant born after a difficult delivery has moderate hypoxic-ischaemic encephalopathy at 3 hours of age. The cooling centre is two hours away by road. [7] [8]

Questions

1. State the cooling eligibility window and what must be done before the baby leaves the referring hospital. (4 marks) [7]
2. Compare passive and active servo-controlled cooling during transport, including the target temperatures and the evidence on which mode holds temperature best. (4 marks) [7] [8]
3. State the complication of active cooling in transit that must be actively prevented, and how. (2 marks) [10]

Model answer

Window and preparation (4). Therapeutic hypothermia for a term or near-term infant (36 weeks or more) with moderate or severe encephalopathy must begin within six hours of birth, and the window runs from birth, not from the decision. Before departure, confirm eligibility, exclude mimics with a septic and metabolic screen, grade the encephalopathy, document cord and early blood gases, secure the airway and vascular access, hold normothermia (36.5 to 37.5 degrees), treat seizures, and book the receiving cooling cot. [7]

Passive versus active (4). Passive cooling means switching off active warming and allowing a gentle fall towards 34 to 35 degrees, accepting some temperature volatility; active servo-controlled cooling uses a transport cooling device to hold the core tightly at 33 to 34 degrees. Akula's randomised trial compared modes during transport and found both feasible, with servo control holding temperature more tightly and reducing over- and under-shoot. Where no servo device is available, the delivering unit maintains strict normothermia and transfers urgently rather than attempting uncontrolled local cooling. [7] [8]

Preventing hypocapnia (2). Active cooling in transit is associated with higher rates of hypocapnia, shown by Szakmar and colleagues, because cooling lowers metabolic rate and alters ventilation; hypocapnia harms the injured brain. Prevent it with continuous capnography and controlled ventilation, targeting a normal carbon dioxide and treating any fall promptly. [10]