Neonatal transport and retrieval — branching viva

Opening (candidate)

My first move is to take the referral with a structured call-back using SBAR, and to make clear that the baby is retrieved at the bedside before any vehicle moves. This is a time-critical retrieval because the cooling clock is running — the six-hour window starts at birth, and the baby is already three hours old. I would activate the specialist neonatal retrieval team, book the cooling cot, and begin the STABLE stabilisation at the referring hospital, starting by correcting the temperature and glucose and securing the airway and access. I would not move an unstabilised, cold infant. [2] [5]

Branch A — Triage and the cooling window

Examiner: Walk me through the urgency and the time window. [7]

Candidate: This is a time-critical retrieval because therapeutic hypothermia for a term infant with moderate or severe encephalopathy must begin within six hours of birth. The window runs from birth, not from the decision, so we have about three hours left. I would confirm eligibility — 36 weeks or more, moderate or severe encephalopathy — exclude mimics with a septic and metabolic screen, document the cord and early blood gases, treat any seizures, secure the airway and vascular access, and book the receiving cooling cot before departure. [7]

Branch B — STABLE and the stabilise-first principle

Examiner: The registrar wants to move the baby now. What do you say, and what do you do? [3]

Candidate: I would say no — the baby is retrieved at the bedside, then moved, because most transport-related deterioration happens during the stabilisation phase, and an unstabilised infant gets worse in the one place help is hardest to give. I would run STABLE: correct the glucose and start a dextrose infusion, actively rewarm to hold 36.5 to 37.5 degrees, confirm and secure the airway, support the blood pressure, take a blood gas and septic screen and speak to the parents, and check the transport equipment and escort. Only when the baby is stable do we package and move. [3] [5]

Branch C — Cooling in transit: passive versus active

Examiner: How will you manage the temperature on the journey? [8]

Candidate: I have two options. Passive cooling means switching off active warming and allowing a gentle fall towards 34 to 35 degrees, accepting some volatility. Active servo-controlled cooling uses a transport cooling device to hold the core tightly at 33 to 34 degrees. Akula's randomised trial found both feasible during transport, with servo control holding temperature more tightly and reducing over- and under-shoot. If a servo device is available I would use it; if not, I would maintain strict normothermia and transfer urgently rather than attempt uncontrolled local cooling. The receiving cooling centre takes over controlled hypothermia on arrival. [7] [8]

Branch D — The complication of active cooling

Examiner: What goes wrong with active cooling in transit, and how do you prevent it? [10]

Candidate: The recognised complication is hypocapnia. Szakmar showed higher hypocapnia rates in infants actively cooled during transport, because cooling lowers metabolic rate and alters ventilation, and hypocapnia itself harms the injured brain. I prevent it with continuous capnography and controlled ventilation, targeting a normal carbon dioxide and correcting any fall promptly. Overcooling beyond the target band and rebound hyperthermia are the other risks, defended by tight servo control and continuous temperature monitoring. [10]

Branch E — Why a specialist team

Examiner: Why insist on a specialist neonatal transport team rather than sending an ambulance? [1]

Candidate: Because the evidence supports it. 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 and maintain it in transit. That is the basis for regionalising retrieval rather than improvising it with whoever is available. [1]

Close

Confirm eligibility and the cooling window, run STABLE and stabilise fully before movement, choose passive or servo-controlled cooling for the journey with mandatory capnography, mobilise the specialist team and book the cot, and give a structured SBAR handover at each interface. Speak honestly and early with the family about what is happening, where the baby is going, and the prognosis, and debrief the team afterwards. [2] [7]