Transport of Sick Neonate

Introduction

The transport of a sick neonate is a highly critical event that requires meticulous planning and execution.
Whenever possible, in utero transfer of the mother to a higher-level facility is preferable to postnatal transport of a sick neonate.
Safe transport requires equipped intensive care unit ambulances, trained manpower, structured communication, and timely referral protocols.
The mobile environment places the baby at a high risk of destabilization due to movement, noise, vibration, and limited space.

Forward or Escalation Transfer: Transferring a neonate from a lower-level birth facility to a regional tertiary neonatal intensive care unit (NICU).
Reverse Transfer: Transferring a recovering infant back to their birth hospital or a facility closer to home for ongoing step-down care.
Wait and Return: A temporary transfer to a higher facility for specific investigations or treatments, followed by a return to the base hospital.
Intra-hospital Transport: Moving the baby within the same hospital, such as from the delivery room to the NICU, operating theater, or radiology suite.

Neonates are transported based on their need for advanced respiratory, cardiovascular, surgical, or specialized medical care.

Category	Specific Clinical Conditions
Extreme Prematurity	Birth weight less than 1500 g or gestation less than 32 weeks.
Respiratory Failure	Severe respiratory distress needing continuous positive airway pressure (CPAP), mechanical ventilation, or inhaled nitric oxide (iNO).
Neurological	Perinatal asphyxia or hypoxic-ischemic encephalopathy (HIE) requiring therapeutic hypothermia, refractory seizures.
Cardiovascular	Suspected congenital heart disease, arrhythmias, or unresponsive shock.
Surgical Emergencies	Major congenital malformations, necrotizing enterocolitis, or intestinal obstruction.
Metabolic/Others	Severe hyperbilirubinemia needing exchange transfusion, refractory hypoglycemia, or inborn errors of metabolism.

Transport teams should ideally consist of trained personnel such as neonatal nurses, respiratory therapists, and physicians.
Unit-based teams: Staffed by nurses and doctors working in the NICU who are deployed when a transport request arises.
Dedicated teams: Staffed entirely separately from the NICU specifically for transport coverage.

Ground ambulance: The most common modality. It offers a larger workspace, the ability to carry multiple team members, and the option to pull over for critical interventions.
Rotor-wing (Helicopter): Suitable for rapid, hospital-to-hospital transport over moderate distances.
Fixed-wing (Airplane): Best suited for long-distance transport, requiring ground ambulances at both ends of the flight.

The team must carry all required equipment and medications in pre-packed bags with strict checklists.

Category	Equipment And Supplies
Incubation & Monitoring	Transport incubator with ventilator, pulse oximeter, temperature probes, and electrocardiogram leads.
Airway & Breathing	Oxygen cylinders, blender, T-piece resuscitator, self-inflating bags, laryngoscopes, endotracheal tubes, and suction machine.
Vascular Access & Fluids	Intravenous cannulas, umbilical vein catheters, infusion pumps, normal saline, 10% dextrose.
Essential Medications	Epinephrine, inotropes (dopamine/dobutamine), phenobarbitone, antibiotics, surfactant, and Prostaglandin E1.

The transport team must stabilize the baby before undertaking the risky journey.
Severity scoring systems like the Transport Risk Index of Physiologic Stability (TRIPS) can predict the occurrence of critical illness.
Stabilization focuses on the "TOPS" mnemonic: Temperature, Oxygenation, Perfusion, and Sugar.

Ensure a neutral thermal environment.
Use a transport incubator, plastic wraps for extremely premature babies, or skin-to-skin contact (Kangaroo Mother Care) for stable babies.
Servo-controlled active cooling should be initiated and maintained for infants meeting the criteria for therapeutic hypothermia.

Ensure airway patency and secure the endotracheal tube properly, as dislodgement is common during movement.
Provide adequate oxygenation and ventilation, using CPAP or mechanical ventilation as indicated.

Establish stable vascular access, preferably through an umbilical venous catheter or a secure peripheral line.
Treat shock with normal saline boluses (10 ml/kg) and initiate vasoactive infusions if required.

Ensure adequate blood glucose concentrations.
Correct hypoglycemia before transport and maintain an ongoing intravenous dextrose infusion.

If a preterm infant requires intubation for mechanical ventilation, exogenous surfactant should be administered before transport.
Anticipate rapid changes in lung compliance post-surfactant and adjust ventilatory support to minimize the risk of pneumothorax.

Ensure optimal lung recruitment but strictly avoid hyperventilation.
Transport teams should be prepared to institute inhaled nitric oxide if available.

For infants with suspected ductal-dependent lesions, initiate a Prostaglandin E1 (PGE1) infusion prior to transport.
Because PGE1 can cause apnea, the threshold for elective intubation before transport should be low.

An orogastric tube must be placed and kept on continuous drainage.
This is critical for intestinal obstruction or congenital diaphragmatic hernia, especially during air transport.

Alveolar hypoxia (Dalton's law): As altitude increases, barometric pressure decreases, causing a fall in alveolar oxygen tension. The fraction of inspired oxygen (FiO2) must be increased to maintain saturation.
Gas expansion (Boyle's law): As barometric pressure drops, trapped gases expand. This mandates the pre-flight drainage of a pneumothorax and continuous venting of the stomach.

Hospitalization and transport precipitate a major emotional crisis for the family.
Allow parents to see and touch their infant prior to the transfer.
Thoroughly explain the clinical condition, the reason for transfer, and the anticipated care during transport.
Obtain formal written consent for the transfer and any anticipated procedures.
Document the infant's health status, interventions performed, and vital signs on a standardized hand-over checklist.
Facilitate a four-way communication stream between the referring team, the receiving team, the transport team, and the baby's family.
Following the transport, the team must call the referring hospital to provide feedback on the baby's arrival condition.