Cooling strategies during neonatal transport for hypoxic-ischaemic encephalopathy.

AIM: We reviewed the literature on cooling methods during transport of newborn infants with hypoxic-ischaemic encephalopathy (HIE) born in a non-tertiary centre and transferred to a neonatal intensive care unit for therapeutic hypothermia. METHODS: The electronic databases CENTRAL, MEDLINE, Embase, CINAHL, and Scopus were searched from inception up to 8 March 2022 for studies comparing cooling versus no cooling, active versus passive cooling, and servo-controlled versus non-servo-controlled cooling. Odds ratio and confidence of interval were calculated for dichotomous outcomes and mean difference and confidence interval for continuous outcomes. RESULTS: The final analysis included 14 studies, 1 randomised and 13 non-randomised, involving 1098 newborn infants. Compared with the other cooling methods, servo-controlled active cooling was more likely to maintain body temperature within the target range of 33°C-34°C on arrival at a neonatal intensive care unit: odds ratio 13.58, 95% confidence interval 4.32-42.66, risk difference 0.33, 95% confidence interval 0.19-0.46; 224 participants; three studies; I2 0%. The certainty of evidence was low. Only five studies reported mortality rates. CONCLUSION: Servo-controlled active cooling may be the preferred method during transport of newborn infants with HIE. A future area of focus should be long-term neurodevelopmental outcomes after servo-controlled active cooling.

The Transport of Respiratory Distress Syndrome Twin Newborns: The 27-Year-Long Experience of Gaslini Neonatal Emergency Transport Service Using Both Single and Double Ventilators.

OBJECTIVE: Twin pregnancy rates have increased in the past 30 years. We describe the experience of the Neonatal Emergency Transport Service of the Gaslini Hospital, Genoa, Italy, in the transport of twin newborns. METHODS: This was a retrospective study (1996-2021); 7,852 medical charts from the Neonatal Emergency Transport Service were reviewed. We included all twin newborns who were transported with respiratory distress syndrome in the study. We split the included patients into 2 groups (group A and group B) based on if they were simultaneously ventilated by a single ventilator or by 2 different ventilators, and then each group was split by the different types of ventilation (nasal continuous positive airway pressure or intermittent positive pressure ventilation). The pH level, base excess, O2 saturation, Pco2, body temperature, plasma glucose, and Transport Risk Index of Physiologic Stability score were recorded at departure and arrival. RESULTS: One hundred thirty-six patients were included (68 pairs of twins); group A consisted of 92 newborns and group B 44 newborns. Although some significant differences were observed (statistic), none of these had real clinical significance. CONCLUSION: Transporting respiratory distress syndrome twin newborns is challenging. Our study provided a 27-year experience in the field. Transporting twins by a single ventilator is possible, but, in our opinion, using 2 ventilators mounted on the same transport module is the best possible choice in terms of clinical performance, logistics, and cost.

Intubation Rate Evaluation of Inborn Versus Outborn Premature Newborns Affected by Respiratory Distress Syndrome: Impact of Neonatal Transport.

OBJECTIVE: The aim of this study was to compare the management of preterm newborns with respiratory distress both in the delivery room and during transportation. METHODS: We retrospectively evaluated the intubation rate in preterm newborns (inborn vs. outborn), gestational age (GA) < 34 weeks, admitted to the Gaslini neonatal intensive care unit, Genoa, Italy (January 2019-December 2020). RESULTS: A total of 251 newborns were included (202 inborn and 49 outborn). The intubation rate was significantly higher in outborn newborns (69.4% vs. 42.1%, P = .001) in the GA 30- to 34- week subgroup (63.2% vs 20.6%, P = .001) but not in the GA < 30-week subgroup (90.9% vs. 81.7%, P = .68). CONCLUSION: Although the medical staff members involved in neonatal transport were the same who work both in the neonatal intensive care unit and the delivery room, we found a significantly higher intubation rate in outborn newborns, probably due to the transport itself. It is fundamental to encourage in utero transportation to reduce the risk linked to invasive ventilation due to neonatal transportation.

Post-haemorrhagic hydrocephalus management: Delayed neonatal transport negatively affects outcome.

BACKGROUND: Post-haemorrhagic ventricular dilatation (PHVD) still represents an important cause of brain injury in premature infants. Intervention for PHVD is recommended once Ventricular Index (VI) crosses the 97th percentile + 4 mm line according to Levene. OBJECTIVES: We aimed to compare PHVD severity, timing of intervention, and outcome between outborn infants transferred to a level IV NICU in order to be treated for PHVD and a control population of inborn infants. METHODS: Preterm infants with PHVD requiring treatment were divided into: outborn infants (transferred to our NICU in order to be treated for PHVD) and inborn infants (PHVD diagnosed at our NICU). Age at intervention, difference between VI and the 97th percentile according to postmenstrual age (VI-p97), permanent shunt rate, and developmental delay rate were compared between the two groups. Neurodevelopmental outcome was assessed using the Vineland Adaptive Behavior Scales II (VABS-II), a parental questionnaire investigating four domains of adaptive behaviour and overall adaptive functioning. Developmental delay was defined as a score <70 (-2 SD or less). RESULTS: Twelve outborn and 15 inborn infants were included. Age at intervention (31.6 vs 17.4 days) and VI-p97 (left 10.0 vs 5.1 mm, right 7.7 vs 5.1 mm) were significantly higher among outborn infants. A permanent shunt was inserted in 66.7% of outborn and in 40.0% of inborn infants (p = 0.18). After excluding subjects with parenchymal lesions, a significantly higher rate of developmental delay was observed at 5 years in outborn patients compared to inborn patients (66.7% of outborn vs 18.2% of inborn patients with VABS-II composite score <70, p = 0.04). CONCLUSIONS: Outborn infants reached a significantly more severe ventricular dilatation than inborn infants, largely exceeding the recommended cutoff for intervention. Our follow-up data showed a trend towards a higher rate of permanent shunt and developmental delay in outborn than in inborn patients. Infants requiring treatment should be timely transported to centres with adequate expertise in PHVD management.

Helicopter Emergency Medical Service in Italy: A 2021 Update.

The purpose of this article is to describe the helicopter emergency medical services (HEMS) presently operating in Italy. The article details all currently operational HEMS bases and all currently used helicopters. A comparison with the HEMS situation in Italy as it was previously described in 2005 is discussed.

Neonatal Air Medical Transportation Practices in Italy: A Nationwide Survey.

The present article shows the current neonatal air transport organization and activity in Italy. The results were obtained on the basis of a recent 2019 survey (year of activity 2018) performed by the Neonatal Transport Study Group of the Italian Society of Neonatology. The total number of newborn transports during the year 2018 was 6,464. The air-suitable transports were 512 of 5,852 (8.74%), and among them, 101 of 512 (19.72%) were performed by helicopter and 34 by airplane. Besides the availability of air transport, the interfacility distance, weather and traffic conditions, and rural mountainous roads were the main factors in determining the vehicle choice. Neonatal air transport in Italy is not homogeneously distributed and needs organizational corrections. The high density of neonatal emergency transport services on the national territory indicates the need to overcome the limits imposed by regional administrative borders, thus expanding the geographic area of competence.

New Formula for Nasal Endotracheal Intubation in Extremely Low-Birth Weight Infants in the Emergency Transport Setting: The "Genoa Formula".

OBJECTIVE: The purpose of this study was to find a predictive equation for estimating the optimal nasal endotracheal tube insertion depth in extremely low-birth weight infants (ELBWs) requiring invasive ventilation in the critical care interfacility transport setting. METHODS: We retrospectively calculated the optimal tube insertion depth in a cohort of neonates ≤ 1,000 g born at our neonatal intensive care unit and nasally intubated within the first 24 hours of life from January 2019 to May 2020. RESULTS: A total of 75 ELBW infants were included, with a median gestational age of 26.6 weeks (range, 22.1-32.6 weeks) and a median birth weight of 780 g (range, 410-990 g). The linear regression of the estimated optimal endotracheal tube insertion depth showed a good correlation when plotted against weight (R2 = 0.491); thus, a new weight-based formula was obtained. CONCLUSION: The proposed weight-based formula (the "Genoa formula") may help in predicting optimal insertion depths for nasal intubation in ELBW neonates, especially when a prompt radiologic confirmation of the tube position is not available, as during neonatal critical care transport.

Helicopter Neonatal Transport: First Golden Hour at Birth Is Useful Tool Guiding Activation of Appropriate Resources.

OBJECTIVE: A lack of consensus exists about the appropriate criteria to activate a helicopter during neonatal transport. The aim of the present study was to explore the possible guiding criteria to justify helicopter activation for neonatal transport (NETS). METHODS: This was a retrospective study of the Gaslini Genoa NETSs from February 1995 to December 2019. The flight and driving times and the reason for helicopter neonatal transport activation were obtained for every subject from the online NETS clinical database. Driving and flight data (mean and standard deviation [SD]) were compared using the Student t-test (P < .05). RESULTS: Five thousand eight hundred sixty-six transported newborn infants were identified. A significant difference emerged between the overall ground (mean = 99.2 minutes [SD = 15.7 minutes]) and overall helicopter transport times (mean = 27.8 minutes [SD = 11.9 minutes], P < .0001). Considering the "golden hour," the chance to stabilize the patient within this time frame could have been possible for 4 of 5 neonatal care centers when using a helicopter. CONCLUSION: On the basis of our observations, we suggest including the golden hour as 1 of the guiding criteria justifying helicopter activation, especially if applied to the reason of transport and the quality of assistance the newborn will receive while waiting for the NETS team.

Development of a novel reference nomogram for endotracheal intubation in neonatal emergency transport setting.

AIM: Neonatal endotracheal intubation is a challenging procedure during transport. The aim of this study was to evaluate the effectiveness of the emergency intubation guidelines followed by our Neonatal Emergency Transport Service (NETS). METHODS: Our transport intubation guidelines follows a weight-based nomogram for nasal intubation, and the tube position is clinically verified after intubation, while the postintubation chest X-ray is postponed to Neonatal Intensive Care Unit (NICU) admission. Data on postnatal age, weight and tube insertion depth were obtained from the online NETS clinical database, and the postintubation chest X-ray images were assessed. RESULTS: During the study period, 161 newborn infants were nasally intubated during transport, and received a postintubation radiograph at NICU admission. A total of 130 neonates (80.7%) had the endotracheal tube (ETT) correctly positioned between T1 and T2 vertebrae, while 12 (7.5%) was at C7 vertebrae level and 19 (11.8%) at T3. No patients had ETT tip positioned at T4 vertebrae level or below. No adverse events related to intubation were observed. CONCLUSION: Our intubation procedure showed a good reliability and safety in neonatal critical care transport, although chest X-ray to confirm the tube placement is postponed to NICU arrival. Based on our results, we suggest a revised version of weight-based nomogram for nasal intubation.

Evaluation of neonatal transport in a European country shows that regional provision is not cost-effective or sustainable and needs to be re-organised.

AIM: There are three dedicated and 41 on-call neonatal emergency transport services (NETS) in Italy, and activity levels vary dramatically. We examined the cost-effectiveness of a hub-and-spoke NETS by looking at the costs and activity levels in the Liguria region and established the financial needs for improving NETS across Italy. METHODS: The cost of running NETS in the Liguria region from 2012 to 2015 was evaluated and analysed, and three different models determined the transports needed each year to provide the best organisational model. RESULTS: The average number of NETS transports in the Liguria region during the study period was 234, and the models indicated that 200-350 transports per year were the optimal amount of activity that was needed to achieve good financial performance and for the personnel to acquire a suitable skill set. Only five of the 41 on-call Italian NETS and the three dedicated services carried out more than 200 transports a year. Of the rest, 26 carried out up to 100 and 10 carried out 101-200. CONCLUSION: Italian NETS, which are managed on the basis of regional decisional autonomy, are expensive and no longer sustainable in this era of limited financial resources. A complete overhaul is urgently needed.

Octreotide for congenital and acquired chylothorax in newborns: A systematic review.

AIM: Chylothorax is a rare but life-threatening condition in newborns. Octreotide, a somatostatin analogue, is widely used as a therapeutic option in neonates with congenital and acquired chylothorax, but its therapeutic role has not been clarified yet. METHODS: We performed a systematic review to assess the efficacy and safety of octreotide in the treatment of congenital and acquired chylothorax in newborns. Comprehensive research, updated till 31 October 2017, was performed by searching in PubMed, MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL) databases using the MeSH terms 'octreotide' and 'chylothorax'. Both term and preterm newborns with congenital or acquired chylothorax treated with octreotide within the 30th day of life were included. Octreotide treatment was considered effective if a progressive reduction/ceasing in drained chylous effusion occurred. RESULTS: A total of 39 articles were included. Octreotide was effective in 47% of patients, with a slight but not significant difference between congenital (30/57; 53.3%) and acquired (9/27; 33.3%) chylothorax (P = 0.10). Marked variation in octreotide regimen was observed. The most common therapeutic scheme was intravenous infusion at a starting dose of 1 µg/kg/h, gradually increasing to 10 µg/kg/h according to the therapeutic response. Side effects were reported in 12 of 84 patients (14.3%). Only case reports were included in this review due to the lack of randomised controlled trials. CONCLUSION: Octreotide is a relatively effective and safe treatment option in neonates with chylothorax, especially for the congenital forms.

Long-Distance, Nonstop Neonatal Transport From Shanghai, China, to Genoa, Italy.

The purpose of this article is to describe the long-distance, nonstop intercontinental transport of a severely ill, mechanically ventilated newborn from Shanghai, China, to Genoa, Italy focusing in particular on the clinical and planning difficulties. The aircraft equipment, the assessment and preparation for transport are discussed.