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Hypoxic Respiratory Failure in Term and Near Term Newborns: Perspective from the Neonatal Transfer Service

Presented as a poster at the Neonatal Society 2013 Summer Meeting (programme).

Davidson SL, Ratnavel N, Mohinuddin S, Hird MF, Sinha A

1 The London Neonatal Transport Service, UK
2 Neonatal Unit of The Childrenís Hospital at The Royal London Hospital, Barts Health NHS Trust, London, UK

Background: Transfer for increased level of care of newborns with Hypoxic Respiratory Failure (HRF) is common and can often be challenging. The data available regarding the transfer of these newborns is limited. Newborns with an oxygenation index (OI) greater than 25 warrant consideration for Extracorporeal Membrane Oxygenation (ECMO) in the event of further clinical deterioration, thus affecting the choice of transfer destination. We aimed to assess the efficacy of management of neonates with hypoxic respiratory failure during inter-hospital transfer and to identify parameters that predict newborns who will have a persistently high OI.

Methods: Retrospective data was collected for all term and near term babies with HRF, who had arterial access at referral, and were transferred by the London Neonatal Transfer Service over a 7 year period.

Results: 83 newborns with HRF were transferred, 8 requiring ECMO. There was no significant difference in median gestation, birth weight and referral age. Management strategies included; adjustments in ventilation, administration of surfactant, the use of sedation or paralysis, the initiation of inotropes and the use of inhaled nitric oxide (iNO). There was no difference between the median FiO2 and mean airway pressure (MAP) from referral to arrival at destination. However, there was a significant rise in median PaO2 from referral to destination (Friedmanís ANOVA: χ2=17.9, p<0.01) and a significant reduction in the OI from arrival to departure (p=0.008). 57 newborns (69%) were commenced on iNO by NTS. There was a significant improvement in median OI in this group (p=0.008). Logistic regression (forward stepwise method) with OI>25 at departure as dependent and OI, PIP, MAP, PEEP, PaO2, PaCO2 and pH on the teams arrival as predictors and OI>25 on teams departure as the dependent variable, showed that only OI at arrival was the only significant predictor. Using an OI at referral of 22 produced a positive predictive value of 16% with a negative predictive value of 100% for babies who went on to require ECMO.

Conclusion: There was a significant improvement in OI during stabilisation and the transfer. A significant improvement in arterial oxygenation appears to be associated with iNO being commenced and is unrelated to changes in MAP and FiO2. The OI on team arrival predicted the likelihood of the OI being greater than 25 at departure but no other parameters were found to be predictors, consistent with previous studies. The study showed that discussing cases for ECMO with a OI of 22 picked up all babies that will go onto require ECMO but this meant discussing 6 babies for every 1 that will go onto need ECMO.

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