Perinatal technology of organization of care is generally accepted in most developed countries. In this regard, transportation in utero is rightfully considered optimal from the point of view of safety and efficiency. The advantages of transporting a child in utero have been actively studied by foreign authors for a number of years [2]. In domestic medicine, the perinatal direction has emerged recently and, in fact, does not fulfill the function assigned to it. In Russia, the main emphasis is on the organization of assistance to newborns. The vast majority of births occur in institutions of 2-3 levels that do not have the material and human resources necessary for the care of premature babies, the implementation of all aspects of providing assistance to such a contingent of patients, including adequate respiratory support, the introduction of surfactant drugs, appropriate monitoring. Therefore, there is a need for remote counseling, monitoring, conducting and correcting intensive therapy, as well as, if necessary, subsequent re-education of newborns in level 4-5 hospitals. When antenatal transportation is not possible, the newborn needs transportation to a neonatal center [3]. The most responsible and "dangerous" stage of re-education is transportation. Transportation is a very difficult, highly technological process that requires proper organization, well-trained personnel and material and technical base. In addition, the re-education of a newborn in a critical condition is associated with a certain risk of deterioration of the child's condition [4]. The priority task of optimizing the inter-hospital transportation of newborns is to minimize the negative impact of the transportation process on the condition of the newborn and on the outcomes of treatment. Hypothermia is a serious problem for a premature newborn. Instability of a child's body temperature can lead to increased morbidity and mortality. Hypothermia indirectly affects carbohydrate metabolism and oxygen status and can provoke a hemorrhagic process. Extreme temperatures can lead to damage to the central nervous system, dehydration, hypernatremia, an increase in the frequency of NEC, VVC and an increase in the duration of ventilation [1]. Laptook A.R. et al. [5] in their study, they showed that low temperature at admission from the maternity hospital to the PIT has a close relationship with mortality (an increase of 28% with a decrease in temperature for every 1 oS) and the frequency of late sepsis (an increase of 11% with a decrease in temperature for every degree of oS).
The purpose of the study is to assess the effect of hypothermia at the stages of re-education of premature newborns on the admission status and outcomes of the intensive stage of treatment.
Research materials and methods
Design: a prospective, observational study. The study included 110 premature newborns with a birth weight of less than 2000 grams, on a ventilator, born in maternity hospitals of the Sverdlovsk region in the service area of the neonatal Resuscitation and Advisory Center of the Regional Children's Clinical Hospital (CSTO), re-hospitalized by the team of the CSTO RCSC No. 1 in the neonatal intensive care unit (ORITN) CSTO No. 1 under the age of 3 days. Exclusion criteria: congenital malformations, including CHD, abdominal surgical pathology, re-education from the ORITN of the CSTO No. 1 before removal from the ventilator. Stratification was carried out according to the temperature at admission to the ORITN. Children with a body temperature of 36.5-37.5 were included in the normothermia group (n=46), newborns with a temperature of less than 36.5 were included in the hypothermia group (n=64). The average body temperature at admission (M (95%CI)) in the normothermy group was 36.93 0C (36.82-37.04) and in the hypothermia group 35.79 0C (35.68-35.90). The newborns had no significant differences according to the analyzed anamnesis data (gestation period, body weight, anthropometric parameters, Apgar score at 1, 5, and 10 minutes, age at the time of re-education, evaluation by ES "DINAR-2", percentage of children after cesarean section, percentage of children who received surfactant within 30 minutes after birth and before transportation, the percentage of newborns being rehabilitated by air transport and the duration of transportation).
The technology of re-education: transportation of all newborns was carried out in the Draeger Transport-Incubator-5400 transport system equipped with a Babylog 2 ventilator, against the background of a constant infusion of 10% glucose solution through an umbilical venous catheter with a Braun Perfusor syringe dispenser. Pulse oximetry was performed at all stages of re-education. Correction of ventilator parameters and monitoring during transportation was performed on the basis of visual data (volume of chest excursion, auscultative picture, skin color) and pulse oximetry data. Noninvasive blood pressure monitoring was performed at the stage of pre-transport preparation and upon admission to the ORITN. Thermometry was carried out during pre-transport training and upon admission to the ORITN. The analysis of CBS (capillary) was performed immediately after admission to the ORITN. Analyzed outcomes: temperature, glycemia, lactate and CBS levels of the patient upon admission to the ORITN; the results of the intensive stage of treatment: lethality, duration of ventilator, duration of nSRAR, duration of the intensive stage of treatment, need for IVF, need for repeated intubation, frequency of pneumothorax, frequency of VVC 1-2, VVC 3-4, occlusive hydrocephalus, gross PVI, BPD, OAP, CVD.
Statistical processing was performed using software packages Microsoft Office Excel 2003, SYSTAT 10.2, BIOSTAT. Statistical tools: mean, standard deviation of the mean, standard error of the mean, 95% confidence interval, Student's criterion, analysis of variance.
Research results and their discussion
The initial parameters of the ventilator (ventilation frequency, FiO2, peak pressure, MPC, inhalation time) did not have significant differences between the groups. At the stages of re-education, there were no significant differences between the groups, significant correction of parameters was carried out only after admission to the ORITN according to the data of the CBS and respiratory monitoring. The volume of intensive therapy (the need for dopamine infusion and the rate of infusion) did not significantly differ between the groups at the stages of re-education. Indicators of percutaneous saturation and noninvasive blood pressure had no intergroup differences at the stages of re-education. The initial heart rate values did not differ between the groups at the start of pre-transport training and at the start of transportation. However, during transportation and by the time of admission to the ORITN, the heart rate in the group of children with hypothermia upon admission to the ORITN was significantly lower than in the group with normothermia, while not exceeding the age norms (M(95% CI): 139.24(134.32-144.61) and 127.95(124.15-131.76) in groups of normothermia and hypothermia, respectively, p<0.001). Initially and before the start of transportation, the body temperature values in the groups did not have significant differences, however, upon admission to the ORITN, there was a significant difference in this indicator between the groups (M (95%CI): in the normothermy group 36.93 0C (36.82-37.04) and in the hypothermia group 35.79 0C (35.68-35.90)). Thus, the groups were stratified by only one parameter – body temperature at admission to the ORITN. Other significant analyzed indicators did not have significant intergroup differences at all stages of re-education. The parameters of the CBS, the level of glycemia and lactate at admission had no significant differences between the groups. The analysis of significant outcomes in the groups revealed a significant increase in the duration of ventilation, the duration of the intensive stage of treatment and the frequency of BPD in the group of newborns with hypothermia at admission. There is a tendency to increase mortality, the need for IVF and the duration of IVF, the frequency of 1-2 and 3-4 degrees of IVF, the frequency of occlusive hydrocephalus and the frequency of CVD in newborns with hypothermia upon admission to the ORITN (see Table).
Table
Outcomes and complications
| Normothermy group (n=46) | Hypothermia group (n=64) | Difference | p | |
|---|---|---|---|---|
| M (95% CI) | M (95% CI) | M (95% CI) | ||
| Lethality, % | 6,52 (-0,98-13,94) | 11,29 (3,19-19,39) | -4,77 (-16,02-6,482) | 0,403 |
| Duration of the ventilator, day | 4,21 (3,09-5,31) | 8,08 (5,87-10,29) | -3,00 (-5,74- -0,27) | 0,032 |
| The need for VCHIVL, % | 8,89 (0,24-17,54) | 14,29 (5,40-23,17) | -5,39 (-18,06-7,27) | 0,400 |
| Duration of VCHIVL, day | 2,25 (-0,06-4,56) | 4,33 (1,64-7,02) | -2,08 (-5,38-1,21) | 0,197 |
| Duration of nSRAR, day | 1,91 (1,48-2,33) | 2,59 (1,96-3,22) | -0,06 (-0,85-0,74) | 0,886 |
| Duration of IT, day | 8,49 (7,04-9,94) | 12,58 (9,61-15,55) | -4,15 (-7,94- -0,37) | 0,032 |
| BPD, % | 4,44 (-1,82-10,71) | 20,97 (10,55-31,39) | -14,91 (-27,81- -2,01) | 0,024 |
| VJK 3-4, % | 20,00 (7,85-32,15) | 28,13 (16,81-39,45) | -8,13 (-24,86-8,61) | 0,338 |
| VJK 1-2, % | 22,72 (9,84-35,62) | 32,26 (20,29-44,23) | -9,53 (-27,21-8,15) | 0,288 |
| PVI, % | 17,79 (6,16-29,39) | 17,46 (7,82-27,09) | 0,32 (-14,55-15,19) | 0,966 |
| CER, % | 24,44 (11,39-37,50) | 34,38 (22,42-46,33) | -9,93 (-27,71-7,85) | 0,271 |
| OAP, % | 9,09 (0,25-17,93) | 7,94 (1,07-14,79) | 1,15 (-9,76-12,07) | 0,834 |
| Unsuccessful extubation, % | 6,67 (-0,91-14,25) | 9,52 (-2,31-6,86) | -2,86 (-13,64-7,92) | 0,600 |
When analyzing the outcomes of the intensive stage of treatment among the surviving newborns of both groups, there was a significant increase in the duration of ventilation and the duration of the intensive stage of treatment in the hypothermia group and a tendency to increase the frequency of severe VVC, the development of occlusive hydrocephalus, the frequency of unsuccessful extubations and the frequency of CVD in the hypothermia group.
The decrease in the body temperature of a premature newborn during transportation is due to ventilation with an unconditioned respiratory mixture, underestimation of the risk of hypothermia and, possibly, the technical features of this transport cuvette (the inability of the incubator to operate in autonomous mode). Decrease in body temperature below 36.50C leads to an increase in the duration of the ventilator, the duration of the intensive stage of treatment and the frequency of BPD.
Conclusions
1. Hypothermia at the stages of re-education negatively affects the outcomes of the intensive stage of treatment, increasing the duration of the ventilator, the duration of the intensive stage of treatment, and the frequency of BPD, worsening outcomes in the study population
2. Constant temperature monitoring is required at all stages of re-education
3. The transport cuvette must be able to operate autonomously without external electrical networks
4. It is necessary to pay attention to the prevention of hypothermia during transportation of premature newborns;
LITERATURE
1. Bethany L. F. Immediate Care and Transport Of The Sick Newborn [electronic resource] / L.F.Bethany, E.T.William.- Access mode: http://depts.washington.edu/.
2. Fenton A.C. Population-based outcomes after antenatal transfer / A.C.Fenton, S.B.Ainsworth, S.N.Sturgiss // Paediatr. Perinat. Epidemiol.- 2002.- N16.- P.278–285
3. Fenton A. C. Optimising neonatal transfer. / A.C.Fenton, A.Leslie, C.H.Skeoch // Archives of Disease in Childhood Fetal and Neonatal Edition.- 2004.- N89.- P.215-218
4. Influence of the transfer mode on short-term outcome in neonates with high perinatal risk / J.Fresson, F.Guillemin, M.Andre, A.Abdouch, B.Fontaine, P.Vert // Arch. Pediatr.- 1997.- Vol.4.- N3.- P.219-226.
5. Laptook A.R. Admission temperature of low birth weight infants: predictors and associated morbidities / A.R.Laptook, W.Salhab, B.Bhaskar // Pediatrics.- 2007.- Vol.119.- N3.- P.643-652.
SAFETY OF INTERHOSPITAL TRANSFER OF CRITICALLY ILL PREMATURE NEWBORNS
Mukhametshin R.F.
Supervisor of study - MDDr Kazakov D.P.
Department of anaesthesiology and intensive care DIC
The key words. Hypothermia, interhospital transfer, premature infants.
Published:collection "Topical issues of modern medical science and healthcare, materials of the 64th scientific and practical conference in UGMA"