R.F. Mukhametshin is a resuscitator at the Neonatal Intensive Care Unit of the Regional Children's Clinical Hospital No. 1 in Yekaterinburg.
F.G. Mukhametshin – Head of the Neonatal Intensive Care Unit of the Regional Children's Clinical Hospital No. 1 in Yekaterinburg, resuscitator, chief freelance neonatologist of the Ministry of Health of the Sverdlovsk Region
Department of Intensive Care and Neonatal Intensive Care of the Regional Children's Clinical Hospital No. 1, Yekaterinburg, Russia.
Introduction
The improvement of emergency care in neonatology is the most important factor in reducing mortality and disability of newborn children. [1], [2], [3] The training of highly qualified specialists, the effective organization of the neonatal service and the availability of modern equipment make it possible to provide high-quality care to critically ill newborn children. It is precisely such a complex three-component system that makes it possible to ensure effective improvement of demographic indicators in the region. [4]
However, the vast majority of births occur in institutions 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, appropriate monitoring. The system of perinatal care in the region in its current form does not solve the tasks assigned to it. 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 specialized centers with the earliest possible start of adequate respiratory and infusion therapy, inotropic support, starting from the pre-transport stage. Since most maternity care institutions cannot provide intensive therapy to a premature newborn with RDSN that meets international standards, the problem of providing such children with adequate assistance with the available forces and means is acute, that is, there is a need for their re-education in specialized hospitals. Therefore, it is obvious that the provision of assistance and the organization of re-education of premature newborns with RDSN from hospitals of the level of qualified care to specialized centers is one of the main tasks in emergency neonatology. In the Russian literature, information on this problem is rare and has appeared only in recent years [5], [6]. The foreign literature describes several models of the organization of the re-education of newborns, implemented in large transport services. [7], [8] However, there is no single solution for all conditions, and the transport service should be developed taking into account local peculiarities. [9], [10] Apparently, it is the stage of re-education that is one of the "bottlenecks" in the neonatal care system in many regions of Russia. Thus, further improvement of the system of assistance to newborns requires standardization of approaches to the inter-hospital transportation of premature newborns and ensuring the safety of the child on the road.
For a number of years, work has been carried out on the basis of the neonatal intensive care unit aimed at improving the quality of neonatal re-education and reducing the number of significant complications.The research carried out made it possible to identify the main directions of optimization of transportation technology. Hypothermia at the stages of re-education is a serious danger. 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). Hypothermia at the stages of re-education of a premature newborn leads to an increase in the duration of ventilation, the duration of the intensive stage of treatment and the frequency of BPD. Therefore, constant thermometry and provision of normothermy at the stages of re-education is an integral component of the safe transportation of a premature newborn [11].
Carrying out infusion therapy during transportation makes it possible to minimize the number of children with hypoglycemia at the time of admission to the ICU without increasing the percentage of children with hyperglycemia. The number of newborns with metabolic acidosis also decreases upon admission, which has certain advantages. Since the infusion therapy during transportation allows to ensure the stability of the glycemic level without increasing the frequency of significant complications, its implementation during the interhospital transportation of premature newborns is mandatory [11].
The use of a respiratory monitor at the stages of re-education provides serious advantages in comparison with the traditional tactics of selecting ventilation parameters based solely on monitoring of oxygenation and clinical assessment of the adequacy of ventilation. Correction of ventilator parameters using a respiratory monitor according to the proposed algorithm in the complex of pre-transport preparation and during transportation allows, due to optimization of pulmonary volumes and individualization of parameters, to reduce the "rigidity" of respiratory support, thereby reducing the percentage of hyperventilated children upon admission to the ORITN, as well as to abandon the use of high oxygen fractions in the inhaled mixture. This tactic made it possible, on the one hand, to reduce the duration of the ventilator and the duration of the intensive stage of treatment, and, on the other, to bring the high level of care to the child in a medical facility with low capabilities as close as possible. Therefore, respiratory monitoring is an important component of intensive care at the stages of re-education. In addition, since the Babylog2 transport respirator does not allow you to adjust the inhalation time and FiO2, it cannot provide ventilation with a peak pressure of less than 17 cm of water, it is not possible to select respiratory support parameters on this device that meet the needs of a premature newborn. This creates prerequisites for hyperventilation and increases the risk of complications associated with it. Thus, the Babylog2 transport respirator does not have sufficient "flexibility" in the selection of ventilation parameters in premature newborns and its use requires a forced, unjustified tightening of ventilation parameters [11].
The purpose of the study.
Evaluation of the integral effectiveness of the proposed measures to optimize the interhospital transportation of premature newborns in critical condition.
Materials and methods
The analysis of the outcomes of the intensive stage of treatment in this population of patients before the introduction of the updated transportation technology (2003-2004) and after its revision (2008-2009) was carried out. The retrospective analysis included 145 premature newborns with RDSN who were re-hospitalized on a ventilator in the ORITN of the CSTO No. 1 from the maternity hospitals of the region in 2003-2004 (control group) and 150 premature newborns who were re-hospitalized on a ventilator in the ORITN of the CSTO No. 1 from the maternity hospitals of the region in 2008-2009 (main group). The updated technology of re-education imposes expanded requirements on the technical equipment of the transport team: an autonomously operating cuvette with double walls and the possibility of thermometry, autonomously operating syringe dispensers, a transport respirator for premature newborns with discretely adjustable FiO2, the ability to control the time of inspiration, air conditioning of the respiratory mixture and a built-in compressor. The proposed technology of interhospital transportation of premature newborns, implemented in the neonatal intensive care center of the Regional Children's Hospital No. 1, includes:
1. Temperature monitoring and compliance with normothermy at the stages of re-education
2. Infusion during transportation to newborns weighing less than 1 kg with 5% glucose solution, to children weighing more than 1 kg – 10% glucose solution based on physical needs.
3. The correction of the ventilator parameters at the stage of pre-transport preparation is carried out on the basis of respiratory monitoring data according to the following algorithm:normalization of respiratory volume (5-6 ml /kg), normalization of minute ventilation (200-300 ml/kg), normalization of the shape of the pressure-volume loop by eliminating the upper and lower inflections of the loop, selection of the optimal time of inspiration along the flow curve.
The data set was carried out from the ORITN electronic database according to the above criteria. The analyzed parameters are: birth weight, gestation period, Apgar score at 1 and 5 minutes, age at the time of admission, duration of transportation, duration of ventilation, frequency of BPD, VJK 1-2, VJK 3-4, occlusive hydrocephalus, duration of the intensive stage of treatment and mortality by the time of its completion. Statistical processing was performed on a personal computer 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. Newborns of both groups had no significant differences in birth weight, gestation period, age at the time of re-education.