Neonatal ICU Considerations

Neonatal ICU Levels

Unlike trauma centers or pediatric ICUs, neonatal ICUs typically are licensed by the individual state to provide a specific level of services for neonatal patients.

• Level I (basic): neonatal resuscitation, postnatal care of healthy neonates, care of infants born at 35 to 37 weeks' gestation who are physiologically stable, and stabilization of the condition of sick neonates or those who are less than 35 weeks' gestational age before transfer to a higher level facility.

• Level II (specialty): neonatal resuscitation, postnatal care of infants born at more than 32 weeks' gestation and birth weight more than 1500 g, care of neonates who are moderately ill and do not require urgent subspecialty services, and care of preterm infants who are convalescing after a course in a level III nursery.

• Level III (subspecialty): neonatal resuscitation and postnatal care that includes advanced life support and/or comprehensive care for high-risk or critically ill neonates.

ECMO and Inhaled Nitric Oxide

The Extracorporeal Life Support Organization (ELSO) categorizes ECMO centers on the basis of the type of patients served: neonatal pulmonary, pediatric pulmonary, adult pulmonary, cardiac (all ages), and extracorpo­real cardiopulmonary resuscitation (E-CPR). There are approximately 115 ECMO centers in the United States, a number that has decreased during the past 15 years. For the neonatal and pediatric population, this reflects the decreased demand for ECLS because of the use of therapies such as high-frequency oscillatory ventilation, inhaled nitric oxide (iNO), and surfactant replacement.

ELSO, based at the University of Michigan, promulgates guidelines for ECLS and maintains a registry of patients who have been treated with ECMO (http://www.elso.med.umich.edu). Neonates represent the largest treatment group to date. ELSO's materials indicate that the decision to transfer a neo­nate to an ECMO center should be influenced by a number of factors and states that there are no standard criteria. In general, ELSO recommends that a neonate whose condition is deteriorating be transferred at a time when the conversion to conventional ventilation still can be tolerated and suggests that an infant whose condition has not improved after 6 hours of high-frequency oscillatory ventilation be considered a candidate for expedient transfer. Individual institutions may use the alveolar-arterial oxygen difference, the oxygenation index, or the persistence of a PaO₂ of less than 50 torr as predic­tors of the need for ECMO. Unfortunately, published experience indicates that the transfer of neonates for ECMO often occurs after the patient has reached commonly agreed on criteria for cannulation.

The staff at the ECMO center who accept a neonate in transfer should clearly indicate to the referring physician that the patient is being transported as an ECMO candidate, without a guarantee that ECMO will be provided. This practice may diminish the likelihood that the referring hospital or the family will question the decision to transport in case ECMO is not required. Furthermore, it communicates the fact that the ECMO center will be evaluat­ing the patient and determining whether the infant is an appropriate candi­date for ECMO after arrival.

The decision to cannulate for ECMO may be facilitated by requesting that the referring facility perform certain diagnostic studies while the trans­port team is mobilizing and responding. These include cardiac echocardiog­raphy to evaluate for noncorrectable conditions or cyanotic heart disease that might have been misdiagnosed as pulmonary hypertension.

In 2000, the US Food and Drug Administration (FDA) approved the use of iNO for the treatment of hypoxic respiratory failure in term and near-term neonates with clinical or echocardiographic evidence of pulmo­nary hypertension. As a result, many neonatal ICUs routinely provide iNO therapy, including facilities that do not have ECMO capabilities. The initia­tion of iNO therapy in a non-ECMO center is controversial, because it may delay transfer to a facility with ECMO capability. This practice has major implications for critical care transport teams, who may be asked to urgently transfer a critically ill neonate who is already receiving maximal medical therapy, short of ECMO. In these situations the transport team is unlikely to have any additional therapies that may offset the instability precipitated by transitioning from high-frequency oscillatory ventilation to conventional ventilation or by the stress of a mobile or air-medical environment.

For these reasons, it is essential that non-ECMO centers that provide iNO therapy for neonatal respiratory failure work closely with an ECMO center to develop criteria for transfer to ensure that there is a “window of opportunity” during which the transport can be accomplished safely. These guidelines should be evaluated regularly by reviewing the outcome of infants transported for ECMO. A certain incidence of “unnecessary” transports (ie, neonates who are referred for but do not require ECMO) may be necessary if the transfer criteria are adequately conservative. Furthermore, any transport team that may be asked to transport a neonate who is already receiving iNO therapy must have the capability of providing iNO during transport because abrupt discontinuation may result in serious deleterious effects.

Because iNO is an FDA-approved therapy, transport teams also may choose to initiate iNO on transport under appropriate circumstances. Infants with hypoxic respiratory failure and clinical or echocardiographic evidence of pulmonary hypertension are candidates for iNO therapy. Of note, there is controversy about the administration of iNO without echocardiographic confirmation of the absence of structural heart disease. The source of the concern is the fact that iNO therapy may be harmful to neonates whose systemic blood flow is dependent on right-to-left flow through the ductus arteriosus, because the subsequent reduction in pulmonary vascular resis­tance may compromise systemic blood flow. Examples include left-sided obstructive lesions such as critical aortic stenosis, hypoplastic left heart syn­drome, and interrupted aortic arch. At a minimum, protocols regarding the initiation of iNO during transport should specifically address the possibility of congenital heart disease and the appropriate steps to take if the patient's condition worsens while receiving iNO. The decision to initiate iNO during transport should reflect consideration of the potential risks and benefits of its use outside of the ICU, including the severity of illness and distance or time to the receiving facility. The practice of empirically initiating iNO during transport to facilitate the transition from high-frequency oscillatory ventila­tion to conventional mechanical ventilation has been reported, but there is no evidence that it improves patient safety or outcome.

Ideally, a neonate with hypoxic respiratory failure whose trajectory predicts the need for ECMO will be transferred to an ECMO center prior to meeting criteria for cannulation or before his or her condition becomes too unstable to permit transport. When this is not possible, a few select programs have the capability to respond to requests for transport by mobilizing an ECMO team that is capable of cannulating at the referring facility and then transporting the patient while receiving ECMO to the base institution.

Extreme Prematurity

The threshold for viability of preterm infants has decreased progressively with improvements in perinatal care. Although survival rates for infants born between 22 and 25 weeks' gestation have improved progressively, there remains a significant incidence of neurodevelopmental disability and other chronic health problems. Parental counseling and decision making around the birth of an extremely preterm infant have medical, legal, and ethical con­siderations. A published survey of neonatologists in the New England region indicated that the decision to resuscitate at the lower limits of viability is based both on gestational age and parental wishes. For example, the major­ity of neonatologists surveyed indicated that they would consider resuscita­tion for infants born at less than 23⁰∕₇ weeks to be futile, but one third would attempt resuscitation at the parents' request. For infants born at 25½ weeks' gestation and later, most neonatologists reported that they would consider treatment clearly beneficial, and 91% would provide resuscitation, even if the parents requested to withhold treatment. Between 24½ and 24⁶∕₇ weeks' gestation, neonatologists were divided on the benefit of treatment, but the majority reported that they would defer to parental wishes with regard to resuscitation.

The AAP and the American College of Obstetricians and Gynecologists have published guidelines for decision making at the threshold of viability. The guidelines acknowledge that delivery room management is made more challenging by the narrow range of gestations during which prognosis can vary significantly. The most reliable indicator of estimated gestational age is the date of the mother's last menstrual period, followed by a first trimester ultrasonographic evaluation.

Transport teams are faced with several dilemmas when the birth of an extremely preterm infant is imminent. Whenever feasible, it is preferable for the referring institution to transfer the mother with the fetus in utero so that delivery can occur in a facility with experience in the care of preterm neo­nates. If delivery is imminent or maternal transfer is judged to be an unac­ceptably high risk to the mother or the fetus, delivery should occur in the referring institution. Neonatal transport teams may be requested to “stand by” to assist in the delivery room resuscitation of an extremely preterm infant who then will require transport after birth. The decision to mobilize a transport team for anticipated problems with a preterm neonate should be made in consultation with the referring providers, the medical control physician, and the transport team leadership. If the timing of delivery can be predicted with reasonable certainty (ie, decision to perform a cesarean deliv­ery), the infant's estimated gestational age and weight indicate the potential for viability, and the referring facility has inadequate resources to manage the initial resuscitation and stabilization of an extremely preterm infant, it may be appropriate to dispatch the transport team before the infant's birth. The transport team may need to be augmented with additional personnel if expectations of assessments and/or interventions could exceed the standard team's level of expertise or scope of practice. Issues surrounding level of involvement and credentialing should be anticipated and agreed on before need. On the other hand, it is usually not appropriate to dispatch the team if there will be an unpredictable period of waiting for a vaginal delivery, if there is a high likelihood that the infant is not viable, or if there are providers who can perform initial resuscitation and stabilization before the transport team's arrival.

Surfactant Replacement Therapy

One of the most significant advances in the care of preterm newborns in the past 3 decades was the availability of surfactant replacement therapies for prevention or treatment of respiratory distress syndrome (RDS). Both animal-based and synthetic surfactant preparations have been shown to improve survival for preterm infants. Infants born at less than 30 weeks' gestation who receive prophylactic surfactant prior to the onset of respiratory symptoms have a lower incidence and severity of RDS as well as decreased mortality and morbidity (ie, pneumothorax, pulmonary interstitial emphy­sema). These findings have implications for preterm infants born in a non­tertiary care environment, where surfactant replacement therapy may or may not be available, and should be one factor taken into consideration when determining whether a transport team is to be dispatched prior to delivery. The AAP recommends that surfactant be administered as soon as possible to preterm infants with RDS, and that prophylactic surfactant should be con­sidered for extremely low birth weight infants who are at high risk of RDS, especially those who have not been exposed to antenatal steroids. When pro­viding surfactant replacement therapy during transport, neonatal teams must be cognizant of the potential for rapid changes in pulmonary compliance during the return transport when the team's ability to assess and monitor the infant may be hindered in the mobile environment. These potential risks must be weighed against the use of higher pressures and oxygen concentra­tions during the transport that could injure the infant's lungs. A recent study looking at over 200 surfactant-treated, transported preterm neonates found a low rate of pneumothorax (2.9%) but a relatively high rate of excessive ven­tilation on admission to the neonatal intensive care unit (18.9%).

Hypothermia for Hypoxic Ischemic Encephalopathy

Therapeutic hypothermia (either by whole body or selective head cooling methods) is now standard of care for selected newborn infants with moder­ate to severe hypoxic ischemic encephalopathy (HIE). Multiple studies have shown that efficacy of treatment is enhanced by meeting early inclusion criteria and starting cooling before 6 hours of life. Hence, starting cool­ing prior to and on transport is a natural extension, because in many cases, the appropriate window to commence treatment may already pass before a neonate is transported and admitted to a tertiary center. There are limited data suggesting how to perform cooling during transport, either passively or by certain manufactured or home-built cooling methods. Programs should work in close connection with their neurologists and intensivists to arrive at an agreed-on method, and appropriate training should be documented for all team personnel. Through outreach education, referring centers should be aware of uniform inclusion criteria and delivery methods. The largest study published in 2013 by the California Perinatal Quality Care Collaborative confirmed earlier observations that there is variability in delivery method, most patients do not achieve target temperature by the time of arrival at the accepting cooling center. Manufactured cooling devices and not passive cooling methods is the recommended mode on transport. Outcome studies now show that infants with moderate HIE may benefit more than those with severe HIE.

Selected Readings

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American Academy of Pediatrics Committee on Fetus and Newborn. Perinatal care at the threshold of viability. Pediatrics. 2002;110(5):1024-1027

American Academy of Pediatrics, Committee on Fetus and Newborn. Surfactant-replacement therapy for respiratory distress in the preterm and term neonate. Pediatrics. 2008;121(2): 419-432

American Academy of Pediatrics, Committee on Fetus and Newborn. Use of inhaled nitric oxide. Pediatrics. 2000;106(2 Pt 1):344-345

American Academy of Pediatrics, Committee on Injury and Poison Prevention. Transporting children with special health care needs. Pediatrics. 1999;104(4 Pt 1):988-992

American Academy of Pediatrics, Committee on Pediatric Emergency Medicine.

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