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Re: Routine mechanical ventilation for transferred neonates with duct dependent congenital heart disease

Dear Editor,

Browning Carmo et al’s demonstrated that neonates with duct dependent congenital heart disease (CHD) treated with low dose prostaglandin E1 (PGE1) may not require mechanical ventilation for safe transport. (1) The Pediatric Department, University of Padova Neonatal Emergency Transport Service (NETS) provides about 200 neonatal transports/year in East-Veneto Region, Italy, with a total population referral base of 2,3 million people in a radius of approximately 150 km. In the referral area, there are approximately 25,700 births/year in 25 units. Tranfers are made generally by ground ambulance and the average time spent for each transport is about 185 min (range 60-346). (2) According to the transport protocol, patients with known or suspected CHD with ductal dependency or with signs of circulatory or respiratory failure are suitable to be cared by the dedicated transport team (a neonatologist, a nurse, and paramedic ambulance personnel). The transport protocol does not recommend routine intubation for apnea prevention during PGE1 infusion. During the period 1 Jan 2002-31 Dec 2006, 115 transferred neonates had cardiovascular problems. Among them, 51 (44%) were treated with PGE1 infusion for CHD (59% cyanogen, 41% left outflow obstruction) and 9 patients (18%) were intubated due to severe hypoxia or acidosis before the transport team arrival. PGE1 starting dose (25 to 50 ng/kg/min) was higher than that reported by Browning Carmo et al.1 Among the spontaneous breathing patients, none required ventilation or emergency intubation and no adverse events were recorded. In agreement with Browning Carmo et coll, 1 our data show that for short distances ground transport, transfer of otherwise stable newborns with CDH needing PGE1 infusion may be safe without routine mechanical ventilation, even with higher PGE1 doses. An improved prenatal diagnosis (only 14% in our population) could help to prevent haemodynamic instability after birth ensuring earlier and safer transfer. However, due to the potential deleterious effects of physiologic derangements in these patients, the presence of personnel with expertise in neonatal resuscitation is best advisable.(3)

References:

1. Browning Carmo KA, Barr P, West M, et al Transporting newborn infants with suspected duct dependent congenital heart disease on low-dose prostaglandin E1 without routine mechanical ventilation. Arch Dis Child Fetal Neonatal Ed 2007; 92:F117-F119.

2. Trevisanuto D, Doglioni N, Ferrarese P, et al. Neonatal pneumothorax: comparison between neonatal transfers and inborn infants. J Perinat Med 2005; 33:449-454.

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Re: Transporting Newborn Infants on Prostaglandin E1

Dear Editor,

North Trent regional Neonatal Intensive Care unit (Jessop Wing) is supported by the tertiary paediatric cardiology in Leeds. Newborn infants with suspected duct dependent cardiac conditions have to be transferred out to Leeds or other paediatric cardiology centre for assessment or further management. We identified 12 babies who were transferred on prostaglandin E1 (Prostaglandin).

Out of 12 cases, 10 were transferred to Leeds while 2 cases had to be transferred to Liverpool. 53% cases (7 out of 12) were transferred on a dose of (≤ 10 ng/kg/min while 47% cases required (¡Ý 10 ng/kg/min of Prostaglandin.

6 out of the 7 infants requiring small dose of Prostaglandin (¡Ü 10 ng/kg/min) were transferred successfully without need of ventilation. They were self breathing in air. One baby was ventilated before transfer because of apnoea after starting Prostaglandin. None of the self breathing infants had apnoea during the transport.

In infants requiring (¡Ý 10 ng/kg/min of Prostaglandin, all required intubation and ventilation before transfer. 3 out of the 5 cases required 100 ng/kg/min of Prostaglandin to open the duct in collapsed infants or non-responding cases. In one case, Prostaglandin was started on 100 ng/kg/min while in 2 cases it was started at 10 ng/kg/min but had to be increased to get the desired response.

In agreement with Browing Carmo et al (1) and Ferrarese P et al (2), we conclude that most of the babies can be safely transported on small dose of Prostaglandin (¡Ü 10 ng/kg/min) without any need of intubation and ventilation. These babies should be accompanied (transported) by the medical personnel with expertise in neonatal intubation and ventilation.

References:

1. Browning Carmo KA, Barr P, West M, Hopper NW, White JP, Badawi N. Transporting newborn infants with suspected duct dependent congenital heart disease on low-dose prostaglandin E1 without routine mechanical ventilation. Arch Dis Child Fetal Neonatal Ed 2007; 92:F117-F119.